bluuebunny/crossref_metadata_2025_split huggingface dataset:
Can we skip the simulation step for radiation treatment planning in patients with symptomatic bone metastases?
Authors: WANG Tingyu , Liu Tian , Chao Ming , Sheu Ren-Dih , Tam James , Dharmarajan Kavita Vyas 
Published: October 2023

255 Background: Patients with bone metastases may require urgent radiation treatment (RT) due to severe pain, neurologic or other symptoms. Conventional approaches typically involve a 3-step process: initial consultation, followed several days later by a planning CT (pCT) simulation and dosimetric planning, and finally RT delivery. The time frame from consultation to RT can be up to 2 weeks, overly lengthy for severely symptomatic patients. We explored the viability of using diagnostic CT (dCT) imaging, usually available to radiation oncologists at the time of consultation, for RT planning - with the ultimate goal of removing the simulation step to reduce the interval from consultation to RT. In this initial phase of the project, we set out to compare differences in key dosimetric parameters from dCT- and pCT- generated RT plans. Methods: We retrospectively reviewed patients (n=28) treated for bone metastases at a single academic institution from 2020-2023. We utilized rigid image registration to transfer physician contours from pCT images to dCT images to account for changes in patient positioning. Beam arrangements, energies, and administered monitor units were also transferred from the pCT to the dCT for accurate dose calculation. We calculated RT dose coverage of each target metastasis using “V100”, or the percentage of the target lesion receiving 100% of the RT prescription dose. Correspondingly, the “V95” and the maximum point dose (“hotspot”) in patients were also calculated. Results: Out of 28 patients, 24 were treated to single and 4 to multiple (2-4) bone metastases. We excluded patients who had no dCT (n=7) or whose body positioning on the dCT (e.g. arms) created obstructions for beam arrangements (n=2). Eventually, 24 clinical plans made from 19 patients’ pCTs were migrated to their dCTs to generate comparable dosimetric plans. For all 24 dCT-based plans (12 spines and 12 extremities), the mean full dose coverage V100 decreased by 7.14% ± 15.89%. Overall, the plans had 91.14% ± 18.6% for V95 to PTV. Hotspots rose by 2.75% ± 3.61%. Two cases were observed to have full-dose-coverage drop over 40%: one was caused by patient’s outline change induced by different couches used for diagnosis and simulation, and the other one had an initial coverage of 57.6% for V100 in the original clinical plan. The remaining plans had a drop of 3.14% ± 8.37% on V100, and 96.1% ± 8.2% for V95. Conclusions: It was feasible to generate radiation treatment plans for bone metastases with good tumor coverage using dCT imaging. Patient selection plays a crucial role in dCT-based treatment planning, as the dose distribution is highly sensitive to anatomical variations resulting from patient positioning. This treatment planning approach circumvents the simulation step and would reduce patients' wait time for RT, thereby enabling more rapid access to RT for patients suffering with symptoms from bone metastases.
Assessing the utilization of palliative care services in the management of patients with metastatic pancreatic adenocarcinoma.
Authors: Gandhi Sonal , Moss Drew , Sheppard Richard Stephen , Omore Ibrahim , Wu Linda , Cohen Deirdre J. , Smith Cardinale B. 
Published: October 2023

256 Background: Pancreatic Cancer is known to be associated with poor survival outcomes and high symptom burden. Integration of early palliative care has been associated with improved end of life care, including reduced hospitalizations and emergency room visits. We conducted a retrospective study to determine the utilization rates of specialist palliative care in patients diagnosed with metastatic pancreatic cancer at an academic teaching hospital and summarize the impact on end-of-life care. Methods: A database of patients diagnosed with metastatic pancreatic cancer on index presentation from 2011 and 2022 was analyzed for utilization of specialist palliative care. Patients who transitioned cancer care to other centers and those who were lost to follow-up were excluded. Data on patient demographics, treatment course, and end-of-life care were collected, and descriptive statistics were used to summarize the data. Results: In our study, 168 patients met the inclusion criteria. The average age of diagnosis was 66 years with a diverse ethnic composition, including White (35.7%), African American (26.8%), and Hispanic (15.5%) patients. Among the cohort, 126 out of 168 (75%) patients were seen by palliative care at least once, with 79 (62.7%) of them initially seen during one of the hospitalizations, and 47 (37.3%) were seen by palliative care outpatient for the first time. The median duration between pancreatic cancer diagnosis and first encounter with palliative care was 145 days (IQR 305 days). No significant differences were found in terms of age, race, sex, ethnicity or insurance type between patients who received palliative care and those who did not. The median time from consultation to death was 57 days and 36.5% patients received palliative care only within one month of their death. Patients who received palliative care were more likely to have a DNR/DNI code status (86.7% vs. 13.3%, p < 0.001) and were more likely to be enrolled in hospice care (86.3% vs. 13.7%, p < 0.001). Conclusions: Early involvement of specialist palliative care in management of patients with metastatic pancreatic cancer may lead to optimization of health care services with earlier hospice referrals and comfort directed care at the end of life. Further research is warranted to explore the impact of palliative care on patient outcomes, quality of life, and the potential benefits of aligning treatment decisions with patients' end-of-life preferences.
EHR-based process to reduce no-shows at the outpatient supportive care clinic at a tertiary cancer center.
Authors: Admane Sonal , Bansal Anjuly , Joy Manju P , Kheirkhah Parviz , Castro Debra , Edwards Tonya , Pangemanan Imelda , Stewart Holly A. , Dalal Shalini , Haider Ali , Amaram-Davila Jaya Sheela , Reddy Akhila , Bruera Eduardo 
Published: October 2023

263 Background: No-Shows are pervasive across healthcare systems and are associated with interrupted clinical workflows, increased cost, healthcare utilization, and increased morbidity, and mortality. In palliative care, patients who miss their appointments are more likely to have uncontrolled symptoms, frequent Emergency Room visits, and unplanned hospitalization. There is an ongoing need to reduce no-shows to improve patient outcomes. Methods: The aim of this quality improvement (QI) project, launched in September 2022 at the outpatient supportive care center (SCC) at the University of Texas MD Anderson Cancer Center, was to reduce overall no-shows by process improvement in the targeted areas. We developed a process map and Ishikawa diagram to outline workflow and reasons for no-shows. Based on the results of a previous study from our center, 8% of no-shows were due to hospitalization. We used the Plan Do Study Act (PDSA) tool. We developed an electronic query for the Electronic Health Record (EHR) to identify hospitalized patients with an upcoming appointment at SCC in the next 10 days. We redesigned the clinical workflow to generate a daily list of such appointments which were canceled and replaced by patients on the waitlist. We assessed overall no-show rate and rate specific to hospitalizations for our center monthly for eight months. This QI project was approved by the Quality Improvement Assurance Board at the University of Texas MD Anderson Cancer Center. Results: Overall no-show rate was 12% before intervention (BI) and decreased to 8% after intervention (AI), measured at 8 months. No-show rate due to hospitalizations decreased from 9% BI to 2% AI. Telehealth visits had a lower rate of no-shows (5.9%) than in person visits (10.4%). No-show rates did not differ based on days of the week (median 7.4%, SD 0.3%), and the type of visit - consult vs. follow-up (8% vs. 7%). Conclusions: Clinical workflow redesign using EHR at our SCC decreased no-shows due to hospitalization, thereby reducing overall no-show rate by 33% of the original. However, most no-shows are due to reasons other than hospital stays, and more research is needed to identify these patient and system level factors.
BE-A-PAL: Behavioral economics and automated analytics to improve palliative care among patients with advanced cancer.
Authors: Mudumbi Sandhya , Bilbrey Larry Edward , Ferrell William , Johnson Nicole , Steckel Jenna , Schleicher Stephen Matthew , Dickson Natalie R. , Bekelman Justin E. , Parikh Ravi Bharat 
Published: October 2023

268 Background: Patients with advanced solid malignancies often experience high symptom burden and aggressive end-of-life care. Early specialist palliative care (PC) can improve symptom management, mood, and quality of life. However, many patients do not receive PC before they die, with clinician inertia and difficulty identifying high-risk patients being barriers to initiating PC referrals. Methods: In a 2-arm pragmatic randomized clinical trial among patients with stage 3 or 4 lung or non-colorectal gastrointestinal malignancies, oncology clinics were randomly assigned to intervention or usual practice. In the intervention arm, oncologists received automated algorithm-based default notifications prompting specialty PC referral. The control arm received usual care, in which oncologists could refer to PC at their discretion. The algorithm was adapted from NCCN guidelines, identified high-risk patients based on prognosis or symptom/psychosocial burden, and was integrated into the EHR. Oncologists were alerted weekly about eligible patients and had the option to opt-out of PC referral. If there was no response or agreement, a PC coordinator introduced and offered a PC visit to the patient. The primary outcome was a completed PC visit within three months of identification among high-risk patients. We report descriptive results from an interim analysis of the trial. Results: 15 practices (7 clinics and 32 physicians in intervention; 8 clinics and 31 physicians in control) and 567 patients (299 intervention; 268 control) were randomized. Rates of completed early PC visits were 46.4% (139/299) the intervention arm and 11.2% (30/268) in the control arm. The opt-out rate in the intervention arm was 10.7%. Among clinicians who did not opt-out, 79% of their patients agreed to an initial PC visit. Adjusted analyses and demographic data will be completed and available by September 2023. Conclusions: Algorithm-based default PC referrals meaningfully increased utilization of specialty PC within a community oncology practice. Targeting high-risk patients using guideline-based risk stratification prevented overwhelming PC capacity. Further analyses will assess the impact of the intervention on end-of-life care, acute care utilization, patient-reported outcomes, and explore clinician perspectives. Clinical trial information: NCT05590962 .
Perceptions of palliative care knowledge among Hispanics in the United States: An analysis of the Health Information National Trends Survey data.
Authors: Kedia Sapna , Rose Brandon Edward , Kareff Samuel A. , Rodriguez Estelamari , Mahmood Asos 
Published: October 2023

270 Background: Patient knowledge of palliative care (PC) has been demonstrated to improve the quality of end-of-life care. Current evidence indicates decreased knowledge of PC and decreased utilization of services such as hospice and advanced directives among Latinos in the US. Hispanic Americans make up 18.9 % of the US population, however, categories of Latino and Hispanic are broad and encompass different ethnic groups, each with unique cultures and experiences. Previous research has demonstrated different ethnicities have differing perspectives on end-of-life care. In this study, we aim to investigate variations in knowledge of PC between different Latino ethnic subgroups in the US. Methods: We employed data from the National Cancer Institute’s Health Information National Trends Survey (HINTS5–Cycle 2; 2018) for a nationally-representative sample of 3,504 adults (aged ≥18 years). Lack of knowledge of PC was assessed by respondents’ selecting “I’ve never heard of it” when asked, “How would you describe your level of knowledge about palliative care?” We performed a binomial regression assessing knowledge of PC and comparing this answer choice between Hispanic and non-Hispanic respondents as well as a Wilcoxon-Mann-Whitney test to compare among Hispanic subgroups. Results: Of all 3,504 survey respondents, 13.07% self-identified as Hispanic, and 65.2% stated they had never heard of palliative care. In the ethnic subgroups analyzed, 173 (79.4%) Mexicans, 33 (71.7%) Puerto Ricans, and 11 (55%) Cubans reported they had never heard of PC compared to 689 (62.2%) of non-Hispanics. We used a binomial regression to compare this response in Hispanics vs. non-Hispanics and found a significant difference in PC knowledge between Hispanics and non-Hispanics (p < 0.001), with an OR of 0.469 between the lack of PC knowledge answer choice and selecting Hispanic (95% CI 0.37-0.6). A Wilcoxon-Mann-Whitney comparing PC knowledge by subgroups found a significant difference between non-Hispanics and Mexicans (p< 0.001) but no differences between Hispanic sub-groups. Conclusions: Hispanics had lower levels of knowledge of PC than non-Hispanics. When stratified by Hispanic subgroups, only Mexicans had significantly lower PC knowledge than non-Hispanics. This calls for further research into why this ethnic group has lower knowledge of PC and what potential moderating factors could affect this association. Additionally, we need more studies on US Hispanics’ level of PC knowledge to assess if the trends seen between Hispanic subgroups in this survey are replicated.
Knowledge of palliative care and barriers to access among outpatients with cancer.
Authors: Schlichte Lindsay , Hildenbrand Jordan , Wolf Steven , Herring Kris W. , Troy Jesse D , LeBlanc Thomas William 
Published: October 2023

271 Background: Integrated specialist palliative care (PC) is known to improve outcomes among ambulatory patients with cancer, yet it remains underutilized for this population. It is known that PC is poorly understood among the public, however very little is known about what ambulatory patients with cancer understand about PC or what barriers to access exist. Methods: Outpatients undergoing cancer treatment completed a survey evaluating their familiarity and knowledge of PC (Palliative Care Knowledge Scale; PaCKS), feelings towards PC (before and after reading a standardized definition of PC), barriers to PC, prognostic awareness, and health literacy. We examined variables associated with participants’ familiarity with PC and current interest in receiving PC by fitting logistic regression models. To determine if there was a difference in patients’ feelings toward PC before and after reading the standardized definition, a Chi-Squared test was conducted. All other responses were summarized descriptively. Results: Of 151 participants, 58.9% reported familiarity with palliative care. The average PaCKs score was 11.9 (standard deviation 1.4), and 46.4% of patients received a perfect score, indicating high knowledge of PC overall. Only time since diagnosis (> 1 year vs < 1 year) was associated with significantly increased odds of being familiar with PC (OR 2.93; 95% CI 1.37-6.25). After reading the standardized definition of PC, participants reported feeling significantly less anxious and more reassured; however, more participants were interested in receiving PC in the future compared to at the time of survey completion (74.2% vs 44.4%, respectively). Patients with stage III or IV cancer had significantly increased odds of having interest in receiving PC at the time of study completion compared to patients with stage I or II (OR 2.66; 95% CI: 1.05, 6.76). Having an aggressive cancer was not associated with interest in receiving PC at the time of study completion. Logistic barriers (additional travel or time at the hospital) were commonly reported barriers to attending palliative care appointments. Conclusions: Outpatients with cancer who are being treated at a large academic cancer center have higher familiarity and knowledge of PC than the average American adult. Despite this, anxiety surrounding PC and hesitations regarding early integration of PC persist. Therefore, factors outside of knowledge may be perpetuating the delayed or lack of involvement with PC in oncology. Future work must seek to overcome these barriers to PC integration in outpatient cancer care.
Total and treatment-related costs of care associated with in patients with metastatic renal cell carcinoma receiving targeted or immune therapy.
Authors: Rahman Syed N. , Long Jessica B. , Westvold Sarah J. , Wheeler Stephanie B. , Spees Lisa P. , Leapman Michael , Hurwitz Michael E. , McManus Hannah Dzimitrowicz , Gross Cary Philip , Dinan Michaela Ann 
Published: October 2023

28 Background: Oral anticancer agents (OAA) and immunotherapy (IO) as initial treatments in metastatic renal cell carcinoma (mRCC) have yielded substantial improvements in disease control and survival but may increase costs. OAA monotherapy has decreased in recent years and use of IOs has increased dramatically, however, their impact on costs in patients with mRCC has not been examined at the population level. Methods: Retrospective cohort study of Medicare beneficiaries over age 65 diagnosed with mRCC from 2015 through 2019, who were enrolled in Medicare Part D for at least 1 year after diagnosis and received OAA or IO within a year of diagnosis. We summarized Medicare payments and out-of-pocket (OOP) responsibility in the year following diagnosis stratified by type of initial treatment and cost component (Treatment, Inpatient, and Outpatient). Dollar amounts were adjusted to 2019 using the Urban All Consumers Price Index. We used multivariate generalized linear models with a gamma distribution to assess the relationship between demographic and treatment variables and costs. All reported differences were significant with p < 0.001. Results: The study sample included 6183 patients. Initial therapy was an OAA in 3630 patients (59%), IO in 2034 patients (33%), and combined OAA+IO in 519 patients (8%). Total mean Medicare payments were substantially higher in patients receiving combination therapy (OAA+IO $149,200) vs. monotherapy with IO ($104,800) or OAAs ($109,900). Direct treatment costs composed at least half of all costs for all patients, including those undergoing first line OAA (56%), IO (50%), or combination OAA+IO (69%) therapy. Costs increased over the study period, with metastatic diagnosis in 2019 vs. 2015 being associated with roughly 33% higher costs [aCRR1.33(1.26-1.40)]. Older age (≥ 81 vs age 66-70 [aCRR 0.74 (0.71-0.77)] and female sex [aCRR 0.93(0.90-0.95] were associated with lower total payments. Total OOP responsibility was higher for individuals who received IO ($18,500) compared to an OAA ($12,200). Those receiving OAA+IO had the highest OOP costs ($21,800). OAA+IO combination therapy was also associated with higher total Medicare payments compared to OAA [adjusted Cost Relative Ratio (aCRR) 1.36 (95% CI; 1.29-1.43)]. Conclusions: Direct costs of treatment are the primary drivers of costs in patients with mRCC initiating therapy during the first year of diagnosis, with half or more of total costs derived from treatment. OOP responsibility remained relatively steady from 2015 to 2019, while total costs to Medicare increased by a third. The recently passed Inflation Reduction Act may impact future total costs in patients with mRCC given the substantial contribution of direct treatment costs to overall costs in this population.
Frequency and characteristics of integrative oncology (IO) consults in patients with cancer receiving inpatient rehabilitation.
Authors: Gupta Ekta , Lopez Gabriel , Fu Jack Brian , Narayanan Santhosshi , Tennison Jegy , Bruera Eduardo 
Published: October 2023

285 Background: IO interventions may provide patients with cancer with relief of physical, psychological, and social distress related to their disease and its treatments. Little is known about the frequency and predictors of IO referral for symptom management in cancer rehabilitation inpatients. Methods: This descriptive retrospective review identified the frequency and characteristics of cancer rehabilitation inpatients referred to IO from 5/2016-8/2019. Results: Out of 1196 inpatient rehabilitation admissions, 100 (8.4%) were referred to IO during the study period. Admission AMPAC 6-click scores were 15 (+/-6) for total mobility and 16 (+/-4) for activities of daily living (equates to a ˃ 50% degree of functional impairment). 35% had brain/spine cancer, 20% hematologic; 67% advanced/metastatic cancer. Top reasons for consultation to IO included: pain (73%), integrative approach (41%), relaxation (38%), stress/anxiety (33%), fatigue (27%), sleep disturbance (23%), spirituality (9%), neuropathy (8%), and nausea/vomiting (7%). Out of the 100 patients referred, 13 did not receive any intervention due to thrombocytopenia, leukopenia, or treatment not completed during hospitalization. Recommendations included: massage therapy (81/100) mostly for pain (94%) and fatigue (11%); acupuncture (53/100) for pain (70%), fatigue (32%), nausea/vomiting (16%), sleep (11%), stress/anxiety (8%), and chemotherapy induced peripheral neuropathy (6%); music therapy (14/100) for anxiety (57%), mood/depression (36%), rehabilitation support (29%), pain (21%), social interaction (14%), and other reasons such as fatigue, motivation (36%); and yoga (2/100) for stress/anxiety. A majority of patients referred to IO received at least one intervention: massage therapy (n=69), acupuncture (n=39), or music therapy (n=11). Conclusions: This exploratory study shows that a small percentage of cancer rehabilitation inpatients were referred to IO. Most patients did receive one or more IO interventions, with pain as the most common indication. Larger trials are needed to characterize the effects of IO on inpatient rehabilitation.