bluuebunny/crossref_metadata_2025 huggingface dataset:
N-acetyl cysteine prevents pain and hypersensitivity of bleaching agents without affecting their aesthetic appeal; evidence from in vitro to animal studies and to human clinical trials
Authors: Wang Diana , Kaur Kawaljit , Paranjpe Avina , Lee Eric , Wasilewski Matthew , Sung Danielle , Han David , Sung Eric C. , Jewett Anahid
Published: November 2019

Background

Tooth hypersensitivity and pain are undesirable side effects of bleaching agents in humans. The aim of this study is to implement strategies to counter such side effects, and to demonstrate the efficacy and mechanisms of action of N-acetyl cysteine (NAC) in countering the side effects of clinically used bleaching agents.

Methods

In a series of in vitro experiments, animal model studies, and human clinical trials, we demonstrate that NAC protects oral mucosa and teeth from damage induced by bleaching agents.

Results

The addition of NAC along with clinically used bleaching agents to dental pulp stromal/stem cells (DPSCs), stem-cells of apical papillae (SCAP) and oral epithelial cells, inhibited cell death mediated by bleaching agents in several in vitro assays. In addition, rat teeth, when treated with chair-side or over-the-counter bleaching agents, exerted adverse side effects to pulpal and gingival tissues as evidenced by the white lesions of gingivae as well as decreased survival and function of DPSCs. These side effects of bleaching agents were greatly mitigated by the application of NAC to the surfaces of the teeth and to the oral mucosa. NAC protected the surface topography and the appearance of the tissues after bleaching using scanning electron microscopic (SEM) analysis. Finally, application of NAC prior to the bleaching demonstrated significant translational benefit for the patients since it ameliorated pain and hypersensitivity and protected gingivae from bleaching induced white lesions and improved inflammatory index in the oral mucosa in human clinical trials.

Conclusions

Therefore, application of NAC to the surfaces of the teeth and oral mucosa prior to the use of bleaching materials is beneficial for countering adverse side effects of bleaching in patients and decreases pain, sensitivity, and potential damage to the dentition and oral mucosa associated with bleaching.

Trial registration

NCT03534115(NAC Prevents Side-Effects of Teeth Bleaching). Registration 4 December 2014.
Low advance directive completion rates in hospitalized oncology patients: Room for improvement.
Authors: Konda Manojna , Ananthula Aneesha , Baltz Alan , Pandey Yadav , Mariam Roy Arya , Godbole Abhijit , Makhoul Issam , Moore Heather
Published: November 2019

1

Background: Advance care planning (ACP), which includes advance directive (AD) completion, ensures that patients receive care that is consistent with their beliefs and preferences. ACP is particularly important to patients with cancer as they have high rates of hospitalization and mortality. However, AD completion rates for oncology patients have been reported to be as low as 10%. We sought to evaluate barriers and improve AD completion rates in hospitalized oncology patients in our institution. Methods: 63 patients with cancer admitted to our inpatient oncology unit were surveyed. A multi-disciplinary team, consisting of resident physicians and social workers, was constituted to educate patients and provide assistance with AD completion. Barriers to AD completion were identified and AD completion and filing rates on patients’ discharge were calculated. Results: Most patients were female (66.6%) with mean age of 63.8 years. Majority of patients had stage IV cancer (71.4%) and were receiving palliative treatment (80.9%). Only 9.5% (6/63) of the patients had completed AD on file. However, 92% of the patients had previously heard about AD. After intervention, the AD filing rate improved to 41.2% (26/63). Some of the patient-reported barriers were needing more time to discuss with family (28.5%), wanting to file in clinic (23.8%), too sick to make decision (6.3%) and did not think they needed it (4.7%). Conclusions: AD completion rate in hospitalized oncology patients in our institute was lower than anticipated. We identified the barriers and improved the AD filing rate, however there is room for further improvement. While AD discussion and filing should ideally be done in clinic, hospitalization is an opportunity that should not be missed to educate and assist completion of AD. [Table: see text]
Digital Supportive Care Awareness and Navigation (D-SCAN): Results of a pilot randomized trial.
Authors: LeBlanc Thomas William , Corbett Cheyenne , Davis Debra M. , Herring Kris , Locke Susan C. , Troy Jesse D , Wolf Steven , Zafar Yousuf , Atlee Darren , Chilcott Jack , Manassei Hugo , McCoy Colette , Mohan Sean , Pendergraft Trudy , Patierno Steven R.
Published: November 2019

101

Background: Cancer patients face many supportive care needs. In crowded clinics with rising care complexity, clinicians struggle to assess and manage these needs. Duke Cancer Patient Support Program (DCPSP) services aim to bridge this gap, but many patients are unaware of these services. We hypothesized that a DCPSP mobile application (app) is a feasible approach to this problem. Methods: We developed an app to enhance DCPSP awareness and facilitate weekly symptom reporting (via the Edmonton Symptom Assessment Scale, ESAS). Based upon symptoms, the app presents information cards and recommendations for specific DCPSP services. We enrolled 50 patients with advanced cancer (2 arms; 25 app intervention, 25 control) and 10 caregivers to a 12-week pilot trial. The primary outcome was feasibility. Secondary measures assessed knowledge/engagement of DCPSP services, usability, satisfaction, quality of life (QoL), and activation. We interviewed a subset of participants about the experience. Results: Forty-five patients completed the study, exceeding our pre-determined feasibility threshold. Most patients were age 50-64; the most common cancers were breast (42%) and lung (18%). Knowledge/use of DCPSP services increased in both arms, with a larger trend in the intervention arm (2.5 vs 4.0 composite score increase). App patients (n=25) completed a median of 7 ESAS surveys for an overall response rate of 57%. The most commonly-reported moderate/severe symptoms were fatigue (40%), drowsiness (22%), and pain (20%), with 54% of surveys from 23 of 25 patients reporting at least one moderate/severe symptom. These patients averaged 20 app interactions versus 9 interactions for those without a moderate/severe symptom. Satisfaction scores were high, and qualitative feedback was positive. We found no differences in QoL or patient activation across study arms. Caregivers had significant improvement in awareness/use of services (median increase 4.5, p=0.01). Conclusions: The D-SCAN app is a feasible approach to augmenting supportive care awareness and navigation, with high satisfaction and usability scores. The trend towards enhanced awareness and engagement of DCPSP services in app utilizers warrants further testing. Clinical trial information: NCT03628794.
Comprehensive geriatric assessment in lung cancer and hematologic malignancy.
Authors: Farmer Zachary Luke , Caprio Anthony James , Induru Raghava Reddy , Parala-Metz Armida , Cooper Markecia Kanese , Lankford Joanna Edeker , Kneuss Tiffany Gabrielle , Knight Thomas Gregory , Haggstrom Daniel Ernest
Published: November 2019

122

Background: The incidence of cancer in patients older than 65 is nearly tenfold higher than in their younger counterparts. Comprehensive geriatric assessment (CGA) is recommended for cancer patients > 65 years, as it can more reliably assess underlying function and predict tolerance to anticancer therapy. We reviewed data for patients with lung cancer and hematologic malignancies who completed comprehensive geriatric assessment by the Senior Oncology Section within the Levine Cancer Institute. Methods: From 2015 to 2019 Levine Cancer Institute (LCI) providers performed 96 CGAs in lung cancer patients and 58 in patients with hematologic malignancy, many of the latter being evaluated for bone marrow transplantation. Data was incorporated into an LCI Senior Oncology Clinic Database using the REDCap secure web application, allowing both quantitative and qualitative data analysis. Results: Median ages were 80 in lung cancer and 67 in hematologic malignancy. The lung cancer patients had a slower gait than patients with hematologic malignancy (0.8 m/s versus 1.3 m/s). Lung cancer patients also had a longer median timed up and go (TUG) test of 13 seconds, versus 8 seconds in hematologic malignancy. Considerably more lung cancer patients had experienced a fall within the preceding six months (32 (33%) versus 9 (16%)). The median Cumulative Illness Rating Scale-Geriatric (CIRS-G) total score was significantly higher in lung than in hematologic malignancy (14 versus 8), indicating a higher degree of comorbid illness. Cognitive functioning was comparable between the two groups, with median Montreal Cognitive Assessment (MoCA) scores of 25 in lung and 26 in hematologic malignancy. Conclusions: Lung cancer patients undergoing CGA had more comorbid illnesses, slower gait speed and timed up and go, and more falls in the preceding 6 months than hematologic malignancy patients. Overall cognitive functioning was not significantly different between the two groups. These findings highlight the importance of comprehensive geriatric assessment in elderly lung cancer patients. [Table: see text]
Microsphere oxycodone for pain management in head and neck cancer (HNC) patients receiving radiotherapy.
Authors: McDonald Andrew Michael , Spencer Sharon , Willey Christopher Douglas , Bonner James A. , Swain Thomas A , Nabell Lisle , McCammon Susan , Carroll William , McGwin Gerald , Bhatia Smita , Yang Eddy Shih-Hsin
Published: November 2019

123

Background: Pain is a common adverse effect of RT in patients with HNC, and extended release analgesic options are limited due to high rates of dysphagia. Wax microsphere bound oxycodone was developed as an abuse-deterrent opioid and maintains a similar pharmacokinetic profile whether administered with or without an intact capsule. We hypothesized that microsphere oxycodone could be used for extended release analgesia in patients undergoing RT for HNC and would not need to be discontinued due to dysphagia or gastrostomy tube dependence. Methods: We performed an open-label prospective clinical trial (NCT03317730) to assess the feasibility of microsphere oxycodone for extended release analgesia during RT for HNC. Participants were > 18y, had histologically confirmed HNC, and were to receive > 50 Gy of RT. Analgesia was prescribed in accordance with the World Health Organization pain ladder. Non-opioid and immediate release opioids were used at the discretion of the treating physicians. Microsphere oxycodone was initiated when total daily opioid dose exceeded 30mg morphine sulfate equivalent and was titrated weekly during RT. The primary feasibility endpoint was frequency of microsphere oxycodone discontinuation within 3 months of RT for reasons other than pain resolution. Secondary endpoints included pain level during RT. Results: Twenty-six eligible patients were enrolled between June and November, 2018. Microsphere oxycodone was initiated in 13 (50%) patients at a median of 5 weeks after beginning RT (range: 0 – 7 weeks). The mean Brief Pain Index Severity composite score at time of microsphere oxycodone initiation was 5.4 (SD ±2.0) and was 4.8 (SD ±1.5) during the final week of RT ( p= 0.21). Six patients utilized a gastrostomy tube to administer microsphere oxycodone for all or part of RT. Microsphere oxycodone was discontinued in 1 (7.6%) patient due to perceived inefficacy, 0 patients due to toxicity, and 0 patients due to difficulty with administration. Conclusions: These results support the feasibility and safety of microsphere oxycodone for extended release analgesia in patients with HNC undergoing RT. Future research should compare microsphere oxycodone and transdermal fentanyl in this population. Clinical trial information: NCT03317730.
Use of medical cannabis in treating anorexia and nausea in elderly cancer patients.
Authors: Nathan Rachel Andrea , Mupamombe Charles Tonderai , Walter Michelle , Case Amy Allen , Hansen Eric
Published: November 2019

124

Background: The use of medical cannabis (MC) in cancer symptom treatment has been increasing. Since its legalization is limited to select states, there are few clinical trials that have studied the effectiveness and safety of MC, and even fewer studies in the elderly patient population. Given this, we aimed to evaluate the effects of MC on nausea, appetite, and body mass index (BMI) of elderly cancer patients. Methods: We conducted a retrospective chart review of patients age 65 and older prescribed MC in the year 2018 in an outpatient palliative care clinic at a comprehensive cancer center. Nausea and appetite were measured by numerical rating (0-10) and BMI was recorded with data collected at consecutive clinic visits before and after MC use. Results: Eight-three patients aged 65 and over were included in our analysis. Half of patients were age 65-70, while 12% were age 76 or older. More than half were male (58%) and Caucasian (92%). For patients with anorexia or nausea, 58% had previously used cannabis. For nausea, 58% were prescribed ondansetron, 53% were prescribed prochlorperazine or metoclopramide, and 20% were prescribed olanzapine. For anorexia, 24% were prescribed mirtazapine, 6% were prescribed dronabinol, and 1% were prescribed megestrol. The majority of patients used oil (64%), with one-third using vape (33%) and fewer using pill (17%) and powder (5%). Patients primarily used high THC (50%) or equal THC:CBD (45%) formulations initially, with only 7% using high CBD products. The median nausea and anorexia trended towards improvement, though neither was significant (delta nausea = 0.1, p = 0.81) nor anorexia score (delta anorexia = 0.7, p = 0.69). BMI worsened despite MC use (delta BMI 1.9, p < 0.001). Conclusions: In this study of elderly patients with cancer prescribed MC, more than half had previously used cannabis. Two-thirds of patients with anorexia were using MC first-line for appetite stimulation. The majority of patients used oil, with vape next most commonly used, and the vast majority of patients using high THC or equal THC:CBD initially. Use of MC was not associated with a significant improvement in nausea nor anorexia, and BMI significantly decreased despite MC use.
Pharmacogenomics: Personalizing palliative pharmacotherapy.
Authors: Scheckel Caleb , Kekic Adrijana , Edwin Mark
Published: November 2019

126

Background: Pharmacogenomics (PGx) is a developing field in individualized medicine concerned with understanding genetic polymorphisms that may explain inter-individual variation in drug efficacy and toxicity. Understanding these polymorphisms is a key tool in guiding clinician’s selection and dosing of specific medications to optimally manage patient symptoms. Common pharmacogenes that impact analgesic prescribing include: CYP2D6, OPRM1, and COMT; for mood disorders: CYP2C19. This cross-sectional study explored the activity of pharmacogenes of clinical significance in palliative medicine with either Level 1 or 2 evidence. Methods: We performed PGx testing on 50 new referrals to the palliative medicine clinic with an active malignancy. Each patient underwent PGx testing with clinical pharmacist review and interpretation prior to their initial office appointment. Results: In our cohort 54% were men and the mean age was 64.7 (24-87). The average number of medications, medication allergies, and creatinine clearance were 10.5 (1-22), 1.3 (0-13), and 78.4 (31-120), respectively. Among the pharmacogenes impacting opiate and antiemetic prescribing, 14% (7/50) of patients were poor metabolizers of CYP2D6 and 8% (4/50) were rapid or ultra-rapid metabolizers. Another 60% (30/50) showed intermediate metabolism which would impact initial dosing. Poor metabolism of COMT or OPRM1 was seen in 8% (4/50) with another 36% (18/50) demonstrating rapid metabolism. Activity for the pharmacogene CYP2C19, which impacts many psychotropics, revealed 32% (16/50) rapid or ultra-rapid metabolizers and no poor metabolizers. Overall, 66% (33/50) of patients had pharmacogene activity suggestive of significant clinical impact necessitating either drug avoidance due to toxicity risks or substantial dose adjustment to be efficacious. Conclusions: Polymorphisms impacting pharmacotherapy were common in our cohort. Patients with difficult-to-control symptoms or multiple medication toxicities can utilize PGx testing as a guide to symptom relief. As PGx technology becomes readily accessible and economical, opportunities for patients to have precision genomic information guide healthcare decisions is expected to increase.
Multimorbidity, cancer, and symptoms: Using electronic health record data to cluster patients in multimorbidity phenotypes.
Authors: Gilbertson-White Stephanie , Srivastava Sanvesh , Li Yunyi , Laures Elyse , Saeidzadeh Seyedehtanaz , Yeung Chi , Chae Sena
Published: November 2019

130

Background: Cancer-related symptoms are associated with decreased quality of life, increased health care utilization, and shorter life expectancy. There is limited understanding of how multiple chronic conditions (MCC) contribute to variability in symptoms experienced in the context of cancer. Data mining the EHR will allow us to use real clinical data to identify multimorbidity phenotypes based on the clinical similarity of patients. Purpose of this study is to identify distinct subgroups of patients based on the MCC and cancer diagnoses and describe differences across these subgroups. Methods: EHR data was extracted from adult patients (n=2977) newly diagnosed with cancer in 2017 at one academic medical center. The SEER cancer site/histology list was used to group cancer diagnosis. MCC present for >6 months on the problem list or ICD-10 billing data were used. K-Means and K-Modes clustering procedures, with K equaling 7, were used to cluster patients based on MCC. Results: The sample consisted of 58% women, 93% white, with mean age of 62.4 (16.1) years. The most frequent cancers were GI (17%), gynecological (14%), and pulmonary (10%). The most frequent MCC were hypertension (33%), anemia (24%), and metabolic diseases (21%). Seven clusters correspond to following primary cancer sites: GI, pulmonary, urinary, gynecological, breast, endocrine, and skin. The MCC rates varied significantly across different primary sites with hypertension being present in call clusters, but anemia was present only in GI and urinary system cancers clusters. Conclusions: K-Means and K-Modes clustering procedures, with K equaling 7, produced similar clusters of cancer primary sites and MCCs, indicating our findings are stable and replicable. Our data extraction methods and clustering techniques worked well and can be expanded upon. Our next step is to repeat the data extraction and clustering analysis with the full data from the data warehouse (>30,000 records). The identified multimorbidity phenotypes will be used as inclusion criteria for prospective research with patients to explore the relationships among MCCs and symptoms in the context of cancer.
Prognostic value of the Memorial Sloan Kettering (MSK) prognostic score (MPS) in pancreatic ductal adenocarcinoma (PDAC).
Authors: Lebenthal Justin , Zheng Junting , Glare Paul A. , O'Reilly Eileen Mary , Epstein Andrew S.
Published: November 2019

133

Background: The MPS, a composite of the Neutrophil-Lymphocyte Ratio (NLR) and albumin, is an alternative prognostic tool to the Glasgow Prognostic Score (C-reactive protein and albumin). A retrospective analysis (jco.2016.34.26_suppl.36) of patients with PDAC suggested that the MPS predicts survival. This did not control for clinically relevant factors such as performance status (PS), metastatic sites, or cancer therapies. More discriminating prognostic tools are needed. Methods: A retrospective chart review identified patients at MSK with pathology-confirmed stage IV PDAC diagnosed from 2011 to 2014. An MPS scale of 0-2 was utilized: MPS = 0 for albumin ≥ 4 g/dl and NLR ≤ 4 g/dl, MPS = 1 for either albumin < 4 g/dl or NLR > 4 g/dl, and MPS = 2 for albumin < 4 g/dl and NLR > 4 g/dl. PS (ECOG or KPS) was abstracted from outpatient visit notes. Metastatic sites at initial MSK visit were assessed from cross-sectional imaging. Cancer therapies were characterized as 5FU-based, gemcitabine-based, experimental, and radiation to primary or metastatic sites. Thromboembolic (TE) diagnoses were also noted. Time-dependent Cox regression analyses identified clinical variables associated with overall survival (OS). Univariately significant variables were utilized in a multivariable regression model to interrogate their effect on the association of MPS and OS. Results: Univariate analyses in n = 833 stage IV PDAC patients identified higher MPS score, higher CA19-9 at diagnosis (n = 737), chemo, radiation, liver metastases, TE, hospital admission, and lower PS (n = 727) as associated with worse OS (p < 0.05). A multivariate model (n = 727) controlling for radiation, liver metastases, TE, admission, and PS demonstrated that higher MPS scores at diagnosis remained associated with worse OS (p < 0.001). Median OS in patients with MPS 0, 1, and 2 were 14.5 (95%CI: 12.9-17), 10.2 (9-11.6), and 6.2 (5.1-8.1) months, respectively. Conclusions: The MPS is an objective prognostic tool associated with OS in advanced PDAC independent of PS, disease characteristics, and types of cancer therapies. Future directions include prospective evaluation and application of the MPS to other PDAC disease settings and other malignancies.
Relationship of spiritual constructs to mental health PROs in adolescents with cancer.
Authors: Lyon Maureen , Grossoehme Daniel H. , Baker Justin N. , Friebert Sarah , Cheng Yao , Chrastek Jody , Thompkins Jessica , Tweddle Matthew , Wang Jichuan , Needle Jennifer
Published: November 2019

136

Background: Global beliefs and goals form a meaning system, which plays a role in adjusting to stressors like cancer. Spirituality (search for the sacred) is a meaning system that can play a role in adolescent coping, and psychosocial adjustment to chronic disease. When malignancies occur during adolescence, there are long-term consequences to adjustment, functioning, and disease self-management. Methods: Data were obtained from 126 adolescents diagnosed with cancer at various stages and 4 sites in a longitudinal pediatric advance care planning intervention trial. Scales used: demographic; 2 spiritual scales (Brief-MMRS and FACIT-Sp v4); and 2 emotional PROMIS items (anxiety and depression). Bivariate relationships were analyzed. Structural equation modeling examined the relationship between spiritual and PROMIS items. Bootstrap with 1000 resamples was applied to due to sample size. Results: Mean age was 16.9 years (range: 14-20), with a mean time since diagnosis of 77 months (range: 1-232); 21% were on active treatment. The majority were female (57%) and white (79%). Most identified as spiritual (89%) and religious (83%). When asked if they believed they will be spiritually healed from cancer by a miracle, 49% reported “yes.” Adolescents viewing cancer as God’s punishment were more likely to have high depression (p = 0.03). Very or moderately spiritual teens were more likely to have high anxiety and high depression (p = 0.02). Meaning/peace (FACIT-Sp subscale) mediated feeling God’s presence on anxiety (β = -3.5; 95% CI: -9.2, -0.48) and depression (β = -4.6; 95%CI: -10.7, -1.1); and mediated religious identification on anxiety (β = -3.1; 95%CI:-6.9, -0.6) and depression (β = -4.1; 95%CI:-9.3,-0.24). Conclusions: Our findings are consistent with adult literature and a single longitudinal study of teens with cancer: spiritual distress (cancer is God’s punishment) is associated with poorer mental health outcomes, and meaning with positive outcomes. Adolescent anxiety and depression were inversely related to feeling God’s presence, and to identifying as religious; this effect was mediated by their sense of meaning/peace. Meaning-making is a modifiable process, opening a novel focus for intervention development. Clinical trial information: NCT02693665.
Factors impacting fertility preservation in children, adolescents, and young adults.
Authors: Mobley Erin Michele , Ryan Ginny L. , Sparks Amy E. , Monga Varun , Terry William W.
Published: November 2019

139

Background: Fertility preservation (FP) prior to therapy is underutilized for those diagnosed with cancer as a child, adolescent or young adult (AYA). This study describes the factors impacting utilization of FP consultations and procedures among childhood and AYA cancer patients at the University of Iowa Health Care (UIHC). Methods: Patients were identified by the oncology registry at UIHC. Disease site, histology, date of diagnosis, sex, race, ethnicity, insurance, and zip code were gathered by the registrars. Disease site and histology were categorized using International Classification of Diseases-Oncology-3 (ICD-O-3). UIHC’s electronic medical record (EMR, Epic) was queried for ICD codes for FP consultation. Data from UIHC’s Reproductive Endocrinology and Infertility clinical database were merged with the primary data set to capture information about those who underwent FP. Rural-Urban Commuting Area codes incorporated a measure of rurality. Descriptive statistics and multivariate linear probability models were used to predict the probability of FP consultation and procedure. Results: From 2008-2017, 3,605 children and AYAs were treated for an invasive malignancy. Of the 637 (18%) who received a FP consultation, 162 (25%) underwent a FP procedure. Multivariate analyses showed that those with public insurance or no insurance, a diagnosis of a CNS tumor, melanoma, or miscellaneous neoplasm, and age over 30 years at diagnosis had a lower probability of having a consultation. The probability of undergoing a procedure was lower for female patients, those with germ cell tumor, melanoma, or carcinoma, seen by a pediatric-based provider, and diagnosed between 15-25 years of age. Conclusions: This study has important implications for survivorship and late effects research. The combination of sample identification via cancer registrars and linkage with EMR data could be used by others. The use of federal data to incorporate rurality is frequently overlooked. The use of this type of publicly available data would help improve the robustness of survivorship and late effects research through the inclusion of measures of rurality, health service availability, and economic indicators at varying levels of geography.
Serious illness communication among patients with head and neck cancer.
Authors: Buen Floyd , Martin Emily J , Wenger Neil , Buen Kirsten , Walling Anne M.
Published: November 2019

2

Background: Head and neck cancer is associated with significant morbidity and mortality, yet little is known about the frequency and content of discussions addressing patients’ values, goals of care, and treatment preferences. Methods: Using an institutional cancer registry, we conducted a retrospective analysis of 70 decedents who underwent surgical treatment for squamous cell carcinoma of the head and neck. We abstracted patients’ medical records using a standardized template. An independent reviewer re-abstracted 20% of the records. For abstracted data pertaining to documented values, goals of care, and/or treatment preferences our inter-rater reliability was greater than 93%. Results: The mean age at diagnosis was 66 years and 69% were male. An enduring advance directive, a completed Physician Order for Life Sustaining Treatment form, and a serious illness conversation documented in the medical record were noted in 27%, 4%, and 49% of the medical records, respectively. Half of the documented goals of care discussions were held in the inpatient setting, over 50% were held in the last month of life, and 25% were held in the last week of life. These conversations involved specialist palliative care providers (47%), hematologist/oncologists (41%), hospitalists (32%), head and neck surgeons (21%), radiation oncologists (19%), and intensivists (18%). None of these discussions involved patients’ primary care providers. Of those with a known location of death, 58% died in the hospital and 4 out of 5 of these patients died during attempted cardiopulmonary resuscitation. Conclusions: In this retrospective analysis, serious illness communication was documented in the minority of patients who died of head and neck cancer. These discussions occurred late in the trajectory of illness. The continuity relationships of teams treating head and neck cancer patients (e.g., head and neck surgeon, radiation/oncologist and hematologist/oncologist) situate these clinicians in the best position to enact serious illness conversations. These data suggest that opportunities to have these discussions upstream are often missed.
Chronic conditions among advanced cancer patients and their spouse caregivers.
Authors: Ketcher Dana , Otto Amy , Reblin Maija
Published: November 2019

20

Background: Chronic conditions and multimorbidity have been recognized to have negative impacts on costs of healthcare, quality of care, and well-being. The interdependence of patients and caregivers has also been highlighted, in that patient factors can impact caregiver outcomes and vice versa. Yet little research has been conducted on how the number of other health conditions among spouse caregivers (CGs) and advanced cancer patients impact their own and their partners’ well-being. Methods: Data were gathered as part of a prospective observational study of couples coping with advanced cancer. Patients had to have a cohabiting spouse/partner who identified as providing some care and also agreed to participate. Results: Patients rated their overall health slightly worse (scale 1-5, M = 2.85, SD = 0.95) than CGs ( M = 2.27, SD = 0.75). Patients also reported more total conditions ( M = 2.59, SD = 1.42) than CGs ( M = 1.4, SD = 1.14). Most patients (81%) reported at least one chronic condition other than cancer (44% of patients reported at least two other conditions); the most common conditions among patients were hypertension (43%), lung disease (36%), arthritis, and diabetes (both 24%). About 23% of CGs reported having no chronic conditions; 36% reported at least one and 41% reported at least two. The most common conditions among CGs were arthritis (40%), hypertension (39%), and heart disease, diabetes, and cancer (13% each). A greater number of CG conditions predicted greater depression symptoms in the patient ( B = 0.60, p = .040), controlling for patient conditions. More conditions among patients was a significant predictor of less patient social support ( B = -0.67, p = .017) and a marginally-significant predictor of greater perceived stress among caregivers ( B = -0.27, p = .064). A history of CG cancer predicted greater depression symptoms in the patient ( B = 2.3, p = .02). Conclusions: Chronic conditions and multimorbidity can have significant psychological consequences for both patient and CG. Clinicians, in addition to making an active effort to incorporate CGs into medical decision making and treatment planning, should also be aware of patient and caregiver multiple chronic conditions in order to provide more holistic care for patients.
Patient perceptions of treatment benefit in advanced cancer.
Authors: Patell Rushad , Einstein David Johnson , Halleck Jennifer , Dodge Laura , Buss Mary K.
Published: November 2019

25

Background: Informed consent assumes accurate perceptions of potential treatment benefits and risks, yet many patients receiving palliative cancer therapies misperceive the likelihood of cure. Patients’ understanding of treatment benefits/risks beyond cure is unknown. We aimed to further explore patient perceptions of benefits/risks of palliative treatment in the era of novel therapeutics. Methods: We surveyed patients with advanced solid cancers and their oncologists regarding benefits/risks of palliative therapies. We assessed perceived likelihood of tumor response, survival benefit, symptom palliation and side effects, as well as information-seeking behavior. We used log binomial regression to estimate risk ratios (RR) and 95% confidence intervals (CI) of the association between misperception (patient perception minus physician’s perception) and various demographic, disease and treatment characteristics. Results: Of 119 patients enrolled: median age was 65 years (range 59–73), 55% male and 56% had prior treatment. Treatments included chemotherapy (60%), immunotherapy (25%) and targeted therapy (16%). Median misperceptions are shown in Table. Factors associated with decreased misperception included male gender (RR=0.70, 95% CI: 0.55–0.89), graduate level education (RR=0.63, 95% CI: 0.41–0.98) and targeted therapy (RR=0.54, 95% CI: 0.30–0.98). There was no correlation between misperceptions of tumor response and curability (r=0.13, P=0.15) or self-education (r=-0.04, P=0.69). Conclusions: Compared with their oncologists, patients’ overestimate not only curability but also chances of tumor response, symptom palliation and survival benefit; though they accurately perceive likelihood of toxicity. There is no correlation between perception of curability and other goals of therapy such as response rate and symptom palliation. Improvements in communication should focus on the likelihood of different treatment goals rather than treatment risks. [Table: see text]
Assessing oncology patients’ perceptions of treatment goals.
Authors: Ngo Phuong , Souders Lisa , Mull Jetta , Powell Stephanie , Hegazi Mohamed M. , Redman Rebecca A.
Published: November 2019

26

Background: Metastatic disease is generally treated with palliative intent. An individual patient’s understanding of his or her treatment goal is highly variable and dependent upon multiple factors. Our study evaluated patients’ understanding of whether their treatment was for curative or palliative purposes and sought to identify factors associated with perception of treatment intent. Methods: This was a prospective study of 65 consecutive patients with stage IV solid tumor malignancies at a single institution. Patients were given a questionnaire during a routine follow up visit. Requested information included primary site of malignancy, stage, duration of treatment, whether they think the treatment is curative, and whether they think the treatment will help them live longer and/or relieve cancer-related symptoms. Patients also provided basic demographic information such as age, gender, marital status, race and education level. Their answers regarding cancer type, stage and length of treatment were compared with their medical records. Results: Median age was 64 with 37% males and 63% females. Of the 65 patients, 50.8% had some college or higher education. The primary malignancies consisted of 40% lung, 18.5% breast, 20% colorectal, and 10.8% melanoma. Forty-nine percent of patients were metastatic at the time of diagnosis, and 55.4% of patients had received two or more lines of therapy for metastatic disease. Nine percent of patients could not identify their primary malignancy or did not know, and only 76.9% of patients knew their cancer is metastatic. Only 29.2% of patients knew their treatment was not curative while 30.8% thought it was, and 40% did not know. The majority of patients (86.2%) believed their treatment would help them live longer and 67.7% believed the treatment would alleviate their symptoms. Conclusions: In our study, less than one-third of patients receiving treatment with palliative intent reported understanding that the goal of his/her treatment was not curative. Factors influencing a patient’s perception of treatment goals are many and include those specific to patients, their cancers, and providers. Ongoing studies will focus on identifying factors most strongly associated with a patient’s perceived intent of treatment.
Four-year overview of enrollment and participation in research studies conducted at the Prostate Cancer Supportive Care (PCSC) Program.
Authors: Wu Eugenia , Arsovska Olga , Sundar Monita , Vivar Michaela , Pang Christopher , Spillane Maria , Hedden Lindsay , Goldenberg Larry , Higano Celestia S.
Published: November 2019

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Background: The mission of the Prostate Cancer Supportive Care (PCSC) Program at the Vancouver Prostate Centre (VPC) is to provide clinical care focused on the needs of prostate cancer patients and partners. It is comprised of six modules that are administered by medical professionals in urology, radiation oncology, sexual health nurses, registered dieticians, certified exercise physiologist, male pelvic floor physiotherapists, and couples’ counselling. Incorporation of research into daily care provides evidence for these practices, identifies areas for improvement, and tests new approaches. In order to evaluate the interface between the clinical and research programs, we reviewed the metrics of our PCSC program. Methods: Research studies were grouped by type. Screening and enrollment logs were reviewed to tally the total number of patients approached versus enrolled. Reasons for non-participation based on data in our enrollment logs were categorized. Results: Between Feb 2015 and Mar 2019, PCSC Program participated in 22 research studies: 9 therapeutic or lifestyle intervention studies (3 RCTs), 3 observational studies, 2 registries, 1 survey, 1 genetic study, 1 databank , 2 collaborative programmatic studies, 3 “permission to contact” studies (referral to the study team only). 8 of the 22 studies included recruitment of dyads (both patient and their partner or caregiver). Of 1080 consenting patients, 760 (70.4%) enrolled in 1 study, 210 (19.4%) in 2 studies, and 110 (10.2%) in > 3 studies. 583 patients did not consent due to lack of interest (43.7%), not available (21.1%), time constraints (10.3%), travel distance (6.7%). Conclusions: Our data show that a subspecialty supportive care program can provide a rich environment in which to conduct clinical research. We believe that the integration of the research program and personnel into the clinical setting is key to our success. Current on-going studies are evaluating the impact of and patient satisfaction with all PCSC modules.
Racial/ethnic disparities in hospice utilization among Medicare beneficiaries dying from pancreatic cancer.
Authors: Paredes Anghela , Hyer Madison , Palmer Elizabeth , Lustberg Maryam B. , Pawlik Timothy M.
Published: November 2019

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Background: While racial/ethnic treatment disparities among patients with pancreatic cancer have been documented, variation in other aspects of care including hospice utilization have not. As such, we sought to define the incidence, as well as characterize the timing, of hospice utilization among racial/ethnic minority patients following pancreatectomy for pancreatic cancer. Methods: The Medicare Standard Analytic Files were used to identify white and racial/ethnic minorities (African Americans and Hispanics) who underwent pancreatectomy for pancreatic cancer. Trends and timing related to overall hospice utilization among racial/ethnic minority and white patients were analyzed. Results: Among the 6,530 individuals (median age: 73, IQR 69-78; 51.5% female; 6.6% % racial/ethnic minority) who underwent a pancreatectomy for pancreatic cancer, 64.6% (n = 4221) had died by the end of the follow-period. Among deceased individuals, three-fourths of patients (n = 3149, 74.6%) had used hospice leading up to the time of death. Among individuals who died, age and comorbidity burden were similar among racial/ethnic minority and white patients; racial/ethnic minority patients were less likely, however, to have used hospice services compared with white patients (racial/ethnic minorities: n = 188, 68.9%, whites: n = 2,961, 75.0%; p = 0.024). On multivariable analysis, after controlling for clinical factors, racial/ethnic minority patients remained 27% less likely than whites to initiate hospice services prior to death (OR 0.73, 95%CI 0.56-0.95, p = 0.021). Despite overall lower use of hospice, racial/ethnic minority patients had comparable odds of late hospice utilization (i.e. within 3 days of death) versus white patients (OR 0.75, 95% CI 0.49-1.14, p = 0.18). Conclusions: While most patients undergoing pancreatectomy for pancreatic cancer utilized hospice services prior to death, ethnic/racial minority were less likely to use hospice services than whites. Further research should seek to better understand possible barriers to hospice initiation among racial/ethnic minority patients with cancer.
Impact of mortality reviews on supportive care utilization, end-of-life care, and inpatient mortality.
Authors: Karimi Yasmin , Divi Vasu , Srinivas Sandy , Segura Smith Andrea , Hansen Jennifer , Tokareva Irina , Tulu Zeynep , Hedlin Haley , Fronk Joshua , Rosenthal Eben Lloyd , Blayney Douglas W.
Published: November 2019

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Background: 22% of US patients with cancer die in a hospital setting. As part of an effort to reduce unexpected inpatient (inpt) mortality, we reviewed records of all inpt cancer deaths at Stanford Hospital and reported findings to the treatment teams. Methods: Deaths with a cancer related ICD 9/10 code between 5/2017 and 6/2019 were reviewed by a multidisciplinary team. Findings and potential opportunities for improvement were communicated to the pt’s primary outpt oncologist, inpt oncologists and other involved providers. Observed to expected (O:E) mortality for the year prior to the intervention (5/2016–4/2017), Year 1 (5/2017–4/2018) and Year 2 (5/2018–4/2019) of the intervention were compared with two sided t test, α=0.05 (Vizient Inc, Irving TX). Changes in supportive care utilization and end of life care between cases reviewed in Year 1 and Year 2 were compared with chi square analysis. Results: There were 236 inpatient deaths reviewed. The median age was 64 years; 76% had solid tumors; 68% had metastatic disease; 33% had a previous inpt admission; 34% received chemotherapy in the last 2 weeks of life. Median length of stay was 7 days and 37% were admitted to the intensive care unit (ICU). The O:E mortality ratio significantly decreased between the year prior to intervention and Year 2 (0.95 vs. 0.69; p = .019), and Years 1 and 2 (0.90 vs. 0.69; p = .003). There was no noted difference in number of palliative care consults or resuscitation status at the time of death between Years 1 and 2. There was an increased frequency of advance care plan documentation on admission in Year 2 (p = .007). Conclusions: Cancer pts who die in the hospital have high rates of recent hospitalizations, chemotherapy/radiation use in the last 2 weeks of life and ICU admissions. Decrease in O:E is likely multifactorial. Potential factors are improved documentation of comorbidities, increased access to palliative care services, and facilitation of hospice referrals which were partially driven by results of our reviews and resulting awareness around end of life care. Work is ongoing to standardize documentation of goals of care conversations in the electronic medical record and employ lay health workers for earlier end of life discussions.
Describing the pediatric resident experience in caring for dying patients.
Authors: Umaretiya Puja J. , Spellun Arielle , Feraco Angela Marie
Published: November 2019

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Background: Cancer remains the leading cause of childhood death beyond infancy. Though growing subspecialty palliative care provides expertise in caring for dying children, all pediatricians encounter dying patients and should feel adequately prepared to participate in their care. Clinicians who feel insufficiently trained in communication or end-of-life care are more likely to distance themselves from seriously ill patients and report higher levels of distress and burnout. Pediatric residents are often responsible for the frontline care of dying children in the hospital and yet, most pediatric residencies lack a formal end-of-life curriculum. Here, we aim to understand the experience of pediatric residents caring for dying patients. Methods: A thirty-four item survey instrument was administered to residents in a large pediatric residency program at a tertiary care center at Rising Junior Orientation and Rising Senior Orientation in spring 2018. All residents present completed the survey. Results: Seventy-six residents completed surveys including 46 rising juniors and 30 rising seniors. Only 19 residents (25%) reported receiving any training in caring for dying children; most of which was by noon/morning conferences or informal teaching. Nearly all (70/74; 95%) residents felt that their training in caring for dying children was not sufficient. A majority of residents reported minimal to no comfort with discussion of goals of care (73%) or resuscitation status (69%), managing pain (76%), anxiety (79%), and dyspnea (80%) at the end-of-life, performing a death exam (81%), and reaching out to families after the death of a child (85%). A majority of residents anticipate continuing to care for dying children after residency (50/76; 66%). Conclusions: Pediatric residents are uncomfortable with caring for dying patients and receive minimal training, suggesting that end-of-life care is a large gap in the pediatric residency training experience.
Effect of inpatient palliative care on supportive care measures in patients undergoing hematopoietic cell transplantation (HCT).
Authors: El-Jawahri Areej , VanDusen Harry , Fenech Alyssa L. , Kavanaugh Alison , Jackson Vicki A. , Traeger Lara , Greer Joseph , Spitzer Thomas R. , Chen Yi-Bin Albert , Temel Jennifer S.
Published: November 2019

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Background: Inpatient palliative care integrated with transplant care has been shown to improve patient-reported quality of life (QOL), symptom burden, and psychological distress during hospitalization for HCT. However, the impact of palliative care on supportive care practices during HSCT remains unknown. Methods: This secondary analysis is based on a single-site randomized clinical trial of 160 patients with hematologic malignancies undergoing HSCT between 8/2014 and 1/2016. Participants received either inpatient palliative care integrated with transplant care (n = 81) or transplant care alone (n = 79). We used the electronic health record to obtain data on supportive care measures during HSCT including the use of patient-controlled analgesia (PCA), intravenous pain medications, atypical antipsychotics (used to treat nausea/anxiety), psychostimulants, antidepressants, hypnotics, and the use of standing orders (as opposed to as needed ‘PRN’) for supportive care medications. We compared the proportion of subjects in each group receiving these supportive care measures using Fisher’s exact test. Results: Patients randomized to the palliative care intervention were more likely to use PCA (32.1% vs. 15.19%, P = 0.015), and atypical antipsychotics (35.8% vs. 17.7%, P = 0.012) compared to those receiving transplant care alone. Intervention participants were also more likely to have standing orders for their supportive care medications (74.1% vs. 56.9%, P = 0.030) compared to those receiving transplant care alone. Study groups did not differ in the of intravenous pain medications, psychostimulants, antidepressants, or hypnotics. Conclusions: Patients receiving inpatient integrated palliative and transplant care were more likely to utilize PCA and atypical antipsychotics during HCT compared to those receiving transplant care alone. Future work should examine whether these differences in supportive care practices mediate the effect of the palliative care intervention on patient-reported outcomes. Clinical trial information: NCT02207322.