Factors Associated with COVID‑19 Vaccine Uptake Among Adolescents and Young Adults Recently Diagnosed with Cancer

Adolescents and young adults (AYAs) recently diagnosed with cancer are medically vulnerable but little is known about vaccine uptake/intent in this group. AYAs reported on their COVID-19 vaccine uptake/intent. Logistic regression models examined factors associated with vaccine uptake. Higher education (adjusted odds ratio [aOR] = 1.9, 95% confidence interval [CI]: 1.0-3.5) and knowing someone diagnosed with COVID-19 (aOR = 7.2, 95% CI: 1.6-33.5) were associated with increased vaccine uptake. Prior personal diagnosis of COVID-19 (aOR = 0.1, 95% CI: 0.1-0.7) was associated with lower odds of uptake. Targeted interventions may be needed to improve uptake among this group. (ClinicalTrials.gov Identifier: NCT04585269).

Stop and Think: A Case Study Illustrating the Implementation of Bright IDEAS-YA Being Delivered via Telehealth to a Young Adult Cancer Patient

Bright IDEAS-Young Adults (Bright IDEAS-YA) is a problem-solving skills training intervention that has been adapted for young adults with cancer. Presently, a multisite randomized control trial is being conducted to determine Bright IDEAS-YA's efficacy in supporting a young adult population. This case study demonstrates the young adult adaptation of Bright IDEAS - Bright IDEAS-YA - being delivered to a young adult cancer patient via telehealth. Telehealth is a novel delivery method for Bright IDEAS and Bright IDEAS-YA that was established due to COVID-19 safety precautions. The patient, who reported challenges in several life domains, was taught how to apply the Bright IDEAS-YA framework over six telehealth sessions. After completing the Bright IDEAS-YA framework, the patient reported increased feelings of confidence in managing new stressors, which was corroborated through outcome measures delivered during and following intervention. This case illustrates how early psychosocial intervention following a cancer diagnosis, delivered via telehealth, can help patients develop and implement personal strategies to reduce stress levels.

Cannabis consumption in young adults with cancer: descriptive study

OBJECTIVE

In the USA, the increase in state-sanctioned medical and recreational cannabis consumption means more young adults (YA) with cancer are using cannabis. Data and information are needed to characterise this use and frame much needed discussions about the role of cannabis in cancer care. To that end, this study's objective was to describe consumption of cannabis in YA with cancer.

METHODS

Four hundred seventy-six patients with cancer ages 18-39 years at a large comprehensive cancer centre responded to a survey about their cannabis consumption. The survey was administered online between July 2019 and June 2020, and respondents were anonymous.

RESULTS

Fifty-two per cent (n=247) of respondents endorsed use within the last year; of these, half reported using cannabis prior to their diagnosis. Consumption was about equally distributed between smoking/inhalation and eating/drinking cannabis products. Seventy-five per cent of consumers used cannabis at least weekly. Top five primary reasons for use were pain, anxiety, nausea, sleep and recreation. More frequent consumption was associated with greater perceived improvement in certain symptoms. Cannabis products tended to be sourced from friends and family and information from non-medical sources. Most YA reported being comfortable discussing their consumption with providers.

CONCLUSIONS

Many YA are using cannabis frequently to manage their cancer-related and treatment-related symptoms. Findings support the need for providers to consider cannabis use in treatment planning and symptom management with YA. Findings should help frame patient and provider discussions and herald much needed research on the effect of cannabis consumption on patient outcomes.

CYP2D6-guided opioid therapy for adults with cancer pain: A randomized implementation clinical trial

INTRODUCTION

The CYP2D6 enzyme metabolizes opioids commonly prescribed for cancer-related pain, and CYP2D6 polymorphisms may contribute to variability in opioid response. We evaluated the feasibility of implementing CYP2D6-guided opioid prescribing for patients with cancer and reported pilot outcome data.

METHODS

Adult patients from two cancer centers were prospectively enrolled into a hybrid implementation-effectiveness clinical trial and randomized to CYP2D6-genotype-guided opioid selection, with clinical recommendations, or usual care. Implementation metrics, including provider response, medication changes consistent with recommendations, and patient-reported pain and symptom scores at baseline and up to 8 weeks, were assessed.

RESULTS

Most (87/114, 76%) patients approached for the study agreed to participate. Of 85 patients randomized, 71% were prescribed oxycodone at baseline. The median (range) time to receive CYP2D6 test results was 10 (3-37) days; 24% of patients had physicians acknowledge genotype results in a clinic note. Among patients with CYP2D6-genotype-guided recommendations to change therapy (n = 11), 18% had a change congruent with recommendations. Among patients who completed baseline and follow-up questionnaires (n = 48), there was no difference in change in mean composite pain score (-1.01 ± 2.1 vs. -0.41 ± 2.5; p = 0.19) or symptom severity at last follow-up (3.96 ± 2.18 vs. 3.47 ± 1.78; p = 0.63) between the usual care arm (n = 26) and genotype-guided arm (n = 22), respectively.

CONCLUSION

Our study revealed high acceptance of pharmacogenetic testing as part of a clinical trial among patients with cancer pain. However, provider response to genotype-guided recommendations was low, impacting assessment of pain-related outcomes. Addressing barriers to utility of pharmacogenetics results and clinical recommendations will be critical for implementation success.

NCCN Guidelines® Insights: Distress Management, Version 2.2023

These NCCN Guidelines for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. All patients experience some level of distress associated with a cancer diagnosis and the effects of the disease and its treatment regardless of the stage of disease. Clinically significant levels of distress occur in a subset of patients, and identification and treatment of distress are of utmost importance. The NCCN Distress Management Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights describe updates to the NCCN Distress Thermometer (DT) and Problem List, and to the treatment algorithms for patients with trauma- and stressor-related disorders.

Effect of COVID-19 Pandemic on Cannabis Use in Cancer Patients

INTRODUCTION

Medical and other cannabis use by cancer patients continues to increase. Reasons for use include management of psychosocial stressors, physical and psychological symptoms. We explored the effect of the coronavirus disease 2019 (COVID-19) pandemic on on patients' cannabis use, hypothesizing that users would be increasing their use due to heightened stress and increased uncertainty.

METHODS

Participants were part of an anonymous online survey of cannabis use in cancer. Items specific to COVID-19 were administered between April and June 2020.

RESULTS

Thirty-one percent of respondents (n = 26) confirmed they used cannabis during COVID-19. The top 5 reasons for use were sleep, anxiety, nausea, pain, and appetite. Ninety-two percent denied they were using cannabis for new or different symptoms. Eighty-one percent were using about the same amount as before, 11.5% were using less, and 8% more. Only 12% reported that product cost affected their use and that they had changed the way in which they used cannabis. Eight percent were stockpiling product so that they did not run out during the pandemic.

CONCLUSIONS

The percentages of those reporting a change in cannabis use were modest. Increased use may reflect efforts to relieve stress. Decreased use may reflect barriers to securing unregulated products and perceived vulnerability to the effects of infection on the respiratory system. As the pandemic continues to evolve, it will be important to monitor its effects on cancer patients as it relates to psychosocial stressors, psychological symptoms, and cannabis use.

Virtual Teaming: Leveraging Team Science Sense-Making During COVID-19

Individuals with cancer anorexia cachexia syndrome (CACS) experience multifaceted distress. To address CACS patient concerns regarding their experience of care, our cancer center established a specialized CACS clinic in 2016. We applied the team science principle of the team mental model (TMM) to support development of an effective interprofessional collaborative CACS care team. In 2020, cessation of CACS clinic in-person visits during coronavirus disease 2019 (COVID-19) threatened the viability of the entrenched TMM and once again jeopardized the patient experience of care. We present a case-based vignette as a representative composite of patient experiences to illustrate the challenges. A 48-year-old female was referred to our CACS clinic for pancreatic cancer-associated appetite and weight loss during COVID-19. To reduce risk of infection, in-person clinic visits were curtailed. When informed about the resulting need to defer the CACS assessment, the patient and her spouse expressed concern that postponement would adversely affect her ability to undergo anticancer treatments or achieve beneficial outcomes. To minimize delays in CACS treatment and optimize the patient experience of care, we applied the team science principle of sense-making to help the team rapidly reformulate the TMM to provide interprofessional collaborative CACS care via telemedicine. The sense-making initiative highlights opportunities to examine sense-making within health care teams more broadly during and after the pandemic. The application of sense-making within interprofessional cancer care teams has not been described previously.

Assessment, Screening, and Case Finding for Depression and Anxiety in People with Cancer

In this chapter, published systematic reviews and meta-analyses were used to identify English-language instruments commonly used to evaluate depression and anxiety in people with cancer. Research evidence regarding the relative merits of these instruments, particularly with respect to assessment, screening, and case finding, is summarized. Clinical practice guidelines and consensus statements regarding the use of these instruments in everyday clinical practice are also summarized. The Center for Epidemiologic Studies Depression Scale and the Hospital Anxiety and Depression Scale are highlighted as the instruments with the strongest evidence for their use. Nevertheless, no single instrument can be recommended for all possible applications; clinicians and researchers alike must choose based on the specific circumstances for which they intend to use an instrument.

The pre-efficacy phase testing for PAfitME™-A behavioral physical activity intervention to manage moderate and severe symptoms among advanced stage cancer patients

Fatigue and pain are the most frequently reported symptoms among advanced-stage cancer patients. Although physical activity (PA) is known to improve the aforementioned symptoms, few patients demonstrate the physically active behavior that adheres to the clinical guidelines regarding PA. The current article presents an exemplar that used the National Institute of Health's Obesity-Related Behavioral Intervention Trial (ORBIT) model and developed a behavioral intervention known as the personalized Physical Activity intervention with fitness graded Motion Exergames (PAfitME™). There were two phases of testing in the ORBIT model presented in the current paper. In Phase I testing, a standardized exergame prescription was evaluated by an advisory board and a single-case study was used to evaluate the personalized exergame prescription with personalization of the fitness levels. In Phase IIa, a within-group pre- and posttest design was used to evaluate the personalized exergame prescriptions with personalization of the fitness levels, self-efficacy, and variation in fatigue/pain. Subsequently, a complete intervention package was developed in accordance with a logic model, driven from the result of the Phase IIa testing with clinically significant findings. Currently, PAfitME™ is under Phase IIb testing in a randomized clinical trial with a control group. PAfitME™ employs a personalized approach to initiate and promote physically active behavior, to facilitate the management of fatigue and pain in cancer patients. Positive results from an efficacy trial would support the use of PAfitME™ in the management of fatigue and pain in advanced-stage cancer patients.

Rate of cannabis use in older adults with cancer

OBJECTIVES

Older adults with cancer are increasingly inquiring about and using cannabis. Despite this, few studies have examined cannabis use in patients with cancer aged 65 years and older as a separate group and identified characteristics associated with use. The current study sought to determine the rate of cannabis use in older adult patients with cancer and to identify demographic and clinical correlates of use.

METHODS

We conducted a retrospective review of patients with cancer referred for specialised symptom management between January 2014 and May 2017 who underwent routine urine drug testing for tetrahydrocannabinol as part of their initial clinic visit.

RESULTS

Approximately 8% (n=24) of patients with cancer aged 65 years and older tested positive for tetrahydrocannabinol compared with 30% (n=51) of young adults and 21% (n=154) of adults. At the univariate level, more cannabis users had lower performance status than non-users (p=0.02, Fisher's exact test). There were no other demographic and clinical characteristics significantly associated with cannabis use in older adults.

CONCLUSIONS

Older adult patients made up nearly 25% (n=301) of the total sample and had a rate of cannabis use of 8%. As one of the first studies to assess cannabis use via objective testing rather than self-report, this study adds significantly to the emerging literature on cannabis use in people aged 65 years and older. Findings suggest the rate of use in older adults living with cancer is higher than that among older adults in the general population.

Edmonton Symptom Assessment Scale and Clinical Characteristics Associated With Cannabinoid Use in Oncology Supportive Care Outpatients

BACKGROUND

Information about the frequency of cannabinoid use and the clinical characteristics of its users in oncology supportive care is limited. This study explored associations between cannabinoid use and cancer-related clinical characteristics in a cancer population.

PATIENTS AND METHODS

This retrospective review included 332 patients who had a urine drug test (UDT) for tetrahydrocannabinol (THC) together with completion of an Edmonton Symptom Assessment Scale (ESAS) and cannabinoid history questionnaire on the same day that urine was obtained during 1 year in the supportive care clinic.

RESULTS

The frequency of positive results for THC in a UDT was 22.9% (n=76). Significant statistical differences were seen between THC-positive and THC-negative patients for age (median of 52 [lower quartile, 44; upper quartile, 56] vs 58 [48; 67] years; P<.001), male sex (53.9% vs 39.5%; P=.034), and past or current cannabinoid use (65.8% vs 26.2%; P<.001). Statistical significance was observed in ESAS items between the THC-positive and THC-negative groups for pain (7 [lower quartile, 5; upper quartile; 8] vs 5 [3; 7]; P=.001), nausea (1 [0; 3] vs 0 [0; 3]; P=.049), appetite (4 [2; 7] vs 3 [0; 5.75]; P=.015), overall well-being (5.5 [4; 7] vs 5 [3; 6]; P=.002), spiritual well-being (5 [2; 6] vs 3 [1; 3]; P=.015), insomnia (7 [5; 9] vs 4 [2; 7]; P<.001), and total ESAS (52 [34; 66] vs 44 [29; 54]; P=.001). Among patients who reported current or past cannabinoid use, THC-positive patients had higher total scores and scores for pain, appetite, overall well-being, spiritual well-being, and insomnia than THC-negative patients.

CONCLUSIONS

Patients with cancer receiving outpatient supportive care who had positive UDT results for THC had higher symptom severity scores for pain, nausea, appetite, overall and spiritual well-being, and insomnia compared with their THC-negative counterparts. These results highlight potential opportunities to improve palliative care.

Age-related differences in cannabis use by cancer patients referred for supportive care

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Background: Increasingly, cancer patients are using cannabis in their efforts to manage symptoms. Studies of legal recreational cannabis suggest young adults (YA) may disproportionately account for increases in cannabis use. There are few studies of cannabis use in cancer patients and its effect on symptoms, however, and most have not stratified their results by age. To address this, we examined rates of cannabis use across three age groups: YA ages 18 to 39, adults 40 to 65, and adults older than 65 (OA). We also examined the effects of age and cannabis use on patients’ report of cancer-related symptoms. Methods: We conducted a retrospective review of 1223 cancer patients referred to outpatient supportive care for symptom management between 2014 and 2017. Patients underwent urine drug testing for tetrahydrocannabinol (THC) and completed the Edmonton Symptom Assessment Scale-Revised-CSS during their initial visit. Results: In Chi square analysis, age was significantly associated with cannabis use (p < .001): 30% of YA tested positive for THC compared to 21% of adults and 8% of OA. As a group, cannabis users reported significantly higher scores for pain, tiredness, nausea, lack of appetite, anxiety, depression, difficulty sleeping, and worse overall well-being (p values < .05). In MANOVA, there was a significant interaction effect between age and cannabis use for pain, lack of appetite, shortness of breath, anxiety, depression, difficulty sleeping, and overall well-being (p values < .05). While YA and adults who tested positive for THC reported higher symptom scores for each of these symptoms, OA patients who were THC positive reported lower scores for pain, anxiety, depression, and better overall well-being. Conclusions: Findings suggest that compared to adults and OA, more YA patients are using cannabis in attempts to control cancer-related symptoms. With the exception of OA, cannabis users rate their cancer-related symptoms as more severe than nonusers. Findings support the need for patient education about potential therapeutic benefits and adverse effects of cannabis use in cancer. Prospective, observational studies are needed to characterize patients’ use before and after a cancer diagnosis.

Update on the Implementation of NCCN Guidelines for Distress Management by NCCN Member Institutions

The first NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Distress Management were published in 1999. Since then, a number of other organizations have advocated for distress screening. Previous surveys of distress screening showed modest progress in implementation of the NCCN Guidelines for Distress Management by NCCN Member Institutions (MIs); this review examined whether further progress has been made. Representatives appointed to the NCCN Distress Management Panel or their designee were asked to complete an online survey in the summer of 2018. The survey was developed based on similar surveys performed in 2005 and 2012 and a survey of psychosocial staffing conducted in NCCN MIs in 2012. New items solicited details about triaging, rescreening, formal screening protocols, and tracking of distressed patients. The survey was completed by representatives from 23 of 27 NCCN MIs (85%). Among the responding institutions, 20 (87%) currently conduct routine screening for distress and 3 are piloting routine screening. All respondents reported use of a self-report measure to screen for distress, with the Distress Thermometer most often used. A total of 70% of respondents rescreen patients for distress and 83% reported having a formal distress screening protocol in place. Once triaged, 65% of institutions who routinely screen for distress track clinical contacts and referrals; 70% track rates of adherence to screening protocols. Findings suggest wide acceptance and implementation of the NCCN Guidelines. Most respondents reported the existence of a formal distress screening protocol, with routine tracking of clinical contacts and referrals and rates of protocol adherence. Clinical experience and the American College of Surgeons Commission on Cancer accreditation standard for cancer centers appear to have resulted in greater adoption and implementation of the guidelines, but considerable opportunities for improvement remain.

Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Distress is defined in the NCCN Guidelines for Distress Management as a multifactorial, unpleasant experience of a psychologic (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Early evaluation and screening for distress leads to early and timely management of psychologic distress, which in turn improves medical management. The panel for the Distress Management Guidelines recently added a new principles section including guidance on implementation of standards of psychosocial care for patients with cancer.

Provider perceptions' of a patient navigator for adolescents and young adults with cancer

PURPOSE

Healthcare providers (HCPs) and other staff at a comprehensive Cancer Center were interviewed on how to best implement a patient navigator position when working with adolescents and young adults (AYA) with cancer. Research objectives included assessing staff perceptions of (a) barriers to optimal care for AYA, (b) roles and responsibilities for a patient navigator, and (c) training needed for future patient navigators.

METHODS

Semi-structured interviews were conducted with 17 staff members providing care to AYA. Verbatim transcripts were hand-coded using inductive content analysis.

RESULTS

Roles and responsibilities of a patient navigator were described as needing to coordinate services, be knowledgeable of resources inside and outside the Cancer Center, provide emotional support, advocate for AYA, assist with financial and insurance issues, and serving as the first point of contact.

CONCLUSIONS

Staff serving AYA reported the desired roles and training they wished a patient navigator to possess. This study contributes to the literature by conducting stakeholder assessment of the goals and roles of an AYA patient navigator (PN). PN positions should be adapted to the workflow and ethos of the institution.

Design and rational for the precision medicine guided treatment for cancer pain pragmatic clinical trial

INTRODUCTION

Pain is one of the most burdensome symptoms associated with cancer and its treatment, and opioids are the cornerstone of pain management. Opioid therapy is empirically selected, and patients often require adjustments in therapy to effectively alleviate pain or ameliorate adverse drug effects that interfere with quality of life. There are data suggesting CYP2D6 genotype may contribute to inter-patient variability in response to opioids through its effects on opioid metabolism. Therefore, we aim to determine if CYP2D6 genotype-guided opioid prescribing results in greater reductions in pain and symptom severity and interference with daily living compared to a conventional prescribing approach in patients with cancer.

METHODS

Patients with solid tumors with metastasis and a self-reported pain score ≥ 4/10 are eligible for enrollment and randomized to a genotype-guided or conventional pain management strategy. For patients in the genotype-guided arm, CYP2D6 genotype information is integrated into opioid prescribing decisions. Patients are asked to complete questionnaires regarding their pain, symptoms, and quality of life at baseline and 2, 4, 6, and 8 weeks after enrollment. The primary endpoint is differential change in pain severity by treatment strategy (genotype-guided versus conventional pain management). Secondary endpoints include change in pain and symptom interference with daily living.

CONCLUSION

Pharmacogenetic-guided opioid selection for cancer pain management has potential clinical utility, but current evidence is limited to retrospective and observational studies. Precision Medicine Guided Treatment for Cancer Pain is a pragmatic clinical trial that seeks to determine the utility of CYP2D6 genotype-guided opioid prescribing in patients with cancer.

Childbearing across borders: Fertility and parenthood attitudes and decisions among breast cancer survivors in USA and Portugal

OBJECTIVE

To compare fertility and childbearing attitudes and decisions of Portuguese and American female reproductive aged breast cancer survivors.

METHODS

This was a cross-sectional study of 102 young breast cancer survivors (59 from Portugal and 43 from USA). Demographic, clinical and reproductive information were collected. Fertility and parenthood attitudes and decisions were assessed through a self-report questionnaire devised specifically for the study.

RESULTS

Fertility issues became very important after the diagnosis for most of the women (51%). Few differences existed between USA and Portuguese participants. USA participants were more likely to undergo FP (23% USA vs Portugal 5%, p = 0.01). Portuguese women were more dissatisfied with their physician's explanations about fertility (Portugal: 23% vs USA: 3%; p = 0.01). Overall, women relied on their oncologist for fertility information (70%); only Portuguese women discussed fertility with their family medicine physician (11%). Overall, women showed positive attitudes towards motherhood. Portuguese women were more likely to report their partners placed more value on the family after their illness (Portuguese agree: 55% vs USA agree: 14%; p < 0.001).

CONCLUSIONS

Fertility and childbearing after breast cancer are important issues regardless of culture, background or country's heath care system. Overall, few differences across the USA and Portuguese samples were found on fertility and childbearing attitudes and decisions.

A systematic review of heart failure dyadic self-care interventions focusing on intervention components, contexts, and outcomes

BACKGROUND

Having support from an informal carer is important for heart failure patients. Carers have the potential to improve patient self-care. At the same time, it should be acknowledged that caregiving could affect the carer negatively and cause emotional reactions of burden and stress. Dyadic (patient and informal carer) heart failure self-care interventions seek to improve patient self-care such as adherence to medical treatment, exercise training, symptom monitoring and symptom management when needed. Currently, no systematic assessment of dyadic interventions has been conducted with a focus on describing components, examining physical and delivery contexts, or determining the effect on patient and/or carer outcomes.

OBJECTIVE

To examine the components, context, and outcomes of dyadic self-care interventions.

DESIGN

A systematic review registered in PROSPERO, following PRISMA guidelines with a narrative analysis and realist synthesis.

DATA SOURCES

PubMed, EMBASE, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials were searched using MeSH, EMTREE terms, keywords, and keyword phrases for the following concepts: dyadic, carers, heart failure and intervention. Eligible studies were original research, written in English, on dyadic self-care interventions in adult samples.

REVIEW METHODS

We used a two-tiered analytic approach including both completed studies with power to determine outcomes and ongoing studies including abstracts, small pilot studies and protocols to forecast future directions.

RESULTS

Eighteen papers - 12 unique, completed intervention studies (two quasi- and ten experimental trials) from 2000 to 2016 were reviewed. Intervention components fell into three groups - education, support, and guidance. Interventions were implemented in 5 countries, across multiple settings of care, and involved 3 delivery modes - face to face, telephone or technology based. Dyadic intervention effects on cognitive, behavioral, affective and health services utilization outcomes were found within studies. However, findings across studies were inconclusive as some studies reported positive and some non-sustaining outcomes on the same variables. All the included papers had methodological limitations including insufficient sample size, mixed intervention effects and counter-intuitive outcomes.

CONCLUSIONS

We found that the evidence from dyadic interventions to promote heart failure self-care, while growing, is still very limited. Future research needs to involve advanced sample size justification, innovative solutions to increase and sustain behavior change, and use of mixed methods for capturing a more holistic picture of effects in clinical practice.

Illicit substance use and opioid misuse in adolescent and young adult (AYA) patients with cancer

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Background: Rates of illicit substance use and misuse of opioid medications are high in the adolescent and young adult (AYA) general population. Despite this, screening for substance use and opioid misuse is not standard in the care of AYA oncology supportive/palliative care. To inform our clinical practice, we sought to determine the prevalence of illicit substance use and potential opioid misuse in AYA cancer patients relative to adult patients and to examine correlates of use and misuse. Methods: We conducted retrospective chart review of patients newly referred to an outpatient palliative care clinic between 2014 and 2016. Results: Consecutive patients (N = 963) underwent urine drug testing as part of their initial visit; 16% of patients were between 18 and 39 years of age. Rate of illicit drug use was 31% for AYAs and 19% for adults. AYAs were nearly 2 times more likely to have positive results for marijuana (OR = 1.79; 95% CI = 1.19 – 2.69) and nearly 3 times more likely to test positive for amphetamines (OR = 2.94; 95% CI = 1.15 – 7.49). AYAs were no more likely than adults to test positive for cocaine, barbiturates or heroin. In univariate analyses, only male sex and being single, and no clinical characteristics or symptom scores, were significantly associated with illicit substance use (ps < .05). AYAs were no more likely than adults to test positive for the presence of opioids, not currently prescribed (OR = 1.07; 95% CI = 0.70 – 1.65). No symptoms scores or demographic and clinical characteristics were significantly associated with misuse. Conclusions: AYA patients demonstrated a high rate of illicit substance use and similar rate of potential opioid misuse relative to adult patients. Findings suggest AYAs may benefit from consistent screening, support and treatment for substance use and potential opioid misuse during anticancer and cancer-related therapies.

Cannabis use in palliative care: The prevalence and clinical characteristics

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Background: Cannabis has growing attention in palliative care, been used for some cancer related symptom burden, but limited data in terms of prevalence in palliative care setting and clinical characteristics with using it. Purpose: To identify the prevalence of positive rate of cannabis metabolite on urine drug sample (UDS) and compare clinical characteristics focused on symptoms burden on Edmonton Symptom Assessment Scale (ESAS) on the same day of UDS. Methods: We conducted retrospective medical records review of 919 consecutive supportive care clinic patients who were seen at a National Cancer Institute center during a 12-month period between 7/01/2015 to 6/30/2016. Results: 531 out of 919 patients were excluded because UDS was not ordered: either patients were established or had low risk of substance abuse by clinicians’ judgement. 2 patients did not complete ESAS on same day of UDS. 137 patients were excluded because of missing UDS results as well. Finally, 249 out of 919 patients were included for data analysis with their UDS and ESAS at same day of visit. 54 patients were positive for cannabis metabolite (THC: tetrahydrocannabinol) on UDS (22%). We found that positive cannabis group was younger (Mean age 56.1 vs 48.8, p-Value .001), reported higher score of total ESAS (Mean 45.5 vs 38.9, p-value 0.023), pain (Mean 6.13 vs 4.99, p-Value 0.007), and insomnia (6.04 vs 4.44, p-Value 0.001). In addition, positive cannabis group reported poorer overall wellbeing (5.43 vs 4.56, p-Value 0.015) and spiritual wellbeing (6.04 vs 4.44, p Value 0.040) compared to negative cannabis group. Conclusions: The positive results of cannabis on UDS may be a marker of greater symptom burden, in particular, pain, insomnia and poorer overall and spiritual wellbeing as assessed by ESAS patient’s self-reporting.

The influence of a cachexia clinic on palliative care integration in oncology

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Background: Appetite and weight loss are common in patients with advanced cancer and specialized cachexia clinics have been established to address these symptoms. Given the association between anorexia/cachexia and other adverse symptoms, these patients may also benefit from specialty level palliative care (PC). However, referral to outpatient specialty level PC is often delayed or does not occur. We sought to examine the prevalence of other factors associated with appetite and weight loss in patients with advanced cancer and the impact of a specialized cachexia clinic on identification and treatment of other PC needs. Methods: The records of patients referred by their Oncologist to the cachexia clinic of a cancer center from August 2016 to June 2017 were reviewed retrospectively. Subjects who had been referred to PC by their Oncologist were excluded. Patients had been assessed for symptom burden using the Edmonton Symptom Assessment Scale (ESAS-r). Patients identified with PC needs had been referred to the PC clinic for follow-up within 30 days after cachexia clinic consultation. Results: Thirty subjects were evaluated in the cachexia clinic (average age 68 years; 63% female). The predominant diagnosis was lung cancer (70%). An average of 6 symptoms per patient were in the moderate to severe range on ESAS, excluding appetite. Depression, fatigue and pain were most common. The average cachexia clinic total ESAS score was 51.61. Only 17% of patients had completed advance directives. Ninety-three % of patients were referred to PC and 68% were seen. The average number of PC visits was 2.79. Within the PC clinic, advance directive completion increased to 37%, goals of care discussion occurred with 50% and 17% received hospice referrals. At the most recent follow-up in the PC clinic, the average total ESAS score had decreased by 11.44 (22%) and all ESAS item scores were improved on average. Conclusions: The cachexia clinic proved a useful means to identify other PC needs and achieve effective PC referrals. We suggest this is proof of concept that specialty clinics can be a meaningful way to achieve an earlier entry point to comprehensive PC in patients who were not previously referred by their Oncologists.

Exploring the relationship of self-reported lack of appetite to patient characteristics and symptom burden

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Background: Cancer anorexia-cachexia syndrome (CACS) in patients is associated with decreases in lean body mass and body weight. Self-reported lack of appetite may be an important indicator for early identification of CACS. The current analyses examined the relationship of perceived lack of appetite to patient characteristics and overall symptom burden in a large mixed cancer sample referred to a palliative care clinic. Methods: We conducted a retrospective review of patients newly referred to an outpatient palliative care clinic over a two-year period. Data on demographic and clinical characteristics and patient-reported symptom scores on the Edmonton Symptom Assessment Scale (ESAS) were abstracted. Pearson’s correlations and ANOVAs were used to assess relationships between variables. Multiple regression analysis was used to evaluate the relative contribution of variables that were significantly correlated with lack of appetite at the univariate level. Results: Data on 544 patients ( M=53.7 years) showed that older age (r=12, p<.01), not being married or in a marriage-like relationship (r=.09, p=.04), having insurance other than managed care insurance (r=.10, p=.02), lower body mass index (BMI; r=.11, p<.01), marijuana use (r=.18, p<.0001), and overall symptom burden (ESAS total score r=.52, p < .0001) were associated with worse lack of appetite ( M=3.5, SD=3.1). Patients who were underweight (BMI <18.5, 46.7%) reported significantly worse lack of appetite than patients who were normal weight, overweight, or obese ( M=3.9, SD=3.2, p<.01). The final hierarchical regression model accounted for 34% of the variance in lack of appetite, with age, marital status, BMI, marijuana use, and total symptom burden remaining significant independent correlates (p’ s <.01). Conclusions: Contrary to expectations, relatively few clinical correlates were associated with self-reported lack of appetite. Future research should explore inter-individual genetic factors to explain alterations in lean body mass and body weight that may contribute to poor appetite in patients. Such factors may be important indicators for early identification of CACS.

Effect of androgen deprivation therapy on sexual function and bother in men with prostate cancer: A controlled comparison

OBJECTIVES

The adverse sexual effects of androgen deprivation therapy (ADT) on men with prostate cancer have been well described. Less well known is the relative degree of sexual dysfunction and bother associated with ADT compared to other primary treatment modalities such as radical prostatectomy. We sought to describe the trajectory and relative magnitude of changes in sexual function and bother in men on ADT and to examine demographic and clinical predictors of ADT's adverse sexual effects.

METHODS

Prostate cancer patients treated with ADT (n = 60) completed assessments of sexual function and sexual bother 3 times during a 1-year period after the initiation of ADT. Prostate cancer patients treated with radical prostatectomy only and not receiving ADT (n = 85) and men with no history of cancer (n = 86) matched on age and education completed assessments at similar intervals.

RESULTS

Androgen deprivation therapy recipients reported worsening sexual function and increasing bother over time compared to controls. Effect sizes for the differences in sexual function were large to very large, and for bother were small to very large. Age younger than 83 years predicted relatively poorer sexual function, and age younger than 78 years predicted greater sexual bother at 12 months in men on ADT compared to men not on ADT.

CONCLUSIONS

Most men on ADT for prostate cancer will never return to baseline levels of sexual function. Interventions focused on sexual bother over function and designed to help couples build and maintain satisfying relationship intimacy are likely to more positively affect men's psychological well-being while on ADT than medical or sexual aids targeting sexual dysfunction.

Adolescent and Young Adult Patients with Cancer: Perceptions of Care

BACKGROUND

Adolescent and young adults with cancer (AYACs) face unique medical, psychosocial, and supportive care needs. The purpose of this study was to identify AYACs perceptions and expectations of cancer care services on and off treatment.

METHODS

Semistructured interviews were conducted with 23 AYACs aged 19-38 years (13 on and 10 off treatment), who were receiving care at a comprehensive cancer center. Verbatim transcripts were created from audiotaped interviews and hand coded using inductive content analysis methodology.

RESULTS

Perceptions of optimal care were reported by AYACs through two main themes as follows: perceived barriers and facilitators during treatment. Within each main theme were three subthemes, including perceived facilitators reported as the provision of social support, the website and patient portal, and the educational information provided by the cancer center. Younger female AYACs (age 19-31) on active treatment reported perceived barriers to optimal care related to the management of physical and mental health symptoms, while older patients (age 32 and up) on active treatment endorsed a fear of cancer returning. The third perceived barrier equally endorsed by patients both on and off treatment and across age ranges included limited assistance with financial issues.

CONCLUSIONS

AYACs reported perceived barriers and facilitators to optimal care. Implications for these findings are discussed in the context of the importance of adding a patient navigator to the AYACs care team.

Health-related quality of life in Black breast cancer survivors with and without triple-negative breast cancer (TNBC)

PURPOSE

Black women are more likely to develop early-onset (≤50 years) breast cancer (BC) and have the lowest five-year, cause-specific survival rate of any United States (U.S.) racial or ethnic group. These disparities can be attributed partially to the higher rate of triple-negative BC (TNBC) in Blacks. Yet, little is known about health-related quality of life (HRQOL) among Black women with TNBC.

METHODS

Black women with invasive BC ≤ 50 years were recruited via the Florida Cancer Data System as part of a population-based case-only study of etiology and outcomes of early-onset invasive BC. Of 460 consented participants, a subset of 355 self-reported sociodemographic, clinical, and psychosocial variables. Descriptive analyses included participants with known TNBC (n = 85) or non-TNBC (n = 245) disease. Univariable and multivariable analyses were conducted to examine differences in factors associated with HRQOL.

RESULTS

In unadjusted analyses, TNBC participants had significantly lower FACT-B total scores (90.1 ± 27.9) compared to non-TNBC (98.5 ± 27.6) participants (p < 0.05). For the TNBC group, multivariable analyses indicated five individual-level, and three systemic-level factors explain 80% of the response variation in HRQOL. For the non-TNBC group, seven individual-level factors and three systemic-level factors account for 76% of the variation in HRQOL scores.

CONCLUSIONS

Compared to Black women with non-TNBC, TNBC women have worse HRQOL. There are key individual and systemic-level factors that are unique to both groups. Findings can inform future HRQOL interventions to support young Black BC survivors.

Leveraging a Team Mental Model to Develop a Cancer Anorexia-Cachexia Syndrome Team

This article discusses the care of a 62-year-old man with non-small-cell lung cancer and associated cancer anorexia-cachexia syndrome (CACS), and demonstrates common challenges faced by such patients and their family caregivers. The case description illustrates the fragmented approach of various disciplines to the patient's CACS care, resulting in undertreatment, delayed and burdensome visits, and patient and caregiver frustration and emotional distress. The mounting problems that arise for the patient over time exemplify the absence of a shared mental model among the various providers, patient, and caregiver for the care of CACS. Shared knowledge among providers regarding the tasks to be performed, the other clinicians' functions, and optimal processes for CACS care was limited. Each provider was responsive to individual symptoms, rather than conceptualizing the constellation of symptoms as a syndrome that warrants coordinated care among clinicians. This resulted in the patient and the family caregiver being at odds with their various providers instead of working in partnership with a shared understanding toward common goals. Team mental models have the potential to enhance development and implementation of care plans and improve patient care and satisfaction by helping clinical care teams establish team membership, identify shared tasks, and facilitate interactions. To help inform ongoing clinical practice and research, this article demonstrates how clinicians at one cancer center are leveraging a team mental model to form and support an interdisciplinary CACS team that provides coordinated patient-centered care.

Predicting hospital readmissions in the oncology population

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Background: The 30-day readmission rate is established as an important indicator of quality of care. The LACE index is commonly used in the general medical setting to predict readmission but its ability to predict readmission with sensitivity and specificity in the oncology population has not yet been examined. At our cancer center, palliative care (PC) consultation is associated with an increased risk for readmission but it is not an element in the LACE index. Methods: We sought to characterize the operating characteristics of the LACE Index using receiver operating characteristics analyses to predict unplanned readmissions to our cancer center over a 6-week period beginning March 2016. Data was gathered from chart review to calculate a total LACE score for each unplanned admission. Logistic regression was used to examine the individual components of the LACE index and whether a PC consult improved the performance of the index. Results: A total of 329 patients with unplanned admissions were included. Fifty-nine (17.9%) were readmitted within 30 days of discharge. There was no difference between the median LACE scores of those readmitted compared to those who were not (Md = 10.0; p = .93). Receiver operating characteristic (ROC) curve analyses of LACE scores yielded an area under the curve estimate relative to 30-day readmissions of .45 indicative of poor overall accuracy. ROC analyses also showed that the previously established LACE cutoff score of 10 had sensitivity of .54 and specificity of .57 relative to readmissions. The positive predictive value was .81 and the negative predictive value was .18. In logistic regression analysis, only direct referral center/emergency department visits were an independent predictor of readmission, with a c-statistics of .64 for readmission. The inclusion of a PC consult did not improve the performance of the index. Conclusions: The LACE Index performed poorly in predicting 30-day readmission in the oncology setting; the inclusion of whether a PC consult took place did not improve the index’s utility. Further research is required to create a new tool or enhance existing indices to predict readmission in the oncology population.

Palliative Care in Adolescents and Young Adults With Cancer

BACKGROUND

Cancer survival rates for adolescents and young adults (AYA) have not improved over time relative to children or adults older than 39 years of age. Palliative care is specialized medical care focused on the control of symptoms and relief of suffering with the goal of improving quality of life for the patient and his or her family. To date, the integration of palliative care in AYA patients with cancer remains suboptimal.

METHODS

We explore the role of palliative care in the continuum of clinical care for AYA patients with cancer.

RESULTS

Clinical practice guidelines highlight the need for integrating palliative care for all patients with cancer, including the AYA population. Despite this, a paucity of evidence exists regarding the use of palliative care with AYA patients with cancer. Graduate clinical education represents an opportunity to promote the full inclusion and early integration of palliative care in the care of AYA patients with cancer. Advance care planning is one area where some agreement exists on the unique needs of AYA patients and their families.

CONCLUSIONS

In general, palliative care is seen as being synonymous with end-of-life care for patients with cancer. However, the emerging trend toward standardizing oncology care to meet the unique medical, psychosocial, and supportive care needs of AYA patients with cancer and their families represents an opportunity for health care professionals to collaborate early with palliative care specialists to control symptoms and relieve suffering in this vulnerable population.

Quality of life and its correlates after pelvic exenteration for gynecologic cancer

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Background: Pelvic exenteration (PE) has been performed historically in women with gynecologic cancer for palliation of recurrent disease. With advances in operative methods, PE in the well-selected patient can produce 5-year survival rates as high as 60%. Despite a recent increase in rate of PE performed with curative intent, there is a paucity of data on its long-term physical and emotional effects. We sought to characterize women’s long-term quality of life (QOL) and its correlates after PE for recurrent gynecologic cancer. Methods: We conducted a mixed methods study combining quantitative measurement of QOL and its demographic, clinical and psychological correlates with concurrent qualitative assessment to probe women’s cognitive and behavioral responses to PE. Results: From 2005 to 2014, 85 women underwent PE at our institution; 44% were still alive at study initiation. Among eligible women, 72% completed their participation. Mean age of the sample at time of study participation was 57.3 (SD = 9.5) years (range = 43 to 75) and median time since surgery was 3.0 years (range = .9 to 8). Women’s self-reported global QOL score was average (54.4 (23); range = 33.3 to 100) and the relationship between QOL and current age or time since surgery was not significant (p > .05). Women reported mild sleep disturbance, mild to moderate pain, moderate fatigue and anxiety and severe depressive symptoms. All of the women exceeded the cut-off for clinically significant depressive symptoms. Qualitatively, women described profound negative changes in their physical and emotional well-being after PE. In nearly all of the women, the extended survival after PE helped to buffer the effects of these changes. Conclusions: Results suggest women’s health-related QOL may return to, or near, pre-surgical levels in long-term survivorship but that symptom control is suboptimal. Findings should facilitate more informed decision making prior to PE and suggest targets for clinical intervention to enhance QOL and improve symptom control after PE. This study highlights the need for more comprehensive assessments pre- and post-PE to examine the effects of disease- and PE-related variables, cultural norms and social support on patient-reported outcomes.

Psychological effects of androgen-deprivation therapy on men with prostate cancer and their partners

The clinical benefits of androgen-deprivation therapy (ADT) for men with prostate cancer (PC) have been well documented and include living free from the symptoms of metastases for longer periods and improved quality of life. However, ADT comes with a host of its own serious side effects. There is considerable evidence of the adverse cardiovascular, metabolic, and musculoskeletal effects of ADT. Far less has been written about the psychological effects of ADT. This review highlights several adverse psychological effects of ADT. The authors provide evidence for the effect of ADT on men's sexual function, their partner, and their sexual relationship. Evidence of increased emotional lability and depressed mood in men who receive ADT is also presented, and the risk of depression in the patient's partner is discussed. The evidence for adverse cognitive effects with ADT is still emerging but suggests that ADT is associated with impairment in multiple cognitive domains. Finally, the available literature is reviewed on interventions to mitigate the psychological effects of ADT. Across the array of adverse effects, physical exercise appears to have the greatest potential to address the psychological effects of ADT both in men who are receiving ADT and in their partners.

Right Place, Right Time: Preferences of Women with Ovarian Cancer for Delivery of CAM Education

The purpose of this pilot study was to assess the feasibility of on-site complementary and alternative medicine (CAM) education sessions to maximize quality of life for women with ovarian cancer. The pilot intervention consisted of four weekly sessions, each focusing the techniques and benefits of a particular CAM topic (e.g., nutrition, massage, relaxation). Participants were recruited from the Center for Women’s Oncology at H. Lee Moffitt Cancer Center from 2010 to 2012. Eligible participants had an ovarian cancer diagnosis with a life expectancy of at least 12 months, and were 18 years or older. The Gynecologic Oncology research nurse invited women in the outpatient clinic who matched the eligibility criteria. The research nurse explained the study and provided an informed consent form and return envelope. Because ovarian cancer is not only a rare cancer but, also, most patients seen at Moffitt have recurrent or advanced disease, many women did not have an adequate ECOG score. Many women who consented had rapid changes in health status, with morbidity and mortality outpacing recruitment of the 20 needed to proceed with the four education sessions. Baseline and follow-up surveys were conducted to assess changes in QOL, knowledge, and satisfaction with the intervention. While 27 women consented and 24 women completed the baseline survey, only five women participated in the intervention. The five women who participated were all white, and at time of consenting had a mean age of 60 (SD 9.08) and an average of 102 months (SD 120.65) since diagnosis, and were all on active treatment, except for one. The intervention pilot did not encounter difficulties with regard to recruitment, but suffered problems in achieving an adequate number of women to launch the on-site sessions because of rapidly changing morbidity and significant mortality. The team recognized that a larger-scaled intervention comprised of on-site sessions was impractical and compared attendance rates with a more convenient format currently underway in the Women’s Oncology program at Moffitt. While low participation prevented an intervention analysis of scientific merit, the study data is informative with regard to barriers, facilitators, and alternative methods for sharing useful information to women with advanced ovarian cancer. The comparison strongly suggested that CAM education for women compromised by the disease and treatment associated with ovarian cancer would best be delivered in the convenient-access format that allowed remote access to live and recorded discussions of specific topics.

Implementation of NCCN Palliative Care Guidelines by member institutions

Increasingly, evidence suggests the integration of palliative care (PC) with standard oncologic care can yield substantial benefits. As part of an effort to improve the PC of cancer patients, the National Comprehensive Cancer Network (NCCN) has developed clinical practice guidelines for PC that promote access to quality, evidence-based PC. This study sought to characterize current implementation of the guidelines by NCCN member institutions. Institutional representatives appointed to the NCCN Palliative Care Guidelines Panel were asked to complete an online survey in the spring of 2014. The survey focused on availability of PC services, screening and referral practices for PC, PC education, and quality improvement programs. The survey was completed by representatives from 21 of 25 NCCN member institutions (84 %). A majority routinely provides PC services via interdisciplinary teams; 52 % routinely inform patients of the availability, elements, and benefits of PC. The guidelines are most often used to guide clinical practice; only 10 % reported using the guidelines to formally screen for PC needs and/or make referrals to PC specialists. Among the 62 % of institutions that screen any patients using any available criteria, when a patient screens positive for PC needs, a referral to a PC specialist is made less than half the time. Implementation of PC Guidelines is incomplete and various aspects of the guidelines, such as the recommendation to screen all patients for PC needs, are applied inconsistently. Despite this, most institutions provide PC services in a manner consistent with the guidelines. Greater implementation of the guidelines' recommendations is needed.

Depressive symptom trajectories during and after adjuvant treatment for breast cancer

BACKGROUND

The course of depressive symptoms during and after breast cancer treatment is not well understood.

PURPOSE

We identified patient subgroups based on distinct trajectories of depressive symptoms and determined whether subgroups could be distinguished by personal characteristics and coping strategies.

METHODS

Breast cancer patients completed the Center for Epidemiologic Studies-Depression Scale on clinically meaningful occasions and during the posttreatment period. The Illness Management Questionnaire was completed prior to treatment.

RESULTS

A three-class mixture model provided the best fit to the data. Subgroup membership was significantly (p < .05) associated with marital status, history of depression, and focusing on symptoms. In multivariate analysis, marital status and focusing on symptoms remained significant (p < .05) predictors of subgroup membership.

CONCLUSIONS

Distinct trajectories can be identified during and after adjuvant breast cancer therapy. Predictors of these trajectories have implications for addressing depressive symptoms in this clinical population and for future research.

Implementation of NCCN palliative care guidelines by member institutions

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Background: To promote access to quality, evidence-based palliative care (PC) and help cancer patients experience the best quality of life possible throughout the illness trajectory, the National Comprehensive Cancer Network (NCCN) has developed PC guidelines to guide symptom screening, assessment, PC interventions, and reassessment by the oncology team. We sought to evaluate use of the guidelines among NCCN member institutions. Methods: In April and May 2014 an invitation and reminders to participate in an online survey were sent electronically to NCCN PC guidelines panel members. If a panel member did not reply, individuals involved in the provision of PC at the same institution were approached. Results: Responses were received from 21 (84%) of the 25 member institutions. All of the institutions report having an interdisciplinary team with PC expertise. Among respondents, 38% have an accredited/certified PC program and 52% have an institutional PC quality improvement program in place. Fifty-two percent submit data to the National Palliative Care Registry. Forty-three percent have guidelines or triggers in place for the use of PC services. Only 10% actively employ the NCCN guidelines to screen for PC needs or make PC referrals; the guidelines are more often used to guide patient assessment (38%) and clinical practice (43%). When asked to endorse other PC referral criteria, 76% indicated the discretion of the oncology provider(s) and 29% the National Consensus Project for Quality Palliative Care. Sixty-two percent agree providers concur on the elements of PC and 29% agree as to who should receive PC. Only 19% agree early integration of PC should occur for all oncology patients and 43% agree PC referrals occur in a timely and efficient manner. The most frequently cited barriers to the provision of quality PC are: attitudes toward PC (71%), insufficient staffing (61%) and limited financial resources (57%). Conclusions: Implementation of the guidelines at NCCN member institutions is incomplete. There appears to be a lack of consensus about when and for whom PC should be provided. Future research should be designed to enhance understanding of the barriers to care and improve implementation of the guidelines.