Management of Fatigue in Adult Survivors of Cancer: ASCO-Society for Integrative Oncology Guideline Update

PURPOSE

To update the ASCO guideline on the management of cancer-related fatigue (CRF) in adult survivors of cancer.

METHODS

A multidisciplinary panel of medical oncology, geriatric oncology, internal medicine, psychology, psychiatry, exercise oncology, integrative medicine, behavioral oncology, nursing, and advocacy experts was convened. Guideline development involved a systematic literature review of randomized controlled trials (RCTs) published in 2013-2023.

RESULTS

The evidence base consisted of 113 RCTs. Exercise, cognitive behavioral therapy (CBT), and mindfulness-based programs led to improvements in CRF both during and after the completion of cancer treatment. Tai chi, qigong, and American ginseng showed benefits during treatment, whereas yoga, acupressure, and moxibustion helped to manage CRF after completion of treatment. Use of other dietary supplements did not improve CRF during or after cancer treatment. In patients at the end of life, CBT and corticosteroids showed benefits. Certainty and quality of evidence were low to moderate for CRF management interventions.

RECOMMENDATIONS

Clinicians should recommend exercise, CBT, mindfulness-based programs, and tai chi or qigong to reduce the severity of fatigue during cancer treatment. Psychoeducation and American ginseng may be recommended in adults undergoing cancer treatment. For survivors after completion of treatment, clinicians should recommend exercise, CBT, and mindfulness-based programs; in particular, CBT and mindfulness-based programs have shown efficacy for managing moderate to severe fatigue after treatment. Yoga, acupressure, and moxibustion may also be recommended. Patients at the end of life may be offered CBT and corticosteroids. Clinicians should not recommend L-carnitine, antidepressants, wakefulness agents, or routinely recommend psychostimulants to manage symptoms of CRF. There is insufficient evidence to make recommendations for or against other psychosocial, integrative, or pharmacological interventions for the management of fatigue.Additional information is available at www.asco.org/survivorship-guidelines.

Symptom Burden in Patients with Malignant Bowel Obstruction Treated With or Without Surgery

BACKGROUND

Gastrointestinal obstruction is the most common indication for palliative surgical consultation. We sought to assess patient-reported outcomes and survival after surgical and nonsurgical treatment of malignant bowel obstruction.

STUDY DESIGN

This was a prospective observational study enrolling patients with advanced malignancy who underwent surgical consultation at a tertiary cancer center. Patient-reported outcomes were evaluated using a previously validated inventory, the MD Anderson Symptom Inventory-Gastrointestinal Obstruction (MDASI-GIO), administered at enrollment and 7 other time points for up to 90 days.

RESULTS

We enrolled 125 patients, of whom 37 underwent surgery and 88 did not. Patients treated nonsurgically were more likely to have carcinomatosis on imaging (71% vs 49%, p = 0.02). Pain medicine, palliative care, and chaplaincy consultations occurred in 17%, 30%, and 15% of patients within the first month of enrollment. Higher mean symptom scores were noted by surgical patients, although the only single scores with effect sizes 0.5 or greater were symptom interference with general activity and work. The composite score for interference in work, activity, and walking had the largest effect size at -0.37, indicating greater interference in patients undergoing surgery. Patients selected for surgery had extended overall survival (median 15 vs 3 months, p < 0.01). Carcinomatosis, palliative care evaluation, and venting gastrostomy tube were associated with increased risk of death, and ability to receive subsequent chemotherapy and surgical management were positive prognostic indicators.

CONCLUSIONS

In this first study evaluating patient-reported outcomes after treatment for malignant bowel obstruction, we found that selection for surgical treatment was associated with improved survival, but also more symptom interference in general activities and work. These results may be useful in palliative surgical decision-making and informing patients during consultation for malignant bowel obstruction.

Open-labeled placebo for the treatment of cancer-related-fatigue in patients with advanced cancer: Results of a randomized controlled trial

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Background: Despite the high frequency of cancer related fatigue (CRF) in patients with advanced cancer (PAdC), there are no effective pharmacological treatments. Our group previously found that the placebo response was 56% among PAdC participating in CRF trials. There are no clinical trials using open label placebo for CRF in PAdC. The purpose of this study was to determine the effects of open labeled placebo (OLP) compared to waitlist control (WLC) in reducing CRF in PAdC using Functional Assessment of Chronic Illness Therapy-Fatigue subscale (FACIT-F). Methods: In this randomized controlled trial, PAdC with fatigue ≥ 4/10 on ESAS were randomized to OLP one tablet twice a day or WLC for seven days (primary end point). After week 1 in patients of both arms received placebo for 3 weeks. Changes in FACIT-F from baseline to Day 8 (primary outcome), and changes after 21 days of placebo in both arms were assessed. Secondary outcomes included quality of life (QOL)[FACT-G], fatigue dimensions(MFSI-SF), depression(CES-D), and Fatigue cluster(ESAS fatigue, pain, and depression). Results: 82/90(91%) patients were evaluable. The adherence to placebo [mean%(SD)], was 93.6(18.6), and 88.1(20.2) at Day 8 and Day 29 respectively in OLP arm, and 89.9 (73) at Day 29 in WLC arm. The mean(SD) FACIT-F change at day 8 was 6.6 (7.6) after OLP, 2.1 (9.4) after WLC (p = 0.016). On days 15 and 29, when all patients received OLP, there was significant improvement of CRF but not difference between arms. FACT-G Total Score, FACT-G EWB, ESAS Fatigue, and Fatigue cluster score, all showed significant evidence of reduced CRF in the OLP arm on Day 8 of the study (p = 0.002, 0.030, 0.029, and 0.044, respectively). There was no significant difference in adverse events between the two groups. Conclusions: Open labeled placebo was efficacious in reducing CRF, fatigue cluster, and QOL in fatigued advanced cancer patients at the end of one week. The improvement in fatigue was maintained for 4 weeks. Further studies of this intervention are justified. Clinical trial information: NCT03927885.

Serial frailty assessments following allogeneic stem cell transplant in older adults: A pilot study

INTRODUCTION

Increasing numbers of older adults undergo allogeneic stem cell transplantation (SCT) as the only chance of meaningful survival for hematologic malignancies. However, toxicities in vulnerable patients may offset the benefits of SCT. Frailty and abnormal geriatric assessment (GA) prior to SCT have been associated with decreased overall survival in persons aged 60 and older. The purpose of this pilot study was to determine the prevalence of baseline GA deficits and frailty, the prevalence of frailty or death at three and six months after allogeneic SCT, and associations between baseline assessments and the presence of frailty or death post-SCT.

METHODS

We enrolled 50 patients aged 60 years and older and completed a baseline GA including comorbidity, polypharmacy, nutrition, physical performance, functional status, social support, depression and anxiety, and cognition. Frailty was defined as three or more abnormalities of gait speed, grip strength, weight loss, physical activity, and exhaustion, and was assessed at baseline, three months, and six months after SCT. A composite outcome of frailty or death at three months and six months was analyzed.

RESULTS

Frailty was present in 11/50 (22%) of patients at baseline. Ten patients did not complete three- month follow-up, and twelve patients did not complete six-month follow-up. Of those with follow-up data, 22 patients (55%) were frail or deceased three months after SCT, and 27 patients (71%) were frail or deceased six months after SCT. Frailty at baseline was not significantly associated with frailty or death at three or six months after SCT. However, the study's small enrollment limits conclusions on these associations.

CONCLUSION

GA deficits and frailty are prevalent in older adult SCT recipients at baseline and after transplant. Future studies should aim for larger enrollment in order to validate associations between these deficits and outcomes, especially survival, functional status, and quality of life following SCT.

Use of Wearable Activity Tracker in Patients With Cancer Undergoing Chemotherapy: Toward Evaluating Risk of Unplanned Health Care Encounters

PURPOSE

Unplanned health care encounters (UHEs) such as emergency room visits can occur commonly during cancer chemotherapy treatments. Patients at an increased risk of UHEs are typically identified by clinicians using performance status (PS) assessments based on a descriptive scale, such as the Eastern Cooperative Oncology Group (ECOG) scale. Such assessments can be bias prone, resulting in PS score disagreements between assessors. We therefore propose to evaluate PS using physical activity measurements (eg, energy expenditure) from wearable activity trackers. Specifically, we examined the feasibility of using a wristband (band) and a smartphone app for PS assessments.

METHODS

We conducted an observational study on a cohort of patients with solid tumor receiving highly emetogenic chemotherapy. Patients were instructed to wear the band for a 60-day activity-tracking period. During clinic visits, we obtained ECOG scores assessed by physicians, coordinators, and patients themselves. UHEs occurring during the activity-tracking period plus a 90-day follow-up period were later compiled. We defined our primary outcome as the percentage of patients adherent to band-wear ≥ 80% of 10 am to 8 pm for ≥ 80% of the activity-tracking period. In an exploratory analysis, we computed hourly metabolic equivalent of task (MET) and counted 10 am to 8 pm hours with > 1.5 METs as nonsedentary physical activity hours.

RESULTS

Forty-one patients completed the study (56.1% female; 61.0% age 40-60 years); 68% were adherent to band-wear. ECOG score disagreement between assessors ranged from 35.3% to 50.0%. In our exploratory analysis, lower average METs and nonsedentary hours, but not higher ECOG scores, were associated with higher 150-day UHEs.

CONCLUSION

The use of a wearable activity tracker is generally feasible in a similar population of patients with cancer. A larger randomized controlled trial should be conducted to confirm the association between lower nonsedentary hours and higher UHEs.

Harmonized Outcome Measures for Use in Non-Small Cell Lung Cancer Patient Registries and Clinical Practice

BACKGROUND

Lung cancer is the leading cause of cancer-related death in the United States and globally, and many questions exist about treatment options. Harmonizing data across registries and other data collection efforts would yield a robust data infrastructure to help address many research questions. The purpose of this project was to develop a minimum set of patient and clinician relevant harmonized outcome measures that can be collected in non-small cell lung cancer (NSCLC) patient registries and clinical practice.

METHODS

Seventeen lung cancer registries and related efforts were identified and invited to submit outcome measures. Representatives from medical specialty societies, government agencies, health systems, health information technology groups, patient advocacy organizations, and industry formed a stakeholder panel to categorize the measures and harmonize definitions using the Agency for Healthcare Research and Quality's supported Outcome Measures Framework (OMF).

RESULTS

The panel reviewed 66 outcome measures and identified a minimum set of 8 broadly relevant measures in the OMF categories of patient survival, clinical response, events of interest, and resource utilization. The panel harmonized definitions for the 8 measures through in-person and virtual meetings. The panel did not reach consensus on 1 specific validated instrument for capturing patient-reported outcomes. The minimum set of harmonized outcome measures is broadly relevant to clinicians and patients and feasible to capture across NSCLC disease stages and treatment pathways. A pilot test of these measures would be useful to document the burden and value of the measures for research and in clinical practice.

CONCLUSIONS

By collecting the harmonized measures consistently, registries and other data collection systems could contribute to the development research infrastructure and learning health systems to support new research and improve patient outcomes.

The impact of a web-based prognostic intervention on physicians’ prognostic confidence

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Background: Clinicians often hesitate to discuss prognosis with patients because of prognostic uncertainty. The use of validated prognostic models may enhance prognostic confidence and/or prognostic accuracy. Prognostic confidence is a novel concept that has not been well studied and may support prognosis-based decision making. We examined the impact of a web-based prognostic intervention on physicians’ prognostic confidence. Methods: In this prospective study, palliative care specialists estimated the prognosis of patients with advanced cancer seen at an outpatient supportive care clinic using the temporal, surprise and probabilistic questions for 6 m, 3 m, 2 m, 1 m, 2 w, 1 w and 3 d survival. They then reviewed information from a web-based prognostic calculator ( www.predictsurvival.com ) that provided survival predictions from 7 validated prognostic scores, including the Palliative Prognostic Score, Palliative Prognostic Index, and Palliative Performance Status. The clinicians then provided their prognostic estimates post-intervention. The primary outcome was prognostic confidence (0-10 numeric rating scale, where 0 = not at all, 10 = most confident) before vs. after the study intervention. Secondary outcomes included (1) confidence to share the prognosis with patients, (2) confidence to make prognosis-based care recommendations (agreement = strongly agree or agree) and (3) prognostic accuracy. With 220 patients, we had 80% power to detect an effect size of 0.66 with 2-sided α 0.05. We compared the pre-post data using the Wilcoxon signed-rank test for the primary outcome and McNemar test for secondary outcomes. Results: 216 patients with advanced cancer (mean age 61, 50% female) were included and 154 (71%) died. The median (IQR) actual survival was 90 (39, 178) days; the median (IQR) predicted survival before and after intervention were 90 (60, 90) and 80 (60, 90) days, respectively. Prognostic confidence significantly increased after the intervention (pre vs. post: median 6 vs. 7, P < 0.001). A significantly greater proportion of clinicians reported that they felt confident enough about their prognostic estimate to share it with patients (44% vs. 74%, P < 0.001) and to formulate care recommendations (80% vs. 94%, P < 0.001) after the intervention. Prognostic accuracy did not differ significantly before and after the intervention, ranging from 72-100% for the temporal question, 45-97% for the surprise questions and 38%-100% for the probabilistic questions (P > 0.05). Conclusions: Among patients with advanced cancer seen at a supportive care clinic, the web-based prognostic intervention was associated with greater prognostic confidence and willingness to discuss prognosis, despite not significantly altering clinicians’ prognostic estimate or prognostic accuracy. Further research is needed to examine how prognostic tools may be able to augment prognostic discussions and clinical decision making.

Optimal Supportive Care for Patients With Metastatic Breast Cancer According to Their Disease Progression Phase

The clinical progression patterns of metastatic breast cancer (MBC) are heterogeneous; patients experience acute and stable phases at different time points. The acute phase consists of rapid progressive symptomatic changes, whereas in the stable phase, patients have relatively low symptom burden. Therefore, personalized interdisciplinary care is essential. The optimal palliative or supportive care in MBC is to provide comprehensive care that is individually prioritized to the patient's disease status. The purpose of this review is to provide a practical guide for oncologists to understand the priorities for supportive care for patients with MBC in the two phases. We note that for better decision making in patient care, performance status should be broadened to consider not only physical status but also psychosocial needs and cognitive condition. We summarize the clinical importance of physical symptom control, psychosocial support, physical activity, nutrition support, and advance care planning. For optimal care, we present palliative or supportive care checklists according to the disease progression phase, combining the limited evidence with expert input. In the acute phase, close monitoring of the patient's status and symptom management take priority. In the stable phase, the focus can shift to maintenance or improvement of physical strength and emotional condition. Finally, we discuss future directions and unmet needs in providing the best supportive care for patients with MBC.

Frequency of Burnout Among Palliative Care Physicians Participating in a Continuing Medical Education Course

CONTEXT

Palliative care (PC) physicians are vulnerable for burnout given the nature of practice. The burnout frequency may be variable and reported between 24% and 38% across different countries.

OBJECTIVE

The main objective of our study was to determine the frequency of burnout among PC physicians participating in PC continuing medical education course.

METHODS

A survey including the Maslach Burnout Inventory-General along with 41 custom questions were administered to determine the frequency of burnout among physicians attending the 2018 Hospice and Palliative Medicine Board review course.

RESULTS

Of 110 physicians, 91 (83%) completed the survey. The median age was 48 years with 65% being females, 81% married, 46% in community practice, 38% in practice for 6-15 years. PC was practiced ≥50% of the time by 62%, and 76% were doing clinical work. About 73 (80%) reported that PC is appreciated at their work, 58 (64%) reported insurance to be a burden, and 58 (64%) reported that the electronic medical record was a burden. About 82 (90%) felt optimistic about continuing PC in future. Maslach Burnout Inventory results suggest that 35 (38%) participants reported at least one symptom of burnout. Only being single/separated showed trend toward significance with burnout (P = 0.056).

CONCLUSION

Burnout among PC physicians who attended a board review course was 38%. Being single/separated showed trend toward association with burnout. Physicians who choose to attend continuing medical education may have unique motivating characteristics allowing them to better cope with stress and avoid burnout.

Quantified Kinematics to Evaluate Patient Chemotherapy Risks in Clinic

PURPOSE

Performance status (PS) is a key factor in oncologic decision making, but conventional scales used to measure PS vary among observers. Consumer-grade biometric sensors have previously been identified as objective alternatives to the assessment of PS. Here, we investigate how one such biometric sensor can be used during a clinic visit to identify patients who are at risk for complications, particularly unexpected hospitalizations that may delay treatment or result in low physical activity. We aim to provide a novel and objective means of predicting tolerability to chemotherapy.

METHODS

Thirty-eight patients across three centers in the United States who were diagnosed with a solid tumor with plans for treatment with two cycles of highly emetogenic chemotherapy were included in this single-arm, observational prospective study. A noninvasive motion-capture system quantified patient movement from chair to table and during the get-up-and-walk test. Activity levels were recorded using a wearable sensor over a 2-month period. Changes in kinematics from two motion-capture data points pre- and post-treatment were tested for correlation with unexpected hospitalizations and physical activity levels as measured by a wearable activity sensor.

RESULTS

Among 38 patients (mean age, 48.3 years; 53% female), kinematic features from chair to table were the best predictors for unexpected health care encounters (area under the curve, 0.775 ± 0.029) and physical activity (area under the curve, 0.830 ± 0.080). Chair-to-table acceleration of the nonpivoting knee (t = 3.39; P = .002) was most correlated with unexpected health care encounters. Get-up-and-walk kinematics were most correlated with physical activity, particularly the right knee acceleration (t = -2.95; P = .006) and left arm angular velocity (t = -2.4; P = .025).

CONCLUSION

Chair-to-table kinematics are good predictors of unexpected hospitalizations, whereas the get-up-and-walk kinematics are good predictors of low physical activity.

Frequency and prediction of non-medical opioid use behaviors (NMOU) among advanced cancer patients referred to a supportive care center (SCC)

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Background: One of the methodological barriers to conducting research on interventions for NOMU (Aberrant Opioid Use Behaviors) among cancer patients is the lack of data on the frequency of this problem. Although the frequency of risk factors has been established by our group and others, not all the patients with risk factors will be diagnosed with having NMOU behaviors, and some patients with no previous risk factors will engage in NMOU. AIM: To characterize the overall frequency of NMOU for a duration of 3 months, as well independent predictors for NMOU. Methods: In this retrospective study, 1558 consecutive patients referred to supportive care clinic (SCC) from 3/18/2016 to 6/6/2018 were reviewed for development of NMOU using established diagnostic criteria. Patients were eligible if they were ≥18 years, had a diagnosis of cancer, and were on opioids for pain for at least a week. All patients were assessed with the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID. Descriptive statistics, spearman correlation coefficient, multivariate analysis were performed. Results: 299 patients (19%) had ≥1 NMOU behavior. The median (IQR) NMOU behavior was 1 (1-2); range 1-10. Most NMOU occurred at 1st and 2nd follow up visits. The most frequent NMOU behavior was unscheduled clinic visit for inappropriate refills. 29/299 (10%) NMOU patients received specialized care for high-risk for aberrant opioid misuse by interdisciplinary team. Results of multivariate logistic regression model showed Marital status (Divorced vs. Married, OR=1.47, 95% CI: 0.98, 2.22, p=0.654 (marginally significant); Single vs. Married, OR=1.68, 95% CI: 1.15, 2.46, p=0.0079), SOAPP (Positive vs. Negative, OR=1.42, 95% CI: 1.05, 1.93, p=0.0238), morphine equivalent daily dose (MEDD) (OR=1.004, 95% CI: (1.003, 1.006), p<0.0001) and ESAS pain (OR=1.11, 95% CI: 1.06, 1.17, p<0.0001) were independently associated with the presence of NMOU during follow-up visits. Conclusions: 19% cancer patients followed at SCC had detectable NMOU behaviors. Being single, SOAPP+, pain severity and high MEDD were independent predictors for NMOU. This information will assist clinicians and investigators designing clinical and research programs in this important field.

Advanced cancer patients' (CP) attitudes and perceptions regarding reasons for outpatient supportive care (SC) referral at a comprehensive cancer center: A randomized controlled study

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Background: Current ASCO guidelines propose early access to SC in all CP to improve quality of care, quality of life, and symptoms. Very few studies have evaluated patients’ perceived criteria for referral to outpatient SC and perceptions of patients who are referred early in their disease trajectory. Methods: In this study we evaluated CP attitudes and perceptions regarding the role of and access to outpatient Supportive Care clinic (SCC) at a comprehensive cancer center. CP with life expectancy of greater than 6 months (as determined by the oncologist) and who are newly registered at MD Anderson Cancer Center were randomized to either obtain an educational brochure that explained the role of the SCC or no brochure. Both groups then completed a survey regarding the role and access to of outpatient SCC. After completion of the survey, patients were asked if they would like to be seen by the SC team. If so, they were scheduled by their oncologist for a SC consult. Results: 288 patients were evaluable: median age was 63, 43% were female, 84% were Caucasian, and the most common cancer type was lung cancer (39%). Median survival was 15 months. Patients who received a brochure reported more understanding of the role of SC vs those who did not receive a brochure (63% vs 37%, p = 0.04). Both groups felt that SC could help to address physical (47% vs 54%) and psychosocial (50% vs 50%) symptoms. Both groups felt SC could help to address questions regarding prognosis (50% vs 50%) and future care (53% vs 47%). Both groups did not feel that time (50% vs 50%) nor financial concerns (49% vs 51%) would be barriers to access SC. Both groups did not feel that receiving SC would impede their cancer care (60% vs 40%) nor change their oncologists’ perspective of them (25% vs 75%). Both groups felt they could receive SC and cancer care simultaneously (50% vs 50%). Approximately half of the patients in both groups perceived it was not too early for a referral to SC. There were no statistical differences in these groups for these findings. Conclusions: Patients who received a brochure had a better understanding of the role of SC. A very significant proportion in both groups had limited awareness of the value of SC. Oncologist driven referral and education of SC may facilitate better understanding of the value of SC. Further studies are needed.

Renal Replacement Therapy in Patients With Stage IV Cancer Admitted to the Intensive Care Unit With Acute Kidney Injury at a Comprehensive Cancer Center Was Not Associated With Survival

INTRODUCTION

In patients with advanced cancer, prolongation of life with treatment often incurs substantial emotional and financial expense. Among hospitalized patients with cancer since acute kidney injury (AKI) is known to be associated with much higher odds for hospital mortality, we investigated whether renal replacement therapy (RRT) use in the intensive care unit (ICU) was a significant independent predictor of worse outcomes.

METHODS

We retrospectively reviewed patients admitted in 2005 to 2014 who were diagnosed with stage IV solid tumors, had AKI, and a nephrology consult. The main outcomes were survival times from the landmark time points, inpatient mortality, and longer term survival after hospital discharge. Logistic regression and Cox proportional regression were used to compare inpatient mortality and longer term survival between RRT and non-RRT groups. Propensity score-matched landmark survival analyses were performed with 2 landmark time points chosen at day 2 and at day 7 from ICU admission.

RESULTS

Of the 465 patients with stage IV cancer admitted to the ICU with AKI, 176 needed RRT. In the multivariate logistic regression model after adjusting for baseline serum albumin and baseline maximum Sequential Organ Failure Assessment (SOFA), the patients who received RRT were not significantly different from non-RRT patients in inpatient mortality (odds ratio: 1.004 [95% confidence interval: 0.598-1.684], P = .9892). In total, 189 patients were evaluated for the impact of RRT on long-term survival and concluded that RRT was not significantly associated with long-term survival after discharge for patients who discharged alive. Landmark analyses at day 2 and day 7 confirmed the same findings.

CONCLUSIONS

Our study found that receiving RRT in the ICU was not significantly associated with inpatient mortality, survival times from the landmark time points, and long-term survival after discharge for patients with stage IV cancer with AKI.

Opioid usage patterns among Medicare pancreatic cancer patients according to palliative care utilization

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Background: Opioid pharmacotherapy is used to manage moderate and severe pain in palliative care (PC). Pain affects 80% pancreatic cancer patients older than 65 years. We assessed the opioid utilization patterns in Medicare patients with pancreatic cancer whom did not use PC (NPC), used community-based PC (CBPC) or used hospital-based PC (HBPC). Methods: We assessed opioid use, types, dispensed days, opioid uptake rates, doses (measured by morphine equivalent doses (MEDs)), and related adverse events (AEs) after pancreatic cancer diagnosis in Medicare beneficiaries selected from the SEER-Medicare database between 2007 and 2013 using the log-binomial, generalized linear mixed, and Cox proportional hazards modeling. Results: 16,106 patients were identified (median age: 78 years; female: 55.2%), of whom 8.3% used CBPC and 19.6% used HBPC. PC users were more likely to use opioids (CBPC: 72.2% vs. HBPC: 63.4% vs. NPC: 56.3%, P<.001). The most commonly prescribed opioid type in NPC, HBPC and CBPC users was fentanyl (54.1%), hydromorphone (27.7%) and morphine (26.1%). Compared to other study patients, CBPC users had shorter median dispensed days per prescription (CBPC: 3 days vs. HBPC: 4 days vs. NPC: 4 days, P<.001) but higher median MEDs per prescription (CBPC: 25 mg vs. HBPC: 25 mg vs. NPC: 0.13 mg, P<.001). Adjusting for demographic and clinical factors, no significantly different uptake rates of opioids were determined in PC users compared to NPC users (CBPC: RR, 1.02, P=.057; HBPC: RR, 1.002, P=.783). HBPC users had higher adjusted daily MEDs than CBPC and NPC users 3 months after diagnosis (135.1 mg/d vs. 126.5 mg/d vs. 65.7 mg/d, P<.001). CBPC users had higher adjusted daily MEDs than HBPC and NPC users 3 months before death (164.3mg/d vs. 155.6 mg/d vs. 92.1 mg/d, P=.0002). CBPC users had lower but HBPC users had higher adjusted hazard ratios of delirium (CBPC: HR, 0.95, HBPC: HR, 1.26, P<.001) and drowsiness (CBPC: HR, 0.94, HBPC: HR, 1.53, P<.001) than NPC users. Conclusions: Older pancreatic cancer patients using PC tended to use opioids and consumed higher opioid doses. CBPC users had lower risks of opioid-related delirium and drowsiness. The factors of the opioid use variations need to be assessed.

High/low dose dexamethasone with physical activity for cancer-related fatigue in patients with advanced cancer: A phase II randomized double blind study

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Background: Cancer-related-fatigue (CRF) is the most debilitating symptom in patients with advanced cancer. Physical activity (PA) improves CRF with lower adherence in advanced cancer. Dexamethasone (Dex) improves CRF but has long-term side effects. The purpose of the study was to determine whether a brief course of Dex improves adherence to PA for CRF management. Methods: Advanced cancer patients with CRF ≥ 4/10 on Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomized to either 4mg of Dex (LoDex) or 8mg of Dex (HiDex) orally BID for 7 days Plus standardized aerobic and resistance exercise for 4 weeks. Change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) fatigue subscale from baseline to Day 8 (primary outcome) and Day 29 were assessed. Secondary outcomes included changes in fatigue (ESAS, PROMIS, MFSI), Sleep Quality (PSQI), fasting blood glucose, and myopathy. Results: Total evaluable patients were 60 (31 LoDex and 29 HiDex arms). The study was feasible (N = 60/67 were evaluable); 84% and 65% LoDex, and 96% and 68% Hi Dex were adherent to aerobic and resistance exercise, respectively [All Patients were adherent to study medication]. There was no significant difference in grade 3+ AE’s between the two arms (P = 0. 92). The FACIT fatigue subscale Cohen’s d in Lo Dex was 0.90 (P < 0.001) and 0.94(P < 0.001); and Hi Dex was 0.86(P < 0.001); and 1.05(P < 0.001) at Day 8 and Day 29, respectively. Similar improvement was found for ESAS Fatigue (P < 0.001), MFSI total (P = 0.005), and PROMIS –fatigue total (P = 0.005). Mixed model analysis showed significant improvement in FACIT-F fatigue scores at Day 8 (P = 0.0006), Day 15 (P = 0.0002), and D (P = 0.0018). There was no significant difference between the two arms at Day 8 and Day 29 in fatigue scores, myopathy, fasting blood glucose levels, symptom distress, and sleep quality scores. Conclusions: Short course of dexamethasone Plus physical activity resulted in sustained and robust improvement in CRF outcomes for upto 3 weeks after discontinuation of steroids suggesting possible priming effects of steroids helped to sustain physical activity. Further larger studies are justified. Clinical trial information: NCT02491632.

Frequency of burn-out among palliative care physicians participating in continuing medical education

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Background: There is a growing concern about high frequency of burn out (BO) among physicians, and higher among palliative care providers, reported to be in the range of 62%. There are very limited studies done among Palliative Care (PC) physicians. Objective: The main objective of our study was to determine the frequency of burnout among PC physicians participating in PC Continuing Medical Education (CME). Secondary objectives included determining characteristics of physicians who expressed higher BO and also to determine overall attitudes towards PC practice. Methods: During 2018 Annual Hospice & Palliative Medicine Board Review Course, we conducted a survey of 41 questions to determine the frequency of BO among physicians. This included Maslach Burn Inventory ( MBI )–General. The survey was given to both the in house and webinar participants. Results: Of 110 physicians who were given the surveys, 91/110 (83%) completed surveys. The median age was 48 years with 59 (65%) being females, 74 (81%) married. Majority, 41 (46%) were in community practice. 24 (38%) were in practice for more than 6 years, and 52 (57%) were board certified. 56 (62%) practiced PC for more than 50 % of time. Majority, 69 (76%) were doing clinical work. The median number of physician in the group practice was 3. 35 (38 %) of participants reported at least one symptom burnout based on MBI criteria. Only being single/separated correlated significantly with burn-out (p = 0.056). PC work is appreciated at their place of work by 73 (80%), 58 (64%) reported insurance was a burden, electronic medical record as a burden by 58 (64%), and 82 (90%) of physicians felt optimistic about continuing PC in future. Conclusions: BO among palliative care physicians who attended a board review course tends to be high, but lower than previously reported. Physicians who choose to attend CME may have unique motivating characteristics to cope better with stress and BO. More research is needed to better characterize BO among PC physicians.

Patient reported outcomes can improve performance status assessment: a pilot study

Background

Patient performance status is routinely used in oncology to estimate physical functioning, an important factor in clinical treatment decisions and eligibility for clinical trials. However, validity and reliability data for ratings of performance status have not been optimal. This study recruited oncology patients who were about to begin emetogenic palliative or adjuvant chemotherapy for treatment of solid tumors. We employed actigraphy as the gold standard for physical activity level. Correspondences between actigraphy and oncologists’ and patients’ ratings of performance status were examined and compared with the correspondences of actigraphy and several patient reported outcomes (PROs). The study was designed to determine feasibility of the measurement approaches and if PROs can improve the accuracy of assessment of performance status.

Methods

Oncologists and patients made performance status ratings at visit 1. Patients wore an actigraph and entered weekly PROs on a smartphone app. Data for days 1–14 after visit 1 were analyzed. Chart reviews were conducted to tabulate all unexpected medical events across days 1–150.

Results

Neither oncologist nor patient ratings of performance status predicted steps/hour (actigraphy). The PROMIS® Physical Function PRO (average of Days 1, 7, 14) was associated with steps/hour at high (for men) and moderate (for women) levels; the PROMIS® Fatigue PRO predicted steps for men, but not for women. Unexpected medical events occurred in 57% of patients. Only body weight in female patients predicted events; oncologist and patient performance status ratings, steps/hour, and other PROs did not.

Conclusions

PROMIS® Physical Function and Fatigue PROs show good correspondence with steps/hour making them easy, useful tools for oncologists to improve their assessment of performance status, especially for male patients. Female patients had lower levels of steps/hour than males and lower correlations among the predictors, suggesting the need for further work to improve performance status assessment in women. Assessment of pre-morbid sedentary behavior alongside current Physical Functioning and Fatigue PROs may allow for a more valid determination of disease-related activity level and performance status.

Integration of a Mandatory Palliative Care Education Into Hematology-Oncology Fellowship Training in a Comprehensive Cancer Center: A Survey of Hematology Oncology Fellows

PURPOSE

The primary aim of this study was to determine the attitudes and beliefs of hematology and medical oncology (HMO) fellows regarding palliative care (PC) after they completed a 4-week mandatory PC rotation.

METHODS

The PC rotation included a 4-week standardized curriculum covering all PC domains. HMO fellows were provided educational materials and attended all didactic sessions. All had clinical rotation in an acute PC unit and an outpatient clinic. All HMO fellows from 2004 to 2017 were asked to complete a 32-item survey on oncology trainee perception of PC.

RESULTS

Of 105 HMO fellows, 77 (73%) completed the survey. HMO fellows reported that PC rotation improved assessment and management of symptoms (98%); opioid prescription (89%), opioid rotation (78%), and identification of opioid adverse effects (87%); communication with patients and families (91%), including advance care planning discussion (88%) and do-not-resuscitate discussion (88%); and they reported comfort with discussing ethical issues (74%). Participants reported improvement in knowledge of symptom assessment and management (n = 76; 98%) as compared with efficacy in ethics (n = 57 [74%]; P = .0001) and for coping with stress of terminal illness (n = 45 [58%]; P = .0001). The PC rotation educational experience was considered either far better or better (53%) or the same (45%) as other oncology rotations. Most respondents (98%) would recommend PC rotations to other HMO fellows, and 95% felt rotation should be mandatory.

CONCLUSION

HMO fellows reported PC rotation improved their attitudes and knowledge in all PC domains. PC rotation was considered better than other oncology rotations and should be mandatory.

Preventing chemotherapy-induced nausea and vomiting with netupitant/palonosetron, the first fixed combination antiemetic: current and future perspective

Chemotherapy-induced nausea and vomiting (CINV) can be prevented in most patients receiving appropriate antiemetic treatment. However, inadequate uptake of current antiemetic guideline recommendations by physicians, and poor treatment adherence by patients, lead to suboptimal CINV control. There is an unmet need to optimize guideline-consistent use of antiemetics to improve CINV management and prevention. Herein, we provide an overview of CINV, then discuss oral and intravenous NEPA, the first fixed combination antiemetic, composed of netupitant/fosnetupitant and palonosetron. We describe the main pharmacologic and pharmacokinetic characteristics of NEPA, and review the clinical evidence supporting its use in the prevention of CINV.

Low-dimensional dynamical characterization of human performance of cancer patients using motion data

BACKGROUND

Biomechanical characterization of human performance with respect to fatigue and fitness is relevant in many settings, however is usually limited to either fully qualitative assessments or invasive methods which require a significant experimental setup consisting of numerous sensors, force plates, and motion detectors. Qualitative assessments are difficult to standardize due to their intrinsic subjective nature, on the other hand, invasive methods provide reliable metrics but are not feasible for large scale applications.

METHODS

Presented here is a dynamical toolset for detecting performance groups using a non-invasive system based on the Microsoft Kinect motion capture sensor, and a case study of 37 cancer patients performing two clinically monitored tasks before and after therapy regimens. Dynamical features are extracted from the motion time series data and evaluated based on their ability to i) cluster patients into coherent fitness groups using unsupervised learning algorithms and to ii) predict Eastern Cooperative Oncology Group performance status via supervised learning.

FINDINGS

The unsupervised patient clustering is comparable to clustering based on physician assigned Eastern Cooperative Oncology Group status in that they both have similar concordance with change in weight before and after therapy as well as unexpected hospitalizations throughout the study. The extracted dynamical features can predict physician, coordinator, and patient Eastern Cooperative Oncology Group status with an accuracy of approximately 80%.

INTERPRETATION

The non-invasive Microsoft Kinect sensor and the proposed dynamical toolset comprised of data preprocessing, feature extraction, dimensionality reduction, and machine learning offers a low-cost and general method for performance segregation and can complement existing qualitative clinical assessments.

Outcomes of a specialized interdisciplinary approach for cancer patients with aberrant opioid-related behavior: A preliminary report

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Background: Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in cancer patients is lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention. Methods: The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015 and August 31, 2016 were reviewed. Results: At baseline, pain intensity (p=0.002) and opioid dose (p=0.001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from 3 pre-intervention to 0.4 post-intervention (p<0.0001). The median morphine equivalent daily dose decreased from 165mg/day at the first intervention visit to 112mg/day at the last follow up (p=0.018) although pain intensity did not significantly change (p= 0.984). ‘Request for opioid medication refills in the clinic earlier than the expected time’ was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age (p<0.0001) and higher ESAS anxiety score (p=0.005) were independent predictors of the presence of AB. Conclusions: The intervention was associated with a reduction in the frequency of AB and opioid utilization among cancer patients receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention. [Table: see text]

Cranial electrotherapy stimulation for the management of depression, anxiety, sleep disturbance, and pain in patients with advanced cancer: A preliminary study

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Background: Cranial Electrotherapy Stimulation (CES) is a safe modulation of brain activity for treating depression, anxiety, insomnia, and pain. However, there are no published studies in patients with advanced cancer (ACP).The aim of the study was to determine the feasibility and preliminary efficacy of a 4-week CES intervention on depression, anxiety, sleep disturbance, and pain scores. Concurrent salivary biomarker studies were conducted. Methods: In this one group open label pre- and post-intervention study with a 4-week CES intervention, ACP’s with one or more of four moderate intensity (≥3/10) ESAS symptoms (depression, anxiety, sleep disturbance, and pain) were eligible. Adherence (0-100%), satisfaction rates(0-10), and safety were assessed. ESAS, HADS, PSQI, BPI, and salivary levels (cortisol, alpha amylase, CRP, and IL-1 beta and IL-6) were assessed from baseline to week 4. Results: 33/38(87%) completed the CES. Median (IQR) adherence for days with 60 min CES use and satisfaction scores were 93(89-100)% and 10(9-10) respectively. CES use was safe (no grade 3 or higher adverse events). HADS anxiety (p < 0.001), HADS depression (p = 0.024), ESAS anxiety (p = 0.001), depression (p = 0.025), BPI pain (p = 0.013), PSQI daytime dysfunction (p = 0.002), and Medication use (p = 0.006) scores improved after 4 week CES treatment. There was no significant change in the salivary cortisol, alpha-amylase, CRP, IL-1β, and IL-6 levels after 4 weeks of CES. Conclusions: In this preliminary study we found that the use of cranial Electrotherapy stimulation (CES) was safe and feasible in ACP. The use of CES was associated with significant improvement of depression, anxiety, pain, and sleep scores. These findings support further studies of CES in ACP for symptom control.

Frequency and factors predicting the risk for aberrant opioid use in patients receiving outpatient palliative care at a comprehensive cancer center

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Background: Opioid misuse is a growing crisis among patients with chronic pain. Cancer patients at risk of aberrant drug behaviors (ADB) are frequently underdiagnosed in routine cancer care. The aim of this study was to determine the frequency and factors predicting risk for Aberrant Opioid and Drug use among Patients receiving Outpatient Supportive Care Consultation at a Comprehensive Cancer Center Methods: In this retrospective study, 690 consecutive patients referred to a supportive care clinic were reviewed. Patients were eligible if they were ≥18 years, had a diagnosis of cancer, and were on opioids for pain for atleast a week. All patients were assessed with the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID. At risk patients with aberrant opioid behavior (+Risk) was defined as SOAPP-14 score ≥7. Descriptive statistics, spearman correlation coefficient, multivariate analysis were performed. Results: 690/752 consults were eligible. A total of 135(20%)were +risk. 69(11%) were CAGE-AID +.SOAPP-14 scores were positively associated with CAGE-AID p < 0.001; male gender p = 0.007; ESAS pain p = < 0.006; ESAS depression p < 0.001; ESAS anxiety, p < 0.001, and ESAS financial distress p = < 0.001. Multivariate analysis indicated that the odds ratio for +Risk was 2.47 in patients with CAGE-AID+ (p < 0.001), 1.95 for male gender (p = 0.005), 1.11 per point for ESAS anxiety (p = 0.019), and 1.1 per point. for ESAS financial distress (p = 0.02). Conclusions: 20% of cancer patients on opioids presenting to supportive care center are at risk of aberrant drug behavior. Male patients with anxiety, financial distress, and prior alcoholism/illicit drug use are significant predictors of +Risk. Further research to effectively manage these patients is needed.

Outcomes of an innovative six-week standardized residential training course for physicians and nurses to provide primary palliative care in India

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Background: The National Program on Palliative Care (NPPC) by the Government of India has emphasized the need for training clinicians in providing palliative care (PC) with minimum of 6 weeks of residential training. However, there are limited studies on feasibility of such standardized training in PC offered to palliative care providers interested in transition to palliative care. Aim: To evaluate the feasibility, and change in the self-reported perception of knowledge in palliative care following a 6 weeks standardized residential training course (SRTC) for physicians and nurses to provide primary PC in India. Methods: A 6 week standardized residential type educational program which combined didactics, and bedside hands on palliative care training by PC specialists in five preselected centers in India. To be eligible licensed physicians and nurses should, (a) qualify in focused interview aimed to evaluate both interest and commitment to provide primary palliative care following the training, (b) Agree to complete all the required surveys. Results: 46/53 (86%) completed the pre and post surveys. 50/53 (94%) participants completed the course and passed the certification exam. Median age (IQR) was 31 (27, 41). 53% were female and 53% were physicians. Median reported knowledge (1-5) for pain, fatigue, delirium, medical ethics were 4,3,2,2.5 before training Vs 5 (P=0.001), 5 (P=0.001), 5 (P=0.001), 5 (P=0.001) after training respectively. All other core areas improved significantly. All participants noted satisfaction with faculty as high (5/5). Conclusions: Conducting a six weeks standardized residential training course in PC for physicians and nurses in India is feasible. There was a significant improvement in self-reported knowledge of all components of palliative care curriculum. Long term impact studies are needed.

Outcomes of a Specialized Interdisciplinary Approach for Patients with Cancer with Aberrant Opioid-Related Behavior

BACKGROUND

Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in patients with cancer are lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention.

MATERIALS AND METHODS

The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015, and August 31, 2016, were reviewed.

RESULTS

At baseline, pain intensity (p = .002) and opioid dose (p = .001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from three preintervention to 0.4 postintervention (p < .0001). The median morphine equivalent daily dose decreased from 165 mg/day at the first intervention visit to 112 mg/day at the last follow-up (p = .018), although pain intensity did not significantly change (p = .984). "Request for opioid medication refills in the clinic earlier than the expected time" was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age (p < .0001) and higher Edmonton Symptom Assessment System anxiety score (p = .005) were independent predictors of the presence of AB.

CONCLUSION

The intervention was associated with a reduction in the frequency of AB and opioid utilization among patients with cancer receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention.

IMPLICATIONS FOR PRACTICE

There are currently no well-defined and evidence-based strategies to manage cancer patients on chronic opioid therapy who demonstrate aberrant opioid-related behavior. The findings of this study offer a promising starting point for the creation of a standardized strategy for clinicians and provides valuable information to guide their practice regarding these patients. The study results will also help clinicians to better understand the types and frequencies of the most common aberrant behaviors observed among patients with cancer who are receiving chronic opioid therapy. This will enhance the process of timely patient identification, management, or referral to the appropriate specialist teams.

Could Objective Tests Be Used to Measure Fatigue in Patients With Advanced Cancer?

CONTEXT

Assessment of cancer-related fatigue is currently based on patient-reported outcomes. We asked whether objective assessments, such as muscle strength and nutritional markers, can be used as surrogate measures of cancer-related fatigue.

OBJECTIVE

We examined the association among three fatigue scales, muscle strength, and nutritional markers in patients with advanced cancer.

METHODS

In this prospective study, we enrolled hospitalized cancer patients who had been seen in palliative care consultation at MD Anderson Cancer Center. We assessed fatigue using three fatigue scales-the Brief Fatigue Inventory (BFI), the Edmonton Symptom Assessment System (ESAS), and the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 (EORTC QLQ-C30)-and determined their association with objective assessments, including handgrip strength, maximal inspiratory pressure, lean body mass, phase angle, and albumin. Spearman's correlation test was used to assess associations.

RESULTS

Among 222 patients, the mean age was 55 years; 59% were women. The median overall survival was 106 days. The total BFI score had weak association with handgrip strength (ρ = -0.18, P = 0.007) and no association with the remaining objective measures. ESAS fatigue and EORTC fatigue showed similar findings. Total BFI had moderate-to-strong association with ESAS (ρ = 0.54, P < 0.0001) and EORTC (ρ = 0.60, P < 0.0001) fatigue.

CONCLUSION

Our study showed that subjective assessment of fatigue based on patient-reported outcomes correlates only weakly with muscle strength and nutritional markers; thus, patient-reported outcomes remain the gold standard for fatigue assessment.

Multimodal therapy for cancer related fatigue in patients with prostate cancer receiving radiotherapy and androgen deprivation therapy

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Background: There are limited studies to evaluate treatments that target causative mechanisms of Cancer-related-fatigue (CRF) using validated tools in a defined population. The objective is to determine the feasibility, and the preliminary estimates of the effects of various combinations of standardized exercise, cognitive behavioral therapy (CBT), and methylphenidate (multimodal therapy, or MMT) on CRF as measured by AUC of Functional Assessment of Chronic Illness Therapy- Fatigue (FACIT-F) subscale scores in Pts with prostate cancer receiving radiotherapy with androgen deprivation therapy. Methods: Prostate cancer Pts with CRF scheduled to receive radiotherapy with androgen deprivation therapy were eligible. Using a double blind (patient, investigators) randomized factorial study design, eligible Pts were randomized into 1 of the 8 arms, which included all possible combinations of the interventions (exercise, CBT, and methylphenidate) and/or their corresponding placebo treatments for a duration of 8 weeks. Results: 62/69 (89%) randomized Pts were evaluable. There were no differences in the demographics and baseline fatigue between groups. The adherence rates for pills, exercise and CBT were 96.5%, 67%, and 90% respectively. The study was feasible and there was no significant difference in adverse events by groups. Table 1 shows the comparison of AUC by treatment. For Pts receiving drug compared to placebo, the median FACIT-F AUC was 2328 vs 2095. The drug effect (estimate, 95% CI) in Pts who received Exercise was 596 (68.3, 1125); CBT was 354 (-121, 830); combined Exercise and CBT was -187 (-802,427); and control Exercise, control CBT was 294 (-192,781). Conclusions: Methylphenidate containing combinations were superior to no drug combinations. Methylphenidate + Exercise provided the best signal and should proceed to large randomized control trials. Clinical trial information: NCT01410942. [Table: see text]

Frequency and factors predictive of aberrant drug behavior in patients presenting to outpatient supportive care center at a comprehensive cancer center

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Background: Opioid misuse is a growing crisis in cancer patients. Cancer patients at risk of aberrant drug behaviors (ADB) are frequently underdiagnosed in routine cancer care. The aim of this study was to determine the frequency and factors associated with ADB using the “Screener and Opioid Assessment for Patients tool” (SOAPP-14) in cancer patients seen at the outpatient supportive care center. We also examined the screening performance of Cut Down, Annoyed, Guilty, and Eye Opener (CAGE-AID) as compared to The SOAPP-14 as a gold standard. Methods: In this retrospective study, 1108 consecutive patients referred to supportive care clinic were reviewed. Patients were eligible if they were ≥18 yrs, have a diagnosis of cancer, and were on opioids for pain for atleast a week. Patients’ demographics, the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID scores were analyzed. ADB+ was defined as SOAPP-14 score ≥7. Descriptive statistics, spearman correlation coefficient, multivariate, and ROC analysis were performed. Results: 703/1108 consults were eligible. A total of 153/703 (22%) were ADB +ve. SOAPP-14 scores were positively correlated with CAGE-AID r = .38, p < 0.001; male gender r = 0.11, p = 0.003; ESAS pain r = 0.11, p = 0.005; ESAS depression r = 0.22, p < 0.001; ESAS anxiety r = 0.22, p < 0.001, and ESAS financial distress r = 0.23, p < 0.001. Multivariate analysis indicated that the odds ratio for ADB +ve was 6.18 in patients with CAGE-AID+ (p < 0.001), 1.8 for male gender (p = 0.007), 1.1/pt. for ESAS anxiety (p = 0.044), and 1.1/pt. for ESAS financial distress (p = 0.007). A CAGE-AID score of 1/4 has a sensitivity of 47%, specificity of 89% positive predictive value 63.6% and negative predictive value 69.2%. Conclusions: Our study suggests that 22% of cancer patients on opioids presenting to supportive care center are at risk of aberrant drug behavior (ADB). Male patients with anxiety, financial distress, and prior alcoholism/illicit drug use are significant predictors of ADB’s. A cut off score of ≥1 out 4 on CAGE-AID questionnaire allows better screening of ADB in outpatient advanced cancer patients. Further research to effectively manage these patients is needed.

Increased Symptom Expression among Patients with Delirium Admitted to an Acute Palliative Care Unit

INTRODUCTION

Delirium is the most common neuropsychiatric condition in very ill patients and those at the end of life. Previous case reports found that delirium-induced disinhibition may lead to overexpression of symptoms. It negatively affects communication between patients, family members, and the medical team and can sometimes lead to inappropriate interventions. Better understanding would result in improved care. Our aim was to determine the effect of delirium on the reporting of symptom severity in patients with advanced cancer.

METHODS

We reviewed 329 consecutive patients admitted to the acute palliative care unit (APCU) without a diagnosis of delirium from January to December 2011. Demographics, Memorial Delirium Assessment Scale, Eastern Cooperative Oncology Group (ECOG) Performance status, and Edmonton Symptom Assessment Scale (ESAS) on two time points were collected. The first time point was on admission and the second time point for group A was day one (+two days) of delirium. For group B, the second time point was within two to four days before discharge from the APCU. Patients who developed delirium and those who did not develop delirium during the entire course of admission were compared using chi-squared test and Wilcoxon rank-sum test. Paired t-test was used to assess if the change of ESAS from baseline to follow-up was associated with delirium.

RESULTS

Ninety-six of 329 (29%) patients developed delirium during their admission to the APCU. The median time to delirium was two days. There was no difference in the length of stay in the APCU for both groups. Patients who did not have delirium expressed improvement in all their symptoms, while those who developed delirium during hospitalization showed no improvement in physical symptoms and worsening in depression, anxiety, appetite, and well-being.

CONCLUSION

Patients with delirium reported no improvement or worsening symptoms compared to patients without delirium. Screening for delirium is important in patients who continue to report worsening symptoms despite appropriate management.

Perception of Helpfulness of a Question Prompt Sheet Among Cancer Patients Attending Outpatient Palliative Care

BACKGROUND

Data on the use of question prompt sheets (QPSs) in palliative care are limited. Our team previously developed a single-page QPS using a Delphi process. The main objective of this study was to determine the perception of helpfulness of a QPS in patient-physician communication among advanced cancer outpatients.

METHODS

Hundred of 104 (96%) eligible patients and 68/68 (100%) caregivers received the QPS during their first palliative care clinic. Twelve palliative medicine specialists also participated in the study. Patient and physician perceptions about the QPS were assessed at the end of the visit. Patients' anxiety was also measured before and after consultation using the Spielberger State Anxiety Inventory.

RESULTS

Among the responders, most agreed that the material was helpful in communicating with their doctor (77%), clear to understand (90%), had the right amount of information (87%), and they would use a similar material in the future (76%) and recommend it to other patients (70%). Overall, 92% were satisfied with their consultation visit. Physicians perceived that the QPS was helpful in 68% of the encounters and it did not prolong the consultation in 73% of the encounters. Physician agreement on helpfulness of the QPS was not significantly different from that of the patients (P = 0.3). Patient anxiety improved after consultation from a mean (SD) Spielberger State Trait Anxiety Inventory score of 39.2 (12.8) to 33.8 (10.7), P < 0.0001).

CONCLUSION

The QPS was perceived as helpful in patient-physician communication among advanced cancer outpatients and it did not increase patient anxiety. Physicians similarly reported that the QPS was helpful and it did not prolong clinic visits. Further research is needed for its widespread adoption and integration into routine clinical practice.

Post-Discharge Survival Outcomes of Patients with Advanced Cancer from the University of Texas MD Anderson Cancer Center Investigational Cancer Therapeutics (Phase I Trials) Inpatient Unit

BACKGROUND

Patients with advanced cancer who progress on standard therapy are potential candidates for phase I clinical trials. Due to their aggressive disease and complex comorbid conditions, these patients often need inpatient admission. This study assessed the outcomes of such patients after they were discharged to hospice care.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with solid tumor malignancies who were discharged to hospice care from the inpatient service.

RESULTS

One hundred thirty-three patients were included in the study cohort. All patients had metastatic disease and an Eastern Cooperative Oncology Group performance status ≥3. The median survival after discharge to hospice from an inpatient setting was 16 days, with a survival rate of 5% at 3 months after discharge. The median survival after the last cancer treatment was 46 days, with survival of 17% at 3 months, and 5% at 6 months. Patients with lactate dehydrogenase (LDH) >618 IU/L had a median post-discharge survival of 11 days versus 20 days for patients with LDH ≤618 IU/L.

CONCLUSIONS

Patients with metastatic cancer participating in phase I trials who have poor performance status and require inpatient admission have a very short survival after discharge to hospice. A high LDH level predicts an even shorter survival.

Survival benefits among patients with end-stage renal disease receiving dialysis versus no dialysis

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Background: Retrospective study of the outcomes of Stage IV Cancer Patients with End Stage Renal disease Receiving Dialysis and comparing the survival benefits among the patients who received Hemodialysis versus who didn’t at a Comprehensive Cancer Center. Methods: Retrospectively review all patients admitted to MDACC from 2005-2014 and diagnosed with stage IV solid tumor admitted with Acute kidney injury and a nephrology consult were included (N = 903) 19.82% received dialysis (n = 179) versus 80.17% did not receive dialysis (n = 724). The main endpoints of the study to be evaluated would be survival & hospital death. Results: Kaplan-Meier overall survival curve of the dialysis group vs the non-dialysis p-value < 0.001 indicating that patients who underwent dialysis had a poorer overall survival. This was further explored in a multivariate model where at any given time; a patient who underwent a dialysis is 1.318 times as likely to experience a death as a patient who did not undergo a dialysis with the same other clinical factors. The association between dialysis and death in hospital was explored using multivariate model indicated dialysis (odds ratio = 3.339, 95% CI (2.212, 5.04), p < 0.001, ICU (odds ratio = 2.624, 95% CI (1.905, 3.613), p < 0.001), and a lower serum albumin level (p < 0.001) are factors associated with a higher probability of death in hospital. Matched sample where evaluated using propensity score matching & Weighting and the dialysis group still shows a significant negative effect on Overall Survival with (p = 0.003). ICU patients Subset Analysis & SOFA Score: 49.9% had ICU visits in our database with SOFA scores (37.9% were dialyzed). Using propensity score weighting method, the estimated hazard rate is 0.892 with 95% CI (0.775, 1.027) and p = 0.113, showing NO evidence that dialysis is a prognostic factor for ICU patients after controlling SOFA score. In the ICU cohort, the median survival time for dialysis 18 days (95% CI: 14-23) and no dialysis 19 days (95% CI: 15-25). Conclusions: We can conclude that Dialysis when offered to advanced cancer patients does not improve mortality. Creating a hemodialysis prognostic tool relevant to cancer population would be of great benefit to Nephrologists, Oncologist and patients.

Frequency and factors associated with placebo response in cancer-related fatigue treatment trials

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Background: There is limited literature on specific patient characteristics associated with response to placebo. The aim of this study was to identify frequency, and predictors of response to placebo. Methods: We conducted pooled analysis of the placebo arm in six randomized, double-blind, placebo-controlled clinical trials for cancer related fatigue. Baseline patient characteristics, symptoms (FACIT-F, and ESAS), Global Symptom Evaluation (GSE, rated as better, same and worse). Response was defined as an increase (D FACIT-F score) ≥ 3.5 points from baseline or change in ESAS of ≤ 1. Baseline patient characteristics and symptoms (as assessed by ESAS) were analyzed to determine their association with response to placebo using logistic regression analysis. ROC was calculated for GSE “better” of “4” or more (i.e., moderately better to very great deal better) and FACIT-F change. Results: Total of 306 patients with advanced cancer received placebo. The median age was 59, 54% were female, 76% were white, 51% were had college education or higher, the most common cancer type was genitourinary 24%. 55% had Zubrod performance ≤ 2. Median FACIF-F subscale score was 21. Placebo response was 176/306 (58%) with FACIT-F subscale ≥ 3.5 points and 185 (60%) with ESAS fatigue ≤ 1. Mean change in fatigue using FACIT- F subscale score was 7.18 (11.68) and ESAS was -2.21 (2.82). Change in FACIT-F and ESAS were significantly correlated (r = 0.56, P ≤ 0.001). 99/306 (32%) reported that their fatigue was “better” by GSE. Female gender (OR 2.72, P = 0.04), and anxiety (OR 1.39, P = 0.046) were significantly associated with placebo response. ROC with cut-off of GSE ≥ 4 and change in FACIT-F score was 11.5 and placebo response rate based on cut-off of 7.5 was 84/306 (27%). Conclusions: Our results confirm that placebo response is substantial in fatigue treatment trials in palliative patients. Placebo response rate varies based on the methods used to estimate response (from 27% to 60%). Female patients and higher anxiety at baseline were significantly associated with placebo response. More research is needed to accurately benchmark placebo response.

Perception of curability in an international cohort of advanced cancer patients receiving palliative care

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Background: There is limited data on the illness understanding and perception of cure among advanced cancer patients (ACP) receiving palliative care around the world. The aim of the study was to determine the frequency and factors associated with perception of curability in countries in North and South Americas , Europe, Asia and Africa. Methods: Secondary analysis of a study to determine the decisional control preferences in different countries. ACP receiving palliative care were surveyed to assess the patients’ Understanding of Illness using a Understanding Of Illness questionnaire. Descriptive statistics and Logistic regression analysis were performed. Results: A total 1390 ACPs were evaluated. The median age was 58, 55% were female, 59% were married, 47% were catholic, 36.2% were educated college or higher degree. 681/1390 (49%) reported that their cancer is curable, 60% felt perceived that the goals of therapy was “to get rid of their cancer,” 79% perceived that the goals of the therapy was to “make them feel better.” 62 % perceived they were relatively healthy. Logistic regression analysis (Table 1) shows that better Karnosfsky performance status (OR 1.009, P = 0.04), higher education (OR 0.52, P = 0.0001), ACP's belonging to Brazil, France and S. Africa were less likely and ACPs from Philippines, Jordan were more likely to have a perception of curability. Age, gender, marital status, religion and passive decision control preferences were not significantly associated with perception of curability. Conclusions: The perception of curability in ACP's is 49% and significantly differs by education, performance status, and country of origin. Integration of Palliative Care can be more complex in these patients. Further studies are needed to develop strategies to reduce this misperception so as to have early integration of palliative care. [Table: see text]

Effects of high-dose Asian ginseng (Panax ginseng) to improve cancer-related fatigue: Results of a double-blind, placebo-controlled randomized controlled trial

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Background: Cancer related fatigue (CRF) is the most common and disabling symptom in cancer.Panax ginseng extract (PG) is frequently used as a nutraceutical treatment for fatigue. There are no well-powered placebo-controlled trials that used validated CRF outcome measures to investigate of PG effects in cancer patients. The primary objective of this trial was to evaluate the effects oral PG versus Placebo (PL) for CRF. Methods: Patients with cancer fatigue ≥ 4/10 on Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomized to either 400mg of standardized PG or matching PL orally twice a day for 28 days. The primary endpoint was change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) fatigue subscale from baseline to Day 28. Secondary outcomes were Functional Assessment of Cancer Therapy-General (FACT-G), Hospital Anxiety and Depression Scale (HADS), and ESAS. Results: Total evaluable patients were 112 (56 for PG and PL groups). No significant differences in baseline characteristics between the two groups except cancer type (p = 0.002). There was significant improvement in FACIT fatigue and ESAS fatigue scores in PG and PL groups at Day 15 and Day 29. The mean (SD) of FACIT-F fatigue scores at baseline, Day 15, and Day 29 were 22.6 (10.4), 29.8(10.7), 30.1 (11.6) and 23.8 (9.1), 30.0 (10.1), 30.4 (11.6) for PG and PL respectively. Mean (SD) improvement in the FACIT-F subscale at Day 29 was not significantly different in PG than in the PL group [7.5 (12.7) vs 6.5 (9.9), P = 0.67]. Mean (SD) improvement in the ESAS fatigue, FACT-G, and HADS at Day 29 were also not significantly different in PG than in the PL group. In a multiple linear model analysis, the change in FACIT-F fatigue from Day 0 to Day 29 was negatively correlated with baseline FACIT-F fatigue (p = 0.0005), baseline HADS score (p = 0.032), and male gender (p = 0.023). There were a significantly higher number of any grade of toxicities in PL group than in PG group (33/62 vs. 28/64, p = 0.024). Conclusions: Both PG and Placebo result in a significant improvement in CRF at Day 15 and Day 29. PG was not significantly superior to placebo after 4 weeks of treatment. Further studies are needed. Clinical trial information: NCT01375114.

Frequency and factors associated patients decisional control preferences (DCP) in patients with advanced cancer (ACP)

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Background: To determine the frequency and socio-demographic and clinical factors associated passive DCP among ACP across the world. Methods: We conducted a survey of ACP referred to palliative care across 11 countries across the five continents across the world. Information was collected on socio-demographic variables, and using validated measures including Karnofsky Performance Scale, Decision Control Preference Scale, and Satisfaction with the Decisions and Care questionnaire. We analyzed using descriptive statistics and logistic regression analysis was performed. Results: Median age was 58 years, karnofsky 70, and 55% were female. Shared, Active and Passive DCP were 33.2%, 44.1% and 22.6% respectively (n = 1490). 91% were satisfied by the way the actual decisions were made. Concordance between the actual decision making and DCP was highest in cohort from USA [k = 0.74 (0.65-0.82) and lowest in Brazil 0.33 (0.22-0.44)]. “Satisfaction with the way the decisions about their care was made” was 91%. Better Karnosfsky performance status (OR 0.99, P = 0.017), higher education status (OR 0.64, P = 0.001) Country of origin (Brazil, France, Singapore, South Africa, Jordan were significantly associated with passive decision making preference (Table 1). Conclusions: DCP is based ACP’s performance status, education and is culture specific. Individualized understanding DCP may be important for quality care and patient satisfaction outcomes. [Table: see text]

Perception of helpfulness of a question prompt sheet among cancer patients attending outpatient palliative care

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Background: Data on the use of question prompt sheets (QPS) in palliative care is limited. Our team previously developed a single page QPS using a Delphi process. The main objective of this study was to determine the perception of helpfulness of a QPS in patient-physician communication among advanced cancer outpatients. Methods: 104 eligible patients received the QPS for use during their first palliative care clinic. Patient and physician perceptions about the QPS were assessed at the end of the visit. Patients’ anxiety was also measured pre- and post-consultation using the Spielberger State Anxiety Inventory. Results: 100/104 (96%) patients completed the study. Among those responders, most agreed that the material was helpful in communicating with their doctor (77%), clear to understand (90%), had the right amount of information (87%), and they would use a similar material in the future (76%) and recommend it to other patients(70%). Overall, 92% were satisfied with their consultation visit. Physicians perceived that the QPS was helpful to 68% of the encounters and it did not prolong the consultation in 73% of the encounters. Physician agreement on helpfulness of the QPS was not significantly different from the patients (p = 0.3). Patient anxiety improved after consultation from a mean (SD) STAI score of 39.2 (12.8) to 33.8 (10.7), p ≤ 0.0001. Conclusions: The QPS was perceived as helpful in patient-physician communication among advanced cancer outpatients and it did not increase patient anxiety. Physicians similarly reported that the QPS was helpful and it did not prolong clinic visits. Further research is needed for its widespread adoption and integration into routine clinical practice.

Referral patterns and characteristics of uninsured versus insured patients referred to the outpatient supportive care center (SCC) at a comprehensive cancer center

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Background: Multiple barriers exist in providing quality palliative care to low-income patients with cancer. Such disparities may negatively influence effective management of symptoms including pain. Our objective was to compare referral patterns and characteristics (level of symptom distress) of uninsured vs insured patients. Methods: We reviewed randomly selected charts of 100 Indigent (IND) and 100 Medicaid (MC) patients and compared them with a random sample of 300 patients with insurance (INS) referred during the same time period (1/2010 to 12/2014) to our SCC. Data was collected for date of registration at the cancer center, diagnosis of Advanced Cancer (ACD), first visit to the SCC (PC1), symptom assessment (Edmonton Symptom Assessment Scale-ESAS) at PC1. We excluded self-pay patients. Results: Results for IND, MC and INS (n = 481) respectively are as follows: Mean (SD) Age in yrs. was 50 (12), 48 (11) and 63 (13); p < 0.001. Percentage of non-white was 44%, 51% and 19.5%; p < 0.001. Percentage of unmarried patients was 64%, 68% and 33%; p < 0.001. Mean (SD) ESAS score at PC1 for pain was 5.6 (3.2), 6.7 (2.5), 4.9 (3.2); p < 0.001. Percentage of patients on opioids upon referral was 86%, 62%, and 54%; p < 0.001. Mean (SD) for referral time in months from ACD to PC1 was 8.7 (SD 10.4), 12.3 (SD 18.1) and 12 (SD 19.9) p = 0.31; for no. of encounters with SC per month were 0.46 (0.45), 0.41 (0.46) and 0.3 (0.55); p = 0.01; for survival in months (PC1 to last contact) was 6.4 (5.8), 5.6 (6.4) & 6 (7.22) p = 0.77. Conclusions: Uninsured patients had significantly higher levels of pain, were more frequently on opioids, younger, non-white and not married. They also required a larger number of SCC encounters. Insurance status did not impact timing of SCC referral or SCC follow ups at our cancer center.

The conversion ratio from intravenous (IV) hydromorphone to oral (PO) opioids in patients with cancer

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Background: Inpatients with cancer frequently undergo conversions from IV to PO hydromorphone (HM) or opioid rotation (OR) from IV HM to another PO opioid prior to discharge. Currently used conversion ratios (CR) between IV and PO HM range from 2-5 and opioid rotation ratios (ORR) between IV HM and oral morphine equivalent daily dose (MEDD) range from 10-20. This large variation in ratios may lead to uncontrolled pain or overdosing. Our aim was to determine the accurate CR from IV to PO HM and ORR from IV HM to PO morphine and oxycodone (measured as MEDD). Methods: We reviewed records of 4745 consecutive inpatient palliative care consults in our institute during 2010-14 for patients who underwent conversion from IV to PO HM or OR from IV HM to PO morphine or oxycodone. Patient characteristics, symptoms and opioid doses were determined in patients successfully discharged on oral opioids without readmission within 1 week. Linear regression analysis was used to estimate the CR or ORR between the 24 hour IV HM mg dose prior to conversion to PO and the oral opioid mg dose used in the 24 hours prior to discharge. Results: Among 394 eligible patients on IV HM, 147 underwent conversion to PO HM and 247 underwent OR to oral morphine (163) or oxycodone (84). Mean age was 54 years, 39% were male, and 95% had advanced cancer. Median time between conversion to PO and discharge was 2 days. In 147 patients the median CR (IQR) from IV to PO HM was 2.5 (2.1-2.7) and correlation of IV to PO dose of HM was .95 (P < .0001). The median CR was 2.5 in patients receiving < 30mg of IV HM/day and 2.1 in patients receiving ≥ 30mg of HM/day (P = .004). In 247 patients the median ORR (IQR) from IV HM to MEDD was 11.5 (10-13) and correlation of IV HM to MEDD was .93 (P < .0001). The median ORR was 11.5 in patients receiving < 30mg of IV HM/day and 9.9 in patients receiving ≥ 30mg of HM/day (P = .0004). ORR from IV HM to MEDDs obtained from morphine (11) and oxycodone (12.1) were significantly different (P = .0023). The CR and ORR were not significantly impacted by other variables. Conclusions: The median CR from IV to PO HM is 2.5 and ORR from IV HM to MEDD is 11.5. This implies that 1 mg IV HM is equivalent to 2.5 mg PO HM and 11.5 mg MEDD. HM may cause hyperalgesia at doses ≥ 30 mg/day and thereby requires a lower ORR to other opioids.

Use of Palliative Care Services in a Tertiary Cancer Center

This study analyzed palliative/supportive care use in a single cancer center over 8 years. Billing data showed the inpatient consultations as a percentage of hospital admissions and the ratio of inpatient consultations to hospital beds almost doubled. In the outpatient setting, data revealed earlier access to outpatient referrals to palliative care service (from 4.8 months to 7.9 months; p = .001) during the study period.

Background.

Despite increasing prevalence of palliative care (PC) services in cancer centers, most referrals to the service occur exceedingly late in the illness trajectory. Over the years, we have made several attempts to promote earlier patient access to our PC program, such as changing the name of our service from PC to supportive care (SC). This study was conducted to determine the use of PC/SC service over the past 8 years.

Methods.

We reviewed billing data for all PC/SC encounters. We examined five metrics for use: inpatient consultations as a percentage of hospital admissions, ratio of inpatient consultations to average number of operational beds, time from hospital registration to outpatient consultation, time from advanced cancer diagnosis to consultation, and time from first outpatient consultation to death/last follow-up.

Results.

Over the years, we found a consistent increase in patient referrals to the PC/SC program. In the inpatient setting, we found approximate doubling of the inpatient consultations as a percentage of hospital admissions and the ratio of inpatient consultations to hospital beds (from 10% to 19% and from 2.4 to 4.9, respectively; p < .001). In the outpatient setting, we observed variations in referral pattern between oncology services, but, overall, the time from consultation to death/last follow-up increased from 4.8 months to 7.9 months (p = .001), which was accompanied by a significant decrease in the interval to consultation from hospital registration and advanced cancer diagnosis (p < .001).

Conclusion.

We have observed a consistent annual increase in new patient referrals as well as earlier access for outpatient referrals to our SC service, supporting increased use of palliative care at our cancer center.

Implications for Practice:

In response to accumulating evidence on the benefits of palliative care (PC) referral to oncology patients, efforts are being made to increase PC use. This study, conducted at MD Anderson Cancer Center, demonstrates consistent annual growth in PC referrals, which was accompanied by a significant increase in the outpatient referral of patients with nonadvanced cancer and earlier referral of those with advanced cancer. However, significant variations in the referral patterns between oncology services were observed. These results have implications for other cancer centers looking to enhance use of PC services by having a business model that allows for appropriate space and staff expansion.

The effects of dexamethasone and placebo on symptom clusters in advanced cancer patients: A preliminary report

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Background: Advanced cancer patients frequently experience debilitating symptoms that occur in clusters, but few pharmacological studies have targeted symptom clusters. Our objective was to examine the effects of dexamethasone on symptom clusters. Methods: Secondary analysis of a recent RCT of dexamethasone (DEX) vs placebo (PL) on cancer symptoms as assessed by FACIT-F-Fatigue; FAACT-Anorexia-Cachexia; BPI - Pain; HADS- Anxiety-Depression; ESAS: Sleep, Drowsiness, Dyspnea. Symptom clusters were identified based on baseline symptoms [ESAS] using principal component analysis. Cluster scores were computed by adding each scale divided by the maximum value for the scale: Fatigue- Anorexia-Depression = (Fatigue /52 + Anorexia/48+ HADS-Depression/21); Sleep-Anxiety-Drowsiness = (Sleep/10+HADS-Anxiety/21+Drowsiness /10); Pain-Dyspnea = (BPI/10 +Dyspnea /10). Higher number indicates better QOL. Correlations and change in the severity of symptom clusters were analyzed. Results: In 114 evaluable patients, 3 clusters accounted for 63% of the total variance at baseline: Fatigue-anorexia/cachexia-depression cluster (FAD); sleep-anxiety-drowsiness cluster (SAD) and Pain-Dyspnea cluster (PD). Median (IQR) improvement in the FAD cluster at Day 15 and Day 8 was significantly higher in the DEX than in the PL group [0.22 (-0.04, 0.45) vs. 0.06 (-.30, .20), P = 0.016)] and [0.15 (-0.84, 0.35) vs-0.095 (-0.35, 0.16), p = 0.017] respectively. There was no significant change observed in SAD and PD after DEX. Median (IQR) scores for FAD and PD of the DEX group at baseline, day 8, and day 15 were 1.42(1.1,1.7),1.71(1.3,2.1),1.78(1.4,2.2); [1.1(0.8,1.4); 1.38(.04,1.6); 1.43(1.3,1.7) respectively and significantly correlated over time at Day 8 (r = 0.76; p < 0.001) Day 15 (r = 0.55;p < 0.001) [FAD]; Day 8 (r = 0.36; p < 0.001) Day 15 (r = 0.45; p < 0.001) [PD]. Conclusions: FAD cluster showed improvement with dexamethasone and consistent correlation overtime, as compared to SAD and PD cluster. These findings suggest that fatigue-anorexia/cachexia- and depression share a common a common pathophysiologic basis. Further studies are needed to investigate this cluster and target anti-inflammatory therapies. Clinical trial information: NCT00489307.