Use of Cancer-Directed therapy at the end of life among adolescents and young adults

BACKGROUND

Adolescents and young adults (AYAs) frequently receive chemotherapy near death. We know less about use of targeted agents and immunotherapy or trends over time.

METHODS

We conducted a retrospective cohort study of 1,836 AYAs with cancer who died between 2009-2019 after receiving care at one of three sites (Dana-Farber Cancer Institute, Kaiser Permanente Northern California, and Kaiser Permanente Southern California). We reviewed electronic health data and medical records to examine use of cancer-directed therapy in the last 90 days of life, including chemotherapy, targeted therapy, immunotherapy, and investigational drugs.

RESULTS

Over the study period, 35% of AYAs received chemotherapy in the last 90 days of life; 24% received targeted therapy, 7% immunotherapy, and 5% investigational drugs. Fifty-six percent received at least one form of systemic cancer-directed therapy in the last 90 days of life. After adjustment for patient sex, race, ethnicity, age, site of care, diagnosis, and years from diagnosis to death, the proportion of AYAs receiving targeted therapy (odds ratio (OR) 1.05 per year of death, 95% confidence interval (CI) 1.02-1.10, P = .006), immunotherapy (OR 1.27, 95%CI 1.18-1.38, P<.0001), and any cancer-directed therapy (OR1.04, 95%CI 1.01-1.08, P=.01) in the last 90 days of life increased over time.

CONCLUSIONS

More than half of AYAs receive cancer therapy in the last 90 days of life, and use of novel agents such as targeted therapy and immunotherapy are increasing over time. While some AYAs may wish to continue cancer therapy while living with advanced disease, efforts are needed to ensure that use of cancer-directed therapy meets preferences of AYAs approaching death.

Quality of End-of-Life Care Among Adolescents and Young Adults With Cancer

Adolescents, young adults with cancer receive limited psychosocial and spiritual support near death.

What Constitutes Quality of Life? Perspectives of Adolescents and Young Adults With Advanced Cancer

BACKGROUND

Adolescents and young adults (AYAs) with advanced cancer identify maintaining a good quality of life (QoL) as a central goal of end-of-life care. QoL is a dynamic and subjective overarching concept that refers to an individual's relative satisfaction with their own life. Despite its importance to AYAs with advanced cancer, a patient-centered definition of QoL is lacking in this population.

PATIENTS AND METHODS

This qualitative secondary analysis of semistructured interviews was conducted across 3 institutions and 1 online support community among AYA patients with advanced cancer, family caregivers, and health care providers who cared for living or recently deceased AYAs. Interviewees were asked about priorities in receipt of care. Interviews were transcribed using NVivo software for primary analysis, and previously coded excerpts were screened for references to QoL. Relevant excerpts were sorted into organizing domains.

RESULTS

Participants included 23 AYA patients, 28 family caregivers, and 29 health care providers (including physicians, nurses, nurse practitioners, social workers, and psychologists). Four domains of QoL were identified: psychosocial and physical well-being, dignity, normalcy, and personal and family relationships. Within each domain there was agreement across AYAs, caregivers, and health care providers, with nuanced perspectives provided by AYAs of different ages. Personal and family relationships was the most frequently referenced domain of QoL among all participants. A common feature of each domain was that adaptation to current circumstances impacted perspectives on QoL. Patients valued active participation in the development of a care plan that supported these domains.

CONCLUSIONS

AYAs with advanced cancer, their caregivers, and health care providers agree on several broad domains of QoL in this population. To provide high-quality, patient-centered care, care plans should integrate these domains to enable AYAs to maximize their QoL throughout their advanced cancer care.

Discussions About Goals of Care and Advance Care Planning Among Adolescents and Young Adults With Cancer Approaching the End of Life

PURPOSE

Adolescents and young adults (AYAs) with cancer receive high rates of medically intensive measures at the end of life. This study aimed to characterize the prevalence and timing of conversations about goals of care and advance care planning among AYAs at the end of life as one potential influence on care received.

METHODS

This was a review of electronic health data and medical records for 1,929 AYAs age 12-39 years who died after receiving care at one of three sites between 2003 and 2019, including documented conversations about goals of care and advance care planning, and care received.

RESULTS

A majority of AYAs were female (54%) and White (61%); 12% were Asian, 8% Black, and 27% Hispanic. Most patients had documented discussions about prognosis (86%), goals of care (83%), palliative care (79%), hospice (79%), and preferred location of death (64%). When last documented goals of care were evaluated, 69% of patients wanted care focused on palliation; however, 29% of those with palliative goals spent time in the intensive care unit (ICU) in the last month of life, and 32% had multiple emergency room (ER) visits. When goals-of-care discussions happened earlier, >30 days before death, AYAs were less likely to receive chemotherapy in the last 14 days of life (P = .001), ICU care (P < .001), ER visits (P < .001), and hospitalizations in the last month (P < .001).

CONCLUSION

High rates of medically intensive measures among AYAs near the end of life do not appear to be the result of a lack of discussions about goals of care and advance care planning. Although some interventions may be used to support palliative goals, earlier discussions have potential to reduce late-life intensive measures.

Patient, Caregiver, and Clinician Perspectives on Core Components of Therapeutic Alliance for Adolescents and Young Adults With Advanced Cancer: A Qualitative Study

IMPORTANCE

The patient-clinician therapeutic alliance is an important aspect of high-quality cancer care. However, components of the therapeutic alliance in adolescents and young adults (AYAs, aged 12-39 years) with cancer have not been defined.

OBJECTIVE

To identify components of and barriers to the therapeutic alliance between AYAs, caregivers, and clinicians from the perspective of all key stakeholders.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, semistructured in-depth interviews with patients, caregivers, and clinicians were conducted from 2018 to 2021 with no additional follow-up, with content analysis of resulting transcripts. Participants were recruited from Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an online cancer support community (Cactus Cancer Society). Eligible participants were English- or Spanish-speaking. Eligible patients were aged 12 to 39 years with stage IV or recurrent cancer. Eligible caregivers cared for an AYA living with advanced cancer or one who had died within 5 years. Eligible clinicians routinely provided care for AYAs with cancer.

MAIN OUTCOMES AND MEASURES

Perspectives on therapeutic alliance.

RESULTS

Interviews were conducted with 80 participants: 23 were patients (48% were female; 78% were White), 28 were caregivers (82% were female; 50% were White), and 29 were clinicians (69% were female; 45% were White). The mean (SD) age of patients was 29 (7.3) years. Interviews identified 6 components of therapeutic alliance: (1) compassion; (2) sense of connection; (3) clinician presence; (4) information sharing; (5) shared goals; and (6) individualization of care. While some domains were represented in prior models of therapeutic alliance, a unique domain was identified related to the need for individualization of the approach to care for AYA patients and their caregivers. Interviews also identified potential barriers to building the therapeutic alliance specific to the AYA population, including managing discordant needs between patients and caregivers and communication challenges at the end of life.

CONCLUSIONS AND RELEVANCE

This study identified core components and barriers to building therapeutic alliance in the AYA advanced cancer population from the perspective of all the key stakeholders in the relationship. A novel component highlighting the need for individualization was identified. This model enables a deeper understanding of how to build therapeutic alliance in the AYA advanced cancer population, which may guide clinician training and facilitate improved care for this vulnerable population.

Quality Indicators for Adolescents and Young Adults With Advanced Cancer: A Modified Delphi Process With Patients, Family Members, and Clinicians

CONTEXT

Quality measures have been devised for end-of-life care of older adults with cancer, but are lacking for adolescents and young adults (AYAs).

OBJECTIVE

We previously conducted interviews with AYAs, family caregivers, and clinicians to identify priority domains for high quality care of AYAs with advanced cancer. The goal of this study was to use a modified Delphi process to form consensus around the highest priority quality indicators.

METHODS

A modified Delphi process was conducted with 10 AYAs with recurrent or metastatic cancer, 11 family caregivers, and 29 multidisciplinary clinicians, using small group web conferences. Participants were asked to rate the importance of each of 41 potential quality indicators, rank the 10 most important, and engage in discussion to reconcile differences.

RESULTS

Of 41 initial indicators, 34 were rated as highly important (rating seven, eight, or nine on a nine-point scale) by >70% of participants. The panel was unable to reach consensus around the 10 most important indicators. Instead, participants recommended retaining a larger set of indicators to reflect potential for different priorities across the population, resulting in a final set of 32 indicators. Recommended indicators broadly encompassed attention to physical symptoms; quality of life; psychosocial, and spiritual care; communication and decision-making; relationships with clinicians; care and treatment; and independence.

CONCLUSION

A patient- and family-centered process for quality indicator development led to strong endorsement of multiple potential indicators by Delphi participants. Further validation and refinement will be performed using a survey of bereaved family members.

"The simple life experiences that every other human gets": Desire for normalcy among adolescents and young adults with advanced cancer

BACKGROUND

Adolescents and young adults (AYAs) with advanced cancer identify normalcy as an important component of quality end-of-life care. We sought to define domains of normalcy and identify ways in which clinicians facilitate or hinder normalcy during advanced cancer care.

PROCEDURE

This was a secondary analysis of a qualitative study that aimed to identify priority domains for end-of-life care. Content analysis of semi-structured interviews among AYAs aged 12-39 years with advanced cancer, caregivers, and clinicians was used to evaluate transcripts. Coded excerpts were reviewed to identify themes related to normalcy.

RESULTS

Participants included 23 AYAs with advanced cancer, 28 caregivers, and 29 clinicians. Participants identified five domains of normalcy including relationships, activities, career/school, milestones, and appearance. AYAs and caregivers identified that clinicians facilitate normalcy through exploration of these domains with AYAs, allowing flexibility in care plans, identification of short-term and long-term goals across normalcy domains, and recognizing losses of normalcy that occur during cancer care.

CONCLUSIONS

AYAs with cancer experience multiple threats to normalcy during advanced cancer care. Clinicians can attend to normalcy and improve AYA quality of life by acknowledging these losses through ongoing discussions on how best to support domains of normalcy and by reinforcing AYA identities beyond a cancer diagnosis.

Patient, Family, and Clinician Perspectives on Location of Death for Adolescents and Young Adults With Cancer

PURPOSE

Adolescents and young adults (AYAs) with cancer have high rates of hospital deaths. It is not clear if this reflects their preferences or barriers to dying at home.

METHODS

Between December 2018 and January 2021, we conducted in-depth interviews with AYAs (age 12-39 years) with stage IV or recurrent cancer, family caregivers including bereaved caregivers, and clinicians of AYAs with cancer. Patients were asked about their priorities for care including location of death, caregivers were asked what was most important in the care of their AYA family member, and clinicians were asked to reflect on priorities identified through caring for AYAs. Directed content analysis was applied to interview data, and themes regarding location of death were developed.

RESULTS

Eighty individuals (23 AYAs, 28 caregivers, and 29 clinicians) participated in interviews. Most AYAs and caregivers preferred a home death. However, some AYAs and caregivers opted for a hospital death to alleviate caregiver burden or protect siblings from the perceived trauma of witnessing a home death. Lack of adequate services to manage intractable symptoms at home and insufficient caregiver support led some AYAs/caregivers to opt for hospital death despite a preference for home death. Participants acknowledged the value of hospice while also pointing out its limitations in attaining a home death.

CONCLUSION

Although most AYAs prefer to die at home, this preference is not always achieved. Robust home-based services for effective symptom management and caregiver support are needed to close the gap between preferred and actual location of death for AYAs.

Patient, Family, and Clinician Perspectives on End-of-Life Care Quality Domains and Candidate Indicators for Adolescents and Young Adults With Cancer

IMPORTANCE

End-of-life care quality indicators specific to adolescents and young adults (AYAs) aged 12 to 39 years with cancer have not been developed.

OBJECTIVE

To identify priority domains for end-of-life care from the perspectives of AYAs, family caregivers, and clinicians, and to propose candidate quality indicators reflecting priorities.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was conducted from December 6, 2018, to January 5, 2021, with no additional follow-up. In-depth interviews were conducted with patients, family caregivers, and clinicians and included a content analysis of resulting transcripts. A multidisciplinary advisory group translated priorities into proposed quality indicators. Interviews were conducted at the Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an AYA cancer support community (lacunaloft.org). Participants included 23 AYAs, 28 caregivers, and 29 clinicians.

EXPOSURE

Stage IV or recurrent cancer.

MAIN OUTCOMES AND MEASURES

Care priorities.

RESULTS

Interviews were conducted with 23 patients (mean [SD] age, 29.3 [7.3] years; 12 men [52%]; 18 White participants [78%]), 28 family caregivers (23 women [82%]; 14 White participants [50%]), and 29 clinicians (20 women [69%]; 13 White participants [45%]). Caregivers included 22 parents (79%), 5 spouses or partners (18%), and 1 other family member (4%); the 29 clinicians included 15 physicians (52%), 6 nurses or nurse practitioners (21%), and 8 social workers or psychologists (28%). Interviews identified 7 end-of-life priority domains: attention to physical symptoms, attention to quality of life, psychosocial and spiritual care, communication and decision-making, relationships with clinicians, care and treatment, and independence. Themes were consistent across the AYA age range and participant type. Although some domains were represented in quality indicators developed for adults, unique domains were identified, as well as AYA-specific manifestations of existing domains. For example, quality of life included global quality of life; attainment of life goals, legacy, and meaning; support of personal relationships; and normalcy. Within communication and decision-making, domains included communication early in the disease course, addressing prognosis and what to expect at the end of life, and opportunity for AYAs to hold desired roles in decision-making. Care and treatment domains relevant to cancer therapy, use of life-prolonging measures, and location of death emphasized the need for preference sensitivity rather than a standard path. This finding differs from existing adult indicators that propose that late-life chemotherapy, intensive measures, and hospital death should be rare.

CONCLUSIONS AND RELEVANCE

The findings of this qualitative study suggest that AYAs with cancer have priorities for care at the end of life that are not fully encompassed in existing indicators for adults. Use of new indicators for this young population may better reflect patient- and family-centered experiences of quality care.

Improving care quality for patients with soft tissue and bone sarcoma by establishing a national virtual tumor board and electronic consultation platform

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Background: Bone and soft tissue sarcomas are relatively uncommon and their management is extremely complex requiring coordinated multidisciplinary expertise for optimal care. Because Kaiser Permanente operates across many geographic regions in the country, in-person tumor board is not practical. Methods: The Kaiser Permanente Northern California medical oncology team has developed a system-based virtual tumor board (VTB) and electronic consultation (EC) platform comprised of experts from several key disciplines including musculoskeletal/surgical oncology, musculoskeletal radiology, pathology, radiation oncology, brachytherapy, medical adult and pediatric oncology. The VTB and EC cases are physician referral-based. The VTB occurs once every two weeks via video conferencing reviewing imaging studies and pathology while EC is available for more urgent cases whenever requested. This platform is available to Kaiser Permanente physicians in Northern and Southern California and other states including Hawaii, Mid-Atlantic, Northwest, Colorado, and Georgia. We conducted a survey targeting referring physicians to assess the value of this service platform in improving sarcoma care. Results: From March 2013 to October 2015, approximately 500 cases have been referred to the VTB and EC. Approximately 2/3 of the cases were referred to the VTB and 1/3 to the EC. The cases include a vast spectrum of bone and soft tissue sarcoma cases that were either newly diagnosed or at the time of relapse or progression. The physician survey on the quality and utilization of this sarcoma platform provided very positive feedback, with 100% responses stating that VTB and EC improved patient care and their confidence in managing patients with sarcoma, 90% stating VTB and EC changed their management to a certain extent. Approximately 90% responders rated VTB and EC very to extremely helpful. Conclusions: We conclude that a system-based VTB and EC can provide an excellent platform for improving quality of care and physician confidence in managing patients with bone and soft tissue sarcoma in an integrated healthcare system.

Threaded cup acetabuloplasty. Early clinical experience

Loosening of the acetabular cup component in total hip arthroplasty (THA) remains a source of ongoing concern. Threaded cup acetabuloplasty (TCA) utilizes torque and compression to gain purchase of the acetabular cup into the bony margin of the acetabulum. In an earlier study of 121 patients who had THA with TCA, patient assessments and roentgenograms were examined at an average of 30 months after surgery. Twenty percent of the cases were carried out for failed arthroplasty and 20% of the procedures required bone-graft reconstruction. A 22% incidence of moderate to severe postoperative pain, a 3% incidence of cup dislodgement, and a 24% incidence of radiolucencies between 1-2 mm were observed. The four cup dislodgements occurred in patients with severe osteopenia or in those requiring extensive bone-graft acetabular reconstruction. Good clinical results were obtained for osteoarthritic patients treated with primary THA. These early findings suggest that there is no advantage, but there are possible disadvantages, to threaded cup acetabuloplasty when compared to cup fixation with cement.

Osteomyelitis of the sacrum as the initial manifestation of Crohn's disease

A 17-year-old boy had low back pain for four months prior to the development of sacral osteomyelitis, which led to the initial diagnosis of Crohn's disease. Musculoskeletal problems occur in about one-third of the patients with Crohn's disease. Only a few patients with osteomyelitis complicating Crohn's disease have been reported. This case is rare because he had had no gastrointestinal symptoms. This patient illustrates the point that musculoskeletal signs and symptoms, including osteomyelitis, may prove to be a manifestation of gastrointestinal tract disease.

Knee arthrodesis for failed total knee arthroplasty

The use of arthrodesis to salvage failed total knee arthroplasty is reviewed in nine patients. Prosthetic failure was due to infection in six cases, aseptic loosening in two cases, and instability in one case. The techniques of arthrodesis included six Hoffman external fixators, two fluted intramedullary rods (3M-Orthopedic Products Division, St Paul), and one pulsing electromagnetic field stimulator. Arthrodesis was successful in eight of nine patients, averaging 5.4 months to union. All eight patients resumed a painfree functional level of activity. Meticulous surgical technique and appropriate method of arthrodesis are emphasized.

Femoral neck fractures in the geriatric population: the influence of perioperative health upon the selection of surgical treatment

The use of a primary prosthetic replacement such as an Austin-Moore hemi-arthroplasty in patients sustaining fractures of the femoral neck has been associated with increased post-operative medical morbidity and mortality. A retrospective review was performed using the medical records of patients greater than 59 years of age who sustained femoral neck fractures and were treated with either internal fixation or primary hemi-arthroplastic replacement at Loyola University Medical Center between 1969 and 1979. Peri-operative data were reviewed and evaluated using computer-aided statistical analysis. Comparing the two forms of surgical treatment, statistically significant factors associated with primary hemi-arthroplastic replacement included: pre-injury nursing home residence, pre-injury ambulation requiring assistance, age greater than 79 years, slight elevation in serum creatinine values, abnormal electrocardiograms in patients over 77 years of age, time from injury to surgery of four or more days, and the use of spinal anesthesia (P less than 0.05). Factors associated with internal fixation were: patient age of 79 years or less, independent ambulation, non-nursing home residence, normal lab values, normal EKGs, less than four days from injury to surgery, and the use of general anesthesia. Within the limits imposed by a retrospective review in this specific patient population, there appears to be a tendency for older, less healthy patients to have been treated with primary hemi-arthroplasty. Possibly the previously reported increased post-operative medical morbidity and mortality associated with this procedure, as compared with internal fixation, may be a result of biased patient selection, and not a fault of the procedure.

Total hip replacement in patients with renal transplants

In a retrospective study of total hip replacement (THR) arthroplasty in patients with renal transplants, femoral head avascular necrosis (AVN) was found in 19 of 138 (15%) patients. Nine THRs in eight of these 19 patients (average age, 47 years) were studied. Preoperatively, all patients had hip pain due to AVN and a history of long-term treatment with systemic corticosteroids. Six of the eight patients had been treated with parenteral pulsed steroids on three occasions, and the other two patients on one occasion, for rejection episodes. All patients showed some degree of femoral head collapse roentgenographically. There were no major surgical complications. All patients had markedly improved functional capacities and relief of pain. With follow-up averaging three years, there has been no evidence of component loosening.

Factitial synovitis

This unusual case of trauma depicts a 17-year-old female who had a history of chronic synovitis of her left knee for several months. The patient demonstrated persistent knee effusion despite treatment of several physicians. Failure of the left knee to respond to several surgical procedures, as well as the finding of numerous foreign bodies not present previously, evoked a high index of suspicion leading to the diagnosis of factitial synovitis. The paper further defines the entity, describes the personalities involved and the numerous methods used to inflict trauma. Lastly, the treatment regime is given.

Indium Telluride (II′): Transitory Intermediate Phase in the Transformation InTe(II) to InTe(I)

The high-pressure cubic metallic form of indium telluride, InTe(II), transforms at 1 atmosphere to a new transitory polymorph, designated InTe(II'), which, in turn, transforms to the stable tetragonal polymorph InTe(I). The new polymorph is apparently tetragonal with unit-cell dimensions a(0) = 6.06 A, c(0) = 6.55 A. The transformation rates of InTe(II) to InTe(II') and of InTe(II') to InTe(I) are dependent on both time and temperature; the former is very rapid above 60 degrees C and the latter is very rapid above 125 degrees C.

High-Pressure Metallic Indium Telluride: Preparation and Crystal Structure

The metallic high-pressure form of indium telluride may be prepared under high pressure at 150 degrees C and retained at ambient conditions without low-temperature quenching. It has the NaCl (type B1) structure with a cell edge of 6.160 +/- .005 A and a calculated density of 6.887 g/cm(2). The density increase relative to the low-pressure polymorph is 15.6 percent.

High-Pressure Synthesis of Molybdates with the Wolframite Structure

A series of small cation molybdates, MgMoO(4), MnMoO(4), FeMoO(4), CoMoO(4), NiMoO(4), and ZnMoO(4) with the wolframite structure characteristic of the corresponding tungstates have been synthesized at high pressure and temperature. The high-pressure compounds revert to the ambient pressure modifications if heated in air at 600 degrees C.

Relation of Infrared Spectra to Coordination in Quartz and Two High-Pressure Polymorphs of SiO 2

Infrared spectra of the four-coordinated quartz and coesite polymorphs of SiO(2), the rutile six-coordinated (stishovite) polymorph of SiO(2), and the quartz and rutile polymorphs of GeO(2) show that a change from tetrahedral to octahedral cation coordination results in (i) a 23-per-cent increase in the wavelength of the main absorption band for both the SiO(2) and GeO(2) polymorphs and (ii) a significant increase in the force constant of the same magnitude for the SiO(2) and GeO(2) polymorphs. The quartz and the rutile isostructural pairs for SiO(2) and GeO(2) show that the effect of increasing mass is to increase proportionally the wavelength of the respective main absorption bands. The infrared data for the rutile form of SiO(2) fit the empirical equation of Dachille and Roy relating cation coordination, mass, atomic number, valence, and main absorption wavelength.