bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes of a specialized interdisciplinary approach for cancer patients with aberrant opioid-related behavior: A preliminary report.
Authors: Edwards Tonya , Arthur Joseph Anthony , Reddy Suresh , Nguyen Kristy , Hui David , Yennu Sriram , Park Minjeong , Liu Diane D , Bruera Eduardo
Published: November 2017

212

Background: Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in cancer patients is lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention. Methods: The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015 and August 31, 2016 were reviewed. Results: At baseline, pain intensity (p=0.002) and opioid dose (p=0.001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from 3 pre-intervention to 0.4 post-intervention (p<0.0001). The median morphine equivalent daily dose decreased from 165mg/day at the first intervention visit to 112mg/day at the last follow up (p=0.018) although pain intensity did not significantly change (p= 0.984). ‘Request for opioid medication refills in the clinic earlier than the expected time’ was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age (p<0.0001) and higher ESAS anxiety score (p=0.005) were independent predictors of the presence of AB. Conclusions: The intervention was associated with a reduction in the frequency of AB and opioid utilization among cancer patients receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention. [Table: see text]
A comparison of Numeric Pain Rating Scale (NPRS) and the Visual Analog Scale (VAS) in patients with chronic cancer-associated pain.
Authors: Firdous Shagufta , Mehta Zankhana , Fernandez Carlos , Behm Bertarnd , Davis Mellar
Published: November 2017

217

Background: Though numerical rating scales (NRS) are frequently used, a subset of patients do not understand the abstract nature on NRS and use quality descriptors of severity. We used a visual analog scale (VAS) using descriptors of “good day”, “average day” and “bad day” along a 10-cm line and compared it to a NRS in patients with cancer diagnosis and pain 1 month or longer. Methods: Eligible patients were verbally consented and completed the two scales. We asked patients thoughts about which they felt was the more appropriate scale to gauge their pain. The scales were compared by the distance from the extreme left of the line to the mark the patient placed on the VAS. Additional data included demographic and diagnosis information. The VAS and NRS were compared using two-sample t-tests or Wilcoxon rank-sum tests and Pearson’s chi-square or Fisher’s exact tests, as appropriate. The relationship between the numeric pain scale and the visual analog scale is described using Pearson’s correlation coefficient. Results: Full data was provided from 94 patient surveys who completed surveys. The mean age was 61 years old, 56.4% were female, and 78.0% had metastatic cancer. Numerous cancer types were reported with gastrointestinal and lung cancers being the most common (30.1% and 23.7%, respectively). The mean NRS rating reported by patients was 5.9 and for the VAS 4.9. Sixty patients (63.8%) preferred the NRS, 32 (34.0%) preferred the VAS, and 2 (2.1%) reported no preference. Patients who preferred the NRS reported a higher NRS rating than patients who preferred the VAS (mean NRS of 6.3 compared to 5.2, p = 0.0409). VAS ratings were higher among patients who preferred the NRS but the difference was not statistically significant (mean rating of 5.2 vs. 4.4, p = 0.1894). There were no differences in patient characteristics between the two groups. There was a moderate association between patients’ NRS and VAS ratings. The Pearson correlation coefficient was 0.653 (p < 0.0001). Conclusions: Majority of patients of all ages and both genders prefer NRS. Future studies involving larger number of patients and adding a question about the reason of scale preference may provide better understanding for scale preference.
Atypical femoral fracture in patients with malignant bone metastasis receiving denosumab therapy: Retrospective study.
Authors: Yukinori Ozaki , Takahashi Momoko , Nakajima Hiromichi , Ohki Ryosuke , Masuda Jun , Kondoh Chihiro , Miura Yuji , Tanabe Yuko , Takano Toshimi
Published: November 2017

220

Background: While denosumab prevent skeletal-related events in patients with malignant bone metastasis, there are concerns that it may be associated with atypical femoral fracture (AFF). AFF in osteoporotic patients receiving denosumab is reported, but few data have been reported in the context of monthly denosumab therapy for patients with malignant tumor and bone metastasis. Methods: We reviewed the medical records and pharmacy database of patients who received denosumab at 120mg monthly for management of bone metastasis from May 2012 to June 2017 at our institution to analyze the incidence of AFF. To identify the risk factors and optimal management of AFF, we reviewed the clinical features and skeletal images of the patients. Results: We analyzed the data of 204 patients receiving a median of 7 doses (range; 1-60) of denosumab, and 150 (74%) patients received more than three times of denosumab. Four patients were diagnosed as AFF and incidence rate was 2.0%. Five limbs of the 4 patients were diagnosed as AFF and performed intramedullary nail fixation, and 2 limbs of the patients were diagnosed of atypical femoral stress reaction (AFSR) with surgical indication. These patients with AFF received 15, 44, 45 and 45 doses of denosumab, which showed higher doses of denosumab (median: 44.5 doses), compared to the patients without AFF or AFSR (median: 6 doses). Median age of the four patients was 59 (range: 50-66), and primary disease were breast cancer in three patients and non-small lung cell cancer in one patient. Conclusions: We experienced four AFF events among 204 patients receiving denosumab 120mg monthly and incident rate was 2.0%. More data are needed about the occurrence of AFF in these patients.
Analysis of retreatment after radiotherapy for bone metastasis at a safety net hospital.
Authors: Jennelle Richard Lester Stephen , Andrade Jacob , Williams Patrick , Bian Shelly , Ragab Omar Medhat , Yoo Stella , Pham Anthony , Lai Peter , Schechter Naomi , Ballas Leslie K. , Chang Eric L.
Published: November 2017

223

Background: The effectiveness of single fraction radiotherapy in the treatment of bone metastasis is firmly established by multiple prospective randomized controlled trials. These trials have also indicated a retreatment rate that is significantly higher for patients treated with single fraction radiotherapy. The reason for this is unclear. The prior studies have confirmed that there are no differences in any objective or subjective measure of response or durability of response. One proposed explanation may be a conscious or subconscious impact of practice based workload accounting for adopting a single fraction treatment strategy that may lead to excess retreatment prescription. In other words, does a decrease in workload accounting due to single fraction treatment lead to an increase in retreatment rates? Our large safety net teaching hospital follows a practice model where department funding is independent of workload accounting. We retrospectively reviewed our data on the radiotherapy of bone metastasis to see if this practice model had any impact on our retreatment rates. Methods: Between October 2012 and June 2017, 225 patients received treatment for 385 target lesions. All referred patients’ entire radiotherapy history was included whether or not it occurred during the target period. 196 target lesions received single fraction treatment and 189 received multiple fractions. 27 target lesions were retreated once and a single target lesion was retreated twice. Results: Target lesions treated with a single fraction resulted in a retreatment rate of 7.7% while multiple fraction treatment resulted in a retreatment rate of 6.4%. This difference was not statistically significant by Chi-Square analysis. Conclusions: Our retrospective analysis confirms no difference in retreatment rates between single and multi-fraction treatment. The retreatment rate is in agreement with the published response rate and introduces a possible explanation for the discordant rates observed in the published literature. Further analysis involving multiple practice models would help further explore these findings.
Methadone as the initial long-acting opioid in children with advanced cancer.
Authors: Madden Kevin , Mills Sarah , Dibaj Seyedeh , Williams Janet L. , Liu Diane D , Bruera Eduardo
Published: November 2017

224

Background: Methadone is an attractive medication for treating children with advanced cancer who have chronic pain, as it is the only long-acting opioid available as a liquid. This formulation allows for precise dosing that is not possible with the fixed dose of extended release tablets or transdermal patches. Additionally, it can be used in children unable to reliably swallow tablets. Many pediatric oncologists are concerned with methadone’s complex pharmacodynamics and pharmacokinetics, and so it is often relegated to being the long-acting opioid to use only after long-acting morphine, long-acting oxycodone, and fentanyl transdermal patches have proven to be ineffective in controlling pain. We believe that methadone has a role as the first long-acting opioid in children who have uncontrolled pain while only on immediate-release mu opioid agonists. Methods: Retrospective chart review of 52 consecutive patients referred to Pediatric Supportive Care for pain management started on methadone as their first long-acting opioid. Data collected at baseline and first follow up visit (F1) included child- and parent-reported outcomes for various physical and psychological symptoms, opioid side effects and other clinical data. All symptoms were rated on a 5 point scale: 0 (not at all), 1 (a little bit), 2 (kind of), 3 (quite a bit) and 4 (a lot). Results: Of 52 eligible patients, a majority (47, 90.3%) were assessed at F1. Reasons for not evaluating patients at F1 included death (3) (none died of cardiac arrhythmia or opioid related toxicity) and transfer of care to another facility (2). Pain as scored by the child was 3.6/4 at baseline and 1.8/4 at F1 (P < 0.0001). Pain as scored by the parent was 3.5/4 at baseline and 1.4 at F1 (P < 0.0001). A majority of patients (33, 70.2%) at F1 did not need a change in their methadone dose. A small number (10, 21.3%) needed an increase in their methadone dose due to inadequate pain control; a few (4, 8.5%) had a lower methadone dose but all were part of tapering methadone due to resolution of the original pain syndrome, not due to opioid toxicity. Conclusions: Initiation of methadone was effective and safe as the first long-acting opioid in children with pain due to advanced cancer.
Phase III study of palonosetron (PALO) given as 30-min IV infusion (IV inf) versus 30-sec IV bolus (IV bol) for prevention of chemotherapy-induced nausea and vomiting (CINV) associated with highly emetogenic chemotherapy (HEC).
Authors: Karthaus Meinolf , Szabò Péter , Voisin Daniel , Rizzi Giada , Ciuleanu Tudor
Published: November 2017

227

Background: PALO (0.50 mg), a distinctive second-generation 5-HT3 receptor antagonist (RA), is a component of the oral fixed combination agent NEPA, the second component being the NK1 RA netupitant. Oral NEPA is approved for acute and delayed CINV prophylaxis after moderately (MEC) and HEC. This study was conducted in support of the NEPA IV formulation (0.25 mg PALO + 235 mg fosnetupitant) administered as a 30-min IV inf, currently under FDA review. Methods: Chemotherapy-naive patients (pts) with solid tumors were randomized (1:1) to receive a single 0.25-mg PALO as a 30-min IV inf or a 30-sec IV bol, 30 min before reference HEC (cisplatin; dacarbazine), with oral dexamethasone (20 mg [D1]; 8 mg BID [D2–4]) (NCT02557035). Primary objective: noninferiority (NI; lower limit of the 99% CI to be > –15% [prespecified NI margin]) in complete response (CR; no emesis/no rescue) in the acute (0–24 h) phase. Secondary objective: safety. Results: 440 pts (median age 59.4 y [25–79]; cisplatin: 97.3%; dacarbazine: 2.7%) were randomized to IV inf (n=225) or IV bol (n=215). Baseline characteristics were similar. Acute CR rate was 82.7% (IV inf) and 86.5% (IV bol), with risk difference of –3.8% (99% CI: –12.2; 4.7) meeting the primary objective of NI. Treatment-emergent AE and study drug-related AE frequency was similar in both arms (Table). One PALO IV inf patient with pre-existing cardiac symptoms, experienced 1 serious AE that eventually lead to death and was considered possibly study drug-related by the investigator. No G≥3 infusion site reactions occurred. No patient in IV inf arm had infusion interruptions. Conclusions: PALO IV inf was noninferior to IV bol in acute CINV prevention after receiving non-AC HEC. Safety profiles were similar. No specific infusion toxicities were observed. The results show that PALO 0.25 mg IV inf is appropriate for the NEPA IV formulation. Clinical trial information: NCT02557035. [Table: see text]
Cranial electrotherapy stimulation for the management of depression, anxiety, sleep disturbance, and pain in patients with advanced cancer: A preliminary study.
Authors: Yennu Sriram , Kang Duck Hee , Hwu Wen-Jen , Padhye Nikhil S , Masino Charles , Liu Diane D , Dibaj Seyedeh , Williams Janet L. , Lu Zhanni , Bruera Eduardo
Published: November 2017

229

Background: Cranial Electrotherapy Stimulation (CES) is a safe modulation of brain activity for treating depression, anxiety, insomnia, and pain. However, there are no published studies in patients with advanced cancer (ACP).The aim of the study was to determine the feasibility and preliminary efficacy of a 4-week CES intervention on depression, anxiety, sleep disturbance, and pain scores. Concurrent salivary biomarker studies were conducted. Methods: In this one group open label pre- and post-intervention study with a 4-week CES intervention, ACP’s with one or more of four moderate intensity (≥3/10) ESAS symptoms (depression, anxiety, sleep disturbance, and pain) were eligible. Adherence (0-100%), satisfaction rates(0-10), and safety were assessed. ESAS, HADS, PSQI, BPI, and salivary levels (cortisol, alpha amylase, CRP, and IL-1 beta and IL-6) were assessed from baseline to week 4. Results: 33/38(87%) completed the CES. Median (IQR) adherence for days with 60 min CES use and satisfaction scores were 93(89-100)% and 10(9-10) respectively. CES use was safe (no grade 3 or higher adverse events). HADS anxiety (p < 0.001), HADS depression (p = 0.024), ESAS anxiety (p = 0.001), depression (p = 0.025), BPI pain (p = 0.013), PSQI daytime dysfunction (p = 0.002), and Medication use (p = 0.006) scores improved after 4 week CES treatment. There was no significant change in the salivary cortisol, alpha-amylase, CRP, IL-1β, and IL-6 levels after 4 weeks of CES. Conclusions: In this preliminary study we found that the use of cranial Electrotherapy stimulation (CES) was safe and feasible in ACP. The use of CES was associated with significant improvement of depression, anxiety, pain, and sleep scores. These findings support further studies of CES in ACP for symptom control.
Randomized trial of a smartphone mobile app for adherence to oral chemotherapy.
Authors: Jacobs Jamie M. , Pensak Nicole , Nisotel Lauren Ellen , Fishbein Joel N , MacDonald James J , Ream Molly , Fuh Charn-Xin , Buzaglo Joanne S. , Muzikansky Alona , Lennes Inga Tolin , Safren Steven A. , Pirl William F. , Temel Jennifer S. , Greer Joseph
Published: November 2017

230

Background: As patients with cancer are increasingly prescribed oral chemotherapy, they share greater responsibility for ensuring adherence and monitoring side effects. The aim of this study was to test the effect of a smartphone mobile app to improve adherence and symptom management in patients prescribed oral chemotherapy. Methods: From 2/15 to 12/16, 181 patients with diverse cancers prescribed oral chemotherapy at an urban cancer center were randomized to receive either the smartphone mobile app or standard care. The mobile app included a medication treatment plan with alerts, symptom reporting module, education library, and cancer-specific resources. The primary outcome was adherence, measured by electronic pill cap (MEMS) and self-report (Morisky Medication Adherence Scale; MMAS). To assess symptoms, mood, and quality of life, participants completed the MD Anderson Symptom Inventory, Hospital Anxiety & Depression Scale (HADS); and Functional Assessment of Cancer Therapy-General (FACT-G) at baseline and 12 weeks. General linear models were used to assess intervention effects on patient outcomes. Results: Study groups did not differ across outcome measures from baseline to week 12, except patients in the mobile app group had less of a reduction in social well-being (FACT-G) over time (Mean Diff = 1.67, 95% CI = -3.12, -0.21, p = .025). Secondary analyses showed that baseline adherence (MMAS) and anxiety (HADS) were moderators of intervention effects on self-reported and electronically monitored adherence. Among patients who reported adherence problems, those assigned to the mobile app had better average MEMS adherence (Mean Diff = -22.30, 95% CI = -42.82, -1.78, p = .034) compared to standard care. Similarly, among patients with higher baseline anxiety, those in the mobile app group had better average MEMS adherence (Mean Diff = -16.08, 95% CI = -31.74, -0.41, p = .044) and reported fewer adherence problems on the MMAS at 12 weeks (4.3% vs 32%, OR = 0.06, 95% CI = 0.003, 0.96, p = .047) compared to standard care. Conclusions: A patient-centered, smartphone mobile app designed to improve adherence to oral chemotherapy may be especially useful for patients with certain risk factors, such as those struggling with adherence or anxiety. Clinical trial information: NCT02157519.
Long-term efficacy and safety of duloxetine in the management of painful chemotherapy induced peripheral neuropathy.
Authors: Ro Sang Mi , Woo In Sook
Published: November 2017

236

Background: Accordingly, Quality of life in the survivorship of patients with cancer is becoming one of the important issues with a development of systemic anticancer treatment. About 40% of the patients who receive chemotherapeutic agents which have neuropathic potential suffer from painful CIPN. Various approaches to relieve the pain associated with CIPN have been attempted in clinical practice. Previously duloxetine, a dual reuptake inhibitor of serotonin and norepinephrine, has been reported to reduce painful CIPN when administered for 5 weeks. We retrospectively investigated the effect of duloxetine on the pain associated with CIPN over a prolonged period of administration. Methods: Between December 2014 and December 2016, patients with advanced cancer who complained of CIPN during or after systemic chemotherapy were eligible. Initially, 30 mg of duloxetine was administered daily for the first week and 60 mg daily was administered from the second week thereafter. The severity of pain was evaluated using a numerical rating scale from 0 to 10. Study follow-up was performed at regular visits according to the chemotherapy schedule or at the time of evaluation of disease status in the patients who completed systemic chemotherapy. However, the patients were allowed to visit whenever needed. Results: Twenty-seven patients were evaluable, the median age was 64 years (range, 23-83 years), and 11 patients were male and 16 patients were female. Twenty-four of the 27 patients received neurotoxic chemotherapeutic agents such as cisplatin, oxaliplatin, taxane and vinca alkaloid. Patients receiving duloxetine showed a significant reduction in the pain intensity from baseline and the mean decrease in the average pain score was 2.85 (95% CI 2.26-3.44, P < 0.001). Twenty-five (92.5%) of the 27 patients showed decreased pain after the use of duloxetine. Mean duration of treatment was 29 weeks (range, 1~130 weeks). Median duration of response was 19 weeks (range, 4~99 weeks). Treatment-related adverse events were nausea (17.2%), vomiting (3.4%) and dizziness (6.8%). Conclusions: Duloxetine demonstrated a durable efficacy and tolerability for painful CIPN in patients with advanced cancer.
Health-related quality of life in patients with advanced colorectal cancer treated with dose reduced capecitabine.
Authors: Breadner Daniel Adam , Welch Stephen , Cripps M. Christine , Jonker Derek J. , Lam Wendy , Klimo Paul , Biagi James Joseph , O'Connell Anne , Whiston Frances , Stitt Larry , Vincent Mark David
Published: November 2017

237

Background: The goal of palliative chemotherapy is to prolong survival and decrease the symptomatic disease burden while minimizing treatment toxicities to preserve or improve quality of life. We recently reported a trial of dose reduced capecitabine in elderly or frail patients with advanced colorectal cancer, demonstrating that dose reduced capecitabine was a safe and efficacious treatment option. We herein report the health related quality of life (HRQoL) outcomes for the trial. Methods: A single arm multi-centered phase I/II trial of dose reduced capecitabine assessed capecitabine in 221 patients in at least one of the following subgroups: Age > 65, ECOG-PS ≥1, elevated LDH, and prior pelvic RT. Capecitabine was given at 2000 mg/m2 days 1-14 q21 days; or 1500 mg/m2 for patients with prior pelvic RT, as determined in the phase I portion of the study. Phase II participant (182 pts) were asked to complete FACT-G questionnaires at enrollment, after each cycle of capecitabine and once after cessation of the study drug, if possible. Results: 157 pts completed a baseline questionnaire (86%), and 137 pts (75%) completed a baseline and at least one subsequent questionnaire. The mean baseline score was 81.6, out of a possible 108. The mean score peaked at 92 after cycle 10. The mean change from baseline was always positive, with the maximum change (4.0), occurring after cycle 12. The number of patients who achieved the minimal important difference, a meaningful improvement in HRQoL, ranged from 30% to 45% during treatment cylces. The differences in HRQoL between capecitabine doses were minimal and did not reach significance. Patients who did not achieve disease control also reported an improvement in mean score from baseline (+3.9) after cycle 2. Changes in subscale mean scores for physical and social/family wellbeing were minimal (-1.2 to +0.5) while emotion and function subscale mean scores never decreased with the peak subscale change from baseline being +3.5. Conclusions: HRQoL improved on capecitabine therapy at 2000 or 1500 mg/m2 daily, further supporting its use in elderly and less fit patients with advanced colorectal cancer.
Frequency of concomitant use of opioids and psychoactive medications among cancer patients referred to outpatient palliative care at a comprehensive cancer center.
Authors: Azhar Ahsan , Haider Ali , Wong Angelique , Cerana Maria Agustina , Adabala Madhuri , Balankari Vishidha Reddy , Liu Diane D , Dibaj Seyedeh , Williams Janet L. , Bruera Eduardo
Published: November 2017

240

Background: There are potential severe effects when patients taking opioids receive other psychoactive medications. However, such combinations are sometimes necessary in palliative care. The purpose of this study was to determine the frequency of concomitant use of opioids + psychoactive medications in cancer patients referred to our outpatient palliative care center. Methods: Retrospective data obtained from consecutive consults was analyzed to determine the frequency of patients on opioids alone versus concomitant opioids + psychoactive medications at first presentation to our clinic. Association of type of medication with demographics and baseline characteristics was evaluated by Wilcoxon rank sum test for continuous variables and Chi-square (Fisher's exact) test for categorical variables. Results: Among 541 consecutive consult visits, 365 (67%) patients were taking opioids at the time of referral to our clinic: 209 (57%) were on opioids alone while 156 (43%) were on concomitant opioids + psychoactive medications [69 (44%) were on Opioid + Benzodiazepine, 46 (30%) were Opioid + Antidepressants, 41(26%) were on both). Patients in the concomitant groups were on higher Morphine Equivalent Daily Dose (MEDD, p = 0.007), had higher Edmonton Symptom Assessment Scores (ESAS) for pain (p = 0.017), anxiety (p < 0.001), depression (p < 0.001) and spiritual pain (p = 0.03). Conclusions: A large proportion (156, 43%) of cancer patients referred to outpatient palliative care was on concomitant opioids + psychoactive medications. These patients were on higher doses of opioids with higher levels of pain and psycho-social distress at the time of first presentation. Further studies are required to better understand the clinical implications of concomitant use of opioids + psychoactive medications in such patients.
Cannabis use in palliative care: The prevalence and clinical characteristics.
Authors: Chang Young Doo , Smith Joshua S. , Oberoi-Jassal Ritika , Desai Vijay , Winn Stephanie L , Portman Diane , Donovan Kristine A.
Published: November 2017

245

Background: Cannabis has growing attention in palliative care, been used for some cancer related symptom burden, but limited data in terms of prevalence in palliative care setting and clinical characteristics with using it. Purpose: To identify the prevalence of positive rate of cannabis metabolite on urine drug sample (UDS) and compare clinical characteristics focused on symptoms burden on Edmonton Symptom Assessment Scale (ESAS) on the same day of UDS. Methods: We conducted retrospective medical records review of 919 consecutive supportive care clinic patients who were seen at a National Cancer Institute center during a 12-month period between 7/01/2015 to 6/30/2016. Results: 531 out of 919 patients were excluded because UDS was not ordered: either patients were established or had low risk of substance abuse by clinicians’ judgement. 2 patients did not complete ESAS on same day of UDS. 137 patients were excluded because of missing UDS results as well. Finally, 249 out of 919 patients were included for data analysis with their UDS and ESAS at same day of visit. 54 patients were positive for cannabis metabolite (THC: tetrahydrocannabinol) on UDS (22%). We found that positive cannabis group was younger (Mean age 56.1 vs 48.8, p-Value .001), reported higher score of total ESAS (Mean 45.5 vs 38.9, p-value 0.023), pain (Mean 6.13 vs 4.99, p-Value 0.007), and insomnia (6.04 vs 4.44, p-Value 0.001). In addition, positive cannabis group reported poorer overall wellbeing (5.43 vs 4.56, p-Value 0.015) and spiritual wellbeing (6.04 vs 4.44, p Value 0.040) compared to negative cannabis group. Conclusions: The positive results of cannabis on UDS may be a marker of greater symptom burden, in particular, pain, insomnia and poorer overall and spiritual wellbeing as assessed by ESAS patient’s self-reporting.
Palliation of urinary obstruction from advanced prostate cancer with SBRT.
Authors: Boreta Lauren , Raleigh David Ronan , Roach Mack
Published: November 2017

246

Background: In patients with advanced prostate cancer (PCa), urinary obstruction (UO) can lead to urinary retention requiring indwelling or suprapubic catheterization, which negatively impacts quality of life. Palliative options for UO from advanced PCa include surgical and medical treatment. Surgical intervention, including prostatectomy, pelvic exenteration and TURP, may confer undue risk to patients with advanced disease. Medical palliation may require months to take effect. Stereotactic Body Radiotherapy (SBRT) is a non-invasive technique that delivers high-dose and highly conformal radiation in ≤5 fractions, often used to treat PCa and metastatic disease. Here, we reviewed the utility of SBRT to treat UO from advanced PCa. Methods: A retrospective review of patients undergoing SBRT for UO was completed at a single institution between 2011 and 2017. Stage, PSA at diagnosis and time of treatment were recorded. Assessment of urinary function by IPSS/SHIM and documentation of catheterization were reviewed at consultation andsubsequent follow-up. Results: A total of 3 patients were treated with SBRT to the prostate for the palliation of urinary obstruction. Patient ages were 67, 57 and 52 years, and all had high risk, stage IV disease, Gleason 4+4 or 4+5, T3 or T4, with regional nodal, bony or visceral metastases. All patients required indwelling catheterization for an average 4 months prior to SBRT. Two patients were treated with whole pelvis irradiation after SBRT. In those who received subsequent pelvic irradiation, the SBRT doses to the prostate were 19 Gy in 2 fractions. The patient treated with SBRT monotherapy received 38 Gy in 4 fractions. Catheters were successfully removed in all 3 patients, one at the completion of radiation, and the others within 4 weeks of completion. With follow-up ranging from 1.2 to 6 years, no patients required re-catheterization, and there were no reports of grade ≥3 acute or long-term toxicity. Conclusions: SBRT is an effective treatment to palliate UO from locally advanced PCa, leading to removal of urinary catheters and presumed improved in quality of life. Further investigation is required to establish the optimal dose and fractionation of palliative SBRT for UO from PCa.
Comparing physician and nurse ECOG performance status ratings as predictors of clinical outcomes in cancer patients.
Authors: Neeman Elad , Gresham Gillian , Hendifar Andrew Eugene , Tuli Richard , Figlin Robert A. , Shinde Arvind Manohar
Published: November 2017

248

Background: The Eastern Cooperative Oncology Group Performance Status (ECOG) scale is commonly used in the clinical and research setting, and has been shown to correlate with cancer morbidity, mortality, and tolerance to chemotherapy. ECOG is frequently rated by physicians (MDs) and nurses (RNs), and MD-RN ECOG score agreement varies widely in the literature. It remains unclear whether MD and RN ECOG scores differ in their ability to predict clinical outcomes. Methods: As part of a quality initiative at Cedars-Sinai Cancer Center, oncologists and chemotherapy RNs independently scored ECOGs for a random sample of 309 patients with various solid malignancies, on one or more visits, for a total of 506 pairs of ECOG scores. MD/RN interrater agreement was evaluated using the Cohen's kappa coefficient. Logistic regression models were fit to evaluate the ability of RN and MD ECOG scores, as well as the RN-MD score difference, to predict the occurrence of chemotoxicity (CTCAE v4, grade≳3) and hospitalizations within 1 month from ECOG ratings as well as 6-month mortality/hospice referrals. Results: The agreement among 506 ECOG MD/RN pairs was 71% (Kappa = 0.485, p < 0.0001). RN ECOGs had a stronger odds ratio (OR) for 6-month mortality/hospice (OR = 3.55, CI 2.2-5.7) compared to MD ECOGs (OR = 2.99, CI 1.67-5.3). RN ECOG scores also significantly correlated with one-month chemotoxicity (OR = 1.39, CI 1.02-1.90), but MD ECOGs did not. Both MD and RN ECOG scores did not significantly correlate with 1-month hospitalizations. The magnitude of RN to MD ECOG score difference was also positively associated with 6-month mortality/hospice (OR = 3.42, CI 1.87-6.3), but not with 1-month hospitalization or chemotoxicity. Conclusions: Our findings suggest that RN-rated ECOGs may be stronger predictors of chemotoxicity and 6-month mortality/hospice compared to MD ECOGs. Furthermore, the magnitude of difference between ECOG MD and RN ratings was associated with increased mortality/hospice rates, specifically when the MD rating was “healthier” than that of the RN. As ECOG scores are frequently used for prognostication and to inform treatment decisions, ECOG scoring by RNs may result in additional clinical benefit.
Evaluating the role of massage therapy on patient caregivers in a comprehensive community cancer center.
Authors: Chandra Abhinav Binod , Alvarez Angelic , Sweigart Mary , Turpin Kathleen M , Kumar Vivek
Published: November 2017

25

Background: Cancer patients and their families undergo a lot of emotional and psychological turmoil during their cancer journey. Addressing cancer patient caregivers’ quality of life and stress is being recognized as equally important as more cancer patients receive treatment as outpatient and at home placing additional stressors on their home support system. Methods: We evaluated the role of massage therapy on the outcomes of cancer patient caregivers. Patient caregivers were evaluated prior to and after receiving massage therapy with the help of a distress screening tool. We looked at the type of massage they received. Patient caregivers were asked about their pain level, emotional comfort, physical comfort, fatigue level, and given the opportunity to express other comments before and after receiving the massage. Results: Between 08/01/2016 and 05/31/2017, 294 participants received massage therapy at the cancer center. Of these, 265 were patients and 29 were patient caregivers. We evaluated the outcome on patient caregivers. Massages were usually 60 minutes long and consisted of either a Swedish or Deep Tissue massage. Upon review, patient caregivers pain score dropped on average of 2 points. Patient caregivers also noted improvement in their emotional comfort, physical comfort and fatigue level. Most of the caregivers had positive comments regarding the intervention. Conclusions: We recognize that supporting cancer patient caregivers benefits the patients and the healthcare team. We were successfully able to document that by offering massage therapy to patient caregivers improve their pain score, emotional comfort, physical comfort and fatigue level. Successfully implementing this service at the cancer center was welcomed by patients, caregivers and providers and led to positive outcomes. Hopefully, further studies are focused on patient caregivers’ outcomes and their impact.
Open notes: A qualitative study of oncology patients’ experiences reading their cancer care notes.
Authors: Kayastha Neha , Pollak Kathryn I. , LeBlanc Thomas William
Published: November 2017

33

Background: Electronic medical record systems and patient portals increasingly allow patients direct access to their clinicians’ notes.While most believe that open notes benefit patients, some suggest negative consequences. Little is known about cancer patients’ experiences reading their own medical records outside of the primary care setting. We aimed to describe the experiences of patients with advanced cancer who read their own cancer care notes. Methods: We recruited 20 adult patients with metastatic or incurable cancer who were receiving active cancer treatment to participate in semi-structured qualitative interviews. The interview included four segments: assessing patients' overall experience reading notes, discussing how notes affected their cancer care experiences, having them read a real note with the interviewer, and making suggestions for improving notes. We used a constant comparison approach to analyze the qualitative data. Results: Four main themes emerged; patients reported that notes: (a) increased comprehension, (b) ameliorated uncertainty, relieved anxiety, and facilitated control, (c) increased trust, and (d) for a subset, increased anxiety. Patients described increased comprehension, as notes refreshed their memory and clarified their understanding of visits. Notes addressed uncertainty and relieved anxiety, in part because enhanced comprehension mitigated the unfamiliarity of cancer. They facilitated control, empowering patients to ask more questions to clinicians. The transparency of notes also increased the trust patients have in their clinicians. For a subset of patients, however, notes were emotionally difficult to read and raised concerns. Patients consistently identified medical jargon and repetition in notes as areas for improvement. Conclusions: Our findings suggest that most patients felt that reading notes improved their care experiences. A small subset experienced increased distress from “open notes.” As reading notes becomes a routine part of the patient experience, it is important for physicians to elicit and address concerns that arise from the notes, further engaging patients in their care.
Managing conflict during home hospice nursing visits: Communication between nurses, cancer patients, and spouse caregivers.
Authors: Reblin Maija , Hudson Janella , Clayton Margaret F. , Ellington Lee
Published: November 2017

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Background: Many hospice cancer patients and their spouse caregivers experience conflict as roles change and patients decline. Nurses can be asked to mediate conflicts during home visits. Our objective is to describe patient-caregiver conflict and nurse responses in home hospice communication. Methods: A secondary, qualitative analysis was conducted on transcripts of nurse visits to home hospice cancer patients and their spouse caregivers. Transcripts were selected based on high caregiver and patient emotion, identified by interaction analysis coding in primary analysis. Using an iterative process of constant comparison, coders inductively categorized nurse and dyad communication behavior during conflict into overarching themes. Results: 19 visits were identified for analysis. Nurses (from 7 hospice agencies) were all female and averaged 13 years nursing experience (SD = 11). Patient-caregiver dyads were all white, heterosexual, married an average 36 years (SD = 20). 84% of patients were male and average age was 72 years (SD = 9). Caregiver average age was 68 years (SD = 11). Patient-caregiver conflict fell under two major content themes 1) negotiating transitions in patient level of independence and 2) navigating patient/caregiver emotions (e.g. frustration, sadness). When not explicitly asked for input during conflict, nurses occasionally did not engage. Nurse response to transition conflict included problem-solving, mediating, or facilitating dyadic discussion about conflicts/concerns raised with her independently. Nurse response to emotional conflict included validation and reassurance. Conclusions: Little research has been conducted on couples’ conflict resolution in cancer home hospice. However, unresolved conflict can impact the quality of care and has been linked to poor bereavement adjustment. Nurses are sometimes asked to take on the role of mediator, often with little training. Our findings provide insight into home hospice patient and caregiver conflict communication with hospice nurses and could be used during nursing education. Further research could address specific patient and caregiver outcomes associated with nurse communication strategies.
A rules-based algorithm to identify patients who would benefit from re-addressing advance care planning.
Authors: Bestvina Christine M. , Daly Robert Michael , Wroblewski Kristen , Huber Michael , Malec Monica , Chow Selina Lai-ming , Hantel Andrew , Beach Brittany , Polite Blase N.
Published: November 2017

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Background: Advance care planning (ACP) should be initiated early and readdressed often for cancer patients. We hypothesize that a rules-based algorithm can predict decreased overall survival, and can be used to target patients who would benefit from readdressing ACP. Methods: We performed a retrospective analysis of 219 patients receiving palliative chemotherapy with leukemia, cholangiocarcinoma, esophageal, gastric, pancreatic, lung or urothelial cancer at the University of Chicago Medicine. Patients were included if they had an index outpatient oncology visit from April 1, 2015 through June 30, 2015. We examined a three-month window from the index visit for a “high-risk event,” defined as: 1. change in chemotherapy 2. emergency department visit 3. hospitalization. Patients were followed from index visit until date of death or last clinical encounter as of January 31, 2017. Each “high-risk event” was treated as a time-varying covariate in a Cox proportional hazards regression model to calculate a hazard ratio of death compared to those without an event. Results: Sixty-seven percent of patients (146/219) experienced at least one high-risk event. A change in chemotherapy regimen, an ED visit, and a hospitalization occurred in 54% (118/219), 10% (22/219) and 26% (57/219) of patients respectively. The hazard ratio of death for patients with at least one high-risk event when compared to those without was 1.72 (95% CI: 1.19-2.46, p=0.003), when adjusted for age, gender, race, marital status, disease type, ECOG, and Charlson score. Inpatient admission independently reached significant for hazard of death. (HR 2.74: 95% CI: 1.84-4.09, p<0.001). Conclusions: The rules-based algorithm identified patients with a greater risk of death. Implementation of this algorithm in the electronic medical record can identify patients with increased urgency to readdress goals of care. [Table: see text]
Oncology nurse perspectives on the nature and meaning of their positive relationships with seriously ill patients.
Authors: Wright Emily M. , Carr Alaina , Cashavelly Barbara J. , Pirl William F. , Traeger Lara
Published: November 2017

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Background: Inpatient oncology nurses regularly care for patients at or near the end of life. Given increasing attention to risk of compassion fatigue in this setting, we conducted a qualitative study to explore nurses’ perspectives on the nature and meaning of their positive relationships with patients who were seriously ill or dying. Methods: We conducted in-depth interviews with 24 registered nurses (RN)s working on an inpatient medical oncology unit at an academic medical center. We used a semi-structured interview guide to elicit RNs’ descriptions of ‘good’ relationships they had with patients/families with attention to aspects that made these relationships meaningful. Using a framework approach, including an iterative coding process, two team members independently coded all interview data (Kappa = .80) and worked with a multidisciplinary team to identify themes. Results: RNs (95.8% female; 95.8% non-Hispanic white, M age = 32.7 yrs [SD = 10.8 yrs], median yrs as RN = 4.0 [range: 1.5-35.0 yrs]) described specific cases in which they felt they had developed ‘good’ relationships with patients and families. RN descriptions centered on highly intimate and transformative moments in patient/family care. These unique moments occurred in the context of longitudinal nurse-patient relationships in which RNs felt able to 1) facilitate patient/family processing of emotions and disclosure of treatment preferences that they otherwise were not able to process or disclose to other loved ones or clinicians; 2) provide highly-skilled patient-centered care to reduce patient suffering; and/or 3) facilitate patient/family prognostic understanding and peace at the end of life. RNs felt privileged to serve these roles. Memorable transformative moments enriched RNs’ professional identities and inspired their continued work. Conclusions: Inpatient oncology nurse-patient relationships serve distinctive functions for both patient-centered care and RN well being. Results underscore the importance of assisting RNs in managing patient symptoms, forming longitudinal relationships with patients/families, and coping with factors that impede ‘good’ relationships.
Four Conversations: A randomized control trial of an online, shared decision making curriculum among the metastatic breast cancer community.
Authors: Smith Sophia Kustas , Westbrook Kelly E. , MacDermott Kristin , LeBlanc Matthew Roger , Amarasekara Sathya , Pan Wei
Published: November 2017

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Background: Evidence shows that shared decision making is effective in improving the quality of end of life care, and that it rarely happens; new interventions are needed. Four Conversations is an evidence-based, online curriculum that facilitates shared decision making. This presentation will report the impact of Four Conversations on key outcomes. Methods: Individuals with metastatic breast cancer and caregivers are being recruited nationally. Consenting participants are randomized 1:1 to the treatment or wait-listed control arm. Treatment arm participants access content online; required activities included viewing interactive videos and completing workbook activities. Surveys are administered at Baseline, Week-4, and Week-8 via REDCap to assess for: decision making self-efficacy and conflict; and program satisfaction. An independent-samples t-test was conducted to compare change in decision making outcomes in treatment and usual care conditions at Week-4. A paired-samples t-test was used to access for changes in outcomes from Baseline to Week-8 among the treatment arm. Results: Participants (n = 138) were: mean age 53.2 (11.8) years; 96% female; 91% white; 72% married. There was significant improvement in decision making self-efficacy and reduction in conflict among the treatment arm at follow-up (p < .05). There was no significant change in decision making self-efficacy and conflict scores for treatment and wait-listed control conditions at the end of the intervention (p > .05). Among treatment arm participants who did not already have an advanced care directive, most (56%) completed one. Most participants (88%) would recommend Four Conversations to others and felt that the program better prepared them to make better decisions. Conclusions: While these results are preliminary (i.e., data collection continues through 9/2017), they suggest that Four Conversations may effect decision-making outcomes for metastatic breast cancer patients and caregivers. Additional research is recommended with larger and more diverse samples following completion of this study. Clinical trial information: NCT02944344.