Palliative Medicine Fellows' Discussions, Perceptions, and Training Regarding Medical Cannabis

CONTEXT

Medical cannabis is increasingly considered for palliation of pain, nausea/vomiting, anorexia, and other symptoms.

OBJECTIVES

We aimed to determine whether training in hospice and palliative medicine (HPM) adequately prepares fellows to counsel patients about medical cannabis.

METHODS

A previously validated questionnaire was adapted for HPM fellows. Domains included fellows' practices recommending cannabis and their knowledge of its effectiveness and risks compared with standard treatments. U.S. HPM fellowships were sent surveys in 2022 and 2023.

RESULTS

Forty six programs participated, 123 fellows responded (response rate of 42%) including 69% female; 55% White, and 28% Asian. Of respondents, 65% reported receiving formal training regarding medical cannabis; 57% reported discussing medical cannabis with over five patients; 23% recommended medical cannabis to more than five patients in the preceding year. Only 19%, however, felt sufficiently informed to issue cannabis-related recommendations. HPM fellows with prior training were not more likely to feel sufficiently informed to discuss cannabis (RR: 1.17; 95% CI: 0.82-1.66) or to recommend cannabis to patients (RR: 2.05, 95% CI: 0.89-4.71). Fellows rate cannabis as equally or more effective than conventional treatments for the following symptoms: anorexia/cachexia (63%), nausea/vomiting (43%), pain (25%), and neuropathic pain (21%).

CONCLUSION

Most HPM fellows report formal training in the use of medical cannabis. Over half of trainees reported discussing medical cannabis with patients, but few considered themselves sufficiently informed to make cannabis-related clinical recommendations. These results suggest both a need for expanded high-quality evidence for medical cannabis in palliative care and for improved formal education for HPM fellows.

Cannabis and Cannabinoids in Adults With Cancer: ASCO Guideline

PURPOSE

To guide clinicians, adults with cancer, caregivers, researchers, and oncology institutions on the medical use of cannabis and cannabinoids, including synthetic cannabinoids and herbal cannabis derivatives; single, purified cannabinoids; combinations of cannabis ingredients; and full-spectrum cannabis.

METHODS

A systematic literature review identified systematic reviews, randomized controlled trials (RCTs), and cohort studies on the efficacy and safety of cannabis and cannabinoids when used by adults with cancer. Outcomes of interest included antineoplastic effects, cancer treatment toxicity, symptoms, and quality of life. PubMed and the Cochrane Library were searched from database inception to January 27, 2023. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The evidence base consisted of 13 systematic reviews and five additional primary studies (four RCTs and one cohort study). The certainty of evidence for most outcomes was low or very low.

RECOMMENDATIONS

Cannabis and/or cannabinoid access and use by adults with cancer has outpaced the science supporting their clinical use. This guideline provides strategies for open, nonjudgmental communication between clinicians and adults with cancer about the use of cannabis and/or cannabinoids. Clinicians should recommend against using cannabis or cannabinoids as a cancer-directed treatment unless within the context of a clinical trial. Cannabis and/or cannabinoids may improve refractory, chemotherapy-induced nausea and vomiting when added to guideline-concordant antiemetic regimens. Whether cannabis and/or cannabinoids can improve other supportive care outcomes remains uncertain. This guideline also highlights the critical need for more cannabis and/or cannabinoid research.Additional information is available at www.asco.org/supportive-care-guidelines.

Dispensary personnel's views and experiences regarding oncologic cannabis and the counsel they offer adults with cancer

BACKGROUND

A minority of oncologists feel qualified to advise adults with cancer on issues pertaining to medicinal cannabis. Adults with cancer frequently access medicinal cannabis information from non-medical sources such as cannabis dispensaries. We explored dispensary personnel's views and experiences regarding oncologic cannabis and the counsel they extend individuals with cancer.

METHODS

Snowball sampling in this qualitative study facilitated recruitment across 13 states (N = 26). Semi-structured phone interviews ceased with thematic saturation. A multi-stage thematic analysis combined inductive and deductive codes.

RESULTS

Of the 26 dispensary personnel interviewed, 54% identified as female and 19% as non-white. Median age was 40 years. A consensus emerged among participants concerning the botanical's efficacy for cancer-related symptoms; less so regarding its antineoplastic potential. Principles for serving those with cancer included provision of client-centered, symptom-based, and trial-and-error approaches. Non-inhalation modes of administration were generally recommended. No consensus was reached as to whether delta-9-tetrahydrocannabinal (THC)- or cannabidiol-predominant products were preferable in this population. Challenges in oncologic advising included successfully identifying individuals with cancer at the dispensary counter, financial toxicity, the special treatment required for the THC-naïve, and operating in the absence of standardized guidelines.

CONCLUSIONS

These informed assertions suggest that members of the oncologic community should grapple with the extent to which they feel comfortable with both the nature and degree of counsel adults with cancer receive through dispensaries.

Willingness toward psychosocial support during cancer treatment: a critical yet challenging construct in psychosocial care

Psychosocial distress screening, mandated by the American College Surgeons' Commission on Cancer, continues to be implemented across cancer centers nationwide. Although measuring distress is critical to identifying patients who may benefit from additional support, several studies suggest that distress screening may not actually increase patients' utilization of psychosocial services. While various investigators have identified barriers that may impede effective implementation of distress screening, we posit that patients' intrinsic motivation, which we term patients' willingness, may be the biggest predictor for whether cancer patients choose to engage with psychosocial services. In this commentary, we define patient willingness towards psychosocial services as a novel construct, distinct from the intention toward a certain behavior described across pre-existing models of health behavior change. Further, we offer a critical perspective of models of intervention design that focus on acceptability and feasibility as preliminary outcomes thought to encompass the willingness construct described herein. Finally, we summarize several health service models that successfully integrate psychosocial services alongside routine oncology care. Overall, we present an innovative model that acknowledges barriers and facilitators and underscores the critical role of willingness in health behavior change. Consideration of patients' willingness toward psychosocial care will move the field of psychosocial oncology forward in clinical practice, policy initiatives, and study design.

Cannabis Use Among Cancer Survivors Before and During the COVID-19 Pandemic, 2019-2021

We estimated the prevalence of past 30-day cannabis use (CU), evaluated reasons for use, and identified individual-level factors associated with CU among cancer survivors before (2019) and during (2020 and 2021) the COVID-19 pandemic. Cancer survivors, 18+ years, were identified from the 2019 (n = 8,185), 2020 (n = 11,084) and 2021 (n = 12,248) Behavioral Risk Factor Surveillance System. Prevalence of past 30-day CU among survivors held steady through the pandemic (8.7%, 7.4%, and 8.4% in 2019, 2020 and 2021, respectively). Of those who used cannabis, 48.7% used it for medical reasons in 2019; 54.5% in 2020; and 43.5% in 2021. Survivors were more likely to report past 30-day CU if they were younger, male, current or former tobacco smokers, binge alcohol consumers; and if they experienced poor mental health in the past 30-days. Our study identified subpopulations of cancer survivors that need to be targeted for evidence-informed discussions about CU.

An acceptance and commitment therapy-based intervention for opioid use disorder risk in individuals with cancer: A treatment development study

This paper describes the iterative development of an evidence-based behavioral intervention for individuals with cancer at risk for opioid use disorder, using the National Institutes of Health Stage Model for Behavioral Intervention Development. Adult patients with cancer from an outpatient palliative care clinic at an academic cancer center, with moderate to high risk of opioid misuse, were enrolled in a treatment development study that aimed to increase psychological flexibility. In this intervention, psychological flexibility is the posited mechanism of change for reduction of opioid use disorder risk. Patients completed baseline (pre-intervention) assessments, a six-session behavioral intervention based in Acceptance and Commitment Therapy, post-intervention assessments, and a semi-structured exit interview. Ten patients with moderate to high risk of opioid misuse completed the intervention. Patients rated the intervention as highly acceptable and were generally highly satisfied. Patients reported finding the coping skills helpful (e.g., mindfulness, cognitive defusion) and reported a preference for more sessions. These treatment development efforts have implications for the development and design of acceptance- and mindfulness-based, targeted interventions for individuals with cancer, receiving palliative care and at risk for opioid use disorder. Specifically, this six-session behavioral intervention to increase psychological flexibility was acceptable to patients and ready to be studied in a pilot RCT.

Proxy ratings of psychological well-being in patients with primary brain tumors: A systematic review

OBJECTIVE

This systematic review examined the agreement of proxy ratings of depression and anxiety in neuro-oncology patients.

METHODS

Searches were conducted across 4 databases (MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science) to identify studies that compared proxy ratings (non-health care providers) of anxiety and depression in patients with brain cancer. Methodological quality and potential risk of bias were evaluated using the Joanna Briggs Institute Critical Appraisal Checklist.

RESULTS

Out of the 936 studies that were screened for inclusion, 6 were included for review. The findings were mixed in terms of whether patient and proxy ratings were accurate (e.g., deemed equivalent), with many of the selected studies suggesting moderate level of agreement for several of the selected studies and, when both depression and anxiety were included, depression ratings from proxy raters were more accurate than for anxiety. We identified important limitations across the selected articles, such as low sample size, clarity on defining proxy raters and the different instructions that proxy raters are given when asked to assess patients' mood symptoms.

CONCLUSIONS

Our findings suggest that proxy ratings of depression and anxiety should be interpreted with caution. While there is some agreement in proxy and patients with brain cancer ratings of depression and anxiety (greater agreement for depression), future work should recruit larger samples, while also remaining mindful of defining proxy raters and the instructions given in collecting these ratings.

Backgrounds and Trainings in Cannabis Therapeutics of Dispensary Personnel

PURPOSE

A growing body of scientific research indicates that oncology teams tend to offer individuals with cancer little clinical advice regarding medicinal cannabis (MC) and that individuals with cancer instead turn to cannabis dispensaries for MC guidance. Our objective was to investigate dispensary personnel's backgrounds and trainings in MC advising.

METHODS

The study design was semistructured interviews across 13 states with cannabis dispensary personnel in managerial or client-facing positions. Of 38 recruited, 26 (68%) completed interview. The primary outcome was training in MC advising. Researchers targeted thematic saturation and adhered to Consolidated Criteria for Reporting Qualitative Research.

RESULTS

Of 26 participants, 54% were female, with an average age of 40 (range: 22-64) years. Half worked in client-facing roles; half worked in managerial ones. Study participants endorsed passionate commitment to their profession, often motivated by personal experience with MC therapeutics. Cannabis dispensaries often privileged sales skills over cannabis therapeutics knowledge when hiring, resulting in uneven baseline levels of cannabis therapeutics expertise among staff. Most participants reported workplace cannabis therapeutics training to be unstandardized and weak. They described dispensary personnel as resourceful in pursuing cannabis knowledge, self-financing learning in off-hours, sampling dispensary products, and exchanging knowledge. Nearly half the participants called for quality, standardized cannabis therapeutics training for dispensary personnel.

CONCLUSION

The many oncology teams who defer to dispensary personnel regarding MC advising rely on a workforce who views themselves as unevenly trained. Further research should include a national survey of cannabis dispensary personnel to learn whether these findings hold true in a larger sample. If so, the oncology community must determine the best approach to clinically advising individuals with cancer about MC.

Developing and Field Testing BOLSTER: A Nurse-Led Care Management Intervention to Support Patients and Caregivers following Hospitalization for Gynecologic Cancer-Associated Peritoneal Carcinomatosis

Introduction: Peritoneal carcinomatosis (PC) afflicts women with advanced gynecologic cancers. Patients with PC often require ostomies, gastric tubes, or catheters to palliate symptoms, yet patients and caregivers report feeling unprepared to manage these devices. The purpose of this study was to develop and field test the Building Out Lifelines for Safety, Trust, Empowerment, and Renewal (BOLSTER) intervention to support patients and their caregivers after hospitalization for PC. Materials and Methods: We adapted components of the Standard Nursing Intervention Protocol with stakeholders and topical experts. We developed educational content; built a smartphone application to assess patients' symptoms; and assessed preliminary feasibility and acceptability in two single-arm prepilot studies. Eligible participants were English-speaking adults hospitalized for gynecologic cancer-associated PC and their caregivers. Feasibility criteria were a ≥50% consent-to-approach ratio and ≥80% outcome measure completion. The acceptability criterion was ≥70% of participants recommending BOLSTER. Results: During the first prepilot, BOLSTER was a 10-week intervention. While 7/8 (87.5%) approached patients consented, we experienced high attrition to hospice. Less than half of patients (3/7) and caregivers (3/7) completed outcome measures. For the second prepilot, BOLSTER was a four-week intervention. All (7/7) approached patients consented. Two withdrew before participating in any study activity because they were "too overwhelmed." We excluded data from one caregiver who completed baseline measures with the patient's assistance. All remaining patients (5/5) and caregivers (4/4) completed outcome measures and recommended BOLSTER. Conclusion: BOLSTER is a technology-enhanced, nurse-led intervention that is feasible and acceptable to patients with gynecologic cancer-associated PC and their caregivers.

Cancer Patients' Experiences with and Perspectives on the Medicinal Cannabis "High"

Background: Patients with cancer employ medicinal cannabis for poly-symptom management and as cancer-directed therapy. Little is known about their perspectives on the medicinal cannabis "high." Methods: Qualitative interviews across eight states with medicinal cannabis users with physician-verified cancer diagnoses (n = 24). Results: Every participant referenced and 15 spoke in depth about the medicinal cannabis "high." Antitheticals characterized it: sleepiness versus heightened attention; calm versus "agitation." The intensity of the "high" served as a proxy metric by which participant's judged medicinal cannabis' cancer-directed therapy and symptom management efficacies. Overall, however, study participants viewed the "high" as a barrier to medicinal cannabis use and worked to avoid experiencing for prolonged periods. Conclusions: The "high" is central to the manner with which patients with cancer experience medicinal cannabis. Clinicians should be aware that patients may struggle to fine-tune medicinal cannabis dosing in the setting of the "high," and this challenge should be included in clinical discussions regarding oncological medicinal cannabis use.

Clinical Decision Support for Symptom Management in Lung Cancer Patients: A Group RCT

CONTEXT

Clinical guidelines are available to enhance symptom management during cancer treatment but often are not used in the practice setting. Clinical decision support can facilitate the implementation and adherence to clinical guidelines. and improve the quality of cancer care.

OBJECTIVES

Clinical decision support offers an innovative approach to integrate guideline-based symptom management into oncology care. This study evaluated the effect of clinical decision support-based recommendations on clinical management of symptoms and health-related quality of life (HR-QOL) among outpatients with lung cancer.

METHODS

Twenty providers and 179 patients were allotted in group randomization to attention control (AC) or Symptom Assessment and Management Intervention (SAMI) arms. SAMI entailed patient-report of symptoms and delivery of recommendations to manage pain, fatigue, dyspnea, depression, and anxiety; AC entailed symptom reporting prior to the visit. Outcomes were collected at baseline, two, four and six-months. Adherence to recommendations was assessed through masked chart review. HR-QOL was measured by the Functional Assessment of Cancer Therapy-Lung questionnaire. Descriptive statistics with linear and logistic regression accounting for the clustering structure of the design and a modified chi-square test were used for analyses.

RESULTS

Median age of patients was 63 years, 58% female, 88% white, and 32% ≤high school education. Significant differences in clinical management were evident in SAMI vs. AC for all target symptoms that passed threshold. Patients in SAMI were more likely to receive sustained-release opioids for constant pain, adjuvant medications for neuropathic pain, opioids for dyspnea, stimulants for fatigue and mental health referrals for anxiety. However, there were no statistically significant differences in HR-QOL at any time point.

CONCLUSION

SAMI improved clinical management for all target symptoms but did not improve patient outcomes. A larger study is warranted to evaluate effectiveness.

Cannabis and the Cancer Patient

Session 2 of the National Cancer Institute's Cannabis, Cannabinoids, and Cancer Research Workshop opened with testimony from a lymphoma survivor who detailed medicinal cannabis-related improvements in nausea, low appetite, insomnia, and mental health and the limited clinical counsel she received regarding cannabis use. Discussion next turned to the evolution of the legal landscape of cannabis in the United States, one in which state and federal laws frequently conflict and the Controlled Substance Act renders cannabis Schedule I. This legal climate creates conundrums for US medicinal cannabis researchers who contend with limited funding opportunities, avenues to source trial drug, and procedural red tape and for oncology clinicians who recommend medicinal cannabis to patients with some frequency while perceiving themselves as ill equipped to make such clinical recommendations. Ultimately, it creates challenges for cancer patients who find themselves turning to nonmedical and anecdotal information sources. The risks of cannabis use by the cancer patient were discussed next. These include infection, pharmacodynamic and pharmacokinetic drug-botanical interactions, cyclic nausea and vomiting, e-cigarette or vaping product use-associated illness, legal issues, and high cost. The session concluded with a broad survey of the research supporting oncologic cannabinoid use, conclusive evidence for chemotherapy-induced nausea and vomiting, and suggestive evidence for cancer-related pain.

Cancer patient's attitudes of using medicinal cannabis for sleep

PURPOSE

Poor sleep is one of the most common side effects of cancer treatment. One increasingly popular approach to manage side effects of cancer treatment is use of medicinal cannabis (MC).

DESIGN

Cancer patients using MC participated in semi-structured interviews to assess their experiences with MC (n = 24). A multi-stage thematic analysis was applied to interview transcripts. Themes related to use of MC for sleep were extracted.

FINDINGS

The majority reported MC use for sleep. These participants reported that MC improved sleep initiation and continuity, resulted in decreased use of sleep medications, and that improved sleep led to better health. No participant reported MC was ineffectual for sleep or caused undesirable side effects when used for sleep.

CONCLUSIONS

Cancer patients often utilize MC to specifically manage poor sleep. There is a need for rigorous studies assessing prevalence of use for this indication and clinical trials to assess comparative efficacy and safety.

Cancer patients' experiences with medicinal cannabis-related care

BACKGROUND

Little is known about medical cannabis (MC)-related care for patients with cancer using MC.

METHODS

Semistructured telephone interviews were conducted in a convenience sample of individuals (n = 24) with physician-confirmed oncologic diagnoses and state/district authorization to use MC (Arizona, California, Florida, Illinois, Massachusetts, Oregon, New York, and Washington, DC) from April 2017 to March 2019. Standard qualitative techniques were used to assess the degree of MC-related health care oversight, MC practices, and key information sources.

RESULTS

Among 24 participants (median age, 57 years; range, 30-71 years; 16 women [67%]), MC certifications were typically issued by a professional new to a patient's care after a brief, perfunctory consultation. Patients disclosed MCuse to their established medical teams but received little medical advice about whether and how to use MC. Patients with cancer used MC products as multipurpose symptom management and as cancer-directed therapy, sometimes in lieu of standard-of-care treatments. Personal experimentation, including methodical self-monitoring, was an important source of MC know-how. Absent formal advice from medical professionals, patients relied on nonmedical sources for MC information.

CONCLUSIONS

Patients with cancer used MC with minimal medical oversight. Most received MC certifications through brief meetings with unfamiliar professionals. Participants desired but were often unable to access high-quality clinical information about MC from their established medical teams. Because many patients are committed to using MC, a product sustained by a growing industry, medical providers should familiarize themselves with the existing data for MM and its limitations to address a poorly met clinical need.

Identifying patient-level factors associated with interest in psychosocial services during cancer: A brief report

OBJECTIVES

Uptake of psychosocial services during cancer treatment remains relatively low. To use these services efficiently, novel approaches - based on evidence-based theory - are needed to understand cancer patients' readiness to seek psychosocial services. Guided by the transtheoretical model (TTM), we investigated individuals' readiness to use psychosocial services by assessing decisional conflict (pros/cons) and self-efficacy, which are established as the most important constructs of predicting a specific behavior.

METHODS

In these secondary analyses, we examined demographic and treatment-related factors in a national sample of adult cancer patients and survivors in the United States as predictors of decisional balance (pros/cons) and self-efficacy (i.e., two core TTM constructs) of engaging in psychosocial services. Participants were recruited through an online survey. In addition to examining demographic factors (age, sex, race, and marital status) as independent variables using t tests and correlations, treatment-related variables, such as having multiple cancers, type of cancer, type of treatment, and treatment setting were included.

RESULTS

Four hundred and sixty-six participants completed the survey. The sample was primarily Caucasian (79%) and female (54.7%); average age was 47.9 (SD = 14.8). While no significant relationships emerged for self-efficacy, younger age and non-Caucasian race were significantly related to greater cons of seeking psychosocial care. Finally, those with multiple cancers versus reporting only one malignancy endorsed more cons of seeking psychosocial care.

CONCLUSIONS

These data highlight the importance of measuring the cons of seeking psychosocial care during cancer treatment, with younger age, non-Caucasian, and those reporting experience with multiple cancers endorsing greater cons. This may impact eventual uptake of available services. Future research should identify individuals at risk for declining services based on perceived cons of seeking psychosocial care during cancer.

1023 Oncologists’ Beliefs About Medical Marijuana’s Effectiveness for Sleep in Cancer Patients: A Nationally Representative Survey

Introduction

Cancer is a qualifying condition for medical marijuana (MM) access in almost every state which has legalized medical use. Over 20% of patients report recent cannabis use to manage cancer treatment side effects, including poor sleep. However, there have been no clinical trials of MM for sleep in oncology populations. This study explores oncologists’ characteristics associated with their views on MM for sleep.

Methods

N=237 medical oncologists completed a mailed survey querying demographics, training history and current practice, and their knowledge and views on MM. In these analyses, we compared oncologists who viewed MM as being equally or more effective than standard treatment approaches to manage poor sleep with those who viewed MM as less effective.

Results

Sixty-four percent of oncologists believed MM to be equally or more effective than standard treatments for poor sleep. They were significantly less likely than peers to have a medical school faculty appointment (53% vs 72%) or self-report sufficient knowledge about MM to make clinical recommendations (42% vs 57%). Oncologists who viewed MM favorably compared to standard treatments for poor sleep were more likely to have recommended its use and to view it as beneficial during end of life care. We identified no differences between groups by age, sex, ethnicity, US vs foreign medical training, patient volume, or whether the state where they practiced had legalized MM.

Conclusion

Oncologists affiliated with a medical school report less knowledge about MM and are more cautious in their views of its effectiveness for treating poor sleep. This may be due to their institutions’ reluctance to draft MM policies for fear of losing federal licensure or their awareness of the limitations of existing data. There are important practice implications related to the likelihood of an oncologist recommending MM for poor sleep.

Support

Hans and Mavis Lopater Foundation.

Defining the Roles and Research Priorities for Psychedelic-Assisted Therapies in Patients with Serious Illness: Expert Clinicians' and Investigators' Perspectives

Background: Recent and preprohibition studies show that patients with serious illness might benefit from psychedelic-assisted therapies for a range of symptoms, physical, psychosocial, and existential. Objective: To explore the potential roles and research priorities of these therapies in patients with serious illness. Design, Setting, and Participants: Qualitative study based on semistructured interviews with 17 experts in serious illness care and/or psychedelic research from the United States and Canada. Measurements: The interview guide elicited participants' perspectives on (1) the potential roles of psychedelic-assisted therapies in this setting, (2) research priorities relevant to this population, and (3) the potential for integrating psychedelic-assisted therapies into existing delivery models of serious illness care. We used thematic analysis until thematic saturation. Results: Domain I: Participants had polar views on the therapeutic potential of psychedelic-assisted therapies, ranging from strong beliefs in their medical utility to reluctance about their use in this patient population. They shared concerns related to the risks of adverse effects, such as delirium or worsening of psychological distress. Domain II: Research priorities primarily concerned patients with clinically diagnosed psychosocial distress, such as depression, anxiety, or demoralization. Participants also articulated potential roles extending beyond traditional medical diagnosis. Domain III: Participants emphasized essential safety and efficacy guidelines relevant to the integration of these therapies into existing models of care. Conclusion: This qualitative study highlights issues and priorities for research on psychedelic-assisted therapies in patients with serious illness and proposes a conceptual framework for integrating these therapies into existing delivery models of serious illness care.

A computationally inspired in-vivo approach identifies a link between amygdalar transcriptional heterogeneity, socialization and anxiety

Pharmaceutical breakthroughs for anxiety have been lackluster in the last half-century. Converging behavior and limbic molecular heterogeneity has the potential to revolutionize biomarker-driven interventions. However, current in vivo models too often deploy artificial systems including directed evolution, mutations and fear induction, which poorly mirror clinical manifestations. Here, we explore transcriptional heterogeneity of the amygdala in isogenic mice using an unbiased multi-dimensional computational approach that segregates intra-cohort reactions to moderate situational adversity and intersects it with high content molecular profiling. We show that while the computational approach stratifies known features of clinical anxiety including nitric oxide, opioid and corticotropin signaling, previously unrecognized druggable biomarkers emerge, such as calpain11 and scand1. Through ingenuity pathway analyses, we further describe a role for neurosteroid estradiol signaling, heat shock proteins, ubiquitin ligases and lipid metabolism. In addition, we report a remarkable behavioral pattern that maps to molecular features of anxiety in mice through counterphobic social attitudes, which manifest as increased, yet spatially distant socialization. These findings provide an unbiased approach for interrogating anxiolytics, and hint toward biomarkers underpinning behavioral and social patterns that merit further exploration.

A systematic review of substance use and substance use disorders in patients with cancer

OBJECTIVE

Few studies examined substance use in cancer patients. The aims of this systematic review were to summarize this evidence, identify methodological limitations, and provide future research directions.

METHOD

Articles on substance use in cancer (focused on illicit substance, opioid, and alcohol use) were searched in Medline, PsycINFO, and PsycARTICLES.

RESULTS

On the basis of inclusion criteria, 28 studies were reviewed. Twenty-one contained empiric data from 500,123 participants; seven were review or conceptual papers. All studies were published between 1995 and 2018. Quality assessment revealed relatively low risk of bias and high methodological quality. Five studies examined substance use or substance use disorder (SUD) broadly. Mean ages ranged from 17.6 to 74.7 years. Substance use rates ranged from 2% to 35%, with a median opioid rate of 18% and 25.5% for alcohol. Nine of the studies had samples comprised either mostly or exclusively of advanced cancer patients. Disease groups included breast, head & neck, and gastric cancer. None of the studies used a theoretical framework or model.

CONCLUSIONS

Given the prevalence of substance use in cancer patients, interventions are needed. Further theory-grounded studies are warranted to foster the translation of research into clinical practice and elucidate substance use management recommendations.

Algorithm-based decision support for symptom self-management among adults with Cancer: results of usability testing

BACKGROUND

It is essential that cancer patients understand anticipated symptoms, how to self-manage these symptoms, and when to call their clinicians. However, patients are often ill-prepared to manage symptoms at home. Clinical decision support (CDS) is a potentially innovative way to provide information to patients where and when they need it. The purpose of this project was to design and evaluate a simulated model of an algorithm-based CDS program for self-management of cancer symptoms.

METHODS

This study consisted of three phases; development of computable algorithms for self-management of cancer symptoms using a modified ADAPTE process, evaluation of a simulated model of the CDS program, and identification of design objectives and lessons learned from the evaluation of patient-centered CDS. In phase 1, algorithms for pain, constipation and nausea/vomiting were developed by an expert panel. In phase 2, we conducted usability testing of a simulated symptom assessment and management intervention for self-care (SAMI-Self-Care) CDS program involving focus groups, interviews and surveys with cancer patients, their caregivers and clinicians. The Acceptability E-scale measured acceptability of the program. In phase 3, we developed design objectives and identified barriers to uptake of patient-centered CDS based on the data gathered from stakeholders.

RESULTS

In phase 1, algorithms were reviewed and approved through a consensus meeting and majority vote. In phase 2, 24 patients & caregivers and 13 clinicians participated in the formative evaluation. Iterative changes were made in a simulated SAMI-Self-Care CDS program. Acceptability scores were high among patients, caregivers and clinicians. In phase 3, we formulated CDS design objectives, which included: 1) ensure patient safety, 2) communicate clinical concepts effectively, 3) promote communication with clinicians, 4) support patient activation, and 5) facilitate navigation and use. We identified patient barriers and clinician concerns to using CDS for symptom self-management, which were consistent with the chronic care model, a theoretical framework used to enhance patient-clinician communication and patient self-management.

CONCLUSION

Patient safety and tool navigation were critical features of CDS for patient self-management. Insights gleaned from this study may be used to inform the development of CDS resources for symptom self-management in patients with other chronic conditions.

Medical Oncologists' Beliefs, Practices, and Knowledge Regarding Marijuana Used Therapeutically: A Nationally Representative Survey Study

Background Although almost every state medical marijuana (MM) law identifies cancer as a qualifying condition, little research supports MM's use in oncology. We hypothesized that the discrepancy between these laws and the scientific evidence base poses clinical challenges for oncologists. Oncologists' beliefs, knowledge, and practices regarding MM were examined in this study. Methods In November 2016, we mailed a survey on MM to a nationally-representative, random sample of 400 medical oncologists. Main outcome measures included whether oncologists reported discussing MM with patients, recommended MM clinically in the past year, or felt sufficiently informed to make such recommendations. The survey also queried oncologists' views on MM's comparative effectiveness for several conditions (including its use as an adjunct to standard pain management strategies) and its risks compared with prescription opioids. Bivariate and multivariate analyses were performed using standard statistical techniques. Results The overall response rate was 63%. Whereas only 30% of oncologists felt sufficiently informed to make recommendations regarding MM, 80% conducted discussions about MM with patients, and 46% recommended MM clinically. Sixty-seven percent viewed it as a helpful adjunct to standard pain management strategies, and 65% thought MM is equally or more effective than standard treatments for anorexia and cachexia. Conclusion Our findings identify a concerning discrepancy between oncologists' self-reported knowledge base and their beliefs and practices regarding MM. Although 70% of oncologists do not feel equipped to make clinical recommendations regarding MM, the vast majority conduct discussions with patients about MM and nearly one-half do, in fact, recommend it clinically. A majority believes MM is useful for certain indications. These findings are clinically important and suggest critical gaps in research, medical education, and policy regarding MM.

Patient and caregiver perspectives on decision support for symptom and quality of life management during cancer treatment: Implications for eHealth

OBJECTIVES

Adequate symptom and quality-of-life (SQL) management is a priority during cancer treatment. eHealth is a timely way to enhance patient-engagement, facilitate communication, and improve health outcomes. The objectives of this study were to describe patient and caregivers' perspectives for providing, processing, and managing SQL data to enhance communication and identify desired components for decision support.

METHODS

Data were collected from 64 participants through questionnaires and focus groups. Analysis was conducted using NVivo. Open and axial coding was completed, grouping commonalities and large constructs into nodes to identify and synthesize themes.

RESULTS

Face-to-face meetings with clinicians were the prime time to communicate, and patients strove to understand treatment options and the effect on SQL by bringing caregivers to their visits, taking notes, tracking symptoms, and creating portable health records. Patients/caregivers struggled to self-manage their symptoms and were uncertain when to contact clinicians when experiencing uncontrolled symptoms. Most participants identified eHealth solutions for decision support. However, 38% of participants (n = 24) rarely used computers and identified non-eHealth options for decision support. Core components for both eHealth and non-eHealth systems were access to (1) cancer information, (2) medical records, (3) peer support, and (4) improved support and understanding on when to contact clinicians.

CONCLUSIONS

Patients were faced with an overwhelming amount of information and relied on their caregivers to help navigate the complexities of cancer care and self-manage SQL. Health technologies can provide informational support; however, decision support needs to span multiple venues to avoid increasing disparities caused by a digital divide.

Retrospective review of serotonergic medication tolerability in patients with neuroendocrine tumors with biochemically proven carcinoid syndrome

BACKGROUND

Patients with carcinoid tumors frequently could benefit from the pharmacologic treatment of depression and anxiety. However, many prescribers avoid serotonergic medications due to the theoretical risk of exacerbating carcinoid syndrome.

METHODS

The authors conducted a retrospective chart review of patients with carcinoid tumors and elevated serotonin levels (as measured by 24-hour urine 5-hydroxyindoleacetic acid [5-HIAA]) at Dana-Farber/Brigham and Women's Cancer Center who initiated treatment with serotonergic antidepressants after a carcinoid diagnosis from 2003 to 2016. Each medication regimen was categorized based on the presence of adverse interactions as defined by clinical worsening of symptoms of carcinoid syndrome in the absence of progressive disease that temporally correlated with a serotonergic medication trial.

RESULTS

A total of 73 serotonergic regimens received by 52 patients were included in the primary analysis. Among these medication trials, 8.2% of the regimens (6 regimens) were categorized as being associated with a likely adverse interaction, 61.6% of the regimens (45 regimens) were categorized as having no adverse reaction, 9.6% of the regimens (7 regimens) were categorized as an unlikely adverse reaction, and 20.6% of the regimens (15 regimens) were categorized as unknown. It is interesting to note that none of the 73 trials resulted in a carcinoid crisis requiring emergency care or hospitalization. Only 3 patients discontinued serotonergic medications due to worsening carcinoid syndrome.

CONCLUSIONS

Serotonergic medications appear to be a safe option for the treatment of depressive and anxiety symptoms in the majority of patients with neuroendocrine tumors and carcinoid syndrome. In the current study, <10% of patients developed a combination of flushing, diarrhea, and bloating after the initiation of serotonergic medications. Clinicians can begin with low doses, monitor these symptoms, and reduce the dose or discontinue the medication if necessary. Cancer 2017;123:2735-42. © 2017 American Cancer Society.

Experts' perspectives on the role of medical marijuana in oncology: A semistructured interview study

BACKGROUND

Expansion of medical marijuana (MM) laws in the United States may offer oncology new therapeutic options. However, the scientific evidence for MM remains in infancy. This study qualitatively explored professional opinion around the role of MM in cancer care.

METHODS

Semistructured interviews were administered to a sample of individuals with expertise at the interface of MM and oncology nationally. Key informant criteria included an oncologic clinical or research background and any of the following: publications, research, or lectures on cannabinoids or cancer symptoms; involvement in the development of MM dispensaries or legislation; and early adoption of state MM certification procedures. A gold standard, grounded, inductive approach was used to identify underlying themes.

RESULTS

Participants (N = 15) were predominantly male, in their sixth decade, working in academic settings. Themes ranged from strong beliefs in marijuana's medical utility to reservations about this notion, with calls for expansion of the scientific evidence base and more stringent MM production standards. All participants cited nausea as an appropriate indication, and 13 of 15 pain. Over one-third believed MM to have a more attractive risk profile than opioids and benzodiazepines.

CONCLUSIONS

Expert opinion was divided between convictions in marijuana's medicinal potential and guardedness in this assertion, with no participant refuting MM's utility outright. Emergent themes included that MM ameliorates cancer-related pain and nausea and is safer than certain conventional medications. Participants called for enhanced purity and production standards, and further research on MM's utility.

Increasing Complexity in Rule-Based Clinical Decision Support: The Symptom Assessment and Management Intervention

BACKGROUND

Management of uncontrolled symptoms is an important component of quality cancer care. Clinical guidelines are available for optimal symptom management, but are not often integrated into the front lines of care. The use of clinical decision support (CDS) at the point-of-care is an innovative way to incorporate guideline-based symptom management into routine cancer care.

OBJECTIVE

The objective of this study was to develop and evaluate a rule-based CDS system to enable management of multiple symptoms in lung cancer patients at the point-of-care.

METHODS

This study was conducted in three phases involving a formative evaluation, a system evaluation, and a contextual evaluation of clinical use. In Phase 1, we conducted iterative usability testing of user interface prototypes with patients and health care providers (HCPs) in two thoracic oncology clinics. In Phase 2, we programmed complex algorithms derived from clinical practice guidelines into a rules engine that used Web services to communicate with the end-user application. Unit testing of algorithms was conducted using a stack-traversal tree-spanning methodology to identify all possible permutations of pathways through each algorithm, to validate accuracy. In Phase 3, we evaluated clinical use of the system among patients and HCPs in the two clinics via observations, structured interviews, and questionnaires.

RESULTS

In Phase 1, 13 patients and 5 HCPs engaged in two rounds of formative testing, and suggested improvements leading to revisions until overall usability scores met a priori benchmarks. In Phase 2, symptom management algorithms contained between 29 and 1425 decision nodes, resulting in 19 to 3194 unique pathways per algorithm. Unit testing required 240 person-hours, and integration testing required 40 person-hours. In Phase 3, both patients and HCPs found the system usable and acceptable, and offered suggestions for improvements.

CONCLUSIONS

A rule-based CDS system for complex symptom management was systematically developed and tested. The complexity of the algorithms required extensive development and innovative testing. The Web service-based approach allowed remote access to CDS knowledge, and could enable scaling and sharing of this knowledge to accelerate availability, and reduce duplication of effort. Patients and HCPs found the system to be usable and useful.

Feasibility of using algorithm-based clinical decision support for symptom assessment and management in lung cancer

CONTEXT

Distressing symptoms interfere with the quality of life in patients with lung cancer. Algorithm-based clinical decision support (CDS) to improve evidence-based management of isolated symptoms seems promising, but no reports yet address multiple symptoms.

OBJECTIVES

This study examined the feasibility of CDS for a Symptom Assessment and Management Intervention targeting common symptoms in patients with lung cancer (SAMI-L) in ambulatory oncology. The study objectives were to evaluate completion and delivery rates of the SAMI-L report and clinician adherence to the algorithm-based recommendations.

METHODS

Patients completed a web-based symptom assessment and SAMI-L created tailored recommendations for symptom management. Completion of assessments and delivery of reports were recorded. Medical record review assessed clinician adherence to recommendations. Feasibility was defined as 75% or higher report completion and delivery rates and 80% or higher clinician adherence to recommendations. Descriptive statistics and generalized estimating equations were used for data analyses.

RESULTS

Symptom assessment completion was 84% (95% CI=81-87%). Delivery of completed reports was 90% (95% CI=86-93%). Depression (36%), pain (30%), and fatigue (18%) occurred most frequently, followed by anxiety (11%) and dyspnea (6%). On average, overall recommendation adherence was 57% (95% CI=52-62%) and was not dependent on the number of recommendations (P=0.45). Adherence was higher for anxiety (66%; 95% CI=55-77%), depression (64%; 95% CI=56-71%), pain (62%; 95% CI=52-72%), and dyspnea (51%; 95% CI=38-64%) than for fatigue (38%; 95% CI=28-47%).

CONCLUSION

The CDS systems, such as SAMI-L, have the potential to fill a gap in promoting evidence-based care.

Advanced cancer as a risk for major depressive episodes

OBJECTIVE

Major depression adversely affects health communication, quality of life, and survival in patients with advanced cancer. Prior research provides limited insight into how patients with advanced cancer differ from the general population in risk for developing a major depressive episode (MDE). This study aims to determine whether advanced cancer poses distinct risks for initial and recurrent MDEs.

METHODS

Advanced cancer patients (N = 628) from Coping with Cancer were compared with propensity-weighted general population controls (N = 9282) from the National Comorbidity Survey Replication.

RESULTS

Patients with advanced cancer were more likely than comparisons to have an initial MDE [OR = 27.3, 95% CI = (14.8-50.4); p < 0.001] but no more likely than comparisons to have a recurrent MDE [OR = 1.5, 95% CI = (0.9-2.6); p = 0.160]. Nearly two thirds (64.4%) of current MDEs in patients were initial onset; the vast majority (91.8%) of current MDEs in comparisons were recurrent.

CONCLUSIONS

Advanced cancer increases risk of an initial MDE but appears not to enhance risk of a recurrent MDE. This suggests the importance of screening widely for depression in patients with advanced cancer as opposed to targeting screening to presumably high-risk subgroups of those with psychiatric histories.

Patterns of psychiatric medication use among nationally representative long-term cancer survivors and controls

BACKGROUND

Investigations of long-term cancer survivors (LTCS) indicate that this population is not appreciably different from cancer-naive peers with respect to several neuropsychiatric domains. The current study sought to determine whether differences in psychiatric medication use might help to explain the negative findings.

METHODS

In a nationally representative sample, 5692 subjects were queried for cancer history, psychiatric diagnoses, and psychotropic medication use. The LTCS were defined as those individuals who were ≥5 years from diagnosis and whose cancer was in remission or cured. Odds ratios and 95% confidence intervals were obtained from multivariable logistic regression models evaluating the relationship between cancer status and use of psychiatric medications. The interaction between case/control status and psychiatric diagnoses was also tested in a logistic regression model to predict psychotropic medication use.

RESULTS

A total of 225 participants met the criteria for LTCS and 3953 met the criteria for cancer-naive controls (CNC). The LTCS were no more likely than CNC to carry a psychiatric diagnosis. Despite the LTCS reporting somewhat greater psychotropic medication use compared with the CNC (28.8% vs 22.3%), unadjusted and adjusted differences did not reach statistical significance, possibly due to sample size. The interaction between case/control status and carrying a psychiatric diagnosis was not found to be significantly associated with receiving a psychiatric medication.

CONCLUSIONS

LTCS and CNC demonstrated comparable rates of psychiatric prescription medication use. The relationship between taking a psychiatric medication and carrying a psychiatric diagnosis was not found to be significantly different between the case and control groups. These findings contribute to an emerging hypothesis that in general LTCS are not a particularly psychiatrically vulnerable group.

Parsing depression from fatigue in patients with cancer using the fatigue symptom inventory

CONTEXT

A central aim in the management of cancer-related fatigue (CRF) is to identify treatable causes, such as depression. However, CRF and depression symptoms overlap and frequently co-occur, complicating diagnostic assessment.

OBJECTIVES

As cancer-related symptoms have been associated with more functional impairment among patients who are depressed, this study tested the ratio of fatigue interference to fatigue severity as a method for identifying depression cases. Patients who reported that interference was greater than severity were expected to show higher rates of depression as measured by self-report instrument or structured interview.

METHODS

A secondary analysis was conducted using data from patients who were attending a hospital thoracic oncology clinic and who completed the Fatigue Symptom Inventory (FSI) and Hospital Anxiety and Depression Scale (Sample 1, n = 86). Analyses were then replicated in a sample of diverse cancer patients who completed the FSI and a structured clinical interview for depression on presentation to a CRF clinic at the same hospital (Sample 2, n = 39).

RESULTS

Receiver operating curve analyses supported use of the FSI interference/severity ratio in distinguishing depression cases and noncases (area under the curve: Sample 1 = 0.84, 95% confidence interval [CI] 0.74-0.94; Sample 2 = 0.87, 95% CI 0.76-0.99). With sensitivity and specificity weighted equally, the optimal cutoff was ≥ 1.0 in Sample 1 (sensitivity = 62.5%, specificity = 91.4%) and Sample 2 (sensitivity = 90.9%, specificity=85.7%).

CONCLUSION

A fatigue score pattern in which interference was greater than or equal to severity predicted depression in two patient samples. This ratio may be useful for brief initial screening of depression in the context of fatigue.

Evidenced-based report on the occurrence of fatigue in long-term cancer survivors

Although some cancer survivors report persistent fatigue years after treatment, little is known about the prevalence of the symptom in this population as compared with the general population. This article examines current evidence for the occurrence of fatigue in long-term cancer survivors by reviewing published population-based studies that incorporated controls from the general population. Using the search criteria "fatigue AND cancer survivors" in PubMed, the authors identified 16 articles (based on 15 cross-sectional datasets) comparing fatigue severities in survivors of adult cancers with those in the general population. When data allowed, Hedges' g effect size calculations were generated. A total of 8096 cancer survivors were examined across datasets. Cancer survivor sample sizes ranged from 15 to 1933 per dataset. Most datasets focused on either breast cancer (7) or Hodgkin's disease survivors (6). Four studies did not clearly exclude patients undergoing active treatment. Nine articles (based on 8 datasets) showed statistically significant (P < .05) differences among groups; 4 articles showed negative results; and 3 showed both positive and negative results depending on fatigue dimension measured. Among the studies that reported scores for the fatigue subscale of the European Organization for Research and Treatment of Cancer Core Questionnaire for Quality of Life (most studies), mean fatigue levels in cancer survivors ranged from 28.7 to 36.5 out of an overall score of 100, and mean fatigue levels in matched general population controls ranged from 20 to 30 out of 100. No associations between instruments and results were apparent. Although the small numbers of studies prevented comparisons among cancer subtypes, equal positive and negative studies were seen in breast cancer survivors and, notably, no negative studies were seen involving Hodgkin's disease survivors. Most effect sizes calculated were small. Fatigue was a burden to both cancer survivors and members of the general population. While evidence for greater fatigue severity in cancer survivors was mixed, most studies reported greater fatigue in cancer survivors as compared with controls. The magnitude of this effect was generally small. Inferences from the data were limited by variability in both the definition of survivor and the fatigue assessments used, as well as by the cross-sectional design of the studies. Prospective longitudinal studies are needed to determine causal relationships between excessive fatigue and surviving cancer.

A personality characteristic, somatic absorption, and the perception of somatic symptoms in rheumatoid arthritis patients

OBJECTIVE

This study tested the hypothesis that a personality trait, somatic absorption, is correlated with symptom severity in patients with rheumatoid arthritis (RA).

METHODS

Patients completed self-report questionnaires assessing intensity of their RA symptoms, somatic absorption, and psychiatric distress. Disease activity and severity were measured through erythrocyte sedimentation rate, joint examination, and aggressiveness of medication regimen. We examined the cross-sectional association between somatic absorption and RA symptoms using multivariable regression analyses.

RESULTS

Somatic absorption was significantly (p < 0.05) associated with an overall measure of RA symptoms, and this association persisted after taking into account demographic data, disease severity, and extent of psychological distress. Somatic absorption was more closely associated with constitutional symptoms than with localized, articular symptoms of arthritis. Somatic symptoms were also independently associated with psychiatric distress (p < 0.001). Psychiatric distress was a more powerful predictor of extraarticular or constitutional symptoms than were measures of arthritis activity and severity.

CONCLUSION

Our findings suggest that there may be a role for psychological intervention in the management of extraarticular symptoms of RA as these symptoms are relatively more influenced by a personality characteristic than the localized articular symptoms of the disease.