Opportunities for Expanding the Integration of Palliative Care in Oncology Care

Patients with cancer and their families comprise a significant population served by palliative care. Close collaboration between oncology clinicians and palliative care teams has demonstrated improved patient-centered care, especially when this care is integrated early in the course of the disease. The American Society of Clinical Oncology recently released their updated clinical practice guidelines for palliative care in oncology, which provide new opportunities for collaboration to expand the scope of care.

Developing a national implementation strategy to accelerate uptake of evidence-based family caregiver support in U.S. cancer centers

OBJECTIVE

Characterize key factors and training needs of U.S. cancer centers in implementing family caregiver support services.

METHODS

Sequential explanatory mixed methods design consisting of: (1) a national survey of clinicians and administrators from Commission-on-Cancer-accredited cancer centers (N = 238) on factors and training needed for establishing new caregiver programs and (2) qualitative interviews with a subsample of survey respondents (N = 30) to elicit feedback on survey findings and the outline of an implementation strategy to facilitate implementation of evidence-based family caregiver support (the Caregiver Support Accelerator). Survey data was tabulated using descriptive statistics and transcribed interviews were analyzed using thematic analysis.

RESULTS

Top factors for developing new caregiver programs were that the program be: consistent with the cancer center's mission and strategic plan (87%), supported by clinic leadership (86.5%) and providers and staff (85.7%), and low cost or cost effective (84.9%). Top training needs were how to: train staff to implement programs (72.3%), obtain program materials (63.0%), and evaluate program outcomes (62.6%). Only 3.8% reported that no training was needed. Qualitative interviews yielded four main themes: (1) gaining leadership, clinician, and staff buy-in and support is essential; (2) cost and clinician burden are major factors to program implementation; (3) training should help with adapting and marketing programs to local context and culture; and (4) the Accelerator strategy is comprehensive and would benefit from key organizational partnerships and policy standards.

CONCLUSION

Findings will be used to inform and refine the Accelerator implementation strategy to facilitate the adoption and growth of evidence-based cancer caregiver support in U.S. cancer centers.

Palliative Care Utilization in Patients Requiring Extracorporeal Membrane Oxygenation: An Observational Study

Palliative care (PC) is a model of care centered around improving the quality of life for individuals with life-limiting illnesses. Few studies have examined its impact in patients on extracorporeal membrane oxygenation (ECMO). We aimed to describe demographics, clinical characteristics, and complications associated with PC consultation in adult patients requiring ECMO support. We analyzed data from an ECMO registry, including patients aged 18 years and older who have received either venoarterial (VA)- or venovenous (VV)-ECMO support between July 2016 and September 2021. We used analysis of variance and Fisher exact tests to identify factors associated with PC consultation. Of 256, 177 patients (69.1%) received VA-ECMO support and 79 (30.9%) received VV-ECMO support. Overall, 115 patients (44.9%) received PC consultation while on ECMO. Patients receiving PC consultation were more likely to be non-white (47% vs. 53%, p = 0.016), have an attending physician from a medical versus surgical specialty (65.3% vs. 39.6%), have VV-ECMO (77.2% vs. 30.5%, p < 0.001), and have longer ECMO duration (6.2 vs. 23.0, p < 0.001). Patients were seen by the PC team on an average of 7.6 times (range, 1-35), with those who died having significantly more visits (11.2 vs. 5.6, p < 0.001) despite the shorter hospital stay. The average time from cannulation to the first PC visit was 5.3 ± 5 days. Congestive heart failure in VA-ECMO, coronavirus disease 2019 infection in VV-ECMO, and non-white race and longer ECMO duration for all patients were associated with PC consultation. We found that despite the benefits of PC, it is underused in this population.

Social determinants of health and lung cancer surgery: a qualitative study

Introduction

Social determinants of health (SDOH) are non-clinical factors that may affect the outcomes of cancer patients. The purpose of this study was to describe the influence of SDOH factors on quality of life (QOL)-related outcomes for lung cancer surgery patients.

Methods

Thirteen patients enrolled in a randomized trial of a dyadic self-management intervention were invited and agreed to participate in semi-structured key informant interviews at study completion (3 months post-discharge). A conventional content analysis approach was used to identify codes and themes that were derived from the interviews. Independent investigators coded the qualitative data, which were subsequently confirmed by a second group of independent investigators. Themes were finalized, and discrepancies were reviewed and resolved.

Results

Six themes, each with several subthemes, emerged. Overall, most participants were knowledgeable about the concept of SDOH and perceived that provider awareness of SDOH information was important for the delivery of comprehensive care in surgery. Some participants described financial challenges during treatment that were exacerbated by their cancer diagnosis and resulted in stress and poor QOL. The perceived impact of education varied and included its importance in navigating the healthcare system, decision-making on health behaviors, and more economic mobility opportunities. Some participants experienced barriers to accessing healthcare due to insurance coverage, travel burden, and the fear of losing quality insurance coverage due to retirement. Neighborhood and built environment factors such as safety, air quality, access to green space, and other environmental factors were perceived as important to QOL. Social support through families/friends and spiritual/religious communities was perceived as important to postoperative recovery.

Discussion

Among lung cancer surgery patients, SDOH factors can impact QOL and the patient's survivorship journey. Importantly, SDOH should be assessed routinely to identify patients with unmet needs across the five domains. SDOH-driven interventions are needed to address these unmet needs and to improve the QOL and quality of care for lung cancer surgery patients.

Availability of Family Caregiver Programs in US Cancer Centers

Importance

Family caregivers provide the majority of health care to the 18 million patients with cancer in the US. Yet despite providing complex medical and nursing care, a large proportion of caregivers report no formal support or training. In recognition of this gap, many interventions to support cancer caregivers have been developed and tested over the past 2 decades. However, there are few system-level data on whether US cancer centers have adopted and implemented these interventions.

Objective

To describe and characterize the availability of family caregiver support programs in US cancer centers.

Design, Setting, and Participants

This cross-sectional national survey study was conducted between September 1, 2021, and April 30, 2023. Participants comprised clinical and administrative staff of Commission on Cancer-accredited US cancer centers. Data analysis was performed in May and June 2023.

Main Outcomes and Measures

Survey questions about the availability of 11 types of family caregiver programs (eg, peer mentoring, education classes, and psychosocial programs) were developed after literature review, assessment of similar program evaluation surveys, and discussions among a 13-member national expert advisory committee. Family caregiver programs were defined as structured, planned, and coordinated groups of activities and procedures aimed at specifically supporting family caregivers as part of usual care. Survey responses were tabulated using standard descriptive statistics, including means, proportions, and frequencies.

Results

Of the surveys sent to potential respondents at 971 adult cancer centers, 238 were completed (response rate, 24.5%). After nonresponse weight adjustment, most cancer centers (75.4%) had at least 1 family caregiver program; 24.6% had none. The most common program type was information and referral services (53.6%). Cancer centers with no programs were more likely to have smaller annual outpatient volumes (χ2 = 11.10; P = .011). Few centers had caregiver programs on training in medical and/or nursing tasks (21.7%), caregiver self-care (20.2%), caregiver-specific distress screening (19.3%), peer mentoring (18.9%), and children caregiving for parents (8.3%). Very few programs were developed from published evidence in a journal (8.1%). The top reason why cancer centers selected their programs was community members requesting the program (26.3%); only 12.3% of centers selected their programs based on scientific evidence. Most programs were funded by the cancer center or hospital (58.6%) or by philanthropy (42.4%).

Conclusions and Relevance

In this survey study, most cancer centers had family caregiver programs; however, a quarter had none. Furthermore, the scope of programming was limited and rarely evidence based, with few centers offering caregiving education and training. These findings suggest that implementation strategies are critically needed to foster uptake of evidence-based caregiver interventions.

Social determinants of health among family caregiver centered outcomes in lung cancer: a systematic review

Background

Lung cancer is the leading cause of cancer death globally. Both lung cancer patients and family caregivers (FCGs) have unmet quality of life (QOL) needs. An understudied topic in lung cancer research is the role of social determinants of health (SDOH) on QOL outcomes for this population. The purpose of this review was to explore the state of research on SDOH FCGs centered outcomes in lung cancer.

Methods

The databases PubMed/MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and American Psychological Association (APA) PsycInfo were searched for peer-reviewed manuscripts evaluating defined SDOH domains on FCGs published within the last ten years. The information extracted using Covidence included patients, FCGs and study characteristics. Level of evidence and quality of articles were assessed using the Johns Hopkins Nursing Evidence-Based Practice Rating Scale.

Results

Of the 344 full-text articles assessed, 19 were included in this review. The social and community context domain focused on caregiving stressors and interventions to reduce its effects. The health care access and quality domain showed barriers and underuse of psychosocial resources. The economic stability domain indicated marked economic burdens for FCGs. Four interconnected themes emerged among articles on the influence of SDOH on FCG-centered outcomes in lung cancer: (I) psychological well-being, (II) overall quality of life, (III) relationship quality, and (IV) economic hardship. Notably, most participants in the studies were White females. The tools used to measure SDOH factors included primarily demographic variables.

Conclusions

Current studies provide evidence on the role of SDOH factors on lung cancer FCGs' QOL. Expanded utilization of validated SDOH measures in future studies would provide greater consistency in data, that could in turn inform interventions to improve QOL. Further research focusing on the domains of education quality and access and neighborhood and built environment should be carried out to bridge gaps in knowledge.

A Statement on the Role and Qualifications of Health Care Chaplains for Research and Quality

CONTEXT

This statement fills a significant gap in the efforts to demonstrate outcomes of the chaplaincy role in health care and to provide direction for quality measurement related to spiritual care as a key domain of serious illness care.

OBJECTIVES

The objective of this project was to develop the first major consensus statement on the role and qualifications of health care chaplains in the Unites States.

METHODS

The statement was developed by a diverse panel of highly regarded professional chaplains and nonchaplain stakeholders.

RESULTS

The document provides guidance to chaplains and other spiritual care stakeholders as they further integrate spiritual care in health care and conduct research and quality improvement efforts to strengthen the evidence base for practice. The consensus statement is in Fig. 1 and available at https://www.spiritualcareassociation.org/role-of-the-chaplain-guidance.html.

CONCLUSION

This statement can potentially drive the standardization and alignment of all phases of health care chaplaincy preparation and practice.

Understanding End of Life Nursing Practices and End of Life Across Cultures

Nurses are the largest group of health and social care professionals globally and they are central to the provision of palliative care.

Socioeconomic and insurance-related disparities in disease-specific survival among patients with metastatic bone disease

BACKGROUND

Approximately 5% of cancer patients in the United States presented with metastatic bone disease (MBD) at diagnosis. Current study explores the disparities in survival for patients with MBD.

METHODS

Patients with the diagnosis of MBD at presentation for the five most common primary anatomical sites were extracted from Surveillance, Epidemiology, and End Results Census tract-level dataset (2010-2016). Kaplan-Meier and Cox Proportional Hazard models were used to evaluate survival, and prognostic factors for each cohort. Prognostic significance of socioeconomic status (SES) and insurance status were ascertained.

RESULTS

The five most common anatomical-sites with MBD at presentation included "lung" (n = 59 739), "prostate" (n = 19 732), "breast" (n = 16 244), "renal and urothelium" (n = 7718) and "colon" (n= 3068). Lower SES was an independent risk factor for worse disease-specific survival (DSS) for patients with MBD originating from lung, prostate, breast and colon. Lack of insurance was an independent risk factor for worse DSS for MBD patients with primary tumors in lung and breast.

CONCLUSIONS

MBD patients from the five most common primary sites demonstrated SES and insurance-related disparities in disease-specific survival. This is the first and largest study to explore SES and insurance-related disparities among patients specifically afflicted with MBD. Our findings highlight vulnerability of patients with MBD across multiple primary sites to financial toxicity.

The impact of the COVID-19 pandemic on care delivery and quality of life in lung cancer surgery

Background

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) (COVID‐19) pandemic and associated restrictions have altered the delivery of surgical care. The purpose of this study was to explore the impact of COVID‐19 on care delivery and quality of life (QOL) from the perspectives of lung cancer surgery patients, family caregivers (FCGs), and thoracic surgery teams.

Methods

Patients/FCGs enrolled in a randomized trial of a self‐management intervention for lung cancer surgery preparation/recovery were invited to participate in this qualitative study. Patients/FCGs data were collected separately 1‐month postdischarge. Interviews were also conducted with thoracic surgery team members. Content analysis approaches were used to develop themes.

Results

Forty‐one respondents including 19 patients, 18 FCGs, three thoracic surgeons, and one nurse practitioner participated in the study. Patient themes included isolation, psychological distress, delayed/impacted care, and financial impact. FCGs themes included caregiving challenges, worry about COVID‐19, financial hardship, isolation, and physical activity limitations. Surgical team themes included witnessing patient/FCG's distress, challenges with telehealth, communication/educational challenges, and delays in treatment.

Conclusions

COVID‐19 had a varied impact on care delivery and QOL for lung cancer surgery dyads. Some dyads reported minimal impact, while others experienced added psychological distress, isolation, and caregiving challenges. Surgical teams also experienced challenges in the approach used to provide care.

Sex, racial/ethnic and socioeconomic disparities in patients with metastatic bone disease

BACKGROUND

We have analyzed sex, race/ethnicity or socioeconomic disparities in the incidence of metastatic bone disease (MBD).

METHODS

Patients with the diagnosis of MBD at presentation for five most common primary anatomical sites was extracted from Surveillance, Epidemiology, and End Results Census tract-level dataset. Mean incidence of MBD for different sex, racial/ethnic and socioeconomic groups were compared.

RESULTS

The five most common anatomical sites with MBD at presentation include "lung: (n = 59 739), "prostate" (n = 19 732), "breast" (n = 16 244), "renal" (n = 7718) and "colon" (n = 3068). There was an increase in incidence of MBD among cancers originating from prostate (annual percentage change [APC] 4.94), renal (APC 2.55), and colon (APC 3.21) (p < 0.05 for all). Non-Hispanic Blacks had higher incidence of MBD for prostate and breast primary sites (p < 0.001). Non-Hispanic American Indian Alaskan Native had higher incidence of MBD for cancers originating from renal (p < 0.001) and colon (p = 0.049). A higher incidence of MBD was seen in lower socioeconomic status (SES) groups for the selected sites (p < 0.001).

CONCLUSIONS

These findings suggest that there are multiple sex-related, racial/ethnic and SES disparities in the incidence of MBD from the 5 most common primary sites. Higher incidence seen among lower SES suggests delay in diagnosis and limited access to screening modalities.

Abstract PO-093: The impact of the COVID-19 pandemic on care delivery and quality of life in lung cancer surgery

The novel coronavirus disease of 2019 (COVID-19) disrupted the healthcare delivery landscape with dramatic impacts on cancer patients and family caregivers (FCGs). Many safety measures were implemented to provide services to patients during the pandemic. However, the impact of these measures on the experiences of lung cancer surgery patients, FCGs, and their healthcare team is not well known. Therefore, the purpose of this study was to describe the changes and experiences with surgical care delivery from the patient, FCG, and surgical team perspectives. Methods: This mixed methods study included healthcare professionals, lung cancer surgery patients, and their FCGs from an NCI-designated Comprehensive Cancer Center. Data was collected between September 2020 through February 2021 using the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences survey (patients and FCGs only). Key informant interviews with patients, FCGs, and surgical team were also conducted. Patients/FCGs were recruited from a randomized efficacy trial of a multimedia self-management intervention in lung cancer surgery. Qualitative data was analyzed using the conventional content analysis approach and demographic descriptive statistics for patients/FCGs were determined through baseline surveys from the randomized trial. Results: Our study participants (n=56) were predominantly English speaking (91%), non-Hispanic White (68%), Asian (14%), and Black (7%) lung cancer surgery patients/FCGs. Most participants achieved more than a high school diploma (77%), 33% were employed full-time, and 50% used Medicare. Providers (n=4) included a nurse practitioner and thoracic surgeons. We identified 5 constructs that were associated with cancer care delivery from perioperative to discharge: 1) increased diagnostic testing—COVID-19 test; 2) visitor restrictions increased patients/FCGs mental health distress and decreased provider-FCG shared-decision making; 3) communication barriers decreased for patients/FCGs due to use of telehealth resources (i.e., Hope Virtual, WhatsApp, FaceTime) which increased frequency of provider engagement throughout care continuum; 4) patients/FCGs concerns and lack of education of COVID-19 risk factors impacted postoperative recovery; and 5) COVD-19 “elevated” the use and need for including telemedicine in standard of care practices. Moreover, patients experienced delays in treatment, isolation, lack of social support, financial hardship, and fear of death from COVID-19. FCGs also experienced psychological distress, financial hardship, fear of contracting COVID-19, and a heightened awareness of public health safety measures. Discussion: The COVID-19 pandemic created challenges to the cancer care delivery landscape for the surgical team and impacted the psychological and financial well-being of lung cancer surgery patients and their FCGs. While the long-term effects of the pandemic is unknown, opportunities to improve patient/FCG quality of life outcomes through targeted mental health/financial toxicity interventions is warranted.

Citation Format: Dede K. Teteh, Betty Ferrell, Xiaoke Zou, Loretta Erhunmwunsee, Dan Raz, Jae Kim, Virginia Sun. The impact of the COVID-19 pandemic on care delivery and quality of life in lung cancer surgery [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-093.

Preparing New Graduate RNs to Provide Primary Palliative Care

BACKGROUND

More than 90 million Americans are struggling to live with serious illness and are in need of palliative and end-of-life care. Yet, many novice RNs have not been adequately prepared during their undergraduate programs to care for them.

METHOD

A large southwestern Magnet comprehensive cancer center piloted integrating the End-of-Life Nursing Education Consortium (ELNEC)-Undergraduate Curriculum into their nurse residency program during 2018 with 55 new RNs.

RESULTS

A pre-and posteducation evaluation questionnaire measured comfort with caring for patients with serious illness, competence, and knowledge in six areas of palliative care. All eight evaluation questions demonstrated statistically significant improvement posteducational intervention. Many nurse residents reported a change in clinical practice 1 month posteducation.

CONCLUSION

The nurse residency is an opportune training time to prepare novice nurses to provide primary palliative care for all patients with serious illness and their families. [J Contin Educ Nurs. 2020;51(6):280-286.].

Self-Management Coaching: Promoting Postoperative Recovery and Caregiving Preparedness for Patients With Lung Cancer and Their Family Caregivers

BACKGROUND

Quality of life (QOL) for patients undergoing lung resection and their family caregivers (FCGs) is often affected by surgical treatment for lung cancer.

OBJECTIVES

Patients and FCGs have a great deal of distress that affects their QOL. Introducing self-management skills soon after diagnosis improves patient and FCG outcomes.

METHODS

This article presents a intervention model for providing patients and FCGs with self-management skills. Patients and FCGs will learn how to identify and overcome challenges, set goals, and address unmet needs throughout the phases of surgery. The model and case examples are presented.

FINDINGS

Patients and FCGs gained self-efficacy. They were able to identify potential stressors that would otherwise become burdensome. Patients remained in control of their preoperative care and recovery, resulting in continued independence. FCGs achieved healthier well-being, which increased positive caregiving experiences.

Preparing Oncology Advanced Practice RNs as Generalists in Palliative Care

OBJECTIVES

To train and support oncology advanced practice RNs (APRNs) to become generalist providers of palliative care.

SAMPLE & SETTING

APRNs with master's or doctor of nursing practice degrees and at least five years of experience in oncology (N = 165) attended a National Cancer Institute-funded national training course and participated in ongoing support and education.

METHODS & VARIABLES

Course participants completed a precourse, postcourse, and six-month follow-up evaluation regarding palliative care practices in their settings, course evaluation, and their perceived effectiveness in applying course content in their practice.

RESULTS

The precourse results showed deficiencies in current practice, with a low percentage of patients having palliative care as part of their oncology care. Barriers included lack of triggers that could assist in identifying patients who could benefit from palliative care. Six-month postcourse data showed more APRNs participating in family meetings, recommending palliative care consultations, speaking with family members regarding bereavement services, and preparing clinical staff for impending patient deaths.

IMPLICATIONS FOR NURSING

APRNs require palliative care training to integrate this care within their role. APRNs can influence practice change and improve care for patients in their settings.

Rationale and Design of a Telehealth Self-Management, Shared Care Intervention for Post-treatment Survivors of Lung and Colorectal Cancer

Survivors of lung and colorectal cancer have high post-treatment needs; the majority are older and suffer from greater comorbidities and poor quality of life (QOL). They remain underrepresented in research, leading to significant disparities in post-treatment outcomes. Personalized post-treatment follow-up care and care coordination among healthcare teams is a priority for survivors of lung and colorectal cancer. However, there are few evidence-based interventions that address survivors' post-treatment needs beyond the use of a follow-up care plan. This paper describes the rationale and design of an evidence-informed telehealth intervention that integrates shared care coordination between oncology/primary care and self-management skills building to empower post-treatment survivors of lung and colorectal cancer. The intervention design was informed by (1) contemporary published evidence on cancer survivorship, (2) our previous research in lung and colorectal cancer survivorship, (3) the chronic care self-management model (CCM), and (4) shared post-treatment follow-up care between oncology and primary care. A two-arm, parallel randomized controlled trial will determine the efficacy of the telehealth intervention to improve cancer care delivery and survivor-specific outcomes. ClinicalTrials.gov Identifier: NCT04428905.

Correction to: Rationale and Design of a Telehealth Self-Management, Shared Care Intervention for Post-treatment Survivors of Lung and Colorectal Cancer

A Correction to this paper has been published: 10.1007/s13187-021-01969-5

Cancer Caregivers

This chapter describes prevalence estimates of cancer caregivers in the United States and provides a comprehensive review of the effect of cancer on caregivers’ psychological, physical, and financial well-being. The unique burden faced by spouse caregivers versus adult child caregivers is clearly delineated. Four evidence-based interventions to assist cancer caregivers or patient-caregiver dyads are described: psychoeducational interventions (e.g., ENABLE), dyadic interventions (e.g., FOCUS), cognitive behavioral therapy (CBT), and Meaning-Centered Psychotherapy for Cancer Caregivers (MCP-C). The chapter also explores the ethical and legal issues faced by caregivers and concludes with important future directions including the need for (1) more comprehensive caregiver assessment, (2) more research on optimal intervention dose and delivery, and (3) more implementation of evidence-based interventions for caregivers in formal health care systems.

Using Patient-Reported Outcomes to Describe the Patient Experience on Phase I Clinical Trials

Background

Symptoms are common among patients enrolled in phase I trials. We assessed the validity of Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) items in relation to previously validated assessments of quality of life and psychological distress. We used data from a randomized trial testing a palliative care support intervention for patients enrolled on phase I trials.

Methods

Patients (n = 479) were accrued to the parent study prior to initiating a phase I clinical trial with data collected at baseline, 4, and 12 weeks. We determined the correlation of PRO-CTCAE with distress level, Functional Assessment of Cancer Therapy - General (FACT-G) total, and subscale domain scores.

Results

Patients were predominantly female (56.8%) and older than age 60 years, and 30.7% were from minority populations. The correlation coefficient for distress level for all PRO-CTCAE items was small to moderate (Pearson r = 0.33-0.46). Pearson correlation coefficient for FACT-G total was moderate (r = -0.45 to -0.69). Stronger associations were noted for mood items of the PRO-CTCAE only (with distress level, r = 0.55-0.6; with FACT-G, r = -0.54 to -0.6). PRO-CTCAE symptom interference scores had the strongest correlation with distress level (Pearson r = 0.46) and FACT-G total (Pearson r = -0.69). Correlations between PRO-CTCAE items and corresponding FACT-G (total and subscales) and distress levels reached statistical significance for all items (P <.001).

Conclusion

Evidence demonstrates validity of PRO-CTCAE in a heterogeneous US sample of patients undergoing cancer treatment on phase I trials, with small to moderate correlations with distress level for all PRO-CTCAE items and moderate correlations with quality of life as measured by FACT-G total.

A Palliative Care Intervention for Patients on Phase 1 Studies

Background: Phase 1 clinical trials remain vital for oncology care. Patients on these trials require supportive care for quality-of-life (QOL) concerns. Objective: To test a Palliative Care Intervention (PCI) for patients with solid tumors enrolled in Phase I therapeutic trials with a priori hypothesis that psychological distress, QOL, satisfaction, symptoms, and resource utilization would be improved in the PCI group. Design: This unblinded randomized trial compared the PCI with usual care in patients accrued to Phase I Clinical Trials. Subjects (n = 479) were followed for 24 weeks, with 12 weeks as the primary outcome. Setting: Two Comprehensive Cancer Centers in the United States. Subjects: A consecutive sample, 21 years or older, English fluency, with solid tumors initiating a Phase 1 trial. Measurements: Psychological Distress (Distress Thermometer), QOL total and subscales (FACT-G), satisfaction (FAM-CARE), survival, and resource utilization (chart audit). Results: PCI subjects showed improved Psychological Distress (-0.47, p = 0.015) and Emotional Well-Being (0.81, p = 0.045), with differences on variables of QOL and distress between sites. High rates of symptom-management admissions (41.3%) and low rates of Advance Directive completion (39.0%), and hospice enrollment (30.7%), despite a median survival in both groups of 10.1 months from initiating a Phase 1 study. Conclusions: A nurse-delivered PCI can improve some QOL outcomes and distress for patients participating in Phase 1 trials. Greater integration of PC is needed to provide quality care to these patients and to support transitions from treatment to supportive care, especially at the end of life. ClinicalTrials.gov Identifier: NCT01612598.

Clinical Trials: Understanding Patient Perspectives and Beliefs About Treatment

BACKGROUND

Understanding the experiences of patients with solid tumors who are in phase 1 clinical trials can help nurses to provide optimal care.

OBJECTIVES

The purpose of this article is to describe patient perspectives of participating in a phase 1 trial and understanding their disease status and treatment options. In addition, the authors describe the impact of the disease and clinical trial participation on quality of life.

METHODS

30 patients were interviewed and audio recorded; the interviews were transcribed and content analysis methods were used to identify common themes.

FINDINGS

Patients reported participating in the phase 1 clinical trial because their doctors informed and encouraged them, they had no other treatment options if they wanted to live longer, or they wanted to help future patients with cancer. Most believed that participation would improve or stabilize their illness and quality of life. They believed that, when the clinical trial ended, there would be new treatments. Participants reported that healthcare providers and family members provided support, and that compassion, cultural awareness, spiritual support, and the need for individual attention were important.

A nurse-led intervention for fear of cancer progression in advanced cancer: A pilot feasibility study

PURPOSE

To assess the feasibility, acceptability, and preliminary effects of a nurse-led intervention for managing fear of cancer progression in advanced cancer patients.

METHODS

A single group mixed methods study was conducted in patients with stage III or IV gynecologic or lung cancer (n = 31) with dysfunctional levels of fear of progression or distress. The intervention consisted of seven videoconferencing sessions with skills practice. Feasibility measures included enrollment rate, attendance, attrition, and home practice adherence. Acceptability was based on exit interview responses. Content analysis was used to analyze the qualitative data. Participants completed quantitative questionnaires assessing fear of progression and secondary outcomes at baseline, eight, and 12 weeks. Linear mixed model analysis was used to assess changes in outcome measures.

RESULTS

The average enrollment rate was seven participants/month over 4.5 months. Participants attended a mean of 5.3 of seven sessions. Attrition rate was 30%. The analysis showed improvements over time in fear of progression and exploratory outcomes. Participants reported feeling calmer and more focused. The skills practice helped to manage anxiety and fears. Themes included: Struggling with fears, Refocusing the fears, and Realizing/reaffirming what is important in life. The most beneficial components included the values clarification exercise, detached mindfulness and worry postponement practices.

CONCLUSION

The intervention was acceptable; most feasibility criteria were met. Preliminary data suggest that the intervention reduced fear of progression and improved secondary outcomes. The intervention required a significant time commitment by participants, which may have contributed to increased attrition. To decrease burden, we will shorten the intervention.

Communication Skills: Use of the Interprofessional Communication Curriculum to Address Physical Aspects of Care

BACKGROUND

The literature has emphasized the importance of effective communication regarding psychosocial needs; however, other aspects of patient care, including attention to physical needs, are equally important.

OBJECTIVES

The aims of this article are to (a) describe an Interprofessional Communication Curriculum (ICC) in oncology, (b) detail the curriculum content specifically focused on physical aspects of care, and (c) illustrate the importance of interprofessional care in oncology.

METHODS

The ICC is organized by the 8 domains of the National Consensus Project for Quality Palliative Care and centers on communication skills needed in oncology clinical practice.

FINDINGS

Based on initial pilot data, oncology clinicians indicate a high level of satisfaction with the ICC. Additional future training courses supported by the National Cancer Institute will prepare oncology teams to enhance communication with patients and families.

Patient-centered and efficacious advance care planning in cancer: Protocol and key design considerations for the PEACe-compare trial

BACKGROUND

Failure to deliver care near the end of life that reflects the needs, values and preferences of patients with advanced cancer remains a major shortcoming of our cancer care delivery system.

METHODS

A mixed-methods comparative effectiveness trial of in-person advance care planning (ACP) discussions versus web-based ACP is currently underway at oncology practices in Western Pennsylvania. Patients with advanced cancer and their caregivers are invited to enroll. Participants are randomized to either (1) in-person ACP discussions via face-to-face visits with a nurse facilitator following the Respecting Choices® Conversation Guide or (2) web-based ACP using the PREPARE for your care™ web-based ACP tool. The trial compares the effect of these two interventions on patient and family caregiver outcomes (engagement in ACP, primary outcome; ACP discussions; advance directive (AD) completion; quality of end-of-life (EOL) care; EOL goal attainment; caregiver psychological symptoms; healthcare utilization at EOL) and assesses implementation costs. Factors influencing ACP effectiveness are assessed via in-depth interviews with patients, caregivers and clinicians.

DISCUSSION

This trial will provide new and much-needed empirical evidence about two patient-facing ACP approaches that successfully overcome limitations of traditional written advance directives but entail very different investments of time and resources. It is innovative in using mixed methods to evaluate not only the comparative effectiveness of these approaches, but also the contexts and mechanisms influencing effectiveness. Data from this study will inform clinicians, payers and health systems seeking to adopt and scale the most effective and efficient ACP strategy in real-world oncology settings.

Integrating Palliative Care for Patients on Clinical Trials: Opportunities for Oncology Nurses

The purpose of this article is to describe the lessons learned in the course of a 5-year research study on a palliative care intervention for persons on a Phase 1 clinical trial. Patients who are participating in Phase 1 trials and the families who care for them may be especially vulnerable and require special attention. The patients are generally experiencing the effects of advanced disease, and they also may soon experience unknown side effects, intense treatment regimens, and the emotional stress of an uncertain future as a result of clinical trial participation. Oncology nurses in all roles including clinical trials/research nurses, clinicians, educators, and advanced practice registered nurses play a critical role in addressing the quality-of-life concerns in this population. Palliative care can provide better symptom control and information on treatment options and facilitate a better understanding of patient/family goals. Attending to these factors can ultimately mean improved survival for the advanced cancer patient, and support for these patients can assist in advancing the field of oncology as these investigational therapies hold the promise for enhancing survival.

Spirituality in cancer patients on phase 1 clinical trials

OBJECTIVES

Patients with cancer who are at a transition to Phase I investigational treatments have been identified as an underserved population with regard to palliative care. This disease transition is often accompanied by spiritual and existential concerns. The study objective was to conduct a secondary analysis of data from a larger study testing a palliative care intervention. This paper reports the findings of this secondary focus on the spiritual needs of this population.

METHODS

Patients (n = 479) were accrued to this study prior to initiating a Phase I clinical trial with data collected at baseline, and 4, 12, and 24 week follow-up.

RESULTS

Qualitative data revealed that the transition to Phase 1 trial participation is a time of balancing hope for extended life with the reality of advancing disease. Quantitative results demonstrated increased spirituality over time in both religious- and non-religious-affiliated patients.

CONCLUSIONS

Patients entering Phase I trials have important spiritual needs as they face treatment decisions, advancing disease, and often mortality. Spiritual care should be provided to seriously ill patients as a component of quality care.

Communication Training: Needs Among Oncology Nurses Across the Cancer Continuum

BACKGROUND

Oncology nurses are responsible for communication-aimed prognosis, patient education about cancer care and treatment, survivorship, and care coordination. Communication difficulties and uncomfortable communication topics put nurses at risk for compassion fatigue.

OBJECTIVES

Supporting nurse communication skills requires institutional policies and structures to foster patient-centered communication. This study reports on communication training needs for oncology nurses to inform future development of communication curricula and institutional training.

METHODS

A national survey of oncology nurse teams (N = 355) attending one of four communication training courses was used. Surveys were used to evaluate institutions' current patient-centered communication practices and to ascertain institutional communication training needs.

FINDINGS

Nurses' role in communicating prognosis remains unclear, and training is needed for discussing survivorship. Curriculum development should be congruent with institutionally defined roles for nurse communication.

Palliative Care Communication: Outcomes From COMFORT, a Train-the-Trainer Course for Providers

BACKGROUND

With increasing support for the integration of palliative care and standard oncology, communication training programs are needed to teach oncology nurses and other providers about palliative care communication.

OBJECTIVES

This study reports on the outcomes of COMFORTTM SM Communication for Oncology Nurses, a train-the-trainer communication course to educate oncology nurses about palliative care communication and improve patient-centered communication and cancer care.

METHODS

355 oncology nurses attended the two-day course. This study used 6- and 12-month follow-up data from nurses who provided feedback on the progress of these goals.

FINDINGS

Nurses taught an additional 9,720 oncology providers, conducted needs assessments of communication processes, and initiated institutionwide palliative care communication training. Barriers to completing outcome goals included a lack of institutional support, specifically an absence of leadership, financial backing, and dedicated time.