Debika Burman

Phase II Study of an Outpatient Palliative Care Intervention in Patients With Metastatic Cancer

PURPOSE Although there is increasing advocacy for timely symptom control in patients with cancer, few studies have assessed outpatient palliative care clinics. This study assessed prospectively the efficacy of an Oncology Palliative Care Clinic (OPCC) in improving patient symptom distress and satisfaction. PATIENTS AND METHODS Eligible patients were new referrals to an OPCC, had metastatic cancer, were at least 18 years old, and were well enough and able to speak and read English sufficiently to provide informed consent and complete questionnaires. Patients received a consultation by a palliative care team. The primary end points of symptom control and patient satisfaction were assessed using the Edmonton Symptom Assessment Scale (ESAS) and patient-adapted Family Satisfaction with Advanced Cancer Care (FAMCARE) scale at baseline, 1 week, and 1 month. Initial and follow-up scores were compared using paired t tests. RESULTS Of 150 patients enrolled, 123 completed 1-week assessments, and 88 completed 4-week assessments. At baseline, the mean ESAS Distress Score (EDS) was 39.5. The mean improvement in EDS was 8.8 points (P < .0001) at 1 week and 7.0 points (P < .0001) at 1 month. Statistically significant improvements were observed for pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, dyspnea, insomnia, and constipation at 1 week (all P < or = .005) and 1 month (all P < or = .05). The mean improvement in FAMCARE score was 6.1 points (P < .0001) at 1 week and 5.0 points (P < .0001) at 1 month. CONCLUSION This phase II study demonstrates efficacy of an OPCC for improvement of symptom control and patient satisfaction with care. Randomized controlled trials are indicated to further evaluate the effectiveness of specialized outpatient palliative care.

Quality of life and mental health in caregivers of outpatients with advanced cancer

This study evaluates the quality of life (QOL) and mental health (MH) of caregivers of patients with advanced cancer who are receiving ambulatory oncology care and associations with patient, caregiver and care‐related characteristics.

Measuring patient satisfaction in oncology palliative care: psychometric properties of the FAMCARE-patient scale

PurposeWe provide preliminary psychometric results concerning the use of a modified FAMCARE scale, adapted for patient use, to assess satisfaction with outpatient care in advanced stage cancer patients.MethodsParticipants were 145 outpatients with advanced cancer who were participating in a phase II trial of an outpatient palliative care intervention. Patients completed our modified FAMCARE measure of patient satisfaction and the Edmonton Symptom Assessment Scale, a measure of symptom burden. Individuals were also assessed for performance status using the Eastern Cooperative Oncology Group scale. We conducted an exploratory factor analysis of the patient satisfaction measure and performed correlations of satisfaction with symptom burden as well as with performance status.ResultsFactor analysis of the satisfaction measure revealed a one-factor structure and suggested the removal of one nonloading item, producing a 16-item scale (FAMCARE-P16) with high internal reliability. Patient satisfaction was not correlated with performance status, but was inversely associated with symptom burden, particularly with depression and anxiety.ConclusionsThe FAMCARE-P16 may be used to assess satisfaction with outpatient palliative care interventions of patients with advanced stage cancer in both clinical settings and prospective trials.

Nurse and physician inter-rater agreement of three performance status measures in palliative care outpatients

IntroductionPerformance status (PS) scales are used widely in oncology practice and research. We compared inter-rater agreement, between nurses and physicians, for three commonly used PS scales.Materials and methodsPatients attending an oncology palliative care clinic were assessed by a physician and nurse who blindly completed Eastern Cooperative Oncology Group (ECOG), Karnofsky PS (KPS), and palliative PS (PPS) scales. Patients completed the Edmonton symptom assessment system (ESAS).ResultsInter-rater agreement (weighted kappa) for the 457 patients was 0.67 for the ECOG, 0.74 for the KPS, and 0.72 for the PPS. There was no difference between proportions of physicians’ vs. nurses’ ratings of KPS, >60 vs. ≤60 (McNemar’s test, p = 0.33); however, physicians were more likely to rate patients as having better PS for the ECOG (77% in the 0–2 range vs. 70% for nurses, p = 0.0003) and PPS (63% in the 70–100 range vs. 54% for nurses, p = 0.0001). Physician and nurse scores of ECOG, KPS, and PPS were all correlated with ESAS distress score (Pearson correlation, r = 0.4–0.5).ConclusionsAlthough inter-rater agreement was good for all three scales, physicians tended to rate patients as healthier for the PPS and ECOG. The KPS may provide greater consistency of PS ratings by different oncology professionals in clinical and research settings.

The FAMCARE-Patient scale: Measuring satisfaction with care of outpatients with advanced cancer

OBJECTIVE To provide confirmatory results concerning the psychometric properties of a measure of satisfaction with oncology care for use with advanced stage cancer patients, and test its sensitivity to change. METHODS We analysed data from 315 outpatients with advanced cancer participating in a randomised controlled trial of early palliative care intervention versus routine oncology care, and their caregivers. Patients completed a 16-item measure of patient satisfaction (FAMCARE-P16), based on the FAMCARE measure of family satisfaction with cancer care, and measures assessing interactions with healthcare providers, performance status and symptom burden. Caregivers completed the original FAMCARE measure. We used confirmatory factor analysis to test the patient satisfaction measure for a single-factor structure. To determine construct validity, we assessed correlations between patient satisfaction and the other patient and caregiver measures. To assess responsiveness to change, we repeated paired t-test analyses on the 13-item and 16-item scales for 150 patients participating in a phase II trial of palliative care effectiveness, in which the FAMCARE-P was measured at baseline, 1-week and 1-month after an outpatient palliative care intervention. RESULTS A reduced 13-item version of our measure (FAMCARE-P13) possessed a one-factor structure with high reliability. Patient satisfaction was correlated in predicted directions with physical distress, communication and relationship with healthcare providers, and caregiver satisfaction. There were statistically significant increases in patient satisfaction at 1 week (p<0.0001) and 1 month (p<0.001). CONCLUSIONS We recommend the use of the FAMCARE-P13 to assess satisfaction with outpatient palliative care interventions of patients with advanced stage cancer.

Predictors of Symptom Severity and Response in Patients With Metastatic Cancer

We examined determinants of symptom severity and response to treatment among 150 patients with cancer participating in a phase II trial of a palliative care team intervention. Patients completed a modified Edmonton Symptom Assessment Scale (ESAS) at baseline and 1 week. Women had a worse baseline ESAS Distress Score (EDS; P = .003) and Total Distress Score (TDS; P = .005); differences were particularly marked for anxiety and appetite. Performance status was inversely associated with EDS, TDS, well-being, appetite, and fatigue (Kruskal-Wallis, all P < .005). Multivariate analysis of covariance (ANCOVA) showed that symptom improvement was independently predicted by worse baseline EDS score and female gender. Performance status, gender, and baseline symptom severity should be accounted for in trials of palliative care interventions; inclusion criteria based on symptom severity should also be considered.

Validation of the QUAL-EC for assessing quality of life in patients with advanced cancer

OBJECTIVE Improving quality of life is the main goal of palliative cancer care. However, there is a lack of measures validated specifically for advanced cancer. The purpose of this study was to validate the Quality of Life at the End of Life (QUAL-E) measure in a sample of patients with advanced cancer. METHODS Data were analysed for 464 patients with advanced cancer who were participating in a randomised controlled trial of early palliative care intervention versus routine care. Patients completed the 26-item QUAL-E, the Functional Assessment of Cancer Therapy (FACT-G) quality of life measure and measures of spiritual well-being, performance status, symptom burden, satisfaction with care and communication with health care providers. We conducted a confirmatory factor analysis on the QUAL-E to test for the hypothesised four-factor structure and examined construct validity by calculating correlations with relevant scales. RESULTS A 17-item reduced version of the QUAL-E, the QUAL-E-Cancer (QUAL-EC) achieved an acceptable fit to a four-factor model. Both the full and reduced versions of the QUAL-E were internally reliable and showed good construct validity. Symptom Control was correlated with other measures of physical functioning; Relationship with Healthcare Provider was correlated with satisfaction with care and better physician and nurse communication; Preparation for End of Life was strongly associated with emotional well-being; and Life Completion was strongly associated with social and spiritual well-being. CONCLUSIONS Due to its good factor structure and sound psychometrics, we recommend the reduced QUAL-EC scale to assess quality of life in patients with advanced cancer.

Spirituality and use of complementary therapies for cure in advanced cancer

Objective: Complementary and alternative medicine (CAM) is frequently used by patients with advanced cancer, for a variety of reasons. We examined the use of CAM in this population, and associations of use for potential cure with spiritual faith and existential well‐being.

Impact of an Oncology Palliative Care Clinic on Access to Home Care Services

Home care (HC) is important for patients with cancer as performance status declines. Our study of 1224 patients at a Canadian cancer center examined the impact of an oncology palliative care clinic (OPCC) on HC referral. The HC referral frequency was calculated before and after the first OPCC consultation, in total and according to performance status (Palliative Performance Scale, PPS). Characteristics associated with HC referral were investigated. After the first OPCC consultation, there was an increase in HC referral from 39% (477 of 1224; 49% of those with PPS ≤60) to 69% (841 of 1224; 88% of those with PPS ≤60). Factors independently associated with HC referral were poor PPS (P < .001) and older age (P = .003). Thus OPCC involvement resulted in markedly increased HC referrals, particularly for older patients with poor performance status.

Predictors of quality of life (QOL) and mental health (MH) in caregivers of patients with advanced cancer.

9110 Background: Growing demands on caregivers (CG) of patients with advanced cancer create a pressing need to understand the factors that impact on CG well-being. This study evaluates CG and patient characteristics that predict caregiver QOL and MH. METHODS Patients with metastatic gastrointestinal, genitourinary, breast, lung, or gynaecologic malignancy, and their CG, were recruited from 24 medical oncology clinics. Measures included the Caregiver QOL-Cancer scale (CQOLC), SF-36 v2 (CG mental and physical health), and FACT-G (patient QOL). The influence of socio-demographic and medical factors on CG QOL and MH were assessed using univariate linear regression. Multivariate analysis (backwards method) was used to determine independent predictors. RESULTS Of 191 CG, 65% were female and the median age was 57 years. The majority were a spouse/partner (84%) and/or lived with the patient (90%); 20% reported having a chronic illness/disability, and 25% stated they had a recent change in work situation. CG spent a mean of 3.5 hours per day directly caring for the patient. Independent predictors of better CG QOL and CG mental health are shown in the table. CONCLUSIONS CG QOL is associated with better patient physical well-being, better CG MH and not caring for others in addition to the patient. CG MH was worse for females, those with a change in work situation and longer caregiving hours, and worse patient emotional well-being. These factors should be considered when developing interventions for caregiver support. [Table: see text].