Anna C. Beck

Palliative care, version 2.2017: Featured updates to the NCCN guidelines

The NCCN Guidelines for Palliative Care provide interdisciplinary recommendations on palliative care for patients with cancer. These NCCN Guidelines Insights summarize and provide context for the updated guidelines recommendations regarding hospice and end-of-life (EOL) care. Updates for 2017 include revisions to and restructuring of the algorithms that address important EOL concerns. These recommendations were revised to provide clearer guidance for oncologists as they care for patients with cancer who are approaching the transition to EOL care. Recommendations for interventions and reassessment based on estimated life expectancy were streamlined and reprioritized to promote hospice referrals and improved EOL care.

Interdisciplinary Team Care and Hospice Team Provider Visit Patterns during the Last Week of Life

BACKGROUND Hospice provides intensive end-of-life care to patients and their families delivered by an interdisciplinary team of nurses, aides, chaplains, social workers, and physicians. Significant gaps remain about how team members respond to diverse needs of patients and families, especially in the last week of life. OBJECTIVE The study objective was to describe the frequency of hospice team provider visits in the last week of life, to examine changes in frequency over time, and to identify patient characteristics that were associated with an increase in visit frequency. DESIGN This was a retrospective cohort study using electronic medical record data. SETTING/SUBJECTS From U.S. not-for-profit hospices, 92,250 records were used of patients who died at home or in a nursing home, with a length of stay of at least seven days. MEASUREMENTS Data included basic demographic variables, diagnoses, clinical markers of illness severity, patient functioning, and number of hospice team member visits in the last seven days of life. RESULTS On average the total number of hospice team member visits in the last week of life was 1.36 visits/day. Most were nurse visits, followed by aides, social workers, and chaplains. Visits increased over each day on average across the last week of life. Greater increase in visits was associated with patients who were younger, male, Caucasian, had a spouse caregiver, and shorter lengths of stay. CONCLUSIONS This study provides important information to help hospices align the interdisciplinary team configuration with the timing of team member visits, to better meet the needs of the patients and families they serve.

Dispositional mindfulness predicts attenuated waking salivary cortisol levels in cancer survivors: a latent growth curve analysis

PurposeCancer survivors experience significant stress and diminished well-being long after treatment. Dispositional mindfulness is linked with salutary coping with stress and enhanced well-being, with potentially beneficial effects on stress-related hormones. In the present study, we evaluated dispositional mindfulness as a predictor of changes in waking salivary cortisol levels among a sample of cancer survivors.MethodsMindfulness, well-being, and saliva samples were collected at baseline and at 4- and 12-week follow-ups. Latent growth curve analysis was conducted to examine baseline dispositional mindfulness as a predictor of changes in waking salivary cortisol over time, and regression analyses examined associations between well-being and cortisol.ResultsFindings indicated that cancer survivors who reported lower baseline levels of dispositional mindfulness exhibited increases in waking cortisol over time, whereas those who reported higher baseline dispositional mindfulness showed comparatively stable waking cortisol over the study period. Furthermore, increases in waking cortisol were associated with decreased well-being over the study period.ConclusionsThis study provides preliminary evidence that cancer survivors with higher levels of dispositional mindfulness may be buffered from deleterious changes in cortisol secretion.Implications for Cancer SurvivorsEnhanced dispositional mindfulness may promote salutary neuroendocrine function among cancer survivors and thereby improve well-being during the survivorship process.

A Phase I Study of Neoadjuvant Chemotherapy With Nab-Paclitaxel, Doxorubicin, and Cyclophosphamide in Patients With Stage II to III Breast Cancer

Background: The aims of this study were to assess the safety and tolerability of nanoparticle albumin bound paclitaxel (nab‐paclitaxel), doxorubicin, and cyclophosphamide as combination therapy for breast cancer patients in the neoadjuvant setting and to assess the overall clinical response and pathologic complete response (pCR). Patients and Methods: Twenty‐six women with newly diagnosed stage II to III histologically or cytologically proven adenocarcinoma of the breast with negative HER2 status were enrolled. Patients were treated with nab‐paclitaxel 100 mg/m2, doxorubicin 50 mg/m2, and cyclophosphamide 500 mg/m2 on day 1 and nab‐paclitaxel 100 mg/m2 on day 8 in a 21‐day cycle for 6 cycles total. Results: Most adverse events attributed to treatment were decreased white blood cell count, neutropenia, anemia, thrombocytopenia, and lymphopenia with a median duration of 8 days. Fifteen of 23 (65.2%; 95% confidence interval [CI], 45.7%‐84.6%) had a complete clinical response and 8 of 23 (34.7%; 95% CI, 15.2%‐54.1%) had a partial clinical response for an overall clinical response rate of 100%. Thirteen of 23 patients (56.5%; 95% CI, 36.2%‐76.7%) had a pCR. All 10 triple‐negative breast cancer (TNBC) patients (100%) achieved a pCR. Conclusion: The regimen of nab‐paclitaxel, doxorubicin, and cyclophosphamide chemotherapy was well tolerated and resulted in high clinical as well as pathologic responses, particularly in TNBC. Micro‐Abstract: We investigated a novel combinatorial approach using old drugs doxorubicin, cyclophosphamide and nab‐paclitaxel in the neoadjuvant setting. Patients were enrolled in Alabama and Utah in a standard 3+3 phase I design. The clinical response rate was 100%; the pathologic complete response (pCR) was over 56%. All 10 patients with triple negative disease (TNBC) achieved pCR (100%). Toxicities were as expected for chemotherapy. This approach warrants further studies in TNBC.

When Is Hospice Appropriate? The Role for Hospice in Palliating Patients with Bone Metastases

At some point in their disease trajectory, cancer patients with bone metastases will become candidates for end of life care. Depending upon the tumor type and treatment options, this point can occur earlier in some tumor types or patients with poor performance status. Hospice services may be the most appropriate means of supporting cancer patients when treatment options are less likely to provide effective relief from symptoms, or when a patient feels that supportive care alone fits best with their goals of care. Advanced cancer patients will be eligible for hospice care, but may be more appropriately palliated with a surgical intervention. Several available prognostic tools are available to help guide both the surgeon and the patient in decision making. Consultation with a palliative care physician will be helpful in difficult case where the risks and benefits of surgical intervention may be less clear.

Making treatment decisions at end of life in a comprehensive cancer center.

51 Background: End of life treatment decisions are challenging for cancer patients and oncology providers. Patients must understand their prognosis and options, deciding if and when to increase palliative care and decrease tumor-focused therapy. Cancer centers committed to offering clinical trials and evaluate new therapies add complexity to these decisions. To better define crucial points for decision making, we reviewed the care patients received during the last 6 months of life at one comprehensive cancer center. METHODS A retrospective chart review was conducted of the 301 cancer patients who died during one calendar year and were treated at the Huntsman Cancer Institute. We abstracted the care documented from all clinic visits, phone calls and hospitalizations including referrals and resources utilized during the last 6 months of life. RESULTS Men and women were equally represented with a mean age of 61at death and a median survival of 13 months after diagnosis. Over 1780 outpatient visits were documented during the last 6 months of life with treatment decision conversations noted at 68% of visits. Results of these discussions included new chemotherapy initiated at 26% of visits, treatment termination at 19% of visits, palliative therapy only at 9% of visits, and no treatment change at 47% of visits. Of the 64% of patients receiving chemotherapy in the last 6 months, 32% continued therapy in the last 30 days of life. Similarly, 34% of patients received radiation therapy in the last 30 days. Hospice was used by 59% of patients, with a mean length from referral to death of 29 days. Conversations about hospice occurred in 65% of patients with a mean/median of 2 conversations/patient. Approximately 37% of these conversations resulted in hospice enrollment, 49% deferred a decision and in 14% the patient requested additional treatment. CONCLUSIONS Defining optimal timing for stopping cancer directed therapy is challenging in medical and radiation oncology, with 1in 3 patients continuing treatment in the last month of life. Goals of care and hospice conversations were required on multiple occasions, underscoring the need for oncology providers to have highly honed communication skills to minimize futile care and maximize palliative care.

Integrated Mindfulness-Oriented Recovery Enhancement (MORE) and physical health intervention for cancer survivors with obesity: Preliminary results from a pilot randomized controlled trial.

237 Background: Hypothetically, interventions that reduce excessive weight and promote nutrition and physical activity may protect against cancer recurrence. Yet, obesity is often fueled by compulsive eating behaviors. Integrative therapies that combine exercise and nutrition training with techniques to enhance interoceptive awareness and cognitive control over automatic, compulsive eating may be especially efficacious. This pilot study tested the preliminary efficacy of an integrated exercise, nutrition, and Mindfulness-Oriented Recovery Enhancement (MORE) intervention in a sample of obese cancer patient. METHODS Obese (Mean BMI = 35.8) female patients (Mean age 58.41) with breast (n = 15), colon (n = 1), and endometrial cancers (n = 1) were recruited and randomly assigned to receive exercise and nutrition intervention without (POWER, n = 10) or with an additional mindfulness component (MORE POWER, n = 7). Participants met twice weekly for 10 weeks for group exercise and nutrition sessions. MORE POWER participants also participated in 10 weekly group mindfulness sessions. Pre- and post-intervention, assessments included self-report measures, weight and BMI measurement, and a cue-elicited heart rate variability (HRV) assessment. RESULTS The MORE POWER group evidenced significantly greater reductions in BMI (p = .015) and weight (p = .034; 6.57 lbs. vs. 1.35 lbs.) than the POWER group. The MORE POWER group also reported significantly greater increases in interoceptive awareness (p = .019) and mindful observation than the POWER group (p = .040). Increases in mindful observation predicted residualized change in BMI, Beta = -.13, SE = .05, p = .03. Lastly, MORE POWER group exhibited significantly greater post-intervention HRV than the POWER group (p = .011). CONCLUSIONS Integrating MORE with an exercise and nutrition training program appeared to enhance weight loss outcomes in this pilot sample of obese cancer patients. Findings suggest that mindfulness training may strengthen cognitive regulation of appetitive and motivational reactions crucial to weight loss, and thereby promote health in cancer survivors.

Linking dispositional mindfulness and positive psychological processes in cancer survivorship: A multivariate path analysis.

237 Background: Research indicates dispositional mindfulness is linked with positive psychological outcomes. This disposition, which is malleable through training, is characterized by the tendency exhibit nonjudgmental and nonreactive awareness of ones thoughts, emotions, and present moment sensory-perceptual experience. Although this trait has been linked with salutary outcomes in the broader mental health literature, less is known about the trait of mindfulness in cancer survivors and how it may be linked with indices of psychological and physical health relevant to cancer survivorship. METHODS We conducted a multivariate path analysis of cross-sectional data from a heterogenous sample of cancer patients (N = 97) to test a conceptual model linking dispositional mindfulness with cancer-related quality of life via positive psychological processes. RESULTS We found that patients with higher levels of dispositional mindfulness were more likely to pay attention to positive experiences (β = 0.47), a propensity which was associated with positive reappraisal of stressful life events (β = 0.46). Patients who endorsed more frequent positive reappraisal had a greater sense of sense of meaning in life (β = 0.43) and savored rewarding or life affirming events (β = 0.45). In turn, those who engaged in high levels of savoring had better quality of life (β = 0.33) and suffered from less emotional distress (β = -0.54). Overall model fit was excellent, χ2/df= 1.18; CFI = 0.99; RMSEA = 0.04 (0.00, 0.12). CONCLUSIONS The data support our hypothetical model of the processes by which mindfulness promotes psychological flourishing in the face of cancer. Dispositional mindfulness appears to broaden attention from a myopic focus on illness to encompass previously unattended positive features of the social and natural environment. With this broader set of information from which new, more adaptive situational appraisals may be generated, mindfulness may engender positive reappraisals of stressful life events and promote sense of meaning in life. When sustained over time, these processes may propel an upward spiral of positive cognition-emotion interactions with salutary consequences for cancer survivorship.