Effect of Inpatient Palliative Care During Hematopoietic Stem-Cell Transplant on Psychological Distress 6 Months After Transplant: Results of a Randomized Clinical Trial

Purpose Inpatient palliative care integrated with transplant care improves patients' quality of life (QOL) and symptom burden during hematopoietic stem-cell transplant (HCT). We assessed patients' mood, post-traumatic stress disorder (PTSD) symptoms, and QOL 6 months post-transplant. Methods We randomly assigned 160 patients with hematologic malignancies who underwent autologous or allogeneic HCT to inpatient palliative care integrated with transplant care (n = 81) or transplant care alone (n = 79). At baseline and 6 months post-transplant, we assessed mood, PTSD symptoms, and QOL with the Hospital Anxiety and Depression Scale and Patient Health Questionnaire, PTSD checklist, and Functional Assessment of Cancer Therapy-Bone Marrow Transplant. To assess symptom burden during HCT, we used the Edmonton Symptom Assessment Scale. We used analysis of covariance while controlling for baseline values to examine intervention effects and conducted causal mediation analyses to examine whether symptom burden or mood during HCT mediated the effect of the intervention on 6-month outcomes. Results We enrolled 160 (86%) of 186 potentially eligible patients between August 2014 and January 2016. At 6 months post-transplant, intervention participants reported lower depression symptoms on the Hospital Anxiety and Depression Scale and Patient Health Questionnaire (adjusted mean difference, -1.21 [95% CI, -2.26 to -0.16; P = .024] and -1.63 [95% CI, -3.08 to -0.19; P = .027], respectively) and lower PTSD symptoms (adjusted mean difference, -4.02; 95% CI, -7.18 to -0.86; P = .013), but no difference in QOL or anxiety. Symptom burden and anxiety during HCT hospitalization partially mediated the effect of the intervention on depression and PTSD at 6 months post-transplant. Conclusion Inpatient palliative care integrated with transplant care leads to improvements in depression and PTSD symptoms at 6 months post-transplant. Reduction in symptom burden and anxiety during HCT partially accounts for the effect of the intervention on these outcomes.

Depression, inflammation, and epidermal growth factor receptor (EGFR) status in metastatic non-small cell lung cancer: A pilot study

OBJECTIVE

Patients with stage IV non-small cell lung cancer (NSCLC) have high risk for depressive symptoms and major depressive disorder (MDD); however, those with epidermal growth factor receptor (EGFR) mutations may have decreased risk. The biological underpinning of this relationship is unknown. We examined differences in depression severity and MDD in patients with newly diagnosed stage IV NSCLC based on EGFR mutation status, and examined proinflammatory cytokines and growth factors known to play a role in cancer progression and depression.

METHODS

Fifty-five patients with newly diagnosed stage IV NSCLC completed self-report and clinician-administered depression assessments prior to receiving results of tumor genotyping. We measured serum levels of circulating biological markers of inflammation: IL-1β, IL-6, TGF-α, and TNF-α. We examined differences in depression severity, MDD, and inflammatory biomarkers in patients with and without EGFR mutations.

RESULTS

Patients with EGFR mutations (n=10) had lower depression severity (t[43]=2.38, p=0.03) than those without EGFR mutations (n=38) and fewer patients with EGFR mutations had concurrent MDD (2.08%) relative to those without mutations (27.08%). Patients with MDD had higher levels of TNF-α than those without MDD (t[40]=2.95, p=0.005). Those with EGFR mutations exhibited higher levels of TNF-α relative to those without EGFR mutations (t[35]=2.17, p=0.04).

CONCLUSIONS

Patients with stage IV NSCLC harboring an EGFR mutation exhibited elevated proinflammatory marker TNF-α, yet had lower depression severity than patients without EGFR mutations. More work is warranted to examine the interaction between tumor genotyping and inflammatory cytokines in the context of depression.

Coping and Prognostic Awareness in Patients With Advanced Cancer

Purpose Patients' understanding of their illness is key for making informed treatment decisions, yet studies suggest an association between prognostic awareness and worse quality of life (QOL) and mood among patients with advanced cancer. We sought to explore the relationships among prognostic awareness, coping, QOL, and mood in patients with newly diagnosed, incurable cancer. Methods We assessed patients' self-reported health status and treatment goal (Prognosis and Treatment Perceptions Questionnaire), coping (Brief COPE), QOL (Functional Assessment of Cancer Therapy-General), and mood (Hospital Anxiety and Depression Scale) within 8 weeks of incurable lung or GI cancer diagnosis. We used linear regression to examine associations and interaction effects among patients' health status and treatment goal, coping strategies, QOL, and mood. Results Patients who reported a terminally ill health status had worse QOL (unstandardized coefficient [B] = -6.88; P < .001), depression (B = 1.60; P < .001), and anxiety (B = 1.17; P = .007). Patients who reported their oncologist's treatment goal was "to cure my cancer" had better QOL (B = 4.33; P = .03) and less anxiety (B = -1.39; P = .007). We observed interaction effects between self-reported health status and treatment goal and certain coping strategies. Specifically, subgroup analyses showed that greater use of positive reframing was related to better QOL (B = 2.61; P < .001) and less depression (B = -0.78; P < .001) among patients who reported a terminally ill health status. Active coping was associated with better QOL (B = 3.50; P < .001) and less depression (B = -1.01; P < .001) among patients who acknowledged their oncologist's treatment goal was not "to cure my cancer." Conclusion Prognostic awareness is related to worse QOL and mood in patients with newly diagnosed, incurable cancer; however, the use of certain coping strategies may buffer these relationships. Interventions to improve patients' prognostic awareness should seek to cultivate more adaptive coping strategies in order to enhance QOL and mood.

Qualitative Study of Patients' and Caregivers' Perceptions and Information Preferences About Hospice

OBJECTIVE

The goal of this study is to assess perceptions about hospice among patients with metastatic cancer and their caregivers (i.e., family and/or friends).

DESIGN AND SETTING

We conducted semi-structured interviews with 16 adult patients with a prognosis ≤12 months and 7 of their caregivers. The interviews focused on perceptions, knowledge, and information preferences about hospice. Two raters coded interviews independently (κ > 0.85). We used a framework approach for data analysis.

RESULTS

Participants showed variable gaps in understanding about hospice, including who would benefit from hospice care and the extent of services provided. They all perceived that hospice involves a psychological transition to accepting imminent death and often referred to hospice from a relatively cognitive distance, using hypothetical scenarios of others for whom hospice would be more relevant. Participants' attitudes about hospice reflected their concerns about suffering, loss of dignity, and death, as well as their perceived understanding of hospice services. These attitudes along with the psychological barriers to projecting a need for hospice and lack of knowledge were all perceived as important barriers to hospice utilization. All participants felt they needed more information about hospice, yet they were mixed regarding the optimal timing of this information.

CONCLUSIONS

Study participants had misunderstandings about hospice and perceived end-of-life (EOL) concerns such as fear of suffering, loss of dignity, and death, as well as lack of knowledge as the main barriers to hospice utilization. Interventions are needed to educate patients and their families about hospice and to address their EOL concerns.

Post-discharge transitions of care for hospitalized patients with advanced cancer

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Background: Patients with advanced cancer experience frequent hospitalizations and burdensome transitions of care post-discharge. We examined predictors of discharge location for patients with advanced cancer. Methods: We prospectively enrolled patients with advanced cancer with unplanned hospitalizations from 9/14 to 3/16. Upon admission, we used the Edmonton Symptom Assessment Scale and Patient Health Questionnaire-4 to assess physical and psychological symptoms, respectively. We used logistic regression models to identify predictors of discharge to location other than home, including post-acute care (PAC) [skilled nursing facility or long term acute care hospital] or hospice [any setting]. We used Cox regression models adjusted for clinical variables to assess the relationship between discharge location and survival. Results: Out of 932 patients, 726 (77.9%) were discharged home, 118 (12.7%) to PAC and 88 (9.4%) to hospice. Compared with patients discharged home, those discharged to PAC or hospice had higher symptom burden, including dyspnea, constipation, low appetite, drowsiness, fatigue, depression, and anxiety (all p < 0.05). Patients discharged to PAC or hospice vs. home were more likely to be older (OR 1.03, p < 0.0001), live alone (OR 1.95, 95% CI: 1.25-3.02, p < 0.003), have impaired mobility (OR 5.08, 95% CI: 3.46-7.45, p < 0.0001), longer length of stay (OR 1.15, 95% CI: 1.11-1.20, p < 0.0001), higher ESAS physical symptoms (OR 1.02, 95% CI: 1.003-1.032, p < 0.017), and higher PHQ-2 depression symptoms (OR 1.13, 95% CI: 1.01-1.25, p < 0.027). Patients discharged to hospice vs. PAC were more likely to receive palliative care consultation (OR 4.44, 95% CI: 2.12 to 9.29, p < 0.0001) and have shorter length of stay (OR 0.84, 95% CI: 0.77 to 0.91, p < 0.0001). Compared with patients discharged home, those discharged to PAC had lower survival (HR 1.53, 95% CI 1.22-1.93, p < 0.0001). Conclusions: Patients with advanced cancer discharged to PAC or hospice have substantial physical and psychological symptom burden and poor physical function. Patients discharged to PAC also have inferior survival compared with those discharged home. They may benefit from targeted interventions to improve their quality of life and care.

Symptom burden and hospital length of stay among patients with curable cancer

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Background: Prolonged hospital admissions are often inconsistent with patients’ preferences and incur significant costs. While patients’ symptoms may result in hospitalizations, the relationship between patients’ symptom burden and their hospital length-of-stay (LOS) has not been fully explored in patients with curable cancers. Methods: We prospectively enrolled patients with curable cancer and unplanned hospital admissions between 8/2015 and 12/2016. Within the first 5 days of admission, we assessed patients’ physical (Edmonton Symptom Assessment System [ESAS]; scored 0-10 with higher scores indicating greater symptom burden) and psychological symptoms (Patient Health Questionnaire 4 [PHQ-4]; scored categorically and continuous with higher scores indicating greater distress). We created summated ESAS total and physical symptom variables. To assess the relationship between patients’ symptom burden and their hospital LOS, we used separate linear regression models adjusted for age, sex, marital status, education level, time since cancer diagnosis, and cancer type. Results: We enrolled 452 of 497 (91%) approached patients (mean age = 61.9 years; 188 [42%] female). Over half had hematologic cancers (n = 249, 55%). Mean hospital LOS was 8.3 days. Over one-tenth of patients screened positive for PHQ-4 depression (n = 74, 16%) and anxiety (n = 60, 13%) symptoms. Mean ESAS symptom scores were highest for fatigue (6.6), drowsiness (5.4), pain (4.9), and lack of appetite (4.8). In multivariable regression analysis, patients’ physical and psychological symptoms were associated with longer hospital LOS (table). Conclusions: Patients with curable cancer and unplanned hospital admissions experience a substantial symptom burden, which predicts for prolonged hospitalizations. Importantly, patients’ symptoms are modifiable risk factors that, if properly addressed, can improve care delivery and may have the potential to help decrease prolonged hospitalizations. [Table: see text]

A multimodal intervention to enhance sexual function and quality of life (QOL) in hematopoietic stem cell transplant (HCT) survivors

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Background: Although sexual dysfunction is a common long-term complication in allogeneic HCT survivors, interventions to address sexual dysfunction are lacking. Methods: We conducted a pilot study to assess the feasibility and preliminary efficacy of a multimodal sexual dysfunction intervention to improve sexual function in allogeneic HCT survivors. Transplant clinicians systematically screened all HCT survivors ≥ 3 months post-HCT for sexual dysfunction causing distress using the NCCN Survivorship Guidelines. Those who screened positive attended monthly intervention visits with trained study clinicians that focused on 1) assessing sexual dysfunction; 2) educating and empowering patients to address this topic; and 3) implementing therapeutic interventions. We used the PROMIS Sexual Function and Satisfaction Measure, Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT), and Hospital Anxiety and Depression Scale (HADS) to assess sexual function, QOL, and mood at baseline and six months post-intervention, respectively. Results: 32.7% (49/150) of patients screened positive for sexual dysfunction causing distress. 95.9% (47/49) of patients who screened positive agreed to participate. We demonstrated significant improvement in patients’ satisfaction and interest in sex as well as sexual function including orgasm, erectile function, lubrication, and vaginal discomfort [Table]. Six of ten patients who were not sexually active prior to the intervention became sexually active post-intervention (P = 0.031). Patients reported improvement in their QOL and a trend toward lower depression [Table]. Conclusions: The multimodal intervention to address sexual dysfunction appears feasible with encouraging preliminary efficacy for improving sexual function, QOL, and mood in allogeneic HCT survivors. Clinical trial information: NCT02492100. [Table: see text]

The importance of recognizing and addressing depression in patients with advanced cancer

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Background: Patients with cancer often experience depression, which is associated with worse outcomes, including longer hospital length of stay (LOS). Although antidepressant medication can improve depressive symptoms in patients with cancer, it is unclear whether their use translates into better outcomes. We sought to clarify the relationship between depressive symptoms, antidepressant medication, and hospital LOS in patients with advanced cancer. Methods: We enrolled hospitalized patients with advanced cancer from 9/2014 to 4/2016 as part of a longitudinal data repository. We examined patients’ medical records to obtain information about documented depressive symptoms in the 3 months prior to admission and use of antidepressant medication at the time of admission. Using descriptive statistics, we compared differences in patient characteristics and hospital LOS across these groups. We used linear regression to examine associations and moderation effects between depressive symptoms, use of antidepressant medication, and hospital LOS. Results: Of 1,036 enrolled patients (89.9% of approached), 126 (12.2%) had documented depressive symptoms in the 3 months prior to admission and 288 (27.8%) were taking an antidepressant medication at the time of admission. Patients with depressive symptoms were more likely to be on antidepressant medication at admission than those without depressive symptoms (48.4% vs 24.9%, p < .001). Patients taking antidepressant medication were younger (62.4 vs 64.4 years, p = .026) and more likely to be female (55.2% vs 47.2%, p = .021). Depressive symptoms were associated with longer hospital LOS (7.3 vs 6.1 days, p = .036), and antidepressant medication was a moderator of this relationship. Among patients not on antidepressant medication, depressive symptoms were associated with longer hospital LOS (7.9 vs 6.1 days, p = .025), but among those on antidepressant medication, depressive symptoms were not associated with hospital LOS (6.6 vs 6.2 days, p = .588). Conclusions: Antidepressant medication moderated the relationship between depressive symptoms and longer hospital LOS. Our results support the need to recognize and address depressive symptoms in patients with advanced cancer.

Potentially avoidable hospitalizations in patients with advanced cancer

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Background: Cancer patients and their clinicians often wish to avoid preventable hospital admissions, but efforts to understand the predictors of avoidable hospitalizations are lacking. We sought to examine reasons for hospital admissions in patients with advanced cancer, identify potentially avoidable hospitalizations (PAH), and explore predictors of PAH. Methods: We prospectively enrolled hospitalized patients with advanced cancer from 9/2014 - 11/2014 as part of a longitudinal data repository to define symptom burden in this population. Upon admission, we assessed patients’ symptom burden (Edmonton Symptom Assessment System [ESAS]; scored 0-10). We created a summated ESAS physical symptom variable. We used consensus-driven medical record review to identify the primary reason for each hospital admission and categorize it as PAH or not based on of an adaptation of Graham’s criteria for PAH. We used mixed multivariable logistic regression analyses to identify predictors of PAH. Results: We assessed 477 hospital admissions in 200 consecutively admitted patients (mean age = 64.6; 47% female; 67% married). Over half of admissions came through the emergency department (56%). The most common reasons for admissions were fever/infection (30%), symptoms (26%), and planned admission for chemotherapy or procedure (10%). We identified 149 (31%) as PAH. Among these PAH, 45 (30%) were readmissions due to failure of timely outpatient follow-up (within 7 days of discharge) and 44 (30%) were due to premature discharge from prior hospitalization. In a mixed logistic regression model, being married (odds ratio [OR] 0.48 [0.28-0.81]; p < 0.01) was associated with lower likelihood of PAH, while higher physical symptom burden (OR 1.02 [1.00-1.04]; p = 0.04) was associated with greater likelihood of PAH. Conclusions: We identified that a substantial proportion of hospitalizations in patients with advanced cancer are potentially avoidable, often related to failure of timely outpatient follow-up and premature hospital discharge. Our results demonstrate that patients’ symptom burden predicts PAH, thus underscoring the need to address patients’ symptoms in order to reduce preventable hospital admissions.

Effect of inpatient palliative care during hematopoietic stem cell transplantation (HCT) hospitalization on psychological distress at six months post-HCT

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Background: Patients’ experience during HCT hospitalization leads to significant psychological distress post-HCT. Inpatient palliative care integrated with transplant care improves patient-reported QOL and symptom burden during hospitalization for HCT. We assessed the impact of the inpatient palliative care intervention on patients’ QOL, mood, and post-traumatic stress disorder (PTSD) at 6 months post-HCT. Methods: We randomized 160 patients with hematologic malignancies admitted for autologous or allogeneic HCT to an inpatient palliative care intervention (n=81) integrated with transplant care compared to transplant care alone (n=79). At baseline and 6 months post-HCT, we assessed QOL, mood, and PTSD symptoms using the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT), the Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire (PHQ-9), and the PTSD checklist, respectively. To assess symptom burden during HCT hospitalization, we used the Edmonton Symptom Assessment Scale. We utilized linear regression models controlling for baseline values to analyze the intervention effects on outcomes at 6 months. We conducted causal mediation analyses to examine whether symptom burden during HCT mediated the effect of the intervention on o utcomes at 6 months. Results: Between 8/14 and 1/16, we enrolled 160/186 (86%) of potentially eligible patients. At 6 months post-HCT, the intervention led to improvements in depression and PTSD symptoms, but not QOL or anxiety [Table]. Improvement in symptom burden during HCT hospitalization partially mediated the effect of the intervention on patient-reported outcomes at six months post-HCT. Conclusions: Inpatient palliative care integrated with transplant care leads to improvements in depression and PTSD symptoms at 6 months post-HCT. Addressing symptom burden during HCT hospitalization partially accounts for the effect of the intervention on these long-term outcomes. Clinical trial information: NCT02207322. [Table: see text]

Association of Race, Ethnicity and Language with Participation in Mental Health Research Among Adult Patients in Primary Care

Racial and ethnic minorities remain underrepresented in clinical psychiatric research, but the reasons are not fully understood and may vary widely between minority groups. We used the Z-test of independent proportions and binary logistic regression to examine the relationship between race, ethnicity or primary language and participation in screening as well as interest in further research participation among primary care patients being screened for a depression study. Minorities were less likely than non-Hispanic Whites to complete the initial screening survey. Latinos and Blacks were more likely to agree to be contacted for research than non-Hispanic Whites. Among Latinos, primary language was associated with willingness to be contacted for research. Associations between research participation and race, ethnicity and language are complex and vary across different enrollment steps. Future research should consider stages of the research enrollment process separately to better understand barriers and identify targets for intervention.

Coping in Patients With Incurable Lung and Gastrointestinal Cancers: A Validation Study of the Brief COPE

CONTEXT

Patients with incurable cancer engage in several coping styles to manage the impact of cancer and its treatment. The Brief COPE is a widely used measure intended to capture multiple and distinct types of coping. The Brief COPE has not been validated among patients with incurable cancer.

OBJECTIVES

We sought to validate seven subscales of the Brief COPE in a large sample of patients newly diagnosed with incurable lung and noncolorectal gastrointestinal cancers (N = 350).

METHODS

Participants completed the Brief COPE and measures assessing quality of life (QOL) (Functional Assessment of Cancer Therapy-General) and psychological distress (Hospital Anxiety and Depression Scale) within eight weeks of diagnosis of incurable cancer. We evaluated the psychometric properties of the Brief COPE using a confirmatory factor analysis and tests of correlation with the QOL and distress scales.

RESULTS

The Brief COPE factors were consistent with the original subscales, although the Behavioral Disengagement Scale had low internal consistency. Factors showed anticipated relationships with QOL and distress measures, except emotional support coping, which was correlated with increased depression and anxiety. We also conducted an exploratory high-order factor analysis to determine if subscales' score variances grouped together. The high-order factor analysis resulted in two factors, with active, emotional support, positive reframing, and acceptance loading onto one factor and denial and self-blame loading onto the second.

CONCLUSION

The selected subscales of the Brief COPE are appropriate measures of coping among individuals newly diagnosed with incurable lung and gastrointestinal cancers.

Effect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell Transplantation: A Randomized Clinical Trial

IMPORTANCE

During hospitalization for hematopoietic stem cell transplantation (HCT), patients receive high-dose chemotherapy before transplantation and experience significant physical and psychological symptoms and poor quality of life (QOL).

OBJECTIVE

To assess the effect of inpatient palliative care on patient- and caregiver-reported outcomes during hospitalization for HCT and 3 months after transplantation.

DESIGN, SETTING, AND PARTICIPANTS

Nonblinded randomized clinical trial among 160 adults with hematologic malignancies undergoing autologous/allogeneic HCT and their caregivers (n = 94). The study was conducted from August 2014 to January 2016 in a Boston hospital; follow-up was completed in May 2016.

INTERVENTIONS

Patients assigned to the intervention (n=81) were seen by palliative care clinicians at least twice a week during HCT hospitalization; the palliative intervention was focused on management of physical and psychological symptoms. Patients assigned to standard transplant care (n=79) could be seen by palliative care clinicians on request.

MAIN OUTCOMES AND MEASURES

Primary: change in patient QOL from baseline to week 2; secondary: patient-assessed mood, fatigue, and symptom burden scores at baseline, 2 weeks, and 3 months after HCT and caregiver-assessed QOL and mood at baseline and 2 weeks after HCT.

RESULTS

Among 160 enrolled patients (mean age, 60 [SD, 13.3] years; 91 women [56.9%]; median hospital stay, 21 days) and 94 caregivers, 157 (98.1%) and 89 (94.7%), respectively, completed 2-week follow-up, and 149 patients (93.1%) completed 3-month follow-up. Patients in the intervention group reported a smaller decrease in QOL from baseline to week 2 (mean baseline score, 110.26; week 2 score, 95.46; mean change, -14.72) compared with patients in the control group (mean baseline score, 106.83; week 2 score, 85.42; mean change, -21.54; difference between groups, -6.82; 95% CI, -13.48 to -0.16; P = .045). Among the secondary outcomes, from baseline to week 2, patients in the intervention group vs those in the control group had less increase in depression (mean, 2.43 vs 3.94; mean difference, 1.52; 95% CI, 0.23-2.81; P = .02), lower anxiety (mean, -0.80 vs 1.12; mean difference, 1.92; 95% CI, 0.83-3.01; P < .001), no difference in fatigue (mean, -10.30 vs -13.65; mean difference, -3.34; 95% CI, -7.25 to 0.56; P = .09), and less increase in symptom burden (mean, 17.35 vs 23.14; mean difference, 5.80; 95% CI, 0.49-11.10; P = .03). At 3 months after HCT, intervention patients vs control patients had higher QOL scores (mean, 112.00 vs 106.66; mean difference, 5.34; 95% CI, 0.04-10.65; P = .048) and less depression symptoms (mean, 3.49 vs 5.19; mean difference, -1.70; 95% CI, -2.75 to -0.65; P = .002) but no significant differences in anxiety, fatigue, or symptom burden. From baseline to week 2 after HCT, caregivers of patients in the intervention group vs caregivers of patients in the control group reported no significant differences in QOL or anxiety but had a smaller increase in depression (mean, 0.25 vs 1.80; mean difference, 1.55; 95% CI, 0.14-2.96; P = .03).

CONCLUSIONS AND RELEVANCE

Among adults at a single institution undergoing HCT for hematologic malignancy, the use of inpatient palliative care compared with standard transplant care resulted in a smaller decrease in QOL 2 weeks after transplantation. Further research is needed for replication and to assess longer-term outcomes and cost implications.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02207322.

Symptom burden to predict health care utilization in hospitalized patients with incurable cancer

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Background: Patients with incurable cancer are often hospitalized and have frequent readmissions after discharge. Considering the high physical and psychological symptom burden in this population, we sought to investigate symptoms as predictors of hospital length of stay (LOS) and time to first unplanned readmission. Methods: We consecutively enrolled incurable cancer patients with unplanned hospital admissions from 9/2014-4/2016. Within the first 5 days of admission, we assessed physical (Edmonton Symptom Assessment System [ESAS]; scored 0-10) and mood symptoms (Patient Health Questionnaire 4 [PHQ-4]; scored categorically). We created summated ESAS total and physical symptom variables. To identify predictors of LOS we used linear regression and for time to readmission we used Cox regression, with all models adjusted for age, sex, marital status, comorbidity, education, cancer type and time since incurable diagnosis. Results: We enrolled 1,000 of 1,227 (81%) eligible patients (mean age = 63.4; 50% female; 66% married). Gastrointestinal (33%) and lung (18%) cancers were the most common. Mean hospital LOS was 6.2 days and 30-day readmission rate was 25%. Over half of patients reported moderate/severe fatigue, drowsiness, lack of appetite, pain and poor well-being. Over one-fourth screened positive for PHQ depression and anxiety. All physical and mood symptoms individually predicted for longer LOS. Pain, nausea, poor well-being, ESAS total, ESAS physical and PHQ anxiety predicted for shorter time to readmission. Conclusions: Hospitalized patients with incurable cancer experience a high symptom burden, which correlates with their health care utilization. Both physical and psychological symptoms predict for longer hospital LOS and shorter time to readmission. These findings can inform interventions targeting patients’ symptoms during hospital admissions in an effort to improve health care delivery and utilization. [Table: see text]

Inpatient integrated palliative and transplant care to improve family caregiver (FC) outcomes of patients hospitalized for hematopoietic stem cell transplantation (HCT)

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Background: As their loved ones struggle physically and psychologically with transplant toxicities, FCs of patients undergoing HCT experience substantial distress. We assessed the impact of an inpatient palliative care intervention on FC quality of life (QOL) and mood during their loved ones’ HCT hospitalization. Methods: We conducted a randomized trial of inpatient palliative care integrated with transplant care versus transplant care alone for patients hospitalized for HCT and their FCs. Eligible FCs were identified as a relative or a friend with regular in-person contact with the patient and enrolled within 72 hours of the patient’s HCT admission. The intervention entailed at least twice weekly visits between the patient and palliative care during the transplant hospitalization, and FCs were welcome but not required to be present for these visits. We used the CareGiver Oncology QOL Questionnaire (CarGOQOL) to examine QOL, and the Hospital Anxiety and Depression Scale (HADS) to assess FC mood at baseline and week-2 during HCT hospitalization. We used the two-sample t-test to assess changes in QOL and mood from baseline to week-2. Results: We enrolled 160 patients and 94 (58.8%) FCs (control n = 49, intervention n = 45) between 8/2014 and 1/2016. Study groups did not differ significantly in baseline characteristics or overall FC QOL. At 2 weeks, FCs of patients randomized to the intervention reported improvements compared to those receiving transplant care alone in some QOL domains including better coping (0.23 vs. -0.74, p = 0.02) and handling of finances (0.24 vs. -0.46, p = 0.02) and also reported lower depression symptoms (HADS-Depression: 0.25 vs. 1.80, p = 0.03). No other CarGOQOL domains or HADS-anxiety symptoms were significantly different. Conclusions: Involvement of palliative care for patients hospitalized for HCT leads to improvement in FC depression and some aspects of their QOL. These findings demonstrate the positive impact of inpatient integrated palliative and transplant care extends to FCs of patients with hematologic malignancies undergoing HCT. Clinical trial information: NCT02207322.

Randomized trial of inpatient palliative care in patients hospitalized for hematopoietic stem cell transplantation (HCT)

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Background: During HCT, patients experience physical and psychological symptoms that negatively impact their quality of life (QOL). We assessed the impact of an inpatient palliative care intervention on patient QOL, symptom burden, and mood during HCT hospitalization and at 3 months post-HCT. Methods: We randomized 160 patients with hematologic malignancies admitted for autologous or allogeneic HCT to an inpatient palliative care intervention (n=81) integrated with transplant care compared to transplant care alone (n=79). We used the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) to assess QOL, the Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire (PHQ-9) to assess mood, and Edmonton Symptom Assessment Scale (ESAS) to measure symptoms at baseline, week-2, and 3 months post-HCT. We measured post-traumatic stress (PTSD) symptoms using the PTSD checklist at baseline and 3 months post-HCT. We used linear regression models controlling for baseline values to assess the intervention effects on outcomes at week-2 and 3 months post-HCT. Results: Between 8/2014 and 1/2016, we enrolled 160/186 (86%) of potentially eligible patients. At week-2, the intervention led to improvements in QOL, depression, anxiety, and symptom burden. At 3 months post-HCT, the intervention led to improvements in QOL, depression, and PTSD [Table 1]. PHQ-9 scores at week-2 and HADS-anxiety scores at 3 months did not differ significantly. Conclusions: Palliative care improved QOL, depression, anxiety, and symptom burden in patients hospitalized for HCT with notable sustained effects 3 months post-HCT. Involvement of palliative care for patients with hematologic malignancies can improve their outcomes and substantially reduce the morbidity of HCT. Clinical trial information: NCT02207322. [Table: see text]

Oncologists' dispositional affect and likelihood of end-of-life discussions

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Background: Oncologist-patient end-of-life (EOL) discussions are associated with less aggressive care at EOL. Prior research on EOL discussions has not explored the role of oncologists’ dispositional affect, trait patterns of emotional responses. Affect could possibly facilitate or hinder broaching difficult EOL topics. We examined associations between oncologists’ disposition for experiencing positive and negative affect and likelihood of EOL discussions reported by their patients with advanced cancers. Methods: 350 patients with incurable lung and GI cancers were enrolled in a randomized trial of early palliative care within 8 weeks of diagnosis. Oncologists providing care for participants completed a measure of dispositional affect, Positive and Negative Affect Schedule (PANAS). Positive and negative affect scales were analyzed dichotomously (above/below sample median). At 24 weeks in the trial, patients reported if they had ever discussed with their oncologist the care they would want to receive if they were dying (yes/no). Associations between oncologists’ affect and patient-reported EOL discussions were tested with multilevel models clustered by oncologist, adjusting for patient age, cancer type, and randomization. Results: At 24 weeks, 57/242 (23.6%) patients reported having had EOL discussions. The PANAS was completed by 17/19 (89%) oncologists with patients in the trial. Patients treated by oncologists with higher negative affect reported more EOL conversations, but this did not reach statistical significance: OR = 1.76 [.81, 3.83], p = .15. Patients treated by oncologists with higher positive affect also reported more EOL conversations, but this did not reach statistical significance: OR = 1.66 [.83, 3.35], p = .15. However, patients treated by oncologists with both higher positive and higher negative affect were over 3 times as likely to report having had EOL discussions: OR = 3.22 [1.02, 10.23], p = .046. Conclusions: Patients treated by oncologists with greater propensity to experience both positive and negative affect were more likely to report EOL discussions compared to those treated by oncologists who experience lower levels of affect. More research is needed to better understand these relationships.

Coping with moderate to severe chronic graft-versus-host disease (cGVHD) among hematopoietic stem cell transplant (HCT) survivors: A qualitative analysis

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Background: HCT survivors with moderate to severe cGVHD experience substantial symptoms, which negatively impact their quality of life. However, data are lacking on how patients cope with their illness. We aimed to achieve a deeper understanding of patients’ illness perception and how they cope with their cGVHD. Methods: We conducted qualitative interviews with 14 HCT survivors with moderate to severe cGVHD as defined by NIH Consensus Criteria. We used a semi-structured interview guide to elicit patients’ illness perception and coping strategies. Two raters coded interviews independently. We used content analysis to identify themes. Results: Patients highlighted two key themes in their efforts to cope with what they perceived as a “full time job” dealing with their cGVHD: personal transformation and empowerment. With respect to transformation, patients expressed the importance of (1) changing the goal of care from recovery to coping with a chronic condition, and (2) seeking new sources of support and connectedness specifically from other patients and caregivers affected by cGVHD. With respect to empowerment, patients sought more information and understanding about cGVHD in order to gain more control over their symptoms and illness experiences. Patients also noted the importance of knowledge and control in coping with their disease. By seeking knowledge and a greater understanding of their disease, patients explained that they felt that they were gaining control and feeling more empowered. Through the lens of change, it is clear that all patients sought an evolution in their care perspective by increasing care motivation, creating active support webs, and seeking further involvement in their own care. Conclusions: The diagnosis and course of cGVHD is psychologically transformative for patients. Although patients demonstrated an understanding of how they cope with the psychological and physical burden, they also expressed a wish for more education, support and a method of connecting with other HCT survivors. Future interventions should focus on enhancing patients’ coping strategies, knowledge of their illness and connections with other HCT survivors.

Oncologists' and cancer patients' views on whole-exome sequencing and incidental findings: results from the CanSeq study

PURPOSE

Although targeted sequencing improves outcomes for many cancer patients, it remains uncertain how somatic and germ-line whole-exome sequencing (WES) will integrate into care.

METHODS

We conducted surveys and interviews within a study of WES integration at an academic center to determine oncologists' attitudes about WES and to identify lung and colorectal cancer patients' preferences for learning WES findings.

RESULTS

One-hundred sixty-seven patients (85% white, 58% female, mean age 60) and 27 oncologists (22% female) participated. Although oncologists had extensive experience ordering somatic tests (median 100/year), they had little experience ordering germ-line tests. Oncologists intended to disclose most WES results to patients but anticipated numerous challenges in using WES. Patients had moderately low levels of genetic knowledge (mean 4 correct out of 7). Most patients chose to learn results that could help select a clinical trial, pharmacogenetic and positive prognostic results, and results suggesting inherited predisposition to cancer and treatable noncancer conditions (all ≥95%). Fewer chose to receive negative prognostic results (84%) and results suggesting predisposition to untreatable noncancer conditions (85%).

CONCLUSION

The majority of patients want most cancer-related and incidental WES results. Patients' low levels of genetic knowledge and oncologists' inexperience with large-scale sequencing present challenges to implementing paired WES in practice.Genet Med 18 10, 1011-1019.

Retrospective evaluation of palliative care and hospice utilization in hospitalized patients with metastatic breast cancer

BACKGROUND

Hospitalizations in patients with metastatic cancer occur commonly at the end of life but have not been well-described in individuals with metastatic breast cancer.

AIM

To describe the reasons for admission and frequency of palliative care and hospice utilization in hospitalized patients with metastatic breast cancer.

DESIGN

This was a retrospective chart review of patients who had their first hospitalization with a diagnosis of metastatic breast cancer between 1 January 2009 and 31 December 2010. To standardize follow-up time, we collected data for 3 years post the index hospitalization.

SETTING/PARTICIPANTS

We identified 123 consecutive patients who were hospitalized for the first time with a diagnosis of metastatic breast cancer at a single, tertiary care center.

RESULTS

Uncontrolled symptoms accounted for half (50%, 62/123) of index admissions. The majority of patients died during the follow-up period (76%, 94/123), and the median time from index admission to death was 6 months (range: 0-34 months). Approximately half (53%, 50/94) died in the hospital or within 14 days of last hospital discharge, and less than one-third (29%, 27/94) were referred to hospice after their last hospitalization. The inpatient palliative care team evaluated 57% (54/94) of those who died at least once during an admission, but only 17% (16/94) of patients attended an outpatient palliative care appointment.

CONCLUSIONS

Hospitalized patients with metastatic breast cancer are commonly admitted for uncontrolled symptoms and have a poor prognosis. However, only a minority receive outpatient palliative care or are referred to hospice during their last hospitalization prior to death.

Cognitive behavioural therapy for adherence and depression in patients with HIV: a three-arm randomised controlled trial

BACKGROUND

Depression is highly prevalent in people with HIV and has consistently been associated with poor antiretroviral therapy (ART) adherence. Integrating cognitive behavioural therapy (CBT) for depression with adherence counselling using the Life-Steps approach (CBT-AD) has an emerging evidence base. The aim of this study was to test the efficacy of CBT-AD.

METHODS

In this three-arm randomised controlled trial in HIV-positive adults with depression, we compared CBT-AD with information and supportive psychotherapy plus adherence counselling using the Life-Steps approach (ISP-AD), and with enhanced treatment as usual (ETAU) including Life-Steps adherence counselling only. Participants were recruited from three sites in New England, USA (two hospital settings and one community health centre). Patients were randomly assigned (2:2:1) to receive CBT-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), ISP-AD (one Life-Steps session plus 11 weekly integrated sessions lasting up to 1 h each), or ETAU (one Life-Steps session and five assessment visits roughly every 2 weeks), randomisation was done with allocation software, in pairs, and stratified by three variables: study site, whether or not participants had been prescribed antidepressant medication, and whether or not participants had a history of injection drug use. The primary outcome was ART adherence at the end of treatment (4 month assessment) assessed via electronic pill caps (Medication Event Monitoring System [MEMS]) with correction for pocketed doses, analysed by intention to treat.

FINDINGS

Patients were recruited from Feb 26, 2009, to June 21, 2012. Patients who were assigned to CBT-AD (94 randomly assigned, 83 completed assessment) had greater improvements in adherence (estimated difference 1·00 percentage point per visit, 95% CI 0·34 to 1·66, p=0·003) and depression (Center for Epidemiological Studies depression [CESD] score estimated difference -0·41, -0·66 to -0·16, p=0·001; Montgomery-Asberg depression rating scale [MADRS] score -4·69, -8·09 to -1·28, p=0·007; clinical global impression [CGI] score -0·66, -1·11 to -0·21, p=0·005) than did patients who had ETAU (49 assigned, 46 completed assessment) after treatment (4 months). No significant differences in adherence were noted between CBT-AD and ISP-AD (97 assigned, 87 completed assessment). No study-related adverse events were reported.

INTERPRETATION

Integrating evidenced-based treatment for depression with evidenced-based adherence counselling is helpful for individuals living with HIV/AIDS and depression. Future efforts should examine how to best disseminate effective psychosocial depression treatments such as CBT-AD to people living with HIV/AIDS and examine the cost-effectiveness of such approaches.

FUNDING

National Institute of Mental Health, National Institute of Allergy and Infectious Diseases.