bluuebunny/crossref_metadata_2025 huggingface dataset:
Involving clinic patients in systematic symptom reporting to improve cancer care: Exploring prevalence of sleep disturbances (SD) and fatigue (FAT).
Authors: Irwin Margaret , Brown Catherine , Vennettilli Ashlee , Eng Lawson , Zarrin Aein , Dobriyal Aditi , Chen Linda , Mirshams Maryam , Patel Deval , Hon Henrique , Pat Vivien , Ho Anthea , Solomon Hannah , Tiessen Kyoko , Thai Henry , Ho Valerie , Mahler Mary , Xu Wei , Liu Geoffrey , Howell Doris
Published: February 2017

68

Background: SD and FAT occur in 30-50% of cancer patients. Patient-reported outcome measure surveys are avenues through which healthcare providers (HCP) can receive symptom-related clinically relevant information directly from patients, and engage them in their own care plan. By asking patients to report symptoms rapidly through tablet/computer-based technology, HCPs can involve patients in the delivery of care. Methods: In a pilot study evaluating utility of systematic symptom reporting, 336 adult cancer patients across all stages and disease sites who were attending outpatient cancer clinics at Princess Margaret Cancer Centre (PMCC) (Toronto, Canada) completed electronic tablet-administered secure surveys on SD (Insomnia Severity Index) and FAT patterns (FACT-fatigue). These tools measured both symptom severity and interference with function. Results: With a median age of 59 (19-91) years, 55% female, across a broad distribution of cancer sites, 56% of our sample reported moderate to very severe (MTVS) SD over the last 7 days: 31% had MTVS difficulty falling asleep; 43% had MTVS difficulties staying asleep; 36% had MTVS problems waking up too early. While 62% who had MTVS SD were not distressed by their SD, 95% who were distressed by their SD met the criteria of MTVS SD. 78% of patients had any level of FAT over the last 7 days, with 40% reporting MTVS FAT. While 40% who had MTVS FAT were still able to perform their usual activities, 67% of patients who were not able to do their usual activities had MTVS FAT. Conclusions: Across all stages and disease sites of cancer patients at PMCC, the prevalence of SD and FAT was both high. Severity and interference with function by FAT and SD were often distinct and non-overlapping. Involving patients in the systematic evaluation of symptoms, particularly using newer tablet-based technology within the clinic, was feasible. Through the use of patient reported electronic applications, patients could easily and systemically report their symptoms in real-time. FAT management has always been a high priority at our institution. However, based on our results, a cancer center-wide self-management plan is being considered for SD.
Initiating a structured advance care planning (ACP) process within a telephonic disease management model.
Authors: Jameson Melissa , Abdullahpour Mitra , Taniguchi Cynthia , Neubauer Marcus A. , Hoverman J. Russell , Hayes Jad , Eagye Kathryn
Published: February 2017

73

Background: Utilizing a telephonic disease management (DM) model for educating and assisting patients to self-manage treatment side effects is a known element of practice quality. Yet, disease management models frequently neglect important aspects of patient education regarding end of life care. A model is needed whereby structured ACP content and processes are included within the disease management scope of work and documented accordingly. Methods: Over a nine month period, a DM model with an ACP education component was applied in a community oncology setting. Practice DM services were provided through a centralized call center and delivered telephonically for patients receiving chemotherapy. DM staff was comprised of registered nurses with oncology credentialing and ACP training. The model included an introduction of ACP principles within the first telephonic outreach to the patient, highlighting the purpose of ACP and the importance of ongoing communication of patient values and goals for care throughout the treatment trajectory. On subsequent calls, with the patient’s permission, DM staff provided education regarding potential end of life treatments and advance directives. Patient education and learning outcomes were documented in the electronic health record (EHR). Results: A total of 154 patients participated in the DM program. An introduction to ACP was provided for 131 patients (85%). EHR inclusion of patient values and goals for care was achieved for 93 patients (60%). 93 patients (60%) agreed to receive subsequent education regarding potential end of life treatment interventions. During the nine-month period, 21 patients (14%) transitioned to hospice care. Conclusions: Telephonic DM offers a realistic and sustainable option for initiating the ACP process. A key learning is that patients are frequently open with discussing end of life care while in the comfort and safety of their home. EHR documentation of ACP content and patient preferences for care is a critical step for real-time sharing of information among the clinical team. Further study is needed to determine whether this intervention has an impact on appropriate hospice enrollment and other quality end points.
Quality care and patient involvement in their care: Preferences for transitioning cancer follow-up care to the community.
Authors: Herzog Lindsay , Howell Doris , Moura Shari , Qiu Xin , Brown Catherine , Vennettilli Ashlee , Eng Lawson , Chen Linda , Malik Noor , Zvetkova Svetlana , Zarrin Aein , Dobriya Aditi , Patel Devalben , Xu Wei , Townsley Carol , Liu Geoffrey
Published: February 2017

75

Background: The cancer survivor rate is rising and a new focus has turned to the appropriate survivorship care for this new population. Although several models of survivorship care are currently present in Canada, few studies have examined cancer patient preferences. This study compared patient preferences for direct referral back to one’s primary care practitioner (PCP) after 2-3 years of oncology specialist care versustransition through a specialized transitional clinic before exclusive follow-up by one’s PCP. The main objectives were to: (1) assess patient interest in a specialized cancer transitional clinic model, and (2) compare patient and demographic characteristics by such preferences. Methods: A cross-sectional scenario-based survey of cancer survivors who had undergone curative therapy at the Princess Margaret Cancer Centre assessed patient preferences for the transitioning of their post-treatment cancer care. Regression models compared clinico-demographic and psychosocial variables (anxiety, depression, distress) to one’s preference for transition of care. Results: Among 242 cancer survivors, 54% were male, 78% Caucasian, 43% with a college degree, median household income between 60-75K, 71% married, with a wide distribution of curable cancer sites (anal, colorectal, breast, testicular, lymphoma, head/neck, lung). 77% preferred transition through a specialized transitional clinic versus direct referral back to their family doctor. No factors were found to be related to preference for transition of care, except individuals who scored high on anxiety using the ESAS scale were significantly more likely to prefer referral to the specialized transitional clinic (p<0.05). No differences in preference were found by other clinico-demographic factors. Conclusions: A specialized transitional clinic is a preferred survivorship option in three-quarters of cancer patients. Anxiety, but not other variables, was associated with preference for the specialized clinic. This study highlights the need for individual decision-making regarding survivorship options. This individualization of transitioning may help improve patient’s perception of quality cancer care.
A standardized approach for managing chemotherapy-induced rash.
Authors: Poggi Laura , Godden Jennifer , Yoder Sol
Published: February 2017

86

Background: Chemotherapy-induced rash can lead to disruptions or discontinuation of therapy, potentially leading to a poorer prognosis for patients. Methods: A retrospective chart review was performed at selected clinics to determine rash incidence, current rash management, and dose reductions, disruptions, and discontinuation of therapy due to rash for epidermal growth factor receptor-inhibitors (EGFR-I) during August and September 2013. A rash management algorithm containing preventative and treatment recommendations was created for selected EGFR-I (cetuximab, panitumumab, erlotinib) and implemented in the clinics’ electronic medical record as part of a pilot study from February through May 2014. When the EGFR-I were ordered, electronic alerts reminded providers of the algorithm. Pharmacists received electronic messages to ensure algorithm compliance. Nurses provided patients with a rash information sheet and preventative prescriptions. Providers assessed patients for rash during follow-up and instituted the rash treatment algorithm, if indicated. Through a chart review, rash incidence, and dose reductions, disruptions, and discontinuation of therapy due to rash were determined. Results: The retrospective chart review revealed 7 of 9 (78%) patients, in whom preventive medications were not utilized, developed rash with the selected EGFR-I. Treatment medications were required in 6 of 7 (86%) patients with rash. Even with treatment, 3 of 7 (43%) patients had a severe rash, making therapy modification necessary. A dose reduction was ordered for 1 patient, a disruption for another, and discontinuation of therapy for a third. During the pilot period, 6 of 7 (86%) patients developed rash, but none required dose reductions or discontinuation of therapy. Of the 6 patients who developed rash, 4 were adequately managed with preventive measures alone. Of the 2 patients who started rash treatment, 1 patient had rash resolution and the other patient continued treatment without any therapy modifications. Conclusions: An algorithm containing preventive and treatment recommendations for EGFR-I-induced rash may be more beneficial than reactive therapy alone in attenuation of dose reductions, disruptions, and discontinuation of therapy.
Comparative effectiveness of antiangiogenesis inhibitors for second-line therapy of metastatic colorectal cancer.
Authors: Chen Christina Xiaoyue , Sadeghi Sarmad , Lenz Heinz-Josef , Barzi Afsaneh
Published: February 2017

9

Background: Treatment guidelines for second-line therapy of metastatic colorectal cancer (mCRC) suggest that addition of an anti-angiogenesis inhibitor to standard chemotherapy will prolong survival. Bevacizumab and aflibercept are two inhibitors that have increased survival in randomized clinical trials, but their cost-effectiveness is unclear. This study uses clinical trial data to compare the addition of aflibercept versus bevacizumab to a chemotherapy regimen in terms of incremental cost-effectiveness ratios (ICERs) in cost per month gained and treatment-related toxicities. Methods: A Markov model was used to simulate survival, toxicities, and costs for each treatment arm. Survival and adverse event probabilities were derived from published clinical trial data, and costs were estimated from the literature and the 2013 Veterans Affairs Federal Supply Schedule. Results: Aflibercept dominates bevacizumab by increasing survival by 1.06 months, while saving $3,526 in total treatment and adverse event costs combined (Table). When evaluating only adverse event-associated costs, the ICER between aflibercept and bevacizumab is $3,675 per month gained. One-way sensitivity analysis of the total cost ICER shows that aflibercept cost-savings are robust to almost all parameters varied, while similar analysis of the adverse event ICER suggests that aflibercept-associated toxicities would cost less than bevacizumab-associated toxicities in the case of a 20% decrease or increase in aflibercept or bevacizumab toxicity costs, respectively. Conclusions: Aflibercept plus chemotherapy is cost saving overall and improves survival compared with bevacizumab plus chemotherapy but results in more adverse events and associated costs. Practitioners treating mCRC patients should weigh survival outcomes against potential increased toxicity between different treatments, especially when evaluating limited survival gains. [Table: see text]
Barriers to clinical trial accrual in a community cancer clinic.
Authors: Santhosh-Kumar Cheruppolil R.
Published: February 2017

91

Background: The availability of and enrollment in clinical trials at an institution may be considered cancer care quality measures. Nationally, most cancer patients are initially diagnosed and treated in the community setting. Data regarding clinical trial accrual of new cancer patients from community-based cancer centers and the barriers they encounter are limited. We sought to identify potential barriers to enrollment in clinical trials at a community cancer clinic. Methods: Data on new cancer patients seen at our comprehensive community cancer clinic were prospectively collected from 2007 through 2010. Factors that potentially affected patient accrual in clinical studies were tracked. Results: During the four-year study period, a total of 662 patients were diagnosed with breast, prostate, colon, lung, gynecological, melanoma and renal cell cancers. No studies were available for 42% of the patients (n=278). Of the remaining patients, 49% (190/384) met protocol eligibility. Of the eligible study patients, 45% (85/190) enrolled, for an overall accrual rate of 13% (85/662), and 55% (105/190) declined participation. Patients declined to participate due to stress of diagnosis, refusal of treatment entirely, issues with randomization and placebo, concerns with side effects of the medications, delay of treatment while awaiting the clinical trial process, patient refusal, transportation concerns and length of treatment. Conclusions: This study demonstrates that above average clinical trial participation can be achieved in community cancer clinics in the rural setting. There are modifiable barriers to clinical trial accrual including study availability, patient eligibility and other patient factors. Improvement of patients’ perceptions and perspectives regarding the clinical trial process could be achieved through patient education. Elimination of barriers to trial accrual could be studied as a quality metric.
Challenges of implementing the ASCO/ONS oral chemotherapy standards in a community practice network.
Authors: Dalby Carole Kathleen , Thiele Jodi , Walsh Jeanna Hamilton , Fuller Frances , Constantine Michael , Burke Reanne , Faggen Meredith , Gilchrist Heather , Norden Andrew David , Kostka Judith , Jacobson Joseph O.
Published: February 2017

93

Background: In March 2013, The American Society of Clinical Oncologists and the Oncology Nursing Society published standards for the safe administration of oral chemotherapy. Gap analysis at Dana-Farber Cancer Institute (DFCI) Satellites revealed opportunities in planning, education, and monitoring of patients prescribed oral chemotherapy. As a quality improvement initiative, the DFCI Satellites designed and implemented a multidisciplinary approach to oral chemotherapy administration. Methods: The Model for Improvement was employed. A process map highlighted gaps in oral chemotherapy. Several improvement opportunities were identified. 1) Pharmacists developed oral chemotherapy treatment algorithms in the EMR. 2) Providers adapted the parenteral chemotherapy treatment plan (CTP) for use with oral chemotherapy. 3) A nursing education program was created, and implemented following completion of the CTP and consent. 4) Continuous monitoring for toxicity and adherence was initiated by providers via clinic visits and telephone screening. Results: Monthly compliance reports measured CTP completion, consent, initial education, and monitoring for adherence. Aggregated rates indicate practice variability. Some sites perform well, while others continue to show room for improvement. Conclusions: Developing a process for oral chemotherapy is challenging. Systems are not set up for oral drug safety. Although we had success with introduction of the intervention, results have not yet demonstrated sufficient reliability. System limitations and human factor challenges have impeded progress. Given the risk potential of oral chemotherapy, adopting a robust process to deliver oral chemotherapy is essential for safe patient care. Oral chemotherapy administration is a work in progress that must be refined to achieve high reliability. [Table: see text]
Timing of access to outpatient palliative care services: What’s in a name?
Authors: Dalal Shalini , Bruera Sebastian , Masino Charles , Williams Janet L. , Zhang Yi , Obasi Emmanuel , Schuren Natalie , Bruera Eduardo
Published: February 2017

10

Background: We have previously shown the name “palliative” to be a barrier to early palliative care (PC) referral. Further, following service name change to supportive care (SC) in late 2007, we immediately observed an increased survival time of about 1.5 months from PC consultation suggesting earlier referral following the name change. This study was conducted to determine the timing of patient access to outpatient PC services over several years period after the name change. Methods: Records of consecutive outpatient referrals in fiscal years (FY) 2007 (pre-name change), 2008 (transition period), 2009-2013 (post-name change) were reviewed. Timing of PC access was determined by 3 time intervals: (a) survival from PC consultation; (b) advanced cancer diagnosis to PC (c) hospital registration to PC; Kruskal-Wallis, Kaplan Meir and Cox regression models were used. Results: 6,624 patients had their first outpatient PC consultation during FY 2007 to 2013. Each year we observed a consistent increase in new patient referrals, as well as a longer median survival time from PC consultation (logrank <0.0001). The table below shows median survival and hazard ratio (HR) for FYs 2008-2013 as compared to FY 2007. In FY 2013 there were 63% greater number of outpatient referrals as compared to FY 2007 (p <0.0001), longer median survival (months) (7.9 vs 4.8; p <0.001), and shorter median interval (months) from advanced cancer diagnosis (5.9 vs 7.8; p< 0.002) and from hospital registration (6.6 vs 14.8; p< 0.0001) to PC consultation. Conclusions: Following the name change of service from PC to SC, there has been consistent annual increase in new patient referrals as well as earlier access to outpatient PC services. The outpatient setting facilitates earlier patient access to SC/PC services and should be established in more centers. [Table: see text]
Trajectories of performance status decline in advanced cancer.
Authors: Ritchie Christine , Abernethy Amy Pickar , Kutner Jean , Levy Cari , O'Mahony Sean , Rhodes Ramona , Roshal Anna , Wiebe Lauren Allison , Blatchford Patrick Jud
Published: February 2017

100

Background: Historically, functional decline is considered to occur steadily and inexorably in the last months of life, with a relatively steep trajectory compared to non-cancer patients (pts). As part of a trial evaluating the safety and clinical impact of discontinuing statin medications for patients in the palliative care setting, we recorded the performance status (PS) in 186 cancer patients regularly during their time on study and compared changes among those with differing baseline PS levels and between those with and without cancer. Methods: This was a multi-center, parallel-group, unblinded pragmatic trial. Eligibility included: age > 18; life expectancy between 1 month and 1 year, on a statin for ≥ 3 months for primary or secondary prevention, recent deterioration in PS and no recent active cardiovascular disease. Participants, randomized to either discontinue or continue statins, were followed monthly for up to 1 year. Outcomes included survival, cardiovascular events, and PS. PS was measured using the Australia-modified Karnofsky Performance Status (AKPS) scale and grouped into 4 categories: AKPS=70, 60; 50 and 0-40. The trajectory of PS decline for each group was modeled using a piecewise-linear function allowing for knots at 4, 8, and 12 weeks and separated out between those participants who died and did not die during their time on study. A mixed model was used allowing for a random intercept for each participant. Results: Among the 186 subjects whose primary diagnosis was cancer, 111 died; among 195 without cancer, 75 died. Those who did not die maintained a relatively flat trajectory of AKPS across 20 weeks; for those who did die, AKPS scores declined somewhat over 20 weeks but this decline was most remarkable among those with a starting AKPS of 0-40. Compared to noncancer patients who died during the study period, PS levels were higher at baseline and had initially greater rates of decline. Conclusions: For advanced cancer patients, PS declines are less dramatic than previous estimates have suggested except for those with AKPS 0-40, suggesting precipitous declines at the very end of life for those with higher initial AKPS. Compared to noncancer patients, PS decline is slightly steeper among cancer pts.
A prognostic model for survival after urinary diversion for malignant ureteral obstruction: A prospective study of 208 patients.
Authors: Cordeiro Mauricio , Coelho Rafael , Pessoa Rodrigo Rodrigues , Chade Daher Cesar , Guglielmetti Giuliano Betuni , Junior Jose Roberto , Chaib Matheus , Srougi Miguel
Published: February 2017

102

Background: To determine prognostic factors and create a model for risk stratification in patients with malignant obstructive uropathy. Methods: We prospectively collected clinical and laboratory variables of 208 patients who underwent palliative urinary diversion by ureteral stenting or percutaneous nephrostomy between January 2009 and November 2011 in two tertiary care university hospitals, with minimum 6 months follow-up. Inclusion criteria were age>18yr and malignant urinary obstruction confirmed by computed tomography, ultrasound or magnetic resonance imaging. Results: Median survival after urinary diversion was 144 days. At the end of the study 164 patients died, 44 (21.2%) during the urinary diversion hospitalization. There was no difference in overall survival between the 2 types of diversion (p=0.216). The number of events related to malignant dissemination (≥4) and ECOG index≥2 were associated with shorter survival in multivariable analysis. Using these 2 risk factors (RF), patients were divided into 3 groups: favorable(no RF), intermediate(1RF) and unfavorable(2RF). The median survival at 1, 6, and 12 months was 94.4%, 57.3% and 44.9% in the favorable group, 78.0%, 36.3%, and 15.5% in the intermediate, and 46.4%, 14.3%, and 7.1% in the unfavorable. There were differences in survival profiles of the 3 groups (p<0.001). Conclusions: Our stratification model may be useful tool to determine whether urinary diversion procedures are indicated in patients with malignant urinary obstruction.
Five-year retrospective review of end-of-life care quality metrics in a large, multidisciplinary community oncology practice.
Authors: Kalisiak Angela , Gandara Elizabeth Ann , Hedlund Susan C , Gress Justin K
Published: February 2017

108

Background: It is increasingly recognized that earlier integration of palliative care for patients with advanced cancers positively impacts both cost and quality of oncology care. Compass Oncology (CO) is a multidisciplinary community oncology practice and a member of The US Oncology Network; 39 medical, gynecologic, and radiation oncologists and 18 advance practice providers serve patients at 6 sites in Oregon and Washington. In 2008, CO prioritized practice improvement in end of life care, identifying metrics for ongoing assessment. Between 2009 and 2014, quality improvement (QI) projects focused on communication skills; whole-staff palliative care education; integration of social workers; initiation of embedded palliative care at 2 sites; and development of a more standardized approach to Advance Care Planning (ACP). Methods: Systematic retrospective record review of patient deaths from January 2009 to December 2013, targeting analysis of hospice utilization, chemotherapy use at end of life, and ACP. Results: Among patients with a CO visit within 6 months of a documented date of death (n= 783 in 2009; n= 909 in 2013), both hospice utilization and ACP participation improved significantly. Percent of patients with evidence for Advance Directive (AD), POLST or code status documented in the electronic medical record (EMR) improved from 36% in 2009 to 50 % in 2013 (p<0.001). Percent of patients enrolled in hospice at the time of death improved from 56% in 2009 to 63% in 2013 (p= 0.003). No statistically significant change was noted in % patients receiving chemotherapy in the last 14 days of life. Conclusions: Focused implementation of end of life care QI strategies in a large multidisciplinary community oncology practice appears to result in both improved hospice utilization and ACP. Chemotherapy usage in the last 14 days of life remains a meaningful target for intervention. Future QI efforts will focus on ongoing, scalable improvement in these metrics. [Table: see text]
Concurrent urologic and palliative care after cystectomy for treatment of muscle-invasive bladder cancer.
Authors: Rabow Michael W. , Benner Carly , Shepard Nancy , Meng Maxwell V.
Published: February 2017

11

Background: To characterize the impact of palliative care concurrent with usual urologic care for bladder cancer patients undergoing cystectomy. Methods: Prospective, 6 month, serial cohort study comparing 33 participants receiving usual care with cystectomy for muscle invasive bladder cancer with 30 participants also receiving concurrent palliative care. Patients and family caregivers completed validated symptom assessment and satisfaction surveys pre-operatively and two, four, and six months post-operatively. Results: The intervention group saw improvements in most symptom measures over the six months following cystectomy compared to the control group. Depression and anxiety decreased over the six-month period for intervention patients, but increased over this time among controls (p=0.01). Fatigue fell to a minimum for intervention group participants at four months, while it peaked at this time for control participants (0.002). Quality of life and post-traumatic growth scores followed a similar pattern, with scores peaking at four months for the intervention group while controls reported their lowest scores at this time (p=0.01 and p=0.03, respectively). Changes in pain scores did not reach statistical significance. Neither family caregiver burden nor patient satisfaction showed statistically significant changes over time. Conclusions: Patients who received concurrent palliative care in addition to usual urologic care following radical cystectomy for muscle-invasive bladder had better outcomes, including improved fatigue, depression, quality of life, and post-traumatic growth. While further research on this topic is needed, our results suggest that providing palliative care services in addition to usual urologic care for bladder cancer patients may significantly reduce post-operative symptoms.
Palliative radiotherapy (PRT) at end of life (EOL): Benchmarks for a proposed metric.
Authors: Yu Hsiang-Hsuan Michael , Lutz Stephen T. , Johnstone Peter Anthony
Published: February 2017

119

Background: The initiation of chemotherapy within 30 days of death is considered a marker of chemotherapy overuse by Quality Oncology Practice Initiative (QOPI). We have previously proposed that the same be considered for RT. However, existing data for PRT delivered at EOL are limited. Methods: We reviewed the published literature for articles reporting PRT at EOL, defined as being within 30 days of death. These articles may be considered as benchmarks for current practice. Results: Published data revealed that frequency of PRT at EOL ranges from 6.2% to 28.6% for adult patients, and an order of magnitude lower in pediatric patients. Many patients received prolonged treatment course, did not complete PRT, and several studies reported median time from PRT to death was less than 2 weeks. A single study reported that only 26% of the patients reported benefit of palliation. The table summarizes published data. Conclusions: Substantial variability exists in published rates and completion of PRT delivery at EOL. Future studies may improve therapy choices at EOL by focusing on efficacy of PRT in this cohort, various PRT techniques including hypofractionation, and clinical variables that predict RT palliation at EOL. [Table: see text]
Retrospective chart review of end-of-life (EOL) care in patients with metastatic lung cancer harboring EGFR mutations.
Authors: Bauman Jessica Ruth , Piotrowska Zofia , Scribner Emily , Temel Brandon , Heist Rebecca Suk , Sequist Lecia V. , Temel Jennifer S.
Published: February 2017

126

Background: Metastatic lung cancer is the leading cause of cancer-related death in the US. In the last decade, however, patients (pts) with EGFR mutations have benefitted from improved outcomes with EGFR-directed targeted therapy. We hypothesized that this improvement might impact EOL care. The objective of this chart review was to describe the care of EGFR mutant pts with attention to EOL care, health care utilization, and palliative care use. Methods: With IRB approval, we retrospectively reviewed medical records of pts at our center diagnosed with advanced EGFR-mutant lung cancer from January 2009 to June 2012. We limited the review to pts who had at least one cancer therapy at MGH, and to those who died by June 2014. Results: 44 pts were included. 30 pts (68%) were female. 32 pts (73%) received cancer-directed therapy within 30 days of death. Of these, 30 pts (68%) received oral chemotherapy and 5 (11%) received IV chemotherapy. 30 pts (68%) were hospitalized within 30 days of death. Over their entire disease course, the median number of hospitalizations was 2 (0-8), and the median number of total inpatient days was 12 (0-88). 21 pts (48%) had a palliative care outpatient visit and 34 (77%) had an inpatient palliative care consult at some point during their care. 24 pts (54%) enrolled on hospice prior to death, 15 (34%) were never on hospice, and the hospice status of 5 (11%) was unknown. Of the 39 pts with known hospice status, median length of stay was 6 days (0-206). 23 pts (52%) died at home with hospice or in an inpatient hospice, 16 (36%) died in the hospital, 2 (4%) died at home without hospice, and the location of death was unknown for 3 (7%). Conclusions: Pts with EGFR mutations had high rates of hospitalization and chemotherapy use in the last month of life, and many died in the hospital. Palliative care utilization was high, but it is unclear how this affected EOL care. Designing innovative care models to support this unique population and understand EOL decision-making should be a priority.
A prospective study: Hypodermoclysis performed by caregivers in the home setting.
Authors: Vidal Marieberta , Hui David , Williams Janet L. , Chisholm Gary B. , Allo Julio , Bruera Eduardo
Published: February 2017

128

Background: Decreased oral intake is very common at the end of life. Dehydration can aggravate symptoms like fatigue, myoclonus, and confusion. Intravenous (iv) hydration at home can be uncomfortable and expensive. Hypodermoclysis (HDC) is a comfortable and inexpensive but rarely used way to provide hydration at the end of life in the home setting. The purpose of this study was to evaluate a program of HDC at home by the caregivers. Methods: All caregivers underwent a 45 minute training session on HDC administration and assessment of infusion site delivered by a specially trained nurse. Caregivers received daily calls and on site evaluation on day 8. Results: A total of 21 patient/caregivers dyads were admitted to this preliminary study: 10 (47%) female patients and 16 (76%) female caregivers. All patients had advanced cancer receiving hospice care at home. All caregivers who received training were able to start the infusion. Side effects were minimal with 1 (5%) care of the needle difficulty and leakage. Conclusions: This preliminary study suggests that subcutaneous hydration can be administered by caregivers at home with minimal burden. It can be easily done by just gravity or weight. It will avoid the use of expensive iv pump devices or need of special technical support. [Table: see text]
Identification of patients at risk for delirium on a medical oncology hospital ward.
Authors: Neefjes Elisabeth , Van Der Vorst Maurice , Verdegaal Bertha , Beekman Aartjan TF , Berkhof Johannes , Verheul Henk M. W.
Published: February 2017

130

Background: Delirium is a distressing experience for patients with cancer. Incidence rates of delirium vary between 5 and 88 percent. We studied the incidence of delirium on our medical oncology ward, along with its predisposing and precipitating factors, in order to identify patients who may benefit from screening and early interventions. Methods: We evaluated patients admitted to our medical oncology ward between January 2011 and June 2012 for delirium. In this period a screening program with the Delirium Observation Screening Scale was initiated. Risk factors for delirium were extracted from the patient’s chart. We developed a prediction model to identify patients who are at risk to develop delirium and optimized this model with a cohort of patients with a delirium diagnosed between June 2012 and September 2013. Results: 1,733 admittances of 574 individual patients were recorded in the study period. Sixty episodes of delirium were identified in 52 patients. The patients had a mean age of 60 years, and most patients (70%) had advanced cancer. The most prevalent predisposing and precipitating factors were age >70, drug intoxication, infection and metabolic imbalances (abnormalities in sodium, potassium, calcium, albumin or glucose levels), which were present in 21, 25, 22, and 18 percent, respectively. The prediction model revealed that patients who were electively admitted had a very low risk to develop delirium (1%), but patients admitted for an emergency with at least one metabolic abnormality, such as hyperkalemia, were at high risk for developing a delirium (delirium risk 33%). Conclusions: Based on our analyses for risk factors of delirium, we developed a new prediction model for the risk for delirium in patients with cancer admitted to an oncology ward that may be used for targeted screening and to study preventive therapy in order to improve their quality of life.
Outcome of patients with an initial presentation of brain metastases.
Authors: Berk Lawrence , Stevens Bryan
Published: February 2017

133

Background: Many studies have looked at the survival of patients with brain metastases but few studies have determined if the survival of patients initally presenting with brain metastases is the same as patients who subsequently develop brain metastases. Methods: Patients with no known history or a malignancy who presented to the hospital with brain metastases were retrospectively revieweed for survival. The survival data were collected from the hospital's tumor registryand the Social Security Index. The years 2010-2011 were studied as of 5/31/2013. Results: Ninety-four patients met the inclusion criteria in 2010 and eight-two patients in 2011. Sixty five percent of the patients in 2010 were male and fifty-five percent were male in 2011. The median age was approximately 60. In 2010 53% of the patients had lung cancer and 12% had breast cancer and in 2011 45% had lung cancer and 13% had breast cancer. zThus the median survival is equivalent to the median survival of the lung cancer patients, which was 71 days in 2010 and 37 days in 2011. the median survival of the breast cancer patients were 153 days in 2010 and 35 days in 2011. Sixty three percent of the patients received radiation therapy as some part of their treatment and eighteen percent received no treatment. The median survival time of patients receiving radiation therapy only as treatment was 84 days and the patients with no treatment had a survival of 34 days. Conclusions: The survival of patients presenting with brain metastases falls within the range expected from previous studies of patients with brain metastases. The survival of patients presenting with lung cancer was much poorer than patients with breast cancer. Patients for no treatment appear to be appropriately selected, with a median surival of approximately one month.
Palliative care issues encountered by radiation oncologists caring for advanced cancer patients.
Authors: Parker Gregory , LeBaron Virginia , Krishnan Monica Shalini , Shiloh Ron Y. , Racsa Margarita , Pacold Michael Edward , Spektor Alexander , Balboni Tracy A.
Published: February 2017

14

Background: Palliative radiation therapy (PRT) is often administered to patients with advanced cancers. These patients may present to radiation oncology clinicians with other palliative care needs. To date, the types and frequencies of palliative care issues encountered in this setting have not been well characterized. Methods: This study assesses palliative care issues encountered by radiation oncology clinicians during PRT consults at 3 Boston-area, community and academic, hospital-based centers. For consecutive consults from 5/19/14 to 9/15/14, participating physicians and nurse practitioners complete a survey to identify and rank the relevance (5-point scale, 'not at all' to 'extremely') of palliative care issues. Eight domains adapted from national palliative care guidelines – physical symptoms, psychosocial issues, cultural considerations, spiritual needs, care coordination, advance care planning, goals of care, and ethical and legal issues – are evaluated. Preliminary descriptive statistics based on 51 completed surveys are reported (response rate = 94%; anticipated sample size = 198). Results: Most (82%) consults had 2 or more palliative care domains ranked as very or extremely relevant to patient care. The domains of physical symptoms (92%), care coordination (75%), and goals of care (57%) were very or extremely relevant in >50% of consults. Within these domains, the issues most often reported as relevant were interdisciplinary care coordination (92%), consideration of prognosis in treatment plan development (86%), pain management (71%), and discussion of patient values and priorities in treatment plan development (67%). Advanced care planning (24%), cultural considerations (10%), spiritual needs (10%), and ethical and legal issues (10%) were least commonly ranked as very or extremely relevant. Conclusions: Radiation oncology clinicians encounter multiple palliative care issues when consulting on patients for PRT. Clinicians identified physical symptoms, care coordination, and goals of care as the most relevant palliative care domains. These findings can help guide palliative care development within radiation oncology, including education and structures of care delivery.
End-of-life discussions with noncurable lung cancer patients: A patients' and oncologists' qualitative study.
Authors: Huillard Olivier , Vinant Pascale , Colombet Isabelle , Montheil Vincent , Guillard Marie Yvonne , Chaillot Nathalie , Moreau Nathalie , Goldwasser Francois
Published: February 2017

151

Background: Discussions concerning patients’ (pts) preferences regarding end-of-life (EOL) care can improve the quality of care in non-curable-cancer-pts. Nevertheless having such discussions is difficult for health care providers and discrepancies exist regarding the frequency of such discussions. Methods: We conducted a single center qualitative study exploring oncologists’ attitudes and practices toward EOL discussions and the feasibility of an intervention designed to explore and collect pts’ preferences regarding EOL care. For oncologists, the intervention consisted in a semi structured interview and in a questionnaire concerning pts included. For pts, semi-structured-in-depth-interviews were conducted to assess their opinion about EOL discussions and the feasibility of exploring and collecting their preferences regarding EOL care in our practice setting. Resulting anxiety was measured. Results: Oncologists’ interviews (n=5), revealed that EOL discussions were rare, more likely to be initiated by pts and to arise lately in the evolution of the disease. Main barriers invoked were the difficulty of having such conversation, the limited time available, the risks of maleficence (mainly anxiety and loss of hope) and the uncertainty concerning expected benefits. Pts’ interviews (n=10) revealed that most of them were willing to be part of medical decisions concerning their EOL care. Few preferences regarding EOL-care were actually collected but the resulting in-depth discussions help mentioning a great variety of unusual topics as well as emotional, cultural and spiritual issues. Anxiety as a side effect was uncommon. Interviewers and oncologists often overestimated pts’ anxiety which is consistent with a projection of their own anxiety. Conclusions: Discussions concerning EOL care are uncommon in the setting studied and four main barriers were identified. Having these conversations was feasible and led to unexpected in-depth interviews concerning topics rarely addressed in our current practice. This intervention could help clarifying pts’ preferences and identifying psychosocial issues that could trigger palliative care team referral.
Care of the caregiver: Transitions at the end of life.
Authors: Page Margaretta , Molina Idonah M. , Patt Judy , Chang Susan Marina
Published: February 2017

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Background: Transitions of care can be particularly stressful on cancer patients and caregivers when goals of care are changing, especially at the time when active specialty care shifts to hospice. There are common caregiver issues at the end of life for the brain tumor patient as for any cancer patient however there are a subset of challenging problems unique to the disease. One of the goals of the UCSF caregiver program is to provide information on effective care at home and at the end of life to the caregiver when faced with a family member with a progressive, life threatening brain tumor. Methods: The caregiver program at UCSF sought to overcome the major caregiver challenges of the brain tumor patient at the end of life in two ways. First, caregivers of patients at the terminal phase in the illness trajectory were proactively contacted by a member of the caregiver team to offer informational and emotional support around end-of-life issues. The team also makes contact with the hospice agency in order to provide information about specifics regarding symptoms, family dynamics, or any relevant history. Second, in collaboration with the palliative care service, a palliative care and end of life handbook for brain tumor patients was planned. Results: Since June 2013, 70 caregivers of patients have been identified as “high risk” for distress because of disease progression or transition to hospice care. In addition to providing support to the caregiver at the end of life, the palliative care handbook was produced and distributed. The handbook provided general information on the role of hospice, advance care planning, and bereavement and more importantly incorporates specific sections that highlight the unique challenges regarding neurological symptoms that include cognitive and behavioral changes, language difficulties, corticosteroid use and the inability of oral intake that can significantly affect anti-seizure medication administration. Conclusions: Additional focus to ease transitions for caregivers of brain tumor patients at end of life is needed. Future projects involve creating a handbook to provide resources to hospice professionals caring for brain tumor patients that will highlight common symptoms expected, (ie. seizures) and options for management.
Association between tobacco use and symptom expression, alcoholism, and illicit drug use in patients with advanced cancer.
Authors: Kim YuJung , Dev Rony , Reddy Akhila Sunkepally , Hui David , Chisholm Gary B. , Williams Janet L. , Bruera Eduardo
Published: February 2017

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Background: Our aim was to determine the association between smoking status and symptom expression, opioid use, alcoholism, and illicit drug use in advanced cancer patients. Methods: We retrospectively reviewed 560 consecutive charts from the outpatient Supportive Care Center and identified 300 advanced cancer patients who completed a comprehensive smoking questionnaire. Data on the Edmonton Symptom Assessment Scale (ESAS), morphine equivalent daily dose (MEDD), CAGE (Cut Down, Annoyed, Guilty, Eye Opener) questionnaire for alcoholism screening, and history of illicit drug use were collected. Results: Among 300 advanced cancer patients, 119 (40%) were never-smokers, 148 (49%) were former smokers, and 33 (11%) were current smokers. Compared with never-smokers, current smokers were more likely to be men (58% vs. 29%, P=0.004), report a higher pain expression (median 7.0 vs. 5.0 by the ESAS, P=0.007), be CAGE positive (≥2 yes response) (42% vs. 3%, P<0.001), and have a history of illicit drug use (33% vs. 3%, P<0.001). Compared with never-smokers, former smokers were more likely to be men (60% vs. 29%, P<0.001), have head and neck cancer or lung cancer (30% vs. 13%, P=0.001), be CAGE positive (21% vs. 3%, P<0.001), and have a history of illicit drug use (16% vs. 3%, P<0.001). Current smokers reported a higher pain expression than former smokers (median 7.0 vs. 6.0 by the ESAS, P=0.01), had higher CAGE positivity (42% vs. 21%, P=0.01) and more frequent illicit drug use (33% vs. 16%, P=0.03). The MEDD and the timing of palliative care referral were not significantly different between current or former smokers compared with never-smokers. However, a higher proportion of current smokers were receiving opioids with MEDD ≥30mg at the time of palliative care consultation compared with never-smokers (70% vs. 52%, P=0.08). Conclusions: Our study suggests that current tobacco use is associated with a higher pain expression. In addition, any history of tobacco use is associated with a history of illicit drug use and alcoholism. Advanced cancer patients who smoked cigarettes may be at an increased risk for chemical coping or stronger opioid utilization and further studies are needed.