Andrew S. Epstein

Identification of germline genetic mutations in patients with pancreatic cancer

Pancreatic adenocarcinoma (PAC) is part of several cancer predisposition syndromes; however, indications for genetic counseling/testing are not well‐defined. In the current study, the authors sought to determine mutation prevalence and characteristics that are predictive of an inherited predisposition for PAC.

Humidified high-flow nasal oxygen utilization in patients with cancer at Memorial Sloan-Kettering Cancer Center.

BACKGROUND Respiratory signs and symptoms are commonly encountered by physicians who care for cancer patients. Supplemental oxygen (SOx) has long been used for treatment of hypoxic respiratory insufficiency, but data reveal mixed efficacy results. The use and outcome patterns of technologically advanced oxygen delivery devices, such as humidified high-flow nasal oxygen (HHFNOx), are incompletely understood. METHODS Institutional database search of the number of patient cases in which the current HHFNOx device was used, and abstraction of 183 patient medical records for usage characteristics. RESULTS Patients have been treated with HHFNOx at Memorial Sloan Kettering Cancer Center (MSKCC) since 2008. Of the 183 patients randomly selected for our study, 72% received HHFNOx in the intensive care unit (ICU) because of hypoxia. Patients usually improved (41%) or remained stable (44%) while on the device, whereas 15% declined. At study completion, 45% of patients were living, and 55% had died. The median time on HHFNOx was 3 days (range: 1-27). A do not resuscitate (DNR) order was present in 101 (55%) patients, either before (12%) or after (43%) device utilization. The majority (78%) of these 101 patients died at MSKCC. CONCLUSION Dyspnea is a common and important symptom in cancer patients for which SOx traditionally has had no clear basis except in select cases of hypoxia and patient preference. Our institutional experience with HHFNOx contributes to the understanding of the applications and challenges surrounding the use of new medical devices in the cancer population. Physiologic and quality-of-life benefits of HHFNOx compared with traditional oxygen delivery methods should be studied prospectively.

Discussions of Life Expectancy and Changes in Illness Understanding in Patients With Advanced Cancer

Purpose Accurate illness understanding enables patients to make informed decisions. Evidence of the influence of prognostic discussions on the accuracy of illness understanding by patients would demonstrate the value of discussions. Methods Recent and past oncology provider-patient discussions about prognosis/life expectancy were examined for their association with changes in illness understanding by patients. Patients (N = 178) with advanced cancers refractory to prior chemotherapy whom oncologists expected to die within 6 months were interviewed before and after a visit in which cancer restaging scan results were discussed. Illness understanding scores were the sum of four indicator variables: patient terminal illness acknowledgment, recognition of incurable disease status, knowledge of the advanced stage of the disease, and expectation to live months as opposed to years. Results Before the restaging scan visit, nine (5%) of 178 patients had completely accurate illness understanding (ie, correctly answered each of the four illness understanding questions). Eighteen patients (10%) reported only recent discussions of prognosis/life expectancy with their oncologists; 68 (38%) reported only past discussions; 24 (13%) reported both recent and past discussions; and 68 (38%) reported that they never had discussions of prognosis/life expectancy with their oncologists. After adjustment for potential confounders (ie, education and race/ethnicity), analysis identified significant, positive changes in illness understanding scores for patients in groups that reported recent only (least-squares mean change score, 0.62; 95% CI, 0.23 to 1.01; P = .002) and both recent and past (least-squares mean change score, 0.37; 95% CI, 0.04 to 0.70; P = 0.028) discussions of prognosis/life expectancy with their oncologists. Conclusion Patients with advanced cancer who report recent discussions of prognosis/life expectancy with their oncologists come to have a better understanding of the terminal nature of their illnesses.

Analysis of incidence and clinical outcomes in patients with thromboembolic events and invasive exocrine pancreatic cancer

Pancreatic adenocarcinoma is among the most common malignancies associated with thromboembolic events (TEs); however, reported incidence figures vary significantly and contain small patient cohorts. Pancreatic cancer‐specific thrombosis studies examining the correlation between clinical variables, including thrombosis timing and the impact of thrombosis on survival, have not been reported.

A Randomized Controlled Trial of a Cardiopulmonary Resuscitation Video in Advance Care Planning for Progressive Pancreas and Hepatobiliary Cancer Patients

BACKGROUND Cardiopulmonary resuscitation (CPR) is an important advance directive (AD) topic in patients with progressive cancer; however such discussions are challenging. OBJECTIVE This study investigates whether video educational information about CPR engenders broader advance care planning (ACP) discourse. METHODS Patients with progressive pancreas or hepatobiliary cancer were randomized to an educational CPR video or a similar CPR narrative. The primary end-point was the difference in ACP documentation one month posttest between arms. Secondary end-points included study impressions; pre- and post-intervention knowledge of and preferences for CPR and mechanical ventilation; and longitudinal patient outcomes. RESULTS Fifty-six subjects were consented and analyzed. Rates of ACP documentation (either formal ADs or documented discussions) were 40% in the video arm (12/30) compared to 15% in the narrative arm (4/26), OR=3.6 [95% CI: 0.9-18.0], p=0.07. Post-intervention knowledge was higher in both arms. Posttest, preferences for CPR had changed in the video arm but not in the narrative arm. Preferences regarding mechanical ventilation did not change in either arm. The majority of subjects in both arms reported the information as helpful and comfortable to discuss, and they recommended it to others. More deaths occurred in the video arm compared to the narrative arm, and more subjects died in hospice settings in the video arm. CONCLUSIONS This pilot randomized trial addressing downstream ACP effects of video versus narrative decision tools demonstrated a trend towards more ACP documentation in video subjects. This trend, as well as other video effects, is the subject of ongoing study.

Augmenting advance care planning in poor prognosis cancer with a video decision aid: a preintervention-postintervention study.

The authors tested whether an educational video on the goals of care in advanced cancer (life‐prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation.

Augmenting advance care planning in poor prognosis cancer with a video decision aid

The authors tested whether an educational video on the goals of care in advanced cancer (life‐prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation.

Current State of the Art and Science of Patient-Clinician Communication in Progressive Disease: Patients' Need to Know and Need to Feel Known

Effective communication rests at the core of medicine, especially when patients are confronted with progressive disease and death. Communication can mitigate the distress of receiving bad news and influence patients’ psychological functioning and adaptation to a new situation. 1-3 Whereas the benefits of good communication might seem clear, the costs of its failure are perhaps even clearer. Especially in progressive disease (which we define as entailing palliative and endof-life care in worsening serious illness) with guarded prognoses and significant psychosocial stressors, the stakes are high in most if not every clinical encounter with patients and families. Communication deficits cause unnecessary distress not only for patients but also their loved ones. 4 It is not surprising that most formal complaints in health care are believed to be related to communication. 5,6 Herein, we therefore tackle the central question that remains: what is good, effective communication in progressive disease and how can it be taught, evaluated, and implemented to improve patient outcomes? In medical consultations, patients experience a double-need: to

Building on Individual, State, and Federal Initiatives for Advance Care Planning, an Integral Component of Palliative and End-of-Life Cancer Care.

Federal and state provisions for advance care planning-the process by which patients, families, and medical professionals plan for future and, in particular, end-of-life care-continue to receive attention. Such planning remains an integral component of palliative care, complementing the recognition and treatment of pain and other symptoms that patients with advanced malignancies and their families encounter. Historically, advance care planning interventions (particularly those involving advance directives) have been unable to consistently demonstrate positive outcomes for patients with life-threatening illnesses. However, more recent literature, including that on patients with cancer, illustrates that both patients and caregivers report improved quality of life and less distress after discussions with their health care teams about end-of-life care. Herein, we discuss recent federal and state public policy that focuses on advance care planning, suggesting the promise for care delivery improvements and the means by which existing barriers might be surmounted. These care delivery issues apply to several disease states but are particularly pertinent to the adult oncology setting.

A 67-Year-Old Woman with BRCA 1 Mutation Associated with Pancreatic Adenocarcinoma

IntroductionThere are approximately 40,000 new cases of pancreatic adenocarcinoma diagnosed in the USA each year. It is estimated that 5–10% of all patients with pancreatic cancer have a first-degree relative with the disease, while up to 20% of cases have a hereditary component. Individuals who carry a germline mutation in the BRCA 1 or 2 genes have an increased lifetime risk of developing pancreatic adenocarcinoma when compared with the general population.Case reportHere, we present a case of metastatic pancreatic adenocarcinoma arising in a 67-year-old carrier of a BRCA 1 germline mutation.DiscussionIn patients with known BRCA 1 or 2 mutation-associated pancreatic adenocarcinoma, the addition of a DNA cross-linking agent such as cisplatin, oxaliplatin, or mitomycin to a standard gemcitabine chemotherapy backbone should be considered. Poly ADP-ribose inhibitors are a novel class of drug, which have demonstrated promising efficacy in trials of BRCA 1 and 2 mutant breast and ovarian cancer, and are currently undergoing prospective evaluation in advanced pancreatic cancer.