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Paudel R, Enzinger AC, Uno H, Cronin C, Wong SL, Dizon DS, Hazard Jenkins H, Bian J, Osarogiagbon RU, Jensen RE, Mitchell SA, Schrag D, Hassett MJ. Effects of a change in recall period on reporting severe symptoms: an analysis of a pragmatic multisite trial. J Natl Cancer Inst 2024:djae049. [PMID: 38445744 DOI: 10.1093/jnci/djae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/23/2024] [Accepted: 02/16/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Optimal methods for deploying electronic patient-reported outcomes (ePROs) to manage symptoms in routine oncologic practice remain uncertain. The eSyM symptom management program asks chemotherapy and surgery patients to self-report 12 symptoms regularly. Feedback from nurses and patients led to changing the recall period from the past 7 days to the past 24 hours. METHODS Using questionnaires submitted during the 16-weeks surrounding the recall period change, we assessed the likelihood of reporting a severe, or a moderate-severe, symptom across all 12 symptoms and separately for the 5 most prevalent symptoms. Interrupted time series analyses modeled the effects of the change using generalized linear mixed-effects models. Surgery and chemotherapy cohorts were analyzed separately. Study-wide effects were estimated using a meta-analysis method. RESULTS In total, 1,692 patients from 6 institutions submitted 7,823 eSyM assessments during the 16-weeks surrounding the recall period change. Shortening the recall period was associated with lower odds of severe symptom reporting in the surgery cohort (OR 0.65; 95% CI 0.46 to 0.93; p = .02) and lower odds of moderate-severe symptom reporting in the chemotherapy cohort (OR 0.83, 95% CI 0.71 to 0.97; p = .02). Among the most prevalent symptoms, 24-hour recall was associated with lower rate of reporting post-operative constipation, but no differences in reporting rates for other symptoms. CONCLUSION A shorter recall period was associated with a reduction in the proportion of patients reporting moderate-severe symptoms. The optimal recall period may vary depending on whether ePROs are collected for active symptom management, as a clinical trial endpoint, or another purpose. (Clinicaltrails.gov (NCT03850912).
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Affiliation(s)
| | | | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Sandra L Wong
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Don S Dizon
- Lifespan Cancer Institute and Brown University, Providence, RI, USA
| | | | | | | | | | | | - Deborah Schrag
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Pozzar RA, Wall JA, Tavormina A, Thompson E, Enzinger AC, Matulonis UA, Campos S, Meyer LA, Wright AA. Experiences of patients with peritoneal carcinomatosis-related complex care needs and their caregivers. Gynecol Oncol 2024; 181:68-75. [PMID: 38141533 PMCID: PMC10922890 DOI: 10.1016/j.ygyno.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/03/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Patients with peritoneal carcinomatosis (PC) frequently undergo palliative procedures, yet these patients and their caregivers report being unprepared to manage ostomies, drains, and other complex care needs at home. The purpose of this study was to characterize the unique needs of these patients and their caregivers during care transitions. METHODS Patients completed measures of health status and advance care planning, caregivers completed measures of preparedness and burden, and all participants completed measures of depression and anxiety. Participants detailed their experiences in individual, semi-structured interviews. We analyzed data using descriptive statistics and conventional content analysis. RESULTS Sixty-one patients and 39 caregivers completed baseline measures. Twenty-four (39.3%) patients acknowledged their terminal illness and seven (11.5%) had discussed end-of-life care preferences with clinicians. Most (26/39, 66.7%) caregivers provided daily care. Among caregivers who managed symptoms, few were taught how to do so (6/20, 30%). Seven patients (11.5%) and seven caregivers (17.9%) met case criteria for anxiety, while 15 patients (24.6%) and two caregivers (5.1%) met case criteria for depression. Interview participants described a diagnosis of PC as a turning point for which there is no road map and identified the need for health systems change to minimize suffering. CONCLUSION Patients with PC and their caregivers are highly burdened by symptoms and care needs. Patients' prognostic understanding and advance care planning are suboptimal. Interventions that train patients with PC and their caregivers to perform clinical care tasks, facilitate serious illness conversations, and provide psychosocial support are needed.
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Affiliation(s)
- Rachel A Pozzar
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Jaclyn A Wall
- University of Alabama, Birmingham, AL, United States
| | | | | | - Andrea C Enzinger
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Ursula A Matulonis
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Susana Campos
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Larissa A Meyer
- University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Alexi A Wright
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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DeForge SM, Smith K, Anderson KA, Baltazar AR, Beck M, Enzinger AC, Tulsky JA, Allsop M, Edwards RR, Schreiber KL, Azizoddin DR. Pain coping, multidisciplinary care, and mHealth: Patients' views on managing advanced cancer pain. Psychooncology 2024; 33:e6308. [PMID: 38366975 PMCID: PMC11071444 DOI: 10.1002/pon.6308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/29/2024] [Accepted: 02/07/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVE Pain is common among people with advanced cancer. While opioids provide significant relief, incorporating psycho-behavioral treatments may improve pain outcomes. We examined patients' experiences with pain self-management and how their self-management of chronic, cancer-related pain may be complemented by behavioral mobile health (mHealth) interventions. METHODS We conducted semi-structured qualitative interviews with patients with advanced cancer and pain. Each participant reviewed content from our behavioral mHealth application for cancer pain management and early images of its interface. Participants reflected on their experiences self-managing cancer pain and on app content. Interviews were transcribed verbatim and analyzed using a combination of inductive and deductive thematic analysis. RESULTS Patients (n = 28; 54% female; mean age = 53) across two geographic regions reported using psychological strategies (e.g., reframing negative thoughts, distraction, pain acceptance, social support) to manage chronic cancer-related pain. Patients shared their perspectives on the integration of psycho-behavioral pain treatments into their existing medical care and their experiences with opioid hesitancy. Patient recommendations for how mHealth interventions could best support them coalesced around two topics: 1.) convenience in accessing integrated pharmacological and psycho-behavioral pain education and communication tools and 2.) relevance of the specific content to their clinical situation. CONCLUSIONS Integrated pharmacological and psycho-behavioral pain treatments were important to participants. This underscores a need to coordinate complimentary approaches when developing cancer pain management interventions. Participant feedback suggests that an mHealth intervention that integrates pain treatments may have the capacity to increase advanced cancer patients' access to destigmatizing, accessible care while improving pain self-management.
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Affiliation(s)
- Sara M. DeForge
- Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, Oklahoma, USA
| | - Kyla Smith
- Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, Oklahoma, USA
| | - Kris-Ann Anderson
- Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, Oklahoma, USA
| | - Ashton R. Baltazar
- Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, Oklahoma, USA
| | - Meghan Beck
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrea C. Enzinger
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Matthew Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kristin L. Schreiber
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Desiree R. Azizoddin
- Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, Oklahoma, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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4
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Azizoddin DR, DeForge SM, Baltazar A, Edwards RR, Allsop M, Tulsky JA, Businelle MS, Schreiber KL, Enzinger AC. Development and pre-pilot testing of STAMP + CBT: an mHealth app combining pain cognitive behavioral therapy and opioid support for patients with advanced cancer and pain. Support Care Cancer 2024; 32:123. [PMID: 38252172 DOI: 10.1007/s00520-024-08307-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024]
Abstract
PURPOSE We developed and piloted a mobile health app to deliver cognitive behavioral therapy for pain (pain-CBT), remote symptom monitoring, and pharmacologic support for patients with pain from advanced cancer. METHODS Using an iterative process of patient review and feedback, we developed the STAMP + CBT app. The app delivers brief daily lessons from pain-CBT and pain psychoeducation, adapted for advanced cancer. Daily surveys assess physical symptoms, psychological symptoms, opioid utilization and relief. Just-in-time adaptive interventions generate tailored psychoeducation in response. We then conducted a single-arm pilot feasibility study at two cancer centers. Patients with advanced cancer and chronic pain used the app for 2 or 4 weeks, rated its acceptability and provided feedback in semi-structured interviews. Feasibility and acceptability were defined as ≥ 70% of participants completing ≥ 50% of daily surveys, and ≥ 80% of acceptability items rated ≥ 4/5. RESULTS Fifteen participants (female = 9; mean age = 50.3) tested the app. We exceeded our feasibility and accessibility benchmarks: 73% of patients completed ≥ 50% of daily surveys; 87% of acceptability items were rated ≥ 4/5. Participants valued the app's brevity, clarity, and salience, and found education on stress and pain to be most helpful. The app helped participants learn pain management strategies and decrease maladaptive thoughts. However, participants disliked the notification structure (single prompt with one snooze), which led to missed content. CONCLUSION The STAMP + CBT app was an acceptable and feasible method to deliver psychological/behavioral treatment with pharmacologic support for cancer pain. The app is being refined and will be tested in a larger randomized pilot study. TRN: NCT05403801 (05/06/2022).
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Affiliation(s)
- Desiree R Azizoddin
- Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Sara M DeForge
- Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ashton Baltazar
- Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Michael S Businelle
- Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrea C Enzinger
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
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5
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Leiter RE, Varas MTB, Miralda K, Muneton-Castano Y, Furtado G, Revette A, Cronin C, Soares HP, Lopez A, Hayman LL, Lindsay AC, Schrag D, Enzinger AC. Adaptation of a Multimedia Chemotherapy Educational Intervention for Latinos: Letting Patient Narratives Speak for Themselves. J Cancer Educ 2023; 38:1353-1362. [PMID: 36773178 PMCID: PMC10772955 DOI: 10.1007/s13187-023-02270-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/29/2023] [Indexed: 06/18/2023]
Abstract
This study aims to adapt a video-based, multimedia chemotherapy educational intervention to meet the needs of US Latinos with advanced gastrointestinal malignancies. A five-step hybrid adaptation process involved (1) creating a multidisciplinary team with diverse Latino subject experts, (2) appraising the parent intervention, (3) identifying key cultural considerations from a systematic literature review and semi-structured Latino patient/caregiver interviews, (4) revising the intervention, highlighting culturally relevant themes through video interviews with Latino cancer patients, and (5) target population review with responsive revisions. We developed a suite of videos, booklets, and websites available in English and Spanish, which convey the risks and benefits of common chemotherapy regimens. After revising the English materials, we translated them into Spanish using a multi-step process. The intervention centers upon conversations with 12 Latino patients about their treatment experiences; video clips highlight culturally relevant themes (personalismo, familismo, faith, communication gaps, prognostic information preferences) identified during the third adaptation step. The adapted intervention materials included a new section on coping, and one titled "how to feel the best you can feel," which reviews principles of side effect management, self-advocacy, proactive communication, and palliative care. Ten Latinos with advanced malignancies reviewed the intervention and found it to be easily understandable, relatable, and helpful. A five-step hybrid model was successful in adapting a chemotherapy educational intervention for Latinos. Incorporation of video interviews with Latino patients enabled the authentic representation of salient cultural themes. Use of authentic patient narratives can be useful for cross-cultural intervention adaptations.
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Affiliation(s)
- Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Ave, Jimmy Fund 805A, MA, 02215, Boston, USA.
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Maria Teresa Bejarano Varas
- Department of Oncology Hospital Medicine, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Keysha Miralda
- Department of Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Grace Furtado
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Anna Revette
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Christine Cronin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Heloisa P Soares
- Division of Oncology, Huntsman Cancer Institute at University of Utah, Salt Lake City, UT, USA
| | - Athalia Lopez
- Department of Patient Care Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Laura L Hayman
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Ana Cristina Lindsay
- Department of Exercise and Health Sciences, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Deborah Schrag
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea C Enzinger
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Ave, Jimmy Fund 805A, MA, 02215, Boston, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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6
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Azizoddin DR, Wilson JM, Flowers KM, Beck M, Chai P, Enzinger AC, Edwards R, Miaskowski C, Tulsky JA, Schreiber KL. Daily pain and opioid administration in hospitalized patients with cancer: the importance of psychological factors, recent surgery, and current opioid use. Pain 2023; 164:1820-1827. [PMID: 36893325 PMCID: PMC10363176 DOI: 10.1097/j.pain.0000000000002880] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/26/2023] [Indexed: 03/11/2023]
Abstract
ABSTRACT Pain is common and variable in its severity among hospitalized patients with cancer. Although biopsychosocial factors are well established as modulators of chronic pain, less is known about what patient-level factors are associated with worse pain outcomes among hospitalized cancer patients. This prospective cohort study included patients with active cancer presenting to the emergency department (ED) with pain severity of ≥4/10 and followed pain outcomes longitudinally throughout hospital admission. Baseline demographic, clinical, and psychological factors were assessed on ED presentation, and daily average clinical pain ratings and opioid consumption during hospitalization were abstracted. Univariable and multivariable generalized estimating equation analyses examined associations of candidate biopsychosocial, demographic, and clinical predictors with average daily pain and opioid administration. Among 113 hospitalized patients, 73% reported pain as the primary reason for presenting to the ED, 43% took outpatient opioids, and 27% had chronic pain that predated their cancer. Higher pain catastrophizing ( B = 0.1, P ≤ 0.001), more recent surgery ( B = -0.2, P ≤ 0.05), outpatient opioid use ( B = 1.4, P ≤ 0.001), and history of chronic pain before cancer diagnosis ( B = 0.8, P ≤ 0.05) were independently associated with greater average daily pain while admitted to the hospital. Higher pain catastrophizing ( B = 1.6, P ≤ 0.05), higher anxiety ( B = 3.7, P ≤ 0.05), lower depression ( B = -4.9, P ≤ 0.05), metastatic disease ( B = 16.2, P ≤ 0.05), and outpatient opioid use ( B = 32.8, P ≤ 0.001) were independently associated with higher daily opioid administration. Greater psychological distress, especially pain catastrophizing, as well as pain and opioid use history, predicted greater difficulty with pain management among hospitalized cancer patients, suggesting that early assessment of patient-level characteristics may help direct consultation for more intensive pharmacologic and nonpharmacologic interventions.
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Affiliation(s)
- Desiree R. Azizoddin
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jenna M. Wilson
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kelsey Mikayla Flowers
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
| | - Meghan Beck
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
| | - Peter Chai
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Fenway Health, Boston, MA
| | - Andrea C. Enzinger
- Harvard Medical School, Boston, MA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Edwards
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Christine Miaskowski
- Schools of Nursing and Medicine, University of California San Francisco, San Francisco, CA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kristin L. Schreiber
- Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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7
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Enzinger AC, Ghosh K, Keating NL, Cutler DM, Clark CR, Florez N, Landrum MB, Wright AA. Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life. J Clin Oncol 2023; 41:2511-2522. [PMID: 36626695 PMCID: PMC10414726 DOI: 10.1200/jco.22.01413] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/16/2022] [Accepted: 11/28/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms. METHODS Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends in opioid prescription fills and potency (morphine milligram equivalents [MMEs] per day [MMEDs]) near the end of life (EOL), defined as 30 days before death or hospice enrollment. We estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. We similarly explored disparities in UDS. RESULTS Between 2007 and 2019, White, Black, and Hispanic decedents experienced steady declines in EOL opioid access and rapid expansion of UDS. Compared with White patients, Black and Hispanic patients were less likely to receive any opioid (Black, -4.3 percentage points, 95% CI, -4.8 to -3.6; Hispanic, -3.6 percentage points, 95% CI, -4.4 to -2.9) and long-acting opioids (Black, -3.1 percentage points, 95% CI, -3.6 to -2.8; Hispanic, -2.2 percentage points, 95% CI, -2.7 to -1.7). They also received lower daily doses (Black, -10.5 MMED, 95% CI, -12.8 to -8.2; Hispanic, -9.1 MMED, 95% CI, -12.1 to -6.1) and lower total doses (Black, -210 MMEs, 95% CI, -293 to -207; Hispanic, -179 MMEs, 95% CI, -217 to -142); Black patients were also more likely to undergo UDS (0.5 percentage points; 95% CI, 0.3 to 0.8). Disparities in EOL opioid access and UDS disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the EOL opioid access disparities. CONCLUSION There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables.
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Affiliation(s)
- Andrea C. Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Kaushik Ghosh
- New England Bureau of Economic Research, Cambridge, MA
| | - Nancy L. Keating
- Department of Healthcare Policy, Harvard Medical School, Boston, MA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - David M. Cutler
- New England Bureau of Economic Research, Cambridge, MA
- Department of Healthcare Policy, Harvard Medical School, Boston, MA
- Department of Economics, Harvard University, Boston, MA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (DMC), Boston, MA
| | - Cheryl R. Clark
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Narjust Florez
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Alexi A. Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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8
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Tian J, Chen JH, Chao SX, Pelka K, Giannakis M, Hess J, Burke K, Jorgji V, Sindurakar P, Braverman J, Mehta A, Oka T, Huang M, Lieb D, Spurrell M, Allen JN, Abrams TA, Clark JW, Enzinger AC, Enzinger PC, Klempner SJ, McCleary NJ, Meyerhardt JA, Ryan DP, Yurgelun MB, Kanter K, Van Seventer EE, Baiev I, Chi G, Jarnagin J, Bradford WB, Wong E, Michel AG, Fetter IJ, Siravegna G, Gemma AJ, Sharpe A, Demehri S, Leary R, Campbell CD, Yilmaz O, Getz GA, Parikh AR, Hacohen N, Corcoran RB. Combined PD-1, BRAF and MEK inhibition in BRAF V600E colorectal cancer: a phase 2 trial. Nat Med 2023; 29:458-466. [PMID: 36702949 PMCID: PMC9941044 DOI: 10.1038/s41591-022-02181-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 12/12/2022] [Indexed: 01/27/2023]
Abstract
While BRAF inhibitor combinations with EGFR and/or MEK inhibitors have improved clinical efficacy in BRAFV600E colorectal cancer (CRC), response rates remain low and lack durability. Preclinical data suggest that BRAF/MAPK pathway inhibition may augment the tumor immune response. We performed a proof-of-concept single-arm phase 2 clinical trial of combined PD-1, BRAF and MEK inhibition with sparatlizumab (PDR001), dabrafenib and trametinib in 37 patients with BRAFV600E CRC. The primary end point was overall response rate, and the secondary end points were progression-free survival, disease control rate, duration of response and overall survival. The study met its primary end point with a confirmed response rate (24.3% in all patients; 25% in microsatellite stable patients) and durability that were favorable relative to historical controls of BRAF-targeted combinations alone. Single-cell RNA sequencing of 23 paired pretreatment and day 15 on-treatment tumor biopsies revealed greater induction of tumor cell-intrinsic immune programs and more complete MAPK inhibition in patients with better clinical outcome. Immune program induction in matched patient-derived organoids correlated with the degree of MAPK inhibition. These data suggest a potential tumor cell-intrinsic mechanism of cooperativity between MAPK inhibition and immune response, warranting further clinical evaluation of optimized targeted and immune combinations in CRC. ClinicalTrials.gov registration: NCT03668431.
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Affiliation(s)
- Jun Tian
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Jonathan H Chen
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Sherry X Chao
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Karin Pelka
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Gladstone-UCSF Institute of Genomic Immunology, Gladstone Institutes Department of Microbiology and Immunology, UCSF, San Francisco, CA, USA
| | - Marios Giannakis
- Dana Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Julian Hess
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Kelly Burke
- Dana Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Vjola Jorgji
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Princy Sindurakar
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Jonathan Braverman
- The Koch Institute, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Arnav Mehta
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Tomonori Oka
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Mei Huang
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - David Lieb
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Maxwell Spurrell
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Jill N Allen
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Thomas A Abrams
- Dana Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Andrea C Enzinger
- Dana Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Peter C Enzinger
- Dana Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Samuel J Klempner
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Nadine J McCleary
- Dana Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | | | - David P Ryan
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Matthew B Yurgelun
- Dana Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Katie Kanter
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Emily E Van Seventer
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Islam Baiev
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Gary Chi
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Joy Jarnagin
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - William B Bradford
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Edmond Wong
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Alexa G Michel
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Isobel J Fetter
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Giulia Siravegna
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Angelo J Gemma
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Arlene Sharpe
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Shadmehr Demehri
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Rebecca Leary
- Novartis Institute for Biomedical Research, Cambridge, MA, USA
| | | | - Omer Yilmaz
- The Koch Institute, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Gad A Getz
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Aparna R Parikh
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Nir Hacohen
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA.
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA.
| | - Ryan B Corcoran
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA.
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9
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Keller RB, Mazor T, Sholl L, Aguirre AJ, Singh H, Sethi N, Bass A, Nagaraja AK, Brais LK, Hill E, Hennessey C, Cusick M, Del Vecchio Fitz C, Zwiesler Z, Siegel E, Ovalle A, Trukhanov P, Hansel J, Shapiro GI, Abrams TA, Biller LH, Chan JA, Cleary JM, Corsello SM, Enzinger AC, Enzinger PC, Mayer RJ, McCleary NJ, Meyerhardt JA, Ng K, Patel AK, Perez KJ, Rahma OE, Rubinson DA, Wisch JS, Yurgelun MB, Hassett MJ, MacConaill L, Schrag D, Cerami E, Wolpin BM, Nowak JA, Giannakis M. Programmatic Precision Oncology Decision Support for Patients With Gastrointestinal Cancer. JCO Precis Oncol 2023; 7:e2200342. [PMID: 36634297 PMCID: PMC9929103 DOI: 10.1200/po.22.00342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE With the growing number of available targeted therapeutics and molecular biomarkers, the optimal care of patients with cancer now depends on a comprehensive understanding of the rapidly evolving landscape of precision oncology, which can be challenging for oncologists to navigate alone. METHODS We developed and implemented a precision oncology decision support system, GI TARGET, (Gastrointestinal Treatment Assistance Regarding Genomic Evaluation of Tumors) within the Gastrointestinal Cancer Center at the Dana-Farber Cancer Institute. With a multidisciplinary team, we systematically reviewed tumor molecular profiling for GI tumors and provided molecularly informed clinical recommendations, which included identifying appropriate clinical trials aided by the computational matching platform MatchMiner, suggesting targeted therapy options on or off the US Food and Drug Administration-approved label, and consideration of additional or orthogonal molecular testing. RESULTS We reviewed genomic data and provided clinical recommendations for 506 patients with GI cancer who underwent tumor molecular profiling between January and June 2019 and determined follow-up using the electronic health record. Summary reports were provided to 19 medical oncologists for patients with colorectal (n = 198, 39%), pancreatic (n = 124, 24%), esophagogastric (n = 67, 13%), biliary (n = 40, 8%), and other GI cancers. We recommended ≥ 1 precision medicine clinical trial for 80% (406 of 506) of patients, leading to 24 enrollments. We recommended on-label and off-label targeted therapies for 6% (28 of 506) and 25% (125 of 506) of patients, respectively. Recommendations for additional or orthogonal testing were made for 42% (211 of 506) of patients. CONCLUSION The integration of precision medicine in routine cancer care through a dedicated multidisciplinary molecular tumor board is scalable and sustainable, and implementation of precision oncology recommendations has clinical utility for patients with cancer.
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Affiliation(s)
- Rachel B. Keller
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Tali Mazor
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Lynette Sholl
- Center for Advanced Molecular Diagnostics, Brigham & Women's Hospital & Harvard Medical School, Boston, MA
| | - Andrew J. Aguirre
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA,Broad Institute of Harvard and MIT, Cambridge, MA
| | - Harshabad Singh
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Nilay Sethi
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Adam Bass
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Ankur K. Nagaraja
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Lauren K. Brais
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Emma Hill
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Connor Hennessey
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Margaret Cusick
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | | | - Zachary Zwiesler
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Ethan Siegel
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Andrea Ovalle
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Pavel Trukhanov
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Jason Hansel
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Geoffrey I. Shapiro
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Thomas A. Abrams
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Leah H. Biller
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Jennifer A. Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - James M. Cleary
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Steven M. Corsello
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Andrea C. Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Peter C. Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Robert J. Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Nadine J. McCleary
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Jeffrey A. Meyerhardt
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Kimmie Ng
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Anuj K. Patel
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Kimberley J. Perez
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Osama E. Rahma
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Douglas A. Rubinson
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Jeffrey S. Wisch
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Matthew B. Yurgelun
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Michael J. Hassett
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Laura MacConaill
- Center for Advanced Molecular Diagnostics, Brigham & Women's Hospital & Harvard Medical School, Boston, MA
| | - Deborah Schrag
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Ethan Cerami
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Brian M. Wolpin
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA
| | - Jonathan A. Nowak
- Center for Advanced Molecular Diagnostics, Brigham & Women's Hospital & Harvard Medical School, Boston, MA
| | - Marios Giannakis
- Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, Boston, MA,Broad Institute of Harvard and MIT, Cambridge, MA,Marios Giannakis, Department of Medical Oncology, Dana-Farber Cancer Institute & Harvard Medical School, 450 Brookline Ave., Boston, MA 02215; e-mail:
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10
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Fenton ATHR, Fletcher KM, Kizildag D, Borstelmann NA, Kessler D, Cronin C, Revette AC, Wright AA, Frank E, Enzinger AC. Cancer Caregivers' Prognostic and End-of-Life Communication Needs and Experiences and their Impact. J Pain Symptom Manage 2023; 65:16-25. [PMID: 36198337 PMCID: PMC9790036 DOI: 10.1016/j.jpainsymman.2022.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/20/2022] [Accepted: 09/27/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Family caregivers of patients with advanced cancer are integrally involved in communications regarding prognosis and end-of-life (EOL) planning and care. Yet little research has examined caregivers' communication experiences or the impact of these experiences on patients and caregivers at EOL. OBJECTIVES Investigate cancer caregivers' communication experiences and potential impact on patient and caregiver outcomes. METHODS Semistructured interviews with bereaved family cancer caregivers (N=19) about their communication needs and experiences as their loved one approached EOL and died. Audiotaped interviews were transcribed and thematically analyzed for communication-related themes. RESULTS Caregivers described fulfilling many important communication roles including information gathering and sharing, advocating, and facilitating-often coordinating communication with multiple partners (e.g., patient, family, oncology team, hospital team). Caregivers reported that, among the many topics they communicated about, prognosis and EOL were the most consequential and challenging. These challenges arose for several reasons including caregivers' and patients' discordant communication needs, limited opportunity for caregivers to satisfy their personal communication needs, uncertainty regarding their communication needs and responsibilities, and feeling unacknowledged by the care team. These challenges negatively impacted caregivers' abilities to satisfy their patient-related communication responsibilities, which shaped many outcomes including end-of-life decisions, care satisfaction, and bereavement. CONCLUSION Caregivers often facilitate essential communication for patients with advanced cancers yet face challenges successfully fulfilling their own and patients' communication needs, particularly surrounding prognostic and end-of-life conversations. Future research and interventions should explore strategies to help caregivers navigate uncertainty, create space to ask sensitive questions, and facilitate patient-caregiver discussions about differing informational needs.
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Affiliation(s)
| | | | - Deniz Kizildag
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | | | - Anna C Revette
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alexi A Wright
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
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11
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Pozzar RA, Enzinger AC, Poort H, Furey A, Donovan H, Orechia M, Thompson E, Tavormina A, Fenton AT, Jaung T, Braun IM, DeMarsh A, Cooley ME, Wright AA. Developing and Field Testing BOLSTER: A Nurse-Led Care Management Intervention to Support Patients and Caregivers following Hospitalization for Gynecologic Cancer-Associated Peritoneal Carcinomatosis. J Palliat Med 2022; 25:1367-1375. [PMID: 35297744 PMCID: PMC9492907 DOI: 10.1089/jpm.2021.0618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction: Peritoneal carcinomatosis (PC) afflicts women with advanced gynecologic cancers. Patients with PC often require ostomies, gastric tubes, or catheters to palliate symptoms, yet patients and caregivers report feeling unprepared to manage these devices. The purpose of this study was to develop and field test the Building Out Lifelines for Safety, Trust, Empowerment, and Renewal (BOLSTER) intervention to support patients and their caregivers after hospitalization for PC. Materials and Methods: We adapted components of the Standard Nursing Intervention Protocol with stakeholders and topical experts. We developed educational content; built a smartphone application to assess patients' symptoms; and assessed preliminary feasibility and acceptability in two single-arm prepilot studies. Eligible participants were English-speaking adults hospitalized for gynecologic cancer-associated PC and their caregivers. Feasibility criteria were a ≥50% consent-to-approach ratio and ≥80% outcome measure completion. The acceptability criterion was ≥70% of participants recommending BOLSTER. Results: During the first prepilot, BOLSTER was a 10-week intervention. While 7/8 (87.5%) approached patients consented, we experienced high attrition to hospice. Less than half of patients (3/7) and caregivers (3/7) completed outcome measures. For the second prepilot, BOLSTER was a four-week intervention. All (7/7) approached patients consented. Two withdrew before participating in any study activity because they were "too overwhelmed." We excluded data from one caregiver who completed baseline measures with the patient's assistance. All remaining patients (5/5) and caregivers (4/4) completed outcome measures and recommended BOLSTER. Conclusion: BOLSTER is a technology-enhanced, nurse-led intervention that is feasible and acceptable to patients with gynecologic cancer-associated PC and their caregivers.
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Affiliation(s)
- Rachel A. Pozzar
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea C. Enzinger
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Hanneke Poort
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ann Furey
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Heidi Donovan
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Meghan Orechia
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Anna Tavormina
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anny T.H.R. Fenton
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Tim Jaung
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ilana M. Braun
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea DeMarsh
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mary E. Cooley
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexi A. Wright
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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12
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Lindvall C, Deng CY, Agaronnik ND, Kwok A, Samineni S, Umeton R, Mackie-Jenkins W, Kehl KL, Tulsky JA, Enzinger AC. Deep Learning for Cancer Symptoms Monitoring on the Basis of Electronic Health Record Unstructured Clinical Notes. JCO Clin Cancer Inform 2022; 6:e2100136. [PMID: 35714301 PMCID: PMC9232368 DOI: 10.1200/cci.21.00136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Symptoms are vital outcomes for cancer clinical trials, observational research, and population-level surveillance. Patient-reported outcomes (PROs) are valuable for monitoring symptoms, yet there are many challenges to collecting PROs at scale. We sought to develop, test, and externally validate a deep learning model to extract symptoms from unstructured clinical notes in the electronic health record. METHODS We randomly selected 1,225 outpatient progress notes from among patients treated at the Dana-Farber Cancer Institute between January 2016 and December 2019 and used 1,125 notes as our training/validation data set and 100 notes as our test data set. We evaluated the performance of 10 deep learning models for detecting 80 symptoms included in the National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) framework. Model performance as compared with manual chart abstraction was assessed using standard metrics, and the highest performer was externally validated on a sample of 100 physician notes from a different clinical context. RESULTS In our training and test data sets, 75 of the 80 candidate symptoms were identified. The ELECTRA-small model had the highest performance for symptom identification at the token level (ie, at the individual symptom level), with an F1 of 0.87 and a processing time of 3.95 seconds per note. For the 10 most common symptoms in the test data set, the F1 score ranged from 0.98 for anxious to 0.86 for fatigue. For external validation of the same symptoms, the note-level performance ranged from F1 = 0.97 for diarrhea and dizziness to F1 = 0.73 for swelling. CONCLUSION Training a deep learning model to identify a wide range of electronic health record-documented symptoms relevant to cancer care is feasible. This approach could be used at the health system scale to complement to electronic PROs.
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Affiliation(s)
- Charlotta Lindvall
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | | | - Nicole D Agaronnik
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | - Anne Kwok
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | - Kenneth L Kehl
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | - James A Tulsky
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | - Andrea C Enzinger
- Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA.,Brigham and Women's Hospital, Boston, MA
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13
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Enzinger AC, Ghosh K, Keating NL, Cutler DM, Landrum MB, Wright AA. Reply to W. E. Rosa et al and T. N. Townsend et al. J Clin Oncol 2021; 40:312-314. [PMID: 34878818 DOI: 10.1200/jco.21.02383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Andrea C Enzinger
- Andrea C. Enzinger, MD, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Kaushik Ghosh, PhD, The New England Bureau of Economic Research, Cambridge, MA; Nancy L. Keating, MD, MPH, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA; David M. Cutler, PhD, The New England Bureau of Economic Research, Cambridge, MA, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Department of Economics, Harvard University, Boston, MA, The Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Mary Beth Landrum, PhD, The Department of Healthcare Policy, Harvard Medical School, Boston, MA; and Alexi A. Wright, MD, MPH, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kaushik Ghosh
- Andrea C. Enzinger, MD, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Kaushik Ghosh, PhD, The New England Bureau of Economic Research, Cambridge, MA; Nancy L. Keating, MD, MPH, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA; David M. Cutler, PhD, The New England Bureau of Economic Research, Cambridge, MA, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Department of Economics, Harvard University, Boston, MA, The Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Mary Beth Landrum, PhD, The Department of Healthcare Policy, Harvard Medical School, Boston, MA; and Alexi A. Wright, MD, MPH, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Nancy L Keating
- Andrea C. Enzinger, MD, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Kaushik Ghosh, PhD, The New England Bureau of Economic Research, Cambridge, MA; Nancy L. Keating, MD, MPH, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA; David M. Cutler, PhD, The New England Bureau of Economic Research, Cambridge, MA, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Department of Economics, Harvard University, Boston, MA, The Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Mary Beth Landrum, PhD, The Department of Healthcare Policy, Harvard Medical School, Boston, MA; and Alexi A. Wright, MD, MPH, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - David M Cutler
- Andrea C. Enzinger, MD, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Kaushik Ghosh, PhD, The New England Bureau of Economic Research, Cambridge, MA; Nancy L. Keating, MD, MPH, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA; David M. Cutler, PhD, The New England Bureau of Economic Research, Cambridge, MA, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Department of Economics, Harvard University, Boston, MA, The Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Mary Beth Landrum, PhD, The Department of Healthcare Policy, Harvard Medical School, Boston, MA; and Alexi A. Wright, MD, MPH, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Mary Beth Landrum
- Andrea C. Enzinger, MD, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Kaushik Ghosh, PhD, The New England Bureau of Economic Research, Cambridge, MA; Nancy L. Keating, MD, MPH, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA; David M. Cutler, PhD, The New England Bureau of Economic Research, Cambridge, MA, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Department of Economics, Harvard University, Boston, MA, The Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Mary Beth Landrum, PhD, The Department of Healthcare Policy, Harvard Medical School, Boston, MA; and Alexi A. Wright, MD, MPH, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Alexi A Wright
- Andrea C. Enzinger, MD, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Kaushik Ghosh, PhD, The New England Bureau of Economic Research, Cambridge, MA; Nancy L. Keating, MD, MPH, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA; David M. Cutler, PhD, The New England Bureau of Economic Research, Cambridge, MA, The Department of Healthcare Policy, Harvard Medical School, Boston, MA, The Department of Economics, Harvard University, Boston, MA, The Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Mary Beth Landrum, PhD, The Department of Healthcare Policy, Harvard Medical School, Boston, MA; and Alexi A. Wright, MD, MPH, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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14
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Azizoddin DR, Adam R, Kessler D, Wright AA, Kematick B, Sullivan C, Zhang H, Hassett MJ, Cooley ME, Ehrlich O, Enzinger AC. Leveraging mobile health technology and research methodology to optimize patient education and self-management support for advanced cancer pain. Support Care Cancer 2021; 29:5741-5751. [PMID: 33738594 PMCID: PMC8410657 DOI: 10.1007/s00520-021-06146-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/08/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE Patient education is critical for management of advanced cancer pain, yet the benefits of psychoeducational interventions have been modest. We used mobile health (mHealth) technology to better meet patients' needs. METHODS Using the Agile and mHealth Development and Evaluation Frameworks, a multidisciplinary team of clinicians, researchers, patients, and design specialists followed a four-phase iterative process to develop comprehensive, tailored, multimedia cancer pain education for a patient-facing smartphone application. The target population reviewed the content and provided feedback. RESULTS The resulting application provides comprehensive cancer pain education spanning pharmacologic and behavioral aspects of self-management. Custom graphics, animated videos, quizzes, and audio-recorded relaxations complemented written content. Computable algorithms based upon daily symptom surveys were used to deliver brief, tailored motivational messages that linked to more comprehensive teaching. Patients found the combination of pharmacologic and behavioral support to be engaging and helpful. CONCLUSION Digital technology can be used to provide cancer pain education that is engaging and tailored to individual needs. A replicable interdisciplinary and patient-centered approach to intervention development was advantageous. mHealth interventions may be a scalable approach to improve cancer pain. Frameworks that merge software and research methodology can be useful in developing interventions.
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Affiliation(s)
- Desiree R Azizoddin
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Thorn Building, Boston, MA, 13-1303, USA.
| | - Rosalind Adam
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Daniela Kessler
- Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Alexi A Wright
- Harvard Medical School, Boston, MA, USA.,Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Benjamin Kematick
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Clare Sullivan
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Haipeng Zhang
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Brigham Digital Innovation Hub, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael J Hassett
- Harvard Medical School, Boston, MA, USA.,Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Mary E Cooley
- Harvard Medical School, Boston, MA, USA.,Phyllis F. Cantor Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Olga Ehrlich
- Phyllis F. Cantor Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Andrea C Enzinger
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA, USA
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15
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Enzinger AC, Wright AA. Reduced Opioid Prescribing by Oncologists: Progress Made, or Ground Lost? J Natl Cancer Inst 2021; 113:225-226. [PMID: 32785658 DOI: 10.1093/jnci/djaa112] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Andrea C Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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16
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Azizoddin DR, Schreiber K, Beck MR, Enzinger AC, Hruschak V, Darnall BD, Edwards RR, Allsop MJ, Tulsky JA, Boyer E, Mackey S. Chronic pain severity, impact, and opioid use among patients with cancer: An analysis of biopsychosocial factors using the CHOIR learning health care system. Cancer 2021; 127:3254-3263. [PMID: 34061975 PMCID: PMC9981278 DOI: 10.1002/cncr.33645] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/09/2021] [Accepted: 04/21/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Despite the biopsychosocial underpinnings of chronic noncancer pain, relatively little is known about the contribution of psychosocial factors to chronic cancer pain. The authors aimed to characterize associations between biopsychosocial factors and pain and opioid use among individuals with chronic pain and cancer. METHODS The authors conducted a retrospective, cross-sectional study of 700 patients with chronic pain and cancer seeking treatment at an academic tertiary pain clinic. Patients completed demographic questionnaires and validated psychosocial and pain measures. Multivariable, hierarchical linear and logistic regressions assessed the relative contributions of biopsychosocial factors to the primary dependent variables of pain severity, pain interference, and opioid use. RESULTS Participants were 62% female and 66% White with a mean age of 59 ± 15 years, and 55% held a college degree or higher. Older age, African American or "other" race, sleep disturbance, and pain catastrophizing were significantly associated with higher pain severity (F(5,657) = 22.45; P ≤ .001; R2 = 0.22). Depression, sleep disturbance, pain catastrophizing, lower emotional support, and higher pain severity were significantly associated with pain interference (F(5,653) = 9.47; P ≤ .001; R2 = 0.44). Lastly, a poor cancer prognosis (Exp(B) = 1.62) and sleep disturbance (Exp(B) = 1.02) were associated with taking opioids, whereas identifying as Asian (Exp(B) = 0.48) or Hispanic (Exp(B) = 0.47) was associated with lower odds of using opioids. CONCLUSIONS Modifiable psychological factors-specifically sleep disturbance, depression, and pain catastrophizing-were uniquely associated with pain and opioid use in patients with chronic pain and diverse cancer diagnoses. Future behavioral pain interventions that concurrently target sleep may improve pain among patients with cancer. LAY SUMMARY Feeling depressed, worrying about pain, and bad sleep are related to higher pain symptoms in individuals with chronic pain and cancer. Specifically, those who struggle to sleep have worse pain and use more opioids. Also, individuals who have a bad prognosis for their cancer are more likely to be using opioid pain medications. Although race and cancer are related to chronic pain in patients, psychological well-being is also strongly related to this same pain.
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Affiliation(s)
- Desiree R. Azizoddin
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Kristin Schreiber
- Harvard Medical School, Boston, Massachusetts,Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Andrea C. Enzinger
- Harvard Medical School, Boston, Massachusetts,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Valerie Hruschak
- Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Beth D. Darnall
- Division of Pain Medicine, Department of Anesthesiology, Perioperative Medicine, and Pain Medicine, Stanford University, Stanford, California
| | - Robert R. Edwards
- Harvard Medical School, Boston, Massachusetts,Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Matthew J. Allsop
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Division of Palliative Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Sean Mackey
- Division of Pain Medicine, Department of Anesthesiology, Perioperative Medicine, and Pain Medicine, Stanford University, Stanford, California
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17
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Azizoddin DR, Knoerl R, Adam R, Kessler D, Tulsky JA, Edwards RR, Enzinger AC. Cancer pain self-management in the context of a national opioid epidemic: Experiences of patients with advanced cancer using opioids. Cancer 2021; 127:3239-3245. [PMID: 33905550 PMCID: PMC8355015 DOI: 10.1002/cncr.33532] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/10/2021] [Accepted: 03/01/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The US opioid epidemic has prompted dramatic changes in public attitudes and regulations governing opioid prescribing. Little is known about the experiences of patients with advanced cancer using opioids in the context of the epidemic. METHODS Semistructured interviews of 26 patients with advanced cancer were conducted between May 2019 and April 2020; their experiences self-managing chronic pain with opioids were evaluated. RESULTS Patients consistently described the negative impact of the opioid epidemic on their ability to self-manage pain. Negative media coverage and personal experiences with the epidemic promoted stigma, fear, and guilt surrounding opioid use. As a result, many patients delayed initiating opioids and often viewed their decision to take opioids as a moral failure-as "caving in." Patients frequently managed this internal conflict through opioid-restricting behaviors (eg, skipping or taking lower doses). Stigma also impeded patient-clinician communication; patients often avoided discussing opioids or purposely conveyed underusing them to avoid being labeled a "pill seeker." Patients experienced structural barriers to obtaining opioids such as prior authorizations, delays in refills, or being questioned by pharmacists about their opioid use. Barriers were stressful, amplified stigma, interfered with pain control, and reinforced ambivalence about opioids. CONCLUSIONS The US opioid epidemic has stigmatized opioid use and undermined pain management in individuals with advanced cancer. Interventions seeking to alleviate cancer pain should attend to the multiple, negative influences of the opioid crisis on patients' ability to self-manage. LAY SUMMARY Patients with advanced cancer suffer from significant pain and frequently receive opioids to manage their pain. Of the 26 patients with advanced cancer interviewed, the majority of patients experienced stigma about their opioid use for cancer pain management. All patients felt that the opioid epidemic fostered this stigma. Several struggled to use opioids for pain because of this stigma and the logistical complications they experienced with pharmacies and insurance coverage. Many were afraid to share their concerns about opioids with their providers. .
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Affiliation(s)
- Desiree R Azizoddin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Faber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Robert Knoerl
- Harvard Medical School, Boston, Massachusetts.,Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rosalind Adam
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
| | - Daniela Kessler
- Department of Medical Oncology, Division of Population Sciences, Dana-Faber Cancer Institute, Boston, Massachusetts
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Faber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrea C Enzinger
- Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Division of Population Sciences, Dana-Faber Cancer Institute, Boston, Massachusetts
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Enzinger AC, Ghosh K, Keating NL, Cutler DM, Landrum MB, Wright AA. US Trends in Opioid Access Among Patients With Poor Prognosis Cancer Near the End-of-Life. J Clin Oncol 2021; 39:2948-2958. [PMID: 34292766 DOI: 10.1200/jco.21.00476] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer. METHODS Among 270,632 Medicare fee-for-service decedents with poor prognosis cancers, we used part D data to examine trends from 2007 to 2017 in opioid prescription fills and opioid potency (morphine milligram equivalents per day [MMED]) near the end-of-life (EOL), defined as the 30 days before death or hospice enrollment. We used administrative claims to evaluate trends in pain-related emergency department (ED) visits near EOL. RESULTS Between 2007 and 2017, the proportion of decedents with poor prognosis cancers receiving ≥ 1 opioid prescription near EOL declined 15.5% (relative percent difference [RPD]), from 42.0% (95% CI, 41.4 to 42.7) to 35.5% (95% CI, 34.9 to 36.0) and the proportion receiving ≥ 1 long-acting opioid prescription declined 36.5% (RPD), from 18.1% (95% CI, 17.6 to 18.6) to 11.5% (95% CI, 11.1 to 11.9). Among decedents receiving opioids near EOL, the mean daily dose fell 24.5%, from 85.6 MMED (95% CI, 82.9 to 88.3) to 64.6 (95% CI, 62.7 to 66.6) MMED. Overall, the total amount of opioids prescribed per decedent near EOL (averaged across those who did and did not receive an opioid) fell 38.0%, from 1,075 morphine milligram equivalents per decedent (95% CI, 1,042 to 1,109) to 666 morphine milligram equivalents per decedent (95% CI, 646 to 686). Simultaneously, the proportion of patients with pain-related ED visits increased 50.8% (RPD), from 13.2% (95% CI, 12.7 to 13.6) to 19.9% (95% CI, 19.4 to 20.4). Sensitivity analyses demonstrated similar declines in opioid utilization in the 60 and 90 days before death or hospice, and suggested that trends in opioid access were not confounded by secular trends in hospice utilization. CONCLUSION Opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related ED visits suggests that EOL cancer pain management may be worsening.
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Affiliation(s)
- Andrea C Enzinger
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Kaushik Ghosh
- New England Bureau of Economic Research, Cambridge, MA
| | - Nancy L Keating
- Department of Healthcare Policy, Harvard Medical School, Boston, MA.,Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - David M Cutler
- New England Bureau of Economic Research, Cambridge, MA.,Department of Healthcare Policy, Harvard Medical School, Boston, MA.,Department of Economics, Harvard University, Cambridge, MA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Alexi A Wright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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19
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Enzinger AC, Uno H, McCleary N, Frank E, Sanoff H, Van Loon K, Matin K, Bullock A, Cronin C, Cibotti H, Bagley J, Schrag D. Effectiveness of a Multimedia Educational Intervention to Improve Understanding of the Risks and Benefits of Palliative Chemotherapy in Patients With Advanced Cancer: A Randomized Clinical Trial. JAMA Oncol 2021; 6:1265-1270. [PMID: 32672806 DOI: 10.1001/jamaoncol.2020.1921] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Despite requirements of informed consent, patients with advanced cancer often receive palliative chemotherapy (PC) without understanding that the likelihood of cure is remote. Objective To determine whether a PC educational video and booklet at treatment initiation could improve patients' understanding of its benefits and risks. Interventions Regimen-specific PC videos and booklets presenting information about logistics, potential benefits, life expectancy (optional), adverse effects, and alternatives. Videos featured authentic patients sharing diverse experiences. After receiving treatment recommendations, research assistants distributed materials to patients for independent review. Design, Setting, and Participants Multicenter randomized clinical trial of patients with advanced colorectal or pancreatic cancer starting first-line or second-line PC in 5 US cancer centers with enrollment from June 2015 to September 2017 and follow-up to December 2019. Main Outcomes and Measures The primary outcome was accurate expectations of chemotherapy benefits at 3 months, defined as responding "not at all likely" to "What is your understanding of how likely the chemotherapy is to cure your cancer?" (from the Cancer Care Outcomes Research and Surveillance study). Secondary outcomes included understanding of adverse effects, decisional conflict (SURE test), regret (Decisional Regret Scale), and distress (Functional Assessment of Cancer Therapy-General emotional well-being subscale). Results Among 186 patients with advanced colorectal or pancreatic cancer who were starting first-line or second-line PC (94 randomized to usual care, 92 to intervention; mean [SD] age, 59.3 [12.6] [range, 28-86] years; 107 [58%] male; 118 [63.4%] colorectal and 68 [36.6%] pancreatic cancer), most patients wanted "a lot" of information or "as much information as possible" about adverse effects (149, 80.1%), likelihood of cure (148, 79.6%), and prognosis (148, 79.6%). Among the intervention arm, 59 (78%) reviewed the booklet and 30 (40%) reviewed the video within 2 weeks. The primary outcome did not differ between intervention and control arms (52.6%; 95% CI, 40.3%-65.0%; vs 55.5%; 95% CI, 45.1%-66.0%). Accurate adverse effect understanding was more common among intervention than control patients (56.0%; 95% CI, 44.3%-67.7%; vs 40.2%; 95% CI, 29.5%-50.9%; P = .05), although this did not meet the threshold for statistical significance. The intervention did not increase distress, despite frank prognostic information. Other secondary outcomes were similar. Conclusions and Relevance Provision of an educational video and booklet did not alter patients' expectation of cure from PC. Alternative delivery strategies, such as integration with nurse teaching, could be explored in future studies. Trial Registration ClinicalTrials.gov Identifier: NCT02282722.
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Affiliation(s)
- Andrea C Enzinger
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts.,Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Nadine McCleary
- Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Elizabeth Frank
- Susan F. Smith Center for Women's Cancers, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Hanna Sanoff
- Division of Medical Oncology, University of North Carolina Lineberger Cancer Center, Chapel Hill
| | - Katherine Van Loon
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco
| | - Khalid Matin
- Division of Medical Oncology, Virginia Commonwealth University, Richmond
| | - Andrea Bullock
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Christine Cronin
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Heather Cibotti
- Department of Nursing, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Janet Bagley
- Department of Nursing, Dana-Farber/Partners CancerCare, Boston, Massachusetts
| | - Deborah Schrag
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts.,Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts
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20
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Enzinger AC, Uno H, McCleary N, Frank E, Sanoff H, Van Loon K, Matin K, Bullock A, Cronin C, Bagley J, Schrag D. The Effect of Disclosing Life Expectancy Information on Patients' Prognostic Understanding: Secondary Outcomes From a Multicenter Randomized Trial of a Palliative Chemotherapy Educational Intervention. J Pain Symptom Manage 2021; 61:1-11.e3. [PMID: 32777456 PMCID: PMC7769864 DOI: 10.1016/j.jpainsymman.2020.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Many advanced patients with cancer have unrealistic prognostic expectations. OBJECTIVES We tested whether offering life expectancy (LE) statistics within palliative chemotherapy (PC) education promotes realistic expectations. METHODS In this multicenter trial, patients with advanced colorectal and pancreatic cancers initiating first or second line PC were randomized to usual care versus a PC educational tool with optional LE information. Surveys at two weeks and three months assessed patients' review of the LE module and their reactions; at three months, patients estimated their LE and reported occurrence of prognosis and end-of-life (EOL) discussions. Wilcoxon tests and proportional odds models evaluated between-arm differences in LE self-estimates, and how realistic those estimates were (based on cancer type and line of treatment). RESULTS From 2015 to 2017, 92 patients were randomized to the intervention and 94 to usual care. At baseline most patients (80.9%) wanted "a lot" or "as much information as possible" about the impact of chemotherapy on LE. Among patients randomized to the intervention, 52.0% reviewed the LE module by two weeks and 66.7% by three months-of whom 88.2% reported the information was important, 31.4% reported it was upsetting, and 3.9% regretted reviewing it. Overall, patients' LE self-estimates were very optimistic; 71.4% of patients with colorectal cancer estimated greater than five years; 50% pancreatic patients estimated greater than two years. The intervention had no effect on the length or realism of patients' LE self-estimates, or on the occurrence of prognostic or EOL discussions. CONCLUSIONS Offering LE information within a PC educational intervention had no effect on patients' prognostic expectations.
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Affiliation(s)
- Andrea C Enzinger
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA; Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA.
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Nadine McCleary
- Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Elizabeth Frank
- Susan F. Smith Center for Women's Cancers, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Hanna Sanoff
- Division of Medical Oncology, University of North Carolina Lineberger Cancer Center, Chapel Hill, North Carolina, USA
| | - Katherine Van Loon
- Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Khalid Matin
- Division of Medical Oncology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Andrea Bullock
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine Cronin
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Janet Bagley
- Department of Nursing, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
| | - Deborah Schrag
- Division of Population Sciences, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA; Division of Gastrointestinal Oncology, Dana-Farber/Partners CancerCare, Boston, Massachusetts, USA
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21
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Azizoddin DR, Lakin JR, Hauser J, Rynar LZ, Weldon C, Molokie R, Enzinger AC, Payvar S, Martin JL. Meeting the guidelines: Implementing a distress screening intervention for veterans with cancer. Psychooncology 2020; 29:2067-2074. [PMID: 33009712 DOI: 10.1002/pon.5565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/02/2020] [Accepted: 09/29/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Guidelines recommend systematic evaluation of distress screening and referral for cancer patients. Implementation remains a notable gap for cancer centers serving disadvantaged communities. We present the implementation of a distress screening program within a Veterans Affairs hospital oncology clinic, serving a majority African American (AA) male population of low socioeconomic status (SES). METHODS The Coleman Foundation funded this program supporting a palliative care physician and psychologist to implement screening in a phased approach as follows: (1) Organizing key stakeholders, (2) educating clinical staff, (3) delivering distress screening, (4) generating documentation, and (5) implementing clinical action and referral pathways. We utilized validated measures in the "Patient Screening Questions for Supportive Care" screening tool. RESULTS This program was unsuccessful in screening all veterans with cancer; however, we were able to implement 3 years of longitudinal screening. In distress screens from the initial program period (n = 253), patients were primarily males (95.6%) of older age (m = 70, standard deviation = 9.45), AA (76.4%), with various cancers of advanced disease (69%). Males reported moderate psychosocial distress and elevated financial needs. For males with elevated psychosocial distress (n = 63, PHQ-4 ≥3), 36% were previously connected with psychosocial services. Following screening, engagement increased as the majority (77%) established psychosocial care. CONCLUSIONS This screening program had mixed success. Centralized program staff and available supportive care referrals were critical for program implementation. Screening may have increased engagement in social work/mental health services for males of low SES. Screening programs should be tailored to the needs of underserved communities with accessible housing/food subsidies.
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Affiliation(s)
- Desiree R Azizoddin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Hauser
- Section of Palliative Care, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Section of Palliative Care, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren Z Rynar
- Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Christine Weldon
- Department of Medicine, Hematology and Oncology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA.,The Center for Business Models in Healthcare, Glencoe, Illinois, USA
| | - Robert Molokie
- Hematology/Medical Oncology, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Department of Hematology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andrea C Enzinger
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Payvar
- Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Joanna L Martin
- Section of Palliative Care, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Section of Palliative Care, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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22
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Azizoddin DR, Enzinger AC, Wright AA, Yusufov M, Tulsky JA, Campbell EG, Bolcic-Jankovic D, Nayak MM, Braun IM. Oncologists' perspectives on medical marijuana use by older adults. J Geriatr Oncol 2020; 11:1034-1037. [PMID: 31928941 DOI: 10.1016/j.jgo.2019.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/07/2019] [Accepted: 12/30/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Desiree R Azizoddin
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Andrea C Enzinger
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Alexi A Wright
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Miryam Yusufov
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Eric G Campbell
- University of Colorado School of Medicine, Denver, CO, United States of America
| | | | - Manan M Nayak
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States of America; University of Colorado School of Medicine, Denver, CO, United States of America
| | - Ilana M Braun
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, United States of America; University of Colorado School of Medicine, Denver, CO, United States of America
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Enzinger AC, Wind JK, Frank E, McCleary NJ, Porter L, Cushing H, Abbott C, Cronin C, Enzinger PC, Meropol NJ, Schrag D. A stakeholder-driven approach to improve the informed consent process for palliative chemotherapy. Patient Educ Couns 2017; 100:1527-1536. [PMID: 28359659 PMCID: PMC5492511 DOI: 10.1016/j.pec.2017.03.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 03/08/2017] [Accepted: 03/17/2017] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Patients often anticipate cure from palliative chemotherapy. Better resources are needed to convey its risks and benefits. We describe the stakeholder-driven development and acceptability testing of a prototype video and companion booklet supporting informed consent (IC) for a common palliative chemotherapy regimen. METHODS Our multidisciplinary team (researchers, advocates, clinicians) employed a multistep process of content development, production, critical evaluation, and iterative revisions. Patient/clinician stakeholders were engaged throughout using stakeholder advisory panels, featuring their voices within the intervention, conducting surveys and qualitative interviews. A national panel of 57 patient advocates, and 25 oncologists from nine US practices critiqued the intervention and rated its clarity, accuracy, balance, tone, and utility. Participants also reported satisfaction with existing chemotherapy IC materials. RESULTS Few oncologists (5/25, 20%) or advocates (10/22, 45%) were satisfied with existing IC materials. In contrast, most rated our intervention highly, with 89-96% agreeing it would be useful and promote informed decisions. Patient voices were considered a key strength. Every oncologist indicated they would use the intervention regularly. CONCLUSION Our intervention was acceptable to advocates and oncologists. A randomized trial is evaluating its impact on the chemotherapy IC process. PRACTICE IMPLICATIONS Stakeholder-driven methods can be valuable for developing patient educational interventions.
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Affiliation(s)
- Andrea C Enzinger
- McGraw Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Jennifer K Wind
- McGraw Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Elizabeth Frank
- Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nadine J McCleary
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Heather Cushing
- Department of Nursing, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Caroline Abbott
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, USA
| | - Christine Cronin
- McGraw Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Peter C Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Neal J Meropol
- Division of Hematology and Oncology, University Hospitals Case Medical Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Deborah Schrag
- McGraw Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Balboni MJ, Sullivan A, Enzinger AC, Smith PT, Mitchell C, Peteet JR, Tulsky JA, VanderWeele T, Balboni TA. U.S. Clergy Religious Values and Relationships to End-of-Life Discussions and Care. J Pain Symptom Manage 2017; 53:999-1009. [PMID: 28185893 PMCID: PMC5474165 DOI: 10.1016/j.jpainsymman.2016.12.346] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 12/27/2016] [Accepted: 12/29/2016] [Indexed: 11/24/2022]
Abstract
CONTEXT Although clergy interact with approximately half of U.S. patients facing end-of-life medical decisions, little is known about clergy-congregant interactions or clergy influence on end-of-life decisions. OBJECTIVE The objective was to conduct a nationally representative survey of clergy beliefs and practices. METHODS A mailed survey to a nationally representative sample of clergy completed in March 2015 with 1005 of 1665 responding (60% response rate). The primary predictor variable was clergy religious values about end-of-life medical decisions, which measured belief in miracles, the sanctity of life, trust in divine control, and redemptive suffering. Outcome variables included clergy-congregant end-of-life medical conversations and congregant receipt of hospice and intensive care unit (ICU) care in the final week of life. RESULTS Most U.S. clergy are Christian (98%) and affirm religious values despite a congregant's terminal diagnosis. Endorsement included God performing a miracle (86%), pursuing treatment because of the sanctity of life (54%), postponement of medical decisions because God is in control (28%), and enduring painful treatment because of redemptive suffering (27%). Life-prolonging religious values in end-of-life medical decisions were associated with fewer clergy-congregant conversations about considering hospice (adjusted odds ratio [AOR], 0.58; 95% CI 0.42-0.80), P < 0.0001), stopping treatment (AOR 0.58, 95% CI 0.41-0.84, P = 0.003), and forgoing future treatment (AOR 0.50, 95% CI 0.36-0.71, P < 0.001) but not associated with congregant receipt of hospice or ICU care. Clergy with lower medical knowledge were less likely to have certain end-of-life conversations. The absence of a clergy-congregant hospice discussion was associated with less hospice (AOR 0.45; 95% CI 0.29-0.66, P < 0.001) and more ICU care (AOR 1.67; 95% CI 1.14-2.50, P < 0.01) in the final week of life. CONCLUSION American clergy hold religious values concerning end-of-life medical decisions, which appear to decrease end-of-life discussions. Clergy end-of-life education may enable better quality end-of-life care for religious patients.
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Affiliation(s)
- Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA.
| | - Adam Sullivan
- Department of Biostatistics, Brown University, Providence, Rhode Island
| | - Andrea C Enzinger
- Departments of Medical Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Patrick T Smith
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA; Gordon-Conwell Theological Seminary, S. Hamilton, Massachusetts, USA
| | - Christine Mitchell
- Department of Social and Behavioral Health, Harvard School of Public Health, Boston, Massachusetts, USA
| | - John R Peteet
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tyler VanderWeele
- Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Department of Epidemiology and Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Brigham and Women's Hospital, Boston, Massachusetts, USA
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Sanders JJ, Chow V, Enzinger AC, Lam TC, Smith PT, Quiñones R, Baccari A, Philbrick S, White-Hammond G, Peteet J, Balboni TA, Balboni MJ. Seeking and Accepting: U.S. Clergy Theological and Moral Perspectives Informing Decision Making at the End of Life. J Palliat Med 2017; 20:1059-1067. [PMID: 28387570 DOI: 10.1089/jpm.2016.0545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND People with serious illness frequently rely on religion/spirituality to cope with their diagnosis, with potentially positive and negative consequences. Clergy are uniquely positioned to help patients consider medical decisions at or near the end of life within a religious/spiritual framework. OBJECTIVE We aimed to examine clergy knowledge of end-of-life (EOL) care and beliefs about the role of faith in EOL decision making for patients with serious illness. DESIGN Key informant interviews, focus groups, and survey. SETTING/SUBJECTS A purposive sample of 35 active clergy in five U.S. states as part of the National Clergy End-of-Life Project. MEASUREMENT We assessed participant knowledge of and desire for further education about EOL care. We transcribed interviews and focus groups for the purpose of qualitative analysis. RESULTS Clergy had poor knowledge of EOL care; 75% desired more EOL training. Qualitative analysis revealed a theological framework for decision making in serious illness that balances seeking life and accepting death. Clergy viewed comfort-focused treatments as consistent with their faith traditions' views of a good death. They employed a moral framework to determine the appropriateness of EOL decisions, which weighs the impact of multiple factors and upholds the importance of God-given free will. They viewed EOL care choices to be the primary prerogative of patients and families. Clergy described ambivalence about and a passive approach to counseling congregants about decision making despite having defined beliefs regarding EOL care. CONCLUSIONS Poor knowledge of EOL care may lead clergy to passively enable congregants with serious illness to pursue potentially nonbeneficial treatments that are associated with increased suffering.
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Affiliation(s)
- Justin J Sanders
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,11 Brigham and Women's Hospital , Boston, Massachusetts
| | - Vinca Chow
- 2 Department of Anesthesia, Duke University , Durham, North Carolina
| | - Andrea C Enzinger
- 3 Departments of Medical Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Tai-Chung Lam
- 4 Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, University of Hong Kong , Hong Kong, China
| | - Patrick T Smith
- 5 Harvard Medical School Center for Bioethics , Boston, Massachusetts.,6 Gordon-Conwell Theological Seminary , South Hamilton, Massachusetts
| | - Rebecca Quiñones
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | | | - Sarah Philbrick
- 8 Kirksville College of Osteopathic Medicine, A.T. Still University , Kirksville, Missouri
| | | | - John Peteet
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Tracy A Balboni
- 10 Department of Radiation Oncology, Dana-Farber Cancer Institute , Boston, Massachusetts.,11 Brigham and Women's Hospital , Boston, Massachusetts.,12 Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts
| | - Michael J Balboni
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,12 Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts
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Enzinger AC, Zhang B, Schrag D, Prigerson HG. Outcomes of Prognostic Disclosure: Associations With Prognostic Understanding, Distress, and Relationship With Physician Among Patients With Advanced Cancer. J Clin Oncol 2015; 33:3809-16. [PMID: 26438121 DOI: 10.1200/jco.2015.61.9239] [Citation(s) in RCA: 229] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine how prognostic conversations influence perceptions of life expectancy (LE), distress, and the patient-physician relationship among patients with advanced cancer. PATIENTS AND METHODS This was a multicenter observational study of 590 patients with metastatic solid malignancies with progressive disease after ≥ one line of palliative chemotherapy, undergoing follow-up to death. At baseline, patients were asked whether their oncologist had disclosed an estimate of prognosis. Patients also estimated their own LE and completed assessments of the patient-physician relationship, distress, advance directives, and end-of-life care preferences. RESULTS Among this cohort of 590 patients with advanced cancer (median survival, 5.4 months), 71% wanted to be told their LE, but only 17.6% recalled a prognostic disclosure by their physician. Among the 299 (51%) of 590 patients willing to estimate their LE, those who recalled prognostic disclosure offered more realistic estimates as compared with patients who did not (median, 12 months; interquartile range, 6 to 36 months v 48 months; interquartile range, 12 to 180 months; P < .001), and their estimates were less likely to differ from their actual survival by > 2 (30.2% v 49.2%; odds ratio [OR], 0.45; 95% CI, 0.14 to 0.82) or 5 years (9.5% v 35.5%; OR, 0.19; 95% CI, 0.08 to 0.47). In adjusted analyses, recall of prognostic disclosure was associated with a 17.2-month decrease (95% CI, 6.2 to 28.2 months) in patients' LE self-estimates. Longer LE self-estimates were associated with lower likelihood of do-not-resuscitate order (adjusted OR, 0.439; 95% CI, 0.296 to 0.630 per 12-month increase in estimate) and preference for life-prolonging over comfort-oriented care (adjusted OR, 1.493; 95% CI, 1.091 to 1.939). Prognostic disclosure was not associated with worse patient-physician relationship ratings, sadness, or anxiety in adjusted analyses. CONCLUSION Prognostic disclosures are associated with more realistic patient expectations of LE, without decrements to their emotional well-being or the patient-physician relationship.
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Affiliation(s)
- Andrea C Enzinger
- Andrea C. Enzinger and Deborah Schrag, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and Baohui Zhang and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Baohui Zhang
- Andrea C. Enzinger and Deborah Schrag, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and Baohui Zhang and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Deborah Schrag
- Andrea C. Enzinger and Deborah Schrag, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and Baohui Zhang and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Holly G Prigerson
- Andrea C. Enzinger and Deborah Schrag, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and Baohui Zhang and Holly G. Prigerson, Weill Cornell Medical College, New York, NY.
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Balboni MJ, Bandini J, Mitchell C, Epstein-Peterson ZD, Amobi A, Cahill J, Enzinger AC, Peteet J, Balboni T. Religion, Spirituality, and the Hidden Curriculum: Medical Student and Faculty Reflections. J Pain Symptom Manage 2015; 50:507-15. [PMID: 26025271 PMCID: PMC5267318 DOI: 10.1016/j.jpainsymman.2015.04.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/13/2015] [Accepted: 04/24/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Religion and spirituality play an important role in physicians' medical practice, but little research has examined their influence within the socialization of medical trainees and the hidden curriculum. OBJECTIVES The objective is to explore the role of religion and spirituality as they intersect with aspects of medicine's hidden curriculum. METHODS Semiscripted, one-on-one interviews and focus groups (n = 33 respondents) were conducted to assess Harvard Medical School student and faculty experiences of religion/spirituality and the professionalization process during medical training. Using grounded theory, theme extraction was performed with interdisciplinary input (medicine, sociology, and theology), yielding a high inter-rater reliability score (kappa = 0.75). RESULTS Three domains emerged where religion and spirituality appear as a factor in medical training. First, religion/spirituality may present unique challenges and benefits in relation to the hidden curriculum. Religious/spiritual respondents more often reported to struggle with issues of personal identity, increased self-doubt, and perceived medical knowledge inadequacy. However, religious/spiritual participants less often described relationship conflicts within the medical team, work-life imbalance, and emotional stress arising from patient suffering. Second, religion/spirituality may influence coping strategies during encounters with patient suffering. Religious/spiritual trainees described using prayer, faith, and compassion as means for coping whereas nonreligious/nonspiritual trainees discussed compartmentalization and emotional repression. Third, levels of religion/spirituality appear to fluctuate in relation to medical training, with many trainees experiencing an increase in religiousness/spirituality during training. CONCLUSION Religion/spirituality has a largely unstudied but possibly influential role in medical student socialization. Future study is needed to characterize its function within the hidden curriculum.
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Affiliation(s)
- Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
| | - Julia Bandini
- Department of Sociology, Brandeis University, Waltham, Massachusetts, USA
| | - Christine Mitchell
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts, USA
| | | | - Ada Amobi
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Cahill
- Theology Department, Boston College, Chestnut Hill, Massachusetts, USA
| | - Andrea C Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - John Peteet
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Tracy Balboni
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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Balboni MJ, Sullivan A, Enzinger AC, Epstein-Peterson ZD, Tseng YD, Mitchell C, Niska J, Zollfrank A, VanderWeele TJ, Balboni TA. Nurse and physician barriers to spiritual care provision at the end of life. J Pain Symptom Manage 2014; 48:400-10. [PMID: 24480531 PMCID: PMC4569089 DOI: 10.1016/j.jpainsymman.2013.09.020] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/24/2013] [Accepted: 10/04/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Spiritual care (SC) from medical practitioners is infrequent at the end of life (EOL) despite national standards. OBJECTIVES The study aimed to describe nurses' and physicians' desire to provide SC to terminally ill patients and assess 11 potential SC barriers. METHODS This was a survey-based, multisite study conducted from October 2008 through January 2009. All eligible oncology nurses and physicians at four Boston academic centers were approached for study participation; 339 nurses and physicians participated (response rate=63%). RESULTS Most nurses and physicians desire to provide SC within the setting of terminal illness (74% vs. 60%, respectively; P=0.002); however, 40% of nurses/physicians provide SC less often than they desire. The most highly endorsed barriers were "lack of private space" for nurses and "lack of time" for physicians, but neither was associated with actual SC provision. Barriers that predicted less frequent SC for all medical professionals included inadequate training (nurses: odds ratio [OR]=0.28, 95% confidence interval [CI]=0.12-0.73, P=0.01; physicians: OR=0.49, 95% CI=0.25-0.95, P=0.04), "not my professional role" (nurses: OR=0.21, 95% CI=0.07-0.61, P=0.004; physicians: OR=0.35, 95% CI=0.17-0.72, P=0.004), and "power inequity with patient" (nurses: OR=0.33, 95% CI=0.12-0.87, P=0.03; physicians: OR=0.41, 95% CI=0.21-0.78, P=0.007). A minority of nurses and physicians (21% and 49%, P=0.003, respectively) did not desire SC training. Those less likely to desire SC training reported lower self-ratings of spirituality (nurses: OR=5.00, 95% CI=1.82-12.50, P=0.002; physicians: OR=3.33, 95% CI=1.82-5.88, P<0.001) and male gender (physicians: OR=3.03, 95% CI=1.67-5.56, P<0.001). CONCLUSION SC training is suggested to be critical to the provision of SC in accordance with national care quality standards.
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Affiliation(s)
- Michael J Balboni
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Center for Psychosocial Epidemiology and Outcomes Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Adam Sullivan
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Andrea C Enzinger
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Center for Psychosocial Epidemiology and Outcomes Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Yolanda D Tseng
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christine Mitchell
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joshua Niska
- Harvard Medical School, Boston, Massachusetts, USA
| | - Angelika Zollfrank
- Department of Chaplaincy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tyler J VanderWeele
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA; Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Center for Psychosocial Epidemiology and Outcomes Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Epstein-Peterson ZD, Sullivan AJ, Enzinger AC, Trevino KM, Zollfrank AA, Balboni MJ, VanderWeele TJ, Balboni TA. Examining Forms of Spiritual Care Provided in the Advanced Cancer Setting. Am J Hosp Palliat Care 2014; 32:750-7. [PMID: 25005589 DOI: 10.1177/1049909114540318] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Spiritual care (SC) is important to the care of seriously ill patients. Few studies have examined types of SC provided and their perceived impact. This study surveyed patients with advanced cancer (N = 75, response rate [RR] = 73%) and oncology nurses and physicians (N = 339, RR = 63%). Frequency and perceived impact of 8 SC types were assessed. Spiritual care is infrequently provided, with encouraging or affirming beliefs the most common type (20%). Spiritual history taking and chaplaincy referrals comprised 10% and 16%, respectively. Most patients viewed each SC type positively, and SC training predicted provision of many SC types. In conclusion, SC is infrequent, and core elements of SC-spiritual history taking and chaplaincy referrals-represent a minority of SC. Spiritual care training predicts provision of SC, indicting its importance to advancing SC in the clinical setting.
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Affiliation(s)
| | - Adam J Sullivan
- Departments of Biostatistics and Epidemiology, School of Public Health, Harvard University, Boston, MA, USA
| | - Andrea C Enzinger
- Harvard Medical School, Harvard University, Boston, MA, USA Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kelly M Trevino
- Department of Psychology, Rowan University, Glassboro, NJ, USA
| | | | - Michael J Balboni
- Harvard Medical School, Harvard University, Boston, MA, USA Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tyler J VanderWeele
- Departments of Biostatistics and Epidemiology, School of Public Health, Harvard University, Boston, MA, USA
| | - Tracy A Balboni
- Harvard Medical School, Harvard University, Boston, MA, USA Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
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Enzinger AC, Zhang B, Weeks JC, Prigerson HG. Clinical trial participation as part of end-of-life cancer care: associations with medical care and quality of life near death. J Pain Symptom Manage 2014; 47:1078-90. [PMID: 24099894 PMCID: PMC3976895 DOI: 10.1016/j.jpainsymman.2013.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/18/2013] [Accepted: 07/23/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Clinical trials are a common therapeutic option for patients with advanced incurable cancer. OBJECTIVES To examine the associations between trial participation and end-of-life (EOL) outcomes, including aggressive care and quality of life (QOL). METHODS Coping with Cancer, a multicenter prospective cohort study of patients with metastatic cancer, progressed after at least first-line chemotherapy. Baseline chart review documented clinical trial participation. Baseline interviews assessed psychosocial characteristics and EOL preferences. Caregiver interview and chart review assessed medical care and QOL near death. The primary outcome was aggressive EOL care (ventilation, resuscitation, or intensive care unit admission in last week of life). Propensity score weighting balanced patient characteristics that differed by trial participation, including care preferences and EOL discussion. Propensity score-weighted regression models estimated the effect of trial participation on outcomes. RESULTS Of 352 patients followed to death, 37 were enrolled in a clinical trial at baseline. In propensity score-weighted analyses, trial participation was significantly associated with aggressive EOL care (21.6% vs. 12.0%, adjusted odds ratio [AOR] 2.04, 95% confidence interval [CI] 1.00-4.15), late hospice enrollment (51.4% vs. 42.2%, AOR 1.96, 95% CI 1.10-3.50), hospital death (48.6% vs. 25.7%, AOR 2.74, 95% CI 1.37-5.47), intensive care unit death (16.2% vs. 6.3%, AOR 3.53, 95% CI 1.29-9.65), and inferior QOL near death (least squares mean 5.93 vs. 7.69, P<0.001). Controlling for EOL care, trial enrollment was no longer associated with QOL near death (P=0.342). CONCLUSION Clinical trial participation is associated with aggressive EOL care. Aggressive EOL care appears to explain the association between trial participation and QOL near death.
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Affiliation(s)
- Andrea C Enzinger
- Center for Psychosocial Epidemiology and Outcomes Research, Dana-Faber Cancer Institute, Boston, Massachusetts, USA; Department of Medical Oncology, Dana-Faber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Faber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Baohui Zhang
- Center for Psychosocial Epidemiology and Outcomes Research, Dana-Faber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Faber Cancer Institute, Boston, Massachusetts, USA
| | - Jane C Weeks
- Department of Medical Oncology, Dana-Faber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Faber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Holly G Prigerson
- Center for Psychosocial Epidemiology and Outcomes Research, Dana-Faber Cancer Institute, Boston, Massachusetts, USA; Department of Medical Oncology, Dana-Faber Cancer Institute, Boston, Massachusetts, USA; McGraw/Patterson Center for Population Sciences, Dana-Faber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
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Balboni TA, Balboni M, Enzinger AC, Gallivan K, Paulk ME, Wright A, Steinhauser K, VanderWeele TJ, Prigerson HG. Provision of spiritual support to patients with advanced cancer by religious communities and associations with medical care at the end of life. JAMA Intern Med 2013; 173:1109-17. [PMID: 23649656 PMCID: PMC3791610 DOI: 10.1001/jamainternmed.2013.903] [Citation(s) in RCA: 203] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Previous studies report associations between medical utilization at the end-of-life (EoL) and religious coping and spiritual support from the medical team. However, the influence of clergy and religious communities on EoL outcomes is unclear. OBJECTIVE To determine whether spiritual support from religious communities influences terminally ill patients' medical care and quality of life (QoL) near death. DESIGN, SETTING, AND PARTICIPANTS A US-based, multisite cohort study of 343 patients with advanced cancer enrolled from September 2002 through August 2008 and followed up (median duration, 116 days) until death. Baseline interviews assessed support of patients' spiritual needs by religious communities. End-of-life medical care in the final week included the following: hospice, aggressive EoL measures (care in an intensive care unit [ICU], resuscitation, or ventilation), and ICU death. MAIN OUTCOMES AND MEASURES End-of-life QoL was assessed by caregiver ratings of patient QoL in the last week of life. Multivariable regression analyses were performed on EoL care outcomes in relation to religious community spiritual support, controlling for confounding variables, and were repeated among high religious coping and racial/ethnic minority patients. RESULTS Patients reporting high spiritual support from religious communities (43%) were less likely to receive hospice (adjusted odds ratio [AOR], 0.37; 95% CI, 0.20-0.70 [P = .002]), more likely to receive aggressive EoL measures (AOR, 2.62; 95% CI, 1.14-6.06 [P = .02]), and more likely to die in an ICU (AOR, 5.22; 95% CI, 1.71-15.60 [P = .004]). Risks of receiving aggressive EoL interventions and ICU deaths were greater among high religious coping (AOR, 11.02; 95% CI, 2.83-42.89 [P < .001]; and AOR, 22.02; 95% CI, 3.24-149.58 [P = .002]; respectively) and racial/ethnic minority patients (AOR, 8.03; 95% CI, 2.04-31.55 [P = .003]; and AOR, 11.21; 95% CI, 2.29-54.88 [P = .003]; respectively). Among patients well-supported by religious communities, receiving spiritual support from the medical team was associated with higher rates of hospice use (AOR, 2.37; 95% CI, 1.03-5.44 [P = .04]), fewer aggressive interventions (AOR, 0.23; 95% CI, 0.06-0.79 [P = .02]) and fewer ICU deaths (AOR, 0.19; 95% CI, 0.05-0.80 [P = .02]); and EoL discussions were associated with fewer aggressive interventions (AOR, 0.12; 95% CI, 0.02-0.63 [P = .01]). CONCLUSIONS AND RELEVANCE Terminally ill patients who are well supported by religious communities access hospice care less and aggressive medical interventions more near death. Spiritual care and EoL discussions by the medical team may reduce aggressive treatment, highlighting spiritual care as a key component of EoL medical care guidelines.
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Affiliation(s)
- Tracy A Balboni
- Center for Psychosocial Epidemiology and Outcomes Research, and Department of Radiation Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA.
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