Early referral to supportive care specialists for symptom burden in lung cancer patients: a comparison of non-Hispanic whites, Hispanics, and non-Hispanic blacks

Naming racism as a root cause of inequities in palliative care research: a scoping review

BACKGROUND

Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist.

OBJECTIVE

To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings.

METHODS

Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results.

RESULTS

We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common.

CONCLUSION

While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.

A Preliminary Validation of an Optimal Cutpoint in Total Number of Patient-Reported Symptoms in Head and Neck Cancer for Effective Alignment of Clinical Resources with Patients' Symptom Burden

Background

Patients with head and neck cancer (HNC) often experience high symptom burden leading to lower quality of life (QoL).

Objective

This study aims to conceptually model optimal cutpoint by examining where total number of patient-reported symptoms exceeds patients' coping capacity, leading to a decline in QoL in patients with HNC.

Methods

Secondary data analysis of 105 individuals with HNC enrolled in a clinical usefulness study of the NYU Electronic Patient Visit Assessment (ePVA)©, a digital patient-reported symptom measure. Patients completed ePVA and European Organization for Research and Treatment of Cancer (EORTC©) QLQ-C30 v3.0. The total number of patient-reported symptoms was the sum of symptoms as identified by the ePVA questionnaire. Analysis of variance (ANOVA) was used to define optimal cutpoint.

Results

Study participants had a mean age of 61.5, were primarily male (67.6%), and had Stage IV HNC (53.3%). The cutpoint of 10 symptoms was associated with significant decline of QoL (F= 44.8, P<.0001), dividing the population into categories of low symptom burden (< 10 symptoms) and high symptom burden (≥ 10 symptoms). Analyses of EORTC© function subscales supported the validity of 10 symptoms as the optimal cutpoint (Physical: F=28.3, P<.0001; Role: F=21.6, P<.0001; Emotional: F=9.5, P=.003; Social: F=33.1, P<.0001).

Conclusions

In HNC, defining optimal cutpoints in the total number of patient-reported symptoms is feasible.

Implications for Practice

Cutpoints in the total number of patient-reported symptoms may identify patients experiencing a high symptom burden from HNC.

Foundational

Using optimal cutpoints of the total number of patient-reported symptoms may help effectively align clinical resources with patients' symptom burden.

Hispanic/Latinx and Spanish Language Concordance Among Palliative Care Clinicians and Patients in Hospital Settings in California

Background: Members of racial or ethnic minority groups utilize palliative care (PC) services less than non-Hispanic White patients and multiple factors contribute to this disparity. The impact of racial, ethnic, and language (REL) concordance between patients and clinicians has been demonstrated in general medical populations, but not in PC populations. We characterized the racial and ethnic composition and languages spoken of California PC clinicians and patients to examine clinical impacts of REL concordance. Methods: Using Palliative Care Quality Network data, 15 inpatient teams were identified in California that had collected data on patient race/ethnicity and language. Patient and clinician data were analyzed using means and medians for continuous variables, and chi-squared tests to explore similarities and differences between clinician and patient data. Results: 51 clinicians from nine teams completed the survey. The largest non-White and non-English speaking groups among patients and clinicians identified as Hispanic/Latinx (31.5% of patients, 16.3% of clinicians) and as Spanish speakers (22.6% of patients, 7.5% of clinicians). There was a significantly higher proportion of Hispanic/Latinx patients compared to clinicians (p-value 0.01), with Southern California demonstrating the largest difference (30.4% of patients vs. 10.7 % of clinicians, p-value 0.01). Similar proportions of patients and clinicians reported Spanish fluency (22.6% vs 27.5%, p-value 0.31). Discussion: We found significant differences in the racial/ethnic distributions of Hispanic/Latinx patients and clinicians in California, prompting consideration of whether a lack of representation of Hispanic/Latinx clinicians relative to the patient population may contribute to lower palliative care utilization among Hispanic/Latinx patients.

The Effect of Race and Area Deprivation on Symptom Profiles over the Course of Early-Stage Breast Cancer

Purpose

This study compared common symptoms (fatigue, pain), overall physical functioning and changes over time between Black and White women receiving early-stage breast cancer (ESBC) chemotherapy.

Methods

A longitudinal, repeated measures comparative design was employed. Time points of symptom measurement (PROMIS domains) at baseline, mid and end point were adjusted as per patient chemotherapy schedule.

Analyses

Linear mixed models were applied.

Results

There were 147 patients, 36% Black 64% White (54±12 years) recommended to receive early-stage breast cancer chemotherapy with adequate data for symptom analysis.

Pain

Main effect of race was significant (F(1, 390) = 29.43, p<.001) for pain with Black patients experiencing significantly higher pain scores compared to White patients at pretherapy (Mean Difference; MD=3.7, p=.034), midpoint (MD=5.8, p=.002), and endpoint (MD=7.8, p<.001).

Fatigue

Fatigue significantly increased (deteriorated) at endpoint (MDT1-T3= 8.7, p<.001) for Black patients. Among White patients, fatigue significantly increased at midpoint (MDT1-T2= 5.7) and at endpoint (MDT1-T3=10.1, p<.001; MDT2-T3=4.3, p= .017). Physical function: Black patients had significantly lower physical function scores compared to White patients at midpoint (MD=4.0, p=.027). Physical function decreased by endpoint in Black (MDT1-T3=7.8, p<.001), and White patients (MDT1-T3=7.7, p<.001).

Conclusion

Symptom burden significantly increased over the course of chemotherapy for all patients. Scores for pain and physical function were higher overall for Black patients and deteriorated at a greater rate for Black vs. White women over the course of chemotherapy. This assessment holds implication for proactive assessment and mitigation strategies.

Are Patient-Reported Outcome Measures for Distal Radius Fractures Validated for Spanish and Culture? A Systematic Review

PURPOSE

Patient-reported outcome measures (PROMs) are used commonly to assess function to direct treatment and evaluate outcomes for patients with distal radius fractures. Most PROMs have been developed and validated in English with minimal report of the demographics of patients studied. The validity of applying these PROMs among Spanish-speaking patients is unknown. The purpose of this study was to evaluate the quality and psychometric properties of Spanish-language adaptations of PROMs for distal radius fractures.

METHODS

We conducted a systematic review to identify published studies of adaptations of Spanish-language PROMs evaluating patients with distal radius fractures. We evaluated the methodologic quality of the adaptation and validation using Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures, Quality Criteria for Psychometric Properties of Health Status Questionnaire, and the Consensus-based Standards for the Selection of Health Measurement Instruments Checklist for Cross-Cultural Validity. The level of evidence was evaluated based upon prior methodology.

RESULTS

Five instruments reported in eight studies were included: the Patient-Rated Wrist Evaluation (PRWE), Disability of Arm Shoulder and Hand, Upper Limb Functional Index, Lawton Instrumental Activities of Daily Living Scale, and Short Musculoskeletal Function Assessment. The PRWE was the most frequently included PROM. No study followed all six processes for adaptation or assessed all measurement properties. No study demonstrated the completion of more than eight of the 14 aspects of cross-cultural validity. The PRWE had moderate evidence to support half of the domains of measurement properties evaluating the level of evidence.

CONCLUSIONS

None of the five instruments identified received a good rating on all three checklists. Only the PWRE demonstrated moderate evidence on half of the measurement domains.

CLINICAL RELEVANCE

Given the lack of strong evidence to support the quality of these instruments, we recommend adaptation and testing of PROMs for this population before use. Currently, PROMs in Spanish-speaking patients should be used with caution so as not to perpetuate health care disparities.

Estimating the prevalence and correlates of pain among people living with HIV who use unregulated drugs in a Canadian setting

Although prevalent among people living with human immunodeficiency virus (HIV) (PLWH) and people who use unregulated drugs (PWUD), pain and its possible links to substance use patterns and engagement in HIV treatment remains poorly characterized. We sought to evaluate the prevalence and correlates of pain among a cohort of PLWH who use un-regulated drugs. Between December 2011 and November 2018, 709 participants were recruited, and data were analyzed using generalized linear mixed-effects (GLMM). At baseline, 374 (53 percent) individuals reported moderate-to-extreme pain in the previous 6 months. In a multivariable model, pain was significantly associated with nonmedical prescrip-tion-opioid use (adjusted odds ratio (AOR) = 1.63, 95 percent confidence interval (CI): 1.30-2.05), nonfatal overdose (AOR = 1.46, 95 percent CI: 1.11-1.93), self-managing pain (AOR = 2.25, 95 percent CI: 1.94-2.61), requesting pain medication in the previous 6 months (AOR = 2.01, 95 percent CI: 1.69-2.38), and ever being diagnosed with a mental illness (AOR = 1.47, 95 percent CI: 1.11-1.94). Establishing accessible pain management interventions that address the complex intersection of pain, drug use, and HIV-infection has potential to improve quality of life outcomes among this population.

A Scoping Review on the Relationship between Race/Ethnicity and the Receipt of Supportive Care Medications during Cancer Treatment: Implications for the Clinical Pharmacist

There is surmounting levels of evidence on the health disparities within cancer treatment in the United States (US). Most of the research focused on cancer specific factors including anticancer incidence, screening, treatment and follow-up, and clinical outcomes such as overall survival (OS). Less is known about the disparities present with supportive care medication use in cancer patients. Supportive care utilization during cancer treatment has been linked to improved quality of life (QoL) and OS among patients. The goal of this scoping review is to summarize findings of current literature on the relationship between race and ethnicity and the receipt of supportive care medications during cancer treatment for pain and chemotherapy-induced nausea and vomiting (CINV). This scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-ScR) guidelines. Our literature search included quantitative studies, qualitative studies, and grey literature written in the English language with clinically relevant outcomes pertaining to pain and CINV management in cancer treatment published from 2001-2021. Articles that met the predefined inclusion criteria were considered for inclusion in the analysis. The initial search yielded 308 studies. Following de-duplication and screening, 14 studies met the predefined inclusion criteria, with majority of the studies being quantitative studies (n=13). Collectively, results were mixed results regarding the presence of racial disparities for supportive care medication use. Half of the studies (n=7) supported this finding whereas, the other half (n=7) did not identify any racial disparities. In our review, multiple studies illustrate the existence of disparities in the use of supportive care medications in some cancer types. Clinical pharmacists should strive to eliminate supportive medication use disparities as part of a multidisciplinary team. In order to develop strategies to prevent supportive care medication use disparities in this population, further research and analysis of external factors that influence them are needed.

Antiracist symptom science: A call to action and path forward

Nurse scientists recognize the experience of racism as a driving force behind health. However, symptom science, a pillar of nursing, has rarely considered contributions of racism. Our objective is to describe findings within symptom science research related to racial disparities and/or experiences of racism and to promote antiracist symptom science within nursing research. In this manuscript, we use an antiracist lens to review a predominant symptom science theory and literature in three areas of symptom science research-oncology, mental health, and perinatal health. Finally, we make recommendations for increasing antiracist research in symptom science by altering (a) research questions, (b) recruitment methods, (c) study design, (d) data analysis, and (e) dissemination of findings. Traditionally, symptom science focuses on individual level factors rather than broader contexts driving symptom experience and management. We urge symptom science researchers to embrace antiracism by designing research with the specific intent of dismantling racism at multiple levels.

Sociodemographic and Clinical Characteristics Associated With Worst Pain Intensity Among Cancer Patients

AIMS

Patients with cancer have pain due to their cancer, the cancer treatment and other causes, and the pain intensity varies considerably between individuals. Additional research is needed to understand the factors associated with worst pain intensity. Our study aim was to determine the association between worst pain intensity and sociodemographics and cancerspecific factors among patients with cancer.

DESIGN

A total of 1,280 patients with cancer recruited from multiple cancer centers over 25 years in the United States were asked to complete a questionnaire that collected respondents' demographic, chronic pain, and cancer-specific information.

SETTINGS

Worst, least, and current pain intensities were captured using a modified McGill Pain Questionnaire (pain intensity measured on 0-10 scale). A generalized linear regression analysis was utilized to assess the associations between significant bivariate predictors and worst pain intensity scores.Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain.

CONCLUSIONS

Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain. Findings identified being Hispanic and having previous severe toothache, stomachache, and headache pain as significant predictors of worst pain intensity among patients with cancer. After controlling for selected covariates, we did not note statistical differences in worst pain during a 25-year period. Therefore,studies focused on improving the management of pain among patients with cancer should target interventions for those with Hispanic heritage and those with past history of severe common pain.

Symptom Burden Is Lower in Asian and Pacific Islander and Black Men Admitted to Home-Based Palliative Care in an Integrated Health Care System

Background: Little is known about racial/ethnic differences in symptom severity among patients receiving home-based palliative care (HomePal). Objectives: To determine whether symptom severity differs between White patients and patients of color receiving HomePal and whether gender moderates the difference. Design: This is a cross-sectional exploratory study. Setting/Subjects: Baseline data were from 2090 patients receiving HomePal in Kaiser Permanente Southern California. Measurements: Multivariable median regression analyses were carried out across race/ethnicity groups and stratified by gender to assess differences in Edmonton Symptom Assessment System (ESAS) scores at HomePal admission. Results: Asian/Pacific Islander men and Black men had lower ESAS scores compared than White men (-5 [-7.8, -2.2], p = 0.0005 and -5.4 [-8.7, -2.1], p = 0.001, respectively); there were marginal ESAS differences across race/ethnic groups for women. Conclusion: Patients of color reported lower symptom severity than White patients. More research is needed to understand how the intersection of culture and gender affects symptom experience and reporting in patients living with serious illness. Trial Registration: ClinicalTrials.gov: NCT#03694431.

Modifiers of and Disparities in Palliative and Supportive Care Timing and Utilization among Neurosurgical Patients with Malignant Central Nervous System Tumors

Patients with primary or secondary central nervous system (CNS) malignancies benefit from utilization of palliative care (PC) in addition to other supportive services, such as home health and social work. Guidelines propose early initiation of PC for patients with advanced cancers. We analyzed a cohort of privately insured patients with malignant brain or spinal tumors derived from the Optum Clinformatics Datamart Database to investigate health disparities in access to and utilization of supportive services. We introduce a novel construct, "provider patient racial diversity index" (provider pRDI), which is a measure of the proportion of non-white minority patients a provider encounters to approximate a provider's patient demographics and suggest a provider's cultural sensitivity and exposure to diversity. Our analysis demonstrates low rates of PC, home health, and social work services among racial minority patients. Notably, Hispanic patients had low likelihood of engaging with all three categories of supportive services. However, patients who saw providers categorized into high provider pRDI (categories II and III) were increasingly more likely to interface with supportive care services and at an earlier point in their disease courses. This study suggests that prospective studies that examine potential interventions at the provider level, including diversity training, are needed.

Disparities in Supportive Care Needs Over Time Between Racial and Ethnic Minority and Non-Minority Patients With Advanced Lung Cancer

CONTEXT

Little is known about inequities in supportive care needs among diverse patients with advanced lung cancer.

OBJECTIVES

We aimed to examine differences in supportive care needs between racial/ethnic minority and non-minority patients with lung cancer and identify how these needs change over time.

METHODS

We performed a prospective cohort study of patients newly diagnosed with advanced lung cancer (stage III and IV). Patients completed a validated survey at baseline, 4-, 8- and 12-months post-diagnosis, assessing supportive care needs: medical communication/information, psychological/emotional support, daily living, financial concerns, physical symptoms, and spiritual and social needs. Univariable and multivariable regression analyses compared differences in supportive care needs between minority (Black and Latinx) and non-minority patients. A mixed effect model with minority status, follow-up time and the interaction between minority status and time assessed the association between each need and minority status with changes over time.

RESULTS

We enrolled 99 patients; 55 (56%) were minorities and 44 (44%) were non-minorities. At baseline, minorities reported significantly higher needs across each domain except medical communication/information. Over time, these reported differences remained consistent except for medical communication. After adjustment, the needs of both minorities and non-minorities increased significantly in the psychological/emotional, daily living and physical symptom domains.

CONCLUSION

Minority patients with advanced lung cancer are more likely to have higher baseline and persistent supportive care needs relatives to non-minority patients. Clinicians caring for minority patients with lung cancer should provide targeted supportive care evaluation and treatment to ensure health equity.

The Role of Experiential Avoidance in Terms of Fatigue and Pain During COVID-19 Among Latinx Adults

Background

Latinx persons are overrepresented in terms of 2019 Coronavirus (COVID-19) infection rates and constitute a subpopulation at increased risk for COVID-19 related physical ailments. Fatigue and pain are among the most prevalent somatic symptoms among the Latinx population; however, there is little understanding of individual difference factors that are related to fatigue and pain during COVID-19 among this health disparities population. Experiential avoidance (EA) reflects the persistent tendency to avoid aversive internal sensations.

Methods

The current study sought to extend past work by exploring EA in relation to fatigue severity, pain intensity, and pain disability among 182 Latinx adult persons during the COVID-19 pandemic.

Results

Results indicated that EA accounted for a statistically significant amount of variance across the criterion variables.

Conclusions

Overall, the current work provides initial empirical evidence that EA is related to greater fatigue severity and pain severity/disability among Latinx persons during COVID-19.

Barriers to Equitable Palliative Care Utilization Among Patients with Cancer

Over the past half century, palliative care has grown to become a pillar of clinical oncology. Its practice revolves around relieving suffering and optimizing quality of life, not just dealing with end-of-life decisions. Despite evidence that palliative care has the potential to reduce health care utilization and improve advance care planning without affecting mortality, palliative care remains inequitably accessible and underutilized. Furthermore, it is still too often introduced late in the care of patients receiving surgical intervention. This article summarizes the numerous and complex barriers to equitable palliative care utilization among patients with cancer. Potential strategies for dismantling these barriers are also discussed.

Patient-reported symptom burden in routine oncology care: Examining racial and ethnic disparities

Background

Racial and ethnic disparities are well‐documented in cancer outcomes such as disease progression and survival, but less is known regarding potential disparities in symptom burden.

Aims

The goal of this retrospective study was to examine differences in symptom burden by race and ethnicity in a large sample of cancer patients. We hypothesized that racial and ethnic minority patients would report greater symptom burden than non‐Hispanic and White patients.

Methods and results

A total of 5798 cancer patients completed the Edmonton Symptom Assessment Scale—revised (ESAS‐r‐CSS) at least once as part of clinical care. Two indicators of symptom burden were evaluated: (1) total ESAS‐r‐CSS score (i.e., overall symptom burden) and (2) number of severe symptoms (i.e., severe symptomatology). For patients completing the ESAS‐r‐CSS on multiple occasions, the highest score for each indicator was used. Zero‐inflated negative binomial regression analyses were conducted, adjusting for other sociodemographic and clinical characteristics. Symptomology varied across race. Patients who self‐identified as Black reported higher symptom burden (p = .016) and were more likely to report severe symptoms (p < .001) than self‐identified White patients. Patients with “other” race were also more likely to report severe symptoms than White patients (p = .032), but reported similar total symptom burden (p = .315). Asian and Hispanic patients did not differ from White or non‐Hispanic patients on symptom burden (ps > .05).

Conclusion

This study describes racial disparities in patient‐reported symptom burden during routine oncology care, primarily observed in Black patients. Clinic‐based electronic symptom monitoring may be useful to detect high symptom burden, particularly in patients who self‐identify their race as Black or other. Future research is needed to reduce symptom burden in racially diverse cancer populations.

Public perception of palliative care: a survey of the general population

Background:

The public’s view of palliative care often involves its potential to improve of quality-of-life as well as its use as a last resource prior to death.

Objective:

To obtain an idea of the image of palliative care held by the public in the German-speaking part of Switzerland, the authors sought to understand (1) the perceptions of palliative care and the (2) elements important when thinking about their own end of life.

Methods and Sample:

A qualitative design with an inductive reasoning approach based on Mayring (2014) was chosen. Visitors at an exhibition about palliative care in six locations provided hand-written answers on provided cards to two statements: (1) if I hear the term ‘Palliative Care’ I think of … and (2) when thinking about my own end of life, the following is important to me …

Results:

Answers of 199 visitors (mean age 52, mostly in a good/very good health status) were analysed. In response to hearing the term palliative care, six areas were categorized: (1) the main focus; (2) ways of providing palliative care; (3) the best timing; (4) places where palliative care is provided; (5) who is seen as provider and (6) outcomes of palliative care. Five categories to the statement about their own end-of-life were identified: (1) the ability to look back on a fulfilled life and being satisfied; (2) maintaining trusting relationships until the end; (3) organizing affairs and having everything settled; (4) having their family being cared for and (5) relief of suffering with the support of knowledgeable people.

Conclusion:

Palliative care was mostly associated with positive terms acknowledging an interprofessional approach. Maintaining one’s dignity as well as dying without suffering pointed at the persisting stigma that palliative care is mainly limited to end-of-life care. The results may help healthcare professionals to better understand how the public view palliative care.

Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors

Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.

Symptom Burden and Palliative Care Needs of Patients with Incurable Cancer at Diagnosis and During the Disease Course

Background

Although current guidelines advocate early integration of palliative care, symptom burden and palliative care needs of patients at diagnosis of incurable cancer and along the disease trajectory are understudied.

Material and Methods

We assessed distress, symptom burden, quality of life, and supportive care needs in patients with newly diagnosed incurable cancer in a prospective longitudinal observational multicenter study. Patients were evaluated using validated self‐report measures (National Comprehensive Cancer Network Distress Thermometer [DT], Functional Assessment of Cancer Therapy [FACT], Schedule for the Evaluation of Individual Quality of Life [SEIQoL‐Q], Patients Health Questionnaire‐4 [PHQ‐4], modified Supportive Care Needs Survey [SCNS‐SF‐34]) at baseline (T0) and at 3 (T1), 6 (T2), and 12 months (T3) follow‐up.

Results

From October 2014 to October 2016, 500 patients (219 women, 281 men; mean age 64.2 years) were recruited at 20 study sites in Germany following diagnosis of incurable metastatic, locally advanced, or recurrent lung (217), gastrointestinal (156), head and neck (55), gynecological (57), and skin (15) cancer. Patients reported significant distress (DT score ≥ 5) after diagnosis, which significantly decreased over time (T0: 67.2%, T1: 51.7%, T2: 47.9%, T3: 48.7%). The spectrum of reported symptoms was broad, with considerable variety between and within the cancer groups. Anxiety and depressiveness were most prevalent early in the disease course (T0: 30.8%, T1: 20.1%, T2: 14.7%, T3: 16.9%). The number of patients reporting unmet supportive care needs decreased over time (T0: 71.8 %, T1: 61.6%, T2: 58.1%, T3: 55.3%).

Conclusion

Our study confirms a variable and mostly high symptom burden at the time of diagnosis of incurable cancer, suggesting early screening by using standardized tools and underlining the usefulness of early palliative care.

Implications for Practice

A better understanding of symptom burden and palliative care needs of patients with newly diagnosed incurable cancer may guide clinical practice and help to improve the quality of palliative care services. The results of this study provide important information for establishing palliative care programs and related guidelines. Distress, symptom burden, and the need for support vary and are often high at the time of diagnosis. These findings underscore the need for implementation of symptom screening as well as early palliative care services, starting at the time of diagnosis of incurable cancer and tailored according to patients’ needs.

Guidelines recommend early integration of palliative care in the treatment of patients with advanced cancer. This study assessed distress, symptom burden, quality of life, and supportive care needs in patients with newly diagnosed incurable cancer to facilitate future implementation of more effective palliative care services.

Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors

Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.

Inpatient Palliative Care Use Among Critically III Brain Metastasis Patients in the United States

OBJECTIVE

The objective of this study was to understand the trends and characteristics of palliative care delivery among critically ill brain metastasis patients using a nationally representative database.

MATERIALS AND METHODS

This study was a retrospective analysis of Nationwide Inpatient Sample data collected during 2005 to 2014. This study included critically ill patients, 18 years and above, diagnosed with brain metastasis, identified using International Classification of Diseases-Ninth Revision-Clinical Modification diagnosis and procedure codes. Multivariable logistic regression models were used for predicting factors associated with inpatient palliative care use.

RESULTS

Among 18,309 critically ill patients with brain metastasis, 3298 (18.0%) received inpatient palliative care. The rate of inpatient palliative care use among these patients increased from 3.2% to 28.5%, during 2005 to 2014 (P<0.001). Regression analysis showed that hospital teaching status (odds ratio [ORs], 1.45; 95% confidence interval [CI], 1.14-1.84), primaries located in head and neck (OR, 1.42; 95% CI, 1.21-2.05) or lung (OR, 1.32; 95% CI, 1.22-1.44), and primary diagnosis of pneumonia (OR, 1.42; 95% CI, 1.22-1.97) or septicemia (OR, 1.59; 95% CI, 1.30-1.97), were associated with higher palliative care use. Hispanic ethnicity (OR, 0.86; 95% CI, 0.67-0.96), and hospital location in Northeast (OR, 0.73; 95% CI, 0.54-0.96), Midwest (OR, 0.63; 95% CI, 0.45-0.87), or South (OR, 0.64; 95% CI, 0.48-0.86) were associated with lower palliative care use.

CONCLUSIONS

Inpatient palliative care use increased significantly among critically ill patients with brain metastases, though overall rate was low. There were geographical and racial disparities among these patients. Health care providers and policy makers should focus on decreasing these disparities. In addition, hospitals should focus on adopting more palliative care services.

Patient-Level Factors Influencing Palliative Care Consultation at a Safety-Net Urban Hospital

The influence of patient-level factors on palliative and hospice care is unclear. We conducted a retrospective review of 2321 patients aged ≥18 that died within 6 months of admission to our institution between 2012 and 2017. Patients were included for analysis if their chart was complete, their length of stay was ≥48 hours, and if based on their diagnoses, they would have benefited from palliative care consultation (PCC). Bayesian regression with a weakly informative prior was used to find the odds ratio (OR) and 99% credible interval (CrI) of receiving PCC based on race/ethnicity, education, language, insurance status, and income. 730 patients fit our inclusion criteria and 30% (n = 211) received PCC. The OR of receiving PCC was 1.26 (99% CrI, 0.73-2.12) for Blacks, 0.81 (99% CrI, 0.31-1.86) for Hispanics, and 0.69 (99% CrI, 0.19-2.46) for other minorities. Less than high school education was associated with greater odds of PCC (OR 2.28, 99% CrI, 1.09-4.93) compared to no schooling. Compared to English speakers, non-English speakers had higher odds of receiving PCC when cared for by medical services (OR 3.01 [99% CrI, 1.44-5.32]) but lower odds of PCC when cared for by surgical services (0.22 [99% CrI, <0.01-3.42]). Insurance status and income were not associated with differences in PCC. At our institution, we found no evidence of racial/ethnic, insurance, or income status affecting PCC while primary language spoken and educational status did. Further investigation is warranted to examine the system and provider-level factors influencing PCC's low utilization by medical and surgical specialties.

Racial and ethnic disparities in palliative care utilization among gynecological cancer patients

BACKGROUND

Palliative care (PC) is recommended for gynecological cancer patients to improve survival and quality-of-life. Our objective was to evaluate racial/ethnic disparities in PC utilization among patients with metastatic gynecologic cancer.

METHODS

We used data from the 2016 National Cancer Database (NCDB) and included patients between ages 18-90 years with metastatic (stage III-IV) gynecologic cancers including, ovarian, cervical and uterine cancer who were deceased at last contact or follow-up (n = 124,729). PC was defined by NCDB as non-curative treatment, and could include surgery, radiation, chemotherapy, and pain management or any combination. We used multivariable logistic regression to evaluate racial disparities in PC use.

RESULTS

The study population was primarily NH-White (74%), ovarian cancer patients (74%), insured by Medicare (47%) or privately insured (36%), and had a Charlson-Deyo score of zero (77%). Over one-third of patients were treated at a comprehensive community cancer program. Overall, 7% of metastatic gynecologic deceased cancer patients based on last follow-up utilized palliative care: more specifically, 5% of ovarian, 11% of cervical, and 12% of uterine metastatic cancer patients. Palliative care utilization increased over time starting at 4% in 2004 to as high as 13% in 2015, although palliative care use decreased to 7% in 2016. Among metastatic ovarian cancer patients, NH-Black (aOR:0.87, 95% CI:0.78-0.97) and Hispanic patients (aOR:0.77, 95% CI:0.66-0.91) were less likely to utilize PC when compared to NH-White patients. Similarly, Hispanic cervical cancer patients were less likely (aOR:0.75, 95% CI:0.63-0.88) to utilize PC when compared to NH-White patients.

CONCLUSIONS

PC is highly underutilized among metastatic gynecological cancer patients. Racial disparities exist in palliative care utilization among patients with metastatic gynecological cancer.

Obesity Trends Amongst Hospitalized Patients with Spinal Cord Stimulator Implants

INTRODUCTION

Chronic pain remains an important public health problem as it continues to increase healthcare-related cost. Comorbidities like obesity have been associated with efficacy of spinal cord stimulator (SCS) therapy and worse outcomes. The goal of this study is to investigate the trends of obesity amongst hospitalized patients with SCS therapy as well as healthcare utilization outcomes.

METHODS

Using the International Classification of Diseases (ICD) ninth and tenth procedure and diagnosis code, we investigated the National Inpatient Sample (NIS) for patients with SCS implants between 2011 and 2015. Patients received a diagnosis of obesity based on the following categories: class I, II and III obesity. Age, gender, and comorbid conditions of patients with obesity were matched 1:1 on propensity score to those without obesity diagnosis. Our primary outcome was defined as trend of obesity diagnosis. Our secondary outcome, healthcare utilization, included in-hospital cost, length of stay, and discharge location.

RESULTS

Between 2011 and 2015, a total of 3893 patients with SCS implants were identified (average age 56 ± 15 years, 58% female, 0.70 ± 1.1 Charlson Comorbidity Index, CCI). Of this cohort, 640 patients were identified as obese. The proportion of patients with obesity diagnosis increased significantly from 13.75% in 2011 to 19.36% in 2015 (p < 0.001). After 1:1 matching on propensity score, 597 patients with obesity were successfully matched to 597 patients without obesity. The total hospital cost for SCS patients with obesity (median $104,845, IQR $74,648-144,292) was not significantly different from patients without obesity diagnosis (median $111,092, IQR $68,990-145,459) (p = 0.161).

CONCLUSIONS

The data from our study suggests that there is an increasing rate of obesity diagnosis amongst patients with SCS therapy. However, there was no difference in healthcare utilization between patients with and without obesity. Additional studies may provide more insight into our findings.

Care and Decision-Making at the End of Life for Patients With a Non-Western Migration Background Living in The Netherlands: A Nationwide Mortality Follow-Back Study

CONTEXT

Migrant populations across Europe are aging and will increasingly need end-of-life care.

OBJECTIVE

The objectives of this study were to gain insight into end-of-life care and decision-making for patients with a non-western migration background and assess differences compared to patients with a Dutch or western migration background.

METHODS

A mortality follow-back study was conducted using a stratified sample of death certificates of persons who died between August and December 2015, obtained from the central death registry of Statistics Netherlands. Questionnaires were sent to the attending physician (n = 9351; response 78%). Patients aged ≥18 years who died a nonsudden death were included in this study (n = 5327).

RESULTS

Patients with a non-western migration background are more likely than patients with a Dutch or western migration background to be admitted to and die in hospital (51.6% vs. 33.9% [OR 1.74; 95% CI 1.26-2.41]; 39.1% vs. 20.1% [OR 1.96; 95% CI 1.39-2.78]); less likely to receive morphine or morphine-like medication and continuous deep sedation (72.8% vs. 80.1% [OR 0.62; 95% CI 0.43-0.89]; 16.8% vs. 25.2% [OR 0.52; 95% CI 0.34-0.80]); and more likely to receive end-of-life care that, according to physicians, is directed at curation for too long (6.8% vs. 1.7% [OR 3.61; 95% CI 1.83-7.12]). End-of-life decisions are made less frequently for patients with a non-western migration background (71.6% vs. 79.2% [OR 0.64; 95% CI 0.45-0.91]). Characteristics of decision-making are similar.

CONCLUSION

End-of-life care for patients with a non-western migration background focuses more, or longer on maximum, curative treatment and end-of-life decisions are made less often.

Multicultural approaches of cancer pain

PURPOSE OF REVIEW

Pain continues to be a prevalent symptom in cancer patients. Patient's ethnicity may influence the experience of pain with variations in pain outcomes among different ethnic groups. The objective of this thematic review is to investigate the relationship between ethnicity and cancer pain experience, assessment and management.

RECENT FINDINGS

Cancer pain is not only a biophysiological construct but is rather a multidimensional concept of physiological and psychosocial responses, including the biocultural dimension. Culture can significantly affect patients' cancer pain-related beliefs and behaviors and patient's ethnicity may influence the experience of pain.We found a scarcity of data and an inconsistent literature that highlights gaps in knowledge, research and clinical practice concerning effective cancer pain management in a multicultural context.

SUMMARY

To face disparities among ethnic minorities in cancer pain management, well-designed randomized controlled trials and robust qualitative research on cancer pain-related issues should inform good clinical practice. A close worldwide collaboration between researchers and clinicians and professional organizations is warranted.

Racial differences in user experiences and perceived value of electronic symptom monitoring in a cohort of black and white bladder and prostate cancer patients

PURPOSE

Electronic patient-reported outcomes (ePROs) are increasingly being used for symptom monitoring during routine cancer care, but have rarely been evaluated in diverse patient populations. We assessed ePRO user experiences and perceived value among Black and White cancer patients.

METHODS

We recruited 30 Black and 49 White bladder and prostate cancer patients from a single institution. Participants reported symptoms using either a web-based or automated telephone interface over 3 months and completed satisfaction surveys and qualitative interviews focused on user experiences and value. Using a narrative mixed methods approach, we evaluated overall and race-specific differences in ePRO user experiences and perceived value.

RESULTS

Most participants selected the web-based system, but Blacks were more likely to use the automated telephone-based system than Whites. In satisfaction surveys, Whites more commonly reported ease in understanding and reporting symptoms compared with Blacks. Blacks more often reported that the ePRO system was helpful in facilitating symptom-related discussions with clinicians. During interviews, Blacks described how the ePRO helped them recognize symptoms, while Whites found value in better understanding and tracking symptoms longitudinally. Blacks also expressed preferences for paper-based ePRO options due to perceived ease in better understanding of symptom items.

CONCLUSION

Electronic patient-reported outcomes are perceived as valuable for variable reasons by Black and White cancer populations, with greater perceived value for communicating with clinicians reported among Blacks. To optimize equitable uptake of ePROs, oncology practices should offer several ePRO options (e.g., web-based, phone-based), as well as paper-based options, and consider the e-health literacy needs of patients during implementation.

Disparities in Palliative Care in Patients With Cancer

In the United States, racial and ethnic minorities and people with lower socioeconomic status (SES) face structural, health system, and interpersonal barriers to optimal health care, including palliative care. Much of the available data on palliative care in racial and ethnic minorities and people with lower SES have identified disparities according to race, ethnicity, and SES. Limitations to understanding disparities in palliative care include the fact that much of the available data are cross-sectional, drawn from administrative or claims data, or based on qualitative work in limited geographic areas. To advance our knowledge and achieve health equity with respect to palliative care in patient groups that have been understudied or that are known to receive disparate care, gaining a deeper understanding of the barriers to palliative care is necessary from patients, families, referring providers, and communities. In addition, cultural competency training for all members of the palliative care team and referring providers needs to be changed from being obligatory to being intentional and assessed continuously. Finally, concerted changes in coordination of care, payment structures, and policy are needed.

Referral Characteristics of Palliative Care Service in Patients With Advanced Non-Small Cell Lung Cancer in a Tertiary Cancer Center

BACKGROUND

The American Society of Clinical Oncology recently recommends patients with metastatic non-small cell lung cancer (NSCLC) should be offered palliative care services earlier. We sought to investigate the timing of palliative care referral of Chinese patients with NSCLC in our center.

METHOD

Retrospective medical data including demographic characteristics and referral information were collected for analysis. Overall survival (OS) was calculated as the time since cancer diagnosis till patient's death. The time interval from palliative care (PC) referral to a patient's death (PC-D) was calculated. The PC-D/OS ratio was calculated to illustrate the comparison of the duration of PC in the overall length of disease.

RESULTS

The mean age of 155 patients with advanced NSCLC was 62.83 years. Before referral to PC, 128 patients received anticancer treatment including surgeon (46.5%). Sixty-three (40.6%) patients died in palliative care unit. The median OS of 144 patients with end cutoff was 19 months (mean = 31.49, 95% confidence interval [CI] = 25.86-37.12). The median PC-D was 41 days (mean = 73.84, 95% CI = 60.37-87.40). The mean interval of PC-D/OS of 144 patients with definitely death time was 0.22 (SD: 0.27, 95% CI: 0.17-0.26). The median interval was 0.089. More than half of patients (n = 75, 51.8%) underwent PC less than 1% time (PC-D/OS < 0.1) of their whole disease course. Patients who were indigenous to Shanghai (P = .013) and who had brain metastasis (P = .072) had the potential longer PC-D/OS ratio. A high proportion of patients reported loss of appetite (92.8%) and fatigue (91.4%) at the initial of referral to PC.

CONCLUSION

This retrospective study, in a population of patients with advanced NSCLC, gave detailed information about PC services in a tertiary cancer center.

Social disparities and symptom burden in populations with advanced cancer: specialist palliative care providers' perspectives

Disparities in access to palliative care services for populations with social disparities have been reported in Western countries. Studies indicate that these populations tend to report higher symptom distress than other population groups. We need to further investigate how social disparities influence symptom burden to improve symptom relief in these populations.

PURPOSE

To examine the perspectives of specialist palliative care providers concerning the relationship between social disparities and symptom burden in populations with advanced cancer.

METHODS

Two sequential qualitative studies that followed a combination of interpretive and critical methodologies. The interpretive approach was outlined by van Manen's hermeneutic phenomenology while the critical component was informed by the works of Paulo Freire. Participants involved two specialist palliative care teams from a large acute care hospital and a large cancer center in Western Canada. Participants included 11 palliative care providers including registered nurses, nurse practitioners, physicians, and pharmacists.

RESULTS

Participants perceived that social conditions that might aggravate symptom burden included low income, low education, lack of social support, language barriers, and rurality. The relationship between income and symptom burden reflected diverse views. Participants identified populations prone to complex symptom burden including homeless individuals, Indigenous people, people with a history of addictions, and people with mental health or psychosocial issues.

CONCLUSION

Participants perceived that social disparities may increase symptom complexity in populations with advanced cancer. Participants did not identify ethnicity and gender as influencing symptom burden. Further research is needed to examine the interactions of social disparities, patient individuality, and symptom burden.

Factors associated with receipt of symptom screening in the year after cancer diagnosis in a universal health care system: a retrospective cohort study

Purpose

Patient-reported symptom data are collected prospectively by a provincial cancer agency to mitigate the significant symptom burden that patients with cancer experience. However, an assessment of whether such symptom screening occurs uniformly for those patients has yet to be performed. In the present study, we investigated patient, disease, and health system factors associated with receipt of symptom screening in the year after a cancer diagnosis.

Methods

Patients diagnosed with cancer between 2007 and 2014 were identified. We measured whether 1 or more symptom screenings were recorded in the year after diagnosis. A multivariable modified Poisson regression with robust error variance was used to identify predictors [age, comorbidity, rurality, socioeconomic status, immigration status, cancer site, registration at a regional cancer centre (cc), and year of diagnosis] of being screened for symptoms.

Results

Of 425,905 patients diagnosed with cancer, 163,610 (38%) had 1 or more symptom screening records in the year after diagnosis, and 75% survived at least 1 year. We identified variability in symptom screening by primary cancer site, regional cc, age, sex, comorbidity, material deprivation, rurality of residence, and immigration status. Patients who had been diagnosed with melanoma or endocrine cancers, who were not registered at a regional cc, who lived in the most urban areas, who were elderly, and who were immigrants were least likely to undergo symptom screening after diagnosis.

Conclusions

Our evaluation of the implementation of a population-based symptom screening program in a universal health care system identified populations who are at risk for not receiving screening and who are therefore future targets for improvements in population symptom screening and better management of cancer-related symptoms at diagnosis.

Social Inequalities in Palliative Care for Cancer Patients in the United States: A Structured Review

OBJECTIVES

To identify patterns of access to and use or provision of palliative care services in medically underserved and vulnerable groups diagnosed with cancer.

DATA SOURCES

Google Scholar, PubMed, MEDLINE, and Web of Science were searched to identify peer-reviewed studies that described palliative care in medically underserved or vulnerable populations diagnosed with cancer.

CONCLUSION

Disparities in both access and referral to palliative care are evident in many underserved groups. There is evidence that some groups received poorer quality of such care.

IMPLICATIONS FOR NURSING PRACTICE

Achieving health equity in access to and receipt of quality palliative care requires prioritization of this area in clinical practice and in research funding.

Understanding racial/ethnic differences in breast cancer-related physical well-being: the role of patient-provider interactions

PURPOSE

Racial/ethnic differences in cancer symptom burden are well documented, but limited research has evaluated modifiable factors underlying these differences. Our objective was to examine the role of patient-provider interactions to help explain the relationship between race/ethnicity and cancer-specific physical well-being (PWB) among women with breast cancer.

METHODS

The Pathways Study is a prospective cohort study of 4505 women diagnosed with breast cancer at Kaiser Permanente Northern California between 2006 and 2013. Our analysis included white, black, Hispanic, and Asian participants who completed baseline assessments of PWB, measured using the Functional Assessment of Cancer Therapy for Breast Cancer, and patient-provider interactions, measured by the Interpersonal Processes of Care Survey (IPC) (N = 4002). Using step-wise linear regression, we examined associations of race/ethnicity with PWB, and changes in associations when IPC domains were added.

RESULTS

We observed racial/ethnic differences in PWB, with minorities reporting lower scores than whites (beta, black: - 1.79; beta, Hispanic: - 1.92; beta, Asian: - 1.68; p < 0.0001 for all comparisons). With the addition of health and demographic covariates to the model, associations between race/ethnicity and PWB score became attenuated for blacks and Asians (beta: - 0.63, p = 0.06; beta: - 0.68, p = 0.02, respectively) and, to a lesser extent, for Hispanic women (beta: - 1.06, p = 0.0003). Adjusting for IPC domains did not affect Hispanic-white differences (beta: - 1.08, p = 0.0002), and slightly attenuated black-white differences (beta: - 0.51, p = 0.14). Asian-white differences narrowed substantially (beta: - 0.31, p = 0.28).

CONCLUSIONS

IPC domains, including those capturing perceived discrimination, respect, and clarity of communication, appeared to partly explain PWB differences for black and Asian women. Results highlight opportunities to improve providers' interactions with minority patients, and communication with minority patients about their supportive care needs.

Differences in the Severity, Distress, Interference, and Frequency on Cancer-Related Symptoms Between Island Hispanic Puerto Ricans and Mainland Non-Hispanic Whites

The knowledge base of cancer-related symptoms is increasing; yet, limited attention has been given to provide evidence on differences in the perception of cancer symptoms between ethnic groups, especially in the Hispanic Puerto Rican (PR) population. To examine whether there are significant differences in the severity, distress, interference, and frequency of cancer symptoms between island Hispanic PR and mainland non-Hispanic whites. In this secondary data analysis, data from 109 Hispanic PR was matched by age, gender and cancer diagnosis with data from non-Hispanic whites. Cancer symptoms were assessed using the Cancer Symptom Scale (CSS). Mann-Whitney statistical test was used to evaluate pairwise differences between Hispanic PR and non-Hispanic whites on symptoms from the CSS. There were significant differences on some symptoms including PR reporting: (a) more intense itching, swelling, taste change, difficulty sleeping, bloating, depression, sadness, worry, and nervousness; (b) significantly greater distress about taste change, appetite, anxiety, depression, worry, and feeling nervous; (c) rash, anxiety, depression, sadness, and nervousness interfered the most with their daily lives; and, (d) that the frequency of occurrence of the symptoms of pain, itching, dizziness, taste change, anxiety, sadness, and nervousness was higher compared to non-Hispanic whites. PR cancer patients are at increased risk for experiencing greater severity of cancer symptoms compared to non-Hispanic whites. But because the Hispanic oncology population does not always report symptoms, risking under-assessment and under-management, this suggests there may be a greater need for symptoms surveillance for this population.

Procedural pain management in patients with cancer

Pain has been identified as one of the most significant factors in patients' experience of cancer and its treatment. Pain experienced during cancer treatment procedures such as radiotherapy can be unpleasant and distressing for the patient, as well as for their family and carers. Nurses have an important role in assessing and managing any pain associated with such procedures. This article explores the procedural pain that may be experienced by patients in general, and by those with cancer specifically, and details the pharmacological and non-pharmacological strategies that nurses can use to manage this challenging complication.

Race and Ethnicity in the Evidence for Integrating Palliative Care Into Oncology

Purpose:

ASCO recommends early involvement of palliative care for patients with advanced cancers on the basis of evidence from 18 randomized trials. We examined racial and ethnic minority representation in these trials and the role of race and ethnicity in the statistical analyses. The goal was to identify specific gaps in the palliative care evidence base for these individuals and potential strategies to address them.

Methods:

We reviewed the 18 trials cited in the 2012 and 2017 ASCO clinical statements on integrating palliative care into oncology. We extracted data on the reporting and categorization of race and ethnicity, on the enrollment of specific racial and ethnic minority groups, and on how race and ethnicity were addressed in the analyses.

Results:

One third of patient trials reported representation of specific racial and ethnic minority groups, one third reported rates of “white” versus “other,” and one third did not report race or ethnicity data. Among the patient trials with race and ethnicity data, 9.9% of participants were Asian, 8.8% Hispanic/Latino, and 5.7% African American. Analyses that used race and ethnicity were primarily baseline comparisons among randomized groups.

Conclusion:

Race and ethnicity were inconsistently reported in the trials. Among those that provided race and ethnicity data, representation of specific racial and ethnic minority groups was low. In addition to more research in centers with large minority populations, consistent reporting of race and ethnicity and supplementary data collection from minority patients who participate in trials may be strategies for improvement.

Development of a Community-Based Palliative Care Screening Tool for Underserved Older Adults With Chronic Illnesses

Although they experience high rates of chronic illness, low-income minority communities have traditionally underutilized palliative care services compared to whites and those with higher incomes. One reason for this trend is lack of screening by community providers. We utilized a community-based participatory research approach to develop and implement an innovative multidomain palliative care screening tool in aging service agencies. Participants were aging service providers and clients in the East and Central Harlem neighborhoods of New York City, which are characterized by high poverty, largely African American and Latino populations, disproportionally high rates of chronic conditions, and limited health-care access. Screening tool development included reviewing existing measures and obtaining feedback from an expert panel, aging service providers, and older adults. We developed a 22-item tool covering 3 domains of palliative care need (physical symptoms, emotional concerns, and goals of care), which can be administered in 10 to 15 minutes. Sixteen providers at 2 aging service agencies were trained to use the tool over a 3-month pilot period. The tool showed evidence of feasibility of implementation, with 44 older adult clients screened. Providers reported high acceptability, 36% of clients screened positive, and the majority accepted referrals to outpatient palliative care clinics. The screening tool has the potential to increase palliative care utilization among underserved community-dwelling older adults and may improve their quality of life, potentially in communities worldwide. Future work should examine the psychometric proprieties of the tool, examine predictors of positive screens, explore its impact on clinical outcomes, and expand its reach.

Pain Perception in Latino vs. Caucasian and Male vs. Female Patients: Is There Really a Difference?

Introduction

Pain is a common emergency department (ED) complaint. It is important to understand the differences in pain perception among different ethnic and demographic populations.

Methods

We applied a standardized painful stimulus to Caucasian and Latino adult patients to determine whether the level of pain reported differed depending on ethnicity (N=100; 50 Caucasian [C], 50 Latino [L] patients) and gender (N=100; 59 female, 41 male). Patients had an initial pain score of 0 or 1. A blood pressure cuff was inflated 20 mm HG above the patient’s systolic blood pressure and held for three minutes. Pain scores, using both a 10-cm visual analog scale (VAS) and a five-point Likert scale, were taken at the point of maximal stimulus (2 minutes 50 seconds after inflation), and at one- and two-minute intervals post deflation.

Results

There was a statistically significant difference between the Likert scale scores of Caucasian and Latino patients at 2min 50sec (mean rank: 4.35 [C] vs. 5.75 [L], p<0.01), but not on the VAS (mean value: 2.94 [C] vs. 3.46 [L], p=0.255). Women had a higher perception of pain than males at 2min 50sec on the VAS (mean value: 3.86 [F] vs. 2.24 [M], p<0.0001), and the Likert scale (mean rank: 5.63 [F] vs. 4.21 [M], p<0.01).

Conclusion

Latinos and women report greater pain with a standardized pain stimulus as compared to Caucasians and men.

Expanding palliative care's reach in the community via the elder service agency network

Over the past two decades, palliative care has established itself as a promising approach to address the complex needs of individuals with advanced illness. Palliative care is well-established in US hospitals and has recently begun to expand outside of the hospital setting to meet the needs of non-hospitalized individuals. Experts have called for the development of innovative community-based models that facilitate delivery of palliative care to this target population. Elder service agencies are important partners that researchers should collaborate with to develop new and promising models. Millions of older adults receive aging network services in the U.S., highlighting the potential reach of these models. Recent health care reform efforts provide support for community-based initiatives, where coordination of care and services, delivered via health and social service agencies, is highly prioritized. This article describes the rationale for developing such approaches, including efforts to educate elder service agency clients about palliative care; training agency staff in palliative care principles; building capacity for elder services providers to screen individuals for palliative care needs; embedding palliative care "champions" in agencies to educate staff and clients and coordinate access to services among those with palliative care needs; and leveraging telehealth resources to conduct comprehensive assessments by hospital palliative care teams for elder service clients who have palliative care needs. We maintain that leveraging the resources of elder service agencies could measurably expand the reach of palliative care in the community.

Symptom Burden: Experiences of Puerto Rican Men With Prostate Cancer Prior to External Beam Radiation Therapy

BACKGROUND

Prostate cancer is the most frequently diagnosed cancer in men in Puerto Rico, and external beam radiation therapy (EBRT) is a popular treatment. Although symptom management is a clinical priority of comprehensive oncology care, symptom assessment at the time of primary or adjuvant EBRT has received limited attention.

OBJECTIVES

This article examines the prevalence and severity of symptoms experienced by 54 Puerto Rican men prior to EBRT.

METHODS

Participants completed a demographic form and the MD Anderson Symptom Inventory. Descriptive statistics were generated.

FINDINGS

Most participants had received hormonal treatment, and about a third had received no treatment prior to EBRT. About a third of those who received hormonal treatment reported experiencing side effects before EBRT, and disturbed sleep, numbness and tingling, fatigue, and dry mouth were the most severe. Puerto Rican men with prostate cancer who receive hormonal treatment are at increased risk for experiencing symptom burden prior to EBRT. Greater need for symptom surveillance, treatment, and control may be needed among this population.

Race as a Predictor of Palliative Care Referral Time, Hospice Utilization, and Hospital Length of Stay: A Retrospective Noncomparative Analysis

BACKGROUND

Palliative care is associated with significant benefits, including reduced pain and suffering, an increased likelihood of patients dying in their preferred location, and decreased health-care expenditures. Racial and ethnic disparities are well-documented in hospice use and referral patterns; however, it is unclear whether these disparities apply to inpatient palliative care services.

OBJECTIVE

To determine if race is a significant predictor of time to inpatient palliative care consult, patient enrollment in hospice, and patients' overall hospital length of stay among patients of an inpatient palliative care service.

DESIGN

Retrospective noncomparative analysis.

SETTING

Urban academic medical center in the United States.

PATIENTS

3207 patients referred to an inpatient palliative care service between March 2006 and April 2015.

MEASUREMENTS

Time to palliative care consult, disposition of hospice/not hospice (excluding patients who died), and hospital length of stay among patients by racial (Asian, black, Native American/Eskimo, Hispanic, white, Unknown) and ethnic (Hispanic/Latino, non-Hispanic, Unknown) background.

RESULTS

Race was not a significant predictor of time to inpatient palliative care consult, discharge to hospice, or hospital length of stay. Similarly, black/white, Hispanic/white, and Asian/white variables were not significant predictors of hospice enrollment ( Ps > .05).

LIMITATIONS

Study was conducted at 1 urban academic medical center, limiting generalizability; hospital race and ethnicity categorizations may also limit interpretation of results.

CONCLUSIONS

In this urban hospital, race was not a predictor of time to inpatient palliative care service consult, discharge to hospice, or hospital length of stay. Confirmatory studies of inpatient palliative care services in other institutions are needed.

Examining racial variation in antiemetic use and post-chemotherapy health care utilization for nausea and vomiting among breast cancer patients

PURPOSE

Racial minority cancer patients may experience underuse of antiemetic medications to prevent chemotherapy-induced nausea and vomiting (CINV). In addition to its adverse implications for quality of life, antiemetic underuse may contribute to observed disparities in acute illness during chemotherapy. To understand the potential contribution of CINV prophylaxis to breast cancer disparities, we assessed racial variation in potent antiemetic use and post-chemotherapy utilization related to CINV and the relationship between the two.

METHODS

We used SEER-Medicare data to evaluate the health care utilization in the 14 days following chemotherapy initiation among black and white women receiving highly emetogenic chemotherapy for breast cancer. We used modified Poisson regression to assess the relationship between (1) race and CINV-related utilization and (2) NK1 use and CINV-related utilization, overall and stratified by race. We report adjusted risk ratios (aRR) and 95 % confidence intervals (CI).

RESULTS

The study included 1130 women. Black women were 11 % less likely than white women to use neurokinin-1 receptor antagonists (NK1s) for CINV prophylaxis (p = 0.02); however, they experienced fewer CINV-related encounters following chemotherapy (unadjusted RR = 0.63, 95 %CI = 0.40-0.99; p = 0.05). After adjustment for clinical covariates, estimates were similar but no longer statistically significant (p = 0.07). Among white women, NK1 use was associated with increased CINV-related utilization (aRR NK1 users vs. non-users: 1.35, 95 % CI = 1.07-1.69, p = 0.01), likely resulting from unmeasured confounders.

CONCLUSION

Black women were less likely to use NK1s- and CINV-related services. Racial variation in CINV-related services use may be partly explained by differential symptom reporting or access to care.

Characteristics of patients with advanced lung cancer referred to a rapid-access supportive care clinic

Objective:

There is a limited number of pragmatic studies to evaluate the criteria for referral to outpatient palliative care. The aim of our study was to compare the characteristics, symptoms, and survival of patients with advanced non-small-cell lung cancer (NSCLC) referred (RF) versus not referred (NRF) to a novel embedded same-day rapid-access supportive care clinic (RASCC) and to compare the subgroups among referred patients.

Method:

We reviewed the medical records of all patients who received treatment at the thoracic oncology clinic for advanced non-small-cell lung cancer between August 1, 2012, and June 30, 2013, who were referred to the RASCC and those who were not referred. An oncology-estimated prognosis of ≤6 months and/or severe symptom distress was employed as criteria for referral to the RASCC.

Results:

Of 410 eligible patients, 155 (37.8%) were referred to the RASCC. RF patients had significantly higher patient-reported scores for pain, fatigue, lack of appetite, and symptom distress, as well as worse performance status and shorter survival than NRF patients. Among the RF patients, those who were referred early (≤3 months) had significantly worse symptom distress and shorter overall survival than patients who were referred later on. The patients treated by thoracic oncologists who referred a smaller proportion of their patients to the RASCC had significantly worse anxiety, well-being, spiritual pain, and symptom distress than patients treated by those who referred a larger proportion of their patients to the RASCC.

Significance of Results:

We found that patients who were referred to the RASCC had higher reported symptom distress and worse survival ratings. Further studies are needed to evaluate the optimal criteria for timely integration of palliative care and oncology care.

Investigation of Racial Disparities in Early Supportive Medication Use and End-of-Life Care Among Medicare Beneficiaries With Stage IV Breast Cancer

PURPOSE

Early supportive care may improve quality of life and end-of-life care among patients with cancer. We assessed racial disparities in early use of medications for common cancer symptoms (depression, anxiety, insomnia) and whether these potential disparities modify end-of-life care.

METHODS

We used 2007 to 2012 SEER-Medicare data to evaluate use of supportive medications (opioid pain medications and nonopioid psychotropics, including antidepressants/anxiolytics and sleep aids) in the 90 days postdiagnosis among black and white women with stage IV breast cancer who died between 2007 and 2012. We used modified Poisson regression to assess the relationship between race and supportive treatment use and end-of-life care (hospice, intensive care unit, more than one emergency department visit or hospitalization 30 days before death, in-hospital death).

RESULTS

The study included 752 white and 131 black women. We observed disparities in nonopioid psychotropic use between black and white women (adjusted risk ratio [aRR], 0.51; 95% CI, 0.35 to 0.74) but not in opioid pain medication use. There were also disparities in hospice use (aRR, 0.86; 95% CI, 0.74 to 0.99), intensive care unit admission or more than one emergency department visit or hospitalization 30 days before death (aRR, 1.28; 95% CI, 1.01 to 1.63), and risk of dying in the hospital (aRR, 1.59; 95% CI, 1.22 to 2.09). Supportive medication use did not attenuate end-of-life care disparities.

CONCLUSION

We observed racial disparities in early supportive medication use among patients with stage IV breast cancer. Although they did not clearly attenuate end-of-life care disparities, medication use disparities may be of concern if they point to disparities in adequacy of symptom management given the potential implications for quality of life.

Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis

CONTEXT

Cancer pain has a severe impact on quality of life and is associated with numerous psychosocial responses. Recent studies suggest that treatment of cancer pain has improved during the last decade.

OBJECTIVES

The aim of this review was to examine the present status of pain prevalence and pain severity in patients with cancer.

METHODS

A systematic search of the literature published between September 2005 and January 2014 was performed using the databases PubMed, Medline, Embase, CINAHL, and Cochrane. Articles in English or Dutch that reported on the prevalence of cancer pain in an adult population were included. Titles and abstracts were screened by two authors independently, after which full texts were evaluated and assessed on methodological quality. Study details and pain characteristics were extracted from the articles with adequate study quality. Prevalence rates were pooled with meta-analysis; meta-regression was performed to explore determinants of pain prevalence.

RESULTS

Of 4117 titles, 122 studies were selected for the meta-analyses on pain (117 studies, n = 63,533) and pain severity (52 studies, n = 32,261). Pain prevalence rates were 39.3% after curative treatment; 55.0% during anticancer treatment; and 66.4% in advanced, metastatic, or terminal disease. Moderate to severe pain (numerical rating scale score ≥5) was reported by 38.0% of all patients.

CONCLUSION

Despite increased attention on assessment and management, pain continues to be a prevalent symptom in patients with cancer. In the upcoming decade, we need to overcome barriers toward effective pain treatment and develop and implement interventions to optimally manage pain in patients with cancer.

Symptom burden in lung cancer: management updates

Lung cancer is recognized to carry a high symptom burden with associated lowered quality of life as compared with other cancers. Research has shown that symptom severity can be a prognostic indicator of poorer clinical outcomes and survival post treatment. The purpose of this paper is to review current literature relative to symptom burden associated with diagnosis, medical and/or surgical intervention, assessment and management updates, and emerging initiatives that promote positive outcomes based on updated evidence. Discussion relative to interdisciplinary coordination of supportive services and palliative care initiation is provided.

Investigating racial disparities in use of NK1 receptor antagonists to prevent chemotherapy-induced nausea and vomiting among women with breast cancer

Chemotherapy-induced nausea and vomiting (CINV) is a major concern for cancer patients and, if uncontrolled, can seriously compromise quality of life (QOL) and other treatment outcomes. Because of the expense of antiemetic medications used to prevent CINV (particularly oral medications filled through Medicare Part D), disparities in their use may exist. We used 2006-2012 SEER-Medicare data to evaluate the use of neurokinin-1 receptor antagonists (NK1s), a potent class of antiemetics, among black and white women initiating highly emetogenic chemotherapy for the treatment of early-stage breast cancer. We used modified Poisson regression to assess the relationship between race and (1) any NK1 use, (2) oral NK1 (aprepitant) use, and (3) intravenous NK1 (fosaprepitant) use. We report adjusted risk ratios (aRR) and 95 % confidence intervals (CI). The study included 1130 women. We observed racial disparities in use of any NK1 (aRR: 0.68, 95 % CI 0.51-0.91) and in use of oral aprepitant specifically (aRR: 0.54, 95 % CI 0.35-0.83). We did not observe disparities in intravenous fosaprepitant use. After controlling for variables related to socioeconomic status, disparities in NK1 and aprepitant use were reduced but not eliminated. We found racial disparities in women's use of oral NK1s for the prevention of CINV. These disparities may be partly explained by racial differences in socioeconomic status, which may translate into differential ability to afford the medication.

End-of-Life Care for People With Cancer From Ethnic Minority Groups: A Systematic Review

BACKGROUND

Ethnic/racial minorities encounter disparities in healthcare, which may carry into end-of-life (EOL) care. Advanced cancer, highly prevalent and morbid, presents with worsening symptoms, heightening the need for supportive and EOL care.

PURPOSE

To conduct a systematic review examining ethnic/racial disparities in EOL care for cancer patients.

DESIGN

We searched four electronic databases for all original research examining EOL care use, preferences, and beliefs for cancer patients from ethnic/racial minority groups.

RESULTS

Twenty-five studies were included: 20 quantitative and five qualitative. All had a full-text English language article and focused on the ethnic/racial minority groups of African Americans, Hispanics Americans, or Asian Americans. Key themes included EOL decision making processes, family involvement, provider communication, religion and spirituality, and patient preferences. Hospice was the most studied EOL care, and was most used among Whites, followed by use among Hispanics, and least used by African and Asian Americans. African Americans perceived a greater need for hospice, yet more frequently had inadequate knowledge. African Americans preferred aggressive treatment, yet EOL care provided was often inconsistent with preferences. Hispanics and African Americans less often documented advance care plans, citing religious coping and spirituality as factors.

CONCLUSION

EOL care differences among ethnic/racial minority cancer patients were found in the processes, preferences, and beliefs regarding their care. Further steps are needed to explore the exact causes of differences, yet possible explanations include religious or cultural differences, caregiver respect for patient autonomy, access barriers, and knowledge of EOL care options.

The lung cancer patient, the pneumologist and palliative care: a developing alliance

Considerable evidence is now available on the value of palliative care for lung cancer patients in all stages and at all times during the course of the disease. However, pneumologists and their institutions seem to be widely in arrears with the implementation of palliative care concepts and the development of integrated structures.

This review focuses on the available evidence and experience of various frequently unmet needs of lung cancer patients, especially psychological, social, spiritual and cultural ones. A PubMed search for evidence on these aspects of palliative care as well as on barriers to the implementation, on outcome parameters and effectiveness, and on structure and process quality was performed with a special focus on lung cancer patients.

As a consequence, this review particularly draws pneumologists’ attention to improving their skills in communication with the patients, their relatives and among themselves, and to establish team structures with more far-reaching competences and continuity than existing multilateral cooperations and conferences can provide. Ideally, any process of structural and procedural improvement should be accompanied by scientific evaluation and measures for quality optimisation.