Diane Portman

Unmet Needs of African Americans and Whites at the Time of Palliative Care Consultation

Context: Differences among patient populations that present to consultative palliative care are not known. Such an appreciation would inform health-care delivery tailored to unique populations. Objectives: We aimed to compare characteristics and palliative care needs of African Americans (AAs) and whites during initial palliative care consultation. Methods: We analyzed patient-reported, clinician-entered clinical encounter data from a large, multisite community-based, nonhospice palliative care collaborative. We included first specialty palliative care consultations from January 1, 2014, to July 2, 2015, across 15 sites within the Global Palliative Care Quality Alliance registry. Demographics, disease, performance status, advance care planning, and symptom prevalence/severity were compared. Results: Of 775 patients, 12.9% (N = 100) were AA. African Americans were younger (63 vs 75.4 years, P < .0001). A larger proportion of AAs had a diagnosis of cancer (45.0% vs 36.3%, P = .09) and in the hospital (71% vs 61.8%, P = .07). African Americans were more likely to have a Palliative Performance Score of 0 to 30 (35.6% vs 23.7%, P = .049). Around 50% in both racial groups were full code; slightly more than 40% had an advance directive. Nearly two-thirds in both racial groups reported 3 or more symptoms of any severity; one-third reported 3 or more moderate or severe symptoms. A larger proportion of Africans than whites reported pain of any severity (66.0% vs 56.1%, P = .06). Conclusion: All patients present to palliative care consultations with significant symptom and advance care planning needs. Further research is needed to identify how to deliver palliative care: earlier, in noncancer conditions, and improve pain management in AA populations.

Single Institute Experience With Methylphenidate and American Ginseng in Cancer-Related Fatigue:

Background: Single therapy with methylphenidate or American ginseng contributes to the reduction in cancer-related fatigue (CRF) with different pharmacologic mechanisms and is relatively safe. However, the safety and efficacy of treating CRF with methylphenidate and AG combination therapy is unknown. Aim: The primary objective was to assess the clinical safety and the change in fatigue with numerical rating scale (NRS) on the Edmonton Symptom Assessment Scale (ESAS) after intervention with methylphenidate and AG combination therapy. Methods: We reviewed the electronic medical records of 857 patients seen in our Palliative Medicine outpatient clinic between February 1, 2015, and December 31, 2015. Fatigue was assessed by NRS on ESAS. Toxicity was reviewed on clinician’s documents. Results: We identified 28 patients who were prescribed a combination of methylphenidate (10-40 mg/d) and AG (2000 mg/d). Ten patients did not comply with the combination therapy. Three patients had stage 2 adverse effects. Fifteen patients completed prescribed combination therapy per instructions. The mean time interval between pre- and postintervention follow-up was 30.5 days (standard deviation [SD]: 7.78). There was a significant reduction in the fatigue score (mean score 6.93-4.13) from the pre- to postscore records (mean: −2.8; SD: 1.61; P < .0002* [*refers to statistically significant]). Sixty percent of patients reported significant reduction in fatigue (cutoff value: ≥3; reduction in fatigue score from baseline: 80% ≥2, 60% ≥3, and 46.7% ≥4). Conclusion: In our retrospective medical record review, the combination treatment of methylphenidate and AG had no discernible associated toxicities and showed potential clinical benefit in CRF.

The combination therapy with methylphenidate and American ginseng in cancer-related fatigue.

215 Background: Fatigue is one of common symptoms among patients with cancer. However, little is known about the pathophysiology and effective pharmacologic intervention. Methylphenidate and American Ginseng were recognized for promising results and safe to use as a single therapy. Psycho-stimulants are commonly used and are effective in moderate to severe fatigue. The mechanism behind the evidence for methylphenidate is rebalancing dopamine neurotransmission which is altered in fatigue. The mechanism behind ginseng benefits appears to be improvement in muscle metabolism and reduction in inflammatory responses thought to cause fatigue in cancer. We hypothesized that combination therapy with methylphenidate and American ginseng is superior to single therapy and safe. METHODS We conducted retrospective chart review in the supportive care medicine outpatient clinic between Feb 01, 2015 and Dec 31, 2015. 28 patients were prescribed methylphenidate and American ginseng for 4 weeks. Methylphenidate dosage was between 10-20mg/day. American ginseng dosage was fixed at 2000mg/day (no control of sources). We investigated compliance rate, positive rate and change of fatigue score on ESAS. We also obtained the data for adverse effect ratio and severity as a safety measure. RESULTS We identified 28 patients (M: F 14/14, Age 50.4) who were prescribed combination therapy with methylphenidate and American ginseng for at least 4 weeks. 18 patients were compliant to combination therapy (Compliance rate 64%). 2 patients (11%) reported Grade 2 adverse effect while on therapy. One patient (5%) became non-compliant during the study period. 15 patients (84%) successfully completed the therapy the average fatigue score of pre and post intervention was 6.93 and 4.13 respectively (mean reduction -2.80, p-Value < 0.0002). 12 patients (80%) showed significant improvement of fatigue (reduced ≥ 2). There was no association between gender and age. CONCLUSIONS Combination therapy with standard dose of methylphenidate and American ginseng were a safe and effective way of treatment for cancer-related fatigue. Further studies to confirm its safety and efficacy are justified.

Implementation of NCCN palliative care guidelines by member institutions.

15 Background: To promote access to quality, evidence-based palliative care (PC) and help cancer patients experience the best quality of life possible throughout the illness trajectory, the National Comprehensive Cancer Network (NCCN) has developed PC guidelines to guide symptom screening, assessment, PC interventions, and reassessment by the oncology team. We sought to evaluate use of the guidelines among NCCN member institutions. METHODS In April and May 2014 an invitation and reminders to participate in an online survey were sent electronically to NCCN PC guidelines panel members. If a panel member did not reply, individuals involved in the provision of PC at the same institution were approached. RESULTS Responses were received from 21 (84%) of the 25 member institutions. All of the institutions report having an interdisciplinary team with PC expertise. Among respondents, 38% have an accredited/certified PC program and 52% have an institutional PC quality improvement program in place. Fifty-two percent submit data to the National Palliative Care Registry. Forty-three percent have guidelines or triggers in place for the use of PC services. Only 10% actively employ the NCCN guidelines to screen for PC needs or make PC referrals; the guidelines are more often used to guide patient assessment (38%) and clinical practice (43%). When asked to endorse other PC referral criteria, 76% indicated the discretion of the oncology provider(s) and 29% the National Consensus Project for Quality Palliative Care. Sixty-two percent agree providers concur on the elements of PC and 29% agree as to who should receive PC. Only 19% agree early integration of PC should occur for all oncology patients and 43% agree PC referrals occur in a timely and efficient manner. The most frequently cited barriers to the provision of quality PC are: attitudes toward PC (71%), insufficient staffing (61%) and limited financial resources (57%). CONCLUSIONS Implementation of the guidelines at NCCN member institutions is incomplete. There appears to be a lack of consensus about when and for whom PC should be provided. Future research should be designed to enhance understanding of the barriers to care and improve implementation of the guidelines.

Design and rational for the precision medicine guided treatment for cancer pain pragmatic clinical trial

INTRODUCTION Pain is one of the most burdensome symptoms associated with cancer and its treatment, and opioids are the cornerstone of pain management. Opioid therapy is empirically selected, and patients often require adjustments in therapy to effectively alleviate pain or ameliorate adverse drug effects that interfere with quality of life. There are data suggesting CYP2D6 genotype may contribute to inter-patient variability in response to opioids through its effects on opioid metabolism. Therefore, we aim to determine if CYP2D6 genotype-guided opioid prescribing results in greater reductions in pain and symptom severity and interference with daily living compared to a conventional prescribing approach in patients with cancer. METHODS Patients with solid tumors with metastasis and a self-reported pain score ≥ 4/10 are eligible for enrollment and randomized to a genotype-guided or conventional pain management strategy. For patients in the genotype-guided arm, CYP2D6 genotype information is integrated into opioid prescribing decisions. Patients are asked to complete questionnaires regarding their pain, symptoms, and quality of life at baseline and 2, 4, 6, and 8 weeks after enrollment. The primary endpoint is differential change in pain severity by treatment strategy (genotype-guided versus conventional pain management). Secondary endpoints include change in pain and symptom interference with daily living. CONCLUSION Pharmacogenetic-guided opioid selection for cancer pain management has potential clinical utility, but current evidence is limited to retrospective and observational studies. Precision Medicine Guided Treatment for Cancer Pain is a pragmatic clinical trial that seeks to determine the utility of CYP2D6 genotype-guided opioid prescribing in patients with cancer.

Exploring the relationship of self-reported lack of appetite to patient characteristics and symptom burden.

187Background: Cancer anorexia-cachexia syndrome (CACS) in patients is associated with decreases in lean body mass and body weight. Self-reported lack of appetite may be an important indicator for early identification of CACS. The current analyses examined the relationship of perceived lack of appetite to patient characteristics and overall symptom burden in a large mixed cancer sample referred to a palliative care clinic. Methods: We conducted a retrospective review of patients newly referred to an outpatient palliative care clinic over a two-year period. Data on demographic and clinical characteristics and patient-reported symptom scores on the Edmonton Symptom Assessment Scale (ESAS) were abstracted. Pearson’s correlations and ANOVAs were used to assess relationships between variables. Multiple regression analysis was used to evaluate the relative contribution of variables that were significantly correlated with lack of appetite at the univariate level. Results: Data on 544 patients (M=53.7 years) show...

The influence of a cachexia clinic on palliative care integration in oncology.

124Background: Appetite and weight loss are common in patients with advanced cancer and specialized cachexia clinics have been established to address these symptoms. Given the association between anorexia/cachexia and other adverse symptoms, these patients may also benefit from specialty level palliative care (PC). However, referral to outpatient specialty level PC is often delayed or does not occur. We sought to examine the prevalence of other factors associated with appetite and weight loss in patients with advanced cancer and the impact of a specialized cachexia clinic on identification and treatment of other PC needs. Methods: The records of patients referred by their Oncologist to the cachexia clinic of a cancer center from August 2016 to June 2017 were reviewed retrospectively. Subjects who had been referred to PC by their Oncologist were excluded. Patients had been assessed for symptom burden using the Edmonton Symptom Assessment Scale (ESAS-r). Patients identified with PC needs had been referred t...

Predicting hospital readmissions in the oncology population.

177 Background: The 30-day readmission rate is established as an important indicator of quality of care. The LACE index is commonly used in the general medical setting to predict readmission but its ability to predict readmission with sensitivity and specificity in the oncology population has not yet been examined. At our cancer center, palliative care (PC) consultation is associated with an increased risk for readmission but it is not an element in the LACE index. METHODS We sought to characterize the operating characteristics of the LACE Index using receiver operating characteristics analyses to predict unplanned readmissions to our cancer center over a 6-week period beginning March 2016. Data was gathered from chart review to calculate a total LACE score for each unplanned admission. Logistic regression was used to examine the individual components of the LACE index and whether a PC consult improved the performance of the index. RESULTS A total of 329 patients with unplanned admissions were included. Fifty-nine (17.9%) were readmitted within 30 days of discharge. There was no difference between the median LACE scores of those readmitted compared to those who were not (Md = 10.0; p = .93). Receiver operating characteristic (ROC) curve analyses of LACE scores yielded an area under the curve estimate relative to 30-day readmissions of .45 indicative of poor overall accuracy. ROC analyses also showed that the previously established LACE cutoff score of 10 had sensitivity of .54 and specificity of .57 relative to readmissions. The positive predictive value was .81 and the negative predictive value was .18. In logistic regression analysis, only direct referral center/emergency department visits were an independent predictor of readmission, with a c-statistics of .64 for readmission. The inclusion of a PC consult did not improve the performance of the index. CONCLUSIONS The LACE Index performed poorly in predicting 30-day readmission in the oncology setting; the inclusion of whether a PC consult took place did not improve the indexs utility. Further research is required to create a new tool or enhance existing indices to predict readmission in the oncology population.

The Value of Advance Directives in an Oncologic ICU (S777)

Objectives Gain an initial understanding of the current state and the gap between patients’ desire to discuss end-of-life issues with their doctors who are often reluctant to do so. Identify the top six barriers to conducting effective end-of-life conversations with diverse patients and families. Gain an initial understanding of the how the clinician’s age, ethnicity, gender and sub-specialty may impact the care they provide. Original Research Background. Though most patients wish to discuss end-of-life (EOL) issues, doctors are reluctant to conduct EOL conversations. Research Objectives. To identify barriers doctors face (if any) in conducting EOL conversations with diverse patients and to determine if the doctors’ age, gender, ethnicity and sub-specialty influenced the barriers reported. Methods. Mixed methods study of doctors caring for diverse, seriously ill patients in two large academic medical centers at the end of the training. Results. 1,040 of 1,234 potential subjects (84.3%) participated. 29participantsweredesignatedas thedevelopment cohort for qualitative analyses using grounded theory methods to identify primary barriers. Codes were validatedbyanalyzing responses from50randomlydrawn subjects from the validation cohort (n1⁄4996 doctors). Only 0.01% doctors denied barriers to conducting EOL conversationswithpatients. 99.99%doctors reportedbarriers with 85.7% finding it very challenging to conduct EOL conversations, especially with patients whose ethnicity was different then their own. Asian-American doctors reported the most struggles (91.3%), followed by African-Americans (85.3%), Caucasians (83.5%) and Hispanic-Americans (79.3%). Barriers included language/medical interpretation issues, patient/family religio-spiritual beliefs, doctors’ ignorance of patients’ cultural values, patient/family’s cultural differences in truth handling and decision making, limited health literacy, patients’ mistrust of doctors. Doctors’ ethnicity (Chi-Square1⁄412.77, DF1⁄44, p1⁄40.0125) and medical-subspecialty (Chi-Square1⁄419.33, DF1⁄410, p1⁄40.036) influenced their reported barriers. Friedman’s test used to examine ranking of the barriers across sub-groups identified significant differences by age (F statistic1⁄4303.5, DF1⁄45, p<0.0001) and medical sub-specialty (F statistic1⁄4163.7, DF1⁄45, p<0.0001). Conclusions. Doctors struggle with conducting effective EOL conversations, especially with patients whose ethnicity is different from theirs. Implications for Research, Policy, or Practice. Culturally competent care is imperative if we want to better serve diverse patients/families. Cultural competence training is vital for all clinicians caring for diverse patients.

Pathways, partners and payers: The trifecta of palliative care integration.

129 Background: Moffitt Cancer Center has developed proprietary oncology clinical pathways. Multiple external partnership agreements which require adoption of these pathways have been completed. Our Center has enacted new cancer care delivery and payment arrangements with payers to foster cost and quality balance via use of the pathways and earlier involvement of palliative care (PC). METHODS Executive and PC leadership collaborated with the clinical pathways and strategic alliance teams to identify high priority disease states for integration of PC. Working with oncologist pathway developers, critical junctures in the pathways for inclusion of PC consultation were proposed and refined. EHR mechanisms to promote pathway adherence by clinicians were initiated. The value of pathway utilization and care coordination to involve PC was promoted to prospective oncology partners and payers. RESULTS PC has been mandated in oncology clinical care pathways, with a focus on thoracic, breast, gastrointestinal, prostate, gynecologic and hematologic malignancies, as directed by specific payer arrangements. Partnerships have expanded, resulting in greater utilization of PC by other centers as well. Increased referral volumes to PC, broader symptom control, and enhanced advance care planning have resulted. CONCLUSIONS Incorporation of PC in oncologic clinical care pathways, with dissemination to internal providers, external partners and as part of novel payment models, optimizes PC integration. [Table: see text].