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Rodriguez GM, Parikh DA, Kapphahn K, Gupta DM, Fan AC, Shah S, Srinivas S, Teuteberg W, Seevaratnam B, Asuncion K, Chien J, Moore K, Ruiz SM, Patel MI. Coaches Activating, Reaching, and Engaging Patients to Engage in Advance Care Planning: A Randomized Clinical Trial. JAMA Oncol 2024:2819054. [PMID: 38780960 PMCID: PMC11117149 DOI: 10.1001/jamaoncol.2024.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/21/2023] [Indexed: 05/25/2024]
Abstract
Importance Advance care planning (ACP) remains low among patients with advanced cancer. Multilevel interventions compared with clinician-level interventions may be more effective in improving ACP. Objective To evaluate whether a multilevel intervention could improve clinician-documented ACP compared with a clinician-level intervention alone. Design, Setting, and Participants This randomized clinical trial, performed from September 12, 2019, through May 12, 2021, included adults with advanced genitourinary cancers at an academic, tertiary hospital. Data analysis was performed by intention to treat from May 1 to August 10, 2023. Intervention Participants were randomized 1:1 to a 6-month patient-level lay health worker structured ACP education along with a clinician-level intervention composed of 3-hour ACP training and integration of a structured electronic health record documentation template (intervention group) or to the clinician-level intervention alone (control group). Main Outcome and Measures The primary outcome was ACP documentation in the electronic health record by the oncology clinician within 12 months after randomization. Secondary, exploratory outcomes included shared decision-making, palliative care use, hospice use, emergency department visits, and hospitalizations within 12 months after randomization. Results Among 402 participants enrolled in the study, median age was 71 years (range, 21-102 years); 361 (89.8%) identified as male. More intervention group participants had oncology clinician-documented ACP than control group participants (82 [37.8%] vs 40 [21.6%]; odds ratio [OR], 2.29; 95% CI, 1.44-3.64). At 12-month follow-up, more intervention than control group participants had palliative care (72 [33.2%] vs 25 [13.5%]; OR, 3.18; 95% CI, 1.91-5.28) and hospice use (49 [22.6%] vs 19 [10.3%]; OR, 2.54; 95% CI, 1.44-4.51). There were no differences in the proportion of participants between groups with an emergency department visit (65 [30.0%] vs 61 [33.0%]; OR, 0.87; 95% CI, 0.57-1.33) or hospitalization (89 [41.0%] vs 85 [46.0%]; OR, 0.82; 95% CI, 0.55-1.22). Intervention group participants had fewer hospitalizations than control group participants (mean [SD] number of hospitalizations per year, 0.87 [1.60] vs 1.04 [1.77]) and a lower risk of hospitalization (incidence rate ratio, 0.80; 95% CI, 0.65-0.98). Conclusions and Relevance In this randomized clinical trial, a multilevel intervention improved oncology clinician-documented ACP compared with a clinician-level intervention alone for patients with genitourinary cancer. The intervention is one approach to effectively increase ACP among patients with cancer. Trial Registration ClinicalTrials.gov Identifier: NCT03856463.
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Affiliation(s)
- Gladys M. Rodriguez
- Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Divya A. Parikh
- Department of Medicine, Stanford University, Stanford, California
- Medical Services, VA Palo Alto Health Care System, Palo Alto, California
| | - Kris Kapphahn
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Divya M. Gupta
- Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Alice C. Fan
- Department of Medicine, Stanford University, Stanford, California
| | - Sumit Shah
- Department of Medicine, Stanford University, Stanford, California
| | - Sandy Srinivas
- Department of Medicine, Stanford University, Stanford, California
| | | | | | - Khay Asuncion
- Department of Medicine, Stanford University, Stanford, California
| | - Joanne Chien
- Department of Medicine, Stanford University, Stanford, California
| | - Kaidi Moore
- Department of Medicine, Stanford University, Stanford, California
| | - Shann Mika Ruiz
- Department of Medicine, Stanford University, Stanford, California
| | - Manali I. Patel
- Department of Medicine, Stanford University, Stanford, California
- Medical Services, VA Palo Alto Health Care System, Palo Alto, California
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Coschi CH, Dodbiba L, Guerry D. Oncology: What You May Have Missed in 2023. Ann Intern Med 2024; 177:S57-S70. [PMID: 38621244 DOI: 10.7326/m24-0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Advances in oncology treatment methods have improved outcomes and quality of life for patients with cancer. However, care of these patients can be complex, and the contribution of physicians from different specialties is crucial. This article highlights important publications from 2023 on topics across a wide spectrum relating to the management of oncology patients. The literature was screened for significant new evidence that is relevant to internal medicine specialists and subspecialists whose focus is not oncology. Two articles address the importance of social interventions targeting end-of-life care for low-income and minority patients and the well-being of caregivers. Two additional articles address screening considerations in patients at risk for colorectal and lung cancer. Two more articles address safe use of hormone-related therapies to treat symptoms of menopause and prevent disease recurrence or progression in patients diagnosed with noninvasive breast neoplasia. Finally, several articles were included on topics related to COVID-19 vaccination in patients with cancer, use of cannabinoids for cancer pain control, chronic autoimmune adverse effects related to use of immune checkpoint inhibitors, and the incidence of second primary neoplasms.
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Affiliation(s)
- Courtney H Coschi
- Division of Medical Oncology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada (C.H.C., L.D.)
| | - Lorin Dodbiba
- Division of Medical Oncology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada (C.H.C., L.D.)
| | - DuPont Guerry
- Associate Editor, Annals of Internal Medicine, and Emeritus Professor of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania (D.G.)
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Patel MI, Hinyard L, Merrill JK, Smith KT, Lei J, Carrizosa D, Kamaraju S, Hlubocky FJ, Kalwar T, Fashoyin-Aje L, Gomez SL, Jeames S, Florez N, Kircher SM, Tap WD. Challenges and Solutions to Support Oncology Professionals Serving Underserved Populations With Cancer in the United States: Results From the ASCO Serving the Underserved Task Force. JCO Oncol Pract 2024; 20:688-698. [PMID: 38354324 DOI: 10.1200/op.23.00595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/17/2023] [Accepted: 12/18/2023] [Indexed: 02/16/2024] Open
Abstract
PURPOSE Little data exist regarding approaches to support oncology professionals who deliver cancer care for underserved populations. In response, ASCO developed the Serving the Underserved Task Force to learn from and support oncology professionals serving underserved populations. METHODS The Task Force developed a 28-question survey to assess oncology professionals' experiences and strategies to support their work caring for underserved populations. The survey was deployed via an online link to 600 oncology professionals and assessed respondent and patient demographic characteristics, clinic-based processes to coordinate health-related social services, and strategies for professional society support and engagement. We used chi-square tests to evaluate whether there were associations between percent full-time equivalent (FTE) effort serving underserved populations (<50% FTE v ≥50% FTE) with responses. RESULTS Of 462 respondents who completed the survey (77% response rate), 79 (17.1%) were Asian; 30 (6.5%) Black; 43 (9.3%) Hispanic or Latino/Latina; and 277 (60%) White. The majority (n = 366, 79.2%) had a medical doctor degree (MD). A total of 174 (37.7%) had <25% FTE, 151 (32.7%) had 25%-50% FTE, and 121 (26.2%) had ≥50% FTE effort serving underserved populations. Most best guessed patients' sociodemographic characteristics (n = 388; 84%), while 42 (9.2%) used data collected by the clinic. Social workers coordinated most health-related social services. However, in clinical settings with high proportions of underserved patients, there was greater reliance on nonclinical personnel, such as navigators (odds ratio [OR], 2.15 [95% CI, 1.07 to 4.33]) or no individual (OR, 2.55 [95% CI, 1.14 to 5.72]) for addressing mental health needs and greater reliance on physicians or advance practice practitioners (OR, 2.54 [95% CI, 1.11 to 5.81]) or no individual (OR, 1.91 [95% CI, 1.09 to 3.35]) for addressing childcare or eldercare needs compared with social workers. Prioritization of solutions, which did not differ by FTE effort serving underserved populations, included a return-on-investment model to support personnel, integrated health-related social needs screening, and collaboration with the professional society on advocacy and policy. CONCLUSION The findings highlight crucial strategies that professional societies can implement to support oncology clinicians serving underserved populations with cancer.
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Affiliation(s)
- Manali I Patel
- Stanford University School of Medicine, Stanford, CA
- VA Palo Alto Health Care System, Palo Alto, CA
| | | | | | | | - Jennifer Lei
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | - Tricia Kalwar
- Veterans Administration, Miami Healthcare System, Miami, FL
| | | | | | | | - Narjust Florez
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Sheetal M Kircher
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - William D Tap
- Memorial Sloan Kettering Cancer Center, New York, NY
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Elias H, Kisembe E, Nyariki S, Kiplimo I, Amisi J, Boit J, Tarus A, Mohamed N, Cornetta K. Impact of training on knowledge, confidence and attitude amongst community health volunteers in the provision of community-based palliative care in rural Kenya. BMC Palliat Care 2024; 23:97. [PMID: 38605309 PMCID: PMC11007868 DOI: 10.1186/s12904-024-01415-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVES Existing literature suggests multiple potential roles for community health volunteers (CHVs) in the provision of palliative care (PC) in low- and middle-income countries. In Kenya the role of CHV in the provision of PC has not been reported. The objective of this study was to assess knowledge, confidence, attitude, and clinical practice of community health volunteers after attending a novel palliative care (PC) training program. METHODS A total of 105 CHVs participated in a 3-day in person training followed by a 1-month in person and telephone observation period of the palliative care activities in the community. Structured questionnaires were used pre- and post-training to assess knowledge acquisition, impact on practice, and content delivery. A mixed method study design was conducted 12-month post training to assess impact on clinical practice. RESULTS Immediately after training, CHV provided positive ratings on relevance and content delivery. In the month following training, CHVs evaluated 1,443 patients, referred 154, and conducted 110 and 129 tele consults with the patients and PC providers respectively. The follow up survey at 12 months revealed improved knowledge and confidence in various domains of palliative care including symptom and spiritual assessment and provision of basic nursing and bereavement care. Focus group discussions revealed the CHVs ability to interpret symptoms, make referrals, improved communication/ interpersonal relationships, spiritual intervention, patient comfort measures and health care practices as newly learned and practiced skills. CONCLUSIONS We noted improved knowledge, new skills and change in practice after CHVs participation in a novel training curriculum. CHVs can make important contributions to the PC work force and be first line PC providers in the community as part of larger hub and spoke care model.
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Affiliation(s)
- Hussein Elias
- Department of Family Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
| | - Evelyne Kisembe
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Sarah Nyariki
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ivan Kiplimo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - James Amisi
- Department of Family Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Juli Boit
- Living Room International Hospital, Eldoret, Kenya
| | | | | | - Kenneth Cornetta
- Department of Family Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Medical and Molecular Genetics, School of Medicine, Indiana University, Indianapolis, IN, USA
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Banks LC, Kapphahn K, Das M, Patel MI. Randomized Trial of a Volunteer-Led Symptom Assessment Intervention on Documentation, Patient-Reported Outcomes, and Health Care Use Among Veterans With Lung Cancer. JCO Oncol Pract 2024; 20:419-428. [PMID: 38207246 DOI: 10.1200/op.23.00557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/03/2023] [Accepted: 11/27/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE Identification and documentation of Veterans' symptoms are crucial for optimal lung cancer care delivery. The objective of this study was to determine whether a volunteer-led proactive telephone symptom assessment intervention could improve comprehensive symptom documentation. METHODS Veterans with lung cancer were randomly assigned to usual care (control group) or usual care with proactive symptom assessment in which a peer volunteer made weekly phone calls to assess patient symptoms under nurse practitioner supervision. The primary outcome was oncologist documentation of symptoms in the electronic health record at all clinical visits within 6 months after enrollment. Secondary outcomes included patient satisfaction with decision, patient activation, health-related quality of life (HRQOL), and symptom burden, measured at baseline, and 3, 6, and 9 months after enrollment, and acute care use within 9 months after enrollment. RESULTS Among 60 Veterans randomly assigned, median (range) age was 70.2 (50-86) years; 57 (95.0%) were male. More intervention participants had oncologist documentation of symptoms than control group participants (24 [77.4%] v seven [24.1%], respectively; odds ratio, 16.46 [95% CI, 4.58 to 59.16]). Intervention group participants had greater improvements over time in HRQOL (expected mean difference, 25.3 [95% CI, 15.00 to 35.70]) and patient activation (expected mean difference, 13.6 [95% CI, 3.79 to 23.39]), lower symptom burden (expected mean difference, -6.39 [95% CI, -15.21 to -2.46]), lower rates of emergency room visits (incidence rate ratio, 0.48 [95% CI, 0.30 to 0.75]), and hospitalizations (incidence rate ratio, 0.47 [95% CI, 0.28 to 0.77]) than control group participants. CONCLUSION This symptom assessment intervention is an effective strategy for Veterans with lung cancer.
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Affiliation(s)
| | - Kris Kapphahn
- Quantitative Sciences Unit, Stanford School of Medicine, Stanford, CA
| | - Millie Das
- Department of Medicine, VA Palo Alto Health Care System, Palo Alto, CA
- Division of Oncology, Stanford School of Medicine, Stanford, CA
| | - Manali I Patel
- Department of Medicine, VA Palo Alto Health Care System, Palo Alto, CA
- Division of Oncology, Stanford School of Medicine, Stanford, CA
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Adelson K, Rocque G. Community Health Worker Navigation for Patients With Cancer: It Is Time to Scale up. J Clin Oncol 2024; 42:491-493. [PMID: 38175984 DOI: 10.1200/jco.23.01723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 08/11/2023] [Accepted: 09/20/2023] [Indexed: 01/06/2024] Open
Affiliation(s)
- Kerin Adelson
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Gabrielle Rocque
- University of Alabama at Birmingham, Department of Medicine, Division of Hematology and Oncology, Birmingham, AL
- O'Neal Comprehensive Cancer Center, Birmingham, AL
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Patel MI, Kapphahn K, Wood E, Coker T, Salava D, Riley A, Krajcinovic I. Effect of a Community Health Worker-Led Intervention Among Low-Income and Minoritized Patients With Cancer: A Randomized Clinical Trial. J Clin Oncol 2024; 42:518-528. [PMID: 37625110 DOI: 10.1200/jco.23.00309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 08/27/2023] Open
Abstract
PURPOSE To determine whether a community health worker (CHW)-led intervention could improve health-related quality of life (HRQoL; primary outcome) more than usual care among low-income and racial and ethnic minoritized populations newly diagnosed with cancer. METHODS This randomized clinical trial was conducted from November 1, 2018, until August 31, 2021, in outpatient cancer clinics in Atlantic City, NJ, and Chicago, IL. Hourly low-wage worker members of an employer union health fund age 18 years or older with newly diagnosed solid tumor and hematologic malignancies were randomly assigned 1:1 to usual care (control group) or usual care augmented with a trained CHW for 12 months (intervention group). The CHW assisted participants with advance care planning (ACP), proactively screened symptoms, and referred participants to community-based resources for identified health-related social needs. Usual care comprised nurse case management and benefits redesign (waived copayments and free transportation for any cancer care received at preferred oncology clinics in each city). The primary outcome was HRQoL. Secondary outcomes included patient activation, satisfaction with decision, ACP documentation, health care use, total health care costs, and overall survival. RESULTS A total of 160 participants were enrolled. Intervention group participants had a greater increase in mean HRQoL scores at 4-month and 12-month follow-up as compared with baseline than control group participants (expected mean difference, 11.25 [95% CI, 7.28 to 15.22]; 11.29 [95% CI, 6.96 to 15.62], respectively). CONCLUSION In this randomized trial, a CHW-led intervention significantly improved HRQoL for low-income and racial and ethnic minoritized patients with cancer more than usual care alone.
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Affiliation(s)
- Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Kris Kapphahn
- Qualitative Sciences Unit, Stanford University School of Medicine, Stanford, CA
| | - Emily Wood
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
| | - Tumaini Coker
- Seattle Childrens Health, University of Washington, Seattle, WA
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Parikh RB, Schriver E, Ferrell WJ, Wakim J, Williamson J, Khan N, Kopinsky M, Balachandran M, Gabriel PE, Schuchter LM, Patel MS, Shulman LN, Manz CR. Remote Patient-Reported Outcomes and Activity Monitoring to Improve Patient-Clinician Communication Regarding Symptoms and Functional Status: A Randomized Controlled Trial. JCO Oncol Pract 2023; 19:1143-1151. [PMID: 37816198 PMCID: PMC10732505 DOI: 10.1200/op.23.00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/08/2023] [Accepted: 08/29/2023] [Indexed: 10/12/2023] Open
Abstract
PURPOSE Routine collection of patient-generated health data (PGHD) may promote earlier recognition of symptomatic and functional decline. This trial assessed the impact of an intervention integrating remote PGHD collection with patient nudges on symptom and functional status understanding between patients with advanced cancer and their oncology team. METHODS This three-arm randomized controlled trial was conducted from November 19, 2020, to December 17, 2021, at a large tertiary oncology practice. We enrolled patients with stage IV GI and lung cancers undergoing chemotherapy. Over 6 months, patients in two intervention arms received PROStep-weekly text message-based symptom surveys and passive activity monitoring using a wearable accelerometer. PGHD were summarized in dashboards given to patients' oncology team before appointments. One intervention arm received an additional text-based active choice prompt to discuss worsening symptoms or functional status with their clinician. Control patients did not receive PROStep. The coprimary outcomes patient perceptions of oncology team symptom and functional understanding at 6 months were measured on a 1-5 Likert scale (5 = high understanding). RESULTS One hundred eight patients enrolled: 55% male, 81% White, and 77% had GI cancers. Patient-reported clinician understanding did not differ between control and intervention arms for symptoms (4.5 v 4.5; P = .87) or functional status (4.5 v 4.3; P = .31). In the intervention arms, combined patient adherence to weekly symptom reports and daily activity monitoring was 64% and 53%, respectively. Intervention patients in the PROStep versus PROStep + active choice arms reported low burden from wearing the accelerometer (mean burden [standard deviation], 2.7 [1.3] v 2.1 [1.3]; P = .15) and completing surveys (2.1 [1.2] v 1.9 [1.3]; P = .44). CONCLUSION Patients receiving PROStep reported high understanding of symptoms and functional status from their oncology team, although this did not differ from controls.
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Affiliation(s)
- Ravi B. Parikh
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Emily Schriver
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, PA
- Penn Medicine Predictive Healthcare, University of Pennsylvania Health System, Philadelphia, PA
| | - William J. Ferrell
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Wakim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joelle Williamson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Neda Khan
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | - Michael Kopinsky
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | | | - Peter E. Gabriel
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lynn M. Schuchter
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | | | - Christopher R. Manz
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Harvard University, Boston, MA
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Mukherjee S, Shupo F, Wayi-Wayi G, Zibelnik N, Jones E, Mason N, Franklin M, Brazier J. Symptom burden in patients with idiopathic multicentric Castleman disease and its impact on daily life: an international patient and caregiver survey. EClinicalMedicine 2023; 64:102192. [PMID: 37727459 PMCID: PMC10505977 DOI: 10.1016/j.eclinm.2023.102192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/21/2023] Open
Abstract
Background Idiopathic Multicentric Castleman Disease (iMCD) is a rare inflammatory lymphoproliferative disorder with heterogenous clinical presentations. The symptomatology in iMCD patients remains poorly understood. The aim of this study was to identify the type, frequency and severity of iMCD-related symptoms and the impact of these on the daily lives of iMCD patients and informal-caregivers. Methods We conducted two bespoke 45-question online surveys for iMCD patients and informal-caregivers of patients recruited from the US, UK, Australia and Canada between April 14 and November 8, 2021. Descriptive data was collected, and a Likert scale was used to quantify the impact of symptoms on various aspects of daily life. Ordinal logistic regression analysis was used to determine associations between age, gender, employment status and symptom burden with aspects of daily life. Findings Eligible respondents included 51 iMCD patients and 11 informal-caregivers. Patients reported up to 27 unique symptoms, the mean number of symptoms experienced by a patient was 6.7 (range 0-22 symptoms). Most symptoms had a moderate to severe impact on patients' daily lives, with 'pain/discomfort', 'ability to travel', and 'sexual functioning' being the most impacted. iMCD patient characteristics such as being 40 years or older, female, and either disabled or unemployed was significantly associated with adverse impact on several aspects of daily life. Among caregivers, the aspects of daily life that were disproportionately affected was their own social life and freedom, emotional wellbeing, travel/relocation, and work. Interpretation iMCD patients have widely varied and unappreciated symptomatology. High symptom burden adversely impacts several aspects of patient daily lives as well as their caregivers. Funding Funding was provided by EUSA Pharma.
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Affiliation(s)
- Sudipto Mukherjee
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | | | - Matthew Franklin
- School of Health and Related Research, Sheffield University, Sheffield, United Kingdom
| | - John Brazier
- School of Health and Related Research, Sheffield University, Sheffield, United Kingdom
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Feng G, Parthipan M, Breunis H, Puts M, Emmenegger U, Timilshina N, Hansen AR, Finelli A, Krzyzanowska MK, Matthew A, Clarke H, Mina DS, Soto-Perez-de-Celis E, Tomlinson G, Alibhai SMH. Feasibility and acceptability of remote symptom monitoring (RSM) in older adults during treatment for metastatic prostate cancer. J Geriatr Oncol 2023; 14:101469. [PMID: 36917921 DOI: 10.1016/j.jgo.2023.101469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/20/2023] [Accepted: 02/28/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Emerging data support multiple benefits of remote symptom monitoring (RSM) during chemotherapy to improve outcomes. However, these studies have not focused on older adults and do not include treatments beyond chemotherapy. Although chemotherapy, androgen receptor axis-targeted therapies (ARATs), and radium-223 prolong survival, toxicities are substantial and increased in older adults with metastatic prostate cancer (mPC). We aimed to assess RSM feasibility among older adults receiving life-prolonging mPC treatments. MATERIALS AND METHODS Older adults aged 65+ starting chemotherapy, an ARAT, or radium-223 for mPC were enrolled in a multicentre prospective cohort study. As part of the RSM package, participants completed the Edmonton Symptom Assessment Scale (ESAS) daily and detailed questionnaires assessing mood, anxiety, fatigue, insomnia, and pain weekly online or by phone throughout one treatment cycle (3-4 weeks). Alerts were sent to the clinical oncology team for severe symptoms (ESAS ≥7). Participants also completed an end of study questionnaire that assessed study burden and satisfaction. Descriptive statistics were used to determine recruitment and retention rates, participant response rates to daily and weekly questionnaires, clinician responses to alerts, and participant satisfaction rates. An inductive descriptive approach was used to categorize open-ended responses about study benefits, challenges, and recommendations into relevant themes. RESULTS Ninety males were included (mean age 77 years, 48% ARAT, 38% chemotherapy, and 14% radium-223). Approximately 38% of patients preferred phone-based RSM. Patients provided RSM responses in 1216 out of 1311 daily questionnaires (93%). Over 93% of participants were satisfied (36%), very satisfied (43%), or extremely satisfied (16%) with RSM, although daily reporting was reported by several (8%) as burdensome. Nearly 45% of patients reported severe symptoms during RSM. Most symptom alerts sent to the oncology care team were acknowledged (97%) and 53% led to follow-ups with a nurse or physician for additional care. DISCUSSION RSM is feasible and acceptable to older adults with mPC, but accommodation needs to be made for phone-based RSM. The optimal frequency and duration of RSM also needs to be established.
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Affiliation(s)
- Gregory Feng
- Department of Medicine, University Health Network, Toronto, Canada.
| | | | | | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
| | - Urban Emmenegger
- Division of Medical Oncology, Odette Cancer Centre, Toronto, Canada.
| | | | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada.
| | - Antonio Finelli
- Division of Urology, Princess Margaret Cancer Centre, Toronto, Canada.
| | - Monika K Krzyzanowska
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada.
| | - Andrew Matthew
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada.
| | - Hance Clarke
- Department of Anesthesia, Toronto General Hospital, Toronto, Canada.
| | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada.
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Salvador Zubirán National Institute of Medical Sciences and Nutrition, Mexico City, Mexico.
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network, Toronto, Canada.
| | - Shabbir M H Alibhai
- Department of Medicine, University Health Network, Toronto, Canada; Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada.
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Patel MI, Murillo A, Agrawal M, Coker T. Health Care Professionals' Perspectives on Implementation, Adoption, and Maintenance of a Community Health Worker-Led Advance Care Planning and Cancer Symptom Screening Intervention: A Qualitative Study. JCO Oncol Pract 2023; 19:e138-e149. [PMID: 36201710 PMCID: PMC10166359 DOI: 10.1200/op.22.00209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Advance care planning (ACP) and symptom screening are nationally recommended for all patients with advanced stages of cancer. Yet, routine delivery of such care remains challenging because of multilevel barriers. We hired and trained community health workers (CHWs) to assist with delivery of these services across the United States. The aim of this study was to explore health care professionals' perspectives on barriers and facilitators to these team-based approaches. METHODS We conducted semistructured interviews with 44 health care professionals in 21 cancer clinics in seven US cities using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. We recorded, transcribed, and analyzed interviews using the framework analysis approach. RESULTS Participants noted barriers and facilitators to implementation, adoption, and maintenance of CHW-led ACP and symptom management approaches. Participants were initially skeptical; however, they noted a positive shift in their views over time because of personal experiences and effectiveness in their clinics. There was significant variation in adoption with some using a prescriptive top-down approach and others a bottom-up approach. Most agreed that the combination of top-down and bottom-up approaches would be most efficient and effective for promoting team-based care. All participants discussed implementation and provided suggestions for maintenance including organizational support, leadership, and CHW retention. CONCLUSION CHW-led ACP and proactive symptom management interventions are effective and accepted by cancer care professionals at scale. Tailoring on the basis of organization and local contexts is required to ensure successful adoption, implementation, and maintenance of these effective team-based care delivery approaches.
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Affiliation(s)
- Manali I. Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
- Center for Primary Care and Outcomes Research/Health Research and Policy, Stanford University School of Medicine, Stanford, CA
| | - Ariana Murillo
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
| | | | - Tumaini Coker
- Seattle Children's Research Institute, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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Caminiti C, Maglietta G, Diodati F, Puntoni M, Marcomini B, Lazzarelli S, Pinto C, Perrone F. The Effects of Patient-Reported Outcome Screening on the Survival of People with Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14215470. [PMID: 36358888 PMCID: PMC9657884 DOI: 10.3390/cancers14215470] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
This study examined the effects of the routine assessment of patient-reported outcomes (PROs) on the overall survival of adult patients with cancer. We included clinical trials and observational studies with a control group that compared PRO monitoring interventions in cancer clinical practice to usual care. The Cochrane risk-of-bias tools were used. In total, six studies were included in the systematic review: two randomized trials, one population-based retrospectively matched cohort study, two pre−post with historical control studies and one non-randomized controlled trial. Half were multicenter, two were conducted in Europe, three were conducted in the USA and was conducted in Canada. Two studies considered any type of cancer, two were restricted to lung cancer and two were restricted to advanced forms of cancer. PRO screening was electronic in four of the six studies. The meta-analysis included all six studies (intervention = 130.094; control = 129.903). The pooled mortality outcome at 1 year was RR = 0.77 (95%CI 0.76−0.78) as determined by the common effect model and RR = 0.82 (95%CI 0.60−1.12; p = 0.16) as determined by the random-effects model. Heterogeneity was statistically significant (I2 = 73%; p < 0.01). The overall risk of bias was rated as moderate in five studies and serious in one study. This meta-analysis seemed to indicate the survival benefits of PRO screening. As routine PRO monitoring is often challenging, more robust evidence regarding the effects of PROs on mortality would support systematic applications.
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Affiliation(s)
- Caterina Caminiti
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy
- Correspondence:
| | - Giuseppe Maglietta
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Francesca Diodati
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Matteo Puntoni
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Barbara Marcomini
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Silvia Lazzarelli
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Carmine Pinto
- Medical Oncology, Comprehensive Cancer Center, Azienda USL-IRCCS Reggio Emilia, 42122 Reggio Emilia, Italy
| | - Francesco Perrone
- Clinical Trials Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, 80131 Naples, Italy
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13
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Patel MI, Kapphahn K, Dewland M, Aguilar V, Sanchez B, Sisay E, Murillo A, Smith K, Park DJ. Effect of a Community Health Worker Intervention on Acute Care Use, Advance Care Planning, and Patient-Reported Outcomes Among Adults With Advanced Stages of Cancer: A Randomized Clinical Trial. JAMA Oncol 2022; 8:1139-1148. [PMID: 35771552 PMCID: PMC9247857 DOI: 10.1001/jamaoncol.2022.1997] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Deficiencies in advance care planning and symptom management are associated with avoidable acute care use among patients with cancer. Community health worker (CHW)-led approaches may be an approach to reduce acute care use but remain untested in community settings. Objective To determine whether a CHW-led advance care planning and symptom screening intervention can reduce acute care use more than usual care in a community setting. Design, Setting, and Participants This randomized clinical trial was conducted among patients with newly diagnosed advanced-stage or recurrent solid and hematologic cancers from August 8, 2017, through November 30, 2021. Data analysis was performed November 30, 2021, through January 1, 2022, by intention to treat. Interventions Participants were randomized 1:1 to usual care (control group) or usual care with the 6-month CHW-led intervention (intervention group). Main Outcomes and Measures The primary outcome was acute care use. Secondary outcomes included advance care planning documentation, supportive care use, patient-reported outcomes, survival, and end-of-life care use. Results Among 128 participants, median (range) age was 67 (19-89) years; 61 (47.7%) were female; and 2 (1.6%) were American Indian or Alaska Native, 11 (8.6%) were Asian, 5 (3.9%) were Black, 23 (18.0%) were Hispanic or Latino, 2 (1.6%) were of mixed race, 2 (1.6%) were Native Hawaiian or other Pacific Islander, 86 (67.2%) were White, and 20 (15.6%) did not report race. Intervention participants had 62% lower risk of acute care use than the control (hazard ratio, 0.38; 95% CI, 0.19-0.76) within 6 months. At 12 months, intervention participants had 17% lower odds of acute care use (odds ratio [OR], 0.83; 95% CI, 0.69-0.98), 8 times the odds of advance care planning documentation (OR, 7.18; 95% CI, 2.85-18.13), 4 times the odds of palliative care (OR, 4.46; 95% CI, 1.88-10.55), nearly double the odds of hospice (OR, 1.83; 95% CI, 1.16-2.88), and nearly double the odds of improved mental and emotional health from enrollment to 6 and 12 months postenrollment (OR, 1.82; 95% CI, 1.03-3.28; and OR, 2.20; 95% CI, 1.04-4.65, respectively) than the control. There were no differences in the death (control, 26 [40.6%] vs intervention, 32 [50.0%]). Fewer intervention participants had acute care use (0 vs 6 [23.1%]) in the month before death than the control. Conclusions and Relevance In this randomized clinical trial, integration of a CHW-led intervention into cancer care reduced acute care use and is one approach to improve cancer care delivery for patients with advanced stages of disease in community settings. Trial Registration ClinicalTrials.gov Identifier: NCT03154190.
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Affiliation(s)
- Manali I. Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, California,Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, California,Center for Primary Care and Outcomes Research/Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Kristopher Kapphahn
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | | | | | | | | | - Ariana Murillo
- Division of Oncology, Stanford University School of Medicine, Stanford, California
| | - Kim Smith
- St Jude Crosson Cancer Institute, Center for Hematology and Oncology, Fullerton, California
| | - David J. Park
- St Jude Crosson Cancer Institute, Center for Hematology and Oncology, Fullerton, California
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Battaglia TA, Zhang X, Dwyer AJ, Rush CH, Paskett ED. Change agents in the oncology workforce: Let's be clear about community health workers and patient navigators. Cancer 2022; 128 Suppl 13:2664-2668. [PMID: 35699614 DOI: 10.1002/cncr.34194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/18/2022] [Accepted: 03/01/2022] [Indexed: 11/12/2022]
Abstract
Despite efforts of professional organizations and government agencies to solidify the professional identities of community health workers and patient navigators in the oncology workforce, the scientific literature perpetuates wide variation in the nomenclature used to define these natural change agents, who have proven efficacy in improving access to quality cancer care for historically marginalized populations. To disseminate, sustain, and scale-up these life-saving roles in cancer care, the oncology field must come together now to adopt clear and consistent job titles and occupational identities.
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Affiliation(s)
- Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Xiaochen Zhang
- Comprehensive Cancer Center, Division of Population Sciences, The Ohio State University, Columbus, Ohio
| | - Andrea J Dwyer
- Department of Community and Behavioral Health, School of Public Health, University of Colorado, Aurora, Colorado
| | - Carl H Rush
- Community Resources, LLC, San Antonio, Texas
| | - Electra D Paskett
- Comprehensive Cancer Center, Division of Population Sciences, The Ohio State University, Columbus, Ohio
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Wood EH, Leach M, Villicana G, Goldman Rosas L, Duron Y, O'Brien DG, Koontz Z, Patel MI. A Community-Engaged Process for Adapting a Proven Community Health Worker Model to Integrate Precision Cancer Care Delivery for Low-income Latinx Adults With Cancer. Health Promot Pract 2022; 24:491-501. [PMID: 35658733 DOI: 10.1177/15248399221096415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Disparities in precision cancer care delivery among low-income Latinx adults are well described. In prior work, we developed a community health worker-led goals of care and cancer symptom assessment intervention. The objective of this study was to adapt this intervention for a community setting, incorporating precision cancer care delivery. METHODS We used a two-phased systematic approach to adapt an evidence-based intervention for our community. Specifically, we used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify barriers and facilitators to precision cancer care delivery via 1-hr interviews with Latinx adults with cancer, Latinx caregivers, community leaders, primary care and oncology clinicians, and community health workers. Interviews were recorded, transcribed, and analyzed using the constant comparative method and grounded theory analysis. Phase 2 involved interviews with key community advisors using the Expert Panels Method to decide on final adaptations. RESULTS Using this community-engaged approach, we identified specific intervention adaptations to ensure precision cancer care delivery in a community setting, which included: (a) expansion of the intervention inclusion criteria and mode of delivery; (b) integration of low-literacy precision cancer care intervention activities in Spanish in collaboration with community-based organizations; (c) ensuring goals reflective of patient and community priorities. CONCLUSIONS This systematic and community-engaged approach to adapt an intervention for use in delivering precision cancer care strengthened an evidence-based approach to promote the needs and preferences of patients and key community stakeholders.
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Affiliation(s)
- Emily H Wood
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | - Manali I Patel
- Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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16
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Patel MI, Banks L, Das M. Improving supportive care for patients with Thoracic Malignancies – A randomized controlled trial. Contemp Clin Trials Commun 2022; 28:100929. [PMID: 35669484 PMCID: PMC9163421 DOI: 10.1016/j.conctc.2022.100929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/16/2022] [Accepted: 05/24/2022] [Indexed: 11/26/2022] Open
Abstract
Veterans have higher lung cancer incidence and mortality rates than civilians. Frequently, Veterans with lung cancer suffer from undertreated symptoms due to complex comorbidities, limited social support, and reluctance in discussing symptoms with their oncologists. Evidence supports proactive symptom screening among civilians with cancer; however, no studies to date have evaluated whether Veteran volunteer-led proactive symptom screening is feasible and effective among Veterans with lung cancer. The “Improving Supportive Care for Patients with Thoracic Malignancies” study was co-developed by a pre-established Veteran and Family Advisory Board. Veterans with lung cancer are randomized in a 1:1 allocation to either a 9-month intervention combined with usual oncology care (intervention group) or usual oncology care alone (control group). A Veteran volunteer is assigned to all Veterans in the intervention group and conducts weekly symptom assessments using validated symptom surveys and reviews all symptom scores with an oncology nurse practitioner. The primary outcome is to evaluate whether the intervention improves documentation of symptoms at 6 months post-enrollment among Veterans in the intervention group as compared with the control group. Secondary outcomes include changes in patient-reported outcomes (i.e., symptom burden, patient activation, patient satisfaction with decision, health-related quality of life) and differences in acute care use (i.e., emergency department visits, hospitalizations) from baseline (time of enrollment in the study) to 3-, 6-, and 9-months post enrollment. This study addresses a significant concern expressed by Veterans and their caregivers. Findings can advance our understanding of how to improve symptom-burden among Veterans with lung cancer. ClinicalTrials.gov Registration #NCT03216109.
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Affiliation(s)
- Manali I. Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA, United States
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
- Corresponding author. Division of Oncology, Stanford University, 1701 Page Mill Drive, Palo Alto, CA, 94306, United States.
| | - Lakedia Banks
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Millie Das
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
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17
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Health care coach support to assist with advance care planning and symptom management -A randomized controlled trial. Contemp Clin Trials 2021; 111:106617. [PMID: 34749008 DOI: 10.1016/j.cct.2021.106617] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/19/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
Advance care planning and symptom management (supportive cancer care) improves patient experiences and reduces acute care use (hospitalizations and emergency department visits). Strong evidence supports team-based approaches to deliver supportive cancer care. However no studies, to our knowledge, have evaluated the use of lay or community health workers to deliver supportive cancer care as compared to usual cancer care. The "Health Care Coach Support" intervention was developed to improve cancer care. The intervention assigns a lay or community health worker "health coach" to all patients newly diagnosed with advanced stages of cancer or patients with recurrent or progressive disease. The intervention aims to educate and activate patients in advance care planning discussions and symptom management with their clinicians. Patients are randomized in a 1:1 allocation to either the 12-month health coach intervention combined with usual oncology care or usual oncology care alone. The primary outcome is to evaluate whether the intervention reduces acute care use measured at 6-months follow-up more than usual care. Secondary outcomes include the effect on acute care, palliative care, and hospice at 12-months follow-up and one month prior to death for patients who die. Additional secondary outcomes include changes in patient satisfaction with decision and patient satisfaction with care from baseline (time of enrollment) to 3-, 6-, 9- and 12-months post-enrollment. The Health Coach Support study addresses an important gap in supportive cancer care by testing whether a team-based approach using non-professional personnel can ensure delivery of these services. Findings can assist in our understanding of how to improve care for patients with cancer. ClinicalTrials.gov Registration #NCT03154190.
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18
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Patel MI, Khateeb S, Coker T. Association of a Lay Health Worker-Led Intervention on Goals of Care, Quality of Life, and Clinical Trial Participation Among Low-Income and Minority Adults With Cancer. JCO Oncol Pract 2021; 17:e1753-e1762. [PMID: 33999691 PMCID: PMC9810146 DOI: 10.1200/op.21.00100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE New approaches are needed to overcome low supportive care and clinical trial participation among low-income and minority adults with cancer. The objective of this project was to determine whether a lay health worker intervention was associated with improvements in supportive care and trial participation. METHODS We conducted a quality improvement initiative in collaboration with a union organization. We enrolled union members newly diagnosed with cancer into a 6-month lay health worker-led intervention from October 15, 2016, to February 28, 2017. The primary outcome was goals of care. Secondary outcomes were health-related quality of life (HRQOL), health care use, and trial participation. All outcomes except HRQOL were compared with a cohort of union members diagnosed within the 6-month preintervention period. RESULTS Sixty-six adults participated in the intervention group, and we identified 72 adults in the control group. Demographic characteristics were similar between groups. The mean age was 56.0 years; 47 (34%) were male, and 22 were White (16%). Within 6 months enrollment, more intervention group participants, as compared with the control, had clinician-documented goals of care (94% v 26%; P < .001) and participated in cancer clinical trials (72% v 22%; P < .001). At 4 months postenrollment, as compared with baseline, intervention participants experienced HRQOL improvements (mean difference, 3.98 points; standard deviation, 2.83; P < .001). Before death, more intervention group participants used palliative care and hospice than the control group. CONCLUSION Lay health worker-led interventions may improve supportive care and clinical trial participation among low-income and minority populations with cancer.
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Affiliation(s)
- Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA.,Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.,Center for Primary Care and Outcomes Research/Health Research and Policy, Stanford University School of Medicine, Stanford, CA
| | - Sana Khateeb
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
| | - Tumaini Coker
- Seattle Children's Research Institute, Seattle, WA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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19
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Lizán L, Pérez-Carbonell L, Comellas M. Additional Value of Patient-Reported Symptom Monitoring in Cancer Care: A Systematic Review of the Literature. Cancers (Basel) 2021; 13:cancers13184615. [PMID: 34572842 PMCID: PMC8469093 DOI: 10.3390/cancers13184615] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/10/2021] [Indexed: 01/28/2023] Open
Abstract
Simple Summary The additional value of patient-reported symptom monitoring in routine cancer is still under discussion. With this in mind, we have reviewed recent evidence on the benefits of this strategy. The evidence examined illustrates that bringing systematic patient feedback into the oncology consultation provides objective advantages over usual care, such as better symptom control, early detection of tumor recurrence, and extended chemotherapy use. Such care improvements ultimately entail an outstanding survival benefit for advanced cancer patients, an increase in their global quality of life, and eventually, medical cost savings. Monitoring patient-reported symptoms might also have other implications in clinical practice, such as promoting patient disease awareness or enhancing patient–physician communication and relationships. Notwithstanding these advantages, there are still logistical barriers that prevent its widespread implementation—especially in the electronic modality. In addition, the real-world effectiveness and the cost-effectiveness of this strategy are yet to be proven in different settings. Abstract Background: To describe the benefit of patient-reported symptom monitoring on clinical, other patient-reported, and economic outcomes. Methods: We conducted a systematic literature review using Medline/PubMed, limited to original articles published between 2011 and 2021 in English and Spanish, and focused on the benefit of patient-reported symptom monitoring on cancer patients. Results: We identified 16 reports that deal with the benefit of patient-reported symptom monitoring (collected mostly electronically) on different outcomes. Five studies showed that patient-reported symptom surveillance led to significantly improved survival compared with usual care—mainly through better symptom control, early detection of tumor recurrence, and extended chemotherapy use. Additionally, three evaluations demonstrated an improvement in Health-Related Quality of Life (HRQoL) associated with this monitoring strategy, specifically by reducing symptom severity. Additionally, six studies observed that this monitoring approach prevented unplanned emergency room visits and hospital readmissions, leading to a substantial decrease in healthcare usage. Conclusions: There is consistent evidence across the studies that patient-reported symptom monitoring might entail a substantial survival benefit for cancer patients, better HRQoL, and a considerable decrease in healthcare usage. Nonetheless, more studies should be conducted to demonstrate their effectiveness in addition to their cost-effectiveness in clinical practice.
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Affiliation(s)
- Luís Lizán
- Department of Medicine, Jaume I University, 12071 Castellón de la Plana, Spain
- Outcomes’10, Jaume I University, 12071 Castellón de la Plana, Spain; (L.P.-C.); (M.C.)
- Correspondence: ; Tel.: +34-608-262-673
| | - Lucía Pérez-Carbonell
- Outcomes’10, Jaume I University, 12071 Castellón de la Plana, Spain; (L.P.-C.); (M.C.)
| | - Marta Comellas
- Outcomes’10, Jaume I University, 12071 Castellón de la Plana, Spain; (L.P.-C.); (M.C.)
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20
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Patel MI, Khateeb S, Coker T. Lay Health Workers' Perspectives on Delivery of Advance Care Planning and Symptom Screening Among Adults With Cancer: A Qualitative Study. Am J Hosp Palliat Care 2020; 38:1202-1211. [PMID: 33267632 DOI: 10.1177/1049909120977841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Advance care planning and symptom screening among patients with cancer require team-based approaches to ensure that these services are equitably and appropriately delivered. In several organizations across the United States, we trained and employed lay health workers (LHWs) to assist with delivering these services for patients with cancer. The aim of this study was to understand LHWs' views on delivering these services. METHODS We conducted semi-structured interviews with 22 LHWs in 6 US-based clinical cancer care settings in 4 large cities. We recorded, transcribed, and analyzed interviews using the constant comparative method of qualitative analysis. RESULTS Participants noted the importance of their role in assisting with the delivery of advance care planning (ACP) and symptom screening services. Participants noted the importance of developing relationships with patients to engage openly in ACP and symptom screening discussions. Participants reported that ongoing training provided skills and empowered them to discuss sensitive issues with patients and their caregivers. Participants described challenges in their roles including communication with oncology providers and their own emotional well-being. Participants identified solutions to these challenges including formal opportunities for introduction with oncology clinicians and staff and grievance sessions with LHWs and other team members. DISCUSSION LHWs from several organizations endorsed the importance of their roles in ensuring the delivery of ACP and proactive symptom screening. LHWs noted challenges and specific solutions to improve their effectiveness in delivering these important services to patients after their diagnosis of cancer.
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Affiliation(s)
- Manali I Patel
- Division of Oncology, 6429Stanford University School of Medicine, Stanford, CA, USA.,Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.,Center for Primary Care and Outcomes Research/Health Research and Policy, 6429Stanford University School of Medicine, Stanford, CA, USA
| | - Sana Khateeb
- Division of Oncology, 6429Stanford University School of Medicine, Stanford, CA, USA
| | - Tumaini Coker
- Seattle Children's Research Institute, Seattle, WA, USA.,Department of Pediatrics, 12353University of Washington School of Medicine, Seattle, WA, USA
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21
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Patel MI, Khateeb S, Coker T. A randomized trial of a multi-level intervention to improve advance care planning and symptom management among low-income and minority employees diagnosed with cancer in outpatient community settings. Contemp Clin Trials 2020; 91:105971. [PMID: 32145441 DOI: 10.1016/j.cct.2020.105971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/20/2020] [Accepted: 02/28/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Equitable delivery of advance care planning and symptom management among patients is crucial to improving cancer care. Existing interventions to improve the uptake of these services have predominantly occurred in clinic settings and are limited in their effectiveness, particularly among low-income and minority populations. METHODS The "Lay health worker Educates Engages and Activates Patients to Share (LEAPS)" intervention was developed to improve advance care planning and symptom management among low-income and minority hourly-wage workers with cancer, in two community settings. The intervention provides a lay health worker to all patients newly diagnosed with cancer and aims to educate and activate patients to engage in advance care planning and symptom management with their oncology providers. In this randomized clinical trial, we will evaluate the effect on quality of life (primary outcome) using the validated Functional Assessment of Cancer Therapy - General Survey, at enrollment, 4- and 12- months post-enrollment. We will examine between-group differences on our secondary outcomes of patient activation, patient satisfaction with healthcare decision-making, and symptom burden (at enrollment, 4- and 12-months post-enrollment), and total healthcare use and healthcare costs (at 12-months post-enrollment). DISCUSSION Multilevel approaches are urgently needed to improve cancer care delivery among low-income and minority patients diagnosed with cancer in community settings. The current study describes the LEAPS intervention, the study design, and baseline characteristics of the community centers participating in the study. ClinicalTrials.gov Registration #NCT03699748.
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Affiliation(s)
- Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA, United States of America; Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States of America; Center for Primary Care and Outcomes Research/Health Research and Policy, Stanford University School of Medicine, Stanford, CA, United States of America.
| | - Sana Khateeb
- Division of Oncology, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Tumaini Coker
- Seattle Children's Research Institute, Seattle, WA, United States of America; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States of America
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Patel MI, Ramirez D, Agajanian R, Agajanian H, Coker T. Association of a Lay Health Worker Intervention With Symptom Burden, Survival, Health Care Use, and Total Costs Among Medicare Enrollees With Cancer. JAMA Netw Open 2020; 3:e201023. [PMID: 32176306 PMCID: PMC7076340 DOI: 10.1001/jamanetworkopen.2020.1023] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Undertreated patient symptoms require approaches that improve symptom burden. OBJECTIVE To determine the association of a lay health worker-led symptom screening and referral intervention with symptom burden, survival, health care use, and total costs among Medicare Advantage enrollees with a new diagnosis of solid or hematologic malignant neoplasms. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study conducted at 9 community oncology practices from November 1, 2016, to October 31, 2018, compared newly diagnosed Medicare Advantage enrollees with solid or hematologic malignant neoplasms with patients diagnosed and treated 1 year prior. Analysis was conducted from August 1, 2019, to January 11, 2020. INTERVENTIONS Usual care augmented by a lay health worker trained to screen symptoms and refer patients to palliative care and behavioral medicine. MAIN OUTCOMES AND MEASURES The primary outcome was change in symptoms using the Edmonton Symptom Assessment Scale and the 9-item Patient Health Questionnaire at baseline and 6 and 12 months after enrollment. Secondary outcomes were between-group comparison of survival, 12-month health care use, and costs. RESULTS Among 425 patients in the intervention group and 407 patients in the control group, the mean (SD) age was 78.8 (8.3) years, 345 (41.5%) were female, and 407 (48.9%) were non-Hispanic white. Patients in the intervention group experienced a lower symptom burden as measured by the Edmonton Symptom Assessment Scale score over time compared with patients in the control group (mean [SD] difference, -1.9 [14.2]; 95% CI, -3.77 to -0.19; P = .01 for the intervention group and 2.32 [17.7]; 95% CI, 0.47 to 4.19; P = .02 for the control group). Similar findings were noted in 9-item Patient Health Questionnaire depression scores (mean [SD] difference, -0.63 [3.99]; 95% CI, -1.23 to -0.028; P = .04 for the intervention group and 1.67 [5.49]; 95% CI, 0.95 to 2.37; P = .01 for the control group). Patients in the intervention group compared with patients in the control group had fewer mean (SD) inpatient visits (0.54 [0.77]; 95% CI, 0.47-0.61 vs 0.72 [1.12]; 95% CI, 0.61-0.83; P = .04) and emergency department visits (0.43 [0.76]; 95% CI, 0.36-0.50 vs 0.57 [1.00]; 95% CI, 0.48-0.67; P = .002) per 1000 patients per year and lower total costs (median, $17 869 [interquartile range, $6865-$32 540] vs median, $18 473 [interquartile range, $6415-$37 910]; P = .02). A total of 180 patients in the intervention group and 189 patients in the control group died within 12 months. Among those who died, patients in the intervention group had greater hospice use (125 of 180 [69.4%] vs 79 of 189 [41.8%]; odds ratio, 3.16; 95% CI, 2.13-4.69; P < .001), fewer mean (SD) emergency department and hospital visits (emergency department: 0.10 [0.30]; 95% CI, 0.06-0.14 vs 0.30 [0.46]; 95% CI, 0.24-0.38; P = .001; hospital: 0.27 [0.44]; 95% CI, 0.21-0.34 vs 0.43 [0.82]; 95% CI, 0.32-0.55; P = .02), and lower costs (median, $3602 [interquartile range, $1076-$9436] vs median, $12 726 [interquartile range, $5259-$22 170]; P = .002), but there was no significant difference in inpatient deaths (18 of 180 [10.0%] vs 30 of 189 [15.9%]; P = .14). CONCLUSIONS AND RELEVANCE This study suggests that a lay health worker-led intervention may be one way to improve burdensome and costly care.
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Affiliation(s)
- Manali I. Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, California
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Center for Primary Care and Outcomes Research/Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | | | - Richy Agajanian
- The Oncology Institute of Hope and Innovation, Downy, California
| | - Hilda Agajanian
- The Oncology Institute of Hope and Innovation, Downy, California
| | - Tumaini Coker
- Seattle Children’s Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
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