Rebecca L. Green

Placement Into Foster Care and the Interplay of Urbanicity, Child Behavior Problems, and Poverty

Child welfare involvement is related to involvement with poverty, but the dimensions of that relationship have not been fully explored. Data from the National Survey of Child and Adolescent Well-Being were used to test the relationship between poverty indicators and placement into foster care. Poverty, ages of children, urban or nonurban settings, and the presence of mental health disorders interact to contribute to placement decisions. In urban areas, poverty is strongly associated with involvement with child welfare services, but childrens mental health problems are not. In nonurban areas, childrens mental health problems are a far greater contributor to child welfare involvement than poverty. Implications for understanding the dual functions of child welfare placements are provided. Child welfare services continue to address the needs of families with children with substantial behavioral problems--yet, federal child welfare policy includes no recognition of this important role.

Predictors of Placement Moves Among Children With and Without Emotional and Behavioral Disorders

Children identified as having emotional and behavioral disorders (EBD) may have different out-of-home care placements than their peers without EBD.This study compared the factors influencing placement movements for 362 children with EBD and 363 children without EBD, using clinical Child Behavior Checklist (CBCL) scores at baseline data collection of the National Survey of Child and Adolescent Well-Being. The analyses explored potential case characteristics influencing the number of placements for children with a clinical CBCL score at baseline data collection. Poisson regression models were used to explain the number of placements experienced during the first 36 months of placement. Overall, children with a clinical-level CBCL score were 2.5 times as likely to experience four or more placements as their nonclinical peers. Findings indicated that the presence of depression and not residing with siblings predicted movement among children with EBD. Among children without EBD, only older age was strongly associated with placement moves. Although the direction of effects is equivocal, these results call for greater attention to childrens experience of out-of-home placement and the lack of homogeneity among children who are placed outside their homes.

Phase 2 Trial of De-intensified Chemoradiation Therapy for Favorable-Risk Human Papillomavirus–Associated Oropharyngeal Squamous Cell Carcinoma

PURPOSE To perform a prospective, multi-institutional, phase 2 study of a substantial decrease in concurrent chemoradiation therapy (CRT) intensity as primary treatment for favorable-risk, human papillomavirus-associated oropharyngeal squamous cell carcinoma. METHODS AND MATERIALS The major inclusion criteria were: (1) T0 to T3, N0 to N2c, M0; (2) human papillomavirus or p16 positive; and (3) minimal/remote smoking history. Treatment was limited to 60 Gy intensity modulated radiation therapy with concurrent weekly intravenous cisplatinum (30 mg/m(2)). The primary study endpoint was pathologic complete response (pCR) rate based on required biopsy of the primary site and dissection of pretreatment positive lymph node regions, regardless of radiographic response. Power computations were performed for the null hypothesis that the pCR rate is 87% and n=40, resulting in a type 1 error of 14.2%. Secondary endpoint measures included physician-reported toxicity (Common Toxicity Terminology for Adverse Events, CTCAE), patient-reported symptoms (PRO-CTCAE), and modified barium swallow studies. RESULTS The study population was 43 patients. The pCR rate was 86% (37 of 43). The incidence of CTCAE grade 3/4 toxicity and PRO-CTCAE severe/very severe symptoms was as follows: mucositis 34%/45%, general pain 5%/48%, nausea 18%/52%, vomiting 5%/34%, dysphagia 39%/55%, and xerostomia 2%/75%. Grade 3/4 hematologic toxicities were 11%. Thirty-nine percent of patients required a feeding tube for a median of 15 weeks (range, 5-22 weeks). There were no significant differences in modified barium swallow studies before and after CRT. CONCLUSIONS The pCR rate with decreased intensity of therapy with 60 Gy of IMRT and weekly low-dose cisplatinum is very high in favorable-risk oropharyngeal squamous cell carcinoma, with evidence of decreased toxicity compared with standard therapies. ClinicalTrials.gov ID: NCT01530997.

Wound Complications in Preoperatively Irradiated Soft-Tissue Sarcomas of the Extremities

PURPOSE To determine whether the involvement of plastic surgery and the use of vascularized tissue flaps reduces the frequency of major wound complications after radiation therapy for soft-tissue sarcomas (STS) of the extremities. METHODS AND MATERIALS This retrospective study evaluated patients with STS of the extremities who underwent radiation therapy before surgery. Major complications were defined as secondary operations with anesthesia, seroma/hematoma aspirations, readmission for wound complications, or persistent deep packing. RESULTS Between 1996 and 2010, 73 patients with extremity STS were preoperatively irradiated. Major wound complications occurred in 32% and secondary operations in 16% of patients. Plastic surgery closed 63% of the wounds, and vascularized tissue flaps were used in 22% of closures. When plastic surgery performed closure the frequency of secondary operations trended lower (11% vs 26%; P=.093), but the frequency of major wound complications was not different (28% vs 38%; P=.43). The use of a vascularized tissue flap seemed to have no effect on the frequency of complications. The occurrence of a major wound complication did not affect disease recurrence or survival. For all patients, 3-year local control was 94%, and overall survival was 72%. CONCLUSIONS The rates of wound complications and secondary operations in this study were very similar to previously published results. We were not able to demonstrate a significant relationship between the involvement of plastic surgery and the rate of wound complications, although there was a trend toward reduced secondary operations when plastic surgery was involved in the initial operation. Wound complications were manageable and did not compromise outcomes.

Comparison of Patient- and Practitioner-Reported Toxic Effects Associated With Chemoradiotherapy for Head and Neck Cancer.

IMPORTANCE Agreement between patient- and practitioner-reported toxic effects during chemoradiotherapy for head and neck cancer is unknown. OBJECTIVE To compare patient-reported symptom severity and practitioner-reported toxic effects among patients receiving chemoradiotherapy for head and neck cancer. DESIGN, SETTING, AND PARTICIPANTS Forty-four patients participating in a phase 2 trial of deintensified chemoradiotherapy for oropharyngeal carcinoma were included in the present study (conducted from February 8, 2012, to March 2, 2015). Most treatment (radiotherapy, 60 Gy, with concurrent weekly administration of cisplatin, 30 mg/m2) was administered at academic medical centers. Included patients had no prior head and neck cancers, were 18 years or older, and had a smoking history of 10 pack-years or less or more than 10 pack-years but 30 pack-years or less and abstinent for the past 5 years. Cancer status was untreated human papillomavirus or p16-positive squamous cell carcinoma of the oropharynx or unknown head and neck primary site; and cancer staging was category T0 to T3, category N0 to N2c, M0, and Eastern Cooperative Oncology Group performance status 0 to 1. Baseline, weekly, and posttreatment toxic effects were assessed by physicians or nurse practitioners using National Cancer Institutes Common Terminology Criteria for Adverse Events (CTCAE), version 4.0. Patient-reported symptom severity was measured using the Patient-Reported Outcomes version of the CTCAE (PRO-CTCAE). Descriptive statistics were used to characterize raw agreement between CTCAE grades and PRO-CTCAE severity ratings. INTERVENTIONS Baseline, weekly, and posttreatment toxic effects assessed using CTCAE, version 4.0, and PRO-CTCAE. MAIN OUTCOMES AND MEASURES Raw agreement indices between patient-reported toxic effects, including symptom frequency, severity, and interference with daily activities (score range, 0 [none] to 4 [very severe]), and practitioner-measured toxic effects, including swallowing, oral pain, and hoarseness (score range, 1 [mild] to 5 [death]). RESULTS Of the 44 patients included in the analysis (39 men, 5 women; mean [SD] age, 61 [8.4] years), there were 327 analyzable pairs of CTCAE and PRO-CTCAE symptom surveys and no treatment delays due to toxic effects. Patient-reported and practitioner-reported symptom severity agreement was high at baseline when most symptoms were absent but declined throughout treatment as toxic effects increased. Most disagreement was due to lower severity of toxic effects reported by practitioners (eg, from 45% agreement at baseline to 27% at the final week of treatment for pain). This was particularly noted for domains that are not easily evaluated by physical examination, such as anxiety and fatigue (eg, severity of fatigue decreased from 43% at baseline to 12% in the final week of treatment). CONCLUSIONS AND RELEVANCE Practitioner-reported toxic effects are lower than patient self-reports during head and neck chemoradiotherapy. The inclusion of patient-reported symptomatic toxic effects provides information that can potentially enhance clinical management and improve data quality in clinical trials.

Comparison of Patient Report and Medical Records of Comorbidities: Results From a Population-Based Cohort of Patients With Prostate Cancer

Importance The comorbid conditions of patients with cancer affect treatment decisions, which in turn affect survival and health-related quality-of-life outcomes. Comparative effectiveness research studies must account for these conditions via medical record abstraction or patient report. Objective To examine the agreement between medical records and patient reports in assessing comorbidities. Design, Setting, and Participants Patient-reported information and medical records were prospectively collected as part of the North Carolina Prostate Cancer Comparative Effectiveness & Survivorship Study, a population-based cohort of 881 patients with newly diagnosed localized prostate cancer enrolled in the North Carolina Central Cancer Registry from January 1, 2011, through June 30, 2013. The presence or absence of 20 medical conditions was compared based on patient report vs abstraction of medical records. Main Outcomes and Measures Agreement between patient reports and medical records for each condition was assessed using the &kgr; statistic. Subgroup analyses examined differences in &kgr; statistics based on age, race, marital status, educational level, and income. Logistic regression models for each condition examined factors associated with higher agreement. Results A total of 881 patients participated in the study (median age, 65 years; age range, 41-80 years; 633 white [71.9%]). In 16 of 20 conditions, there was agreement between patient reports and medical records for more than 90% of patients; agreement was lowest for hyperlipidemia (68%; &kgr; = 0.36) and arthritis (66%; &kgr; = 0.14). On multivariable analysis, older age (≥70 years old) was significantly associated with lower agreement for myocardial infarction (odds ratio [OR], 0.31; 95% CI, 0.12-0.80), cerebrovascular disease (OR, 0.10; 95% CI, 0.01-0.78), coronary artery disease (OR, 0.37; 95% CI, 0.20-0.67), arrhythmia (OR, 0.44; 95% CI, 0.25-0.79), and kidney disease (OR, 0.18; 95% CI, 0.06-0.52). Race and educational level were not significantly associated with &kgr; in 18 of 19 modeled conditions. Conclusions and Relevance Overall, patient reporting provides information similar to medical record abstraction without significant differences by patient race or educational level. Use of patient reports, which are less costly than medical record audits, is a reasonable approach for observational comparative effectiveness research.

A Multidisciplinary Breast Cancer Brain Metastases Clinic: The University of North Carolina Experience

The University of North Carolina at Chapel Hill has created a clinic to provide medical and radiation oncology, neurosurgical, and supportive services to patients with breast cancer brain metastases. Of the 65 patients seen between January 2012 and January 2015, 78% returned for a follow-up visit and 32% were enrolled in a clinical trial. The clinic is a model that can be adapted at other centers.

Unanticipated hospital admissions during or soon after radiation therapy: Incidence and predictive factors

PURPOSE Unplanned hospital admissions in cancer patients undergoing treatment is an understudied area with important implications for both health care costs and patient outcomes. The goal of this retrospective study was to evaluate the rate, reasons for, and predictors of unplanned hospital admissions during or soon after palliative or curative radiation therapy for cancer, with or without chemotherapy. METHODS AND MATERIALS A total of 1116 consecutive patients who received external beam radiation therapy for a malignancy at the University of North Carolina at Chapel Hill from January 1 through December 31, 2010, were studied. The primary outcome was unplanned hospitalization within 90 days of starting radiation therapy (ie, during or soon after). Multivariable logistic regression was used to examine patient and treatment factors associated with admissions. RESULTS Twenty percent of patients experienced an unplanned admission, which was especially likely in patients with lung (25% of such patients admitted), head and neck (22%), and gastrointestinal (21%) cancers, as well as those treated with palliative intent (31%). The most common causes for admission were gastrointestinal symptoms, neurologic symptoms, respiratory symptoms, pain, and fever or infection. Forty-seven percent of admitted patients were seen in the clinic within 2 weeks of unplanned hospital admission, and 61% of those patients had a related complaint in the clinic. Multivariate analysis showed that married patients (odds ratio [OR] = 0.58; P < .001), curative intent (OR = 0.38; P < .001), and no concurrent chemotherapy (OR = 0.55; P < .001) were associated with decreased odds for admission. CONCLUSIONS Unplanned admissions are relatively common during or soon after radiation therapy in our patient series. Additional work is needed to gather data from other centers and to better understand, and hopefully reduce, these unplanned admissions.

Impact of post-chemoradiotherapy superselective/selective neck dissection on patient reported quality of life

OBJECTIVES To describe patient-reported quality of life (QoL) for patients with HPV/p16-positive oropharyngeal squamous cell carcinoma undergoing post-chemoradiation (CRT) superselective or selective neck dissection (ND) as part of a prospective de-intensification study. MATERIALS AND METHODS Patients received 60Gy IMRT with concurrent weekly cisplatin (30mg/m(2)), followed by preplanned neck dissection of only originally involved nodal levels. QoL measures were assessed using the EORTC QLQ-C30 (general), EORTC H&N-35 (head and neck specific), EAT-10 (swallowing), and NDII (Neck Dissection Impairment Index) questionnaires. Early and late post-ND time points were compared to baseline and post-CRT/pre-ND time points. RESULTS 37 patients underwent post-CRT superselective or selective ND. Median # of levels and nodes dissected were 2 and 12, respectively. EORTC QLQ-C30, H&N-35, and EAT-10 QoL scores worsened after CRT but continued to improve thereafter despite post-CRT ND. NDII score worsened initially after ND at the early post-ND time point (p=0.023) but had recovered by the late post-ND time point (p=0.672). Initial decrease in NDII was greater with ⩾12 nodes dissected (p=0.007) and was correlated with the total number of nodes dissected (Spearman p=0.027). CONCLUSION Use of post-CRT superselective and selective ND did not prevent recovery of most QoL metrics to near baseline. There was early but not late decrement in neck dissection specific QoL (NDII), more pronounced with more nodes dissected.

Unanticipated hospital admissions in patients undergoing radiotherapy with or without concurrent chemotherapy: Incidence and predictive factors.

114 Background: Unanticipated admissions are burdensome for patients and the healthcare system. An improved understanding of their frequency and predictive factors can inform initiatives to prevent such admissions and mitigate their associated human and financial costs. METHODS Electronic medical records of all patients (n=1144) undergoing external beam radiotherapy (RT) at our center in 2010 were reviewed in this retrospective study. Unanticipated admission within 90 days of initiating RT, and associated clinical factors, were recorded. Chi-squared and uni- and multivariate logistic regression was used to examine factors associated with admission. RESULTS Unanticipated admissions occurred in 19% (213/1144) of patients, median length of stay was 3 days (range 1-22), and the mean interval between the start of RT till admission was 28 days (1-89 days). The most common indications for admissions were pain (19% of admissions), GI toxicity (18%), and respiratory distress (15%). On univariate analysis, admission rates were higher in patients treated with palliative vs. curative intent (30% vs. 14%, p<0.001), with concurrent chemotherapy (23% vs. 18% RT alone, p=0.047), in those who had a recent admission prior to RT initiation (37% vs. 14% with no prior admission, p<0.001), and patients on their second or third course of RT (27% vs. 16% first treatment course, p<0.001). Multivariable analysis showed treatment intent, chemotherapy, and prior admissions to be associated with unplanned admissions (Table). CONCLUSIONS Rates of unanticipated admissions are ≈20% in patients undergoing RT. Slightly less than 1/3 of patients receiving palliative RT, and nearly 1/4 receiving concurrent chemoradiation, experienced an unplanned admission. Prophylactic measures should be studied in these high-risk patients to reduce admission rates, as unplanned admission may be an important quality of care indicator in oncology. [Table: see text].