Carolyn Lefkowits

Improvement in symptom burden within one day after palliative care consultation in a cohort of gynecologic oncology inpatients

OBJECTIVE The aim of this study is to evaluate the magnitude and time course of change in symptom burden after palliative care (PC) consultation in a cohort of gynecologic oncology inpatients. METHODS Women with a gynecologic malignancy and PC consultation for symptom management between 3/1/12 and 2/28/13 were identified. Charts were reviewed for demographic and disease characteristics. Symptom scores on a modified Edmonton Symptom Assessment System (ESAS) scale were abstracted for pain, anorexia, fatigue, depression, anxiety, nausea and dyspnea. Prevalence of moderate-to-severe symptom intensity was compared between the day of PC consultation (D1), the day after PC consultation (D2) and the last recorded symptoms before discharge (DLast). RESULTS PC was consulted for symptom management during 129 admissions of 95 unique patients. Median age was 59, 84% were white and 67% had stage III/IV disease, with ovarian the most common site (52%). Symptom prevalence on D1 for at least mild intensity ranged 14% (dyspnea) to 80% (pain) and for at least moderate intensity from 3% (dyspnea) to 50% (pain). Statistically significant decreases in prevalence of moderate to severe symptom intensity between D1 and DLast occurred for pain, anorexia, fatigue and nausea (magnitude 58-66%) and between D1 and D2 for pain, fatigue and nausea (magnitude 50-55%). The majority of the improvement that occurred between D1 and DLast happened by D2. CONCLUSIONS PC consultation is associated with improvement in symptom burden, the majority of which occurs within one day of consultation. PC may be an effective tool for symptom management in patients with moderate to severe symptom intensity even during short hospitalizations and should be considered early in the hospitalization to effect timely symptom relief.

Predictors of high symptom burden in gynecologic oncology outpatients: Who should be referred to outpatient palliative care?

OBJECTIVE To characterize symptom prevalence in gynecologic oncology outpatients and identify predictors of high symptom burden. METHODS We performed a retrospective analysis of a convenience sample of symptom surveys from gynecologic oncology patients at a single cancer center over a 20-month period. The survey was based on the Edmonton Symptom Assessment System (ESAS), and assessed pain, depression, anxiety, fatigue and well-being. Information on demographics, disease, treatment and history of chronic pain, depression or anxiety was abstracted from medical records. Data was analyzed with descriptive and t-test statistics. RESULTS We analyzed 305 surveys from unique patients. Symptom prevalence (severity score>0/10) ranged from 60.1% (pain) to 79.7% (fatigue). Prevalence of moderate to severe symptoms (score≥4/10) ranged from 32% (pain) to 47% (fatigue). There were no differences in symptom burden by site or stage of cancer. Patients with no active disease (38%) were less symptomatic. There was a trend toward higher symptom burden in patients younger than 50years. There was higher symptom burden in patients receiving cancer treatment or with a pre-existing history of pain, anxiety or depression. Patients who expressed an interest in being seen by a symptom management service also had higher symptom burden. CONCLUSIONS Gynecologic oncology outpatients have a high symptom burden regardless of stage and site of cancer. Patients who are young, on treatment or have a history of chronic pain, depression or anxiety have a higher symptom burden. Consideration should be given to targeting these patients for outpatient palliative care services.

Predictors of palliative care consultation on an inpatient gynecologic oncology service: Are we following ASCO recommendations?

OBJECTIVE Determine predictors of inpatient palliative care (PC) consultation and characterize PC referral patterns with respect to recommendations from the American Society of Clinical Oncology (ASCO). METHODS Women with a gynecologic malignancy admitted to the gynecologic oncology service 3/2012-8/2012 were identified. Demographic information, disease and treatment details and date of death were abstracted from medical records. Students t-test, Fischers exact test or χ(2)-test was used for univariate analysis. Binomial logistic regression was used for multivariate analysis. RESULTS Of 340 patients analyzed, 82 (24%) had PC consultation. Univariate predictors of PC consultation included race, cancer type and stage, recurrent disease, admission frequency, admission for symptom management or malignant bowel obstruction (MBO), discharge to skilled nursing facility (SNF) and number of lines of chemotherapy. On multivariate analysis, significant predictors of PC consultation were recurrent disease (OR 2.4, 95% CI 1.1-5.3), number of admissions (≥ 3, OR 10.9, 95% CI 3.4-34.9), admission for symptom management (OR 19.4, 95% CI 7.5-50.1), discharge to SNF (OR 5, 95% CI 1.9-13.5) and death within 6 months (OR 16.5, 95% CI 6.9-39.5). Of patients considered to meet ASCO guidelines, 53% (63/118) had PC referral. Of patients referred to PC, 51.2% (42/82) died within 6 months of last admission. CONCLUSIONS Patients referred to inpatient PC have high disease and symptom burden and poor prognosis. High-risk patients, including those meeting ASCO recommendations, are not captured comprehensively. We continue to use PC referrals primarily for patients near the end of life, rather than utilizing early integration as recommended by ASCO.

Strategies for Introducing Outpatient Specialty Palliative Care in Gynecologic Oncology

PURPOSE Concern that patients will react negatively to the idea of palliative care is cited as a barrier to timely referral. Strategies to successfully introduce specialty palliative care to patients have not been well described. We sought to understand how gynecologic oncologists introduce outpatient specialty palliative care. METHODS We conducted a national qualitative interview study at six geographically diverse academic cancer centers with well-established palliative care clinics between September 2015 and March 2016. Thirty-four gynecologic oncologists participated in semistructured telephone interviews focusing on attitudes, experiences, and practices related to outpatient palliative care. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine a coding framework. This analysis focuses on practices for introducing palliative care. RESULTS Mean participant age was 47 years (standard deviation, 10 years). Mean interview length was 25 minutes (standard deviation, 7 minutes). Gynecologic oncologists described the following three main strategies for introducing outpatient specialty palliative care: focus initial palliative care referral on symptom management to dissociate palliative care from end-of-life care and facilitate early relationship building with palliative care clinicians; use a strong physician-patient relationship and patient trust to increase acceptance of referral; and explain and normalize palliative care referral to address negative associations and decrease patient fear of abandonment. These strategies aim to decrease negative patient associations and encourage acceptance of early referral to palliative care specialists. CONCLUSION Gynecologic oncologists have developed strategies for introducing palliative care services to alleviate patient concerns. These strategies provide groundwork for developing system-wide best practice approaches to the presentation of palliative care referral.

How do palliative care needs vary across the disease trajectory in patients with gynecologic cancer

106 Background: The WHOs integrated model emphasizes that palliative care (PC) should be provided concurrently with curative and life-prolonging care, with disease-directed treatments decreasing and PC increasing over time. This study aimed to understand how accurately this theoretical model matches the PC needs of gynecologic cancer (GC) patients. METHODS GC patients at a comprehensive cancer center completed a symptom and needs assessment questionnaire as part of routine care. Needs were divided into physical, emotional, social, practical, and informational domains. Patients reporting at least one symptom score ≥ 4/10 made the physical need domain positive. For the remainder of the categories, patients endorsing at least one need in a given domain made that domain positive. Time points in the illness trajectory were categorized as diagnosis, primary treatment, remission, and progression/recurrence. Univariate analyses were utilized to assess differences in needs at various time points. RESULTS Questionnaires from 1348 patient visits over 3 months were included. Patients had ovarian (39%), uterine (36%), cervical (16%), and vulvar (5%) cancer. Visits occurred around the time of diagnosis (6%), during primary therapy (28%), during remission (42%), and during disease progression or recurrence (23%). Physical needs were most common at diagnosis and during progression/recurrence (p < 0.01). Emotional needs (p < 0.01), social needs (p < 0.01), and informational needs (p < 0.01) all varied throughout the course of disease and were highest at diagnosis. At each time point, at least 65% of patients had one or more PC needs. Having needs in multiple domains ( ≥ 3) was associated with time point, with patients around the time of diagnosis having the highest rate of need in multiple domains (p < 0.01). CONCLUSIONS GC patients have a broad range of PC needs across the trajectory of their illness. The WHO schema fails to capture the full scope of these needs and under-appreciates their prevalence earlier in the course of the disease. These results underscore the importance of training gynecologic oncologists in primary PC as well as increasing referrals to specialist PC providers.

Critical conversations in gynecologic oncology: Pilot study of communication skills training for fellows and advanced practice providers.

29 Background: Good communication is crucial to good patient care. Gynecologic oncology providers often face challenging communication scenarios, including giving serious news and discussing goals of care. Communication skills training (CST) has been shown to improve skill acquisition among providers of multiple specialties, but it has not been described in providers from gynecologic oncology or any surgical oncology specialty. METHODS We conducted a two-day CST workshop, based on the VitalTalk© model, with four faculty members (2 gynecologic oncologists and 2 palliative care physicians) and 10 gynecologic oncology provider participants (5 fellows and 5 advanced practice providers). Using didactics, demonstrations and practice sessions with simulated patients we focused on giving serious news and discussing goals of care. Pre and immediate post-workshop surveys evaluated acceptability of the workshop, perceived impact of preparedness to address challenging communication scenarios and anticipated impact on clinical practice. We compared pre and post-workshop prevalence of score of 4 or 5 out of 5 on a Likert scale for preparedness to handle 14 challenging communication scenarios. RESULTS Participants reported statistically significant increase in preparedness to handle 13 out of 14 challenging communication scenarios. Among those 13 topics, magnitude of improvement in proportion of participants rating preparedness 4 or 5 out of 5 ranged from 40-100% (all p < 0.05). All participants would recommend the course to others and all strongly agreed that this training should be required of all gynecologic oncology clinicians. CONCLUSIONS Participants felt strongly that the workshop provided high quality education relevant to their practice. As a result of the workshop, participants reported statistically significantly increased preparedness to handle challenging communication scenarios. CST is feasible and has high perceived effectiveness for clinicians in the primarily surgical oncologic specialty of gynecologic oncology.

Improvement in Symptom Burden Within One Day After Palliative Care Consultation in a Cohort of Gynecologic Oncology Inpatients (FR435-B)

Objectives List three symptoms that were statistically significantly improved within one day of PC consultation for symptom management in our cohort of gynecologic oncology inpatients. Synthesize the results of this study into one or two sentences that could be used to advocate for greater integration of specialty palliative care consultation into the care of gynecologic oncology inpatients. Original Research Background: The impact of inpatient palliative care (PC) on symptom burden in the gynecologic oncology (GO) population has not been evaluated. Research Objectives: Evaluate the magnitude and time course of change in symptom burden after PC consultation in a cohort of GO inpatients. Methods:

“Ask me, do you want to know the big picture?” Gynecologic oncology patient and provider perspectives on discussing prognosis.

37 Background: Prognosis affects decision making by providers and patients and accurate understanding of prognosis may help avoid futile end-of-life care. Gynecologic oncology (GO) patient and provider perspectives on discussing prognosis have not been described. We sought to analyze patient and provider preferences regarding timing, amount and type of information included in discussions of prognosis. METHODS Semi-structured qualitative interviews regarding palliative care with 19 GO providers (7 physicians, 7 advanced practice providers, 5 nurses) and 29 patients with advanced or recurrent gynecologic cancer at an academic medical center. Communication about prognosis was one interview domain. Two coders independently and iteratively analyzed transcripts using qualitative analysis. RESULTS Median patient age was 61, the most common cancer was ovary (59%) and 90% had recurrent disease. Providers were 74% female with median 15 years in practice. Themes included patients wanting frank discussions about prognosis, not limited to life expectancy. Further preferences regarding timing and content were individualized. All categories of providers reported having prognosis conversations. Providers saw these conversations as part of their clinical role, though they often found them difficult. Providers commonly equated prognosis purely with life expectancy. Providers recognized variation among patients in preferences regarding these conversations, but did not discuss asking patients directly about their preferences. CONCLUSIONS GO patients want frank discussions about what the future might hold, often including but not limited to life expectancy. Providers see these discussions as being within their scope of practice but often find them difficult. Opportunities exist for provider education regarding communication skills for assessing patient preferences and conducting patient centered prognosis discussions. Education should include GO physicians, advanced practice providers and nurses. Collaboration with specialty palliative care providers could facilitate that education and provide assistance with challenging cases.

Implementation of clinical triggers for palliative care consultation on a gynecologic oncology inpatient service: A pilot study.

51 Background: Our objectives were to (1) Assess the feasibility of creating clinical triggers for Palliative Care (PC) consultation on a large gynecologic oncology service and (2) Use triggers to increase PC consultation rates among trigger positive patients. METHODS Clinical triggers for PC consultation are listed below. Over a six month period, patients meeting triggers were prospectively identified and PC consultation was requested for those patients. Retrospective chart review was used to identify patients meeting triggers and gather clinical information. PC consultation rates were compared for patients meeting triggers in the 6 months pre and post trigger implementation. Statistical analysis utilized χ2 test, Fishers exact test and independent samples t-tests. RESULTS There was no difference in PC consultation rates among patients meeting triggers between the pre and post-triggers periods (see table). There was also no change in time from admission to PC consult (median time to PC consultation 1.56d vs. 2.24d, p=0.28) and no change in overall PC consultation volume (mean 17.3 new PC consults per 100 admissions/month vs. 18.5, p=0.67). Of the 38 patients in the post-triggers period who were not seen by PC, 50% (n=19) were inaccurately deemed trigger negative during their admission and 13% (n=5) were not screened at all. CONCLUSIONS Creation of clinical triggers for PC consultation was feasible in terms of investment from relevant stakeholders. Trigger implementation was not associated with increased rates of PC consultation for those patients. High baseline rates of PC consultation and screening process issues contributed significantly to the lack of change in PC consultation rates. Use of clinical triggers may still hold promise as a strategy for standardizing PC consultation patterns and capturing subgroups of patients with high needs. Next steps include modifying our clinical triggers and screening process and expanding into the outpatient setting. [Table: see text].

Change in symptom burden within one day of palliative care consultation in a cohort of gynecologic oncology inpatients.

28 Background: Change in symptom burden after inpatient palliative care consultation for symptom management in gynecologic oncology patients has not been described. Our objective was to evaluate the magnitude and time course of change in symptom burden after palliative care (PC) consultation in a cohort of gynecologic oncology inpatients. METHODS Women with a gynecologic malignancy and a PC consultation for symptom management between 3/1/12 and 2/28/13 were identified. Charts were reviewed for demographics and disease characteristics. PC provider reports of patient symptom intensity on a modified Edmonton Symptom Assessment System were retrospectively reviewed. Data was analyzed with descriptive statistics and two sample test of proportions to compare prevalence of moderate to severe symptom intensity on the day of consultation to the day after consultation. RESULTS Over 12 months, there were 172 PC consultations for symptom management involving 123 unique patients. The median age was 58 and most common cancer was ovarian (44%), followed by cervical (26%) and uterine (24%). Prevalence of moderate to severe symptoms on the day of consultation is outlined below. There were statistically significant decreases in prevalence of moderate to severe symptom intensity within one day of PC consultation for pain, anorexia, fatigue and shortness of breath (SOB) (see table). CONCLUSIONS PC consultation is associated with significant improvements in symptoms within one day of consultation. Palliative care consultation may be an effective tool for symptom management during even very short hospitalizations and should be considered early in the hospitalization to effect timely symptom relief. [Table: see text].