bluuebunny/crossref_metadata_2025_split huggingface dataset:
Palliative care from cancer diagnosis for all: Memorial Sloan Kettering’s “One-Two-Three” program.
Authors: Epstein Andrew S. , Klimek Virginia M. , Chow Kimberly , Desai Anjali V. , Wan Peter Justin , Anderson Kelley , Ranghan Coleen , Okpako Molly , Rawlins-Duell Robin , Kramer Dana , Goldberg Jessica , O'Shea Debra , Nelson Judith Eve 
Published: November 2017

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

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

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

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

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

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

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

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

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

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