Opportunities to improve care for patients with peritoneal carcinomatosis and their caregivers

207

Background: Cancers of the gynecologic and gastrointestinal tracts (GYN/GI) often metastasize along the peritoneum (peritoneal carcinomatosis; PC), causing ascites and malignant obstructions of the bowel, urinary tract, and biliary tree. Patients with PC frequently require palliative surgical interventions; e.g., ostomies, gastric tubes, and catheters. To date, few researchers have described the unique needs of these patients and their caregivers. Methods: We recruited adult patients with advanced GYN/GI cancers, a recent hospitalization for PC, and a new complex care need. We invited adult caregivers of enrolled patients to participate. We abstracted patients’ clinical characteristics and outcomes from the medical record. At baseline, patients completed items related to perceived health status and advance care planning, while caregivers completed the Caregiver Reaction Assessment (CRA) and items related to their caregiving role. All participants completed the Hospital Anxiety and Depression Scale. Results: Sixty-five patients and 40 caregivers completed surveys. Fifty-six (86%) patients had GYN and nine (14%) had GI cancers. Most (56/65, 86%) were re-hospitalized within two months, and over a quarter (18/65, 27%) died within six months of enrollment. Twenty-four (37%) reported they were terminally ill, but only nine (14%) had spoken with a physician about the care they would want to receive if they were dying. Caregivers were primarily spouses (27/40, 70%) who provided most or all of the care for their loved one (25/40, 63%) and engaged in caregiving seven days per week (27/40, 68%). Of the four CRA subscales measuring negative caregiving experiences, mean scores were highest for impact on schedule (3.3, SD = 0.8; possible range 1-5, higher scores indicate greater burden), followed by impact on finances (2.3, SD = 1.1), impact on health (2.0, SD = 0.65), and lack of family support (1.8, SD = 0.67). Caregivers reported that they received training on a mean of 1.1 (SD = 1.3) clinical care tasks but performed a mean of 2.9 (SD = 1.7) clinical care tasks. Thirty-two (49%) patients and 9 (23%) caregivers met borderline case or case criteria for depressive symptoms, while 26 (40%) patients and 15 (38%) caregivers met borderline case or case criteria for anxiety symptoms. Conclusions: Patients with PC and their caregivers are highly burdened and distressed. Patients are at high-risk for re-hospitalization, but few have discussed their end-of-life wishes with their medical teams. Interventions that train these patients and their caregivers to perform clinical care tasks, facilitate serious illness conversations, and provide psychosocial support are needed. Clinical trial information: NCT03367247.

Prediction of daily pain and opioid consumption in hospitalized patients with cancer: The importance of psychological symptoms, previous pain, and opioid use

195

Background: Pain is among the most common reasons that cancer patients present to the emergency department (ED) and are ultimately hospitalized, yet little is known about the patient-level predictors and outcomes of pain-related ED visits and hospitalizations. This study sought to evaluate the predictive association of clinical pain and psychological variables on ED admission with average daily pain and opioid consumption in subsequently hospitalized patients with cancer. Methods: A prospective cohort study of patients with active cancer presenting to the ED with pain severity ≥4/10 on presentation completed baseline surveys that assessed demographic, socioeconomic, cancer diagnosis and treatment, medication use, and psychosocial profiles using validated questionnaires. Daily pain scores and opioids administrated were abstracted from the hospital record. Univariable and multivariable general estimating equation (GEE) analyses examined associations of baseline socioeconomic and clinical variables with the primary outcomes, average daily pain and total daily opioid administration. Results: Patients (N = 113) had various types of cancer, with 91% having a diagnosis of > 1 year, 80% with metastatic solid tumors, 73% reported pain as the primary reason for the ED visit, 43% were taking opioids, and 27% had chronic pain predating their cancer. Average daily pain scores ranged between (3.4 to 5.0 out of 10) and daily MMEs ranged between 0 to 1136 MMEs, yet the majority received lower than 60 MMEs per day. In multivariable models, higher pain catastrophizing (B = 0.1, p= 0.001), more recent surgery (B = -0.2 p= 0.016), outpatient opioid use (B = 1.4, p<0.001), and history of chronic pain (B = 0.8, p= 0.022) before cancer diagnosis were independent predictors of greater average daily pain during hospitalization. Higher pain catastrophizing (B = 1.6, p= 0.049), higher anxiety (B = 3.7, p= 0.030), lower depression (B = -4.9, p= 0.028), metastatic disease (B = 16.2, p= 0.038), and outpatient opioid use (B = 32.8, p<0.001) were independent predictors of greater daily opioid administration during hospitalization. Conclusions: An evaluation of psychological distress and current opioid use may help to identify cancer patients at increased risk for more severe pain and higher analgesic requirements during hospitalization. This identification will facilitate the delivery of more intensive pharmacologic and nonpharmacologic interventions.

Development of an mHealth app integrating pain-cognitive behavioral therapy and opioid support for patients with advanced cancer (STAMP+CBT)

418

Background: Pain affects 40-90% of patients with advanced cancer. Supplementing pharmacologic therapy with behavioral skills may improve pain outcomes. We sought to evaluate patients’ perspectives of a pain-cognitive behavioral therapy (CBT) mobile health intervention for cancer pain. Methods: We recruited patients from the Dana-Faber Cancer Institute outpatient palliative care clinic to review the pain-CBT mHealth intervention. Eligible patients were >21 years old, had an incurable solid malignancy, chronic pain related to cancer, and were using opioids for cancer. We excluded hospitalized patients and those with pain from a recent surgery, dementia/delirium, or an opioid use disorder. In individual, qualitative interviews patients reviewed pain-CBT content modified for advanced cancer and mHealth delivery, and provided feedback on the relevance of the content in the context of their own pain. Results: Patients (n = 14) reviewed pain-CBT app content and wireframes. Most rated the content and user interface as highly usable, informative, aesthetically pleasing, convenient, and relevant to their experiences. Suggested improvement included revising technical content to increase clarity/reduce literacy, shortening length of texts, and including additional tracking for daily opioid use. Six subthemes regarding patients’ current pain management approaches were identified. Individuals endorsed using physical coping skills including engaging in physical activity and at times struggling to recognize physical limits. Many endorsed utilizing psychological coping such as accepting their pain, reframing thoughts about pain, and using distraction or relaxation to cope. Social support was relevant to coping for almost all patients, and many described COVID-19 distancing guidelines as disruptive. Patients endorsed complex relationships with opioids including guilt related to use or difficulty understanding prescription instructions. Most patients emphasized the relationship between sleep, stress, and pain as central to their pain management, and that they wished their clinicians reviewed the relationship between pain and stress earlier. Conclusions: MHealth delivery was viewed as an attractive method to both integrate and deliver behavioral pain management skills with opioid support to alleviate cancer pain. A future pilot study will evaluate the app’s feasibility and acceptability in patients with advanced cancer.

Building out lifelines for safety, trust, empowerment, and renewal: Development, feasibility, and acceptability of the BOLSTER intervention for patients with gynecologic cancers and their caregivers

187

Background: Peritoneal carcinomatosis (PC) afflicts over half of women with advanced gynecologic (GYN) cancers. Patients with PC often require ostomies, gastric tubes, or catheters to palliate their symptoms, yet patients and caregivers report feeling unprepared to manage these devices at home. Our aims were to develop and assess the feasibility and acceptability of an intervention (BOLSTER) to support patients with GYN cancers and their caregivers after hospitalization for PC. Methods: We used the ADAPT-ITT approach to adapt components of the Standard Nursing Intervention Protocol for the target population. First, we assembled a team of stakeholders and topical experts to identify gaps in patient resources. Next, we developed patient- and family-centered educational materials. We augmented written materials with illustrations and produced short videos of patients and caregivers managing medical devices. We developed a protocolized manual for a baccalaureate-prepared nurse to provide care coordination, skills training, and symptom management education across several in-person or telehealth visits. We also created a smartphone application to assess patient-reported outcomes, deliver tailored educational content, and trigger clinical action between visits. Finally, we assessed the feasibility and acceptability of two iterations of BOLSTER in single-arm pilot studies of English-speaking adult patients hospitalized for PC and their caregivers. We defined feasibility as a ≥50% consent-to-approach ratio and acceptability as ≥70% of participants recommending BOLSTER. Results: Intervention characteristics during and the results of each single-arm pilot study are shown in Table. In the first single-arm pilot, 2/4 participants declined home visits, 2/4 wished BOLSTER were shorter, and 3/4 desired access to BOLSTER earlier in their disease course. For the second single-arm pilot, we expanded participant eligibility criteria, eliminated home visits, and reduced the duration of the intervention. Conclusions: BOLSTER is a technology-enhanced, nurse-led care management intervention that is feasible and acceptable to patients with GYN cancer-associated PC and their caregivers. A randomized controlled pilot study of BOLSTER represents a logical next step. Clinical trial information: NCT03367247. [Table: see text]

Self-reported overall wellbeing (OWb), physical function (PFn), and PRO-CTCAE symptom scores in post-operative and chemotherapy patients

2064

Background: A standardized, validated tool for capturing symptoms from cancer patients, PRO-CTCAE, has been used to reduce symptom burden, decrease acute care needs, and preserve quality of life. The association between specific PRO-CTCAE symptom scores and single item measures of OWb and PFn were characterized to understand symptom constellations. Methods: A novel Epic-based symptom management program (eSyM) was deployed for GI, GYN, and thoracic cancer patients starting chemotherapy (Memphis Baptist) or having surgery (WVU Medicine). Patients received automated prompts to complete surveys via the patient portal (MyChart) on a fixed schedule, approximately twice/week. Each survey included one OWb item, one PFn item, and at least 6 PRO-CTCAE items (pain, nausea, vomiting, fatigue, anxiety, insomnia). The OWb and PFn items, which were created de novo, included 5 ordinal response options with corresponding pictograms (emojis from very happy to very sad for OWb; a figure walking to one prone in bed for PFn). Composite scores were generated: 0 for no symptoms, 1-2 for mild/moderate symptoms, and 3 for severe symptoms. We describe OWb and PFn and analyze associations between these items and PRO-CTCAE symptom scores. Results: Between 9/10/19-1/22/20, we collected 908 eSyM responses from 166 chemotherapy patients at Baptist (Age, M = 65), and 480 eSyM responses from 97 postoperative patients at WVU (Age, M = 57). The OWb and PFn scores demonstrated moderate correlation with PRO-CTCAE symptom scores (Baptist r = 0.63; WVU r = 0.75), and moderate correlation with mean symptom scores among surgery patients at WVU (r = 0.74); but lower correlation among chemotherapy patients at Baptist (r = 0.53-0.55). Scores improved over time following surgery, but not after initiation of chemotherapy. Among the 730 eSyM responses with none/mild values for both OWb and PFn (52.9% of all responses), only 4.5% reported any severe symptom; among 651 responses with impairment of OWb and/or PFn, 45.2% reported at least one severe symptom. Conclusions: Integration of eSyM into the Epic EHR enabled tracking of OWb, PFn, and PRO-CTCAE items. When asked alongside PRO-CTCAE symptom items, two single item OWb and PFn measures provided distinct information and correlated with symptom burden. These results demonstrate the feasibility of integrating ePRO collection into routine post-operative and medical oncology care and that PRO-CTCAE items provide information that is distinct from that obtained from global metrics of well-being. Clinical trial information: NCT03850912.

U.S. trends and racial/ethnic disparities in opioid access among patients with poor prognosis cancer at the end of life (EOL)

7005

Background: Heightened US opioid regulations may limit advanced cancer patients’ access to effective pain management, particularly for racial/ethnic minority and other vulnerable populations. We examined trends in opioid access, disparities in access, and pain-related emergency department (ED) visits among cancer patients near end of life (EOL). Methods: Using a 20% random sample of Medicare FFS beneficiaries, we identified 243,124 patients with poor prognosis cancers who died between 2007-2016. We examined trends in outpatient opioid prescription fills and pain-related ED visits near EOL (30 days prior to death or hospice enrollment), for the overall cohort and by race (white, black, other). Per-capita opioid supply by state was obtained from the federal Drug Enforcement Agency ARCOS database. Geographic fixed-effects models examined predictors of opioid use near EOL, opioid dose in morphine milligram equivalents (MMEs), and pain-related ED visits, adjusted for patient demographic and clinical characteristics, state, opioid supply, and year. Results: From 2007-2016 the proportion of patients with poor prognosis cancers filling an opioid prescription near EOL fell from 41.7% to 35.7%, with greater decrements among blacks (39.3% to 29.8%) than whites (42.2% to 36.5%) and other races (38.2% to 32.4%). The proportion of patients receiving long-acting opioids near EOL fell from 17% to 12% overall (15% to 9% among blacks). Among patients receiving EOL opioids, the median daily dose fell from 40MMEs (IQR 16.5-98.0) to 30MMEs (IQR 15.0–78.8). In adjusted analyses, blacks were less likely than whites to receive EOL opioids (AOR 0.85; 95% CI, 0.80 to 0.91) and on average received 10MMEs less per day (b -9.9; 95% CI -15.7 to -4.2). Patients of other race were also less likely to receive EOL opioids (AOR 0.92; 95% CI, 0.85-0.95), although their dose did not differ significantly from whites. Rates of pain-related ED visits near EOL increased from 13.2% to 18.8% over the study period. In adjusted analyses, blacks were more likely than whites to have pain-related ED visits (AOR 1.29, 95% CI, 1.16-1.37) near death, as were those of other races (AOR 1.30; 95% CI, 1.17-1.37). Conclusions: While lawmakers have sought to mitigate the impact of opioid regulations upon cancer patients, access to EOL opioids have decreased substantially over time with concomitant increases in pain-related ED visits. There are significant racial/ethnic disparities in opioid access, with blacks receiving fewer opioids at lower doses and having more ED-based care for pain near EOL.

Oncologists’ perspectives on medical marijuana for the elderly

78

Background: Cancer patients are increasingly using medical marijuana (MM) to manage symptoms and treatment side effects. Although cancer disproportionately affects the elderly, little is known about oncologists’ attitudes toward MM in this population. We surveyed US oncologists’ beliefs about the benefits of MM for older adults, and examined their associations with oncologists’ perceptions of MM efficacy and safety. Methods: 232 out of 400 randomly selected U.S. oncologists (63% response rate) completed a cross-sectional survey about their beliefs and recommendations regarding MM for cancer patients. Using Chi-square tests, we examined associations between oncologists’ demographics, their perceptions of geriatric MM use, as well as beliefs about comparative effectiveness of MM for cancer related symptoms, and comparative risks of MM to prescription opioids. Results: Among 232 oncologists included in this cohort, 109 (47.0%) reported that MM had at least some benefit for elderly cancer patients, 66 (28.4%) responded it was rarely or never beneficial, and 57 (24.6%) reported not knowing. There were no significant associations between oncologists’ beliefs about MM’s benefit for older adults and their sociodemographic characteristics. Those who believed MM was beneficial for the elderly were significantly more likely to report that MM was at least as effective as standard treatments for the following indications: coping (58.3% vs. 26.6%), appetite (83.3% vs 58.5%), depression (46.3% vs 25.0%), and nausea (66.7% vs 33.9%), respectively ( p < 0.001). In contrast, oncologists’ beliefs about MM for the elderly were not significantly associated with perceptions of the comparative risks of MM ( p > 0.05). Conclusions: In this nationally-representative sample of US oncologists, about half thought MM was beneficial for older adults with cancer. Oncologists’ support of MM for older adults was associated with perceptions of MM’s efficacy but was not associated with perceptions of MM’s risks. More research is needed regarding the safety and efficacy of MM to guide oncologists’ recommendations about its use in older adults.

Understanding the non-curative potential of palliative chemotherapy: Do patients hear what they want to hear?

6575

Background: Misconceptions about the curative potential of PC are common, and may arise from gaps in informed consent. Another contributing factor could be patients’ desire, or lack of desire, for information about prognosis and PC outcomes. Methods: We surveyed 137 patients with advanced colorectal (N = 102) or pancreatic cancer (N = 35) within 2 weeks of consultation about 1st or 2ndline PC, as part of randomized trial of a PC education intervention at 6 US sites. Patients rated how much information they wanted about PC risks/benefits, including impact on prognosis. Responses ranged from no information to as much as possible on a 5-point Likert scale. They reported decision-making preferences; whether a doctor discussed curability, and how likely they thought PC was to cure their cancer. Chi square and Wilcoxon tests examined whether information and decision-making preferences, or curability discussions were associated with expectations of cure. Multivariable logistic regressions evaluated whether associations were modified by age, race, gender, marital status, or cancer type. Results: Only 44.5% of patients accurately reported that their cancer was not at all likely to be cured by PC. Most patients wanted a lot, or as much information as possible about PC risks/benefits, including likelihood of cure (81.7%), cancer control (84.7%), and impact on length of life (80.3%). Most patients preferred shared (70.8%) versus active or passive decision-making. Neither decision-making nor prognostic information preferences were associated with expectations of cure. Patients (13.9%) who did not recall curability discussions were less likely to have accurate expectations (21% v 48%; OR, 0.29; 95% CI, 0.07-.97). Patient characteristics did not significantly confound this association. Conclusions: Most patients value shared decision-making and want maximal information about PC risks/benefits, including impact on prognosis. Despite wanting prognostic information and reporting curability discussions, many patients report inaccurate expectations about cure from PC. Future studies should examine whether these assertions reflect misunderstandings, differences in belief, or expressions of hope.

Racial/ethnic differences in end-of-life (EoL) treatment preferences: The role of religious beliefs about care

6529

Background: Racial/ethnic minorities and patients who turn to religion to cope receive more aggressive EOL care. Beliefs underlying these associations are unknown. Methods: Coping with Cancer is an ongoing, multi-site, NCI-funded study examining factors influencing racial/ethnic EoL disparities. From 11/2010-10/2012, 133 advanced cancer patients underwent baseline interviews, including 7 items assessing religious beliefs about EoL care (RBEC). Univariate analyses assessed racial/ethnic differences in RBEC and EoL treatment preferences. Multivariable analyses (MVA) modeled mean RBEC score as a function of race/ethnicity, controlling for confounders, and assessed the relationship of race/ethnicity and RBEC to treatment preferences. Results: Religious beliefs about EoL care are common and more often held by racial/ethnic minorities (Table); racial/ethnic differences persisted in MVA (p<.0001). Black patients were more likely than Whites to prefer aggressive EOL care (OR=5.03, p=.02), whereas Latino’s EOL preferences did not differ from Whites (p=.87). In MVA including race and RBEC score, Black race was not related to EOL care preferences (OR 1.61, p=0.55), whereas greater RBEC score was associated with greater preference for aggressive care (OR 2.48, p=0.003). Conclusions: Religious beliefs about EoL care are common and significantly more so among racial/ethnic minorities. Preliminary data suggest these beliefs mediate the relationship between race/ethnicity and EoL treatment preferences. [Table: see text]

Outcomes of prognostic disclosure: Effects on advanced cancer patients’ prognostic understanding, mental health, and relationship with their oncologist

9519

Background: Many oncologists are reluctant to discuss life expectancy with advanced cancer patients. We examined the frequency of prognostic disclosure and its impact on patients’ prognostic understanding, the patient-doctor relationship, and psychological distress. Methods: Coping with Cancer was an NCI-funded, multi-site prospective cohort of 726 patients with advanced incurable cancer, enrolled 2002-2008. At baseline, patients were asked if their oncologist had ever discussed prognosis, and if so what estimate was communicated. Patients also estimated their prognosis. The therapeutic alliance scale measured patient-doctor relationship, and the McGill QOL instrument assessed symptoms of depression and anxiety. Multivariable analyses (MVA) assessed relationships between prognostic disclosure and psychological symptoms, controlling for confounds. Results: Among this cohort of terminally ill patients (median survival 4mos), most (72%) wanted to be told their life expectancy. Only 19.8% (104/525) of patients had received a prognostic estimate from their oncologist (median estimate 6mos; IQR 6-15mos). When queried about factors informing their prognostic understanding, 85.9% of patients cited personal or religious beliefs; only 11.7% cited a physician’s estimate. Of the 299 patients willing to estimate their life expectancy, patients who had been previously informed of their prognosis were substantially more realistic in their own estimate (median 12mos v 48mos, Wilcoxon test p<0.001). Moreover, patients’ and oncologists’ prognostic estimates were significantly correlated (ρ=0.49, p<0.001). Prognostic disclosure was not associated with poor patient-doctor relationship rating (Fisher’s Exact, p=0.625), nor was it associated with depressive symptoms (β 0.06, p=0.242) or anxiety (β 0.06, p=0.234) in MVA. Conclusions: Few advanced cancer patients are informed of their life expectancy, although most want this information. Prognostic disclosure is associated with substantial improvement in patients’ prognostic understanding, without compromising the patient-doctor relationship or increasing psychological distress.