bluuebunny/crossref_metadata_2025_split huggingface dataset:
Combination external beam and brachytherapy for intermediate- to high-risk prostate cancer: Comparison of high-dose rate (HDR) and seed (LDR) implant methods.
Authors: Daniel Sarah E. , Carion Thomas , Schervish Edward , Frontera Rene , Aref Amr M. , Browne Cynthia Holland , Campbell Todd , Chuba Paul J. 
Published: February 2017

90 Background: Maximizing the therapeutic ratio for intermediate to high risk localized prostate cancer may be accomplished by using a combination of external beam radiotherapy (EBRT) and radiation implant. Differences in implant methods could be expected to influence mortality. We compared outcomes for patients treated using combination EBRT and high dose rate (HDR) versus EBRT and low dose rate (LDR) seed implant methods. Methods: Between 12/1993 and 05/2010 there were 307 cases of combination therapy with analyzable data: 227 HDR + EBRT (HDRe) and 81 LDR + EBRT (LDRe) Intermediate risk patients had 1+ risk factors: PSA ≥ 10, Gleason score (GS) ≥ 7, or AJCC clinical stage ≥ T2b. High risk patients exhibited either 2+ of these risk factors or PSA ≥ 20, GS ≥ 8, or AJCC clinical stage ≥ T3. External beam radiation was 45 Gy in 1.8 Gy daily fractions using 3D conformal or IMRT methods. The prostate, seminal vesicles, and (in some patients) pelvic lymph nodes were treated. HDR brachytherapy was delivered one week prior to beginning EBRT. Afterloading HDR catheter needles were surgically implanted into the prostate. HDR dose was 21 Gy in three equal fractions of 7 Gy peripheral dose given over two days. LDR was performed 2-3 weeks after EBRT using I-125 or Pd-103 seeds and 109 or 90 Gy respectively. PSA failure was defined as “nadir plus two.” Results: HDRe and LDRe cases were well matched for pretreatment risk factors. There were 18 PSA failures in the HDRe group (7.9%) and 6 PSA failures in the LDRe group (7.4%). Adjusted Cox proportional hazard models showed no statistically significant difference between the treatment groups with regard to PSA failure. Hazard ratio for LDRe compared to HDRe was 0.82 (95% CI 0.28, 2.46; p=0.73). There were 26 deaths from any cause (11.45%) in the HDRe group and 11 deaths from any cause (13.58%) in the LDRe group. Adjusted Cox models showed no statistically significant difference between the treatment groups for survival. Hazard ratio for LDRe compared to HDRe was 1.49 (95% CI 0.68, 3.25; p=0.32). Conclusions: There were no statistically significant differences in PSA failure free survival or overall survival detected in LDRe versus HDRe patient groups.
A community-based approach to educating black men in underserved communities about the risks and benefits of prostate cancer screening.
Authors: Kennedy Mark Wendell , Carter Jacques , Wright Stephen , Contreras Magnolia , Winkfield Karen Marie 
Published: February 2017

99 Background: Black men have the highest incidence of prostate cancer (PCa) and are twice as likely to die of the disease than any other race/ethnic group in the United States. The recent controversy related to PCa screening may disproportionately impact black men who are already at greatest risk from the disease. This project sets out to develop culturally-competent educational and screening programs for men in high-risk populations so they can make an informed decision about PCa screening. Methods: A community-based education and screening program targeted towards black men living in an under-resourced community in Boston, MA was implemented. A mobile PCa screening van was initially employed and stationed at a local community health center (CHC) twice annually. Education about PCa screening was provided by a trained racially-concordant patient navigator (PN). Screening was available on the van by a primary care physician (PCP). In 2013, the pre-screening educational model was incorporated into the clinical practice of a single PCP practicing at the CHC. Every male patient over the age of 40 had an educational consultation about PCa screening with the PN before seeing their PCP. The patient would then discuss screening with the doctor and decide whether to proceed at that visit. Results: From 2004 to 2013, 20 van visits were conducted at the CHC. Two-hundred seven (207) men received PCa screening education; 179 (86.5%) elected to undergo screening. Of the men screened, 26 (14.5%) were referred for further testing as a result of their screening test. From January 2013 to September 2014, 121 men received PCa education; 100 men (82.6%) were screened. Ninety percent had both prostate-specific antigen testing and a digital rectal exam. Conclusions: These data suggest that formal PCa screening education prior to meeting with a physician is welcomed and may be a way to increase baseline screening in high risk populations. This provides an opportunity to develop an individualized prostate health management program based on individual risk profiles and to carefully monitor PSA fluctuations. The ultimate goal is to reduce unnecessary interventions while capturing PCa early in men at greatest risk.
Disparities in the availability of and access to antiemetics recommended by the international antiemetic guidelines in Serbia, Japan, and Nepal.
Authors: Bosnjak Snezana , Zilic Ana , Gyawali Bishal 
Published: February 2017

117 Background: Guideline-consistent antiemetic therapy requires 4 classes of antiemetics (AEs) to be available and accessible for the optimal prevention of chemotherapy induced nausea and vomiting (CINV): serotonin3 receptor antagonists (5HT3RAs), neurokinin 1 receptor antagonists (NK1RAs), dopamine receptor antagonists (DOPRAs) and dexamethasone. To evaluate disparities in the availability and accessibility of AEs recommended by the international antiemetic guidelines for the prevention of CINV inpatients treated in governmental hospitals in Nepal (low), Serbia (upper-middle) and Japan (high-income). Methods: Availability was evaluated by the formulary availability and marketing authorization (MA) in Serbia (RS), Japan (JP) and Nepal (NP). Accessibility was assessed by the National Health Insurance Fund (NHIF) coverage in Serbia and Japan and by the affordability in Nepal. Off-label use of medications is not legitimate in Serbia and Japan. Results: Barriers are presented in Table. Serbia has no access to NK1RAs and palonosetron for the prevention of CINV after HEC-AC and carboplatin. There are no barriers in Japan to provide all 4 classes of AEs. In Nepal all AEs are payed out of pocket and the guideline implementation completely depends on the affordability. Olanzapine is accessible in Nepal, but not in Japan and Serbia due to restricted off-label use of medications. Conclusions: The real life implementation of antiemetic guidelines for the prevention of CINV in various countries depends on the availability of and access to AEs recommended by the guideline. Identified barriers in Serbia and Nepal preclude physicians from providing optimal supportive care. [Table: see text]
Evaluation of patient's versus hematologist/oncologist's office visit agenda.
Authors: Patrick Cory , McIntyre Kaitlin , Singal Rakesh , Hansra Damien Mikael 
Published: February 2017

125 Background: Few studies have been reported in oncology regarding elements of physician agenda. We aim to compare elements of a doctor office visit agenda between hem/onc physicians (MD) and patients (pts). Methods: Pts and MDs were enrolled to completed a five question survey. Pts were asked: “My doctor” Focuses more on quantity of life and less on quality of life, spends enough time with me, addresses symptoms, addresses chemo side effects, and addresses prognosis. MDs were asked the same questions but worded: "I” spend enough time with pts for example. Answers were recorded on a 5 point scale (1 = highly disagree, 2 = disagree, 3 = neutral, 4 = agree,5 = highly agree) and converted into 2 categories (1,2,3 = neutral/disagree vs 4,5 = agree). Fisher’s exact test with 2 sided p-value was used to compare significance between MD & pts. Results: 1008 pts and 55 MDs were enrolled between 06/2013 - 10/2015. Pt mean age 55 (18-88) with 45% male and 55% female. Racial profile: 16% white, 14% black, 2% Asian/Pacific Islander. Ethnicity: 62% of pts were Hispanic vs. 38% not Hispanic, & 6% other. A significant number of pts feel MDs focus more on quantity of life vs. quality of life (64% pt vs 26% MD p < 0.0001) and MD spend enough time (94% pt vs 82% MD p < 0.05). No differences were seen for symptoms (92% vs 87% p = 0.2), side effects (92% vs 94% p = 1.0), or prognosis (91% vs 96% p = 0.3) pt vs MD respesctively. Conclusions: Pts feel MDs focus more on quantity of life vs. the quality of life. MDs feel they focus more on quality of life vs. quantity of life. Perhaps bridging the gap in what constitutes “quality of life” may improve patient satisfaction. Furthermore MDs underestimate the time spent with their patients. Perhaps MD are spending too much time with some patients resulting in inefficient office visits.
Contribution of polypharmacy and potentially inappropriate medication use to inferior survival in older patients with aggressive lymphoma.
Authors: Lin Richard Jirui , Guo Robin , Becker Daniel Jacob , Grossbard Michael L. , Magid Diefenbach Catherine S. 
Published: February 2017

129 Background: Survival outcomes for older patients with aggressive non-Hodgkin’s lymphoma (NHL) are disproportionally inferior to those of younger patients. While differences in tumor biology may play a role, older patients are often frail with comorbidities, polypharmacy, and use potentially inappropriate medications (PIM). Methods: Using Cox proportional hazard and logistic regression models, we retrospectively analyzed all aggressive NHL patients age 60 and older diagnosed and treated at our institution from 2009-2014 to examine the effect of polypharmacy and PIM use on progression-free survival (PFS), overall survival (OS), and treatment-related toxicities. Results: We included 141 patients with evaluable data after excluding patients with incomplete record. The median age was 71 years. At the time of diagnosis, 44% of patients used more than 4 medications and 47% used at least one PIM. During first-line treatment, only 43% of patients received chemotherapy of adequate relative dose intensity (>85% scheduled dose), and 63% experienced grade 3 or greater toxicities. Age, International Prognostic Index, and PIM use correlated with each other. Number of medications (p = 0.005) and PIM use (p < 0.001) were associated with shortened PFS by log-rank test, and PIM use remained a strong independent predictor of PFS in multivariable analysis (HR 1.84, p = 0.005). Number of medications (p = 0.003) and PIM use (p = 0.009) were also associated with shortened OS by log-rank test, although only albumin level predicted OS in multivariable analysis. Most importantly, PIM use was strongly associated with grade 3 or greater toxicities in multivariable analysis (OR 7.4, p = 0.001). Conclusions: We report here for the first time adverse impacts of polypharmacy and PIM use in older patients with aggressive lymphoma. We suggest that drug-drug interactions may significantly impair the delivery of adequate chemotherapy dosage and increase toxicities thus resulting in inferior survival outcome. Our findings support the use of evidence-based geriatric and palliative care principles to guide meticulous medication management to eliminate outcome disparity in older lymphoma patients.
Impact of cachexia at diagnosis on radiotherapy utilization and survival in non-small cell lung cancer.
Authors: Lau Steven , Giap Fantine , Gannavarapu Bhavani S. , Iyengar Puneeth 
Published: February 2017

133 Background: The presence of cachexia at the time of cancer diagnosis and its influence on disease management and treatment outcomes for patients receiving radiotherapy are poorly described. Here, we assess the role of baseline cachexia in patients with NSCLC on first-line treatment modality and clinical outcomes. Methods: Retrospective review of medical records identified 1,334 patients with NSCLC consecutively treated at a tertiary care health system between 1/1/06 and 12/31/13. Cachexia was defined using the well-accepted and validated international consensus definition. The delivery of radiotherapy and its treatment intent were abstracted. Results: The cohort included a representative group of patients with a median age at diagnosis of 64 years, 47% females, and 32% patients of non-White race. Stage at diagnosis was I, II, III, and IV in 291, 105, 356, and 578 (43.3%) patients, respectively. Cachexia was present at the time of diagnosis in 403 (30.2%) patients including 18%, 14%, 32%, and 39% of stage I, II, III, and IV patients, respectively. Palliative intent radiotherapy was received by significantly more stage IV patients with cachexia (74%) than without cachexia (63%) (X2, P = .01). In contrast, baseline cachexia was not associated with curative intent radiotherapy in stage I-III disease. At a median follow-up of 24 months, 857 deaths have been observed. Cachexia at the time of diagnosis was prognostic for worse survival by stage. For patients with stage IV NSCLC, median survival was 11 months for patients without cachexia but 6 months for patients with cachexia at diagnosis (P < .001). Cachexia remained significant in stage I NSCLC, with median survival of 45 and 67 months with or without cachexia at diagnosis, respectively (P = .03). Conclusions: Cancer cachexia at the time of diagnosis is common in patients with NSCLC even with early stage disease. The presence of cachexia at diagnosis is associated with utilization of radiotherapy as a palliative treatment. However, cachexia at diagnosis of NSCLC, even with early stage disease, is prognostic of worse outcomes despite curative intent radiotherapy.
Pilot study of incorporating a supportive care program into a small community oncology practice.
Authors: Kalstrom Karly , Schultz Kelly , Thompson Jennifer , Byrne Michael Thomas , Buresh Andrew J. , Curley Brendan F. 
Published: February 2017

149 Background: Incorporation of supportive care has become standard of care in patients with advanced or metastatic cancer undergoing palliative chemotherapy. Implementation of a supportive care program is often difficult in a small community practice due to a multitude of factors. Methods: We piloted a supportive care program with the partnership of Sage Hospice & Palliative Care in which patients with advanced or metastatic cancer undergoing chemotherapy would be evaluated by a certified nurse practitioner (CNP). Patients were selected for evaluation based on age, stage of cancer, and likelihood of needing additional supportive measures during their oncologic treatment. Patients were enrolled in the program by seeing the CNP and being followed throughout their chemotherapy, or until their death. Home visits were done by the CNP after hours, on weekends, or during business hours if it was noted to be medically necessary. Results: Forty-four patients were enrolled in the supportive care program. All patients either had metastatic or advanced cancer that required chemotherapy. The most common diagnoses are breast, pancreatic, prostate and lung cancer. The average number of patient home visits was 3.35 visits. Interventions varied, but the most common tasks performed were IV hydration, pain control and symptom management. Of the 44 patients, only 7 required an inpatient stay (15.9%) and none of these patients required a second hospital stay or were noted to be a 30 day readmission. Ten patients were enrolled in hospice, and 7 of those patients died. Zero patients died while on treatment or died without being enrolled on hospice. Conclusions: Incorporation of a supportive care program is feasible in a small community practice. The benefits may include improved patient outcomes, decreased hospitalizations, and smoother transition to end of life care.
Influence of early-phase clinical trial enrollment on patterns of end-of-life care for children with advanced cancer.
Authors: Ananth Prasanna Janaki , Monsereenusorn Chalinee , Ma Clement , Al-Sayegh Hasan , Wolfe Joanne , Rodriguez-Galindo Carlos 
Published: February 2017

151 Background: Early phase clinical trials are critical to enhancing therapies for children with advanced cancer. However, trial enrollment may intensify end-of-life (EOL) care. We evaluated patterns of EOL care for patients at a large cancer center. Methods: Single-center, retrospective cohort study of pediatric oncology patients, ages 6 months-21 years, who died in 2010-2014. We queried electronic medical records to assess frequencies of medical procedures (e.g. intubations), clinic visits, and hospital admissions in the last 6 months of life. We assessed timing of pediatric palliative care (PPC) consultation, initial advance care planning (ACP) discussion, and entry of do-not-attempt resuscitation (DNAR) orders in the chart, in relation to date of death. Patients enrolled in early phase clinical trials for at least 1 cycle (EP) were compared with those not enrolled (NEP), using Wilcoxon rank sum and Fisher exact tests. Results: For N = 125 patients, median age at death was 11.6 years (IQR 5.8-16.3); 46% were female; 70% were White, non-Hispanic. 26% were trial enrollees. Diagnoses included 42% solid tumors, 41% brain tumors, and 18% hematologic malignancies. Most patients had PPC consultation (83%), ACP discussions (91%), and DNAR orders (86%). EP and NEP cohorts did not significantly differ in baseline demographic or clinical characteristics, frequencies of medical procedures, or hospital admissions. EP patients had a higher median number of clinic visits than NEP patients (18.5 [16.3-27.2] vs. 14.1 [6.5-20.7], p = 0.0003) and received PPC consultation significantly closer to death than NEP patients (median days before death = 58 [16-84] vs. 85 [32-173], p = 0.04). There was no difference between EP and NEP patients in timing of initial ACP discussion or of DNAR order entry. Conclusions: Near the EOL, EP patients had more frequent clinic visits and later PPC consultation, but trial enrollment did not appear to delay ACP discussions or increase hospital resource use. These results suggest that early phase clinical trial enrollment does not substantially alter EOL care patterns for children with advanced cancer.
Implementing an emergency department EMR trigger tool for palliative medicine consultation and its effect on length of stay and health care costs: A retrospective study.
Authors: Kozhevnikov Dmitry , Rivera Felix , Edwards Wendy 
Published: February 2017

167 Background: Several studies have shown that palliative medicine consultation can improve multiple patient-centered outcomes, especially when provided early. Our goal is to show that our electronic health record (EHR) trigger tool is a cost-effective way for hospitals to identify patients who may benefit from early consultation, improving outcomes such as hospital length of stay and facilitating appropriate disposition for patients with metastatic cancer. Methods: Retrospective chart review of 721 patients at an urban community hospital who were identified by a trigger system integrated into the Emergency Department (ED) EHR. Patients who met criteria for a palliative consultation as determined by ED physicians at the time of inpatient admission were tracked by the palliative medicine department as part of a pilot phase. Those that were triggered and received usual care made up the control group. The intervention group was made up of patients who were triggered and seen in consultation. Results: Patients who were seen within 3 days of trigger were found to have a mean length of stay of 7.57 days, while those seen after 3 days had a mean length of stay 10.61 days. Patients who were triggered for metastatic cancer were found to have differences in final disposition between the two groups. Discharge to subacute rehabilitation facilities (SAR) in these patients decreased from 24% in the control group to 12% in the intervention group, while use of home hospice more than doubled to 11%. The percentage of these patients dying in the hospital decreased from 18% to 12%. Conclusions: Our study showed that earlier consultation was associated with shorter hospital length of stays if patients were seen within 3 days of being flagged as having palliative care needs in the ED. We also found that our EHR trigger doubled home hospice utilization in patients with metastatic cancer, decreased the proportion of discharges to SAR, and decreased in-hospital death in these patients.
Development and implementation of a clinical pathway for radiation of bone metastases on a palliative radiation oncology service.
Authors: Rotenstein Lisa , Killoran Joseph , Balboni Tracy A. , Krishnan Monica Shalini , Taylor Allison , Martin Neil E. 
Published: February 2017

170 Background: Clinical pathways increase compliance with treatment guidelines and reduce in-hospital complications. Evidence around treatment of complicated bone metastases is increasingly nuanced and although ASTRO/ACR recommend single fraction radiation therapy for uncomplicated bone metastases, implementation is variable. We sought to determine the effects of a bone metastases-focused clinical pathway on the practice patterns of our institution’s palliative radiation oncology service (SPRO), which sees 600 patients yearly and on a rotating basis, involves 23 physicians, 28 residents, 2 nurse practitioners, and 1 fellow. We hypothesized that pathway implementation would augment data-driven use of palliative radiation for bone metastases, including use of 8 Gy x 1 for uncomplicated metastases. It would also enhance physician efficiency and confidence. Methods: Using published literature, clinical guidelines, and expert input, we designed a comprehensive clinical pathway for bone metastases radiation. This was translated to a secure electronic interface as a decision support tool and integrated into daily SPRO workflows. Providers were surveyed pre and post implementation to assess expectations and elicit feedback. Rates of pathway compliance and reasons for non-compliance were assessed. Rates of 8 Gy x 1 use for uncomplicated metastases were compared pre and post implementation. Our aim was for approximately 70-80% on-pathway rates. Results: The final pathway, which includes twenty endpoints, integrates several validated scoring systems, including assessments of life expectancy, spinal stability, and appropriateness of surgical management. The pathway has been well received on the SPRO service, with addition of extra steps to workflows being the main cause of resistance to use. Data on rates of pathway adherence will be reported, and rates of 8 Gy x 1 use will be compared to the baseline of 22%. Conclusions: Our experience suggests the utility of pathways-based decision support for bone metastases radiation on a palliation consult service. Next steps include assessing the pathway’s effects on guideline-concordant care and calculating associated cost savings.