Outcomes of a specialized interdisciplinary approach for cancer patients with aberrant opioid-related behavior: A preliminary report

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Background: Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in cancer patients is lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention. Methods: The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015 and August 31, 2016 were reviewed. Results: At baseline, pain intensity (p=0.002) and opioid dose (p=0.001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from 3 pre-intervention to 0.4 post-intervention (p<0.0001). The median morphine equivalent daily dose decreased from 165mg/day at the first intervention visit to 112mg/day at the last follow up (p=0.018) although pain intensity did not significantly change (p= 0.984). ‘Request for opioid medication refills in the clinic earlier than the expected time’ was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age (p<0.0001) and higher ESAS anxiety score (p=0.005) were independent predictors of the presence of AB. Conclusions: The intervention was associated with a reduction in the frequency of AB and opioid utilization among cancer patients receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention. [Table: see text]

Cranial electrotherapy stimulation for the management of depression, anxiety, sleep disturbance, and pain in patients with advanced cancer: A preliminary study

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Background: Cranial Electrotherapy Stimulation (CES) is a safe modulation of brain activity for treating depression, anxiety, insomnia, and pain. However, there are no published studies in patients with advanced cancer (ACP).The aim of the study was to determine the feasibility and preliminary efficacy of a 4-week CES intervention on depression, anxiety, sleep disturbance, and pain scores. Concurrent salivary biomarker studies were conducted. Methods: In this one group open label pre- and post-intervention study with a 4-week CES intervention, ACP’s with one or more of four moderate intensity (≥3/10) ESAS symptoms (depression, anxiety, sleep disturbance, and pain) were eligible. Adherence (0-100%), satisfaction rates(0-10), and safety were assessed. ESAS, HADS, PSQI, BPI, and salivary levels (cortisol, alpha amylase, CRP, and IL-1 beta and IL-6) were assessed from baseline to week 4. Results: 33/38(87%) completed the CES. Median (IQR) adherence for days with 60 min CES use and satisfaction scores were 93(89-100)% and 10(9-10) respectively. CES use was safe (no grade 3 or higher adverse events). HADS anxiety (p < 0.001), HADS depression (p = 0.024), ESAS anxiety (p = 0.001), depression (p = 0.025), BPI pain (p = 0.013), PSQI daytime dysfunction (p = 0.002), and Medication use (p = 0.006) scores improved after 4 week CES treatment. There was no significant change in the salivary cortisol, alpha-amylase, CRP, IL-1β, and IL-6 levels after 4 weeks of CES. Conclusions: In this preliminary study we found that the use of cranial Electrotherapy stimulation (CES) was safe and feasible in ACP. The use of CES was associated with significant improvement of depression, anxiety, pain, and sleep scores. These findings support further studies of CES in ACP for symptom control.

Frequency and factors predicting the risk for aberrant opioid use in patients receiving outpatient palliative care at a comprehensive cancer center

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Background: Opioid misuse is a growing crisis among patients with chronic pain. Cancer patients at risk of aberrant drug behaviors (ADB) are frequently underdiagnosed in routine cancer care. The aim of this study was to determine the frequency and factors predicting risk for Aberrant Opioid and Drug use among Patients receiving Outpatient Supportive Care Consultation at a Comprehensive Cancer Center Methods: In this retrospective study, 690 consecutive patients referred to a supportive care clinic were reviewed. Patients were eligible if they were ≥18 years, had a diagnosis of cancer, and were on opioids for pain for atleast a week. All patients were assessed with the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID. At risk patients with aberrant opioid behavior (+Risk) was defined as SOAPP-14 score ≥7. Descriptive statistics, spearman correlation coefficient, multivariate analysis were performed. Results: 690/752 consults were eligible. A total of 135(20%)were +risk. 69(11%) were CAGE-AID +.SOAPP-14 scores were positively associated with CAGE-AID p < 0.001; male gender p = 0.007; ESAS pain p = < 0.006; ESAS depression p < 0.001; ESAS anxiety, p < 0.001, and ESAS financial distress p = < 0.001. Multivariate analysis indicated that the odds ratio for +Risk was 2.47 in patients with CAGE-AID+ (p < 0.001), 1.95 for male gender (p = 0.005), 1.11 per point for ESAS anxiety (p = 0.019), and 1.1 per point. for ESAS financial distress (p = 0.02). Conclusions: 20% of cancer patients on opioids presenting to supportive care center are at risk of aberrant drug behavior. Male patients with anxiety, financial distress, and prior alcoholism/illicit drug use are significant predictors of +Risk. Further research to effectively manage these patients is needed.

Outcomes of an innovative six-week standardized residential training course for physicians and nurses to provide primary palliative care in India

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Background: The National Program on Palliative Care (NPPC) by the Government of India has emphasized the need for training clinicians in providing palliative care (PC) with minimum of 6 weeks of residential training. However, there are limited studies on feasibility of such standardized training in PC offered to palliative care providers interested in transition to palliative care. Aim: To evaluate the feasibility, and change in the self-reported perception of knowledge in palliative care following a 6 weeks standardized residential training course (SRTC) for physicians and nurses to provide primary PC in India. Methods: A 6 week standardized residential type educational program which combined didactics, and bedside hands on palliative care training by PC specialists in five preselected centers in India. To be eligible licensed physicians and nurses should, (a) qualify in focused interview aimed to evaluate both interest and commitment to provide primary palliative care following the training, (b) Agree to complete all the required surveys. Results: 46/53 (86%) completed the pre and post surveys. 50/53 (94%) participants completed the course and passed the certification exam. Median age (IQR) was 31 (27, 41). 53% were female and 53% were physicians. Median reported knowledge (1-5) for pain, fatigue, delirium, medical ethics were 4,3,2,2.5 before training Vs 5 (P=0.001), 5 (P=0.001), 5 (P=0.001), 5 (P=0.001) after training respectively. All other core areas improved significantly. All participants noted satisfaction with faculty as high (5/5). Conclusions: Conducting a six weeks standardized residential training course in PC for physicians and nurses in India is feasible. There was a significant improvement in self-reported knowledge of all components of palliative care curriculum. Long term impact studies are needed.

Outcomes of a Specialized Interdisciplinary Approach for Patients with Cancer with Aberrant Opioid-Related Behavior

BACKGROUND

Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in patients with cancer are lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention.

MATERIALS AND METHODS

The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015, and August 31, 2016, were reviewed.

RESULTS

At baseline, pain intensity (p = .002) and opioid dose (p = .001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from three preintervention to 0.4 postintervention (p < .0001). The median morphine equivalent daily dose decreased from 165 mg/day at the first intervention visit to 112 mg/day at the last follow-up (p = .018), although pain intensity did not significantly change (p = .984). "Request for opioid medication refills in the clinic earlier than the expected time" was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age (p < .0001) and higher Edmonton Symptom Assessment System anxiety score (p = .005) were independent predictors of the presence of AB.

CONCLUSION

The intervention was associated with a reduction in the frequency of AB and opioid utilization among patients with cancer receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention.

IMPLICATIONS FOR PRACTICE

There are currently no well-defined and evidence-based strategies to manage cancer patients on chronic opioid therapy who demonstrate aberrant opioid-related behavior. The findings of this study offer a promising starting point for the creation of a standardized strategy for clinicians and provides valuable information to guide their practice regarding these patients. The study results will also help clinicians to better understand the types and frequencies of the most common aberrant behaviors observed among patients with cancer who are receiving chronic opioid therapy. This will enhance the process of timely patient identification, management, or referral to the appropriate specialist teams.

Could Objective Tests Be Used to Measure Fatigue in Patients With Advanced Cancer?

CONTEXT

Assessment of cancer-related fatigue is currently based on patient-reported outcomes. We asked whether objective assessments, such as muscle strength and nutritional markers, can be used as surrogate measures of cancer-related fatigue.

OBJECTIVE

We examined the association among three fatigue scales, muscle strength, and nutritional markers in patients with advanced cancer.

METHODS

In this prospective study, we enrolled hospitalized cancer patients who had been seen in palliative care consultation at MD Anderson Cancer Center. We assessed fatigue using three fatigue scales-the Brief Fatigue Inventory (BFI), the Edmonton Symptom Assessment System (ESAS), and the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 (EORTC QLQ-C30)-and determined their association with objective assessments, including handgrip strength, maximal inspiratory pressure, lean body mass, phase angle, and albumin. Spearman's correlation test was used to assess associations.

RESULTS

Among 222 patients, the mean age was 55 years; 59% were women. The median overall survival was 106 days. The total BFI score had weak association with handgrip strength (ρ = -0.18, P = 0.007) and no association with the remaining objective measures. ESAS fatigue and EORTC fatigue showed similar findings. Total BFI had moderate-to-strong association with ESAS (ρ = 0.54, P < 0.0001) and EORTC (ρ = 0.60, P < 0.0001) fatigue.

CONCLUSION

Our study showed that subjective assessment of fatigue based on patient-reported outcomes correlates only weakly with muscle strength and nutritional markers; thus, patient-reported outcomes remain the gold standard for fatigue assessment.

Multimodal therapy for cancer related fatigue in patients with prostate cancer receiving radiotherapy and androgen deprivation therapy

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Background: There are limited studies to evaluate treatments that target causative mechanisms of Cancer-related-fatigue (CRF) using validated tools in a defined population. The objective is to determine the feasibility, and the preliminary estimates of the effects of various combinations of standardized exercise, cognitive behavioral therapy (CBT), and methylphenidate (multimodal therapy, or MMT) on CRF as measured by AUC of Functional Assessment of Chronic Illness Therapy- Fatigue (FACIT-F) subscale scores in Pts with prostate cancer receiving radiotherapy with androgen deprivation therapy. Methods: Prostate cancer Pts with CRF scheduled to receive radiotherapy with androgen deprivation therapy were eligible. Using a double blind (patient, investigators) randomized factorial study design, eligible Pts were randomized into 1 of the 8 arms, which included all possible combinations of the interventions (exercise, CBT, and methylphenidate) and/or their corresponding placebo treatments for a duration of 8 weeks. Results: 62/69 (89%) randomized Pts were evaluable. There were no differences in the demographics and baseline fatigue between groups. The adherence rates for pills, exercise and CBT were 96.5%, 67%, and 90% respectively. The study was feasible and there was no significant difference in adverse events by groups. Table 1 shows the comparison of AUC by treatment. For Pts receiving drug compared to placebo, the median FACIT-F AUC was 2328 vs 2095. The drug effect (estimate, 95% CI) in Pts who received Exercise was 596 (68.3, 1125); CBT was 354 (-121, 830); combined Exercise and CBT was -187 (-802,427); and control Exercise, control CBT was 294 (-192,781). Conclusions: Methylphenidate containing combinations were superior to no drug combinations. Methylphenidate + Exercise provided the best signal and should proceed to large randomized control trials. Clinical trial information: NCT01410942. [Table: see text]

Frequency and factors predictive of aberrant drug behavior in patients presenting to outpatient supportive care center at a comprehensive cancer center

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Background: Opioid misuse is a growing crisis in cancer patients. Cancer patients at risk of aberrant drug behaviors (ADB) are frequently underdiagnosed in routine cancer care. The aim of this study was to determine the frequency and factors associated with ADB using the “Screener and Opioid Assessment for Patients tool” (SOAPP-14) in cancer patients seen at the outpatient supportive care center. We also examined the screening performance of Cut Down, Annoyed, Guilty, and Eye Opener (CAGE-AID) as compared to The SOAPP-14 as a gold standard. Methods: In this retrospective study, 1108 consecutive patients referred to supportive care clinic were reviewed. Patients were eligible if they were ≥18 yrs, have a diagnosis of cancer, and were on opioids for pain for atleast a week. Patients’ demographics, the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID scores were analyzed. ADB+ was defined as SOAPP-14 score ≥7. Descriptive statistics, spearman correlation coefficient, multivariate, and ROC analysis were performed. Results: 703/1108 consults were eligible. A total of 153/703 (22%) were ADB +ve. SOAPP-14 scores were positively correlated with CAGE-AID r = .38, p < 0.001; male gender r = 0.11, p = 0.003; ESAS pain r = 0.11, p = 0.005; ESAS depression r = 0.22, p < 0.001; ESAS anxiety r = 0.22, p < 0.001, and ESAS financial distress r = 0.23, p < 0.001. Multivariate analysis indicated that the odds ratio for ADB +ve was 6.18 in patients with CAGE-AID+ (p < 0.001), 1.8 for male gender (p = 0.007), 1.1/pt. for ESAS anxiety (p = 0.044), and 1.1/pt. for ESAS financial distress (p = 0.007). A CAGE-AID score of 1/4 has a sensitivity of 47%, specificity of 89% positive predictive value 63.6% and negative predictive value 69.2%. Conclusions: Our study suggests that 22% of cancer patients on opioids presenting to supportive care center are at risk of aberrant drug behavior (ADB). Male patients with anxiety, financial distress, and prior alcoholism/illicit drug use are significant predictors of ADB’s. A cut off score of ≥1 out 4 on CAGE-AID questionnaire allows better screening of ADB in outpatient advanced cancer patients. Further research to effectively manage these patients is needed.

Increased Symptom Expression among Patients with Delirium Admitted to an Acute Palliative Care Unit

INTRODUCTION

Delirium is the most common neuropsychiatric condition in very ill patients and those at the end of life. Previous case reports found that delirium-induced disinhibition may lead to overexpression of symptoms. It negatively affects communication between patients, family members, and the medical team and can sometimes lead to inappropriate interventions. Better understanding would result in improved care. Our aim was to determine the effect of delirium on the reporting of symptom severity in patients with advanced cancer.

METHODS

We reviewed 329 consecutive patients admitted to the acute palliative care unit (APCU) without a diagnosis of delirium from January to December 2011. Demographics, Memorial Delirium Assessment Scale, Eastern Cooperative Oncology Group (ECOG) Performance status, and Edmonton Symptom Assessment Scale (ESAS) on two time points were collected. The first time point was on admission and the second time point for group A was day one (+two days) of delirium. For group B, the second time point was within two to four days before discharge from the APCU. Patients who developed delirium and those who did not develop delirium during the entire course of admission were compared using chi-squared test and Wilcoxon rank-sum test. Paired t-test was used to assess if the change of ESAS from baseline to follow-up was associated with delirium.

RESULTS

Ninety-six of 329 (29%) patients developed delirium during their admission to the APCU. The median time to delirium was two days. There was no difference in the length of stay in the APCU for both groups. Patients who did not have delirium expressed improvement in all their symptoms, while those who developed delirium during hospitalization showed no improvement in physical symptoms and worsening in depression, anxiety, appetite, and well-being.

CONCLUSION

Patients with delirium reported no improvement or worsening symptoms compared to patients without delirium. Screening for delirium is important in patients who continue to report worsening symptoms despite appropriate management.

Perception of Helpfulness of a Question Prompt Sheet Among Cancer Patients Attending Outpatient Palliative Care

BACKGROUND

Data on the use of question prompt sheets (QPSs) in palliative care are limited. Our team previously developed a single-page QPS using a Delphi process. The main objective of this study was to determine the perception of helpfulness of a QPS in patient-physician communication among advanced cancer outpatients.

METHODS

Hundred of 104 (96%) eligible patients and 68/68 (100%) caregivers received the QPS during their first palliative care clinic. Twelve palliative medicine specialists also participated in the study. Patient and physician perceptions about the QPS were assessed at the end of the visit. Patients' anxiety was also measured before and after consultation using the Spielberger State Anxiety Inventory.

RESULTS

Among the responders, most agreed that the material was helpful in communicating with their doctor (77%), clear to understand (90%), had the right amount of information (87%), and they would use a similar material in the future (76%) and recommend it to other patients (70%). Overall, 92% were satisfied with their consultation visit. Physicians perceived that the QPS was helpful in 68% of the encounters and it did not prolong the consultation in 73% of the encounters. Physician agreement on helpfulness of the QPS was not significantly different from that of the patients (P = 0.3). Patient anxiety improved after consultation from a mean (SD) Spielberger State Trait Anxiety Inventory score of 39.2 (12.8) to 33.8 (10.7), P < 0.0001).

CONCLUSION

The QPS was perceived as helpful in patient-physician communication among advanced cancer outpatients and it did not increase patient anxiety. Physicians similarly reported that the QPS was helpful and it did not prolong clinic visits. Further research is needed for its widespread adoption and integration into routine clinical practice.

Post-Discharge Survival Outcomes of Patients with Advanced Cancer from the University of Texas MD Anderson Cancer Center Investigational Cancer Therapeutics (Phase I Trials) Inpatient Unit

BACKGROUND

Patients with advanced cancer who progress on standard therapy are potential candidates for phase I clinical trials. Due to their aggressive disease and complex comorbid conditions, these patients often need inpatient admission. This study assessed the outcomes of such patients after they were discharged to hospice care.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with solid tumor malignancies who were discharged to hospice care from the inpatient service.

RESULTS

One hundred thirty-three patients were included in the study cohort. All patients had metastatic disease and an Eastern Cooperative Oncology Group performance status ≥3. The median survival after discharge to hospice from an inpatient setting was 16 days, with a survival rate of 5% at 3 months after discharge. The median survival after the last cancer treatment was 46 days, with survival of 17% at 3 months, and 5% at 6 months. Patients with lactate dehydrogenase (LDH) >618 IU/L had a median post-discharge survival of 11 days versus 20 days for patients with LDH ≤618 IU/L.

CONCLUSIONS

Patients with metastatic cancer participating in phase I trials who have poor performance status and require inpatient admission have a very short survival after discharge to hospice. A high LDH level predicts an even shorter survival.

Survival benefits among patients with end-stage renal disease receiving dialysis versus no dialysis

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Background: Retrospective study of the outcomes of Stage IV Cancer Patients with End Stage Renal disease Receiving Dialysis and comparing the survival benefits among the patients who received Hemodialysis versus who didn’t at a Comprehensive Cancer Center. Methods: Retrospectively review all patients admitted to MDACC from 2005-2014 and diagnosed with stage IV solid tumor admitted with Acute kidney injury and a nephrology consult were included (N = 903) 19.82% received dialysis (n = 179) versus 80.17% did not receive dialysis (n = 724). The main endpoints of the study to be evaluated would be survival & hospital death. Results: Kaplan-Meier overall survival curve of the dialysis group vs the non-dialysis p-value < 0.001 indicating that patients who underwent dialysis had a poorer overall survival. This was further explored in a multivariate model where at any given time; a patient who underwent a dialysis is 1.318 times as likely to experience a death as a patient who did not undergo a dialysis with the same other clinical factors. The association between dialysis and death in hospital was explored using multivariate model indicated dialysis (odds ratio = 3.339, 95% CI (2.212, 5.04), p < 0.001, ICU (odds ratio = 2.624, 95% CI (1.905, 3.613), p < 0.001), and a lower serum albumin level (p < 0.001) are factors associated with a higher probability of death in hospital. Matched sample where evaluated using propensity score matching & Weighting and the dialysis group still shows a significant negative effect on Overall Survival with (p = 0.003). ICU patients Subset Analysis & SOFA Score: 49.9% had ICU visits in our database with SOFA scores (37.9% were dialyzed). Using propensity score weighting method, the estimated hazard rate is 0.892 with 95% CI (0.775, 1.027) and p = 0.113, showing NO evidence that dialysis is a prognostic factor for ICU patients after controlling SOFA score. In the ICU cohort, the median survival time for dialysis 18 days (95% CI: 14-23) and no dialysis 19 days (95% CI: 15-25). Conclusions: We can conclude that Dialysis when offered to advanced cancer patients does not improve mortality. Creating a hemodialysis prognostic tool relevant to cancer population would be of great benefit to Nephrologists, Oncologist and patients.

Frequency and factors associated with placebo response in cancer-related fatigue treatment trials

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Background: There is limited literature on specific patient characteristics associated with response to placebo. The aim of this study was to identify frequency, and predictors of response to placebo. Methods: We conducted pooled analysis of the placebo arm in six randomized, double-blind, placebo-controlled clinical trials for cancer related fatigue. Baseline patient characteristics, symptoms (FACIT-F, and ESAS), Global Symptom Evaluation (GSE, rated as better, same and worse). Response was defined as an increase (D FACIT-F score) ≥ 3.5 points from baseline or change in ESAS of ≤ 1. Baseline patient characteristics and symptoms (as assessed by ESAS) were analyzed to determine their association with response to placebo using logistic regression analysis. ROC was calculated for GSE “better” of “4” or more (i.e., moderately better to very great deal better) and FACIT-F change. Results: Total of 306 patients with advanced cancer received placebo. The median age was 59, 54% were female, 76% were white, 51% were had college education or higher, the most common cancer type was genitourinary 24%. 55% had Zubrod performance ≤ 2. Median FACIF-F subscale score was 21. Placebo response was 176/306 (58%) with FACIT-F subscale ≥ 3.5 points and 185 (60%) with ESAS fatigue ≤ 1. Mean change in fatigue using FACIT- F subscale score was 7.18 (11.68) and ESAS was -2.21 (2.82). Change in FACIT-F and ESAS were significantly correlated (r = 0.56, P ≤ 0.001). 99/306 (32%) reported that their fatigue was “better” by GSE. Female gender (OR 2.72, P = 0.04), and anxiety (OR 1.39, P = 0.046) were significantly associated with placebo response. ROC with cut-off of GSE ≥ 4 and change in FACIT-F score was 11.5 and placebo response rate based on cut-off of 7.5 was 84/306 (27%). Conclusions: Our results confirm that placebo response is substantial in fatigue treatment trials in palliative patients. Placebo response rate varies based on the methods used to estimate response (from 27% to 60%). Female patients and higher anxiety at baseline were significantly associated with placebo response. More research is needed to accurately benchmark placebo response.

Perception of curability in an international cohort of advanced cancer patients receiving palliative care

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Background: There is limited data on the illness understanding and perception of cure among advanced cancer patients (ACP) receiving palliative care around the world. The aim of the study was to determine the frequency and factors associated with perception of curability in countries in North and South Americas , Europe, Asia and Africa. Methods: Secondary analysis of a study to determine the decisional control preferences in different countries. ACP receiving palliative care were surveyed to assess the patients’ Understanding of Illness using a Understanding Of Illness questionnaire. Descriptive statistics and Logistic regression analysis were performed. Results: A total 1390 ACPs were evaluated. The median age was 58, 55% were female, 59% were married, 47% were catholic, 36.2% were educated college or higher degree. 681/1390 (49%) reported that their cancer is curable, 60% felt perceived that the goals of therapy was “to get rid of their cancer,” 79% perceived that the goals of the therapy was to “make them feel better.” 62 % perceived they were relatively healthy. Logistic regression analysis (Table 1) shows that better Karnosfsky performance status (OR 1.009, P = 0.04), higher education (OR 0.52, P = 0.0001), ACP's belonging to Brazil, France and S. Africa were less likely and ACPs from Philippines, Jordan were more likely to have a perception of curability. Age, gender, marital status, religion and passive decision control preferences were not significantly associated with perception of curability. Conclusions: The perception of curability in ACP's is 49% and significantly differs by education, performance status, and country of origin. Integration of Palliative Care can be more complex in these patients. Further studies are needed to develop strategies to reduce this misperception so as to have early integration of palliative care. [Table: see text]

Effects of high-dose Asian ginseng (Panax ginseng) to improve cancer-related fatigue: Results of a double-blind, placebo-controlled randomized controlled trial

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Background: Cancer related fatigue (CRF) is the most common and disabling symptom in cancer.Panax ginseng extract (PG) is frequently used as a nutraceutical treatment for fatigue. There are no well-powered placebo-controlled trials that used validated CRF outcome measures to investigate of PG effects in cancer patients. The primary objective of this trial was to evaluate the effects oral PG versus Placebo (PL) for CRF. Methods: Patients with cancer fatigue ≥ 4/10 on Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomized to either 400mg of standardized PG or matching PL orally twice a day for 28 days. The primary endpoint was change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) fatigue subscale from baseline to Day 28. Secondary outcomes were Functional Assessment of Cancer Therapy-General (FACT-G), Hospital Anxiety and Depression Scale (HADS), and ESAS. Results: Total evaluable patients were 112 (56 for PG and PL groups). No significant differences in baseline characteristics between the two groups except cancer type (p = 0.002). There was significant improvement in FACIT fatigue and ESAS fatigue scores in PG and PL groups at Day 15 and Day 29. The mean (SD) of FACIT-F fatigue scores at baseline, Day 15, and Day 29 were 22.6 (10.4), 29.8(10.7), 30.1 (11.6) and 23.8 (9.1), 30.0 (10.1), 30.4 (11.6) for PG and PL respectively. Mean (SD) improvement in the FACIT-F subscale at Day 29 was not significantly different in PG than in the PL group [7.5 (12.7) vs 6.5 (9.9), P = 0.67]. Mean (SD) improvement in the ESAS fatigue, FACT-G, and HADS at Day 29 were also not significantly different in PG than in the PL group. In a multiple linear model analysis, the change in FACIT-F fatigue from Day 0 to Day 29 was negatively correlated with baseline FACIT-F fatigue (p = 0.0005), baseline HADS score (p = 0.032), and male gender (p = 0.023). There were a significantly higher number of any grade of toxicities in PL group than in PG group (33/62 vs. 28/64, p = 0.024). Conclusions: Both PG and Placebo result in a significant improvement in CRF at Day 15 and Day 29. PG was not significantly superior to placebo after 4 weeks of treatment. Further studies are needed. Clinical trial information: NCT01375114.

Frequency and factors associated patients decisional control preferences (DCP) in patients with advanced cancer (ACP)

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Background: To determine the frequency and socio-demographic and clinical factors associated passive DCP among ACP across the world. Methods: We conducted a survey of ACP referred to palliative care across 11 countries across the five continents across the world. Information was collected on socio-demographic variables, and using validated measures including Karnofsky Performance Scale, Decision Control Preference Scale, and Satisfaction with the Decisions and Care questionnaire. We analyzed using descriptive statistics and logistic regression analysis was performed. Results: Median age was 58 years, karnofsky 70, and 55% were female. Shared, Active and Passive DCP were 33.2%, 44.1% and 22.6% respectively (n = 1490). 91% were satisfied by the way the actual decisions were made. Concordance between the actual decision making and DCP was highest in cohort from USA [k = 0.74 (0.65-0.82) and lowest in Brazil 0.33 (0.22-0.44)]. “Satisfaction with the way the decisions about their care was made” was 91%. Better Karnosfsky performance status (OR 0.99, P = 0.017), higher education status (OR 0.64, P = 0.001) Country of origin (Brazil, France, Singapore, South Africa, Jordan were significantly associated with passive decision making preference (Table 1). Conclusions: DCP is based ACP’s performance status, education and is culture specific. Individualized understanding DCP may be important for quality care and patient satisfaction outcomes. [Table: see text]

Perception of helpfulness of a question prompt sheet among cancer patients attending outpatient palliative care

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Background: Data on the use of question prompt sheets (QPS) in palliative care is limited. Our team previously developed a single page QPS using a Delphi process. The main objective of this study was to determine the perception of helpfulness of a QPS in patient-physician communication among advanced cancer outpatients. Methods: 104 eligible patients received the QPS for use during their first palliative care clinic. Patient and physician perceptions about the QPS were assessed at the end of the visit. Patients’ anxiety was also measured pre- and post-consultation using the Spielberger State Anxiety Inventory. Results: 100/104 (96%) patients completed the study. Among those responders, most agreed that the material was helpful in communicating with their doctor (77%), clear to understand (90%), had the right amount of information (87%), and they would use a similar material in the future (76%) and recommend it to other patients(70%). Overall, 92% were satisfied with their consultation visit. Physicians perceived that the QPS was helpful to 68% of the encounters and it did not prolong the consultation in 73% of the encounters. Physician agreement on helpfulness of the QPS was not significantly different from the patients (p = 0.3). Patient anxiety improved after consultation from a mean (SD) STAI score of 39.2 (12.8) to 33.8 (10.7), p ≤ 0.0001. Conclusions: The QPS was perceived as helpful in patient-physician communication among advanced cancer outpatients and it did not increase patient anxiety. Physicians similarly reported that the QPS was helpful and it did not prolong clinic visits. Further research is needed for its widespread adoption and integration into routine clinical practice.

Referral patterns and characteristics of uninsured versus insured patients referred to the outpatient supportive care center (SCC) at a comprehensive cancer center

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Background: Multiple barriers exist in providing quality palliative care to low-income patients with cancer. Such disparities may negatively influence effective management of symptoms including pain. Our objective was to compare referral patterns and characteristics (level of symptom distress) of uninsured vs insured patients. Methods: We reviewed randomly selected charts of 100 Indigent (IND) and 100 Medicaid (MC) patients and compared them with a random sample of 300 patients with insurance (INS) referred during the same time period (1/2010 to 12/2014) to our SCC. Data was collected for date of registration at the cancer center, diagnosis of Advanced Cancer (ACD), first visit to the SCC (PC1), symptom assessment (Edmonton Symptom Assessment Scale-ESAS) at PC1. We excluded self-pay patients. Results: Results for IND, MC and INS (n = 481) respectively are as follows: Mean (SD) Age in yrs. was 50 (12), 48 (11) and 63 (13); p < 0.001. Percentage of non-white was 44%, 51% and 19.5%; p < 0.001. Percentage of unmarried patients was 64%, 68% and 33%; p < 0.001. Mean (SD) ESAS score at PC1 for pain was 5.6 (3.2), 6.7 (2.5), 4.9 (3.2); p < 0.001. Percentage of patients on opioids upon referral was 86%, 62%, and 54%; p < 0.001. Mean (SD) for referral time in months from ACD to PC1 was 8.7 (SD 10.4), 12.3 (SD 18.1) and 12 (SD 19.9) p = 0.31; for no. of encounters with SC per month were 0.46 (0.45), 0.41 (0.46) and 0.3 (0.55); p = 0.01; for survival in months (PC1 to last contact) was 6.4 (5.8), 5.6 (6.4) & 6 (7.22) p = 0.77. Conclusions: Uninsured patients had significantly higher levels of pain, were more frequently on opioids, younger, non-white and not married. They also required a larger number of SCC encounters. Insurance status did not impact timing of SCC referral or SCC follow ups at our cancer center.

The conversion ratio from intravenous (IV) hydromorphone to oral (PO) opioids in patients with cancer

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Background: Inpatients with cancer frequently undergo conversions from IV to PO hydromorphone (HM) or opioid rotation (OR) from IV HM to another PO opioid prior to discharge. Currently used conversion ratios (CR) between IV and PO HM range from 2-5 and opioid rotation ratios (ORR) between IV HM and oral morphine equivalent daily dose (MEDD) range from 10-20. This large variation in ratios may lead to uncontrolled pain or overdosing. Our aim was to determine the accurate CR from IV to PO HM and ORR from IV HM to PO morphine and oxycodone (measured as MEDD). Methods: We reviewed records of 4745 consecutive inpatient palliative care consults in our institute during 2010-14 for patients who underwent conversion from IV to PO HM or OR from IV HM to PO morphine or oxycodone. Patient characteristics, symptoms and opioid doses were determined in patients successfully discharged on oral opioids without readmission within 1 week. Linear regression analysis was used to estimate the CR or ORR between the 24 hour IV HM mg dose prior to conversion to PO and the oral opioid mg dose used in the 24 hours prior to discharge. Results: Among 394 eligible patients on IV HM, 147 underwent conversion to PO HM and 247 underwent OR to oral morphine (163) or oxycodone (84). Mean age was 54 years, 39% were male, and 95% had advanced cancer. Median time between conversion to PO and discharge was 2 days. In 147 patients the median CR (IQR) from IV to PO HM was 2.5 (2.1-2.7) and correlation of IV to PO dose of HM was .95 (P < .0001). The median CR was 2.5 in patients receiving < 30mg of IV HM/day and 2.1 in patients receiving ≥ 30mg of HM/day (P = .004). In 247 patients the median ORR (IQR) from IV HM to MEDD was 11.5 (10-13) and correlation of IV HM to MEDD was .93 (P < .0001). The median ORR was 11.5 in patients receiving < 30mg of IV HM/day and 9.9 in patients receiving ≥ 30mg of HM/day (P = .0004). ORR from IV HM to MEDDs obtained from morphine (11) and oxycodone (12.1) were significantly different (P = .0023). The CR and ORR were not significantly impacted by other variables. Conclusions: The median CR from IV to PO HM is 2.5 and ORR from IV HM to MEDD is 11.5. This implies that 1 mg IV HM is equivalent to 2.5 mg PO HM and 11.5 mg MEDD. HM may cause hyperalgesia at doses ≥ 30 mg/day and thereby requires a lower ORR to other opioids.

Use of Palliative Care Services in a Tertiary Cancer Center

This study analyzed palliative/supportive care use in a single cancer center over 8 years. Billing data showed the inpatient consultations as a percentage of hospital admissions and the ratio of inpatient consultations to hospital beds almost doubled. In the outpatient setting, data revealed earlier access to outpatient referrals to palliative care service (from 4.8 months to 7.9 months; p = .001) during the study period.

Background.

Despite increasing prevalence of palliative care (PC) services in cancer centers, most referrals to the service occur exceedingly late in the illness trajectory. Over the years, we have made several attempts to promote earlier patient access to our PC program, such as changing the name of our service from PC to supportive care (SC). This study was conducted to determine the use of PC/SC service over the past 8 years.

Methods.

We reviewed billing data for all PC/SC encounters. We examined five metrics for use: inpatient consultations as a percentage of hospital admissions, ratio of inpatient consultations to average number of operational beds, time from hospital registration to outpatient consultation, time from advanced cancer diagnosis to consultation, and time from first outpatient consultation to death/last follow-up.

Results.

Over the years, we found a consistent increase in patient referrals to the PC/SC program. In the inpatient setting, we found approximate doubling of the inpatient consultations as a percentage of hospital admissions and the ratio of inpatient consultations to hospital beds (from 10% to 19% and from 2.4 to 4.9, respectively; p < .001). In the outpatient setting, we observed variations in referral pattern between oncology services, but, overall, the time from consultation to death/last follow-up increased from 4.8 months to 7.9 months (p = .001), which was accompanied by a significant decrease in the interval to consultation from hospital registration and advanced cancer diagnosis (p < .001).

Conclusion.

We have observed a consistent annual increase in new patient referrals as well as earlier access for outpatient referrals to our SC service, supporting increased use of palliative care at our cancer center.

Implications for Practice:

In response to accumulating evidence on the benefits of palliative care (PC) referral to oncology patients, efforts are being made to increase PC use. This study, conducted at MD Anderson Cancer Center, demonstrates consistent annual growth in PC referrals, which was accompanied by a significant increase in the outpatient referral of patients with nonadvanced cancer and earlier referral of those with advanced cancer. However, significant variations in the referral patterns between oncology services were observed. These results have implications for other cancer centers looking to enhance use of PC services by having a business model that allows for appropriate space and staff expansion.

The effects of dexamethasone and placebo on symptom clusters in advanced cancer patients: A preliminary report

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Background: Advanced cancer patients frequently experience debilitating symptoms that occur in clusters, but few pharmacological studies have targeted symptom clusters. Our objective was to examine the effects of dexamethasone on symptom clusters. Methods: Secondary analysis of a recent RCT of dexamethasone (DEX) vs placebo (PL) on cancer symptoms as assessed by FACIT-F-Fatigue; FAACT-Anorexia-Cachexia; BPI - Pain; HADS- Anxiety-Depression; ESAS: Sleep, Drowsiness, Dyspnea. Symptom clusters were identified based on baseline symptoms [ESAS] using principal component analysis. Cluster scores were computed by adding each scale divided by the maximum value for the scale: Fatigue- Anorexia-Depression = (Fatigue /52 + Anorexia/48+ HADS-Depression/21); Sleep-Anxiety-Drowsiness = (Sleep/10+HADS-Anxiety/21+Drowsiness /10); Pain-Dyspnea = (BPI/10 +Dyspnea /10). Higher number indicates better QOL. Correlations and change in the severity of symptom clusters were analyzed. Results: In 114 evaluable patients, 3 clusters accounted for 63% of the total variance at baseline: Fatigue-anorexia/cachexia-depression cluster (FAD); sleep-anxiety-drowsiness cluster (SAD) and Pain-Dyspnea cluster (PD). Median (IQR) improvement in the FAD cluster at Day 15 and Day 8 was significantly higher in the DEX than in the PL group [0.22 (-0.04, 0.45) vs. 0.06 (-.30, .20), P = 0.016)] and [0.15 (-0.84, 0.35) vs-0.095 (-0.35, 0.16), p = 0.017] respectively. There was no significant change observed in SAD and PD after DEX. Median (IQR) scores for FAD and PD of the DEX group at baseline, day 8, and day 15 were 1.42(1.1,1.7),1.71(1.3,2.1),1.78(1.4,2.2); [1.1(0.8,1.4); 1.38(.04,1.6); 1.43(1.3,1.7) respectively and significantly correlated over time at Day 8 (r = 0.76; p < 0.001) Day 15 (r = 0.55;p < 0.001) [FAD]; Day 8 (r = 0.36; p < 0.001) Day 15 (r = 0.45; p < 0.001) [PD]. Conclusions: FAD cluster showed improvement with dexamethasone and consistent correlation overtime, as compared to SAD and PD cluster. These findings suggest that fatigue-anorexia/cachexia- and depression share a common a common pathophysiologic basis. Further studies are needed to investigate this cluster and target anti-inflammatory therapies. Clinical trial information: NCT00489307.