Matthew J. Loscalzo

ACCO: ASCO Core Curriculum Outline

Purpose. Medical Oncology is a rapidly growing specialty, not only in its membership, but in its knowledge base as well. In order to keep pace with the changing profile of health care delivery and still ensure uniform quality subspecialty training, a template for education is needed. Design and Results. An Ad Hoc Committee was created from the American Society of Clinical Oncology (ASCO) membership in 1997. Goals of training were discussed, and curriculum guidelines were created. The great expansion in knowledge related to cancer care has led to this current revision of the initial curriculum. The goals of this second edition of ASCO curriculum remain the same and emphasize formal instruction in the following: (1) the treatment of individual malignancies, with an emphasis on a coordinated multidisciplinary approach; (2) a clinical experience that emphasizes patient management in both the inpatient and outpatient settings; (3) the ability to perform specified procedures; and (4) the key tools in basic science that apply to patient management. This document should be considered the educational framework around which a training program is developed. The American Society of Clinical Oncology was founded in 1965, and by 1979, the membership had grown to 2,950. Today, more than 20,000 physicians are members of ASCO. Since the first subspecialty examination in medical oncology was offered in 1973, the number of certified medical oncologists has risen to over 8,000. Medical Oncology is not only one of the youngest subspecialties in internal medicine, but also one of the fastest growing. The recent years have witnessed an explosion in medical technology. The pharmacopoeia of chemotherapeutic agents has grown from the three available agents in 1950 to over 50 antineoplastic agents. Molecular diagnostic testing is now commonplace, and more widespread use of genetic screening is on the horizon. Moreover, an entirely new area of clinical research trials has been initiated in pharmacologic cancer prevention. At the same time, health care has become an “industry” that has resulted in the shift of the majority of cancer care to the outpatient setting, with a focus on costcontainment. It is a challenge to develop a curriculum for training physicians in so dynamic an environment. While the American Board of Internal Medicine (ABIM) and Accreditation Council on Graduate Medical Education (ACGME) create a basic structure for subspecialty training, the specific items that are to be included in the training curriculum are not within their purview. ASCO leadership has thus taken on the task of creating a “Competence Comprising Curriculum” for From the University of Vermont, Burlington, VT; Northwestern University, Chicago, IL; University of California-San Francisco, San Francisco; Scripps Clinic; Moores UCSD Cancer Center, San Diego, CA; Memorial Sloan-Kettering Cancer Center; New York University Medical Center, New York; Albert Einstein Cancer Center, Bronx, NY; Wayne State University, Detroit, MI; University of Wisconsin, Madison, WI; University of Colorado Health Science Center, Denver, CO; Texas Oncology PA, Dallas; University of Texas M.D. Anderson Cancer Center, Houston, TX; Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Mayo Clinic, Jacksonville, FL; Massachusetts General Hospital, Boston, MA.

Bereavement needs of adults, children, and families after cancer.

Many families and close friends are experiencing bereavement due to cancer. A review of recent studies of bereavement outcomes, mainly elevated psychological distress, suggests that bereaved family members, compared with nonbereaved, have poorer quality of life. They display high levels of complicated grief, anxiety, and depression and use bereavement services, but also report finding meaning in the loss, during the first 6 months after death. Similar demographic (e.g., female sex and younger age) and psychological (e.g., premorbid mental health conditions and lack of preparedness for the death) predictors are related to the bereavement outcomes across different familial groups. However, the severity of psychological distress and bereavement needs expressed vary by familial groups. Unrelieved pain and anxiety of the patient before the death and family members being unprepared for the impending death appear to be related to several postdeath psychological and physical morbidities of the surviving family members. Although the number of articles addressing bereavement-related issues associated with cancer has been growing in recent years, more rigorous studies that use longitudinal prospective designs, which bridge cancer survivorship with bereavement research, are needed.

Historical Threads in the Development of Oncology Social Work

As the Association of Oncology Social Work celebrates its 25th year, we pause to reflect on the many historical threads that contributed to its development and hear from each of the presidents who helped create the organization, as we know it today. Set within hospitals, medical social work was born in the early 20th century. In the 1940s medical social work became necessary for hospital accreditation. Two additional historical shifts, one in medical improvements in treating cancer, the other a shift to a consumer-oriented American Cancer Society, contributed to the push for a greater role for the federal government in funding cancer research. Oncology social work came to full blossom in the 1970s, a result of the physicians’ need for a member of the health care team who understood cancer, its treatment, and the patients need to address his or her psychosocial needs resulting from cancer. Today, oncology social work is a fully developed profession with a national organization providing education and support to oncology social workers’ in their use of psychosocial interventions and research in behalf of cancer patients and their families.

Role of biopsychosocial screening in cancer care.

This review focuses on the aspects of biopsychosocial screening that have specific and significant implications for supportive care related to cancer care and research. There is a robust literature relating to the unmet supportive care needs of cancer patients and their families and the clinical interventions needed to effectively manage many of their problems. The Zeitgeist movement, which promotes the idea that the resources of this planet are the inherent right of all peoples, is also uniquely aligned to see supportive care services in oncology bringing significant value (cost and quality) to a health care system that is experiencing great uncertainty. Overall, there is a broadening of perspective within the supportive care community that there needs to be greater levels of interdisciplinary integration. More significantly, there is a growing realization that for cancer care to be truly patient and family centered and even minimally efficient, disease-directed care and supportive care need to be integrated from the time of diagnosis. The coordination of these services should not be based on the stage of the disease but rather tailored to the needs of the patient, family, and social context. Biopsychosocial screening programs have the potential to be the connective tissue of these patient- and family-centered systems.

Seventeen years of progress for supportive care services: A resurvey of National Cancer Institute-designated comprehensive cancer centers.

OBJECTIVEnWe replicated a 1994 study that surveyed the state of supportive care services due to changes in the field and the increased need for such services. We provide an updated assessment, comparing the changes that have occurred and describing the current status of supportive care services in comprehensive cancer settings.nnnMETHODnWe used Coluzzi and colleagues 60-question survey from their 1995 Journal of Clinical Oncology article to frame the 98-question survey employed in the current study. Medical and palliative care directors for the 2011 National Cancer Institute (NCI) comprehensive cancer centers were surveyed regarding their supportive care services and their subjective review of the overall effectiveness of the services provided.nnnRESULTSnWe achieved a 76% response rate (n = 31). The data revealed increases in the number of cancer beds in the hospitals, the degree of integration of supportive care services, the availability of complementary services, and the number of pain and palliative care services offered. There was also an overall shift toward centers becoming more patient centered, as 65% reported now having a patient and family advisory council. Our findings revealed a growing trend to offer distress screening for both outpatients and inpatients. Medical and palliative care directors evaluations of the supportive care services they offered also significantly improved. However, the results revealed an ongoing gap in services for end-of-life care and timely referrals for hospice services.nnnSIGNIFICANCE OF RESULTSnOverall, both the quantity and quality of supportive care services in the surveyed NCI-designated cancer centers has improved.

Are Disagreements in Caregiver and Patient Assessment of Patient Health Associated with Increased Caregiver Burden in Caregivers of Older Adults with Cancer

Cancer‐related therapy is increasingly administered in the outpatient setting, resulting in increased dependence on caregivers suggest to provide physical and emotional support to patients. This article describes differences in patient versus caregiver assessments of patient health, considering caregiver perceptions of the patients health and abilities compared to that reported by the patient.

Walls or Bridges: “No Gobbledygook”: The International Psycho-Oncology Society 2017 Sutherland Award Lecture

Illness, health, and wellness happen in social contexts. The present political environment is highly divisive and plays to the most primitive fears of people. Never have the stakes been so high. History is replete with putative leaders who create walls that separate people in ways that inevitably leads to dehumanization, suffering, and eventually violence. Timely and openly shared psychosocial insights by experts in mental health into the evil consequences of “wall builders” are essential to the physical, mental, and spiritual health of individuals and nations. For health care professionals (in particular) to ignore the dangers posed by the ill equipped self‐serving leaders who now dominate the news and exploit the dark psyche of the world stage would be at the very least unethical and at worst collusion in repeating the sins of the past. This article first recognizes the impact of leaders who, at great personal costs, have built bridges (with relentless compassion and courage) where only chasms existed before. Although international politics may seem like a universe away, in which people may (erroneously) feel powerless to influence change, our home health care settings can be dramatically improved and humanized by the application of universally accepted humanistic values. Health care, as it is practiced today, is an anachronism at multiple levels. Supportive care in general and psychosocial values specifically offer a more inclusive and realistic alternative. Based on an inclusive staff leadership model, a strategic, hands‐on, practical, and compassionate approach to creating and implementing supportive care programs of excellence is described. Finally, potentially fruitful areas in which supportive care and psychosocial values can provide leadership as bridges to more accessible, affordable, and humanistic care are provided for contemplation.

Elevated distress, race/ethnicity age, education, income, and type of cancer: It is complicated

Distress is defined as a multifactorial, unpleasant, emotional experience of a psychological, social and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. According to the National Center for Health Statistics, women are one‐third more likely to experience elevated levels of distress than men. However, men are more vulnerable to distress than previously thought, particularly for men who deal with chronic illnesses like cancer. Prior research suggests that a quarter to a third of men diagnosed with cancer experience significant emotional distress that extended to extreme levels for some. A retrospective study involving 6462 patients who were screened for biopsychosocial distress prior to starting treatment showed a significant interaction of age and sex on the total distress score. Male patients between 18 and 39 rated significantly more problems as highly distressing than female patients in the same age group. Orom et al have shown that younger age and lower income are associated with greater distress in men with cancer. In addition, Traeger et al showed that race and sex together predict increased risk of distress although discrepancies exist regarding the highest risk racial group. Presently, most studies related to distress in men focus on prostate cancer or involve relatively small samples. Few studies include populations other than Black Americans and White Caucasians. Moreover, many studies use the “single item” Distress Thermometer (DT) introduced in 1998 as a “single measure” of distress. Although the DT is frequently cited in the literature there is little evidence to support its validity and little is known about what the tool actually measures. The DT has never been compared with qualitative interviews and the true “gold standard” of asking patients how distressed they feel and what concerns are contributing to that distress.

Preferences for Help with a Sleep Problem Before Starting Cancer Treatment

To the Editor Being diagnosed with cancer can be overwhelming and is often associated with significant disruptions. Before beginning cancer treatment, many patients experience poor sleep. Disrupted sleep has meaningful clinical implications beyond ‘‘just’’ not feeling rested. Patients who sleep poorly prior may experience worse pain, fatigue, and depression during treatment. Furthermore, sleep often gets worse as treatment progresses, and chronic sleep problems are associated with major negative health consequences. Unfortunately, patients are unlikely to seek treatment for sleep problems despite robust evidence supporting the effectiveness of interventions. These interventions are often disregarded in the oncology setting by patients and providers who consider them to be an expected problem after a cancer diagnosis. Cancer patients about to begin treatment are actively engaged with the medical system due to ongoing treatment and follow-up. This provides an opportunity to screen for sleep disorders and provide affected patients with evidence-based treatments. Unfortunately, only a handful of reports have explored cancer patients’ information preferences for learning about sleep treatment. It is critical to investigate helpseeking among cancer patients to improve the clinical management of sleep disorders at oncology centers. We sought to address this key gap by surveying a large cohort of newly diagnosed cancer patients across a range of diagnoses to understand their treatment interest and preferences as it relates to sleep.

Best Practices in Oncology Distress Management: Beyond the Screen

The field of psychosocial oncology is a young discipline with a rapidly expanding evidence base. Over the past few decades, several lines of research have established that psychosocial problems, such as anxiety, depression, post-traumatic stress, fatigue, sexual dysfunction, and cognitive complaints, are common and consequential in patients with cancer. The word distress was chosen deliberately to capture a broad concept; consequently, distress screening is meant to function as an initial step in the more targeted evaluation of the source(s) of the patients distress. In 2015, the American College of Surgeons Commission on Cancer mandated psychosocial distress screening as part of their accreditation process. Similar screening requirements are in place internationally, including in Canada, where screening for distress is endorsed as the sixth vital sign and a standard of care that must be met by any Canadian health care organization providing cancer services that seeks to be accredited. Over the past few years, cancer centers around the world have been exploring optimum ways to implement and evaluate distress screening initiatives. This paper presents three approaches to distress screening implementation: (1) a model that incorporates the importance of shared values, perceived benefits, and relevant outcomes in the implementation of distress management protocols; (2) a Canadian knowledge translation application to distress screening, including triage considerations and interventions; and (3) a novel approach to distress management via the use of a mobile application to manage post-traumatic stress symptoms. In closing, future opportunities and challenges associated with the emergence of technology will be discussed.