bluuebunny/crossref_metadata_2025 huggingface dataset:
The utilization of inpatient palliative care services (PCS) in patients with metastatic cancer receiving critical care therapies (CCTs).
Authors: Loh Kah Poh , Shieh Meng-Shiou , Abdallah Maya , Pekow Penelope , Lindenauer Peter , Stefan Mihaela , Mohile Supriya Gupta , Lagu Tara
Published: November 2017

103

Background: PCS have been shown to improve symptom management, quality of life and survival in patients with metastatic cancer as well as reduce healthcare costs. We aimed to investigate the utilization pattern of inpatient PCS and outcomes in metastatic cancer patients across the various cancer subtypes who received CCTs. Methods: We used the 2010 California Healthcare Cost and Utilization Project - State Inpatient Database to identify patients (≥18 years) and above with metastatic cancer who received CCTs, defined as the use of invasive mechanical ventilation, acute dialysis, total parenteral nutrition, percutaneous endoscopic gastrostomy or tracheostomy. We examined the use of inpatient PCS and outcomes including inpatient mortality, length of stay, discharge to skilled nursing facility, cost of care and presence of do-not-resuscitate. Results: A total of 9,348 hospitalizations were identified. The cancer subtypes were lung (14%), breast (5%), colorectal (13%), genitourinary (8%) and others (37%). Overall, 19% had documented involvement of inpatient PCS. Patients with lung cancer had the highest utilization of inpatient PCS (25%), compared to breast (20%), genitourinary (17%) and colorectal (13%) cancers. Other outcomes are shown in Table. Conclusions: Inpatient PCS were underutilized in patients with metastatic cancer who were critically ill. Future studies should look into the benefits of early integration of inpatient PCS in this population who are at high-risk of mortality. [Table: see text]
Engaging oncologists toward integrating a shared mental model for palliative oncology within a large academic oncology practice.
Authors: Walling Anne Margaret , Pietras Christopher , Ahmed Kauser , Coscarelli Anne , Hurvitz Sara A. , Simon Wendy , Phung Peter , Nechrebecki Meghan , DAmbruoso Sarah F. , Wenger Neil , Kung Jennie , Goldman Jonathan Wade , Rosen Lee S. , Alexandra Drakaki , Peddi Parvin F. , Wong Deborah J. , Glaspy John A. ,   Oncology Communication Collaborative Team Members
Published: November 2017

105

Background: We aimed to engage oncologists to disseminate a successful pilot-tested shared mental model (SMM) for the integration of early advance care planning (ACP) and identification of palliative care (PC) needs across a health system’s oncologic practice. Methods: Our Oncology Communication Collaborative Team (OCCT) had oncology leadership support and included a multidisciplinary team representing leaders in oncology, ACP, PC, psycho-social oncology and quality. To communicate the SMM developed by our team, the OCCT developed an interactive Saturday session (1-hr didactic, 3-hr small group role-play) that focused on early ACP and the cognitive and emotional aspects of communication. Before and after the training, we asked participants to rate their ability to communicate with patients as well as their readiness, self-efficacy, and need for help to improve communication regarding prognosis, ACP, end of life care and symptom management using a previously validated survey. We computed means and compared matched pairs of pre and post surveys using a paired t-test. We also surveyed participants about whether they would recommend the course to others and planned changes to practice. Results: All but one oncologist (52/53), 3/4 invited fellows, and 12/14 oncology nurse practitioners participated and 90% of attendees completed pre and post surveys. Participants rated their communication ability higher (6.7 v. 7.6, p < 0.01) on a 10-point scale after the training. Readiness to improve communication in this domain (9.1 v. 9.2, p = 0.35) was similar before and after the training. Self-efficacy (1.5 v. 1.5, p = 0.70) and needing help to improve (1.6 v. 1.7, p = 0.37) were rated highly (1 = A lot and 4 = Not at all) but did not change with training. All but one participant reported they would recommend the course to others and free text responses about changes they planned to make to their practice based on the training included: having earlier ACP discussions, focusing on patient goals/priorities and asking open-ended questions. Conclusions: Conducting a training to disseminate a SMM of oncology and PC is feasible, valuable, and can be the first step for partnered continuous quality improvement.
The expanding role of patients in integrated cancer network governance.
Authors: Tremblay Dominique , Marchand Jean-Sébastien , Lévesque Lise
Published: November 2017

106

Background: The expanding role of patients (including family) at all levels of healthcare systems is increasingly recognized to favour changes in cancer services delivery. The province of Quebec (Canada) is no exception and promotes patients involvement in governance activities such as the implementation of the National cancer program, local integrated cancer networks, practice guidelines, and patient information material. Generally speaking, network governance refers to the steering process carried out to ensure goals’ achievement. However, we lack sufficient understanding of how patients contribute to this process, at local and national levels. This presentation seeks to report on patients involvement in governance activities within integrated cancer networks. Methods: Design: Qualitative data comprising semi‐structured interviews, focus groups and review of documents. Setting: Four Integrated Local Cancer Networks (ILCN) in Quebec purposively selected to provide variation in size, geographic location and time since implementation of the ILCN. Participants: Key stakeholders including policy-makers (n = 8), managers (n = 56), clinicians (n = 39), patients and their family members (n = 28). Analysis: Content analysis using open-ended coding. Results: This study shows the added value of the formalization of patients involvement in the governance committees at local and national levels of the cancer network. It illustrates the operationalization of the political will to translate the Quebec cancer program ideas into concrete patient-centred practice. Enlightening patients experience through discussion leads to shared decision making, building a “community of patients”, the diffusion of supportive tools, and the development, use and interpretation of performance indicators. Conclusions: Patients involvement is a major, but manageable, change in the integration of care across the cancer continuum. Formalizing the expending role of patients in local and national levels governance committees narrows the macro (hierarchical) and micro (relational) governance divide, which in turn contributes to patient-centred and integrated cancer care.
Comparison of hydration events in patients (pts) receiving highly (HEC) or moderately (MEC) emetogenic chemotherapy treated with granisetron extended-release subcutaneous (GERSC) or palonosetron (PALO).
Authors: Vacirca Jeffrey , Caruana Dennis , Calcanes George , Mosier Michael , Boccia Ralph V. , McBride Ali
Published: November 2017

108

Background: Breakthrough CT-induced nausea and vomiting (CINV) may increase resource needs, eg, hydration. GERSC (SUSTOL) + other antiemetics prevent CINV associated with MEC or anthracycline + cyclophosphamide–based therapy. This retrospective analysis evaluated CINV-related hydration in pts treated with PALO or GERSC antiemetic therapy. Methods: Pts at a multisite community practice had MEC or HEC and a 3-drug antiemetic regimen: NK-1 receptor antagonist (RA), dexamethasone, and 5-HT3 RA (PALO only, GERSC only, or PALO then GERSC). CT emetogenicity (HEC, MEC), number of cycles, and CINV-related hydration were extracted from medical records. Hydration rate (events per cycle) was analyzed for pts who had PALO vs GERSC (group 1; nonparametric 2-sided Wilcoxon rank sum test) and pts who had PALO then GERSC (group 2; paired t-test). Results: There were 93 PALO, 91 GERSC, and 48 PALO-then-GERSC pts. Group 1 had mean (SD) CT cycles of 5.4 (2.8) on PALO vs 4.1 (2.2) on GERSC. The whole group ( P<.0001) and HEC subgroup ( P<.0001) had significantly higher hydration rates with PALO vs GERSC (Table). Overall, 22% (PALO) vs 58% (GERSC) of pts had no hydration. In HEC/MEC subgroups, respectively, 19%/33% (PALO) vs 60%/56% (GERSC) of pts had no hydration. Group 2 switched pts had mean (SD) 3.5 (3.2) cycles on PALO vs 3.1 (2.2) on GERSC. All pts and MEC subgroup had no differences in hydration rate with PALO vs GERSC. HEC subgroup hydration rates were significantly higher for PALO vs GERSC ( P=.028; Table). Conclusions: In a multisite practice, CINV-related hydration was ~3 times less per CT cycle for pts receiving GERSC vs PALO as part of a 3-drug antiemetic regimen. Pts on HEC and treated with PALO then GERSC had significantly reduced hydration needs with GERSC. Reduced hydration needs may improve quality of life and simplify pt management. [Table: see text]
Palliative care in the ambulatory setting: Bon Secours St. Francis Hospital (BSSFH).
Authors: Ashley Jennifer , Bayne Jennifer Huggins , Weems John , Spann Terra , Stinnett Leigh , Strobel Maryjane , Hegedus Patricia , Siegel Robert D.
Published: November 2017

109

Background: Palliative care is integral to holistic cancer therapy. Early integration of palliative principles results in improvements in quality of life and survival. Despite the evident value of specialized palliative services, the conventional delivery paradigm, particularly in community centers, has remained episodic, crisis driven, and principally provided in the acute care setting. BSSFH opened its cancer center in October 2014. We chose to embed palliative services in the ambulatory setting to introduce patients early in their cancer journey to an integrated program of symptom management. Methods: The BSSFH Cancer Center is a 65,000 sq ft facility located in Greenville, SC. The analytic caseload for 2016 was approximately 1250. One palliative care practitioner per day sees patients both independently and concurrently with medical, gynecological and radiation oncology colleagues. These individuals also participate in Lean projects optimizing care in a variety of disease states. Mandatory referrals at presentation were initially codified for patients with stage 4 lung , and subsequently for pancreatic and all patients receiving multimodality therapy for head and neck carcinomas. Additional patients are referred from our weekly Interdisciplinary Care Rounds or otherwise at the discretion of their attendings. Results: The program showed ongoing growth through 2016, shortly following its inception. Total outpatient encounters in 2015 were 559 while in 2016 were 928. Total new referrals were 158 in 2015 and 190 in 2016 implying that the increase in total visits had less to do with new patient referrals and were more a result of visit-to-visit management of complex circumstances. Conclusions: Palliative medicine is optimally provided with consistency and not episodically. This is best accomplished when such care occurs in both the acute and ambulatory settings through an ongoing therapeutic relationship. BSSFH has created a model in which such care is feasible in the community setting. We are now trying to assess what impact this intervention has had on quality of life, simplifying transitions of care, and on the economics of health care within our system.
Palliative care from cancer diagnosis for all: Memorial Sloan Kettering’s “One-Two-Three” program.
Authors: Epstein Andrew S. , Klimek Virginia M. , Chow Kimberly , Desai Anjali V. , Wan Peter Justin , Anderson Kelley , Ranghan Coleen , Okpako Molly , Rawlins-Duell Robin , Kramer Dana , Goldberg Jessica , O'Shea Debra , Nelson Judith Eve
Published: November 2017

111

Background: Early, universal palliative care is an unmet need for cancer patients. Our new program aims to provide palliative care, by primary oncology teams with support from palliative care specialists, from diagnosis as an institutional standard. Methods: One-Two-Three is a structured program of assessment and response addressing palliative care needs regardless of cancer stage or prognosis starting with the first 3 visits after diagnosis. Assessments include patient physical/emotional/spiritual symptoms (10 symptoms, self-reported 0-10), communication needs (information preferences, illness understanding), and proactive care planning through exploration of core values. As first responders, oncology nurses are guided by “ready responses” in an empathic framework and coaching or direct patient consultation by palliative care specialists. Feasibility, acceptability, and impact on patient, caregiver, and utilization outcomes are evaluated quantitatively and qualitatively. Results: Assessments were piloted with 25 consecutive, newly-diagnosed patients in blood cancer and solid tumor clinics. Symptom and communication assessments each took < 5 minutes and showed high prevalence of moderate/severe distress ( > 50% for 8/10 symptoms, 144 assessments), variation in information preferences (76% wanting detail, 24% broad overview only), and unmet communication needs. All but 1 patient without a health care proxy chose one. Oncology nurses engaged patients in structured discussions ( < 15 minutes) of core values. Clinic workflow was maintained. Patients, families, and oncology clinicians endorsed the initiative. As palliative care skills of oncology teams improved, specialists focused on more complex issues. Conclusions: Routine interprofessional primary palliative care with specialist support from diagnosis is feasible and acceptable in our center’s high-volume outpatient oncology clinics. Ongoing evaluations will assess other outcomes (e.g., quality of life); impact on clinicians/ processes; and utilization (e.g., ED/hospital visits, hospice use).
Exploring the association between KRAS mutations and depression in non-small cell lung cancer (NSCLC) patients.
Authors: Li Jenny Jing , Harper Jessica , Bhulani Nizar , Gerber David E. , Khan Saad A. , Madrigales Alejandra , Gates Samantha , Toups Marisa , Beg Muhammad Shaalan
Published: November 2017

114

Background: Previous studies have demonstrated a higher rate of depression in cancer patients harboring KRAS mutations. We evaluated the feasibility of using secondary Electronic Medical Record (EMR) data to examine the association of KRAS mutations with depression in NSCLC patients. Methods: We identified cases with NSCLC from an institutional Cancer Registry. Tumor molecular profiles were obtained as standard of care. Depression was assessed using the Patient Health Questionnaire-2 (PHQ-2), which is part of the institution’s universal Distress Screening tool completed at the time of clinic visit. PHQ-2 score of 2 and above was considered positive for depression. Data was extracted from EMR via Clinical Data Exchange Network bioinformatics tool and confirmed by chart review. Results: Of the 692 NSCLC patients, KRAS status was known in 174 cases: 40 (23%) were KRAS mutated and 134 (77%) were KRAS wild type. 101 (58%) had stage 4 NSCLC. PHQ-2 score was 0 in 146 (83.9%), 1 in 7 (4%), 2 in 19 (10.9%), and > 2 in 2 (1.1%). The rate of positive PHQ-2 for KRAS mutated vs wild type was 15% vs 11% (p = NS). Conclusions: This study in patients with NSCLC did not demonstrate an association between KRAS mutation and depression. Bioinformatics studies harnessing EMR data are a feasible platform to assess the association of genomic data with clinical outcomes and validated algorithms are needed.
Education of residents in palliative and hospice care.
Authors: Eris Ela , Ravisankar Shyam , Larosa Jennifer A
Published: November 2017

118

Background: Patients with chronic advanced illness have a heavy burden of physical and emotional symptoms. In addition to these symptoms, social and spiritual supports are fundamental tenets of palliative care (PC). PC is most effective when delivered early and when routine reassessments are undertaken. Ideally, it is woven into the daily practice of all practitioners. However, current medical education has far too little education around this vital discipline in their curricula. We hypothesized that a single palliative medicine didactic experience would increase practitioners’ familiarity with core concepts of PC. Methods: Palliative care education was delivered as a single interactive lecture for 27 Internal Medicine residents. Information was primarily derived from resources from the Center to Advance Palliative Care (CAPC). The lecture focused on the definition of PC, optimal symptom management and support structures in palliative medicine, and how palliative medicine differs from hospice care (HC). An online questionnaire with ten questions was used to assess pre- and post-lecture knowledge of fundamentals of this discipline. Results: 27 residents participated in the pre-test and 23 participated in post-test. The overall pre-test score was 70% and the post-lecture score was 77%. The biggest difference was seen in the comfort level of first year residents in referring patients to PC and the purpose of PC. Residents had good baseline knowledge of when to refer to HC and the purpose of HC. Conclusions: A single, interactive lecture based on the fundamental tenets of hospice and palliative medicine can improve residents’ knowledge of this discipline. [Table: see text]
Impact of pharmacy interventions on pain management in an oncology palliative medicine (PM) outpatient clinic.
Authors: Patel Jai Narendra , Hamadeh Issam , Symanowski James Thomas , Edwards Rebecca , Susi Beth , Edelen Connie
Published: November 2017

119

Background: PM can improve the quality of life and survival for cancer patients (pts); however, the demand for PM challenges providers with delayed follow ups resulting in less than one-third of pts achieving significant pain improvement between clinic visits. Engaging pharmacists in the provision of PM may help improve pain management in cancer pts. Methods: Adult cancer pts starting a new pain regimen or requiring changes to an existing regimen at baseline were referred for pharmacy follow up in 3-7 days (assessment #1). The pharmacist evaluated each pt using the Edmonton Symptom Assessment Scale and recommended changes to the referring PM provider, prompting a 2nd follow up in 3-7 days (assessment #2). If no changes were required, pts continued therapy and returned for the final clinic visit (day 28 +/- 7). The primary endpoint was the proportion of pts achieving significant pain improvement (≥ 2-point decrease in pain score on a scale of 0-10) from baseline to final visit, which was compared to historical controls using Fisher’s Exact test. Changes in pain severity from baseline to final visit were compared using Generalized McNemar’s test, and descriptive statistics were used to describe characteristics at assessment #1. Results: Of 102 pts evaluable for the primary endpoint, 76% had stage IV disease, 58% were female, and median age was 57 yrs. Significantly more pts achieved pain improvement from baseline to final visit compared to historical controls (49% v 30%; P < 0.001). Changes in pain severity from baseline to final visit are described in the table. At assessment #1, 70% of pts required an intervention, primarily due to uncontrolled pain (72%), side effects (26%), and/or lack of response to non-pain medications (22%). The most common types of interventions were dose adjustments (62%), education (36%), and/or adding a new medication (30%). Over 90% of recommendations were accepted by the referring PM provider. The median time of assessment was 15 mins. Conclusions: Routine inclusion of pharmacists in the outpatient PM interdisciplinary team improves the effectiveness of pain management. [Table: see text]
Evaluation of daily breakthrough chemotherapy-induced nausea and vomiting (CINV) rates in a phase III study of NEPA versus an aprepitant (APR)/granisetron (GRAN) regimen.
Authors: Roeland Eric , Binder Gary , Ma Joseph , Lanzarotti Corinna , Zhang Li
Published: November 2017

120

Background: Antiemetic trials typically evaluate CINV control during acute (Day 1), delayed (Days 2-5), and overall (Days 1-5) phases post-chemotherapy; the daily course of events is often unstudied in the delayed phase. In a head-to-head study evaluating NK1RA-containing regimens, a single dose of NEPA, an oral fixed combination of the NK1RA netupitant and 5-HT3RA palonosetron, was non-inferior to a 3-day regimen of APR and GRAN for overall complete response (no emesis/no rescue use) rates (74% NEPA vs 72% APR/GRAN) in 828 patients receiving cisplatin-based highly emetogenic chemotherapy (HEC). This secondary analysis explores daily rates of breakthrough CINV in this study. Methods: This was a double-blind study in chemotherapy-naïve patients with solid tumors. Daily rates of breakthrough CINV, defined as the % of patients with emesis and/or rescue use were calculated with differences between treatment groups evaluated by the Cochran-Mantel-Haenszel method stratified by sex. Results: While daily rates of patients with breakthrough CINV remained stable between 13%-15.1% for APR/GRAN, they declined from 15.5% to 8% over the 5 days for NEPA, with the difference between groups reaching statistical significance on Day 5 (Table). Percent of total patient days with CINV events were 11.7% [NEPA] and 14.0% [APR/GRAN]. The % of patients with ≥ 3 days of breakthrough CINV were 8.5% and 12.3%, respectively. Conclusions: In this study evaluating guideline-recommended antiemetic regimens for HEC, CINV was prevented in most patients during the overall phase yet breakthrough CINV on individual days differed between treatment groups. APR/GRAN showed a relatively constant rate over time, while NEPA rates decreased and patients had fewer total days with breakthrough. This suggests the need for close monitoring of CINV events during the delayed phase. [Table: see text]
The influence of a cachexia clinic on palliative care integration in oncology.
Authors: Portman Diane , Thirlwell Sarah , Donovan Kristine A.
Published: November 2017

124

Background: Appetite and weight loss are common in patients with advanced cancer and specialized cachexia clinics have been established to address these symptoms. Given the association between anorexia/cachexia and other adverse symptoms, these patients may also benefit from specialty level palliative care (PC). However, referral to outpatient specialty level PC is often delayed or does not occur. We sought to examine the prevalence of other factors associated with appetite and weight loss in patients with advanced cancer and the impact of a specialized cachexia clinic on identification and treatment of other PC needs. Methods: The records of patients referred by their Oncologist to the cachexia clinic of a cancer center from August 2016 to June 2017 were reviewed retrospectively. Subjects who had been referred to PC by their Oncologist were excluded. Patients had been assessed for symptom burden using the Edmonton Symptom Assessment Scale (ESAS-r). Patients identified with PC needs had been referred to the PC clinic for follow-up within 30 days after cachexia clinic consultation. Results: Thirty subjects were evaluated in the cachexia clinic (average age 68 years; 63% female). The predominant diagnosis was lung cancer (70%). An average of 6 symptoms per patient were in the moderate to severe range on ESAS, excluding appetite. Depression, fatigue and pain were most common. The average cachexia clinic total ESAS score was 51.61. Only 17% of patients had completed advance directives. Ninety-three % of patients were referred to PC and 68% were seen. The average number of PC visits was 2.79. Within the PC clinic, advance directive completion increased to 37%, goals of care discussion occurred with 50% and 17% received hospice referrals. At the most recent follow-up in the PC clinic, the average total ESAS score had decreased by 11.44 (22%) and all ESAS item scores were improved on average. Conclusions: The cachexia clinic proved a useful means to identify other PC needs and achieve effective PC referrals. We suggest this is proof of concept that specialty clinics can be a meaningful way to achieve an earlier entry point to comprehensive PC in patients who were not previously referred by their Oncologists.
Randomized controlled trial (RCT) of a dyadic yoga program for lung cancer patients undergoing radiotherapy and their family caregivers.
Authors: Milbury Kathrin , Mallaiah Smitha , Liao Zhongxing X. , Shannon Vickie , Yang Claire , Cohen Lorenzo
Published: November 2017

125

Background: Thoracic radiation (RT) is associated with respiratory toxicities, which may reduce patients’ physical performance and their overall quality of life (QOL). Yoga therapy may buffer against disease and treatment-related sequelae. The purpose of this RCT is to establish feasibility and preliminary efficacy of a yoga intervention. Because family caregivers also report symptom burden (e.g., distress, sleep disturbances) we included them as active participants in this trial. Methods: Non-small cell lung cancer patients undergoing RT and their caregivers were randomized to a 15-session yoga or a waitlist control (WLC) group. Prior to RT initiation and randomization, both groups completed measures of QOL (SF-36 domains). Patients also completed the 6-minute walk test (6MWT) to measure physical performance. Dyads were reassessed at the last day of RT and then 3 months later. Results: We approached 47 eligible dyads of which 32 (68%) consented and 26 (81%) completed all assessments. Patients (mean age: 73 yrs., 63% female, 67% stage III) and caregivers (mean age: 62 yrs., 38% female, 63% spouses) completed a mean of 12 sessions, and 96% of them rated the program as “very useful”. Controlling for baseline levels and other relevant covariates, multilevel modeling revealed a clinically and statistically significant difference in patients’ 6MWT (yoga mean = 478m vs. WLC mean = 402m, d= 1.19; p < .05) and clinically significant differences in the physical function, role performance and mental health domains of the SF-36. For caregivers, clinically significant improvements were found in vitality and role performance. Conclusions: Yoga therapy appears to be a feasible and beneficial supportive care strategy for lung cancer patients and caregivers. A larger efficacy trial with a more stringent control group is warranted. Clinical trial information: NCT02196844.
Code status communication training in Canadian postgraduate oncology programs: A needs assessment survey.
Authors: Levine Oren Hannun , Dhesy-Thind Sukhbinder K. , McConnell Meghan , Brouwers Melissa C. , Mukherjee Som
Published: November 2017

13

Background: Discussions with cancer patients on cardiopulmonary resuscitation directives, or ‘code status,’ are often led by trainees in oncology. This study was carried out across Canada to identify current educational practices and gaps in training for this communication skill. Methods: Medical and radiation oncology residents and program directors (PDs) from across Canada were invited to complete a survey. Questions addressed current teaching practices, perceived importance of this competency, satisfaction with current education and barriers to teaching code status discussion skills. Relative frequencies of categorical and ordinal responses were calculated. Results: Between November 2016 and February 2017, 95 residents (58.6% response rate [RR]) and 17 PDs (63% RR) completed surveys. Both oncology disciplines and trainees at all levels were represented. Only 54.1% and 48.3% of medical and radiation oncology residents, respectively, had experienced any form of code status communication training before entering an oncology program. During oncology training, 41.1% of residents expect to receive formal teaching on this topic and 47.1% of PDs endorsed inclusion of this topic in curricula. Only 20% of residents reported receiving any formal evaluation for this competency while 41.2% of program directors indicated that formal evaluations are provided. All PDs and 98% of residents positively endorsed the importance of this competency in residency and clinical practice. Among residents, 88% felt that more training would be beneficial, and 82.3% of PDs identified a need for new educational resources in this area. Lack of time, educational resources and evaluation tools were among the most commonly identified barriers to teaching (by PDs and trainees). Conclusions: Canadian medical and radiation oncology residency PDs and trainees feel that code status communication is an important competency, yet teaching and evaluation are limited in this area. Barriers to teaching and skill-building have been identified. Further work is underway to develop novel educational resources for code status communication training to include in postgraduate curricula.
Overcoming recruitment challenges in a randomized clinical trial of early palliative care.
Authors: Zwahlen Susanne , Fliedner Monica , Eychmüller Steffen
Published: November 2017

140

Background: Reasons why clinical trials of early palliative care (ePC) interventions have prolonged patient recruitment time frames have been researched mainly qualitatively. Our objective was to identify major recruitment barriers encountered in our ePC trial, as well as to implement actions to overcome them. The impact of these changes on recruitment was measured. Methods: Data from all patients screened at the main study site (Inselspital, University Hospital Bern) between October 2013 and April 2016 were prospectively analyzed for: date of contact, reporting department, eligibility status, as well as consent status. Data until march 2014 was used to identify the main recruitment barriers. Starting in march 2014 changes to the recruitment process were implemented and all data from then onwards was used to estimate the impact of these adaptations. Results: The three main barriers identified were: Logistic, motivational, or related to eligibility criteria. Logistic barriers were overcome by changing from voluntary referral by the treating physician to systematically screening outpatient clinics of medical oncology, radio-oncology, gyneco-oncology and the internal medicine ward. Motivational barriers were addressed through education and dedicated study staff. Eligibility criteria were widened to include pancreatic and urothelial cancer. The actions implemented increased the accrual rate from one patient during a five month period to 2,8 patients per month. The widening of the eligibility criteria contributed to this result by recruiting 0,5 patients per month. The implementation of a systematic screening procedure increased the number of eligible patients invited to participate from one per month to 4,8 per month. An increase in the study consent rate from 20 % to 58 % can be translated into an increased acceptance of early palliative care. Conclusions: Education and dedicated study staff in order to increase the acceptance of ePC as well as a tool to identify eligible patients in a time-efficient manner improved patient recruitment in our ePC trial. We suggest that these factors can be relevant for the successful integration of ePC in standard oncology care.
Role of palliative radiotherapy (PRT) in patients with malignant airway obstruction (MAO) in the intensive care unit (ICU).
Authors: Fotouhi Ghiam Alireza , Singh Yash , Venigalla Sriram , Bassett Jaclyn , Jones Joshua Adam
Published: November 2017

143

Background: MAO is a challenging sequela of advanced cancer, leading to significant morbidity and mortality. A number of patients with MAO present with significant airway compromise necessitating intubation and mechanical ventilation. PRT for MAO patients in the ICU is complex, requiring high levels of coordination and support. The role and efficacy of PRT in intubated patients is not well defined. We performed a retrospective review of intubated patients with MAO receiving PRT to understand efficacy of treatment and patient outcomes. Methods: After obtaining IRB approval, a retrospective query was performed to identify all patients who received PRT and required mechanical ventilation at some point during the course of RT at the Hospital of the University of Pennsylvania from 2008 to 2016. Data was analyzed looking at demographics, reason for intubation, PRT dose and fractionation, length of intubation, extubation success and overall survival. Data was subsequently entered into a database using the secure online application, REDCap. Results: 22 (M:13; F:9) patients with different histologies (most common: lung (11) and lymphoma (3)) were studied. 14 patients had stage IV and 8 had stage II-III disease. All patients had KPS ≤ 50 (ECOG ≤3) at the time PRT initiation. Two patients received PRT and then completed definitive course when became medically stable. The median RT dose was 2000cGy (300 - 7000cGy) given over 1 – 35 (median: 6) fractions. 13 (59%) patients received a full course of initially planned RT. Successful extubation was achieved in 13 (59%) cases but only 11 (50%) patients were survived to hospital discharge. 11 (50%) patients died despite PRT. The average ICU stay was 41.4 days (1 – 75 days). The median overall survival measured from the time of intubation to death or the last follow-up was 23.5 days (1 day - 5.3 year). Favorable histology and lower stage were associated with better outcome following PRT. Conclusions: We found that, in carefully selected patients, PRT can yield successful extubation and potentially improve survival in patients with MAO intubated in ICU. PRT should be considered early in the management of these patients, particularly when it is the treatment of last resort.
Perceptions of palliative care: Cancer and non-cancer.
Authors: Harle Ingrid , Knott Christine
Published: November 2017

148

Background: Palliative Medicine consultation is greater for cancer than non-cancer patients. Decreased symptom burden, improved survival time and quality of life, and cost savings are associated with palliative care. Most patients do not receive information about palliative care until end of life, resulting in negative outcomes. We examined perceptions and access to Palliative Medicine for persons living with advanced illnesses. The purpose was to inform the design of palliative care pathways for cancer and non-cancer diagnoses. Methods: Using Interpretive Phenomenological Analysis, patients/caregivers with metastatic cancer, chronic kidney disease, chronic obstructive pulmonary disease and advanced heart failure were interviewed. This qualitative research method explores an individual’s lived illness experience. Interviews addressed care processes, teams, understanding of palliative care and goals of care. Six reviewers read, coded, categorized interview transcripts and extracted themes. Results: Fifty interviews were completed, 36/50 with metastatic cancer or COPD. Despite different diagnoses, themes were similar. Caregiver’s responses reflected the patient’s burden and overall experience. Themes were: focused individual care; multiple dimensions of time; 24/7 home care; physical and psychological impacts; and spirituality. Perceptions about Palliative Medicine remain aligned with end of life. Conclusions: Palliative Medicine remains associated with end of life, regardless of the diagnosis. Majority had limited access to palliative care, despite pursuing information on supportive services. They also expressed high expectations of receiving such information from physicians and other providers. Results are similar to national strategies on palliative care. The project’s findings have informed the design of clinical pathways for early integration of Palliative Medicine for patients with cancer and non-cancer diagnoses.
Does use of the POLST form implicate overall care for patients with advanced cancer syndromes?
Authors: Lebenthal Justin , Barile David , Sedhom Ramy
Published: November 2017

15

Background: The POLST “Practitioner Orders for Life-Sustaining Treatments” form addresses patient goals, scope of therapies, artificial nutrition, and resuscitation status. In New Jersey, Section A offers a unique opportunity for patients to describe in their own words overall goals of care. We investigated if completion of Section A influences aggressiveness of care at end of life for patients with advanced cancer syndromes. Methods: All POLST forms completed in 2015 at the University Medical Center of Princeton were retrospectively reviewed. Patients 18 years or older, electing for DNAR/DNAI status, were eligible for inclusion. All other responses on the POLST form were collected. Chart review was used to collect admitting diagnosis, referral and/or admission to the intensive care unit, palliative care and hospice use, length of stay, number of readmissions and deaths in the hospital. Discharge summaries were reviewed to assess if advance care planning discussions were documented. Results: 57 charts were reviewed: 34% were female, age 41 to 99 (mean 82), and average LOS was 6 days. 19% preferred “symptom treatment only” on their POLST forms and 70% preferred “limited treatment.” Section A was completed for 34 of 57 patients (60%). Those completing section A were less likely to be referred to the ICU, had a shorten length of stay (5 vs. 9 days), and had fewer unexpected deaths in the hospital. In addition, those completing section A were more likely to utilize both palliative and hospices services. Though physicians rarely documented code status on discharge summaries (38%), all patients with a palliative care consult while hospitalized had advance care planning discussions documented at discharge. Conclusions: Use of the POLST form provides a very natural order for discussion of life sustaining treatments and end-of-life care. Patients completing section A were more likely to utilize palliative care, hospice services, and advance care planning. The benefits of the POLST form extends beyond patient outcomes and may positively impact the care patients with advanced cancer syndromes. The importance of individualized preferences seems logical, but larger studies are needed to validate our findings.
Practice patterns in radiation therapy for bone metastases in multiple histologies.
Authors: Taylor Trent N , Kinchen Catherine Lee , Johnstone Candice Aitken , Robbins Jared R.
Published: November 2017

151

Background: Radiation therapy (RT) is a common palliative treatment for bone metastasis. Despite copious evidence of palliative equipoise between single and multiple fractions, practice patterns vary widely amongst physicians. We evaluate practice patterns and the impact of treatment regimens on percentage of remaining life spent receiving RT (PRLSRT) and overall survival. Methods: Patients with metastases from Prostate, Lung, Breast, and Kidney to the bone who received RT were identified from the National Cancer Database. The percentage of remaining life spent receiving RT (PRLSRT) was calculated by dividing the elapse days of RT by the number of days they survive from starting RT to death. Results: 43516 patients met the inclusion criteria. The majority were non-small cell lung (64.7%), while breast (13.5%), prostate (11.0%), and kidney (10.8%) had almost equal amounts. Median patient age was 67 years old (18-90). Treated metastatic sites included the spine (61.9%), hip/pelvis (11.2%), and extremity (8.13%). A higher percentage of patients had a PRLSRT over 50% depending on the primary site of their cancer: Lung was the highest (14.4%), followed by kidney (8.9%), breast (6.2%), and prostate (1.4%). Prostate cancer was most often treated with 11+ treatments (38.4%), followed by breast (34.1%), Kidney (33.1%), and finally lung (28.5%) PRLSRT was highest in those who received multiple treatments, with 11.4% of patients receiving 11+ fractions and 11.5% of those receiving 6-10 treatments with a PRLSRT above 50% compared to 1.2% of those receiving a single treatment. Conclusions: Despite the increased burden on patients with more fractions of therapy and the lack of clinical benefit, multiple fractionations remains a common practice , which can impact the way patients spend the end of their lives. More care should be taken to reduce fractionation whenever possible to allow for patient comfort and autonomy.
Implications for the future of palliative care for pancreatic cancer: A retrospective institutional study.
Authors: Basnet Alina , Syed Wajihuddin , Sinha Shreya , Khan Rashad , Kopparthy Pallavi , Madhira Bhaskara Reddy , Huang Danning , Lemke Sheila M.
Published: November 2017

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Background: Five year overall survival rate for localized and metastatic pancreatic adenocarcinoma (PAC) is discouraging at 31.5% and 2.7%, respectively. Evidence supports that early palliative care (PC) involvement leads to better quality of life and prolongs OS. Referral to PC is often delayed as it is perceived as an alternative rather than adjunctive care. We conducted a retrospective study to identify different variables that affect PC consultation among patients (pts) with PAC admitted to the hospital and to study the impact of health care utilizations on OS. Methods: A retrospective medical record review of pts with PAC diagnosed/treated at SUNY Upstate University hospital was conducted (2011-2015). Variables like age, sex, race, stage at diagnosis, insurance status, performance status (PS), frequency of hospital admissions, nights spent, procedure visits, blood products used, and time variable to PC referral from diagnosis were collected. OS was calculated using Kaplan Meier analysis. Results: We identified 325 pts with diagnosis of PAC. 86.72% pts had one or more hospital admissions during course of their illness and of these, 15.85% saw PC during initial inpatient admission. 36.23% saw PC later in the course of their illness and 13.96% pts were offered palliative care in first outpatient visit. Median time interval to see palliative care was 75 days (d) from diagnosis, with 25% pts seeing PC 304d from diagnosis. Variables that had significant impact on early palliative care encounter (0-30d) were age > 70, stage IV at diagnosis, PS of 4, medicare insurance, offered PC in first visit (p< 0.001). OS was not statistically significant between groups who had ≥ 1 vs 0 blood products given, < 3 vs ≥ 3 hospital admissions, ≤ 13 vs > 13 nights spent, ≥ 1 vs 0 procedures done, ≤ 3 vs > 3 consults service seen. Median OS for pts with time interval to see PC 0-30d vs > 120d was 33d and 510d respectively with adjusted hazard ratio of 6.252 (95% CI 3.462-11.29). Conclusions: We demonstrated that PC is underutilized with only minority of pts benefiting from it during their cancer treatment. OS was poor in group evaluated by palliative care early than late which could be due to patients with advanced disease and poor PS being referred early.
Novel malignant bowel obstruction (MBO) management program for women with advanced gynecological cancer.
Authors: Lee Yeh Chen , Jivraj Nazlin , O'Brien Catherine , Lau Jenny , Chawla Tanya , Shlomovitz Eran , Buchanan Sarah , Croke Jennifer , Allard Johane P , Dhar Preeti , Laframboise Stephane , Ferguson Sarah E , Dhani Neesha C. , Butler Marcus O. , Ng Pamela , Stuart-McEwan Terri , Savage Pamela , Tinker Lisa Michele , Oza Amit M. , Lheureux Stephanie
Published: November 2017

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Background: Malignant bowel obstruction (MBO) is a common and challenging clinical predicament in women with advanced gynecological cancers. However, there is a lack of evidence-based guidelines or innovative approaches to improve patient care and quality of life. We implemented an inter-professional MBO management program incorporating a nurse-led ambulatory symptom management algorithm and multidisciplinary care conferences (MCC) as hallmarks of this program. Methods: Princess Margaret Cancer Centre has piloted an inter-professional MBO management program that supports women with advanced gynecological cancers who are at risk of/have developed MBO. The MBO team includes oncologists (medical, surgical, gynecologic and radiation), palliative care physicians, diagnostic and interventional radiologists, home parenteral nutrition physicians, specialized oncology nurses, dietitians, pharmacists and social workers. Complex MBO cases are discussed at regular MCC to derive treatment consensus. A symptom-driven MBO management algorithm has been devised and all patients are educated with a personalized bowel symptom management and dietary plan. For outpatient care, patients with MBO are proactively monitored by our specialized oncology nurses via phone or an eHealth bowel application to facilitate communication of symptoms and early intervention. Access to community services and home palliative care services are utilized to support care at home. All patients are enrolled into a prospective database to assess care impact and quality. Results: A total of 145 patients have been followed through the MBO management program over 12 months. At time of data cutoff, 14 had MBO (3 inpatients and 11 outpatients) and 22 were deemed at risk of MBO. Majority patients are managed as an outpatient and avoided unnecessary emergency department episodes. Detailed methodology and data analyses will be presented. Conclusions: A successful novel MBO program incorporating inter-professional care model and nurse-led ambulatory symptom management algorithm optimizes patient care in this vulnerable population and foster collaboration in implementing best practice clinical processes.
Development of a serious illness care model implementation framework.
Authors: Nguyen Khue , Schmidt Theresa , Ozcelik Sibel , Bell Janice , Whitney Robin L.
Published: November 2017

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Background: Care of individuals with cancer and other serious illness is complex and often results in unmet needs and high costs. Despite growing national interest in innovative care models for serious illness that improve quality and reduce costs, limited information is available to guide health care organizations from program innovation to implementation. Methods: With funding from the Gordon and Betty Moore Foundation, we sought to develop a flexible serious illness care model implementation framework to inform program development, replication, and scaling across a broad range of serious illness populations and settings. A draft framework was developed, guided by review of white papers and peer reviewed evidence and of existing serious illness care programs. Expert panelists—representative of serious illness care providers, policy experts, payers, and researchers—were recruited to review and provide feedback in two rounds of group discussion and additional 1:1 interviews. Results: The resulting framework implementation process begins with setting a vision and completing a local needs assessment. We present a range of evidence-based options for each facet of care model implementation (e.g., possible business models, target populations, services, and outcomes) to guide healthcare organizations in adapting serious illness programs to their local context. Key considerations for encouraging program success include leveraging existing programs and resources, recruiting strong program leaders, engaging staff, assembling experienced multidisciplinary care teams, building strong relationships among team members and with patients/caregivers, and establishing processes for program evaluation and continuous quality improvement. Conclusions: Our framework reflects a growing landscape of care models for cancer and other serious illness, offering a range of potential approaches to program implementation. Next steps include dissemination, framework impact assessment, creating a simulator for payment models, and piloting framework for use with future programs.