Effects of tertiary palliative care on the pattern of end-of-life care in patients with hematologic malignancies in Korea

INTRODUCTION

Patients with hematologic malignancies (HMs) often face challenges in accessing palliative care (PC) and receiving quality end-of-life (EOL) care. We examined factors associated with referrals to tertiary PC and the effects of tertiary PC on EOL care in patients with HMs.

METHOD

We included patients with HMs who were admitted to a university-affiliated hospital and died during hospitalization between January 2018 and December 2021. We investigated the receipt of PC consultations, patient characteristics, and EOL care indicators.

RESULTS

Overall, 487 patients were included in the analysis, with 156 (32%) undergoing PC consultation. Sex, residence, disease status, and admission purpose were factors associated with the likelihood of PC consultation, and there has been an increasing trend in the frequency of consultations in recent cases. A higher proportion of patients who received PC completed advance statements and life-sustaining treatment documents. Patients who received PC had lower rates of aggressive EOL care, including chemotherapy and intensive care unit admission, than those who did not receive PC. Notably, PC reduced the number of blood transfusions.

CONCLUSION

Tertiary PC aims to reduce aggressive EOL care through patient-centered goal-of-care discussions. Therefore, there is an imperative need for concerted efforts toward seamless integration of PC.

Opioid use and subsequent delirium risk in patients with advanced cancer in palliative care: a multicenter registry study

The prevalent use of opioids for pain management in patients with advanced cancer underscores the need for research on their neuropsychiatric impacts, particularly delirium. Therefore, we aimed to investigate the potential association between opioid use and the risk of delirium in patients with advanced cancer admitted to the acute palliative care unit. We conducted a retrospective observational study utilizing a multicenter, patient-based registry cohort by collecting the data from January 1, 2019, to December 31, 2020, in South Korea. All data regarding exposures, outcomes, and covariates were obtained through retrospective chart reviews by a team of specialized medical professionals with expertise in oncology. Full unmatched and 1:1 propensity-score matched cohorts were formed, and stratification analysis was conducted. The primary outcome, delirium, was defined and diagnosed by the DSM-IV. Of the 2,066 patients with advanced cancer, we identified 42.8% (mean [SD] age, 64.4 [13.3] years; 60.8% male) non-opioid users and 57.2% (62.8 [12.5] years; 55.9% male) opioid users, respectively. Opioid use was significantly associated with an increased occurrence of delirium in patients with advanced cancer (OR, 2.02 [95% CI 1.22-3.35]). The risk of delirium in patients with advanced cancer showed increasing trends in a dose-dependent manner. High-dose opioid users showed an increased risk of delirium in patients with advanced cancer compared to non-opioid users (low-dose user: OR, 2.21 [95% CI 1.27-3.84]; high-dose user: OR, 5.75 [95% CI 2.81-11.77]; ratio of OR, 2.60 [95% CI 1.05-6.44]). Patients with old age, male sex, absence of chemotherapy during hospitalization, and non-obese status were more susceptible to increased risk of delirium in patients with cancer. In this multicenter patient-based registry cohort study, we found a significant, dose-dependent association between opioid use and increased risk of delirium in patients with advanced cancer. We also identified specific patient groups more susceptible to delirium. These findings highlight the importance of opioid prescription in these patients with advanced cancer, balancing effective doses for pain management and adverse dose-inducing delirium.

Healthcare Utilization and Supportive Care Timing in South Korean People Living With Amyotrophic Lateral Sclerosis: A Single-Center Retrospective Study

BACKGROUND AND PURPOSE

Despite the growing demands and challenges faced by patients with amyotrophic lateral sclerosis (ALS) in accessing healthcare services, our understanding of this access remains poor. This study aimed to investigate the healthcare utilization patterns and timing of nutritional and respiration support in patients with ALS in South Korea.

METHODS

A retrospective cohort study was conducted on patients diagnosed with ALS at a single tertiary hospital between 2016 and 2019 and followed up for 2 years. We evaluated patient characteristics, healthcare utilization (hospital admissions, outpatient visits, and emergency department [ED] visits), and the timing of nutritional and respiration support (noninvasive positive pressure ventilation [NIPPV], tracheostomy, gastrostomy, and nasogastric tube) at 6-month intervals from the first outpatient visit.

RESULTS

Among the 143 included patients, 73.4% were admitted at least once, 18.9% experienced unplanned admissions, and 30.1% visited the ED at least once during the study period. The most-common reason for ED visits was neurological symptoms during the first 6 months (59.1%), followed by respiratory symptoms. One fifth of patients who visited the ED underwent tracheostomy (20.9%) or NIPPV (20.9%). Two years after the first visit, 32.2% used a ventilator, and 13.3%, 26.6%, and 6.3% had undergone tracheostomy, gastrostomy, and nasogastric tube insertion, respectively.

CONCLUSIONS

During the 2 years following their first outpatient visit, 20% of patients with ALS experienced unplanned admissions and 30% visited the ED. An active and prompt supportive-care program should be implemented to ensure timely functional support in order to reduce these risks of unplanned admissions.

Development of a Prediction Model for Delirium in Hospitalized Patients with Advanced Cancer

Purpose

Delirium is a common neurocognitive disorder in patients with advanced cancer and is associated with poor clinical outcomes. As a potentially reversible phenomenon, early recognition of delirium by identifying the risk factors demands attention. To develop a model to predict the occurrence of delirium in hospitalized patients with advanced cancer.

Materials and Methods

This retrospective study included patients with advanced cancer admitted to the oncology ward of four tertiary cancer centers in Korea for supportive cares and excluded those discharged due to death. The primary endpoint was occurrence of delirium. Sociodemographic characteristics, clinical characteristics, laboratory findings, and concomitant medication were investigated for associating variables. The predictive model developed using multivariate logistic regression was internally validated by bootstrapping.

Results

From January 2019 to December 2020, 2,152 patients were enrolled. The median age of patients was 64 years, and 58.4% were male. A total of 127 patients (5.9%) developed delirium during hospitalization. In multivariate logistic regression, age, body mass index, hearing impairment, previous delirium history, length of hospitalization, chemotherapy during hospitalization, blood urea nitrogen and calcium levels, and concomitant anti-depressant use were significantly associated with the occurrence of delirium. The predictive model combining all four categorized variables showed the best performance among the developed models (area under the curve 0.831, sensitivity 80.3%, and specificity 72.0%). The calibration plot showed optimal agreement between predicted and actual probabilities through internal validation of the final model.

Conclusion

We proposed a successful predictive model for the risk of delirium in hospitalized patients with advanced cancer.

Emergency department visits of newly diagnosed cardiovascular disease patients in Korea during the COVID-19 pandemic

This study aimed to examine the impact of the COVID-19 pandemic on the emergency department (ED) visits of cardiovascular disease (CVD) patients. The customized data of the National Health Insurance Service (NHIS) from 2017 to 2020 were analyzed. CVD patients were defined by the code 'V192' based on the NHIS coverage benefit expansion policy. The number of ED visits of CVD patients, as well as executed procedures in 2020 (during the pandemic), were compared to the corresponding average numbers in 2018 and 2019 (prepandemic). Stratification by age group, residential area and hospital location was performed. The number of ED visits of newly diagnosed CVD patients decreased by 2.1% nationwide in 2020 (2018-2019: 97,041; 2020: 95,038) and decreased the most (by 14.1%) in March (2018-2019: 8539; 2020: 7334). However, the number of executed procedures increased by 1.1% nationwide in 2020 (2018-2019: 74,696; 2020: 75,520), while it decreased by 11.9% in April (2018-2019: 6603; 2020: 5819). The most notable decreases in the number of newly diagnosed CVD patients (31.7%) and procedures (29.2%) in March 2020 were observed in the Daegu·Gyeongbuk area. CVD patients living in the epicenter of the COVID-19 pandemic may experience difficulty accessing healthcare facilities and receiving proper treatment.

Home-based supportive care in advanced cancer: systematic review

OBJECTIVES

This study systematically reviewed the literature on the effect of home-based supportive care (HbSC) programmes on the quality of life (QoL) of patients with advanced cancer.

METHODS

The research question 'Do home-based supportive care programmes for patients with advanced cancer improve their QoL?' was addressed. After registering the plan with PROSPERO (CRD42022341237), literature published from 1 January 1990 to 30 May 2023 was searched on PubMed, Embase, Cochrane database, CINAHL and Web of Science, and reviewed for inclusion based on predefined criteria. This review only included trial studies published in English.

RESULTS

Of 5,276 articles identified, 17 studies were judged suitable for inclusion in this review. The components of HbSC programmes included home visits, patient and caregiver education, home nursing, psychotherapy, exercise, telephone consultation, and multidisciplinary team meetings. Nine studies reported improvements in QoL, including social functioning, emotional functioning, and subjective QoL.

CONCLUSION

HbSC programmes appear to enable the improvement of the QoL of patients with advanced cancer. The area of QoL that shows improvement could vary depending on the HbSC components. More studies that address HbSC programmes are needed to select patients at the proper time and provide suitable programmes for patients to benefit most.

Epidemiology and characteristics of emergency department utilization by patients with amyotrophic lateral sclerosis in Korea from 2016 to 2020: A nationwide study

INTRODUCTION/AIMS

Patients with amyotrophic lateral sclerosis (ALS) inevitably visit the emergency department (ED) due to their increased risk of respiratory failure and mobility limitations. However, nationwide data on ED visits by patients with ALS are limited. This study investigated the characteristics of patients with ALS-related ED visits.

METHODS

We conducted a cross-sectional study from 2016 to 2020, utilizing a nationwide ED database. The total number of patients with ALS who visited the ED and their primary reasons for visiting/diagnoses were analyzed.

RESULTS

In total, 6036 visits to the ED were made by patients with ALS. Of these, 41.8% arrived by ambulance and 27.7% spent >9 h in the ED. Following ED treatment, 57.4% were hospitalized, including 19.3% admitted to the intensive care unit (ICU) and 5.4% who died in the hospital. The primary reasons for ALS-related ED visits were dyspnea (35.2%), feeding tube problems (10.1%), fever (7.8%), and mental status changes (3.6%). The most common diagnoses were pneumonia (14.5%), respiratory failure (5.7%), dyspnea (5.5%), aspiration pneumonia (4.3%), and tracheostomy complications (3.4%).

DISCUSSION

Reasons for ED visits for patients with ALS include acute respiratory distress, as well as concerns related to tube feeding and tracheostomy. To reduce the risk of patients with ALS requiring ED visits, it is essential to ensure the provision of timely respiratory support and high-quality home-based medical care teams that can support and address patients before their condition deteriorates.

Preferred versus Actual Place of Care and Factors Associated with Home Discharge among Korean Patients with Advanced Cancer: A Retrospective Cohort Study

Respecting the preference for a place of care is essential for advance care planning in patients with advanced cancer. This retrospective study included adult patients with cancer referred to an inpatient palliative care consultation team at a tertiary acute care hospital in South Korea between April 2019 and December 2020. Patients' preference for place of care and demographic and clinical factors were recorded, and the actual discharge locations were categorized as home or non-home. Patients discharged home but with unintended hospital visits within 2 months were also investigated. Of the 891 patients referred to the palliative care consultation team, 210 (23.6%) preferred to be discharged home. Among them, 113 (53.8%) were discharged home. No significant differences were found between patients who preferred home discharge and those who did not. Home discharge was higher among female patients (p = 0.04) and lower in those with poor oral intake (p < 0.001) or dyspnea (p = 0.02). Of the 113 patients discharged home, 37 (32.8%) had unintended hospital visits within 2 months. Approximately one-quarter of hospitalized patients with advanced cancer preferred to be discharged home, but only half of them received the home discharge. To meet patients' preferences for end-of-life care, individual care planning considering relevant factors is necessary.

Changes in the Utilization of Health Care Services by Cancer Patients during the COVID-19 Pandemic

PURPOSE

The first year of the COVID-19 pandemic in Korea elicited changes in healthcare service utilization. This study aimed to report changes in healthcare service utilization among cancer patients during the first year of the COVID-19 pandemic in Korea.

MATERIALS AND METHODS

We analyzed records from National Health Insurance Service Database and identified cancer patients as those with specific beneficiary codes ("V193" or "V194") assigned to cancer patients. We calculated percentage changes in the number of patients between 2019 and 2020 based on claims records for outpatient clinic visits, hospitalization, and emergency room visits by month, age group, residential areas, and hospital location.

RESULTS

The number of newly diagnosed cancer patients in 2020 decreased by 3.2%, compared to the previous year. The number of patients who visited an outpatient clinic, were hospitalized, and visited the emergency room decreased by 2.6%, 4.0%, and 3.5%, respectively, in 2020, compared to the year 2019.

CONCLUSION

During the first year of the COVID-19 pandemic, the number of newly diagnosed cancer patients decreased by 3.2%, compared to the previous year, and their utilization of healthcare services declined significantly after the outbreak of COVID-19.

Ethical Issues Referred to Clinical Ethics Support at a University Hospital in Korea: Three-Year Experience After Enforcement of Life-Sustaining Treatment Decisions Act

BACKGROUND

Clinical ethics support is a form of preventive ethics aimed at mediating ethics-related conflicts and managing ethical issues arising in the healthcare setting. However, limited evidence exists regarding the specific ethical issues in clinical practice. This study aimed to explore the diverse ethical issues of cases referred to clinical ethics support after the new legislation on hospice palliative care and end-of-life decision-making was implemented in Korea in 2018.

METHODS

A retrospective study of cases referred to clinical ethics support at a university hospital in Korea from February 2018 to February 2021 was conducted. The ethical issues at the time of referral were analyzed via qualitative content analysis of the ethics consultation-related documents.

RESULTS

A total of 60 cases of 57 patients were included in the study, of whom 52.6% were men and 56.1% were older than 60 years of age. The majority of cases (80%) comprised patients from the intensive care unit. One-third of the patients were judged as being at the end-of-life stage. The most frequent ethical categories were identified as goals of care/treatment (78.3%), decision-making (75%), relationship (41.7%), and end-of-life issues (31.7%). More specifically, best interests (71.7%), benefits and burdens/harms (61.7%), refusal (53.3%), and surrogate decision-making (33.3%), followed by withholding or withdrawal (28.3%) were the most frequent ethical issues reported, which became diversified by year. In addition, the ethical issues appeared to differ by age group and judgment of the end-of-life stage.

CONCLUSION

The findings of this study expand the current understanding of the diverse ethical issues including decision-making and goals of care/treatment that have been referred to clinical ethics support since the enforcement of the new legislation in Korea. This study suggests a need for further research on the longitudinal exploration of ethical issues and implementation of clinical ethics support in multiple healthcare centers.

Moral Distress Regarding End-of-Life Care Among Healthcare Personnel in Korean University Hospitals: Features and Differences Between Physicians and Nurses

BACKGROUND

Healthcare professionals often experience moral distress while providing end-of-life care. This study explored how physicians and nurses experienced moral distress when they cared for critically and terminally ill patients in tertiary hospitals in South Korea.

METHODS

This study used semi-structured in-depth interviews. A total of 22 people in two tertiary hospitals were interviewed, nine (40.9%) of which were physicians and 13 (59.1%) were nurses. The recorded interview files and memos were analyzed using grounded theory.

RESULTS

Most physicians and nurses encountered similar feelings of anger, helplessness, and burden owing to a lack of appropriate resources for end-of-life care. However, the factors and contexts of their moral distress differed. Nurses mainly addressed poorly organized end-of-life care, intensive labor conditions without support for nurses, and providing care without participation in decision-making. Meanwhile, physicians addressed the prevailing misperceptions on end-of-life care, communication failure between physicians owing to hierarchy and fragmented disciplines, the burden of responsibility in making difficult decisions, and the burden of resource allocation.

CONCLUSION

Differences in moral distress between physicians and nurses leave them isolated and can affect communication regarding healthcare. Mutual understanding between job disciplines will enhance their communication and help resolve conflicts in end-of-life care.

Antibiotic prescription patterns during last days of hospitalized patients with advanced cancer: the role of palliative care consultation

OBJECTIVES

Issues regarding antibiotic use in end-of-life patients with advanced cancer present a challenging ethical dilemma in academic referral centres. This study aimed to investigate the role of palliative care consultation on antibiotic prescription patterns among hospitalized patients with advanced cancer during their last days of life.

METHODS

This retrospective cohort study included adult patients with metastatic solid cancer admitted to a tertiary referral hospital for at least 4 days and subsequently died and who were given antibiotics 4 days before death between January 2018 and December 2021. Patients were divided into palliative care consultation (PC) and non-consultation (non-PC) groups. The outcomes were the proportion of patients who received antibiotic combination treatment, antibiotic escalation and antibiotic de-escalation within 3 days of death. Propensity score analysis with the inverse probability of the treatment weighting method was used to compare the outcomes.

RESULTS

Among the 1177 patients enrolled, 476 (40.4%) received palliative care consultation and 701 (59.6%) did not. The PC group received considerably less antibiotic combination treatment (49.0% versus 61.1%, adjusted OR: 0.69, 95% CI: 0.53-0.90, P = 0.006) and antibiotic escalation (15.8% versus 34.8%, adjusted OR: 0.41, 95% CI: 0.30-0.57, P < 0.001) than the non-PC group. Additionally, the PC group reported significantly higher antibiotic de-escalation (30.7% versus 17.4%, adjusted OR: 1.74, 95% CI: 1.28-2.36, P < 0.001).

CONCLUSION

Receiving palliative care consultation may minimize aggressive antibiotic prescription patterns in the last days of patients with advanced cancer in an academic referral centre setting.

Use of high-flow nasal cannula oxygen therapy for patients with terminal cancer at the end of life

BACKGROUND

Few studies have focused on high-flow nasal cannula (HFNC) usage in the last few weeks of life. The aim of this study was to identify the status of HFNC use in patients with cancer at the end of life and the relevant clinical factors.

METHODS

We performed a retrospective cohort study in a tertiary hospital in the Republic of Korea. Among patients with cancer who died between 2018 and 2020, those who initiated HFNC within 14 days before death were included. Patients were categorized based on the time from HFNC initiation to death as imminent (<4 days) and non-imminent (≥4 days).

RESULTS

Among the 2191 deceased patients with terminal cancer, 329 (15.0%) were analyzed. The median age of the patients was 66 years, and 62.9% were male. The leading cause of respiratory failure was pneumonia (70.2%), followed by pleural effusion (30.7%) and aggravation of lung neoplasms (18.8%). Most patients were conscious (79.3%) and had resting dyspnea (76.3%) at HFNC initiation. Patients received HFNC therapy for a mean of 3.4 days in the last 2 weeks of life, and 62.6% initiated it within 4 days before death. Furthermore, female sex, no palliative care consultation, no advance statements in person on life-sustaining treatment, and no resting dyspnea were independently associated with the imminent use of HFNC.

CONCLUSIONS

Many patients with cancer started HFNC therapy at the point of imminent death. However, efforts toward goal-directed use of HFNC at the end-of-life stage are required.

Risk factors for delirium among patients with advanced cancer in palliative care: a multicenter, patient-based registry cohort in South Korea

OBJECTIVE

Previous studies have comprehensively investigated the prevalence and various potential risk factors for delirium among patients with advanced cancer admitted to the acute palliative care unit (APCU). Our objective was to evaluate the comprehensive association between delirium and various risk factors among patients with advanced cancer in an acute palliative care setting using a patient-based multicenter registry cohort.

PATIENTS AND METHODS

We performed a multicenter, patient-based registry cohort study collected in South Korea between January 1, 2019, and December 31, 2020. Delirium was identified using a medical record review based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

RESULTS

In total, 2,124 eligible patients with advanced cancer in the APCU met the inclusion criteria. There were 127 out of 2,124 patients (prevalence, 6.0%; 95% CI, 5.0 to 7.1) with delirium during admission. Delirium in patients with advanced cancer was associated with age >70 years (OR, 1.793; 95% CI, 1.246 to 2.581), male sex (OR, 1.675; 95% CI, 1.131 to 2.479), no chemotherapy during hospitalization (OR, 2.019; 95% CI, 1.236 to 3.298), hearing impairment (OR, 3.566; 95% CI, 1.176 to 10.810), underweight (OR, 1.826; 95% CI, 1.067 to 3.124), current use of opioid medication (OR, 1.942; 95% CI, 1.264 to 2.982), previous history of delirium (OR, 12.497; 95% CI, 6.920 to 22.568), and mental illness (OR, 2.333; 95% CI, 1.251 to 4.352).

CONCLUSIONS

In a large-scale multicenter patient-based registry cohort, delirium was associated with old age, male sex, no chemotherapy during hospitalization, hearing impairment, underweight, current use of opioid medication, and a history of delirium and mental illness. Our findings suggest physicians should pay attention to delirium in patients with advanced cancer admitted to the APCU with the above risk factors.

Challenges in Care for Non-COVID-19 Patients with Severe Chronic Illnesses during COVID-19 Pandemic: A Qualitative Study of Healthcare Providers Working around Acute Care Hospitals in South Korea

BACKGROUND

The COVID-19 epidemic has afflicted patients with severe chronic illnesses who need continuous care between home and hospitals. This qualitative study examines the experiences and challenges of healthcare providers around acute care hospitals who have cared for patients with severe chronic illness in non-COVID-19 situations during the pandemic.

METHODS

Eight healthcare providers, who work in various healthcare settings around acute care hospitals and frequently care for non-COVID-19 patients with severe chronic illnesses, were recruited using purposive sampling from September to October 2021 in South Korea. The interviews were subjected to thematic analysis.

RESULTS

Four overarching themes were identified: (1) deterioration in the quality of care at various settings; (2) new emerging systemic problems; (3) healthcare providers holding on but reaching their limit; and (4) a decline in the quality of life of patients at the end of their lives, and their caregivers.

CONCLUSION

Healthcare providers of non-COVID-19 patients with severe chronic illnesses reported that the quality of care was declining due to the structural problems of the healthcare system and policies centered solely on the prevention and control of COVID-19. Systematic solutions are needed for appropriate and seamless care for non-infected patients with severe chronic illness in the pandemic.

The impact of palliative care consultation on reducing antibiotic overuse in hospitalized patients with terminal cancer at the end of life: a propensity score-weighting study

OBJECTIVES

A substantial number of hospitalized patients with terminal cancer at the end-of-life phase receive antibiotics, even with imminent death. We evaluated the impact of palliative care consultation on antibiotic use in hospitalized patients with terminal cancer during the end-of-life phase.

METHODS

We identified adult patients with metastatic solid cancer who died at a tertiary medical centre in Seoul, Republic of Korea, following at least 4 days of hospitalization (January 2018-December 2020). Patients were divided into palliative and non-palliative care consultation groups. Propensity score-weighted, multivariable logistic regression analysis was used to compare the proportion of patients receiving antibiotics within 3 days before death between the two groups.

RESULTS

Among 1143 patients analysed, 940 (82.2%) received antibiotics within 3 days before death. The proportion of patients receiving antibiotics was significantly lower (propensity score-weighted P < 0.001) in the palliative care consultation group (344/468; 73.5%) than in the non-palliative care consultation group (596/675; 88.3%). The decrease in the proportion of patients receiving antibiotics in the palliative care consultation group was significant for a carbapenem (42.4% versus 22.4%; P < 0.001), a glycopeptide (23.3% versus 11.1%; P < 0.001) and a quinolone (30.5% versus 19.4%; P = 0.012). In the multivariable logistic regression analysis, receiving palliative care consultation (adjusted OR 0.46, 95% CI 0.33-0.65; P < 0.001) was independently associated with reduced antibiotic use during the end-of-life phase.

CONCLUSIONS

Palliative care consultation may reduce aggressive antibiotic use in hospitalized patients with terminal cancer during the end-of-life phase.

Impact of COVID-19 on the End-of-Life Care of Cancer Patients Who Died in a Korean Tertiary Hospital: A Retrospective Study

Purpose

Social distancing and strict visitor restrictions at hospitals have been national policies since the onset of the coronavirus disease 2019 (COVID-19) pandemic. This has challenged the concept of a good death in comfort with the opportunity to say goodbye. Little is known about how these measures have influenced end-of-life (EOL) care among cancer patients who die in acute care hospitals. This study examined changes in the EOL care of cancer patients during the COVID-19 pandemic.

Methods

We retrospectively analyzed 1,456 adult cancer patients who died in 2019 (n=752) and 2020 (n=704) at a tertiary hospital. Data on EOL care-symptom control and comfort care in an imminently dying state, preparation for death, place of death, and aggressive care in the last month-were reviewed.

Results

The 1,456 patients had a median age of 67 years, and 62.5% were men. Patients who died in 2020 were more likely to experience agitation or delirium before death (17.2% vs. 10.9%), to use inotropes/vasopressors near death (59.2% vs. 52.3%), and to receive cardiopulmonary resuscitation in their last months (16.3% vs. 12.5%) than those who died in 2019. Additionally, the number of deaths in the emergency room doubled in 2020 compared to 2019 (from 7.1% to 14.1%).

Conclusion

This study suggests that EOL care for cancer patients who died in a tertiary hospital deteriorated during the COVID-19 pandemic. The implementation of medical care at the EOL and the preferred place of death should be discussed carefully in advance for high-quality EOL care.

The Medical Needs and Characteristics of Cancer and Progressive Neurologic Disease Patients Who Use Home-Based Medical Care in Korea: A Retrospective Study for 2011-2020

OBJECTIVES

To investigate the needs and characteristics of patients with cancer and neurologic disorders requiring home-based medical care (HBMC).

DESIGN

Retrospective observational study.

SETTING AND PARTICIPANTS

Patients receiving HBMC on discharge from a tertiary hospital in Korea during 2011-2020.

METHODS

Patients were classified into 3 disease groups: cancer, progressive neurologic disorders (NR), and others. Characteristics and medical needs were assessed in each disease group. Medical needs were categorized based on functional items requiring support or management at the time of registration: respiratory, feeding, urinary system, drain tube, central catheter, wound, medication, and other. Patients with multiple medical needs were assigned to multiple categories. Patients who used HBMC for more than 3 months were defined as long-term users; their characteristics were evaluated in the same way.

RESULTS

Of the total 655 patients, 47.0% (308) had cancer and 17.3% (113) were NR patients. Among all patients, 78.8% were partially dependent (44.0%) or completely dependent (34.8%) in daily activities, and there were more dependent patients in the NR group (80.5%) than cancer (26.6%). Patients with cancer needed central catheter management the most (43.5%), followed by wound care (36.7%), feeding support (35.1%), and drain tube management (22.1%). NR patients required feeding support the most (80.5%), followed by respiratory support (43.4%), wound care (41.6%), and urinary system support (19.5%). Of all patients, 30.2% (198) were long-term users (NR, 37.9%; cancer, 35.4%). Long-term users were common among patients who needed respiratory support (59.4%), feeding support (48.75), and urinary system support (34.6%).

CONCLUSIONS AND IMPLICATIONS

Homebound patients with cancer and progressive neurologic disorders need medical services at home after discharge. Patients who need feeding and respiratory support usually use HBMC for more than 3 months. Further studies are needed to design an optimal HBMC that continuously provides medical services to patients with serious illnesses living at home.

The impact of COVID-19 on screening for colorectal, gastric, breast, and cervical cancer in Korea

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has affected the utilization of healthcare services, including participation in cancer screening programs. We compared cancer screening participation rates for colorectal, gastric, breast, and cervical cancers among participants in the National Cancer Screening Program (NCSP) in 2019 and 2020 to address the potential distraction effect of COVID-19 on cancer screening.

METHODS

Data from the NCSP for 4 cancer types (stomach, colorectal, breast, and cervical) in 2019 and 2020 were used to calculate cancer screening participation rates by calendar month, gender, age group, and geographical region. Monthly participation rates were analyzed per 1,000 eligible individuals.

RESULTS

The screening participation rate decreased in 2020 compared to 2019 for all 4 cancers: colorectal (40.5 vs. 35.3%), gastric (61.9 vs. 54.6%), breast (63.8 vs. 55.8%), and cervical (57.8 vs. 52.2%) cancers. Following 2 major COVID-19 waves in March and December 2020, the participation rates in the 4 types of cancer screening dropped compared with those in 2019. The highest decline was observed in the elderly population aged 80 years and older (percentage change: -21% for colorectal cancer; -20% for gastric cancer; -26% for breast cancer; -20% for cervical cancer).

CONCLUSIONS

After the 2 major COVID-19 waves, the screening participation rate for 4 types of cancer declined compared with 2019. Further studies are needed to identify the indirect effects of the COVID-19 pandemic on cancer patients, such as delayed diagnoses of cancer or excess cancer deaths.

Abstract 433: Colorectal and gastric cancer screening rates in Korea during the COVID-19 pandemic

Background: The COVID-19 pandemic has disrupted healthcare delivery, which is widely discussed as the distraction effect. This study aimed to estimate the distraction effect of the COVID-19 pandemic in Korea by analyzing colorectal and gastric cancer screening rates in the years 2019 and 2020.

Methods: Information of eligible population who had colorectal and gastric cancer screening provided by the National Cancer Screening Program in the years 2019 and 2020 was collected. Participation rates were analyzed by age group, sex, geographic region, and calendar month. Percentage change was calculated by dividing the percentage point difference by the screening rate of the reference period (2019).

Results: Overall, the colorectal and gastric cancer screening rates had decreased in 2020, compared to the reference period. For colorectal cancer, the screening rate decreased from 68.3% in 2019 (5,886,319 participants/14,526,424 eligible population) to 54.6% in 2020 (5,135,218/9,410,525) For gastric cancer, the screening rates decreased from 61.9% in 2019 (7,194,489/11,625,627) to 54.6% in 2020 (6,244,491/11,439,246). In March, during the first wave, the screening rates declined sharply (percentage change: colorectal, 56.6%; gastric, 57.3%). Although the screening rates had rebounded aftermath, they declined again in December, during the third wave (percentage change: colorectal, 17.0%; gastric, 13.8%). According to specific-age group, we found a substantial decline in screening rates for older adults aged 80~84, and those over 85 (percentage change: colorectal, 19.0% & 23.0%; gastric, 17.4% & 25.1% respectively).

Conclusion: During the COVID-19 pandemic, the screening rates for both colorectal and gastric cancer decreased. There was a substantial decline during the first and the third waves of the epidemic, in March and in December. The older adults group showed the highest reduction in screening rates. However, comparing the screening rate by region and sex, we did not find a significant difference. Delayed cancer diagnosis or excess death due to distraction effect of the COVID-19 pandemic has not yet been detected in Korea, therefore, further studies are needed.

Citation Format: Seung Hee Seo, Hyeree Park, Jong Heon Park, Bhumsuk Keam, Shin Hye Yoo, Aesun Shin. Colorectal and gastric cancer screening rates in Korea during the COVID-19 pandemic [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 433.

Abstract 441: The impact of the COVID-19 on the screening of breast and cervical cancer in Korea

Background: The COVID-19 pandemic has affected use of healthcare services, especially disrupting individual participation in cancer screening programs. The National Cancer Screening Program (NCSP) of Korea provides screening services for six common cancers - stomach, liver, colorectum, breast, cervix, and lung. As complete national lockdown measures were not implemented, the NCSP continued operation during the three major COVID-19 waves in Korea, which allowed us to assess the changes in health-seeking behavior. We examined the cancer screening rates for breast and cervical cancers among NCSP participants in different geographic regions and by age group, in association with the COVID-19 pandemic.

Methods: From the National Health Insurance Service database, we obtained information on the number of eligible population and NCSP participants from January 2019 to December 2020. The target group for biennial mammography screening is women aged 40 years and over, and that for biennial pap smear is women aged 20 years and over. We compared monthly screening rates for breast and cervical cancer between 2020 vs 2019 and described them as a percentage change.

Results: The overall cancer screening rate has decreased in both cancers in 2020 compared with that of 2019: breast (55.8% vs 63.8%), cervical (52.2% vs 57.8%). Screening rates for both cancers declined in all age groups in March and December of 2020, which corresponds to the first and third COVID-19 wave. The month of March 2020 had the sharpest drop in screening rates, by 57.9% for breast cancer and 43.7% for cervical cancer compared with March 2019. In June 2020, screening rates for both cancers rebounded compared with 2019 (breast, +29.2%; cervical, +26.3%), which remained higher compared with the same months in 2019 until November 2020. By December 2020, screening rates for both cancers have dropped, compared with December 2019 (breast, -19.5%; cervical, -21.0%). For breast cancer, the screening rate decreased in all age groups, and the largest decline was observed in women aged 80 years and over. Although the cervical cancer screening rate has been steadily increasing since 2010, it decreased in all age groups in 2020 compared with that of 2019, with the exception of the 20-29 age group. Considering social distancing measures that were implemented nationwide during each COVID-19 wave, we observed a similar pattern of cancer screening rates in major cities.

Conclusions: It was observed that after the two major COVID-19 waves, mammography and pap smear rates declined compared with that of 2019. The largest decline in cancer screening rates was seen in elderly women. The pattern of screening rate changes was comparable according to geographic region. In contrast to reports showing a deficit in cancer screening in other countries, our results suggest a substantial recovery in cancer screening in Korea. Additional analyses are needed to assess the effect of the 6-month extension of NCSP.

Citation Format: Hyeree Park, Seung Hee Seo, Jong Heon Park, Bhumsuk Keam, Shin Hye Yoo, Aesun Shin. The impact of the COVID-19 on the screening of breast and cervical cancer in Korea [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 441.

Aggressiveness of care in the last days of life in the emergency department of a tertiary hospital in Korea

Background

High-quality end-of-life (EOL) care requires both comfort care and the maintenance of dignity. However, delivering EOL in the emergency department (ED) is often challenging. Therefore, we aimed to investigate characteristics of EOL care for dying patients in the ED.

Methods

We conducted a retrospective cohort study of patients who died of disease in the ED at a tertiary hospital in Korea between January 2018 and December 2020. We examined medical care within the last 24 h of life and advance care planning (ACP) status.

Results

Of all 222 disease-related mortalities, 140 (63.1%) were men, while 141 (63.5%) had cancer. The median age was 74 years. As for critical care, 61 (27.5%) patients received cardiopulmonary resuscitation, while 80 (36.0%) received mechanical ventilation. The absence of serious illness (p = 0.011) and the lack of an advance statement (p < 0.001) were both independently associated with the receipt of more critical care. Only 70 (31.5%) patients received comfort care through opioids. Younger patients (< 75 years) (p = 0.002) and those who completed life-sustaining treatment legal forms (p = 0.001) received more comfort care. While EOL discussions were initiated in 150 (67.6%) cases, the palliative care team was involved only in 29 (13.1%).

Conclusions

Patients in the ED underwent more aggressive care and less comfort care in a state of imminent death. To ensure better EOL care, physicians should minimize redundant evaluations and promptly introduce ACP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00988-3.

The Impact of COVID-19 on Cancer Care in a Tertiary Hospital in Korea: Possible Collateral Damage to Emergency Care

Objectives

We investigated the impact of the COVID-19 pandemic on cancer care in a tertiary hospital of South Korea without the specific lockdown measures.

Methods

A retrospective cohort of cancer patients from one of the largest tertiary hospitals in South Korea was used to compare the healthcare utilization in different settings (outpatient clinic, emergency department (ED), and admission) between the period of January 1 and December 31, 2020 and the same time period in 2019. The percent changes in healthcare utilization between two periods were calculated.

Results

A total of 448,833 cases from the outpatient cohort, 26,781 cases from the ED cohort, and 14,513 cases from the admission cohort were reviewed for 2019 and 2020. The total number of ED visit cases significantly decreased in 2020 than in 2019 by 18.04%, whereas the proportion of cancer patients maintained. The reduction in ED visits was more prominent in cases with COVID-19 suspicious symptoms, with high acuity, and those who lived in non-capital city area. There were no significant changes in the number of total visits and new cases in the outpatient clinic between two periods. No significant differences in the total number of hospitalizations were observed between two periods.

Conclusion

During the pandemic, the number of ED visits significantly decreased, while the use of outpatient clinic and hospitalizations were not affected. Cancer patients' ED visits decreased after the COVID-19 outbreak, suggesting the potential for collateral damage outside the hospital if the ED could not be reached in a timely manner.

Problems Related to the Act on Decisions on Life-Sustaining Treatment and Directions for Improvement

The Act on Decisions on Life-Sustaining Treatment has been in effect since 2018 for end-of-life patients. However, only 20~25% of deaths of terminally ill patients comply with the law, while the remaining 75~80% do not. There is significant confusion in how the law distinguishes between those in the terminal stage and those in the dying process. These 2 stages can be hard to distinguish, and they should be understood as a single unified "terminal stage." The number of medical institutions eligible for life-sustaining treatment decisions should be legally expanded to properly reflect patients' wishes. To prevent unnecessary suffering resulting from futile life-sustaining treatment, life-sustaining treatment decisions for terminal patients without the needed familial relationships should be permitted and made by hospital ethics committees. Adult patients should be permitted to assign a legal representative appointed in advance to represent them. Medical records can be substituted for a patient's judgment letter (No. 9) and an implementation letter (No. 13) for the decision to suspend life-sustaining treatment. Forms 1, 10, 11, and 12 should be combined into a single form. The purpose of the Life-sustaining Medical Decisions Act is to respect patients' right to self-determination and protect their best interests. Issues related to the act that have emerged in the 3 years since its implementation must be analyzed, and a plan should be devised to improve upon its shortcomings.

Practical Considerations in Providing End-of-Life Care for Dying Patients and Their Family in the Era of COVID-19

In the era of coronavirus disease 2019 (COVID-19), social distancing and strict visitation policies at hospitals have made it difficult for medical staff to provide high-quality end-of-life (EOL) care to dying patients and their families. There are various issues related to EOL care, including psychological problems of patients and their families, difficulties in EOL decision-making, the complicated grief of the bereaved family, moral distress, and exhaustion of medical staff. In relation to these issues, we aimed to discuss practical considerations in providing high-quality EOL care in the COVID-19 pandemic. First, medical staff should discuss advance care planning as early as possible and use the parallel planning strategy. Second, medical staff should play a role in facilitating patient-family communication. Third, medical staff should actively and proactively evaluate and alleviate dying patients' symptoms using non-verbal communication. Lastly, medical staff should provide care for family members of the dying patient, who may be particularly vulnerable to post-bereavement problems in the COVID-19 era. Establishing a system of screening high-risk individuals for complicated grief and connecting them to bereavement support services might be considered. Despite the challenging and limited environment, providing EOL care is essential for patients to die with dignity in peace and for the remaining family to return to life after the loved one's death. Efforts considering the practical issues faced by all medical staff and healthcare institutions caring for dying patients should be made.

Analysis of Cancer Patient Decision-making and Health Service Utilization after Enforcement of the Life-Sustaining Treatment Decision-Making Act in Korea

Purpose

This study aimed to confirm the decision-making patterns for life-sustaining treatment (LST) and analyze medical service utilization changes after enforcement of the Life-Sustaining Treatment Decision-Making Act.

Materials and Methods

Of 1,237 patients who completed legal forms for life-sustaining treatment (hereafter called the LST form) at three academic hospitals and died at the same institutions, 1,018 cancer patients were included. Medical service utilization and costs were analyzed using claims data.

Results

The median time to death from completion of the LST form was three days (range, 0 to 248 days). Of these, 517 people died within two days of completing the document, and 36.1% of all patients prepared the LST form themselves. The frequency of use of the intensive care unit, continuous renal replacement therapy, and mechanical ventilation was significantly higher when the families filled out the form without knowing the patient’s intention. In the top 10% of the medical expense groups, the decision-makers for LST were family members rather than patients (28% patients vs. 32% family members who knew and 40% family members who did not know the patient’s intention).

Conclusion

The cancer patient’s own decision-making rather than the family’s decision was associated with earlier decision-making, less use of some critical treatments (except chemotherapy) and expensive evaluations, and a trend toward lower medical costs.

Difficulties Doctors Experience during Life-Sustaining Treatment Discussion after Enactment of the Life-Sustaining Treatment Decisions Act: A Cross-Sectional Study

Purpose

This study aimed to investigate difficulties doctors experience during life-sustaining treatment (LST) discussion with seriously ill patients and their families after enactment of the LST Decisions Act in February 2018.

Materials and Methods

A cross-sectional survey was conducted in a tertiary hospital in the Republic of Korea in August 2019. Six hundred eighty-six doctors who care for seriously ill patients were given a structured questionnaire, and difficulties during the discussion were examined.

Results

One hundred thirty-two doctors completed the questionnaire. Eighty-five percent answered they treat cancer patients. Most (86.4%) experienced considerable difficulties during LST discussions (mean score, 7.4±1.6/10). The two most common difficulties were communication with patients and family and determining when to discuss LST. Two-thirds of doctors found direct discussions with the patient difficult and said they would initiate LST discussions only with family. LST discussions were actually initiated later than considered appropriate. When medically assessing whether the patient is imminently dying, 56% of doctors experienced disagreements with other doctors, which could affect their decisions.

Conclusion

This study found that most doctors experienced serious difficulties regarding communication with patients and family and medical assessment of dying process during LST discussions. To alleviate these difficulties, further institutional support is needed to improve the LST discussion between doctors, patients, and family.

Barriers to Counseling on Advance Directives Based on Counselors' Experiences: Focus Group Interviews

Purpose

In Korea, since the Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End of Life was implemented in February 2018, advance directives (ADs) have become legally effective and should be documented after sufficient explanation by a registered counselor. However, little is known regarding the adequacy of current AD counseling. This qualitative study aimed to explore the barriers to AD counseling based on counselors' experiences.

Methods

We conducted focus group interviews using purposive sampling. Seven counselors working at hospitals, community health institutions, and non-profit organizations participated in this study. They were asked about the challenges and problems they encountered during AD counseling.

Results

Three themes emerged from this study; 1) issues regarding consistency in AD counseling, 2) issues regarding AD counselors' competency and work environment, and 3) issues regarding the adequacy of the service system. The interviewees stated that the lack of a manual for standardized service made AD counseling inconsistent. The limited competency and poor work environment of counselors were pointed out as major barriers. The interviewees also stated that a proper service system considering individual circumstances is absent.

Conclusion

The goals of AD counseling should be clarified and guidance should be implemented for providing standardized services. Further efforts to enhance the competency of AD counselors and to improve their working conditions are needed. Establishing an integrated framework for an adequate service system is also essential to overcome systematic barriers to AD counseling.

Impact of family caregivers' awareness of the prognosis on their quality of life/depression and those of patients with advanced cancer: a prospective cohort study

PURPOSE

A caregiver's prognostic awareness can affect clinical decisions for the patient. The purpose of this study was to examine the impact of family caregivers' prognostic awareness on the quality of life (QOL) and emotional state of both patients with advanced cancer and their caregivers.

METHODS

This prospective cohort study was conducted from December of 2016 to January of 2018. A total of 159 patients with advanced cancer and an equal number of caregivers participated. The investigation tools used include the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C15-Palliative, the McGill Quality of Life Questionnaire, and the Patient Health Questionnaire-9, and evaluation was performed at baseline, 3 months, and 6 months. Covariance analysis with a general linear modeling was used to compare changes in quality of life scores according to the caregivers' awareness of the prognosis.

RESULTS

Mean patient overall QOL score increased in the group of caregivers who were aware of prognosis and decreased in the caregivers who were not aware of the prognosis (p = 0.018). The changes over time in the patients' QOL scores associated with symptoms improved with caregiver awareness (pain, p = 0.017; dyspnea, p = 0.048; appetite loss, p = 0.045). The percentage of depressed patients was smaller after 3 months in the group with caregivers aware of the prognosis (baseline to 3 months p = 0.028). Caregivers who did not understand their patients' prognosis exhibited better existential well-being (p = 0.036), and the incidence of depression was lower in this group at 3 months (p = 0.024).

CONCLUSION

Caregivers' prognostic awareness may improve the quality of life and mood in patients with advanced cancer; however, this awareness may harm the quality of life and mood of the caregivers. These results may aid in developing in-depth interventions regarding prognosis for both patients and their caregivers.

Enhanced antimicrobial stewardship based on rapid phenotypic antimicrobial susceptibility testing for bacteraemia in patients with haematological malignancies: a randomized controlled trial

OBJECTIVES

Recently, rapid phenotypic antimicrobial susceptibility testing (AST) based on microscopic imaging analysis has been developed. The aim of this study was to determine whether implementation of antimicrobial stewardship programmes (ASP) based on rapid phenotypic AST can increase the proportion of patients with haematological malignancies who receive optimal targeted antibiotics during early periods of bacteraemia.

METHODS

This randomized controlled trial enrolled patients with haematological malignancies and at least one positive blood culture. Patients were randomly assigned 1:1 to conventional (n = 60) or rapid phenotypic (n = 56) AST. The primary outcome was the proportion of patients receiving optimal targeted antibiotics 72 hr after blood collection for culture.

RESULTS

The percentage receiving optimal targeted antibiotics at 72 hr was significantly higher in the rapid phenotypic AST group (45/56, 80.4%) than in conventional AST group (34/60, 56.7%) (relative risk (RR) 1.42, 95% confidence interval (CI) 1.09-1.83). The percentage receiving unnecessary broad-spectrum antibiotics at 72 hr was significantly lower (7/26, 12.5% vs 18/60, 30.0%; RR 0.42, 95% CI 0.19-0.92) and the mean time to optimal targeted antibiotic treatment was significantly shorter (38.1, standard deviation (SD) 38.2 vs 72.8, SD 93.0 hr; p < 0.001) in the rapid phenotypic AST group. The mean time from blood collection to the AST result was significantly shorter in the rapid phenotypic AST group (48.3, SD 17.6 vs 83.1, SD 22.2 hr).

DISCUSSION

ASP based on rapid phenotypic AST can rapidly optimize antibiotic treatment for bacteraemia in patients with haematological malignancy. Rapid phenotypic AST can improve antimicrobial stewardship in immunocompromised patients.

Implication of the Life-Sustaining Treatment Decisions Act on End-of-Life Care for Korean Terminal Patients

Purpose

Life-sustaining treatment (LST) decisions for patients and caregivers at the end-of-life (EOL) process are supported by the “Act on Hospice and Palliative Care and Decisions on LST for Patients at the EOL,” enforced in February 2018. It remains unclear whether the act changes EOL decisions and LST implementation in clinical practice. For this study, we investigated patients’ decision-making regarding LSTs during the EOL process since the act’s enforcement.

Materials and Methods

Retrospective reviews were conducted on adult patients who were able to decide to terminate LST and died at Seoul National University Hospital between February 5, 2018, and February 5, 2019. We examined demographics, who made the decisions, the type and date of documentation confirming patient's LST, and whether the LST was withheld or withdrawn.

Results

Of 809 patients who were enrolled, 29% (n=231) completed forms regarding LST themselves, and 71% (n=578) needed family members to decide. The median time from confirmation of the EOL process to death and from the Advance Statement to death were 2 and 5 days, respectively (both ranges, 0 to 244). In total, 90% (n=727) of patients withheld treatment, and 10% (n=82)withdrew it. We found a higher withdrawal rate when family members made the decisions (13.3% vs. 1.7%, p < 0.001).

Conclusion

After the act’s enforcement, withdrawing LSTs became lawful and self-determination rates increased. Family members still make 71% of decisions regarding LSTs, but these are often inconsistent with the patients’ wishes; thus, further efforts are needed to integrate the new act into clinical practice.

Poor prognostic factors in human papillomavirus-positive head and neck cancer: who might not be candidates for de-escalation treatment?

BACKGROUND/AIMS

Since patients with human papillomavirus (HPV)-associated head and neck squamous cell carcinoma (HNSCC) have favorable outcomes after treatment, treatment de-escalation for these patients is being actively investigated. However, not all HPV-positive HNSCCs are curable, and some patients have a poor prognosis. The purpose of this study was to identify poor prognostic factors in patients with HPV-positive HNSCC.

METHODS

Patients who received a diagnosis of HNSCC and tested positive for HPV from 2000 to 2015 at a single hospital site (n = 152) were included in this retrospective analysis. HPV typing was conducted using the HPV DNA chip assay or liquid bead microarray system. Expression of p16 in the tumors was assessed by immunohistochemistry. To determine candidate factors associated with overall survival (OS), univariate and multivariable Cox regression analyses were performed.

RESULTS

A total of 152 patients with HPV-positive HNSCC were included in this study; 82.2% were male, 43.4% were current or former smokers, and 84.2% had oropharyngeal cancer. By univariate analysis, old age, performance status ≥ 1, non-oropharyngeal location, advanced T classification (T3-4), and HPV genotype 18 were significantly associated with poor OS. By multivariable analysis, performance status ≥ 1 and non-oropharyngeal location were independently associated with shorter OS (hazard ratio [HR], 4.36, p = 0.015; HR, 11.83, p = 0.002, respectively). Furthermore, HPV genotype 18 positivity was also an independent poor prognostic factor of OS (HR, 10.87, p < 0.001).

CONCLUSION

Non-oropharyngeal cancer, poor performance status, and HPV genotype 18 were independent poor prognostic factors in patients with HPV-positive HNSCC. Patients with these risk factors might not be candidates for de-escalation treatment.

Development of a Nomogram to Predict the Recurrence Score of 21-Gene Prediction Assay in Hormone Receptor-Positive Early Breast Cancer

INTRODUCTION

A 21-gene prediction assay (Oncotype DX) is helpful to estimate benefit from adjuvant chemotherapy in patients with hormone receptor-positive, lymph node-negative early breast cancer. This study was conducted to develop a model to estimate high recurrence score (RS) using easily available clinicopathologic parameters in limited-resource countries.

PATIENTS AND METHODS

Hormone receptor-positive, lymph node-negative early breast cancer patients who underwent Oncotype DX were enrolled onto the training set (n = 192). The risk category range of the RS was the same as in the TAILORx study. The multivariable logistic regression model was used to identify significant variables associated with high RS. The independent validation set (n = 264) was established from patients of a different time period.

RESULTS

The median age in the training set was 47 years, and 78.0% were premenopausal. The number of patients with low RS (< 11), intermediate RS (11-25), and high RS (> 25) were 42 (22.0%), 122 (63.9%), and 27 (14.1%), respectively. High nuclear grade, no progesterone receptor expression, and high Ki-67 were associated with high RS, and these variables were used to construct the nomogram. It had significant discriminatory power in internal validation (area under the curve = 0.856) and in the validation set (area under the curve = 0.828). The calibration plot showed optimal agreement between predicted and actual probabilities in both sets.

CONCLUSION

A nomogram was successfully developed with 3 simple parameters. The probability of high RS can be easily and conveniently estimated using our nomogram. It might be useful to determine whether or not Oncotype DX is conducted in the TAILORx era. Future large-scale prospective studies are warranted.

Correction to: Priorities of a "good death" according to cancer patients, their family caregivers, physicians, and the general population: a nationwide survey

While recently extending that research, however, we discovered that 236 members of the general population were mistakenly duplicated by the investigating agency (Word Research) and 1241 were reported rather than 1005. Here, we present corrections and discuss the relevant data.

Abstract 1079: Prognostic role of tumor microenvironment in correlation with CD8+ T cells in TCGA pan-cancer

Purpose: Tumor microenvironment (TME) is a complex mixture of cells around tumor, showing different associations with tumor growth and survival outcomes. CD8+ T cell plays a key role in adaptive anti-tumor immunity and can predict favorable prognosis with better outcome from immunotherapy. However, little has been known whether various components of TME in correlation with CD8+ T cells affect prognosis. We aimed to investigate the prognostic role of immune cells in TME in correlation with CD8+ T cells using The Cancer Genome Atlas (TCGA) pan-cancer database.

Experimental Design: The fraction of 21 immune cell subpopulations in TME and CD8+ T cell were extracted from mRNA expression data obtained by RNA sequencing of the TCGA samples to which a deconvolution algorithm (CIBERSORT) was applied. The samples were classified into CD8low, CD8high-Xlow/int, and CD8high-Xhigh groups (X is a component of TME), and survival was compared between them in TCGA pan-cancer and each cancer cohort. To determine the associations between each cell type and treatment outcomes, we also evaluated the immune cell subpopulations with CD8+ T cell in patients treated with programmed death-1 blockades using previously reported data on the nCounter system by the PanCancer 730-Immune Panel (GEO accession number: GSE93157).

Results: Profiles of immune subpopulation in correlation with CD8+ T cell varied between different cancer types. In TCGA pan-cancer cohort with available survival data (N=8903), increased regulatory T cells (Treg) (P=2.48× 10-4), M1 and M2 macrophages (P=9.53× 10-3; P=4.72× 10-6, respectively), resting natural killer cells (P=7.29× 10-4), and activated dendritic cells (P=0.00579) were associated with poor prognosis despite high level of CD8+ T cells, whereas elevated germinal center follicular helper T cells (P=8.44 × 10-5) and naïve B cell (P=2.46× 10-7) were good prognostic subpopulations. By each cancer type, kidney cancers (renal papillary tumors and clear cell carcinoma) showed significantly poor prognostic role of Treg (Hazard ratio (HR) 2.59, 95% confidence interval (CI) 1.13 to 5.93; HR 1.62, 95% CI 1.07 to 2.45, respectively). In patients treated with immunotherapy (N=65), shorter progression-free survival was observed in CD8high-Treghigh group than in CD8high-Treglow/int group (P=0.0476). The fraction of CD8high-Treghigh group was higher in non-responders than in responders (15.6% vs. 5.0%).

Conclusions: Our findings suggest that differences in immune cell subpopulations even with high CD8+ T cell might determine the prognosis. Immunosuppressive components in TME such as Treg can be negative factor for both prognosis and response to immunotherapy. A large prospective study is needed to validate the negative predictive role of immunosuppressive TME for patients treated with immunotherapy.

Citation Format: Shin Hye Yoo, Changhee Park, Chan-Young Ock, Miso Kim, Bhumsuk Keam, Tae Min Kim, Dong-Wan Kim, Dae Seog Heo. Prognostic role of tumor microenvironment in correlation with CD8+ T cells in TCGA pan-cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1079.

Predictive Role of Temporal Changes in Intratumoral Metabolic Heterogeneity During Palliative Chemotherapy in Patients with Advanced Pancreatic Cancer: A Prospective Cohort Study

Metabolic intratumoral heterogeneity (ITH) is known to be related to cancer treatment outcome. However, information on the temporal changes in metabolic ITH during chemotherapy and the correlations between metabolic changes and treatment outcomes in patients with pancreatic cancer is sparse. We aimed to analyze the temporal changes in metabolic ITH and the predictive role of its changes in advanced pancreatic cancer patients who underwent palliative chemotherapy. Methods: We prospectively enrolled patients with unresectable locally advanced or metastatic pancreatic cancer before first-line palliative chemotherapy. ¹⁸F-FDG PET was performed at baseline and at the first response follow-up. SUVs, volumetric parameters, and textural features of the primary pancreatic tumor were analyzed. Relationships between the parameters at baseline and first follow-up were assessed, as well as changes in the parameters with treatment response, progression-free survival (PFS), and overall survival (OS). Results: Among 63 enrolled patients, the best objective response rate was 25.8% (95% confidence interval [CI], 14.6%-37.0%). The median PFS and OS were 7.1 mo (95% CI, 5.1-9.7 mo) and 10.1 mo (95% CI, 8.6-12.7 mo), respectively. Most parameters changed significantly during the first-line chemotherapy, in a way of reducing ITH. Metabolic ITH was more profoundly reduced in responders than in nonresponders. Multiple Cox regression analysis identified high baseline compacity (P = 0.023) and smaller decreases in SUV_peak (P = 0.007) and entropy gray-level cooccurrence matrix (P = 0.033) to be independently associated with poor PFS. Patients with a high carbohydrate antigen 19-9 (P = 0.042), high pretreatment SUV_peak (P = 0.008), and high coefficient of variance at first follow-up (P = 0.04) showed worse OS. Conclusion: Reduction in metabolic ITH during palliative chemotherapy in advanced pancreatic cancer patients is associated with treatment response and might be predictive of PFS and OS.

Prognostic value of the association between MHC class I downregulation and PD-L1 upregulation in head and neck squamous cell carcinoma patients

The purpose of this study was to evaluate the prognostic impact of major histocompatibility complex (MHC) class I expression and programmed death-ligand 1 (PD-L1) expression in patients with head and neck squamous cell carcinoma (HNSCC). A total of 158 patients with HNSCC were evaluated retrospectively. The expression of MHC class I and PD-L1 was analyzed in tumor specimens using immunohistochemistry. The association between MHC class I/PD-L1 expression and clinical outcome was evaluated by Kaplan-Meier and Cox regression analyses. Among 158 patients, 103 (65.2%) showed positive PD-L1 expression, and 20 (12.7%) showed no detectable expression of MHC class I. The frequency of PD-L1 positive expression with concomitant MHC class I loss was 7.0%. In the PD-L1-positive group, MHC class I loss was associated with a significantly worse survival compared with MHC class I positivity (median overall survival 39.3 months vs. not reached; P = 0.005), whereas MHC class I status provided no prognostic impact in the PD-L1 negative group. Neither PD-L1 nor MHC class I alone showed a significant difference in overall survival. The loss of MHC class I expression in PD-L1-positive HNSCC was associated with a poor clinical outcome. This suggested that MHC class I expression status might be useful for the prognosis of tumor progression in HNSCC when combined with PD-L1 expression status. External validation with enough numbers of participants in such subgroup should be needed for validation.

Prospective evaluation of metabolic intratumoral heterogeneity using 18F-FDG-PET-CT in patients with advanced gastric cancer receiving palliative chemotherapy

4059

Background: Metabolic intratumoral heterogeneity (ITH) gives important information on treatment response and prognosis. However, temporal changes in metabolic ITH and their associations with treatment outcome have not been reported yet in gastric cancer (GC). We aimed to evaluate the early changes in metabolic ITH and their predictive roles in advanced GC patients receiving palliative chemotherapy. Methods: Unresectable locally advanced or metastatic GC patients were prospectively enrolled before the first-line palliative chemotherapy and underwent 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET-CT) at baseline (T1) and at the first response evaluation follow-up (T2). SUVs (Standardized uptake values), volumetric parameters, and textural features including entropyHisto and contrastGLCM were extracted from the primary gastric tumor at T1, T2, and ΔT (T2-T1) was evaluated. Associations of these parameters with treatment response, progression-free survival (PFS), and overall survival (OS) were analyzed. Results: 87 patients were analyzed. Of 86 evaluable patients, 44 obtained partial response, 33 stable disease, and 8 progressed. The objective response rate was 51.8% (95% confidence interval [CI], 40.7% to 62.7%). The median PFS and OS were 7.3 months (95% CI, 5.4 to 8.2 months) and 11.5 months (95% CI, 10.1 to 14.3 months), respectively. From T1 to T2, metabolic ITH was significantly reduced ( P < 0.01), and the degree of decrease was greater in responders than in non-responders ( P < 0.01). By multiple Cox regression analyses adjusted for clinical variables, low entropyHisto at T2 ( P= 0.001), larger decreases in coefficient of variance ( P= 0.003) and contrastGLCM ( P= 0.017) were associated with better PFS. Low SUVpeak at T2 ( P= 0.001), larger decreases in coefficient of variance ( P= 0.032) and being a responder were associated with better OS. Conclusions: Early reduction in metabolic ITH is useful to predict response to palliative chemotherapy, PFS and OS in advanced GC patients.

Correction to: The impact of caregiver's role preference on decisional conflicts and psychiatric distresses in decision making to help caregiver's disclosure of terminal disease status

In the original publication of the article, the incorrect grant number HC13C1391 was published in the acknowledgement section. The correct grant number is HC15C1391.

Predictive role of temporal changes in intratumoral metabolic heterogeneity during palliative chemotherapy in advanced pancreatic cancer patients: A prospective cohort study

311

Background: Metabolic intratumoral heterogeneity (ITH) is known to be related with cancer treatment outcome. However, information on the temporal changes in metabolic ITH during chemotherapy and the correlations between metabolic changes and treatment outcomes in patients with pancreatic cancer (PC) is sparse. We aimed to analyze the temporal changes in metabolic ITH and the predictive role of its changes in advanced PC patients who underwent palliative chemotherapy. Methods: We prospectively enrolled unresectable locally advanced or metastatic PC patients before initiation of first-line palliative chemotherapy. 18F-fluorodeoxyglucose positron emission tomography was performed at baseline (T1) and at the first response follow-up (T2). Standardized uptake values (SUVs), volumetric parameters, and textural features of the primary pancreatic tumor were analyzed. Relationships between the parameters at T1, T2, and changes in the parameters with response to therapy, progression-free survival (PFS), and overall survival (OS) were assessed. Results: Among 63 enrolled patients, the best objective response rate was 25.8% (95% confidence interval [CI], 14.6% to 37.0%). Sixteen (25.8%) patients who obtained partial response were classified as responders and 46 (74.2%) as nonresponders. The median PFS and OS were 7.1 months (95% CI, 5.1 to 9.7 months) and 10.1 months (95% CI, 8.6 to 12.7 months), respectively. Most of the parameters changed significantly during the first-line chemotherapy, in a way of reducing ITH. Metabolic ITH was more profoundly reduced in responders than in nonresponders. Multiple Cox regression analysis identified high baseline compacity ( P = 0.023) and smaller decreases in SUVpeak ( P = 0.007) and entropyGLCM ( P = 0.033) to be independently associated with poor PFS. Patients with a high CA 19-9 ( P = 0.042), high pretreatment SUVpeak ( P = 0.008), and high coefficient of variance at T2 ( P = 0.04) showed worse OS. Conclusions: Reduction in metabolic ITH during palliative chemotherapy in advanced PC patients is associated with response to therapy and might be predictive of PFS and OS.

Early development of de novo hepatocellular carcinoma after direct-acting agent therapy: Comparison with pegylated interferon-based therapy in chronic hepatitis C patients

Patients with chronic hepatitis C who achieve a sustained viral response after pegylated interferon therapy have a reduced risk of hepatocellular carcinoma, but the risk after treatment with direct-acting antivirals is unclear. We compared the rates of early development of hepatocellular carcinoma after direct-acting antivirals and after pegylated interferon therapy. We retrospectively analysed 785 patients with chronic hepatitis C who had no history of hepatocellular carcinoma (211 treated with pegylated interferon, 574 with direct-acting antivirals) and were followed up for at least 24 weeks after antiviral treatment. De novo hepatocellular carcinoma developed in 6 of 574 patients receiving direct-acting antivirals and in 1 of 211 patients receiving pegylated interferon. The cumulative incidence of early hepatocellular carcinoma development did not differ between the treatment groups either for the whole cohort (1.05% vs 0.47%, P = .298) or for those patients with Child-Pugh Class A cirrhosis (3.73% vs 2.94%, P = .827). Multivariate analysis indicated that alpha-fetoprotein level >9.5 ng/mL at the time of end-of-treatment response was the only independent risk factor for early development of hepatocellular carcinoma in all patients (P < .0001, hazard ratio 176.174, 95% confidence interval 10.768-2882.473) and in patients treated with direct-acting agents (P < .0001, hazard ratio 128.402, 95% confidence interval 8.417-1958.680). In conclusion, the rate of early development of hepatocellular carcinoma did not differ between patients treated with pegylated interferon and those treated with direct-acting antivirals and was associated with the serum alpha-fetoprotein level at the time of end-of-treatment response.

Comparison of attitudes towards five end-of-life care interventions (active pain control, withdrawal of futile life-sustaining treatment, passive euthanasia, active euthanasia and physician-assisted suicide): a multicentred cross-sectional survey of Korean patients with cancer, their family caregivers, physicians and the general Korean population

OBJECTIVES

This study determined attitudes of four groups-Korean patients with cancer, their family caregivers, physicians and the general Korean population-towards five critical end-of-life (EOL) interventions-active pain control, withdrawal of futile life-sustaining treatment (LST), passive euthanasia, active euthanasia and physician-assisted suicide.

DESIGN AND SETTING

We enrolled 1001 patients with cancer and 1006 caregivers from 12 large hospitals in Korea, 1241 members of the general population and 928 physicians from each of the 12 hospitals and the Korean Medical Association. We analysed the associations of demographic factors, attitudes towards death and the important components of a 'good death' with critical interventions at EoL care.

RESULTS

All participant groups strongly favoured active pain control and withdrawal of futile LST but differed in attitudes towards the other four EoL interventions. Physicians (98.9%) favoured passive euthanasia more than the other three groups. Lower proportions of the four groups favoured active euthanasia or PAS. Multiple logistic regression showed that education (adjusted OR (aOR) 1.77, 95% CI 1.33 to 2.36), caregiver role (aOR 1.67, 95% CI 1.34 to 2.08) and considering death as the ending of life (aOR 1.66, 95% CI 1.05 to 1.61) were associated with preference for active pain control. Attitudes towards death, including belief in being remembered (aOR 2.03, 95% CI 1.48 to 2.79) and feeling 'life was meaningful' (aOR 2.56, 95% CI 1.58 to 4.15) were both strong correlates of withdrawal of LST with the level of monthly income (aOR 2.56, 95% CI 1.58 to 4.15). Believing 'freedom from pain' negatively predicted preference for passive euthanasia (aOR 0.69, 95% CI 0.55 to 0.85). In addition, 'not being a burden to the family' was positively related to preferences for active euthanasia (aOR 1.62, 95% CI 1.39 to 1.90) and PAS (aOR 1.61, 95% CI 1.37 to 1.89).

CONCLUSION

Groups differed in their attitudes towards the five EoL interventions, and those attitudes were significantly associated with various attitudes towards death.

Low-dose nivolumab can be effective in non-small cell lung cancer: alternative option for financial toxicity

Objectives

Nivolumab is used at 3 mg/kg or fixed doses of 240 mg every 2 weeks. There was no dose–response/toxicity relationship of nivolumab. This study evaluated the efficacy of low-dose nivolumab as an alternative to the financial toxicity of standard-dose nivolumab in treatment of non-small cell lung cancer (NSCLC).

Methods

Outcomes of patients with NSCLC treated with nivolumab as a routine practice at two tertiary hospitals in Korea were retrospectively analysed. Patients who could not afford standard nivolumab treatment received low-dose nivolumab (20 or 100 mg fixed dose every 3 weeks). Others received standard dose of 3 mg/kg every 2 weeks. Progression-free survival (PFS) and overall survival (OS) were measured and compared between low-dose and standard-dose groups in overall and stratified analyses according to programmed death-ligand 1 (PD-L1) status.

Results

Among the 47 patients with NSCLC, 18 received low-dose nivolumab. PD-L1 positivity was observed in 13 (27.7%) patients and did not differ between the groups. During 5.2 months of follow-up, the objective response rate was 13.8% in the standard-dose group and 16.7% in the low-dose group (p=0.788). Dosing of nivolumab or PD-L1 expression did not significantly affect PFS or OS.

Conclusion

Low-dose nivolumab can be effective in NSCLC and is worth considering as an alternative option to reducing financial toxicity. The efficacy of low-dose nivolumab requires study.

Priorities of a "good death" according to cancer patients, their family caregivers, physicians, and the general population: a nationwide survey

PURPOSE

Understanding the concept of a "good death" is crucial to end-of-life care, but our current understanding of what constitutes a good death is insufficient. Here, we investigated the components of a good death that are important to the general population, cancer patients, their families, and physicians.

METHODS

We conducted a stratified nationwide cross-sectional survey of cancer patients and their families from 12 hospitals, physicians from 12 hospitals and the Korean Medical Association, and the general population, investigating their attitudes toward 10 good-death components.

FINDINGS

Three components-"not be a burden to the family," "presence of family," and "resolve unfinished business"-were considered the most important components by more than 2/3 of each of the three groups, and an additional three components-"freedom from pain," "feel that life was meaningful," and "at peace with God"-were considered important by all but the physicians group. Physicians considered "feel life was meaningful," "presence of family," and "not be a burden to family" as the core components of a good death, with "freedom from pain" as an additional component. "Treatment choices' followed, "finances in order," "mentally aware," and "die at home" were found to be the least important components among all four groups.

CONCLUSION

While families strongly agreed that "presence of family" and "not be a burden to family" were important to a good death, the importance of other factors differed between the groups. Health care providers should attempt to discern each patient's view of a good death.

Generalization and representativeness of phase III immune checkpoint blockade trials in non-small cell lung cancer

Background

Strict eligibility criteria for patient enrollment in phase III trials raise questions regarding generalization to ineligible patients. We evaluated whether pivotal phase III trials of immune checkpoint blockades (ICBs) represent the overall population of non‐small cell lung cancer (NSCLC) patients.

Methods

We reviewed the inclusion and exclusion criteria of three phase III trials (CheckMate057, CheckMate017, and KEYNOTE‐010). Stage IIIB or IV NSCLC patients diagnosed from 2011 to 2013 at Seoul National University Hospital (cohort 1) were reviewed. We also analyzed the criteria in 53 patients with NSCLC who were treated with nivolumab or pembrolizumab as routine practice (cohort 2).

Results

Among the 715 patients in cohort 1, 499 (69.9%) were ineligible for the three trials. Reasons for ineligibility included: no prior platinum doublet treatment (23.6%), lack of tissue availability (22.7%), Eastern Cooperative Oncology Group performance status > 1 (14.1%), steroid use (18.2%), active cerebral nervous system metastasis (8.3%), hepatitis B/hepatitis C/human immunodeficiency virus (8.0%), and no measurable lesion (7.3%). EGFR mutations were more common in the ineligible group. In cohort 2, 67.9% of patients were classified as ineligible. Treatment outcomes of ICB in cohort 2 appeared inferior to those in the three pivotal trials, with a response rate of 11.3% and median progression‐free survival of 1.67 months.

Conclusion

Only 30% of NSCLC patients were eligible for ICB phase III trials. The actual efficacy in the 70% of ineligible patients is unknown. These findings suggest a huge gap between practice‐changing phase III trials and the overall population of NSCLC patients.

Attitudes toward early palliative care in cancer patients and caregivers: a Korean nationwide survey

Integrated early palliative care (EPC) improves quality of life and reduces psychological distress in adult patients with cancer and caregivers, but attitudes toward EPC have been poorly studied. We aimed to investigate attitudes toward EPC in a nationwide survey of patients with cancer and caregivers. From July to October 2016, we administered nationwide questionnaires examining attitudes toward EPC in patients with cancer (n = 1001) and their families (n = 1006) from 12 Korean hospitals. When an individual considered EPC unnecessary, the reasons were collected and analyzed. Factors associated with perception of EPC were examined. A majority of patients (84.5%) and caregivers (89.5%) had positive attitudes toward EPC. The most common reasons for deeming EPC unnecessary were that EPC may be an obstacle to cancer treatment (patients: 37%; caregivers: 23%; respectively) or that they were not sure if EPC is beneficial (patients: 21%; caregivers: 24%; respectively). Financial burden as a reason was more evident in caregivers (23%) than in patients (17%). Male gender, age <50, early stage, intensive care unit admission, and not believing that dying people should prepare to practice charity were associated with patients’ negative attitudes. In caregivers, opposition to EPC was associated with not thinking death should be feared, not thinking people should be remembered, and lower educational level. Our findings showed that significant numbers of patients with advanced cancer and family caregivers showed positive attitudes toward EPC. However, more than 10% of participants did not consider EPC necessary. Physicians’ communication with patients and caregivers and financial support could help overcome the barriers of EPC.

Adult chronic myelomonocytic leukemia with trisomy 11: a case report

Chronic myelomonocytic leukemia (cmml) is an indolent disease in the category of myelodysplastic and myeloproliferative neoplasms, which can often evolve into acute leukemic neoplasms. Although cytogenetic abnormalities such as trisomy 8 or absence of chromosome Y are well known, few reports about cmml with trisomy 11 have been published. Here, we report a case of cmml with trisomy 11 as the sole chromosomal abnormality, resulting in a very poor outcome. Based on a bone marrow specimen, cmml-1 with trisomy 11 was diagnosed in a 79-year-old man presenting with anemia and atypical peripheral blood cells. Because of the patient's age, he was followed without receiving anticancer treatment. Two months after his diagnosis, the patient's leucocytosis and anemia rapidly worsened, with increasing numbers of immature peripheral cells, which was strongly suggestive of leukemic transformation. Because of acute kidney injury superimposed on chronic kidney disease that led to poor performance status, cytotoxic chemotherapy was not considered feasible, and the patient was transferred to a hospice care facility.