Safe Prescribing Practices: Clinicians' Views on Prescribing Opioids to Patients With Early-Stage Cancer

PURPOSE

Opioids are often necessary for patients experiencing high-intensity pain. However, side effects exist and some patients may misuse opioids. To better understand how opioids are prescribed to patients with early-stage cancer and how to enhance opioid safety, clinicians' views of opioid prescribing were explored.

METHODS

This was a qualitative inquiry including any Alberta clinician prescribing opioids to patients with early-stage cancer. Semistructured interviews were conducted with nurse practitioners (NP), medical oncologists (MO), radiation oncologists (RO), surgeons (S), primary care physicians (PCP), and palliative care physicians (PC) between June 2021 and March 2022. Interpretive description was used to analyze the data using two coders (C.C. and T.W.). Debriefing sessions were used to resolve and discrepancies.

RESULTS

Twenty-four clinicians were interviewed (NP [n = 5], MO [n = 4], RO [n = 4], S [n = 5], PCP [n = 3], and PC [n = 3]). The majority had been in practice at least 10 years. Prescribing practices were related to disciplinary perspective, goals of care, patient condition, and resource availability. Most clinicians did not see opioid misuse as a problem but were aware that specific patient risk factors are present and that long-term use can be problematic. Most clinicians undertake safe prescribing approaches tacitly (eg, screening for past opioid misuse and reviewing number of prescribers) and not all agreed they should be universally applied. Barriers (eg, procedural and time) and facilitators (eg, education) to safe prescribing approaches were identified.

CONCLUSION

To enhance uptake and cross-disciplinary consistency of safe prescribing approaches, clinician education regarding opioid misuse and benefits of safe prescribing practices, and addressing procedural barriers are necessary.

Abstract B005: Investigating the effects of cancer treatment on gut microbiota in colorectal cancer patients: Study protocol

Background: Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer mortality. Acute adverse effects (AEs) from CRC treatments (surgery, chemotherapy, radiation therapy) may cause dose limitations and/or treatment discontinuation. Chronic AEs may include bowel symptoms, fatigue, anxiety, depression, and sarcopenic obesity. These acute and chronic AEs significantly impact quality of life (QoL). A comprehensive understanding of the pathophysiological mechanism(s) driving these AEs is lacking. Evidence supports the hypothesis that the gut microbiota may be an integrative point in the pathogenesis of several AEs. Dysbiosis alters the normal function of the gut and gut-brain-axis. CRC treatments can lead to dysbiosis and in turn may drive acute and chronic AEs. Our aims are to explore how CRC treatment affects the microbiota and the further path to recovery. Methods: A prospective feasibility study of n=35 participants in Calgary, Alberta of stage I-III CRC patients to evaluate: 1) The feasibility of collecting microbiota samples at diagnosis to one-year post diagnosis; 2) Longitudinal changes to microbiota over a 1-year period; and 3) Preliminary associations between changes in the microbiota and treatment completion, treatment AEs, clinical and tumor characteristics, and changes to patient reported outcomes (PROs). Inclusion: Newly diagnosed stage I-III CRC, aged ≥18, English speaking, and willing to provide 4 fecal samples. Exclusion: Inflammatory bowel disease, hereditary CRC syndromes, or stage IV. Convenience sampling will be used. Feasibility will include recruitment and retention rates, adherence to specimen collection protocols, specimen quality, and patient satisfaction. Microbiota will be evaluated using longitudinal fecal sampling for metabolomics, culture, and mechanistic studies to examine intra-individual differences in microbiota (α and b diversity). Shotgun sequencing libraries will be prepared to generate approximately 4M 150 bp read pairs/sample. Clinical data on tumor characteristics, treatments, and treatment AEs will be abstracted from medical records. Demographic data and a battery of PROs (diet, physical activity, depression, anxiety, QoL, CRC symptoms, cognitive function, and fatigue using validated questionnaires) will be collected. Results: This study will determine the feasibility of longitudinal prospective collection of biospecimen, clinical, and PROs in newly diagnosed stage I-III CRC patients. This study will also provide preliminary data on changes to the gut microbiota as a result of treatments and how these changes may in turn impact clinical and PROs. Conclusions: This novel investigation into dysbiosis as an integrative point driving CRC treatment AEs is timely and warranted given the persistence of debilitating problems post CRC treatment. Building on data from this project we plan to conduct a population-based cohort study. Our goal is to ultimately inform interventions to manage treatment AEs, improve clinical outcomes, and improve QoL for CRC survivors.

Citation Format: Colleen Ann Cuthbert, Kathy McCoy, Anthony MacLean, Lin Yang, May Lynn Quan, Donald Buie. Investigating the effects of cancer treatment on gut microbiota in colorectal cancer patients: Study protocol [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer; 2022 Oct 1-4; Portland, OR. Philadelphia (PA): AACR; Cancer Res 2022;82(23 Suppl_1):Abstract nr B005.

Examining social media peer support and improving psychosocial outcomes for young women with breast cancer

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Background: Young women with breast cancer (YWBC) have unique survivorship needs due to life stage at point of diagnosis. Peer support sought by YWBC through social media channels appears to be rising. We aimed to understand the unmet needs of YWBC in order to develop a tailored peer support program to improve young women’s breast cancer experience and ultimately reduce psychosocial morbidity long-term. Methods: Using qualitative inquiry, we conducted semi-structured interviews with YWBC survivors and clinicians using purposive sampling. Inclusion criteria were women aged 40 years or younger at diagnosis, stage 0-IV disease. Survivors were minimum one year post-diagnosis and with active treatment complete. Interviews were recorded and transcribed verbatim and data was analyzed using Thorne’s Interpretive Description. Themes were reviewed with study team throughout data analysis. Results: Thirty-six participants were interviewed from ten centers across seven Canadian provinces; mean age 36 years. Participant reported demographics:18% ‘visible minority’, 9% ‘born outside Canada’, 7% ‘Indigenous’ and 54% of patients’ household income at or below Canadian average. At point of diagnosis 69% married, 44% had children and 9% pregnant or postpartum. Themes from YWBC interviewed focused on coping needs: feeling alone, misunderstood by professionals and misplaced among peers. Participants described all-age peer support groups risked triggering anxieties, lacked convenience and were comprised of women at later life stages with differing needs. YWBC reported lack of young age breast cancer-specific peer support. YWBC frequently found support through social media de novo, by following young-age breast cancer survivor pages, blogs and forums as well as virtual support groups. YWBC also report benefit from identifying similar life and cancer stage survivors globally and forming individual relations virtually, through direct messaging. Additionally, benefits described from age-specific social media support included unique shared experience and understanding, hope from positive outcomes of similar life stage diagnoses, and increased confidence and healthcare navigation for YWBC. Women unanimously requested one on one peer support program development - a survivor mentorship scheme specifically for YWBC that would provide the convenience of online support without the obligations or emotionally overwhelming nature of structured support groups. Conclusions: We have identified unique support needs from this young cohort of women that are not currently being met within standard Canadian healthcare pathways. We aim to develop a novel one on one peer support program for YWBC, to optimize psychosocial support and improve young women’s empowerment and autonomy in managing the effects of cancer long-term.

Impact of baseline symptom burden as assessed by patient-reported outcomes (PROs) on overall survival (OS) of patients with metastatic cancer

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Background: Patients with metastatic cancer experience variable symptom burden, but serial symptom assessments using PROs may be challenging to implement in routine clinical practices. We aimed to determine if a single measurement of symptom burden at the time of metastatic diagnosis is associated with survival. Methods: We examined prospectively collected baseline PROs of patients newly diagnosed with metastatic breast, lung, colorectal, or prostate cancer using the revised Edmonton Symptom Assessment System (ESASr) questionnaire from a large province (Alberta, Canada) between 2016 and 2019. The ESASr was categorized into physical (PH), psychosocial (PS), and total symptom (TS) domains whereby scores were classified as mild (0-3), moderate (4-6), or severe (7-10). Multivariable Cox proportional hazards models were constructed to evaluate the effect of baseline symptom scores on OS. Results: We identified 1,315 patients, of whom 57% were men and median age was 66 (IQR, 27-93) years. There were 180, 601, 240, and 294 patients with breast, lung, colorectal, and prostate cancer, respectively. Approximately one-quarter of all patients reported moderate to severe PH, PS, and TS scores, with lung cancer patients experiencing the highest symptom intensity across all domains ( P<0.0001). While age did not affect symptom scores, women were more likely to report severe PH, PS, and TS scores as compared to men ( P=0.02, 0.002, and 0.007, respectively). On multivariable Cox regression analysis, older age (HR 1.02, 95% CI, 1.02-1.03, P<0.0001) and female sex (HR 1.67, 95% CI, 1.39-1.99, P<0.0001) were predictive of worse OS as were severe baseline PH and TS scores (see Table) . However, baseline PS scores were not related to OS. Conclusions: A single assessment of baseline symptom burden using the ESASr in patients with metastatic cancer has significant prognostic value. This may represent a feasible first step toward routine collection of PROs in real-world settings where serial symptom measurements can be challenging to implement. [Table: see text]

Patient-reported outcomes in Alberta: rationale, scope, and design of a database initiative

Background

The collection of patient reported outcomes (pros) is a standard of care in many cancer organizations. In Alberta, pros have been integrated into routine clinical practice since 2012. This longitudinal collection of pros provides a wealth of data and a unique research opportunity to improve cancer care. The goal of this pro data initiative is to establish a robust repository of information for ongoing clinical care and research focused on pros. In this paper, we describe the rationale, scope, and design of this initiative.

Implementation

The initiative consists of pros and other administrative health data from the province of Alberta. Retrieval of health data from a variety of provincially governed sources will create a platform of information on pros, health outcomes, cancer data, other health conditions, and demographics. The aims of the initiative are to use the data to inform best practices at the point of care; to conduct health services research, particularly clinical epidemiology studies; and to evaluate a variety of pro-related outcomes.

Discussion

Because this effort represents our first to integrate routinely collected pros with other administrative health data, a unique and robust data repository will be created. The ability to integrate various types of data will provide a comprehensive mechanism to evaluate a variety of outcomes. Because cancer care in Alberta is governed by a single health care system, the data linkages will include population health and psychosocial cancer data. We anticipate that research related to this initiative will ultimately help to inform more patient-centred care.

Association of providers’ prescribing patterns with postsurgical opioid use among cancer patients undergoing curative-intent surgery

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Background: Patients with cancer are vulnerable to chronic opioid use. Although opioid use may be appropriate, preliminary data suggest that a significant proportion may be using opioids inappropriately. This study aims to evaluate the association between the history of the providers’ opioid-prescribing patterns and post-surgical opioid use in cancer patients undergoing curative-intent surgery. Methods: This population-based study included all patients diagnosed with common solid tumors who received curative-intent surgery and were non-opioid users prior to surgery between 2009 and 2015 in Alberta, Canada. Based on previously published methods, a new persistent opioid user was defined as opioid-naïve prior to surgery and who subsequently filled at least one opioid prescription between 60 and 180 days after surgery. The opioid-prescribing patterns of a patient’s most responsible provider (MRP) were measured as the mean daily dosage (oral morphine equivalent, OME) that was prescribed to all other patients by that provider prior to the surgical date. Multivariable logistic regression was performed to identify associations between the MRP’s prescribing patterns and the patient’s opioid use after surgery. Results: 14,780 patients met the inclusion criteria and were associated with 2,880 MRPs, among which 2,364 (16%) patients became new persistent opioid users after surgery. Multivariate analysis demonstrated that patients with MRPs who routinely prescribed higher doses of opioids (≥60 vs. 0-59 mg OME: OR = 2.33, P < 0.0001) for their patients were associated with a greater risk of new persistent opioid use after surgery. In addition, those with a higher Charlson comorbidity index (P = 0.006), visited more prescribers (P < 0.0001), had a specific tumor type (breast, colorectal, lung, prostate, melanoma or kidney vs. others, P < 0.0001), received adjuvant chemotherapy (OR = 1.37, P < 0.0001), and received adjuvant radiation (OR = 1.3, P = 0.0004) were also associated with greater risk of new persistent opioid use after surgery. Conclusions: Our results suggest that prescribers with a history of prescribing higher opioid doses are an important predictor of chronic opioid use among cancer patients undergoing curative-intent surgery. Awareness of physician prescribing practices and their unintended consequences may inform strategies to minimize persistent post-operative opioid use in cancer patients.

Patient level factors associated with chronic opioid use in cancer patients

11580

Background: Opioid prescribing in oncology is increasingly scrutinized given public health concerns about chronic opioid use, misuse, and harms. We aimed to evaluate patient reported pain scores, mental health indicators, prior opioid use, and number of opioid prescribers as potential risk factors for chronic opioid use in a large Canadian province. Methods: This was a population-based cohort study using administrative health data of patients in Alberta, Canada, diagnosed between Jan 2016 and Jan 2017, and completed a prospective comprehensive symptom survey within +/- 60 days of diagnosis. Patients were divided into two groups: chronic opioid use (COU) (defined as continuous prescriptions for opioids for at least 90 days post diagnosis) and non-chronic opioid use (NCOU). Logistic regression models were used to evaluate factors associated with COU. Results: We included 694 patients. Most had breast (20%), colorectal (13%), and lung (33%) cancers. There were no differences in mean age (65 years) or gender (50% female) between the groups. In total, 32% had moderate to high pain scores at diagnosis. Of the 14% with COU, 79% were opioid naïve at diagnosis. Those in the COU group were more often diagnosed with advanced stage of disease (66% vs 40%), had lung cancer (47%), and were opioid tolerant at diagnosis (defined as > 90 days of continuous opioids within 1 year prior to their diagnosis) (21% vs 3%). In comparison, 64% of COU versus 27% of NCOU had moderate to severe pain scores at diagnosis (p < 0.001). COU had significantly higher anxiety and depression scores at diagnosis versus NCOU (p = 0.004). Among patients with COU, morphine equivalent daily doses increased from 27.3 (pre-diagnosis) to 65.1 (post-diagnosis). Irrespective of treatment type or stage, those who had moderate to high pain scores, were opioid tolerant at diagnosis, or had multiple prescribers were at greater risk for COU (see Table). Conclusions: Specific patient groups were at increased risk of COU and should be the focus of adaptive prescribing approaches to ensure that opioid use is appropriate. [Table: see text]

Effectiveness and components of self-management interventions in adult cancer survivors: a protocol for a systematic review and planned meta-analysis

BACKGROUND

Self-management interventions have been proposed as effective strategies to improve health and well-being and promote optimal coping in cancer survivors. Several reviews have shown benefits of self-management interventions on a variety of patient-reported outcomes. Effective self-management strategies in other chronic disease populations are typically based on theories of behavior change, but the extent of theoretical underpinnings in cancer self-management programs has not been evaluated to date. Our aim is to expand on previous reviews by evaluating the effectiveness of self-management interventions in cancer survivors as well as the theoretical components of such interventions.

METHODS

We will conduct a systematic review of self-management interventions for adults who have completed primary treatment for their solid or hematological cancer. Interventions tested using experimental or quasi-experimental methods, with any type of comparator, will be included. A search strategy will be designed with a health sciences librarian and then performed using MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, the Cochrane database of systematic reviews, the National Institutes of Health clinical trials registry, and the Cochrane CENTRAL registry of controlled trials. Data synthesis will include a narrative and tabular summary of the results. Appropriate statistical analysis may include a meta-analysis using random effects methods to determine the effectiveness of self-management interventions and a meta-regression to evaluate how characteristics of the interventions are associated with the intervention effect. Risk of bias will be evaluated using the Cochrane risk of bias tool or the Risk of Bias in Non-randomized studies tool (RoBANS).

DISCUSSION

The results of this systematic review will add to previous reviews and expand the existing knowledge base of the effectiveness and active components of self-management interventions for adult cancer survivors.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018085300.

Creating an upward spiral: A qualitative study of caregivers' experience of participating in a structured physical activity programme

Family caregivers' physical and emotional well-being may be negatively impacted while in the caregiver role. Interventions to support caregiver health have largely focused on psychological support, with only a few studies to date evaluating the role of exercise. Of the exercise studies conducted, there has been one qualitative study examining caregivers' perspectives on the value and impact of this type of intervention. This qualitative study was part of a larger mixed methods investigation including a randomised controlled trial investigating the effects of a 24-week exercise programme for cancer caregivers conducted in western Canada. We aimed to explore cancer family caregivers' experience of participating in a structured exercise programme. We conducted face-to-face interviews with 20 of the participants from the exercise intervention and analysed transcribed data using Thorne's interpretive description as a guiding framework. Two main patterns characterised the experiences of the caregivers. The metaphor of a downward spiral represented the experience of being in the caregiver role, while the metaphor of an upward spiral represented the experience of participating in the exercise programme. Our findings highlight that caregivers valued the exercise programme, experienced positivity through exercise and the group-based format, and noticed improvements to their physical and emotional well-being.

Exploring correlates of quality of life in older family caregivers to cancer patients

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Background: Family caregivers (FCs) have negative impacts to their physical and emotional health, and poorer quality of life (QoL) compared to non-caregivers. Most research on FCs has included heterogeneous samples, therefore little is known about specific groups such as older (age 60+) FCs. Older persons are at increased risk for health problems, may have co-morbidities, and be socially isolated. Understanding factors related to QoL may lead to interventions targeted to older FCs. The purpose of this study was to examine factors associated with QoL in older FCs to cancer patients. Methods: The data for this study are from a larger survey of FCs aged 60+, recruited from a hospital-based cancer facility. FCs were included if their care recipient had breast, prostate or colorectal cancer. QoL was measured using the MOSF-36. Analyses using descriptive statistics and Pearson’s correlations were conducted. Results: n = 168 participants consented, with n = 129 surveys returned. The majority of participants were female (60.5 %), 70 yrs old (sd 7.4), had at least a college diploma (65.2 %), were spouses of the patient 92.2%, and retired (60.5%). Mean caregiving hours per week was 24.2 (sd 26.3). Mean time as a caregiver was 31 months (45.9). The majority of patients were on treatment (75.2%) and were 71.3 yrs old (sd 7.5). The Physical Component Summary (PCS) of the MOSF-36 was significantly correlated with gender r = -.24, social support r = .25, sleep quality r = -.47, depression r = -.51, state anxiety r = -.40, and trait anxiety r = -.45 (all p’s < .01). There were significant correlations between the Mental Component Summary (MCS) and social support r = .40, sleep quality r = -.40, depression r = -.77, gender r = -.25, state anxiety r = -.72, and trait anxiety r = -.71 (all p’s < .01). The MCS was correlated with caregiving hours, r = -.197 (p < .05), however, not with patient treatment status. The PCS was not correlated with caregiving hours or patient treatment status. Conclusions: Consistent with previous FC research across different diseases, QoL was associated with gender, caregiving hours per week, social support, sleep quality, depression, and anxiety. Interventions for older FCs of cancer patients could be targeted to specific factors of overall QoL.

The application of qualitative research findings to oncology nursing practice

The Oncology Nursing Society (ONS) has established an ambitious research agenda and professional priorities based on a survey by LoBiondo-Wood et al. (2014). With the overall goal to "improve cancer care and the lives of individuals with cancer" (Moore & Badger, 2014, p. 93) through research activities, translating those research findings to direct clinical practice can be overwhelming. As clinicians, understanding how to critique research for quality prior to incorporating research findings into practice is important. The ultimate goal in this critique is to ensure that decisions made about patient care are based on strong evidence. However, the process for appraisal of qualitative research can be ambiguous and often contradictory as a result of the elusive aspect of quality in qualitative research methods (Seale, 1999). In addition, with more than 100 tools available to evaluate qualitative research studies (Higgins & Green, 2011), a lack of consensus exists on how to critically appraise research findings.