bluuebunny/crossref_metadata_2025_split huggingface dataset:
Pilot study to evaluate a novel advance-care planning tool to identify informed health care proxies in an oncology palliative care clinic.
Authors: Roeland Eric , Benn Melanie , Heavey Sean , Campillo Ashleigh , Revta Carolyn , Atayee Rabia S. , Ma Joseph D. 
Published: February 2017

136 Background: To increase the probability that cancer patients receive care consistent with their wishes, medical providers require simple, practical, and effective communication tools to initiate and complete meaningful advance care planning (ACP) discussions. Ideally, ACP discussions occur in the non-emergent setting with a selected health care proxy and trusted medical provider and may lead to completion of an advance directive (AD). The primary aim of this study is to determine the proportion of advanced cancer patients who identify an informed health care proxy implementing a novel ACP tool. Methods: In an American Cancer Society funded pilot study, advanced cancer patients were evaluated in an academic oncology palliative care clinic (n=35). Subjects engaged in a 1-hour ACP intervention completed by a licensed clinical social worker utilizing a novel ACP tool developed by the investigators. The ACP tool identifies a health care proxy and defines three key elements an informed health care proxy must know. Details of this ACP conversation were documented in the electronic medical record with the goal of completing an AD. After subject’s death, health care proxies were contacted to determine if end-of-life wishes were honored. Results: 35 subjects (51% woman, 71% Caucasian, 54% married) were enrolled with a mean age ± SD of 57.4 ± 14.1 years with gastrointestinal as the most common primary cancer (13/35). The ACP intervention was completed in 80% in 1-2 clinic visits. After the ACP intervention, 94% of subjects (33/35) identified an informed health care proxy. The most common identified health care proxies were either a spouse (17/35) or child (11/35). 43% of subjects (15/35) completed an AD after the ACP intervention. As of July 2014, 69% (24/35) of subjects had died and 71% of these (17/24) died in a setting consistent with their end-of-life wishes. Mean time to death from ACP intervention was 4.5 ± 3.2 months. 11 subjects remain in surveillance. Conclusions: Results suggest that this novel ACP tool facilitates successful identification of an informed health care proxy. Despite low AD completion, death consistent with end-of-life wishes was achieved in the majority of patients.
Structured advanced care planning facilitated by case managers.
Authors: Rackow Eric , Rodkey Wendy , Morrison Jackie 
Published: February 2017

142 Background: Although advanced care planning facilitates end-of-life decisions, less than half of severely or terminally ill patients have completed an advanced care plan. Accordingly, Humana launched a pilot of care manager-facilitated structured advanced care planning discussions among individuals with complex chronic conditions, including cancer. Process metrics were reviewed to determine whether the pilot would be scalable to a larger population. Methods: The pilot included two groups, 1) high-severity patients who had been receiving long term in-home care management for ≥30 days with a high comorbidity burden, and 2) functionally-challenged patients who had been receiving telephonic care management for ≥30 days and had a moderate comorbidity burden. Twenty care managers participated in 2 live and 9 virtual training sessions on the structured discussion approach. Care managers documented the following process metrics: number and length of structured advanced care planning discussions, number of advanced directives completed or updated, and number of times hospice services were reviewed. Results: Among the 169 high-severity patients in home settings, structured discussions occurred with 54.4% of the population, and 20.1% either updated or completed an advanced directive. Among the 106 functionally challenged patients receiving telephonic care management, 37.7% had structured discussions, and 13.2% either updated or completed an advanced directive. Hospice services were reviewed with 23.6% of the high-severity patients, and 3.7% of the functionally-challenged patients. The amount of time spent by the care managers was longer for the home consultations (average=15.1 minutes) compared to the telephonic consultations (average=10.24 minutes). Conclusions: In this pilot, a higher percentage of advanced care discussions were completed with high-severity patients receiving home care management than functionally-challenged patients receiving telephonic care management. The differences could be attributed many variables, including the health state or setting. This pilot was determined not to be scalable to a broader population, and alternative approaches for advanced care planning currently being evaluated.
Integration of system-level patient-reported outcome measurement into everyday clinical care: Lessons learned from the cancer care Ontario experience.
Authors: Molloy Sean , Pereira Jose , Green Esther , Dudgeon Deborah Jane , Howell Doris , Krzyzanowska Monika K. , Mahase Wenonah , Tabing Reena , Urowitz Sara , Macdougall Laura 
Published: February 2017

159 Background: The goal of the collaborative is to improve the quality and consistency of physical and emotional symptom management across the cancer journey. Objectives are to promote the adoption of electronic symptom assessment using a standardized tool and to increase the clinical use of evidence based guidelines to effectively manage patient identified symptoms. Methods: The actions taken for this initiative are (a) manage cancer symptoms through a patient reported measurement tool; (b) improve the quality of symptom management through the uptake of symptom management guides and algorithms for care; and (c) drive improvement through the adoption of an electronic symptom assessment platform. The following aims were established for this work: (1) aim for symptom screening and assessment (70% of ambulatory cancer clinic patients are screened for symptom severity using ESAS at least once/month); (2) aim for symptom management (evidence from chart audits show intervention as per evidence based guidelines for patients reported symptom scores); (3) aim for patient satisfaction (90% of target population indicates that their health care team took their scores into consideration when developing a care plan); and (4)aim for evidence of use (90% of patients state that their doctor or nurse spoke with them about their symptom screen). Results: 60% of cancer patients are screened each month representing over 28,000 people. Six of fourteen cancer regions are above the provincial target of 70%, with some close to 90%. 92% of patients felt ESAS was important to complete to help health care providers know how they are feeling. Conclusions: Cancer Care Ontario has been able to drive improvements in symptom management through the implementation of system wide electronic symptom assessment. For other jurisdictions interested in adopting this approach, the following areas are critical for success: a) leadership at all levels of the system; b) clinical tools at the point of care; c) engagement of patients in the design of care; d) communications support to spread information to all stakeholders; and e) using to data to drive performance improvement and accountability.
Symptom burden, quality of life, and distress in acute myeloid leukemia patients receiving induction chemotherapy: A prospective electronic patient-reported outcomes study.
Authors: LeBlanc Thomas William , Wolf Steven , Davis Debra M. , Samsa Greg , Locke Susan C. , Steinhauser Karen E. , Ubel Peter A. , Tulsky James A. , Abernethy Amy Pickar 
Published: February 2017

167 Background: Induction chemotherapy for acute myeloid leukemia (AML) is more intensive than many solid tumor treatments, and may be associated with a different symptom burden. Little is known about the most prevalent symptoms during AML induction, nor how they change over time. Methods: We enrolled AML inpatients at initiation of induction chemotherapy, and assessed their symptoms, quality of life (QoL), and distress weekly during their month-long hospitalization for treatment, using 3 validated instruments: Patient Care Monitor v2.0 (PCM); Functional Assessment of Cancer Therapy–Leukemia (FACT-Leu); and NCCN distress thermometer (DT). Here we report results from the first 16 enrolled patients, using standard descriptive statistics. Results: Mean age of study participants was 59.6 (SD 12.2), and most were newly diagnosed with AML (SD 87.5%, n=14). Patients were mostly high-risk for recurrence, with 50% (8) being >60 years old and 71% (10) having high-risk cytogenetics. Fatigue was the most prevalent symptom, with an average of 59% of patients reporting moderate to severe fatigue at each assessment. The other most prevalent moderate/severe non-functional symptoms were dysgeusia (50%), dry mouth (42%), diarrhea (41%), decreased appetite (37.5%), insomnia (37.5%), daytime sleepiness (36%), nausea (36%), hair loss (36%), and mouth sores (34%). Median QoL by FACT-Leu total score decreased substantially between weeks 1 and 2 (118.5 to 104.5); the most substantial decrements were in subscales for personal well-being and functional well-being (20.5 to 14.5, and 13.5 to 8.5, respectively). QoL did not return to baseline by week 4. Median DT score at baseline was 6.5, with a trend towards weekly improvements in distress (DT = 3 at week 4). Depressive symptoms like hopelessness and sadness were reported by an average of 25% and 31.3% of patients, respectively. Conclusions: AML patients receiving induction chemotherapy have significant symptom burden, impaired QoL, and psychological distress. The prevalence of these issues suggests sizeable unmet palliative care and psychosocial needs in AML patients receiving induction chemotherapy.
Development and validation of a patient-reported tool to evaluate legal and financial needs in patients with advanced cancer.
Authors: Kamal Arif , Bain Richard Morgan , Zafar Yousuf , Uronis Hope Elizabeth , Strickler John H. , Nicolla Jonathan , Goodman Abigail H. , Liu Chrissy 
Published: February 2017

174 Background: Cancer patients frequently report problems with finances, housing, advance care planning, and work-related issues. Because of these complex legal needs, cancer centers are developing Medical-Legal Programs (MLP) to connect referred patients with legal professionals. These programs lack validated screening methods to target services to those with the greatest legal distress. To date, no validated, patient-reported measure to assess the portfolio of legal needs has been developed for patients with cancer. Methods: We developed the Cancer Legal Screener to address five common domains within MLP practice: Housing; Income and Insurance; Employment; Family Stability; and Legal Status and General concerns. The 15 questions were then reviewed in two rounds for face validity by two of each: social workers, oncologists, palliative care physicians, attorneys, and lay persons. After two iterative updates, we piloted the screener in our palliative care and gastrointestinal malignancies clinics for six months. After participants completed the screener, they responded to a 10-item survey rating three areas: Consent/Presentation, Ease of Use, and Value to Care. Each question was measured on a 5-point Likert scale. Scores were weighted one through five and averages calculated. Results: We received scores from 79 patients. Their median age was 61 years; 39% were female, 29% were African-American. Regarding socioeconomic status, 75% had completed at least some college and 53% reported having an income level ≤ $50,000. During patient-reported validation testing, all 10 items across the three domains satisfied the feasibility criteria with average weighted satisfaction scores ranging from 3.22-3.89. Of patients surveyed, most indicated “Agree” or “Strongly Agree” regarding understandability of included questions (84%), prompts being “easy to follow” (81%), and “this form may help my doctors deliver better care” (63%). Conclusions: We have developed and validated one of the first patient-reported tools to assess medical-legal needs in patients with cancer. Future research will test triage models to target the appropriate legal resources to patients with the greatest legal needs.
The impact of radiotherapy technique on normal tissue dose in treatment of spinal vertebral metastases.
Authors: Pieters Richard S. , Kuo I-Lin Eric , Bornstein Bruce A , Fitzgerald Thomas J. 
Published: February 2017

179 Background: The optimal management of uncomplicated spinal vertebral metastases has yet to be determined. Preliminary evidence, suggesting single fraction therapy may be associated with fewer gastrointestinal side effects, did not report radiotherapy (RT) technique. Recent clinical experience with more advanced imaging and treatment delivery systems leads us to question if this approach is optimal given the radiation therapy dose to the surrounding normal tissues. The purpose of this study is to examine the impact of current RT techniques on normal tissue dose, which is known to affect acute tolerance of sensitive organs. The focus is on the bowel, an organ known for its radio-sensitivity which can impact quality of life. Methods: In a de-identified treatment planning CT of a patient with spinal metastases, the target volume of vertebrae from T9-L5 was defined and the normal bowel was outlined. Five RT techniques were planned: 1) the former standard, posterior/anterior (PA) 6MV field prescribed to a depth of 5 cm, 2) a PA 18MV field prescribed to a depth of 5 cm, 3) an opposed AP/PA dual energy plan, weighted posteriorly 2:1, 4) a 3-field 18MV plan (PA & 2 posterior oblique fields), and 5) an intensity modulated radiotherapy (IMRT) plan, using 4 arcs. The last 3 techniques were optimized to minimize anterior dose to the bowel. Results: The 5 techniques delivered varying RT doses (Dmax%) to the bowel ranging from the highest (AP/PA dual energy plan) to the lowest (IMRT), expressed as a percentage of the prescription dose. Conclusions: Single fraction RT techniques, with the exception of IMRT, approach tolerance (Dmax%) for some bowel tissue, which may preclude retreatment. IMRT would also allow for dose escalation to the spinal target volume, possibly improving efficacy and reducing the need for retreatment. Future studies should report RT technique, dose and fractionation to optimize efficacy and tolerance. [Table: see text]
Relationship of peripheral neuropathy grades with increase of skin perfusion by compression therapy for breast cancer patients.
Authors: Ohno Tsuyoshi , Mine Takashi , Yoshioka Hiroki , Kosaka Mikiko , Matsuda Sadayuki , de Kerckhove Maiko , de Kerckhove Charles , Matsuo Shigetoshi , Azuma Takashi , Sanada Yuichi , Mishima Takehiro , Inoue Satoshi , Hamada Takashi 
Published: February 2017

182 Background: Chemotherapy-induced peripheral neuropathy (CIPN) has become a substantial problem because of specific cytotoxic agents such as nab-paclitaxel, oxaliplatin, and eribulin. In addressing CIPN-related side effects caused by nab-PTX, we previously reported better CTCAE v4.0 grades and superior nab-PTX dose maintenance in breast cancer treatment adopting our 3S approach. Our 3S approach combines compression therapy (stockings and sleeves applied 24 hours from the beginning of nab-PTX administration) with medication therapy (selected prophylactic medications goshajinkigan, lafutidine, and mecobalamin applied over the course of treatment). In revisiting how stocking use restored skin perfusion levels decreased by nab-PTX chemotherapy, we examined whether the skin perfusion increases differ by CIPN grade. Methods: Using a laser Doppler blood flow meter with integrated probe (NL-101 Nahri Nexis Japan), we measured the skin perfusion of the lower limbs before and after stocking use across four groups: three groups of 3S prophylactics-treated nab-PTX patients divided by CIPN grade (Grade 0 [G0, n=12], Grade 1 [G1, n=20], Grades 2 and 3 combined [G2+3, n=12]), and one control group of healthy volunteers (GH, n=50). Results: In the control group (GH), the mean increase in skin perfusion level (mL/min/100g) after wearing stockings was 0.90 (SD= 3.36). For the 3S prophylactic treatment patients, the mean increase was 4.25 (4.98) in the G0 group, 2.11 (4.93) in the G1 group, and 2.69 (2.53) in the G2+3 group. ANOVA analysis indicated a significant difference in skin perfusion increase among the groups (p=0.0493). Analysis between the groups indicated significance in the G0 group increase over the control group increase (p=0.0255). Conclusions: CIPN was previously shown to decrease skin perfusion; in the current study skin perfusion responsiveness to stockings differed significantly between chemotherapy patients and healthy volunteers. Restorative skin perfusion increase is potentially related with alleviating CIPN grade, for which further evaluation is needed.
Differences in performance status assessments between palliative care specialists, nurses, and oncologists.
Authors: Kim YuJung , Zhang Yi , Park Ji Chan , Hui David , Chisholm Gary B. , Williams Janet L. , Bruera Eduardo 
Published: February 2017

19 Background: The Eastern Cooperative Oncology Group (ECOG) performance status (PS) is one of the most commonly used assessment tools among oncologists and palliative care specialists caring advanced cancer patients. However, the inter-observer difference between the oncologist and palliative care specialist has never been reported. Methods: We retrospectively reviewed the medical records of all patients who were first referred to an outpatient palliative care clinic in 2013 and identified 278 eligible patients. The ECOG PS assessments by palliative care specialists, nurses, and oncologists, and the symptom burden measured by Edmonton Symptom Assessment Scale (ESAS) were analyzed. Results: According to the pairwise comparisons using Sign tests, palliative care specialists rated the ECOG PS grade significantly higher than oncologists (median 0.5 grade, P<0.0001) and nurses also rated significantly higher (median 1.0 grade, P<0.0001). The assessments of palliative care specialists and nurses were not significantly different (P=0.10). Weighted kappa values for inter-observer agreement were 0.26 between palliative care specialists and oncologists, and 0.61 between palliative care specialists and nurses. Palliative care specialists’ assessments showed a moderate correlation with fatigue, dyspnea, anorexia, feeling of well-being, and symptom distress score measured by ESAS. The ECOG PS assessments by all three groups were significantly associated with survival (P<0.001), but the assessments by oncologists could not distinguish survival of patients with PS 2 from 3. Independent predictors of discordance in PS assessments between palliative care specialists and oncologists were the presence of an effective treatment option (odds ratio [OR] 2.39, 95% confidence interval [CI] 1.09-5.23) and poor feeling of well-being (≥4) by ESAS (OR 2.38, 95% CI 1.34-4.21). Conclusions: ECOG PS assessments by the palliative care specialists and nurses were significantly different from the oncologists. Systematic efforts to increase regular interdisciplinary meetings and communications might be crucial to bridge the gap and establish a best care plan for each advanced cancer patients.
Supporting meaningful advance care planning: A quality-improvement initiative to enhance number and preparedness of individuals selected as medical power of attorney.
Authors: Zhukovsky Donna S. , Gaeta Maria Susan , Stepan Karen , Meyer Margaret W. 
Published: February 2017

201 Background: Few health care organizations have successfully implemented a systematic process for meaningful advance care planning (ACP). An available and capable medical power of attorney (MPOA) allows early engagement in the process and is a foundation for successful ACP. As a first step, we implemented a quality improvement (QI) initiative to systematically offer patients (pts) an opportunity to select a MPOA that is valid*, incorporating quality measures to better prepare selected individuals for medical decision-making in a manner that supports the patient’s values and goals. Here we report on yield of valid MPOA documents (MPOAD) obtained. Methods: After QI Assessment Board approval was obtained, baseline data were collected for all head and neck medical oncologists (HNMO) over a 2-week period. In cycle 1, electronic health records (EHR) of pts seen by 2 HNMO were screened by clinic RN for MPOA. Those with MPOAD that were not available in EHR underwent RN follow up. All others were referred to social work (SW) for education regarding value of MPOA and factors important to preparation of decision maker. In cycle 2, revisions made to process included limiting targeted pts to new pts and consults (NPC). Results: See Table. Conclusions: Systematic SW contact and counseling increases the yield of valid MPOA, but is still insufficient for optimal results. Additional measures to be evaluated in future cycles include scheduled appointments for all NPC to increase SW contact, tighter follow up after initial SW contact and MD discussion with NPC to indicate importance of selecting a prepared MPOA. [Table: see text]
PROMs from hospital to hospice.
Authors: Teunissen Saskia cornelia , De Graeff Alexander 
Published: February 2017

209 Background: Symptom burden in advanced cancer patients (pts) influences quality of life (QoL) and should be leading in advanced care planning for both hospital and hospice populations. The objective is to describe the course of symptomburden in those patients over time. Methods: Symptoms were biweekly assessed with the self-assessment tool Edmonton Symptom Assessment System (ESAS; Dutch translation) in a prospective longitudinal study of hospitalized patients and patients admitted to a hospice. Prevalence and intensity data were entered in a web-based database by distinguishing patients into 3 groups regarding the aim of palliative care: tumor palliation, symptom palliation and terminal care. Results: 808 pts included, mean age 65 (18-93), 57% female; 224 (30%) pts admitted in the hospice-setting, 584 (70%) in a medical oncology ward. The care aimed 36 % tumor palliation, 59% symptom management, 4% terminal care. Most prevalent symptoms were similar in hospital and hospice: fatigue, anorexia, dry mouth, pain, constipation. The highest clinical relevance (score > 4 on NRS 0-10; 0 = no symptom, 10 = worst symptom) was found in hospital for fatigue (56%), anorexia (54%), constipation (48%), dry mouth (44%), pain (33%). In hospice patients fatigue (88%), dry mouth (66%), anorexia (63%), pain (4%), constipation (40%). In both care settings same national guidelines for symptom management are used as bottom line for interventions. 48% hospital patients scored > 4 for overall wellbeing (0= very good, 10 = very bad) vs 68% in hospice. In the hospice cohort pts are discriminated by prognosis, symptomburden, QoL: > 3 months survival, 2 – 12 weeks, < 2 weeks. Analysis is ongoing, data will be presented at the conference. Conclusions: The course of symptom intensity in advanced cancer populations in hospital and hospice setting is quite similar. A combination of general, specialized and expert palliative care competencies are needed during the cancer continuum. Prospective monitoring of patients during the continuum is a methodological and practical challenge.