Shiva Shrotriya

C-Reactive Protein Is an Important Biomarker for Prognosis Tumor Recurrence and Treatment Response in Adult Solid Tumors: A Systematic Review

Purpose A systematic literature review was done to determine the relationship between elevated CRP and prognosis in people with solid tumors. C-reactive protein (CRP) is a serum acute phase reactant and a well-established inflammatory marker. We also examined the role of CRP to predict treatment response and tumor recurrence. Methods MeSH (Medical Subject Heading) terms were used to search multiple electronic databases (PubMed, EMBASE, Web of Science, SCOPUS, EBM-Cochrane). Two independent reviewers selected research papers. We also included a quality Assessment (QA) score. Reports with QA scores <50% were excluded. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology was utilized for this review (S1 PRISMA Checklist). Results 271 articles were identified for final review. There were 45% prospective studies and 52% retrospective. 264 had intermediate QA score (≥50% but <80%); Seven were adequate (80% -100%); A high CRP was predictive of prognosis in 90% (245/271) of studies—80% of the 245 studies by multivariate analysis, 20% by univariate analysis. Many (52%) of the articles were about gastrointestinal malignancies (GI) or kidney malignancies. A high CRP was prognostic in 90% (127 of 141) of the reports in those groups of tumors. CRP was also prognostic in most reports in other solid tumors primary sites. Conclusions A high CRP was associated with higher mortality in 90% of reports in people with solid tumors primary sites. This was particularly notable in GI malignancies and kidney malignancies. In other solid tumors (lung, pancreas, hepatocellular cancer, and bladder) an elevated CRP also predicted prognosis. In addition there is also evidence to support the use of CRP to help decide treatment response and identify tumor recurrence. Better designed large scale studies should be conducted to examine these issues more comprehensively.

Predicting early mortality in resectable pancreatic adenocarcinoma: A cohort study

Survival after surgical resection for pancreatic cancer remains poor. A subgroup of patients die early (<6 months), and understanding factors associated with early mortality may help to identify high‐risk patients. The Khorana score has been shown to be associated with early mortality for patients with solid tumors. In the current study, the authors evaluated the role of this score and other prognostic variables in this setting.

Connected health: cancer symptom and quality-of-life assessment using a tablet computer: a pilot study.

Incorporation of tablet computers (TCs) into patient assessment may facilitate safe and secure data collection. We evaluated the usefulness and acceptability of a TC as an electronic self-report symptom assessment instrument. Research Electronic Data Capture Web-based application supported data capture. Information was collected and disseminated in real time and a structured format. Completed questionnaires were printed and given to the physician before the patient visit. Most participants completed the survey without assistance. Completion rate was 100%. The median global quality of life was high for all. More than half reported pain. Based on Edmonton Symptom Assessment System, the top 3 most common symptoms were tiredness, anxiety, and decreased well-being. Patient and physician acceptability for these quick and useful TC-based surveys was excellent.

Reducing Unplanned Medical Oncology Readmissions by Improving Outpatient Care Transitions: A Process Improvement Project at the Cleveland Clinic

PURPOSE Reducing 30-day unplanned hospital readmissions is a national policy priority. We examined the impact of a quality improvement project focused on reducing oncology readmissions among patients with cancer who were admitted to palliative and general medical oncology services at the Cleveland Clinic. METHODS Baseline rates of readmissions were gathered during the period from January 2013 to April 2014. A quality improvement project designed to improve outpatient care transitions was initiated during the period leading to April 1, 2014, including: (1) provider education, (2) postdischarge nursing phone calls within 48 hours, and (3) postdischarge provider follow-up appointments within 5 business days. Nursing callback components included symptom management, education, medication review/compliance, and follow-up appointment reminder. RESULTS During the baseline period, there were 2,638 admissions and 722 unplanned 30-day readmissions for an overall readmission rate of 27.4%. Callbacks and 5-day follow-up appointment monitoring revealed a mean monthly compliance of 72% and 78%, respectively, improving over time during the study period. Readmission rates declined by 4.5% to 22.9% (P < .01; relative risk reduction, 18%) during the study period. The mean direct cost of one readmission was

Predictors and prognostic importance of weight change in adult solid tumors.

10,884, suggesting an annualized cost savings of

Symptoms, Quality of Life, and Daily Activities in People With Newly Diagnosed Solid Tumors Presenting to a Medical Oncologist.

1.04 million with the observed reduction in unplanned readmissions. CONCLUSION Modest readmission reductions can be achieved through better systematic transitions to outpatient care (including follow-up calls and early provider visits), thereby leading to a reduction in use of inpatient resources. These data suggest that efforts focused on improving outpatient care transition were effective in reducing unplanned oncology readmissions.

A prospective study of the clinical content of palliative medicine interdisciplinary team meetings.

103 Background: Body weight change in adults with solid tumors was examined in outpatients. Objective was to determine if demographics, clinical and biochemical characteristics were associated with change in weight between visit 1 and visit 2. Examine if weight change and related parameters were associated with survival. METHODS Electronic medical records (EMR) from a tertiary cancer center retrospectively reviewed from 2009-2011. Body weight and other clinical parameters on visit 1 - within a year post diagnosis; visit 2 ≥3 weeks after visit 1. Weight change categorized as: weight gain, 0-5%, 5.01-10%, >10%. Ordinal logistic regression and Cox proportional hazards utilized for WL predictors and prognostic factors respectively. RESULTS N = 5,901; Mean age (±SD): 61 ± 12 years; 82% were Caucasians; 16% African Americans. Common cancers were prostate 19%; breast 15%; lung 15%; head and neck 6%; colorectal 6%; others 12%. Metastatic disease was present in 18%. Bone, brain, lymph nodes - were common metastatic sites. 45% had radiotherapy; 41% chemotherapy. Median weight change from visit 1 to visit 2 = -1 (-48, 66) kgs. Weight loss (WL) in 57% (≤5%: 30%, 5.01-10%: 13%, >10%: 14%). Different primary cancer sites, number of metastatic sites, radiotherapy/chemotherapy/hormonal therapies, older age, body mass index (BMI), and albumin predicted weight change. Median survival in 5.01-10.0% WL= 9.4 months, >10.0% = 5.3 months, and not observed ≤ 5%. CONCLUSIONS 1. Majority lost ≤5% of body weight by visit 2. 2. Esophagus, head and neck, and pancreas (primary) - the greatest risk of WL; prostate - lowest. 3. High BMI predicted greater WL compared to normal or underweight. 4. ≤5% WL had a survival advantage compared to 5.01-10% and >10%. 5. WL remained prognostic for survival after adjusting for other prognostic factors.

Serum C-reactive protein is an important and powerful prognostic biomarker in most adult solid tumors

Introduction: Symptom and Quality of Life (QOL) data are important patient reported outcomes. Early identification of these is critical for appropriate interventions. Data collection may be helped by modern information technology. Aim: This study examined symptoms and QOL in people with solid tumors at their first visit to a medical oncologist. We also evaluated the clinical utility of tablet computers (TC) to collect this data. Methods: This was a prospective study of 105 consecutive patients in the cancer outpatient clinic of a tertiary level academic medical center. Symptom and QOL data was collected by TC with wireless database upload. Results: One-third participants had moderate to severe pain; almost half clinically significant pain that interfered with daily activities. Tiredness, anxiety, and drowsiness were common (prevalence - 79%, 63% and 50% respectively). One-third of those who had items identified from the Edmonton System Assessment System also volunteered other symptoms, mostly gastrointestinal problems. Many of those affected also reported impaired Global Wellbeing and low Overall QOL. There was a 98% completion rate, which took on average ten minutes. Direct observation and informal feedback from patients and physicians regarding the acceptability of TC in this setting was uniformly positive. Conclusions: Amongst people with newly diagnosed solid tumors clinically important psychological and physical symptoms, QOL problems and difficulties with daily activities were commonly present in the 24-hour period and in the week before a first Medical Oncology visit. Symptom and QOL data collection by TC in busy outpatient clinics showed good clinical utility.

The Care of the Actively Dying in an Academic Medical Center A Survey of Registered Nurses’ Professional Capability and Comfort

Structured interprofessional communication should improve the structure and clarity of the plan of care. The interdisciplinary team meeting (IDTM) is an opportunity for shared information on patients’ and family care needs. We report a prospective observations study of palliative medicine IDTM, which recorded the clinical issues discussed. One hundred and forty-five disparate clinical items were identified for 59 patients and were discussed by the IDTM in about 240 minutes. By content analysis and research meeting consensus, they were grouped into 9 agreed interdisciplinary themes. The 9 themes were then subjected to biostatistical analysis and 3 communication clusters identified. Themes consisted of 3 major communication clusters: (1) clinical services, (2) psychosocial, and (3) care plan. Two themes (information exchange and clinical transitions) did not cluster. The IDTM identified patient care need, reported concerns, and supported collaboration in proactive patient care plans. Future research projects with more patients and a large number of meetings can confirm our findings. This should also examine specific contributions by professional discipline.

Low 25-hydroxyvitamin D levels in people with a solid tumor cancer diagnosis: the tip of the iceberg?

Introduction Prognostication in cancer is challenging and inaccurate. C-Reactive Protein (CRP), a cheap and sensitive marker of inflammation may help. This study investigated the relationship between CRP and prognosis in a large cohort of solid tumors with mixed cancer diagnoses and stages. Methods Electronic medical records of 4931 adults with solid tumors who attended the Taussig Cancer Institute from 2006–2012 were reviewed. Demographic and clinical characteristics were recorded. Maximum CRP (mCRP) was identified for each individual. CRP was analysed as a time-dependent, continuous and categorical variable for association with survival. Results Two thirds of patients had a high mCRP. This was consistently associated with shorter survival, even after correction for time from diagnosis, and when analysed as a continuous or a categorical variable. When mCRP values above 10 mg/L were subcategorized, a higher mCRP was always worse. Even among those with normal values, statistically and clinically significant shorter survival was noted at mCRP levels >5 mg/L. Conclusions In a large representative cohort of consecutive solid tumor patients the risk of death was clinically and statistically significantly greater with a high mCRP. This was independent of other variables and regardless of statistical method from both dates of diagnosis and test. CRP appeared to be underutilized. Our results support the routine use of CRP as a universal cost-effective independent prognostic indicator in most solid tumors.