Paracentesis for cancer-related ascites in palliative care: An international, prospective cohort study

BACKGROUND

Paracentesis is commonly undertaken in patients with cancer-related ascites.

AIM

To systematically investigate the symptomatic benefits and harms experienced by patients with cancer undergoing paracentesis using real-world data in the palliative care setting.

DESIGN

Prospective, multisite, observational, consecutive cohort study. Benefits and harms of paracentesis were assessed between 01/07/2018 and 31/02/2021 as part of routine clinical assessments by treating clinicians at four timepoints: (T0) before paracentesis; (T1) once drainage ceased; (T2) 24 h after T1 and (T3) 28 days after T1 or next paracentesis, if sooner.

SETTING/PARTICIPANTS

Data were collected from 11 participating sites across five countries (Australia, England, Hong Kong, Malaysia and New Zealand) on 111 patients undergoing paracentesis via a temporary (73%) or indwelling (21%) catheter: 51% male, median age 69 years, Australia-modified Karnofsky Performance Score 50.

RESULTS

At T1 (n = 100), symptoms had improved for most patients (81%), specifically abdominal distension (61%), abdominal pain (49%) and nausea (27%), with two-thirds experiencing improvement in ⩾2 symptoms. In the remaining patients, symptoms were unchanged (7%) or worse (12%). At least one harm occurred in 32% of patients, the most common being an ascitic leak (n = 14). By T3, 89% of patients had experienced some benefit and 36% some harm, including four patients who experienced serious harm, one of which was a fatal bowel perforation.

CONCLUSION

Most patients obtained rapid benefits from paracentesis. Harms were less frequent and generally mild, but occasionally serious and fatal. Our findings help inform clinician-patient discussions about the potential outcomes of paracentesis in this frail population.

Informational needs and the quality of life of patients in their first year after metastatic breast cancer diagnosis

BACKGROUND

Little is known about the informational needs and quality of life (QOL) of patients with metastatic breast cancer (MBC) within the first year of their diagnosis.

OBJECTIVES

To describe the informational needs and QOL of patients with MBC within the first year of diagnosis, and to identify sociodemographic and medical factors that may be associated with informational needs and QOL.

METHODS

52 patients (50 women, 2 men) enrolled within a year of diagnosis of MBC completed a cross-sectional, self-administered paper survey that included patient demographics, the Toronto Informational Needs Questionnaire-Breast Cancer (TINQ), the Hospital Anxiety and Depression Scale (HADS), and Medical Outcomes Study Short Form-36 (SF-36). High informational need was defined as a TINQ score of ≥ 200.

RESULTS

Of the total 52 patients, 69% (35/52) had high informational needs, 20% met the criteria for anxiety (HADS-Anxiety score, ≥ 11), and 8% met the criteria for depression. SF-36 scores were lower in all 8 subscales compared with the general population. Multivariate analyses showed that patients who were married or living as married (OR, 6.1; 95% CI, 1.4-28.9) and patients with de novo MBC (OR, 2.8; 95% CI, 0.5-14.3) or a shorter disease-free interval (DFI; < 5 years; OR, 24.2; 95% CI, 3.1-187.4) were more likely to have more informational needs (C statistic, 0.824) than were patients with a longer DFI (≥ 5 years).

LIMITATIONS

This is a small cross-sectional study of a single academic institution.

CONCLUSIONS

Patients with recently diagnosed MBC have high informational needs and decreased overall QOL. Additional research and supportive services meeting the informational and psychosocial needs of patients living with MBC are warranted.

Attitudes of patients with metastatic breast cancer toward research biopsies

BACKGROUND

Research studies involving human tissue are increasingly common. However, patients' attitudes toward research biopsies are not well characterized, particularly when the biopsies are carried out outside the context of therapeutic trials.

PATIENTS AND METHODS

One hundred sixty patients with metastatic breast cancer (MBC) from two academic (n = 80) and two community (n = 80) hospitals completed a 29-item self-administered survey to evaluate their willingness to consider providing research purposes only biopsies (RPOBs) (as a stand-alone procedure) and additional biopsies (ABs) (additional needle passes at the time of a clinically indicated biopsy).

RESULTS

Eighty-two (51%) of 160 patients would consider having RPOBs, of which 42 (53%) and 40 (50%) patients were from academic and community hospitals, respectively. Patients who had more prior biopsies were less likely to consider RPOBs (RR = 0.6, 95% CI: 0.4-1.0, P = 0.03). Of 160 patients, 115 (72%) patients would consider having ABs. Of these, 64 (80%) and 51 (64%) patients from academic and community hospitals, respectively, would consider ABs (RR = 1.2, 95% CI: 1.0-1.5, P = 0.03).

CONCLUSIONS

Many patients with MBC in both academic and community settings report willingness to consider undergoing biopsies for research. Further research is needed to understand ethical, logistical and provider-based barriers to broader participation in such studies.

A phase II study of bevacizumab in combination with vinorelbine and trastuzumab in HER2-positive metastatic breast cancer

We aimed to evaluate the efficacy and feasibility of combining trastuzumab/vinorelbine with bevacizumab in patients with first-or second-line HER2-positive, metastatic breast cancer (MBC). Eligible patients had HER2-positive measureable MBC, with no more than one prior line of chemotherapy, and were treated with trastuzumab (4 mg/kg × 2 mg/kg weekly thereafter), vinorelbine (25 mg/m(2) weekly), and bevacizumab (10 mg/kg every 2 weeks). Co-primary endpoints were (a) the proportion of patients alive and progression-free at 1 year and (b) safety profile/feasibility. Feasibility was defined as a rate of grade 3/4 non-hematologic toxicity attributable to protocol-based therapy <20 %. Twenty-nine patients were enrolled (n = 22 first-line, n = 7 second-line). Median age was 48 years (range 37-68). The median number of cycles received was 8 (1-23) and median duration on treatment was 7.4 months (range 1-22). The study was closed early due to higher-than-expected rates of grade 3/4 non-hematologic toxicities, with 50 events in 20 patients. A total of six patients (21 %) were taken off study for treatment-related toxicity. Most common treatment-related toxicities included fatigue (n = 7), febrile neutropenia (n = 4), and headache (n = 3). At 1 year, 8/22 first-line (36 %) and 2/7 second-line (29 %) patients were alive and progression-free. Median PFS was 9.9 months and 7.8 months in the first- and second-line cohorts, respectively. Objective responses were observed in 16/22 (73 %) and 5/7 (71 %) patients in the first- and second-line settings. Although the combination of vinorelbine, trastuzumab, and bevacizumab showed notable activity in HER2-positive MBC, the proportion of first-line patients alive and progression-free at 1 year was deemed unlikely to reach the pre-defined threshold for declaring success. Additionally, unacceptable toxicity was observed, at rates greater than previously reported with vinorelbine/trastuzumab or vinorelbine/bevacizumab doublet combinations.

Abstract P2-16-04: Attitudes of metastatic breast cancer patients towards research biopsies

Background: In the era of molecularly targeted therapy, developing an understanding of the molecular basis of cancer is a principal or secondary goal of many research studies. For this reason, studies collecting tissue for research purposes are increasingly common. Understanding patients' attitudes towards research biopsies may lead to improvement in accrual to research biopsy studies.

Methods: Patients with metastatic breast cancer from two academic and two community hospitals completed a self-administered paper survey consisting of 29 questions in clinic to evaluate their willingness to consider providing additional biopsies (additional biopsy performed with a clinically indicated biopsy) and research purposes only biopsies (RPOB) (research biopsy performed as a stand alone procedure).

Results: 160 patients (n = 80 academic, n=80 community) completed the survey, with a response rate of 98%. As expected, demographic variables differed between sites, with patients from academic sites likely to be younger (p = 0.01), more educated (p = 0.002), employed (p = 0.01), have prior trial participation (P &lt;0.001) and have a longer travel time (P &lt;0.0001). 64 (80%) academic patients and 51 (64%) community patients would definitely or probably consider additional biopsies. 42 (53%) academic patients and 40 (50%) community patients would consider RPOB.

In univariate analyses of patients' willingness to have additional biopsies, patients in academic sites were more likely to agree to additional biopsies than those at community sites (RR = 1.2, 95% CI 1.0–1.5, p = 0.03). Statistically significant differences based on demographic characteristics such as age, education, marital status, prior trial participation, number of prior biopsies, and travel time were not observed.

For RPOB, patients having had more prior biopsies were less likely to consider research biopsies (RR = 0.6, 95% CI 0.4–1.0, p = 0.03). The following variables did not reach statistical significance: type of practice, age, education, marital status, prior trial participation, and travel time.

Patients' willingness in both academic and community sites to consider RPOB declined with more invasive biopsies. Although differences were observed, none were statistically significant between academic and community; skin (56%, 65%), bone marrow (30%, 27%), breast (43%, 49%) or liver (24%, 19%).

Of the 13/160 (8%) patients who would not consider additional biopsies, the most common reasons cited included pain or discomfort (n = 8/13, 62%), risk of biopsy (n = 8/13, 62%) and anxiety related to the biopsy (n = 6/13, 46%). Of the 37/160 (23%) patients who would not consider RPOB, the most common reasons cited included pain or discomfort (n = 23/37, 62%), risk of biopsy (n = 15/37, 41%) and inconvenience of the procedure to the patient (n = 13/37, 35%).

Conclusions: The majority of patients in this study indicated they would consider research biopsies, with a larger proportion willing to consider additional biopsies; patients seen at academic hospitals were more likely to consider additional biopsies compared to those seen at community hospitals. Breast cancer patients' willingness to undergo research biopsies may be higher than generally expected by clinicians and may not be the primary barrier to obtaining research biopsies.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-16-04.

Abstract P6-08-03: Informational needs and psychosocial assessment of patients in their first year after metastatic breast cancer diagnosis

Background: Psychosocial distress is common after a diagnosis of breast cancer. Little is known about the informational needs and the psychosocial adjustment of patients diagnosed with metastatic breast cancer (MBC) within the first year of their diagnosis.

Methods: Patients with MBC from a single academic institution completed a cross-sectional self-administered paper survey. The survey included demographics, the Medical Outcomes Study Short Form-36 (SF-36), the Hospital Anxiety and Depression Scale (HADS), and Toronto Informational Needs Questionnaire-Breast Cancer (TINQ). Medical history was obtained by chart review. The Spearman correlation coefficient assessed the relationship between TINQ and the following: age at MBC diagnosis, disease free interval (DFI), time between survey completion and MBC diagnosis, number of lines of therapy, and HADS.

Results: Fifty-two (90%, 50F 2M) patients completed the survey. Median age at MBC diagnosis was 52 yrs (range 22–81). Thirty-nine (75%) patients had completed college, 92% were Caucasian. Median time between MBC diagnosis and survey completion was 6 months (range 1–12). Sixteen (31%) patients had de novo stage 4 disease. At time of survey completion, 36 (69%) patients were on 1st line therapy with some patients were receiving their 4th line of therapy. SF-36 scores were lower in all 8 subscales compared to the general population. In particular, role limitations due to physical health (Norm-based transformation mean score 39.3, SD=12.1), social functioning (Mean 41.8, SD=12.7), role limitations due to emotional problems (Mean 43.3, SD=13.3), vitality (Mean 44.1, SD=10.8) and general health (Mean 44.3, SD=12.1) were diminished. The Physical and Mental Component Summary norm-based transformation scores were 43.2 (SD = 11.7) and 45.4 (SD = 11.3) respectively.9/48 (19%) patients met criteria for anxiety, and 4/48 (8%) patients met criteria for depression by HADS criteria (scores &gt; 11). TINQ scores range from 51 to 255, with 35/52 (69%) having a total score &gt; 200, suggesting high informational need. Of the 5 subscales, treatment information was most important, followed by information about disease, physical care, psychosocial needs and investigative tests. The most important informational issues for patients were: if there was cancer anywhere else in their body (Mean score 4.78), how to deal with side effects (Score 4.78), and if there were ways to prevent treatment side effects (Score 4.77), with a score of 5=extremely important, and 1= not important.

Only DFI correlated with TINQ (Spearman coefficient −0.413, p = 0.011), with patients who had a shorter DFI having greater informational needs. Age at MBC diagnosis, time of completion of survey, number of lines and HADS were not significant.

Conclusion: Based on this study, patients with recently diagnosed MBC have high informational needs and poor psychosocial adjustment. The overall quality of life appears to be worse in this population of patients compared to the general population. There is also a subset of patients who are dealing with significant anxiety and depression. Additional research, education, and supportive care services aimed at meeting the informational and psychosocial needs of women living with MBC are warranted.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-08-03.