A permanent legacy of the pandemic? Outcomes of and staff views on the introduction of virtual clinics to an Irish oncology service

BACKGROUND

Virtual clinics were introduced to our practice in March 2020. We aimed to assess outcomes from virtual clinics and to assess staff views on them and their barriers to implementation nationally.

METHODS

We prospectively assessed outcomes from 53 planned virtual consultations in a cancer centre oncology outpatient department (April-July 2020). Thirty-two oncologists completed an online survey.

RESULTS

Visit durations ranged from < 5 min (n = 2, 4%) to 30 + min/patient (n = 9, 20%) (median: 18 min (range 4-141, IQR 10-30 min)). Median time spent preparing for patients who did not attend (n = 6, 11%) was 15 min (range 9-15 min). Most patients were scheduled for routine follow-up (n = 41, 87%), with some planned for an early in-person visit (n = 3) or investigation (n = 3). Where bloods had been requested (n = 25), samples had often not been taken (n = 20, 80%) or results were unavailable (n = 3, 12%). Different plans may have been agreed with two patients (4%) had they attended in-person. Virtual visits were perceived as faster by most doctors in the online survey (n = 26, 84%), with some (n = 5, 16%) reporting a difference of 10 min per patient. Many (n = 13, 42%) arranged earlier follow-up appointments. Low satisfaction was associated with difficulty with patient assessment (81%) or communication (63%), resource limitation (48%), or poor access to results of investigations (40%). The majority (n = 21, 67%) do not feel their virtual clinic quality is as good as in-person.

CONCLUSIONS

If virtual clinics are to play a long-term role in oncology, it is essential to monitor clinic quality and plan visits proactively.

Patient knowledge, personal experience, and impact of the first wave of the COVD-19 pandemic in an Irish oncology cohort

Background

Oncology patients have had to make many changes to minimise their exposure to COVID-19, causing stress. Despite education, some patients still do not recognise potential COVID symptoms.

Aims

We assessed patient knowledge of COVID, and its impact on their behaviours, concerns, and healthcare experience.

Methods

A 16-page questionnaire was distributed to 120 oncology patients attending the day unit of a tertiary Irish cancer centre for systemic anti-cancer therapy (May/June 2020). The Irish 7-day COVID incidence during this period ranged from 2 to 11 cases/100,000 people.

Results

One hundred and one responses were received, 1% had tested positive for COVID, and 31% had undergone testing. Participant insight into their knowledge about COVID and their own behaviour was limited in some cases. Seventy-five percent reported total compliance with restrictions, but many were not fully compliant. Self-reported confidence in knowledge was high, but did not predict demonstrated knowledge. Sixty percent did not recognise two or more symptoms; 40% did not self-identify as high-risk. Patients reported more health-related worry (72%), loneliness (51%), and lower mood (42%) since the pandemic began. Financial toxicity worsened, with increased financial worry (78%), reductions in household income (40%), and increased costs due to lockdown (62%). Use of facemasks introduced new communications barriers for 67% of those with hearing loss.

Conclusions

Despite self-reported confidence in knowledge, some patient’s recognition of COVID symptoms and the preventative strategies they should use are not optimal, highlighting the need for further education in this regard. COVID has been a significant stressor for patients and more practical, financial, and psychological supports are needed.

Supplementary information

The online version contains supplementary material available at 10.1007/s11845-022-02999-8.

Prevalence of Insomnia in an Oncology Patient Population: An Irish Tertiary Referral Center Experience

BACKGROUND

The NCCN Guidelines for Survivorship recommend dedicated sleep assessment. Reported insomnia prevalence in the general Irish population is 6% to 15%. Reported insomnia prevalence internationally among new/recently diagnosed patients with cancer varies from 30.9% to 54.3%. Insomnia prevalence has not been previously quantified in an Irish oncology cohort.

METHODS

A 40-item questionnaire was prospectively administered to ambulatory patients with cancer aged ≥18 years. Prespecified criteria to define insomnia syndrome combined those of the International Classification of Sleep Disorders, version 1, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The Hospital Anxiety and Depression Scale-Depression/Anxiety (HADS-D/A) was used to screen for potential confounding variables.

RESULTS

The response rate to the questionnaire was 87% (294/337). The predominant respondent age group was 55 to 64 years (26%; 77/294), 70.7% were female (208/294), and the most common cancer subtypes were breast (37.4%), colorectal (12.9%), and lung (12.2%). A total of 62% (183/294) of patients reported sleep disturbance after diagnosis, 63% (115/183) reported moderate/severe distress related to this disturbance, and 37% (61/183) reported a significant impact on physical function. Although 33% (98/294) met insomnia syndrome criteria, only 34% (33/98) of these patients had a preexisting history of sleep disturbance. Female sex, age <65 years, cancer subtype, alcohol consumption, and HADS-D/A ≥11 were associated with statistically significant higher odds ratios (OR) of insomnia syndrome. Multivariate analysis identified breast cancer (OR, 3.17; P=.01), age <65 years (OR, 1.8; P=.03), and alcohol consumption (OR, 2.3; P=.005) as independent predictors of insomnia syndrome.

CONCLUSIONS

Insomnia syndrome prevalence in this cohort is comparable to that reported previously and supports dedicated sleep assessment. This study identifies potentially modifiable risk factors for insomnia and demonstrates additional utility of the HADS score in identifying patients at risk.

Patient self-reported awareness of COVID: Overconfidence in knowledge, underestimation of risk

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Background: Oncology patients have had to adapt to minimize the risks of contracting COVID-19. We assessed patient knowledge of COVID, and the impact of the pandemic on their behaviours, concerns and healthcare experience, to identify any further education/quality improvement needs. Methods: Following ethical approval, a 16 page survey was distributed to 120 oncology patients attending the day unit of a tertiary Irish cancer center for systemic anti-cancer therapy (May/June 2020). The Irish COVID rate during this period was 33.8 new cases/day (pop. 4.9 million). Results: 101 responses were received. Cancer types included breast (19%), gastrointestinal (29%), head and neck (11%), and lung (13%). 31% had been tested for COVID; just 1 patient was positive. 100% were aware of advice to “cocoon” and reported good understanding of this. 75% reported complete compliance, but of those, 73% were not social-distancing within their homes, 22% received visitors, and 36% continued to shop in-store; of these, 42% shopped as/more often than pre-COVID. Of the 51 patients regularly shopping, many were not using risk-reduction strategies e.g. social distancing (22%), mask-wearing (20%), using “priority shopping’ hours (31%), avoiding public transport (26%). 94% felt confident/very confident in recognizing COVID symptoms, but 66% did not recognize two or more key symptoms from a list of 10, most frequently aches/pains (58%), fatigue (55%), altered smell/taste (33%) and dyspnea (14%). The number recognized did not correlate with confidence (p = 0.9) or desire for more information about COVID (p = 0.9). 40% did not feel they were at higher risk of contracting COVID, while 15% thought they were no more likely to be very sick than an average person if infected. Many did not know that chemotherapy, steroids, radiation, and immunotherapy can impact morbidity/mortality in COVID (31%, 70%, 44% and 49% respectively). 46% were somewhat/very fearful of COVID, but this did not strongly predict for either protective (e.g. mask-wearing: OR 1.1, 95% CI 0.3-4.8 p = 0.9), or risk behaviors (e.g. continuing to shop frequently: OR 0.5, 95% CI 0.1-1.4 p = 0.2). 66% would like more cancer specific information, particularly about prevention (45%) and symptoms (33%), with a preference for written information (74%). Conclusions: Despite self-reported confidence in knowledge, patient’s self-assessments of their risk category and the preventative strategies they should use may be inaccurate. Increased education about risk, cocooning and symptom recognition is necessary.

A review of head and neck squamous cell carcinoma response to taxane chemotherapy treatment in the pre versus post nivolumab era

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Background: Nivolumab received FDA approval as monotherapy for the treatment of recurrent or metastatic squamous cell carcinoma (SCC) of the head and neck after failure of platinum-based therapy in 2016. This approval was based on CheckMate 141. When patients ultimately relapse after immunotherapy in the second line setting, third line agents include single agent or combination treatment with a Taxane. Methods: We identified patients with metastatic or recurrent squamous cell head and neck cancer in an Irish hospital who had received Taxane chemotherapy after immunotherapy. We looked at outcomes for these patients including progression free survival (PFS) and overall survival (OS). We then identified a group of patients who received a Taxane following platinum failure in the pre-Nivolumab era to act as a comparator. Our objective was to compare PFS and OS to subsequent Taxane chemotherapy in the era before and after the introduction of Nivolumab as a therapy for platinum refractory head and neck SCC. Results: This retrospective cohort study was made up of 26 patients with metastatic or recurrent head and neck cancer. Primary sites included oropharynx, oral cavity, larynx and nasal cavity squamous cell cancers. The patients had a median age of 56. 13 of these patients identified had progressed on Nivolumab but remained fit for a next line of treatment. Median PFS in this group on Taxane based chemotherapy in the third line setting was 3.8 months. Median OS post progression on Nivolumab was 10 months. One patient remarkably had a complete response to Paclitaxel chemotherapy after progression on previous lines of treatment including immunotherapy, platinum chemotherapy and radiotherapy. We then identified a group of 13 patients with metastatic or recurrent head and neck cancer that had progressed on platinum based therapy in the era before Nivolumab was available. Median PFS after Taxane second line chemotherapy was 2.2 months. Median OS in this group after progressing on platinum treatment was 5.8 months. Conclusions: We set out to share our experience of real-world outcomes for head and neck cancer patients in the Nivolumab era. We found that our patients have shown to have an improved overall survival benefit with subsequent Taxane chemotherapy after immunotherapy compared to those who have not received immunotherapy. All fit patients should be considered for Taxane therapy post failure of Nivolumab.

ADAM-17: a novel therapeutic target for triple negative breast cancer

BACKGROUND

Validated targeted therapy is currently unavailable for patients with invasive breast cancer negative for oestrogen receptors, progesterone receptors and HER2 [i.e., those with triple-negative (TN) disease]. ADAM-17 is a protease involved in the activations of several ligands that bind to and promotes intracellular signalling from the EGFR/HER family of receptors.

PATIENTS AND METHODS

Expression of ADAM-17 was measured in 86 triple-negative and 96 non-triple-negative breast cancers. The ADAM-17 specific inhibitor, PF-5480090 (TMI-002, Pfizer) was tested in a panel of breast cancer cell lines for effects on functional outputs.

RESULTS

In this study we show using both Western blotting and immunohistochemistry that ADAM-17 is expressed at significantly higher levels in TN than non-TN breast cancers. Using a panel of breast cancer cell lines in culture, PF-5480090 was found to decrease release of the EGFR ligand, TGF-alpha, decrease levels of phosphorylated EGFR and block cell proliferation in a cell-type-dependent manner. Potentially important was the finding of a significant and moderately strong correlation between ADAM-17 activity and extent of proliferation inhibition by PF-5480090 (r = 0.809; p = 0.003; n = 11). Pretreatment of cell lines with PF-5480090 enhanced response to several different cytotoxic and anti-EGFR/HER agents.

CONCLUSION

It is concluded that inhibition of ADAM-17, especially in combination with chemotherapy or anti-EGFR/HER inhibitors, may be a new approach for treating breast cancer, including patients with TN disease.