Angelique Wong

Frequency, Predictors, and Medical Record Documentation of Chemical Coping Among Advanced Cancer Patients

BACKGROUND In this prospective study, we determined the frequency of opioid-related chemical coping among advanced cancer patients, as diagnosed by palliative medicine specialists. We also determined predictors for chemical coping and the concordance between the physicians diagnosis and documentation in the medical records. PATIENTS AND METHODS Palliative medicine specialists evaluated and diagnosed consecutive patients seen for chemical coping. The proportion of patients identified as chemically coping was compared with the proportion documented in the medical records. Demographic data; cancer diagnosis; history of smoking; substance abuse; psychiatric disease; morphine equivalent daily dosage; Cut-down, Annoyed, Guilty, and Eye-opener (CAGE) questionnaire scores; and Edmonton Symptom Assessment System scores were also collected. RESULTS A total of 432 patients were evaluated. Overall, 76 patients (18%; 95% confidence interval [CI]: 14%-21%) were diagnosed as chemically coping. Documentation of chemical coping in the medical records was reported for only 15 patients (4%; 95% CI: 2%-6%). CAGE positivity (odds ratio [OR]: 2.89), younger age (OR: 0.97 per year), better performance status (OR: 0.68 per point), pain (OR: 1.20 per point), and well-being (OR: 1.28 per point) were found to be significant predictors of chemical coping by protocol definition. After recursive partitioning, 21 of 50 patients (42%) who were CAGE positive and had an Eastern Cooperative Oncology Group performance status ≤2 were diagnosed as chemically coping. CONCLUSION Approximately 18% of palliative care patients seen were diagnosed as chemically coping by palliative medicine specialists. The frequency of documentation in the medical records was significantly lower. Better and safer ways for physicians to assess and report chemical coping are needed. IMPLICATIONS FOR PRACTICE Cancer pain is a multidimensional symptom for which opioids are the mainstay of treatment. However, opioids can have a double effect resulting in drug-seeking behaviors. Chemical coping occurs when a patient uses opioids in a nonprescribed way to cope with various stressful events. This can lead to misuse of opioids and complications including neurotoxicities, respiratory depression, and death. Proper diagnosis and documentation is needed to ensure proper management of pain and to avoid unnecessary harm. The findings of this study suggest that ∼18% of advanced cancer patients seen by a palliative care service were diagnosed as chemical coping, but only 4% were documented in the medical records.

The opioid rotation ratio of strong opioids to transdermal fentanyl in cancer patients

Transdermal fentanyl (TDF) is 1 of the most common opioids prescribed to patients with cancer. However, the accurate opioid rotation ratio (ORR) from other opioids to TDF is unknown, and various currently used methods result in wide variation of the ORR. The objective of this study was to determine the ORR of the oral morphine equivalent daily dose (MEDD) to the TDF dose when correcting for the MEDD of breakthrough opioids (the net MEDD) in cancer outpatients.

ReCAP: Attitudes, Beliefs, and Awareness of Graduate Medical Education Trainees Regarding Palliative Care at a Comprehensive Cancer Center

PURPOSE Palliative care (PC) training and integration with oncology care remain suboptimal. Current attitudes and beliefs of the oncology trainees regarding PC are not fully known. This study was undertaken in an attempt to address this issue. PARTICIPANTS AND METHODS We conducted a survey to determine awareness of PC among graduate medical trainees at a comprehensive cancer center with an established PC program. One hundred seventy oncology trainees who completed

A double-blind, randomized, placebo-controlled trial of panax ginseng for cancer-related fatigue in patients with advanced cancer

9 months of training in medical, surgical, gynecologic, and radiation oncology fellowships and residency programs during the 2013 academic year completed an online questionnaire. Descriptive, univariable, and multivariable analyses were performed. RESULTS The response rate was 78% (132 of 170 trainees); 10 trainees without hands-on patient care were excluded. Medical (53 of 60 [88%]), gynecologic (six of six [100%]), and radiation oncology (20 of 20 [100%]) trainees reported more awareness of PC compared with surgical oncology (22 of 36 [61%]) trainees (P = .001). One hundred twelve of 122 (92%) perceived PC as beneficial to patients and families. One hundred eight of 122 (89%) perceived that PC can reduce health care costs, 78 (64%) believed that PC can increase survival, and 90 (74%) would consult PC for a patient with newly diagnosed cancer with symptoms. Eighty-two trainees (67%) believed a mandatory PC rotation is important. Trainees with previous exposure to PC rotations were more aware of the role of PC services than were trainees without PC rotation (96% [46 of 48] v 74% [55 of 74]; P = .005, respectively). CONCLUSION Surgical trainees and trainees without previous PC rotation had significantly less awareness of PC. Overall, trainees perceived PC as beneficial to patients and capable of reducing costs while increasing survival; they also supported early PC referrals and endorsed a mandatory PC rotation.

Snapshot of an Outpatient Supportive Care Center at a Comprehensive Cancer Center

Background: Despite the high frequency, severity, and effects of cancer-related fatigue (CRF) on the quality of life (QoL) of patients with cancer, limited treatment options are available. The primary objective of this study was to compare the effects of oral Panax ginseng extract (PG) and placebo on CRF. Secondary objectives were to determine the effects of PG on QoL, mood, and function. Methods: In this randomized, double-blind, placebo-controlled study, patients with CRF ≥4/10 on the Edmonton Symptom Assessment System (ESAS) were eligible. Based on a pilot study, we randomized patients to receive either 400 mg of standardized PG twice daily or a matching placebo for 28 days. The primary end point was change in the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) subscale from baseline to day 29. Results: Of 127 patients, 112 (88.2%) were evaluable. The mean (SD) FACIT-F subscale scores at baseline, day 15, and day 29 were 22.4 (10.1), 29.9 (10.6), and 30.1 (11.6) for PG (P<.001), and 24.0 (9.4), 30.0 (10.1), and 30.4 (11.5) for placebo (P<.001). Mean (SD) improvement in the FACIT-F subscale at day 29 was not significantly different in the PG than in the placebo group (7.5 [12.7] vs 6.5 [9.9]; P=.67). QoL, anxiety, depression, symptoms, and functional scores were not significantly different between the PG and placebo groups. Improvement in the FACIT-F subscale correlated with baseline scores (P=.0005), Hospital Anxiety and Depression Scale results (P=.032), and sex (P=.023). There were fewer any-grade toxicities in the PG versus placebo group (28/63 vs 33/64; P=.024). Conclusions: Both PG and placebo result in significant improvement in CRF. PG was not significantly superior to placebo after 4 weeks of treatment. There is no justification to recommend the use of PG for CRF. Further studies are needed. Trial Registration: ClinicalTrials.gov identifier: NCT01375114.

Edmonton Symptom Assessment Scale (ESAS): Time duration of self-completion versus assisted-completion in palliative care patients—A randomized controlled trial.

BACKGROUND Integration of palliative care (PC) in oncology have been found to improve symptom distress, quality of life, and survival in patients with advanced cancer. Early integration is most appropriate in the outpatient setting. However, most PC services in the United States do not have an outpatient component. Our study aims to provide a snapshot of the type of patients and families who are referred to this novel setting for the delivery of early PC. CONCLUSION Traditionally, PC has been delivered predominantly to patients with advanced disease and to aid in transition to end of life. In recent years, outpatient centers have dramatically changed the nature of PC work as in our snapshot, which shows that in addition to patients regarded as more traditional patients, such as those transitioning to end of life, there are now patients who come in very soon after arrival to a cancer center requiring specialized care to address a variety of symptom and educational needs, thus requiring adaptation of structure and processes to allow access for frequent follow-ups, counseling, and flexibility for walk-in visits. Our findings suggest that Supportive Care Clinic needs to practice in a very different way, which requires certain skills and assessment tools that are not conventionally present in traditional oncology clinic settings. More research is needed to identify the type of patients who would benefit most from a PC referral.

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

67 Background: ESAS is a multidimensional assessment tool for self-reporting of symptom intensity. Unfortunately, ESAS is not used often in clinical care due to the perception that it may be time consuming. Our aim was to compare the time duration of self-completion (SC) of ESAS for the first time by patients with advanced cancer vs. assisted-completion (AC) with a health care professional (HCP). METHODS In this randomized controlled trial, patients with advanced cancer who have never completed the ESAS at MD Anderson were allocated (1:1) with a web-based system to either to self-completion of the ESAS form vs assisted completion by the research assistant. Time of completion was measured by the research assistant using a stop watch. Patients completed the Rapid Estimate of Adult Literacy in Medicine (REALM) test prior to administration of the ESAS. In the self-completion group, the nurse reviewed the responses to verify that the reported ESAS scores were correct (nurse review). RESULTS 127 patients were enrolled (69 patients to AC and 58 to SC). The median age was 60 years old, and median REALM score was 65. The median (IQR) time of SC alone was significantly less than AC (1.2 minutes (.7, 1.5) vs 1.82 minutes (1.3, 2.3), p = .000). With nurse review time included, the SC time increased to 1.92 minutes (p (vs. AC) = .28). Lower literacy (REALM) score was significantly associated with increased completion time (p = .007). Other demographical and clinical variables were not significantly associated with completion time. 73/127 (58%) patients reported they did not mind completing the ESAS alone or with the help of the nurse. CONCLUSIONS The ESAS can be completed in less than 2 minutes with or without assistance by a HCP. When nurse review time was included, there was no difference in time of completion as compared to assisted completion. Our results support that regular clinical use of ESAS will have minimal impact on clinical time.

Snapshot of an outpatient supportive care center at a comprehensive cancer center.

209 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.

Characteristics of patients with unscheduled versus scheduled visits to outpatient supportive care center (SCC) at a comprehensive cancer center.

145 Background: Integration of Palliative Care (PC) in oncology has been found to improve symptom distress, quality of life and survival in patients with advanced cancer. Early integration is most appropriate in the outpatient (OP) setting. However, most PC services in the U.S. do not have an OP component. Our study aims to provide a snapshot of the type of patients that are referred to this novel setting for the delivery of early PC. METHODS We reviewed a day in the SCC to illustrate the structure and process involved in the delivery of outpatient PC. We highlighted 9 patients seen that day to show the variety of patients, scope of services, and the unique roles that PC interdisciplinary team members perform. RESULTS 41 patients were seen that day in the SCC: 10 scheduled consults, 22 scheduled follow-ups, 9 (22%) same-day unscheduled patients: 4 follow-ups, 1 consult and 4 nurse triages. There were also 31 telephone encounters. Most patients seen were for routine follow-up and symptom assessment. However, 10 presented with worsening symptoms with one needing hospital admission. 21 patients required additional counseling: 2 for hospice transitioning, 12 for psychosocial distress, 7 for opioid education. PC was delivered predominantly by physicians and nurses with collaboration with our pharmacist, counselors, and case manager. CONCLUSIONS Traditionally, PC has been delivered predominantly to patients with advanced disease and to aid in transition to end of life. In recent years, OP centers have dramatically changed the nature of PC work as in our snapshot. In addition to patients regarded as traditional PC patients, such as those transitioning to end of life, there are now patients who come in soon after arrival to a cancer center requiring specialized care to address a variety of symptom and educational needs, thus requiring adaptation of structure and processes to allow access for frequent follow ups and counseling and flexibility for walk-in visits. Our findings suggest that SCC needs to practice in a very different way which requires certain skills and assessment tools that are not conventionally present in traditional oncology clinic setting. More research is needed to identify the type of patients that would benefit most from a PC referral.

Palliative Care and End of Life Options for Patients with Endometrial Cancer

144 Background: There is limited literature regarding outpatient palliative care, and even more limited literature describing factors associated with unscheduled visits. Our aim was to identify clinical characteristics of patients who walk-in (present unscheduled) to the outpatient SCC with the hypothesize that the patients who present for unscheduled visits have more severe symptom distress as compared to those patients who present for scheduled appointments. METHODS We compared 183 patients with unscheduled consults (CO) vs a random sample of 361 patients with scheduled CO and 159 patients with unscheduled follow-up (FU) visits vs a random sample of 318 patients with scheduled FU visits. RESULTS Among 544 total CO visits, unscheduled visits had worse median Edmonton Symptom Assessment Scale (ESAS) symptoms (on a scale from 0 to 10): pain (6.5 vs 4.7, p < .0001), fatigue (p = .002), nausea (p = .017), depression (p = .003), anxiety (p = 0.02), sleep (p = .0002), and overall feeling of well-being (p = 0.0009). There was no statistical difference in shortness of breath, financial distress, nor spiritual pain. Daily opioid dose (MEDD in mg) was significantly higher in unscheduled CO visits (119.7 vs 62.9, p = .0004). Among 344 total FU visits, unscheduled visits had worse median ESAS symptoms: pain (5.7 vs 4.2, p = .0001), fatigue (p = .0006), depression (p = .019), anxiety (p = .014) and higher MEDD (111.3 vs 73.6, p = .0009). There was no difference in type of insurance coverage and better ECOG (p = .015) in unscheduled vs scheduled CO visits. Unscheduled CO visits were more likely to be from outside the Houston area (161/361, 45% vs. 40/133, 30%, p < 0.0001). CONCLUSIONS Patients who are either referred as unscheduled CO visits or who present as unscheduled FU visits have higher levels of physical and psychosocial distress and higher opioid dose. Outpatient palliative care centers need to provide opportunity for walk-in referrals for timely management of these issues.