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Oraiqat A, Nardella N, Berhan D, Lu D, Goodchild S, Gruchow T, Chang Y, Rajasekhara S, Hodul P. HSR24-167: Improved Access Through an Integrated Supportive Care Model Reduced Urgent Care Referral and Admission Rates for Patients With Gastrointestinal Malignancy. J Natl Compr Canc Netw 2024; 22:HSR24-167. [PMID: 38579809 DOI: 10.6004/jnccn.2023.7225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
| | | | | | - Denny Lu
- 3Harvard University, Cambridge, MA
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Berhan D, Nardella N, Oraiqat A, Lu D, Goodchild S, Gruchow T, Chang Y, Rajasekhara S, Hodul P. HSR24-166: Implementation of an Integrated Supportive Care Medicine Consultation Service Within a Gastrointestinal Cancer Clinic: Timeliness of Referrals and Patient Access. J Natl Compr Canc Netw 2024; 22:HSR24-166. [PMID: 38580275 DOI: 10.6004/jnccn.2023.7130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
| | | | | | - Denny Lu
- 3Harvard University, Cambridge, MA
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Turner K, Kim DW, Gonzalez BD, Gore LR, Gurd E, Milano J, Riccardi D, Byrne M, Al-Jumayli M, de Castria TB, Laber DA, Hoffe S, Costello J, Robinson E, Chadha JS, Rajasekhara S, Hume E, Hagen R, Nguyen OT, Nardella N, Parker N, Carson TL, Tabriz AA, Hodul P. Support Through Remote Observation and Nutrition Guidance (STRONG), a digital health intervention to reduce malnutrition among pancreatic cancer patients: A study protocol for a pilot randomized controlled trial. Contemp Clin Trials Commun 2024; 38:101271. [PMID: 38440777 PMCID: PMC10910065 DOI: 10.1016/j.conctc.2024.101271] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 01/19/2024] [Accepted: 02/13/2024] [Indexed: 03/06/2024] Open
Abstract
Background Malnutrition is a common and distressing condition among pancreatic cancer patients. Fewer than a quarter of pancreatic cancer patients receive medical nutrition therapy (MNT), important for improving nutritional status, weight maintenance, quality of life and survival. System, provider, and patient level barriers limit access to MNT. We propose to examine the feasibility of a 12-week multi-level, digital health intervention designed to expand MNT access among pancreatic cancer patients. Methods Individuals with advanced pancreatic cancer starting chemotherapy (N = 80) will be 1:1 randomized to the intervention or usual care. The Support Through Remote Observation and Nutrition Guidance (STRONG) intervention includes system-level (e.g., routine malnutrition and screening), provider-level (e.g., dietitian training and web-based dashboard), and patient-level strategies (e.g., individualized nutrition plan, self-monitoring of dietary intake via Fitbit, ongoing goal monitoring and feedback). Individuals receiving usual care will be referred to dietitians based on their oncologists' discretion. Study assessments will be completed at baseline, 4-, 8-, 12-, and 16-weeks. Results Primary outcomes will be feasibility (e.g., recruitment, retention, assessment completion) and acceptability. We will collect additional implementation outcomes, such as intervention adherence, perceived usability, and feedback on intervention quality via an exit interview. We will collect preliminary data on outcomes that may be associated with the intervention including malnutrition, quality of life, treatment outcomes, and survival. Conclusion This study will advance our knowledge on the feasibility of a digital health intervention to reduce malnutrition among individuals with advanced pancreatic cancer. Trial registration: NCT05675059, registered on December 9, 2022.
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Affiliation(s)
- Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, USA
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
| | - Dae Won Kim
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
| | - Brian D. Gonzalez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
| | - Laurence R. Gore
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, USA
| | - Erin Gurd
- Department of Nutrition Therapy, Moffitt Cancer Center, USA
| | - Jeanine Milano
- Department of Nutrition Therapy, Moffitt Cancer Center, USA
| | - Diane Riccardi
- Department of Nutrition Therapy, Moffitt Cancer Center, USA
| | - Margaret Byrne
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
| | | | - Tiago Biachi de Castria
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
| | - Damian A. Laber
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, USA
| | - James Costello
- Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, USA
| | - Edmondo Robinson
- Department of Oncological Sciences, University of South Florida, USA
- Department of Internal and Hospital Medicine, Moffitt Cancer Center, USA
- Center for Digital Health, Moffitt Cancer Center, USA
| | | | | | - Emma Hume
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, USA
| | - Ryan Hagen
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, USA
| | - Oliver T. Nguyen
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, USA
| | - Nicole Nardella
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, USA
| | - Nathan Parker
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, USA
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
| | - Tiffany L. Carson
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, USA
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, USA
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
| | - Pamela Hodul
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, USA
- Department of Oncological Sciences, University of South Florida, USA
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Mosley SA, Cicali E, Del Cueto A, Portman DG, Donovan KA, Gong Y, Langaee T, Gopalan P, Schmit J, Starr JS, Silver N, Chang YD, Rajasekhara S, Smith JE, Soares HP, Clare-Salzler M, Starostik P, George TJ, McLeod HL, Fillingim RB, Hicks JK, Cavallari LH. CYP2D6-guided opioid therapy for adults with cancer pain: A randomized implementation clinical trial. Pharmacotherapy 2023; 43:1286-1296. [PMID: 37698371 PMCID: PMC10840965 DOI: 10.1002/phar.2875] [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: 04/05/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION The CYP2D6 enzyme metabolizes opioids commonly prescribed for cancer-related pain, and CYP2D6 polymorphisms may contribute to variability in opioid response. We evaluated the feasibility of implementing CYP2D6-guided opioid prescribing for patients with cancer and reported pilot outcome data. METHODS Adult patients from two cancer centers were prospectively enrolled into a hybrid implementation-effectiveness clinical trial and randomized to CYP2D6-genotype-guided opioid selection, with clinical recommendations, or usual care. Implementation metrics, including provider response, medication changes consistent with recommendations, and patient-reported pain and symptom scores at baseline and up to 8 weeks, were assessed. RESULTS Most (87/114, 76%) patients approached for the study agreed to participate. Of 85 patients randomized, 71% were prescribed oxycodone at baseline. The median (range) time to receive CYP2D6 test results was 10 (3-37) days; 24% of patients had physicians acknowledge genotype results in a clinic note. Among patients with CYP2D6-genotype-guided recommendations to change therapy (n = 11), 18% had a change congruent with recommendations. Among patients who completed baseline and follow-up questionnaires (n = 48), there was no difference in change in mean composite pain score (-1.01 ± 2.1 vs. -0.41 ± 2.5; p = 0.19) or symptom severity at last follow-up (3.96 ± 2.18 vs. 3.47 ± 1.78; p = 0.63) between the usual care arm (n = 26) and genotype-guided arm (n = 22), respectively. CONCLUSION Our study revealed high acceptance of pharmacogenetic testing as part of a clinical trial among patients with cancer pain. However, provider response to genotype-guided recommendations was low, impacting assessment of pain-related outcomes. Addressing barriers to utility of pharmacogenetics results and clinical recommendations will be critical for implementation success.
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Affiliation(s)
- Scott A Mosley
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
- Department of Clinical Pharmacy, University of Southern California, Los Angeles, California, USA
| | - Emily Cicali
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Alex Del Cueto
- Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Diane G Portman
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Kristine A Donovan
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Priya Gopalan
- Division of Hematology and Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jessica Schmit
- Division of Hematology and Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jason S Starr
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Natalie Silver
- Department of Otolaryngology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Young D Chang
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Sahana Rajasekhara
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Joshua E Smith
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Heloisa P Soares
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael Clare-Salzler
- Department of Pathology, Immunology & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Petr Starostik
- Department of Pathology, Immunology & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Thomas J George
- Division of Hematology and Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Roger B Fillingim
- Department of Community Dentistry and Behavioral Science, College of Dentistry, Gainesville, Florida, USA
- Clinical and Translational Science Institute, University of Florida, Gainesville, Florida, USA
| | - J Kevin Hicks
- Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
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Marshall VK, Chavez M, Efre A, Lake PW, Rigg KK, Lubrano B, Pabbathi S, Rajasekhara S, Tyson DM. Barriers to Adequate Pain Control and Opioid Use Among Cancer Survivors: Implications for Nursing Practice. Cancer Nurs 2023; 46:386-393. [PMID: 37607374 PMCID: PMC10232667 DOI: 10.1097/ncc.0000000000001126] [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] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cancer survivors can experience long-term negative effects from cancer and its treatment. Pain is one of the most common and distressing symptoms that cancer survivors experience. Opioids are often prescribed for pain; however, cancer survivors who have completed active treatment may have unique challenges with regard to pain management. OBJECTIVE The aim of this study was to explore barriers to pain management and perceptions of opioid use among cancer survivors. METHODS This research was an exploratory pilot study using in-depth qualitative interviews with adult cancer survivors who were recruited from community-based survivorship organizations. Data were analyzed using applied thematic analysis techniques. RESULTS Participants (n = 25) were mostly women (96%), diagnosed with breast cancer (88%) and stages I to III disease (84%), with a mean age of 56.2 years. Three themes on barriers to adequate pain control emerged: (1) taking just enough to take the edge off: self-medicating behaviors and nonadherence to prescribed regimen; (2) lack of insurance coverage and costly alternative pain treatment options; and (3) chronicity of cancer-related pain not adequately addressed and often mismanaged. CONCLUSIONS Discussions with cancer survivors unveiled personal accounts of unmanaged pain resulting from limited pain management/opioid education, fear of opioid addiction, negative perceptions/experiences with opioids, lack of insurance coverage for alternative pain therapies, and regulatory policies limiting access to opioids. IMPLICATIONS FOR PRACTICE There is a clear need for improved access to multimodal pain management options and nonopioid alternatives for cancer survivors. Oncology nurses should endeavor to support policies and procedures aimed at opioid education, training, and legislation.
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Affiliation(s)
- Victoria Kate Marshall
- Author Affiliations: Colleges of Nursing (Drs Marshall and Efre) and Public Health (Mss Chavez and Lake and Dr Tyson) and Department of Mental Health Law and Policy, College of Behavioral and Community Science (Dr Rigg), University of South Florida; and Moffitt Cancer Center (Drs Lubrano, Pabbathi, and Rajasekhara), Tampa, Florida
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Loggers ET, Case AA, Chwistek M, Dale W, Delgado Guay MO, Edge SB, Grossman SR, Gustin J, Nelson J, Rajasekhara S, Reddy A, Tulsky JA, Zachariah F, Landrum KM. ADCC's Improving Goal Concordant Care Initiative: Implementing Primary Palliative Care Principles. J Pain Symptom Manage 2023; 66:e283-e297. [PMID: 37257523 DOI: 10.1016/j.jpainsymman.2023.05.008] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND High-quality, timely goals of care communication (GOCC) may improve patient and caregiver outcomes and promote care that is consistent with patient preferences. PROBLEM Cancer patients, and their loved ones, appreciate GOCC; however, oncologists often lack formal communication training, institutional support and structures necessary to promote the delivery, documentation, and longitudinal follow-up of GOCC. PROPOSED SOLUTION The Alliance of Dedicated Cancer Centers (ADCC), representing 10 U.S. academic cancer hospitals, undertook the Improving Goal Concordant Care Initiative (IGCC). This national, 3-year implementation initiative was designed in Fall 2019 by a workgroup of quality, oncology, and palliative care leaders, as well as patient and family advisory committee members (PFAC). IGCC addresses systemic gaps by requiring four core components for participation: 1) Implementation of a formal communication skills training (CST) program, 2) Structured GOCC documentation in the electronic medical record that is visible to all clinicians, 3) Expectations regarding the timing and patient populations for GOCC, and 4) Implementation of a measurement framework. METHOD Dyads of palliative and oncology leaders committed to attend regularly scheduled, ADCC-led, virtual meetings during the design and implementation phase, incorporating PFAC feedback at every stage. Using the RE-AIM framework, we describe process and outcome evaluation measures defined by implementation and measures workgroups and collected routinely, including: CST completion; trainee evaluation response rate, trainee-reported quality of CST, trainee changes in self-efficacy and distress; percent of high-priority patients participating in GOCC, and patient-reported response to the "Heard and Understood" scale (HU). IGCC's impact will be assessed using claims-based utilization metrics near the end of life (EOLM) and followed longitudinally. Qualitative evaluations near the completion of IGCC will provide insight into perceived barriers, enabling factors, and sustainability. OUTCOMES Implementation of all IGCC components has begun at all sites. ADCC-wide, 35% of MD/DOs have completed CST (range by site: 8%-100%). CST is highly rated; in Quarter 3, 2022, 93%-100%, 90%-100% and 87%-100% of respondents reported above average to excellent CST quality, likelihood to use the skills and likelihood to recommend CST to others, respectively. Clinician self-efficacy and distress ratings are expected in late 2023. All sites have identified patient populations and continue to refine automated triggers and timelines; uptake of GOCC documentation has been slow. Eight of 10 sites have submitted patient-reported HU data. EOLM data are expected for all sites in early 2024. LESSONS LEARNED Flexibility in implementation with shared definitions, measures, and learnings about approaches optimizes the ability of all centers to collaborate and make progress in improving GOCC. Flexibility adds to the complexity of understanding intervention effectiveness, the critical intervention components and the fidelity necessary to achieve specific outcomes.
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Affiliation(s)
- Elizabeth T Loggers
- Clinical Research Division, Fred Hutchinson Cancer Center, Division of Oncology (E.T.L.), University of Washington, Seattle, WA, USA.
| | - Amy A Case
- Roswell Park Comprehensive Cancer Center, Chair Dept Supportive & Palliative Care (A.A.C.), Buffalo, NY, USA
| | - Marcin Chwistek
- Supportive Oncology and Palliative Care Program (M.C.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA
| | - William Dale
- Supportive Care Medicine (W.D.), City of Hope, Duarte, CA, USA
| | - Marvin O Delgado Guay
- Department of Palliative, Rehabilitation, and Integrative Medicine (M.O.D.), The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen B Edge
- VP System Quality and Outcome, Roswell Park Comprehensive Cancer Center (S.B.E.), Buffalo, NY, USA
| | - Steven R Grossman
- USC Norris Comprehensive Cancer Center (S.R.G.), University of Southern California, Los Angeles, CA, USA
| | - Jillian Gustin
- Division of Palliative Medicine (J.G.), The Ohio State University Comprehensive Cancer Caner-Arthur G James Cancer Hospital, Columbus, OH, USA
| | - Judith Nelson
- Memorial Sloan Kettering Cancer Center (J.N.), New York, NY, USA
| | | | | | - James A Tulsky
- Poorvu Jaffe Chair, Psychosocial Oncology and Palliative Care (J.A.T.), Dana-Farber Cancer Institute
| | - Finly Zachariah
- Informatics & Value-Based Supportive Care (F.Z.), City of Hope, CA, USA
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Marshall VK, Chavez MN, Rigg KK, Lubrano di Ciccone B, Rajasekhara S, Efre A, Martinez Tyson D. Framing Cancer Survivors' Access to and Use and Disposal of Prescribed Opioids Within the Opioid Epidemic. Oncol Nurs Forum 2022; 50:25-34. [PMID: 37677788 DOI: 10.1188/23.onf.25-34] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE To explore cancer survivors' access to and use and disposal of opioids in the context of the opioid epidemic. PARTICIPANTS & SETTING Community-based recruitment strategies were employed for individuals aged 18 years or older who were previously diagnosed with cancer, completed cancer treatment within the past five years, or were cancer free, and who were prescribed opioids for cancer-related pain. METHODOLOGIC APPROACH This qualitative study used semistructured interviews. Data were analyzed using applied thematic analysis techniques. FINDINGS Themes included the following: (a) restrictive policies affecting opioid access and supply, (b) decreased opioid use because of concerns of addiction and other opioid-related side effects, and (c) lack of clarity on safeguarding and disposal of opioids. IMPLICATIONS FOR NURSING Cancer survivors may encounter barriers to opioid access, alter medication-taking behavior over fear of addiction and side effects, and face inadequate education regarding proper disposal of opioids. Nurses can advocate for appropriate access to prescribed opioids, assess opioid-taking behavior, provide education regarding storage and disposal, and implement educational interventions accordingly.
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Chavez MN, Tyson DM, Lake PW, Gutierrez A, Sherry P, Rigg KK, Marshall V, Henderson H, Rajasekhara S, Pabbathi S, Lubrano B. 'They say you can get addicted': Exploring factors that fuel the fear of addiction to prescription opioids among cancer survivors. Eur J Cancer Care (Engl) 2022; 31:e13582. [PMID: 35354227 DOI: 10.1111/ecc.13582] [Citation(s) in RCA: 1] [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: 07/09/2021] [Revised: 12/21/2021] [Accepted: 03/02/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To explore misconceptions regarding addiction potential of prescription opioids among cancer survivors. METHODS A qualitative study using semi-structured interviews were conducted with a purposive sample of cancer survivors (N = 25) treated with prescription opioids for pain management. Interviews were audio recorded, transcribed and coded using Atlas.ti version 8. Inductive applied thematic analysis techniques were employed to identify emergent themes. RESULTS The majority of participants were breast cancer survivors (88%) who underwent a combination of surgery, chemotherapy and radiation (72%). Thematic analysis revealed that (1) cancer survivors view opioids as an illicit drug, (2) media narrative of the opioid epidemic increased negative perception of opioid use for cancer-related pain, (3) perceptions of opioids were also informed by experiences of friends and family with an opioid use disorder, (4) poor understanding of terminology resulted in misconceptions of opioid use and addiction and (5) fear of opioid addiction resulted in unrelieved cancer pain and poor quality of life. CONCLUSION Our findings support previously identified concerns among cancer patients about fear of addiction to opioids, a barrier to effective pain management. It highlights the importance for health care providers caring for cancer survivors to continue to address misconceptions about prescribed opioids.
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Affiliation(s)
- Melody N Chavez
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | | | - Paige W Lake
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Ana Gutierrez
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | | | - Khary K Rigg
- Department of Mental Health Law and Policy, University of South Florida, Tampa, Florida, USA
| | - Victoria Marshall
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Heather Henderson
- Department of Anthropology, University of South Florida, Tampa, Florida, USA
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Tyson DM, Chavez MN, Lubrano B, Lake P, Gutierrez A, Marshall VK, Rigg KK, Henderson H, Pabbathi S, Sherry P, Rajasekhara S. Correction to: Understanding Cancer Survivors' Educational Needs about Prescription Opioid Medications: Implications for Cancer Education and Health Literacy. J Cancer Educ 2021; 36:893. [PMID: 34143414 DOI: 10.1007/s13187-021-02009-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Dinorah Martinez Tyson
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA.
| | - Melody N Chavez
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA
| | - Barbara Lubrano
- Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Paige Lake
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA
| | - Ana Gutierrez
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA
| | - Victoria K Marshall
- College of Nursing, University of South Florida, 12912 Bruce B. Downs, MDC 22, Tampa, FL, 33612, USA
| | - Khary K Rigg
- Department of Mental Health Law and Policy, University of South Florida, 13301 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - Heather Henderson
- Department of Anthropology, University of South Florida, 4202 E. Fowler Ave. SOC 107, Tampa, FL, 33620, USA
| | - Smitha Pabbathi
- Faces of Courage, 10006 Cross Creek Blvd #519, Tampa, FL, 33647-2595, USA
| | - Peggie Sherry
- Faces of Courage, 10006 Cross Creek Blvd #519, Tampa, FL, 33647-2595, USA
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Tyson DM, Chavez MN, Lubrano B, Lake P, Gutierrez A, Marshall VK, Rigg KK, Henderson H, Pabbathi S, Sherry P, Rajasekhara S. Understanding Cancer Survivors' Educational Needs About Prescription Opioid Medications: Implications for Cancer Education and Health Literacy. J Cancer Educ 2021; 36:215-224. [PMID: 33428119 DOI: 10.1007/s13187-021-01957-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 01/03/2021] [Indexed: 05/05/2023]
Abstract
Cancer survivors' perceptions of prescription opioid medication (POM) and the health communications they receive about POM's safety and effectiveness are embedded within the national discourse of the opioid epidemic. Using qualitative methods, this community-based study explored the health communication and the educational needs of diverse cancer survivors who received opioid agonist treatment to manage cancer pain. Our community-based sample consisted of 25 cancer survivors, 24 healthcare providers, and six community-level stakeholders. Over half of the cancer survivors interviewed were from underrepresented minority groups (52% African American and 12% Hispanic/Latino). The data were analyzed using applied thematic analysis techniques. The over-arching themes include the need to (1) provide clear, consistent, and comprehensive education and information about POM to ensure safe use; (2) discuss the risks, benefits, and proper use of POM in the treatment of cancer-related pain; (3) communicate realistic expectations and address common misconceptions about pain; and (4) address cancer survivor beliefs and concerns surrounding fear of addiction. Our findings highlight the need for effective cancer education and communication about opioid agonist treatment and POM in plain simple language that is easy to understand, relevant, and culturally appropriate. Recommendations for cancer education and suggestions for future research are discussed.
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Affiliation(s)
- Dinorah Martinez Tyson
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA.
| | - Melody N Chavez
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA
| | - Barbara Lubrano
- Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Paige Lake
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA
| | - Ana Gutierrez
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA
| | - Victoria K Marshall
- College of Nursing, University of South Florida, 12912 Bruce B. Downs, MDC 22, Tampa, FL, 33612, USA
| | - Khary K Rigg
- Department of Mental Health Law and Policy, University of South Florida, 13301 Bruce B. Downs Blvd., Tampa, FL, 33612, USA
| | - Heather Henderson
- Department of Anthropology, University of South Florida, 4202 E. Fowler Ave. SOC 107, Tampa, FL, 33620, USA
| | - Smitha Pabbathi
- College of Nursing, University of South Florida, 12912 Bruce B. Downs, MDC 22, Tampa, FL, 33612, USA
| | - Peggie Sherry
- Faces of Courage, 10006 Cross Creek Blvd #519, Tampa, FL, 33647-2595, USA
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11
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Tyson DM, Chavez MN, Lake P, Gutierrez A, Sherry P, Rigg KK, Marshall VK, Henderson H, di Ciccone BL, Rajasekhara S, Pabbathi S. Perceptions of prescription opioid medication within the context of cancer survivorship and the opioid epidemic. J Cancer Surviv 2021; 15:585-596. [PMID: 33405057 DOI: 10.1007/s11764-020-00952-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 10/06/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE Prescription opioid medication can be of great benefit for cancer patients and survivors who suffer from cancer-related pain throughout their cancer care trajectory. However, the current opioid epidemic has influenced how such medications are perceived. The purpose of this study was to explore the perceptions of opioid use and misuse in cancer survivorship within the context of the opioid epidemic. METHODS pt?>A qualitative study using a semi-structured interview was conducted with a purposive sample of health care professionals (n = 24), community-level stakeholders (n = 6), and cancer survivors (n = 25) using applied thematic analysis techniques. RESULTS Crosscutting themes include (1) fear of addiction and living with poorly managed pain, (2) the importance of good patient/provider communication and the need for education around the use/handling/disposal of prescription opioid medication, (3) preference for nonopioid alternatives for pain management, (4) cancer survivors perceived to be low risk for developing opioid use disorder (include inconsistent screening), and (5) impact of policies aimed at curbing the opioid epidemic on cancer survivors. CONCLUSION This study illustrates the intersecting and sometimes conflicting assumptions surrounding the use of opioids analgesics in the management of cancer pain among survivors embedded within the national discourse of the opioid epidemic. IMPLICATIONS FOR CANCER SURVIVORS A system of integrated cancer care using psychosocial screening, opioid risk mitigation tools, opioid treatment agreements, and specialist expertise that cancer care providers can rely on to monitor POM use in conjunction with patient-centered communication to empower patients informed decision making in managing their cancer pain could address this critical gap in survivorship care.
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Affiliation(s)
- Dinorah Martinez Tyson
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA.
| | - Melody N Chavez
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA
| | - Paige Lake
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA
| | - Ana Gutierrez
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL, 33612-3805, USA
| | - Peggie Sherry
- Faces of Courage, 10006 Cross Creek Blvd #519, Tampa, FL, 33647-2595, USA
| | - Khary K Rigg
- Department of Mental Health Law and Policy, University of South Florida, 13301 Bruce B. Downs Blvd, Tampa, FL, 33612-3805, USA
| | - Victoria K Marshall
- College of Nursing, University of South Florida, 12912 USF Health Dr., Tampa, FL, 33612, USA
| | - Heather Henderson
- Department of Anthropology, University of South Florida, 4202 E. Fowler Ave. SOC 107, Tampa, FL, 33620, USA
| | | | | | - Smitha Pabbathi
- Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
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Wang HL, Donovan KA, Rajasekhara S, Padhya T, Buck HG, Szalacha L, Chang JM, Brown JD, Smith B. The pre-efficacy phase testing for PAfitME™-A behavioral physical activity intervention to manage moderate and severe symptoms among advanced stage cancer patients. Res Nurs Health 2020; 44:238-249. [PMID: 33373078 DOI: 10.1002/nur.22099] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/19/2020] [Accepted: 12/05/2020] [Indexed: 11/08/2022]
Abstract
Fatigue and pain are the most frequently reported symptoms among advanced-stage cancer patients. Although physical activity (PA) is known to improve the aforementioned symptoms, few patients demonstrate the physically active behavior that adheres to the clinical guidelines regarding PA. The current article presents an exemplar that used the National Institute of Health's Obesity-Related Behavioral Intervention Trial (ORBIT) model and developed a behavioral intervention known as the personalized Physical Activity intervention with fitness graded Motion Exergames (PAfitME™). There were two phases of testing in the ORBIT model presented in the current paper. In Phase I testing, a standardized exergame prescription was evaluated by an advisory board and a single-case study was used to evaluate the personalized exergame prescription with personalization of the fitness levels. In Phase IIa, a within-group pre- and posttest design was used to evaluate the personalized exergame prescriptions with personalization of the fitness levels, self-efficacy, and variation in fatigue/pain. Subsequently, a complete intervention package was developed in accordance with a logic model, driven from the result of the Phase IIa testing with clinically significant findings. Currently, PAfitME™ is under Phase IIb testing in a randomized clinical trial with a control group. PAfitME™ employs a personalized approach to initiate and promote physically active behavior, to facilitate the management of fatigue and pain in cancer patients. Positive results from an efficacy trial would support the use of PAfitME™ in the management of fatigue and pain in advanced-stage cancer patients.
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Affiliation(s)
- Hsiao-Lan Wang
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | | | | | - Tapan Padhya
- College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Harleah G Buck
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Laura Szalacha
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - J Morris Chang
- College of Engineering, University of South Florida, Tampa, Florida, USA
| | - Jaelyn D Brown
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - Barbara Smith
- College of Nursing, University of South Florida, Tampa, Florida, USA
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13
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Rajasekhara S, Portman DG, Chang YD, Haas MF, Randich AL, Bromberg HS, Rashid S, Donovan KA. Rate of cannabis use in older adults with cancer. BMJ Support Palliat Care 2020; 12:178-181. [PMID: 33177114 DOI: 10.1136/bmjspcare-2020-002384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/28/2020] [Revised: 10/02/2020] [Accepted: 10/16/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Older adults with cancer are increasingly inquiring about and using cannabis. Despite this, few studies have examined cannabis use in patients with cancer aged 65 years and older as a separate group and identified characteristics associated with use. The current study sought to determine the rate of cannabis use in older adult patients with cancer and to identify demographic and clinical correlates of use. METHODS We conducted a retrospective review of patients with cancer referred for specialised symptom management between January 2014 and May 2017 who underwent routine urine drug testing for tetrahydrocannabinol as part of their initial clinic visit. RESULTS Approximately 8% (n=24) of patients with cancer aged 65 years and older tested positive for tetrahydrocannabinol compared with 30% (n=51) of young adults and 21% (n=154) of adults. At the univariate level, more cannabis users had lower performance status than non-users (p=0.02, Fisher's exact test). There were no other demographic and clinical characteristics significantly associated with cannabis use in older adults. CONCLUSIONS Older adult patients made up nearly 25% (n=301) of the total sample and had a rate of cannabis use of 8%. As one of the first studies to assess cannabis use via objective testing rather than self-report, this study adds significantly to the emerging literature on cannabis use in people aged 65 years and older. Findings suggest the rate of use in older adults living with cancer is higher than that among older adults in the general population.
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Affiliation(s)
- Sahana Rajasekhara
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida, USA
| | - Diane G Portman
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida, USA
| | - Young D Chang
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida, USA
| | - Meghan F Haas
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida, USA
| | - Anthony L Randich
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida, USA
| | - Hannah S Bromberg
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida, USA
| | - Saima Rashid
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida, USA
| | - Kristine A Donovan
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida, USA
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Bobonis Babilonia M, Donovan KA, Lubrano di Ciccone BB, Rajasekhara S. When orthorexia nervosa meets cancer—A case review. Psychooncology 2020; 29:1507-1509. [DOI: 10.1002/pon.5419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/03/2020] [Accepted: 05/11/2020] [Indexed: 11/10/2022]
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15
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Chang YD, Jung JW, Oberoi-Jassal R, Kim J, Rajasekhara S, Haas M, Smith J, Desai V, Donovan KA, Portman D. Edmonton Symptom Assessment Scale and Clinical Characteristics Associated With Cannabinoid Use in Oncology Supportive Care Outpatients. J Natl Compr Canc Netw 2020; 17:1059-1064. [PMID: 31487688 DOI: 10.6004/jnccn.2019.7301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Information about the frequency of cannabinoid use and the clinical characteristics of its users in oncology supportive care is limited. This study explored associations between cannabinoid use and cancer-related clinical characteristics in a cancer population. PATIENTS AND METHODS This retrospective review included 332 patients who had a urine drug test (UDT) for tetrahydrocannabinol (THC) together with completion of an Edmonton Symptom Assessment Scale (ESAS) and cannabinoid history questionnaire on the same day that urine was obtained during 1 year in the supportive care clinic. RESULTS The frequency of positive results for THC in a UDT was 22.9% (n=76). Significant statistical differences were seen between THC-positive and THC-negative patients for age (median of 52 [lower quartile, 44; upper quartile, 56] vs 58 [48; 67] years; P<.001), male sex (53.9% vs 39.5%; P=.034), and past or current cannabinoid use (65.8% vs 26.2%; P<.001). Statistical significance was observed in ESAS items between the THC-positive and THC-negative groups for pain (7 [lower quartile, 5; upper quartile; 8] vs 5 [3; 7]; P=.001), nausea (1 [0; 3] vs 0 [0; 3]; P=.049), appetite (4 [2; 7] vs 3 [0; 5.75]; P=.015), overall well-being (5.5 [4; 7] vs 5 [3; 6]; P=.002), spiritual well-being (5 [2; 6] vs 3 [1; 3]; P=.015), insomnia (7 [5; 9] vs 4 [2; 7]; P<.001), and total ESAS (52 [34; 66] vs 44 [29; 54]; P=.001). Among patients who reported current or past cannabinoid use, THC-positive patients had higher total scores and scores for pain, appetite, overall well-being, spiritual well-being, and insomnia than THC-negative patients. CONCLUSIONS Patients with cancer receiving outpatient supportive care who had positive UDT results for THC had higher symptom severity scores for pain, nausea, appetite, overall and spiritual well-being, and insomnia compared with their THC-negative counterparts. These results highlight potential opportunities to improve palliative care.
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Affiliation(s)
- Young D Chang
- Department of Supportive Care Medicine, Moffitt Cancer Center, and.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Jae-Woo Jung
- Department of Supportive Care Medicine, Moffitt Cancer Center, and.,Department of Internal Medicine, Chung-Ang University, College of Medicine, Seoul, Korea; and
| | | | - Jongphil Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Sahana Rajasekhara
- Department of Supportive Care Medicine, Moffitt Cancer Center, and.,Department of Internal Medicine, Chung-Ang University, College of Medicine, Seoul, Korea; and
| | - Meghan Haas
- Department of Supportive Care Medicine, Moffitt Cancer Center, and.,Department of Internal Medicine, Chung-Ang University, College of Medicine, Seoul, Korea; and
| | - Joshua Smith
- Department of Supportive Care Medicine, Moffitt Cancer Center, and
| | - Vijay Desai
- Department of Supportive Care Medicine, Moffitt Cancer Center, and
| | | | - Diane Portman
- Department of Supportive Care Medicine, Moffitt Cancer Center, and.,Department of Internal Medicine, Chung-Ang University, College of Medicine, Seoul, Korea; and
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Donovan KA, Oberoi-Jassal R, Chang YD, Rajasekhara S, Haas MF, Randich AL, Portman DG. Cannabis Use in Young Adult Cancer Patients. J Adolesc Young Adult Oncol 2020; 9:30-35. [DOI: 10.1089/jayao.2019.0039] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristine A. Donovan
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
| | | | - Young D. Chang
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
| | - Sahana Rajasekhara
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
| | - Meghan F. Haas
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
| | - Anthony L. Randich
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
| | - Diane G. Portman
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
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Donovan KA, Chang YD, Oberoi-Jassal R, Rajasekhara S, Smith J, Haas M, Portman DG. Relationship of Cannabis Use to Patient-Reported Symptoms in Cancer Patients Seeking Supportive/Palliative Care. J Palliat Med 2019; 22:1191-1195. [DOI: 10.1089/jpm.2018.0533] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristine A. Donovan
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
| | - Young D. Chang
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
| | | | - Sahana Rajasekhara
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
| | - Joshua Smith
- Palliative Care Services, Greenville Health System, Greenville, South Carolina
| | - Meghan Haas
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
| | - Diane G. Portman
- Department of Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida
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18
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Bulls HW, Hoogland AI, Craig D, Paice J, Chang YD, Oberoi-Jassal R, Rajasekhara S, Haas M, Bobonis M, Gonzalez BD, Portman D, Jim HSL. Cancer and Opioids: Patient Experiences With Stigma (COPES)-A Pilot Study. J Pain Symptom Manage 2019; 57:816-819. [PMID: 30703463 PMCID: PMC6433506 DOI: 10.1016/j.jpainsymman.2019.01.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [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: 11/16/2018] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 11/17/2022]
Abstract
CONTEXT Cancer-related pain is a common symptom that is often treated with opioids. However, legislation aimed at containing the opioid crisis, coupled with public fears about opioid risks, may contribute to opioid stigma in cancer patients. To our knowledge, no prior research has examined opioid stigma and stigma-related behavior in this population. OBJECTIVE The objectives of this study were to describe opioid use, including reasons for use and overuse and underuse behavior; characterize opioid stigma; and identify potentially maladaptive stigma-related behaviors. METHODS Participants were 125 adults undergoing active cancer treatment seen at the Moffitt Supportive Care Medicine Clinic. Patients completed a brief, anonymous questionnaire evaluating opioid use, opioid stigma, and stigma-related behaviors. RESULTS Patients were primarily women (65%) aged 45-64 years (49%), most commonly diagnosed with breast (23%) and hematologic (15%) cancer. Among patients who reported opioid use (n = 109), the most common reason for use was pain relief (94%), followed by improved sleep (25%). A subset of patients reported using less (13%) or more (8%) opioid medication than advised. Opioid stigma was endorsed by 59/97 patients prescribed opioids (61%), including fear of addiction (36%), difficulty filling prescriptions (22%), and awkwardness communicating with providers (15%). Stigma-related behaviors were endorsed by 28 (29%) respondents prescribed opioids, with "taking less opioid medication than needed" as the most commonly endorsed behavior (20%). CONCLUSION To our knowledge, this study provides the first evidence of opioid stigma and its consequences in cancer patients and offers potential targets for interventions aimed at reducing stigma and encouraging safe, effective opioid use.
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Moale AC, Rajasekhara S, Ueng W, Mhaskar R. Educational Intervention Enhances Clinician Awareness of Christian, Jewish, and Islamic Teachings around End-of-Life Care. J Palliat Med 2018; 22:62-70. [PMID: 30004831 DOI: 10.1089/jpm.2018.0077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients' religious and spiritual values impact their goals and perception of illness, especially at the end of life (EOL). According to the Joint Commission, identifying spiritual beliefs may improve cultural competency and patient-centered care. However, clinicians may be uncomfortable discussing spirituality and unaware of basic religious teachings. OBJECTIVES To assess clinician understanding and knowledge of key Christian, Jewish, and Islamic teachings around EOL care before and after a one-hour educational intervention through video podcast. DESIGN After literature review and consultation with religious leaders, a pre- and post-test (10 questions per religion plus demographic questions) to assess knowledge of Christian, Jewish, and Islamic teachings and an educational video podcast were developed. The pretest was administered to healthcare providers, followed by a one-hour educational intervention through a video podcast. Next, a post-test was administered. SUBJECTS Seventy-three healthcare providers participated in this study. MEASUREMENTS Differences between pretest and post-test scores were analyzed employing paired t-test tests using SPSS software. RESULTS The median score on the pretest was Christian: 6 [2-9], Jewish: 6 [4-10], and Islamic: 6 [2-8]. After the educational intervention, the median Christian, Jewish, and Islamic scores improved to 8 [4-10], 9 [6-10], and 10 [3-10], respectively (p < 0.0001). Additionally, the total pretest median score improved from 17 [10-24] to 27 [16-30]. CONCLUSIONS A one-hour educational intervention through video podcast significantly improved understanding of Christian, Jewish, and Islamic teachings around EOL care. The video podcast enabled easy distribution of the educational session to multiple facilities and providers. Additional research is needed to determine the longitudinal outcomes and impact on patient outcomes of this intervention.
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Affiliation(s)
- Amanda Copenhaver Moale
- 1 Scholarly Concentrations Program, University of South Florida Health Morsani College of Medicine , Tampa, Florida.,6 Department of Medicine, Johns Hopkins School of Medicine , Baltimore, Maryland
| | - Sahana Rajasekhara
- 2 Supportive Care Medicine Department, University of South Florida Health Morsani College of Medicine , Tampa, Florida.,3 Moffitt Cancer Center , Tampa, Florida
| | - William Ueng
- 4 Department of Medicine , University of South Florida Health Morsani College of Medicine , Tampa, Florida
| | - Rahul Mhaskar
- 5 Department of Internal Medicine, University of South Florida Health Morsani College of Medicine , Tampa, Florida
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20
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Mosley SA, Hicks JK, Portman DG, Donovan KA, Gopalan P, Schmit J, Starr J, Silver N, Gong Y, Langaee T, Clare-Salzler M, Starostik P, Chang YD, Rajasekhara S, Smith JE, Soares HP, George TJ, McLeod HL, Cavallari LH. Design and rational for the precision medicine guided treatment for cancer pain pragmatic clinical trial. Contemp Clin Trials 2018; 68:7-13. [PMID: 29535047 PMCID: PMC5899651 DOI: 10.1016/j.cct.2018.03.001] [Citation(s) in RCA: 10] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 03/05/2018] [Accepted: 03/05/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Pain is one of the most burdensome symptoms associated with cancer and its treatment, and opioids are the cornerstone of pain management. Opioid therapy is empirically selected, and patients often require adjustments in therapy to effectively alleviate pain or ameliorate adverse drug effects that interfere with quality of life. There are data suggesting CYP2D6 genotype may contribute to inter-patient variability in response to opioids through its effects on opioid metabolism. Therefore, we aim to determine if CYP2D6 genotype-guided opioid prescribing results in greater reductions in pain and symptom severity and interference with daily living compared to a conventional prescribing approach in patients with cancer. METHODS Patients with solid tumors with metastasis and a self-reported pain score ≥ 4/10 are eligible for enrollment and randomized to a genotype-guided or conventional pain management strategy. For patients in the genotype-guided arm, CYP2D6 genotype information is integrated into opioid prescribing decisions. Patients are asked to complete questionnaires regarding their pain, symptoms, and quality of life at baseline and 2, 4, 6, and 8 weeks after enrollment. The primary endpoint is differential change in pain severity by treatment strategy (genotype-guided versus conventional pain management). Secondary endpoints include change in pain and symptom interference with daily living. CONCLUSION Pharmacogenetic-guided opioid selection for cancer pain management has potential clinical utility, but current evidence is limited to retrospective and observational studies. Precision Medicine Guided Treatment for Cancer Pain is a pragmatic clinical trial that seeks to determine the utility of CYP2D6 genotype-guided opioid prescribing in patients with cancer.
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Affiliation(s)
- Scott A Mosley
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA; Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - J Kevin Hicks
- DeBartolo Family Personalized Medicine Institute, Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Diane G Portman
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kristine A Donovan
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Priya Gopalan
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jessica Schmit
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jason Starr
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Natalie Silver
- Department of Otolaryngology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA; Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA; Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Michael Clare-Salzler
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA; Department of Pathology, Immunology & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Petr Starostik
- Department of Pathology, Immunology & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Young D Chang
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Sahana Rajasekhara
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Joshua E Smith
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Heloisa P Soares
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Thomas J George
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Howard L McLeod
- DeBartolo Family Personalized Medicine Institute, Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA; Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA; Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA.
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Oberoi-Jassal R, Portman D, Smith J, Rajasekhara S, Desai VV, Donovan KA, Chang YD. Burning Mouth Pain: A Case Report. J Oncol Pract 2018; 14:447-448. [PMID: 29589986 DOI: 10.1200/jop.17.00080] [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
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Oberoi-Jassal R, Chang YD, Smith J, Rajasekhara S, Desai V, Fenech AL, Reed DR, Portman D, Donovan KA. Illicit substance use and opioid misuse in adolescent and young adult (AYA) patients with cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.31_suppl.205] [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
205 Background: Rates of illicit substance use and misuse of opioid medications are high in the adolescent and young adult (AYA) general population. Despite this, screening for substance use and opioid misuse is not standard in the care of AYA oncology supportive/palliative care. To inform our clinical practice, we sought to determine the prevalence of illicit substance use and potential opioid misuse in AYA cancer patients relative to adult patients and to examine correlates of use and misuse. Methods: We conducted retrospective chart review of patients newly referred to an outpatient palliative care clinic between 2014 and 2016. Results: Consecutive patients (N = 963) underwent urine drug testing as part of their initial visit; 16% of patients were between 18 and 39 years of age. Rate of illicit drug use was 31% for AYAs and 19% for adults. AYAs were nearly 2 times more likely to have positive results for marijuana (OR = 1.79; 95% CI = 1.19 – 2.69) and nearly 3 times more likely to test positive for amphetamines (OR = 2.94; 95% CI = 1.15 – 7.49). AYAs were no more likely than adults to test positive for cocaine, barbiturates or heroin. In univariate analyses, only male sex and being single, and no clinical characteristics or symptom scores, were significantly associated with illicit substance use (ps < .05). AYAs were no more likely than adults to test positive for the presence of opioids, not currently prescribed (OR = 1.07; 95% CI = 0.70 – 1.65). No symptoms scores or demographic and clinical characteristics were significantly associated with misuse. Conclusions: AYA patients demonstrated a high rate of illicit substance use and similar rate of potential opioid misuse relative to adult patients. Findings suggest AYAs may benefit from consistent screening, support and treatment for substance use and potential opioid misuse during anticancer and cancer-related therapies.
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Affiliation(s)
| | - Young Doo Chang
- H. Lee Moffitt Cancer Center, Department of Supportive Care, Tampa, FL
| | - Joshua Smith
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | | | - Vijay Desai
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Alyssa L Fenech
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Damon R. Reed
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Diane Portman
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
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Chang YD, Smith J, Portman D, Kim R, Oberoi-Jassal R, Rajasekhara S, Davis M. Single Institute Experience With Methylphenidate and American Ginseng in Cancer-Related Fatigue. Am J Hosp Palliat Care 2017; 35:144-150. [PMID: 28299946 DOI: 10.1177/1049909117695733] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Single therapy with methylphenidate or American ginseng contributes to the reduction in cancer-related fatigue (CRF) with different pharmacologic mechanisms and is relatively safe. However, the safety and efficacy of treating CRF with methylphenidate and AG combination therapy is unknown. AIM The primary objective was to assess the clinical safety and the change in fatigue with numerical rating scale (NRS) on the Edmonton Symptom Assessment Scale (ESAS) after intervention with methylphenidate and AG combination therapy. METHODS We reviewed the electronic medical records of 857 patients seen in our Palliative Medicine outpatient clinic between February 1, 2015, and December 31, 2015. Fatigue was assessed by NRS on ESAS. Toxicity was reviewed on clinician's documents. RESULTS We identified 28 patients who were prescribed a combination of methylphenidate (10-40 mg/d) and AG (2000 mg/d). Ten patients did not comply with the combination therapy. Three patients had stage 2 adverse effects. Fifteen patients completed prescribed combination therapy per instructions. The mean time interval between pre- and postintervention follow-up was 30.5 days (standard deviation [SD]: 7.78). There was a significant reduction in the fatigue score (mean score 6.93-4.13) from the pre- to postscore records (mean: -2.8; SD: 1.61; P < .0002* [*refers to statistically significant]). Sixty percent of patients reported significant reduction in fatigue (cutoff value: ≥3; reduction in fatigue score from baseline: 80% ≥2, 60% ≥3, and 46.7% ≥4). CONCLUSION In our retrospective medical record review, the combination treatment of methylphenidate and AG had no discernible associated toxicities and showed potential clinical benefit in CRF.
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Affiliation(s)
- Young D Chang
- 1 Supportive Care Medicine, Department of Oncology Science, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Joshua Smith
- 1 Supportive Care Medicine, Department of Oncology Science, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Diane Portman
- 1 Supportive Care Medicine, Department of Oncology Science, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Richard Kim
- 1 Supportive Care Medicine, Department of Oncology Science, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Ritika Oberoi-Jassal
- 1 Supportive Care Medicine, Department of Oncology Science, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Sahana Rajasekhara
- 1 Supportive Care Medicine, Department of Oncology Science, Moffitt Cancer Center, University of South Florida, Tampa, FL, USA
| | - Mellar Davis
- 2 Palliative Medicine, Geisinger Medical Center, Danville, PA, USA
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Chang Y, Smith J, Portman DG, Oberoi-Jassal R, Rajasekhara S, Davis MP. The combination therapy with methylphenidate and American ginseng in cancer-related fatigue. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.26_suppl.215] [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
215 Background: Fatigue is one of common symptoms among patients with cancer. However, little is known about the pathophysiology and effective pharmacologic intervention. Methylphenidate and American Ginseng were recognized for promising results and safe to use as a single therapy. Psycho-stimulants are commonly used and are effective in moderate to severe fatigue. The mechanism behind the evidence for methylphenidate is rebalancing dopamine neurotransmission which is altered in fatigue. The mechanism behind ginseng benefits appears to be improvement in muscle metabolism and reduction in inflammatory responses thought to cause fatigue in cancer. We hypothesized that combination therapy with methylphenidate and American ginseng is superior to single therapy and safe. Methods: We conducted retrospective chart review in the supportive care medicine outpatient clinic between Feb 01, 2015 and Dec 31, 2015. 28 patients were prescribed methylphenidate and American ginseng for 4 weeks. Methylphenidate dosage was between 10-20mg/day. American ginseng dosage was fixed at 2000mg/day (no control of sources). We investigated compliance rate, positive rate and change of fatigue score on ESAS. We also obtained the data for adverse effect ratio and severity as a safety measure. Results: We identified 28 patients (M: F 14/14, Age 50.4) who were prescribed combination therapy with methylphenidate and American ginseng for at least 4 weeks. 18 patients were compliant to combination therapy (Compliance rate 64%). 2 patients (11%) reported Grade 2 adverse effect while on therapy. One patient (5%) became non-compliant during the study period. 15 patients (84%) successfully completed the therapy the average fatigue score of pre and post intervention was 6.93 and 4.13 respectively (mean reduction -2.80, p-Value < 0.0002). 12 patients (80%) showed significant improvement of fatigue (reduced ≥ 2). There was no association between gender and age. Conclusions: Combination therapy with standard dose of methylphenidate and American ginseng were a safe and effective way of treatment for cancer-related fatigue. Further studies to confirm its safety and efficacy are justified.
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Ganesh KJ, Darbal AD, Rajasekhara S, Rohrer GS, Barmak K, Ferreira PJ. Effect of downscaling nano-copper interconnects on the microstructure revealed by high resolution TEM-orientation-mapping. Nanotechnology 2012; 23:135702. [PMID: 22418052 DOI: 10.1088/0957-4484/23/13/135702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In this work, a recently developed electron diffraction technique called diffraction scanning transmission electron microscopy (D-STEM) is coupled with precession electron microscopy to obtain quantitative local texture information in damascene copper interconnects (1.8 µm-70 nm in width) with a spatial resolution of less than 5 nm. Misorientation and trace analysis is performed to investigate the grain boundary distribution in these lines. The results reveal strong variations in texture and grain boundary distribution of the copper lines upon downscaling. Lines of width 1.8 µm exhibit a strong <111> normal texture and comprise large micron-size grains. Upon downscaling to 180 nm, a {111}<110> bi-axial texture has been observed. In contrast, narrower lines of widths 120 and 70 nm reveal sidewall growth of {111} grains and a dominant <110> normal texture. The microstructure in these lines comprises clusters of small grains separated by high angle boundaries in the vicinity of large grains. The fraction of coherent twin boundaries also reduces with decreasing line width.
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Affiliation(s)
- K J Ganesh
- Materials Science and Engineering, The University of Texas at Austin, 1 University Station, C2200, Austin, TX 78712, USA
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Abstract
ABSTRACTOver the course of use, both in-service and during storage, fuel claddings for nuclear reactors undergo complex changes that can drastically change their material properties. Exposures to irradiation, temperature changes, and stresses, as well as contact with coolant, storage pool, and dry storage environments, may induce microstructural changes, such as formation of radiation defects, precipitate dissolution, and chemical segregation, that can ultimately result in failure of the cladding if pushed beyond its limit. In order to predict the performance of cladding in-service and during storage, understanding of the dominant processes related to these changes and their consequences is essential. In situ transmission electron microscopy (TEM) allows dynamic observation, at the nanoscale, of microstructural changes under a range of stimuli, making it an excellent tool for deepening our understanding of microstructural evolution in claddings. This proceeding presents details of the new in situ ion irradiation TEM and in situ gas cell TEM capabilities developed at Sandia National Laboratories. In addition, it will present the initial results from both systems investigating radiation tolerance of potential Generation IV cladding materials and understanding degradation mechanisms in Zr-based claddings of importance for dry storage.
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