bluuebunny/crossref_metadata_2025_split huggingface dataset:
The sooner the better: Analysis of proactive palliative medicine consultation in the medical intensive care unit amongst patients with stage IV malignancy.
Authors: Levine Shanna R , Bridget Earle I , Edwards Wendy S.A. 
Published: February 2017

78 Background: Palliative care has been shown to improve quality of life and prolong median survival in patients with advanced cancer. Sadly, patients are still suffering at the end of their lives perhaps secondary to aggressive hospital care. ICU use in the last month of life increased from 24.3% to 29.2% over the last study decade. Our objective was to evaluate and quantify outcomes, including survival, of patients with active stage IV malignancy admitted to an urban university affiliated hospital MICU who had a palliative medicine consult. Methods: A retrospective chart review of patients from 04/2013 - 04/2014 admitted to the MICU with active stage IV malignancy identified via a validated proactive case finding trigger tool. The trigger was based on eight criteria, one of which being active stage IV malignancy. The MICU census was reviewed biweekly. Data collected included pain and symptom relief, clarification of goals of care, length of stay, and disposition (hospice, rehabilitation facility, home and death). Results: Four hundred sixty eight patients were assessed. One hundred and twenty two patients met 1 of the 8 criteria, and 24 patients met the inclusion criteria for review. Three patients were not seen due to attending and/or family preference. Thirty eight percent of patients had improved symptoms and management control, 42% had clarification of goals of care and medically appropriate decision making, and 42% experienced psychosocial spiritual counseling. Eight patients died during their hospital stay, 4 were transferred to inpatient hospice facilities, 3 to rehabilitation facility, 2 went home and the remainder was “other”. The average length of stay of patients seen by palliative care was 20 days compared to 31 days for patients not seen by the palliative team. Conclusions: Nearly 40% of patients with active stage IV malignancy admitted to the MICU died during their hospital stay. We believe this study illuminates the futility of ICU care in this patient population. Consultation from the palliative medicine team using a proactive trigger tool can be beneficial to allow for better symptom control, clarification of goals and psychosocial counseling.
Timely education about palliative care (PC) among pancreatic cancer patients.
Authors: Grenon Nina N. , Sommer Karen A. , Barysauskas Constance 
Published: February 2017

81 Background: A majority of cancer patients only receive PC at the end-of-life despite the physical, emotional, and existential distress throughout the continuum of the disease. The literature suggests early PC combined with standard care, improves quality of life and potentially extends survival. A four month retrospective chart review of patients diagnosed with pancreatic cancer at Dana-Farber Cancer Institute (DFCI) revealed only 19% of patients had a documented PC educational conversation within the first four weeks of care. Although early incorporation of PC education is imperative for patient quality of care it is not taking place. Methods: A quality improvement project was designed to increase the number of documented PC discussions among all new locally advanced and metastatic pancreatic cancer patients who were followed at the DFCI for the first four weeks of care. An educational brochure about PC was developed for providers and providers were educated about PC at a monthly staff meeting after completing a brief survey. Providers received an email reminder for all eligible patients and the PC brochure was attached to all patient encounter forms. Follow-up chart audits were conducted and pre and post surveys were administered to patients. Results: Providers and patients indicated no barriers to PC education. Providers indicated the onset of difficult to manage symptoms as the appropriate time to discuss PC and patients indicated first treatment or first treatment failure as the appropriate time to discuss PC. Chart audits revealed all eligible patients were educated about PC between April 14 and May 9, 2014 (n=13). Conclusions: Following implementation of this successful initiative, all eligible patients were educated about PC, conversations were documented and providers identified no barriers in the process. Due to the small scope of this project, further work is needed to improve sustainability, including ongoing identification of the number of patients who enroll in PC services concurrently with standard care, measure patient satisfaction, and implement our initiative in additional disease centers. In the future, infusion nurses, practice nurses, and social workers will participate in PC education training.
Care of the caregiver: Improving caregiver outcomes across the disease trajectory.
Authors: Page Margaretta , Molina Idonah M. , Patt Judy , Chang Susan Marina 
Published: February 2017

82 Background: Caregivers are essential members of the health team, often assuming diverse primary care roles for the cancer patient. Caregiver needs vary across the trajectory of illness and range from informational needs to emotional support to assistance with accessing resources. The needs of caregivers of brain tumor patients are complex not only because of the life threatening nature of the illness but also because of the wide range of neurological and cognitive deficits patients experience, a known risk factor for added stress to the caregiver. To address these challenges and improve caregiver outcomes, the Neuro Oncology Division at UCSF developed a program to provide an additional layer of care that includes information and support to caregivers of brain tumor patients across the trajectory of illness, from diagnosis to death. Methods: The program consists of a medical director and a dedicated nurse practitioner, social worker and coordinator, all focused on the caregiver of the brain tumor patient. The goals of the program are to provide information needed to assist with disease and symptom management, effective communication with the health care team, maximization of use of available resources, and to provide emotional support. Three groups of caregivers were targeted: caregivers of all new patients with a focus on newly diagnosed glioblastoma and caregivers of patients deemed at “high risk,” either identified by the provider, or because of the phase in the illness trajectory. Results: Since June 2013, 13 caregivers reported no needs for the first 4 months from diagnosis. 13 caregivers received care, with over half reporting concerns regarding financial issues and disability as well as need for emotional support around adjusting to the diagnosis, role changes, and care demands. In addition, varying levels of care have been provided to 70 caregivers of patients identified at “high risk” for distress due to disease progression or when transitioning to hospice. Conclusions: This program provides care to caregivers of brain tumor patients at specific time points to improve caregiver outcomes. Challenges include tailoring the information at the right time as well as measuring outcomes with minimal extra burden to the caregiver.
Patient evaluation of a physician conveying a more optimistic versus a less optimistic message: A randomized controlled trial.
Authors: Tanco Kimberson , Rhondali Wadih , Perez-Cruz Pedro Emilio , Tanzi Silvia , Chisholm Gary B. , Baile Walter F. , Sisson Amy , Arthur Joseph , Bruera Eduardo 
Published: February 2017

88 Background: Information regarding treatment options and prognosis is essential for patient decision making near end of life. However, physicians are frequently reluctant to deliver bad news due to multiple factors, including fear of being perceived as less compassionate. This randomized controlled double blind trial aimed to examine the patient’s perception of physician compassion after being exposed to a more optimistic vs. a less optimistic message. Methods: 100 patients were randomized to observe 2 standardized videos, depicting a physician discussing treatment and prognostic information (more optimistic message and less optimistic message) with a patient with advanced cancer. Both physicians displayed identical number of empathetic statements (5) and posture. Three sets of surveys were completed including the Physician Compassion Questionnaire (0=best, 50=worst). Actors and patients were blinded to the purpose of the study. Investigators were blinded to the video observed by the patient. Results: Patients reported significantly better compassion scores after watching the more optimistic video as compared to the less optimistic video [median (Q1-Q3): 15 (5-23) vs. 23 (10-31), p=0.0002]. Results were equally significant after parallel analysis of first video only and after cross-over analysis. There was also an order effect with compassion scores (p=0.0002) favoring the second video. Univariate analysis showed that degree of trust in the medical profession, ESAS fatigue, ESAS anxiety and ESAS depression had significant association with compassion perception independent of message observed. After applying Bonferonni correction, only degree of trust in the medical profession reached the corrected p value of p=0.0014 (p=0.0002). Conclusions: A more optimistic message resulted in a physician being perceived as more compassionate by the patient. The physician seen in second order is also perceived to be more compassionate. More research is needed to better understand patient perception of compassion in communication with physicians.
“Allow natural death” versus “Do not resuscitate”: What do patients with advanced cancer choose?
Authors: Miljkovic Milos , Emuron Dennis Omoding , Rhodes Lori , Abraham Joseph , Miller Kenneth David 
Published: February 2017

89 Background: Many patients with advanced cancer at our hospital request full resuscitative efforts at the end of life. In the first in a series of quality improvement projects to improve end-of-life (EOL) care, we assessed the knowledge and attitudes of patients towards it to determine if “Allow Natural Death” (AND) orders were more acceptable than “Do Not Resuscitate” (DNR) orders. Methods: Adult patients with advanced cancer being treated at a single community hospital were invited to participate. The first 100 consenting patients were surveyed regarding their diagnosis, prognosis, and attitudes about critical care and resuscitation. They were then presented with hypothetical scenarios in which a decision on their code status had to be made if they had 1 year, 6 months or 1 month left to live. Fifty patients were given a choice between being “full code“ and “DNR”, and 50 could choose between ”full code" and “AND”. Results: Participants were equally likely to choose either of the “no code” options in all hypothetical scenarios (p > 0.54). The choice was not affected by age, sex, race, type of cancer, education, or income level. Patients who said they would want life-prolonging measures such as CPR, tracheostomies, and feeding tube placement in case of a permanent vegetative state were significantly less likely to choose “AND” than “full code” (p=0.001–0.002). A similar proportion of patients who had a living will chose “AND” and “DNR” orders instead of “full code” in all the scenarios (47–74% and 63–71%). In contrast, among patients who did not have a living will 52% chose “DNR”, while 19% opted for “AND”. More than a third (39 of 93) patients were not aware their illness was terminal. Conclusions: We hypothesized that “AND” orders may be more acceptable to patients with advanced cancer, but the wording of the “no code” order does not seem to be related to the patients’ code status decisions. The “Do not resuscitate” phrasing may be more acceptable to patients who view life-prolonging measures favorably.
Formation of an international quality improvement collaborative for palliative care: The Global Palliative Care Quality Alliance (GPCQA).
Authors: Kamal Arif , Nicolla Jonathan , Friedman Fred , Stinson Charles S. , Patel Laura , Swetz Keith Mark , Strand Jacob , Portman Diane G. , Thirlwell Sarah , Groninger Hunter , Tuch Howard , Twaddle Martha , Kennedy William , Kyler Andy , Matthews Loretta , Candell Greg , Baker Karen , Anwar Zeba , Abernethy Amy Pickar , Bull Janet 
Published: February 2017

91 Background: Formal mechanisms to share data on quality remain immature in specialty palliative care. As the field grows, infrastructure that promotes collaboration among academic and community-based practice will be required to foster comparisons and benchmarking of data to inform areas for quality improvement. Further, such relationships will create a palliative care “quality improvement laboratory”, where proposed guidelines and best practices can be developed, implemented, and tested. Methods: We set out to bring together specialty palliative care practices with a shared vision for collaborative quality improvement. We modeled our approach after the Institute for Healthcare Improvement Breakthrough Series alongside our Rapid Learning Quality Improvement paradigm. We use a set of common data collection procedures, across an electronic point-of-care platform called Quality Data Collection Tool (QDACT), alongside a centralized data registry. Further, we meet and discuss challenges and issues, compare best practices, and brainstorm new projects through biweekly conference calls. Results: We have created a multi-institutional collaboration for quality assessment and improvement in specialty palliative care. Termed the Global Palliative Care Quality Alliance, we have brought together 11 academic and community organizations, both general and oncology-specific, across six states to study various areas of quality practice. Short-term, we will conduct rapid-cycling quality improvement projects addressing National Quality Forum domains for quality palliative care, including documentation of spiritual assessment and timely advance care planning. Long-term, we aim to study the link between quality measure adherence and outcomes and further align our initiatives with those of other large consortia, like the Palliative Care Research Cooperative and Palliative Care Quality Network. Conclusions: Collaborative quality improvement is needed in specialty palliative care across a national platform. Developing the infrastructure to perform standardized quality improvement is achievable across multiple palliative care settings.
Processes of discontinuing chemotherapy for metastatic non-small cell lung cancer at the end of life.
Authors: Pirl William F. , Greer Joseph A. , Irwin Kelly , Lennes Inga Tolin , Jackson Vicki A. , Park Elyse R. , Fujisawa Daisuke , Wright Alexi A. , Temel Jennifer S. 
Published: February 2017

96 Background: Administration of chemotherapy close to death is widely recognized as poor quality care. The goals of this study were to describe the processes of how chemotherapy is discontinued and examine their relationships with timing before death, hospice referrals, and terminal hospitalizations. Methods: We reviewed electronic health records of a prospective cohort of 151 patients with newly diagnosed metastatic non-small cell lung cancer (NSCLC) who participated in a randomized trial of early palliative care. Chemotherapy treatment during the final regimen was qualitatively analyzed, identifying categories of discontinuation processes. We then quantitatively investigated predictors and outcomes of the discontinuation process categories. Results: 144 patients had died, with 81 and 48 receiving intravenous (IV) and oral chemotherapy as final regimens, respectively. Five discontinuation processes were identified: definitive decisions; deferred decisions (breaks); disruptions for radiation therapy; disruptions due to hospitalizations; and no decisions. For patients receiving IV chemotherapy, definitive decisions were least frequent (19.7%), while disruptions due to hospitalizations were most frequent (27.2%). The different processes occurred at significantly different times before death; and often hospice referrals occurred months after chemotherapy discontinuation. Deferred decisions, or “breaks,” occurred at the longest interval before death, but definitive decisions resulted in greatest hospice utilization. Among patients receiving oral chemotherapy, 83.3% were switched from IV to oral as their final regimen, sometimes concurrent with or even after hospice referral. Conclusions: Patients with metastatic NSCLC stop their final chemotherapy regimen via different processes, which significantly vary in time before death and in subsequent end-of-life care.
A phase I/II study of DHP107, a novel oral paclitaxel formulation, in patients with advanced solid tumors (phase I) and gastric cancer (phase II).
Authors: Ryu Min-Hee , Ryoo Baek-Yeol , Kim Tae Won , Kim Sung-Bae , Lim Hyeong-Seok , Bae Kyun-Seop , Park Sook Ryun , Jo Yeong-Woo , Cho Hyun Ju , Kang Yoon-Koo 
Published: February 2017

101 Background: Paclitaxel has been proven to be effective and widely used in various types of cancers. DHP107 is a novel oral paclitaxel formulation. In the previous first-in-human study, DHP107 showed no DLTs at a single dose-escalating schedule and was reported safe and feasible in patients with advanced malignancies. This study was conducted to determine 1) recommended dose (RD) for multiple dosing of DHP107 in patients with metastatic solid tumor and 2) efficacy in patients with advanced gastric cancer (AGC). Methods: In phase I study, standard 3 + 3 dose escalation scheme was used, and the planned dose of DHP107 was 150 mg/m2 bid at level 1, 200 mg/m2 bid at level 2, and 250 mg/m2 bid at level 3 on days 1, 8, and 15, every 4 weeks. In phase II study planned by Simon’s optimal two stage design (P0=0.05, P1=0.25, α=0.05, and β=0.2), DHP107 was administered at the RD in patients with AGC refractory to first-line chemotherapy containing fluoropyrimidine and platinum. Results: In the phase I study, no dose-limiting toxicity (DLT) was observed at level 1 (n=3) and at level 2 (n=6). At level 3, 2 out of 4 patients showed a DLT (one grade 4 neutropenia over 7 days and one febrile neutropenia). At additional dose level 2A (225 mg/m2 bid), 2 out of 4 patients experienced febrile neutropenia. Finally, the RD of DHP107 was determined as level 2 (200 mg/m2 bid). In PK analysis, 200 mg/m2 bid of DHP107 showed similar AUC, Cmax and half-life to i.v. paclitaxel at 80 mg/m2. Out of the 11 patients enrolled in the phase II study, 3 patients achieved a confirmed partial response (27%; 95% C.I. 0-59%). Grade 3/4 adverse events with frequency > 5% included neutropenia (27.3%), stomatitis (18.2%), anemia (9.1%), and febrile neutropenia (9.1%). There was no treatment-related death. Conclusions: RD of DHP107 was determined as 200 mg/m2 bid. At the RD, DHP107 was generally well tolerated and showed anti-tumor activity comparable to i.v. paclitaxel as a second-line chemotherapy in AGC. Based on these results, a phase III study to compare DHP107 with i.v. paclitaxel is currently ongoing in AGC. This study was supported by DAEHWA Pharmaceutical Co. and Gangwon Institute for Regional Program Evaluation by Korean government.
Distribution and timing of distant metastasis (DM) after definitive therapy for patients with esophageal and esophagogastric junction (E-EGJ) cancer.
Authors: Shiozaki Hironori , Sudo Kazuki , Wadhwa Roopma , Hofstetter Wayne Lewis , Skinner Heath D. , Komaki Ritsuko , Lee Jeffrey H. , Weston Brian , Bhutani Manoop S. , Maru Dipen M. , Blum Mariela A. , Ajani Jaffer A. 
Published: February 2017

105 Background: For localized E-EGJ cancer patients, the preferred therapy is chemoradiation (CRT) followed by surgery (TMT). Definitive CRT (BMT) has been also established for the patients who do not qualify for surgery. Distribution and timing of distant metastasis has not been described. Methods: Between 2002 and 2013, 629 patients with localized E-EGJ cancer who underwent TMT or BMT were reviewed the distribution and timing of DM over time. Overall survival (OS) was estimated by the Kaplan-Meier method. Results: The median follow-up time was 37.2 months (interquartile range: 17.8-65.0) among patients with data that were censored. Among 356 patients with TMT, 33% (119) developed DM as their first relapse. Among 273 patients with BMT, 40% (109) developed DM. Following TMT and BMT, 91% and 96% of DM were diagnosed within 2 years of treatment, respectively. The 7 most common anatomic sites of DM were: lung (20% of DM for TMT and 17% of DM for BMT), distant lymph node (13% and 20%), liver (14% and 11%), peritoneum (10% and 13%), bone (6% and 11%), brain (8% and 8%) and pleura (7% and 5%). The median OS from DM were 10.2 months (95% CI: 7.8-12.7) for TMT patients and 7.8 months (95% CI: 5.7-9.9) for BMT patients. The median OS of patients with pleura metastasis was the shortest (1.5 months [95% CI: 1.0-2.1] for TMT and 3.5 months [95% CI: 3.3-3.6]) for BMT. Conclusions: After TMT and BMT, 33% and 40% of patients had DM and most DM occurred within 2 years (91% and 96%). Common sites of DM sites are lung, distant lymph node and liver. The risk factors associated with DM need to be elucidated. Supported by UT M. D. Anderson Cancer Center Multidisciplinary Research G rants, CA138671, CA172741, CA129926 from NCI (JAA) and Generous Donors. [Table: see text]
Trastuzumab with triple chemotherapy (DOC) in patients with advanced gastroesophageal cancer: A phase I dose-finding trial.
Authors: Schoennemann Katrine R. , Yilmaz Mette K. N. , Baeksgaard Lene , Jensen Helle Anita , Vestermark Lene Weber , Hansen Tine Plato , Pfeiffer Per 
Published: February 2017

108 Background: Trastuzumab (T) improves efficacy of doublet chemotherapy (TOGA trial) in HER2 positive patients with advanced gastro-esophageal (GE) cancer but safety and efficacy with triple chemotherapy is presently unknown. We initiated a dose-finding trial to establish a safe 4 drug combination of docetaxel (D), short-time infusion of oxaliplatin (O), continuously capecitabine (C) and trastuzumab (T). Methods: This phase I, dose-finding trial was approved by the local etic committee. All pts had histologically confirmed GE adenocarcinoma. Therapy was given day 1 with escalating doses of D (42mg/m2 to 51 mg/m2 as a 60 minutes infusion), O (100 mg/m2 as a 30 minutes infusion) and C (1,250 mg/m2/day continuously). DOC was repeated every 3 weeks for a maximum of 6 courses. T was given as a loading dose (8 mg/kg) followed by 6 mg/kg every 3 weeks until PD or unacceptable toxicity. Toxicity was evaluated according to NCIC-CTC 3.0. DLT was evaluated after the first course and defined as non-haematological toxicity grade ≥ 3, neutropenia grade 4 more than 7 days or febrile neutropenia. Response was evaluated by the investigator according to RECIST 1.0 every 9th weeks. Data was updated September 1, 2013. Results: From May 2010 to October 2012 we included 11 pts. Median age was 62years (range 32-73), 5/11 pts had PS 0, all pts had metastatic disease. Neutropenia grade 3-4 was observed in two pts, one had febrile neutropenia grade 3 after four courses. Two pts had grade 3 vomiting, fatigue, or nausea, respectively and one patient had diarrhoea grade 3. Only one pt developed a DLT (grade 3 vomiting, nausea and fatigue). Dose-intensity, after six courses, in all 11 pts was: D = 89%, O= 88% C = 81% and T = 100%. Median number of DOC was 6; all pts continued T to a median of 12 courses and one pt is presently receiving T. Partial response was obtained in 9 pts (81%). Progression free survival was 8.8 months and overall survival was 16.5 months. Five pts are presently alive. Conclusions: DOC-T in HER2 positive GE pts is safe and easily administered in an out-patient setting. The recommended doses for further evaluation are: D 51 mg/m2, O 100 mg/m2, C 1,250 mg/m2. Efficacy is very promising and deserves evaluation in larger trials. Clinical trial information: NCT01295086.