Seyedeh Dibaj

Practice Patterns and Perceptions of Thoracic Oncology Providers on Tobacco Use and Cessation in Cancer Patients

Introduction: Tobacco use is associated with poor outcomes in cancer patients, but there is little information from oncology providers on their practice patterns or perceptions regarding tobacco use and smoking cessation in these patients. Methods: An online survey of practices, perceptions, and barriers to tobacco assessment and cessation in cancer patients was conducted in members of the International Association for the Study of Lung Cancer (IASLC). Responses of physician-level respondents were analyzed and reported. Results: Responses from 1507 IASLC members who completed the survey are reported as representing 40.5% of IASLC members. More than 90% of physician respondents believe current smoking affects outcome and that cessation should be a standard part of clinical care. At the initial patient visit, 90% ask patients about tobacco use, 79% ask patients whether they will quit, 81% advise patients to stop tobacco use, but only 40% discuss medication options, 39% actively provide cessation assistance, and fewer yet address tobacco at follow-up. Dominant barriers to physician cessation effort are pessimism regarding their ability to help patients stop using tobacco (58%) and concerns about patient resistance to treatment (67%). Only 33% report themselves to be adequately trained to provide cessation interventions. Conclusion: Physicians who care for lung cancer patients recognize the importance of tobacco cessation as a necessary part of clinical care, but many still do not provide assistance to their patients as a routine part of cancer care. Increasing tobacco cessation activities will require increased assessment and cessation at diagnosis and during follow-up, increased clinician education, and improved tobacco cessation methods.

Addressing Tobacco Use in Patients With Cancer: A Survey of American Society of Clinical Oncology Members

PURPOSE Assessing tobacco use and providing cessation support is recommended by the American Society for Clinical Oncology (ASCO). The purpose of this study was to evaluate practice patterns and perceptions of tobacco use and barriers to providing cessation support for patients with cancer. METHODS In 2012, an online survey was sent to 18,502 full ASCO members asking about their practice patterns regarding tobacco assessment, cessation support, perceptions of tobacco use, and barriers to providing cessation support for patients with cancer. Responses from 1,197 ASCO members are reported. RESULTS At initial visit, most respondents routinely ask patients about tobacco use (90%), ask patients to quit (80%), and advise patients to stop using tobacco (84%). However, only 44% routinely discuss medication options with patients, and only 39% provide cessation support. Tobacco assessments decrease at follow-up assessments. Most respondents (87%) agree or strongly agree that smoking affects cancer outcomes, and 86% believe cessation should be a standard part of clinical cancer care. However, only 29% report adequate training in tobacco cessation interventions. Inability to get patients to quit (72%) and patient resistance to treatment (74%) are dominant barriers to cessation intervention, but only 8% describe cessation as a waste of time. CONCLUSION Among ASCO members who responded to an online survey about their practice patterns regarding tobacco, most believe that tobacco cessation is important and frequently assess tobacco at initial visit, but few provide cessation support. Interventions are needed to increase access to tobacco cessation support for patients with cancer.

Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial

Importance The use of benzodiazepines to control agitation in delirium in the last days of life is controversial. Objective To compare the effect of lorazepam vs placebo as an adjuvant to haloperidol for persistent agitation in patients with delirium in the setting of advanced cancer. Design, Setting, and Participants Single-center, double-blind, parallel-group, randomized clinical trial conducted at an acute palliative care unit at MD Anderson Cancer Center, Texas, enrolling 93 patients with advanced cancer and agitated delirium despite scheduled haloperidol from February 11, 2014, to June 30, 2016, with data collection completed in October 2016. Interventions Lorazepam (3 mg) intravenously (n = 47) or placebo (n = 43) in addition to haloperidol (2 mg) intravenously upon the onset of an agitation episode. Main Outcomes and Measures The primary outcome was change in Richmond Agitation-Sedation Scale (RASS) score (range, −5 [unarousable] to 4 [very agitated or combative]) from baseline to 8 hours after treatment administration. Secondary end points were rescue neuroleptic use, delirium recall, comfort (perceived by caregivers and nurses), communication capacity, delirium severity, adverse effects, discharge outcomes, and overall survival. Results Among 90 randomized patients (mean age, 62 years; women, 42 [47%]), 58 (64%) received the study medication and 52 (90%) completed the trial. Lorazepam + haloperidol resulted in a significantly greater reduction of RASS score at 8 hours (−4.1 points) than placebo + haloperidol (−2.3 points) (mean difference, −1.9 points [95% CI, −2.8 to −0.9]; P < .001). The lorazepam + haloperidol group required less median rescue neuroleptics (2.0 mg) than the placebo + haloperidol group (4.0 mg) (median difference, −1.0 mg [95% CI, −2.0 to 0]; P = .009) and was perceived to be more comfortable by both blinded caregivers and nurses (caregivers: 84% for the lorazepam + haloperidol group vs 37% for the placebo + haloperidol group; mean difference, 47% [95% CI, 14% to 73%], P = .007; nurses: 77% for the lorazepam + haloperidol group vs 30% for the placebo + haloperidol group; mean difference, 47% [95% CI, 17% to 71%], P = .005). No significant between-group differences were found in delirium-related distress and survival. The most common adverse effect was hypokinesia (3 patients in the lorazepam + haloperidol group [19%] and 4 patients in the placebo + haloperidol group [27%]). Conclusions and Relevance In this preliminary trial of hospitalized patients with agitated delirium in the setting of advanced cancer, the addition of lorazepam to haloperidol compared with haloperidol alone resulted in a significantly greater reduction in agitation at 8 hours. Further research is needed to assess generalizability and adverse effects. Trial Registration clinicaltrials.gov Identifier: NCT01949662

Frequency and Characteristics of Recommendations from Interdisciplinary Outpatient Cancer Rehabilitation Monthly Team Meetings

Ambulatory cancer rehabilitation programs vary widely in the types of services offered, and there is a lack of consistency with respect to the coordination of rehabilitation with oncologic treatment plans. There are no guidelines for outpatient interdisciplinary rehabilitation team meetings, and the types and characteristics of recommendations that a physiatrist can provide during these meetings have not been reported.

Outpatient acupuncture effects on patient self-reported symptoms in oncology care: a retrospective analysis

Background: Increased access to complementary therapies such as acupuncture at academic medical centers has created new opportunities for management of cancer and cancer treatment related symptoms. Methods: Patients presenting for acupuncture treatment during calendar year 2016 at an outpatient integrative medicine clinic in a comprehensive cancer center were asked to complete a modified Edmonton Symptom Assessment Scale (ESAS; 16 symptoms, score 0-10, 10 worst possible) before and after each visit. ESAS subscales analyzed included global (GDS; score 0-90), physical (PHS, 0-60) and psychological distress (PSS, 0-20). ESAS symptom score change pre/post acupuncture treatment & from baseline visit to first follow up were evaluated by paired t-test. Results: Of 375 participants [mean age 55.6, 68.3% female, 73.9% white, most common cancer diagnosis of breast (32.8%) and thoracic/head & neck (25.9%)], 73.3% had at least one follow up acupuncture treatment [mean 4.6 (SD 5.1) treatments]. Highest/worst symptoms at baseline were poor sleep (3.92), fatigue (3.43), well-being (3.31), and pain (3.29). Statistically significant reduction/improvement (pre/post) was observed for all ESAS symptoms and subscales for the initial acupuncture treatment (p <0.001). Hot flashes had the highest mean reduction (-1.93), followed by fatigue (-1.72), numbness/tingling (-1.70), and nausea (-1.67). Clinically significant reductions were also observed for ESAS subscales of GDS (-12.2), PHS (-8.5), and PSS (-2.6). For symptom change from initial acupuncture treatment to first follow up (pre/pre), statistically and clinically significant improvement was observed for spiritual pain (-1.10; p<0.001) and ESAS subscale of GDS (-6.09; p=0.048). Clinical response rates (reduction ≥1) on follow up were highest for symptoms of spiritual pain (58.9%), dry mouth (57.8%) and nausea (57.3%). Conclusions: Outpatient acupuncture was associated with immediate & longitudinal significant improvement across a range of symptoms commonly experienced by individuals during cancer care. Further research is needed to better understand frequency of treatments needed in clinical practice to help maintain benefit.

Poster 476: Bleeding Events Among Hematologic Inpatient Rehabilitation Patients with Severe Thrombocytopenia

Objective: Improving PM&R residents’ ability to teach patients MSK exercises in the clinic setting. Increase treatment outcomes in an outpatient PM&R Clinic where physical therapy wait times are over 3 months. Design: An educational pamphlet was created under the guidance of a physical therapist to aid residents in the outpatient setting with instructing patients on exercises they can perform independently, without need for equipment. Handouts were made available in clinic to any patient requiring, but not able to, obtain formal physical therapy. Preand post-test surveys were given to the residents to assess if the intervention met the stated objectives. Setting: Outpatient PM&R Clinic, University Based Academic Medical Center. Participants: PM&R Residents. Interventions: 1. Resident pamphlet of therapeutic exercises 2. Patient musculoskeletal exercise handouts. Main Outcome Measures: 1. Improvement of PM&R resident’s knowledge of exercises and their ability to teach MSK exercises to patients. 2. Improvement in patient outcomes in General PM&R outpatient clinic. Results: In the pre-intervention survey, greater than 30% of residents who consulted PT, had “no idea” what that would entail, 70% had “somewhat an idea”, and no resident felt completely confident. Greater than 40% of residents admitted that if patients were not eligible for therapy, they were simply sent home. In the post-intervention survey, after giving out the resident handouts and making patient handouts available, positive improvements were seen. Only 15% of residents had “no idea” what PT would entail. The residents who simply sent patients home without any form of intervention, dropped from over 40% to 15%. 100% of residents felt the patient handouts adequately provided good treatment to those patients who could not get formal physical therapy. Conclusions: The objective of improving resident knowledge with providing exercises to patients with common musculoskeletal disorders was achieved. Residents felt the handouts resulted in the improvement of quality of care offered in the PM&R clinic. Level of Evidence: Level V