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Amaram-Davila J, Reddy A, Arthur J, Narayanan S, Gogineni M, Mallipeddi T, Moraes ARD, Maddi R, Shelal Z, Urbauer D, Chen M, Bruera E. Efforts to Improve Naloxone Co-Prescription for Patients with Cancer Pain at Risk of Opioid Overdose. J Palliat Med 2023. [PMID: 37074064 DOI: 10.1089/jpm.2022.0389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
Importance: Naloxone can be lifesaving in an opioid-related overdose (OD). However, the co-prescription of take-home naloxone (THN) is not widely adopted in routine clinical practice. We implemented a pilot program focused on increasing clinicians' awareness of THN and observed if this impacts THN prescriptions for our patients with cancer pain receiving opioids. Intervention: In January 2020, we initiated an educational program by twice-weekly video presentations and installed pamphlets in all clinic workstations highlighting the risk factors for ODs. We retrospectively reviewed electronic health records (EHR) of randomly selected patient visits, 200 each from eight weeks before intervention (BI) and eight weeks after the intervention (AI). Data on patient characteristics, risk factors for ODs, and THN prescriptions were collected. Results: In all, 380 unique patients were eligible for analysis. The median age was 60, 53% female, and 70% Caucasian. Eighty-two percent (152) BI and 73% (142) AI carried risk factors for ODs (p = 0.13). THN was prescribed to 21% (32/152) BI and 26% (37/142) AI (p = 0.53). Morphine-equivalent daily dose (MEDD) ≥100 mg (30%) and pulmonary disease (25%) were the most prevalent risk factors. The patient's likelihood of receiving a THN prescription increased by 0.9% for every 1-milligram increase in MEDD (p < 0.001, 95% confidence interval: 1.006-1.011). Conclusion: The educational intervention did not significantly increase the frequency of THN prescriptions. More direct interventions, including automatic EHR triggers, may need to be tested in future trials.
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Affiliation(s)
- Jaya Amaram-Davila
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Santhosshi Narayanan
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Meghana Gogineni
- The University of Texas, University of Southwestern School of Medicine, Dallas, Texas, USA
| | - Tarun Mallipeddi
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aline Rozman De Moraes
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Rama Maddi
- Department of Leukemia, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Diana Urbauer
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Minxing Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
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Amaram-Davila J, Kim MJ, Reddy A, Edwards T, Dai J, Urbauer D, Shelal Z, Ross Y, Hosain M, Bruera E, Arthur J. Health Care Provider Attitudes and Beliefs Toward Nonmedical Opioid Use in Patients with Cancer Pain. J Palliat Med 2023; 26:248-252. [PMID: 36476019 PMCID: PMC9894589 DOI: 10.1089/jpm.2022.0293] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Data on health care providers' (HCPs') perceptions about patients with cancer pain and nonmedical opioid use (NMOU) are lacking. We examined the perceptions and attitudes of HCPs and assessed the usefulness of an interdisciplinary opioid stewardship program (OSP) while caring for these patients. Methods: An anonymous cross-sectional survey was conducted among the supportive care HCPs between September and November 2021. Results: Of 85 HCPs, 64 responded (75%) to the survey. Participants perceived that NMOU is underdiagnosed (42/64; 67%), and caring for such patients is difficult (58/64, 91%) and time consuming (54/64, 87%). A majority (50/51, 98%) were aware of the OSP, and (48/51; 94%) found it helpful. Conclusion: HCPs reported that NMOU is underdiagnosed and is challenging to manage. They endorsed the utility of an OSP in managing patients with concurrent cancer pain and NMOU. Future research should identify ways to standardize care and integrate OSP in routine supportive oncology practice.
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Affiliation(s)
- Jaya Amaram-Davila
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Min Ji Kim
- Department of Supportive and Palliative Care, Baylor University Medical Center, Dallas, Texas, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Tonya Edwards
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Jianliang Dai
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Diana Urbauer
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Yvette Ross
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Monawar Hosain
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer, Houston, Texas, USA
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Reddy A, Haider A, Arthur J, Hui D, Dalal S, Dev R, Tanco K, Amaram-Davila J, Hernandez F, Chavez P, De Moraes AR, Wu J, Nguyen K, Subbiah I, Epner D, Shelal Z, Guay MOD, Mallipeddi T, Bruera E. Levorphanol as a Second Line Opioid in Cancer Patients Presenting to an Outpatient Supportive Care Center: An Open-label Study. J Pain Symptom Manage 2023; 65:e683-e690. [PMID: 36720398 DOI: 10.1016/j.jpainsymman.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/27/2022] [Accepted: 01/13/2023] [Indexed: 01/30/2023]
Abstract
CONTEXT Levorphanol is a potent opioid agonist and NMDA receptor blocker with minimal drug interactions, and there are few reports of its use in cancer patients. OBJECTIVES We aimed to determine the frequency of successful opioid rotation (OR) to levorphanol and the median opioid rotation ratio (ORR) from Morphine Equivalent Daily Dose (MEDD). METHODS This is a prospective, single-group, interventional study. Cancer outpatients requiring an OR and receiving a MEDD of 60-300 mg were rotated to levorphanol using a ratio of 10:1 and assessed daily for 10-day. Successful OR was defined as a 2-point improvement in the Edmonton Symptom Assessment System (ESAS) pain score on day 10 or achieving the personalized pain goal between days 3-10 in patients with uncontrolled pain or resolution of opioid side effects (OSE) in those undergoing OR for OSE alone. The ORR to levorphanol was calculated using net-MEDD (MEDD before OR minus the MEDD of the breakthrough opioid used along with levorphanol after OR). RESULTS Forty patients underwent OR to levorphanol, and uncontrolled pain 35/40 (87.5%) was the most common indication. The median net-MEDD and levorphanol doses were 95 and 10 mg, respectively, and 33/40 (82.5%) had a successful OR with a median (IQR) ORR of 8.56 (7.5-10). Successful OR was associated with significant improvement in ESAS and OSE scale scores. There was a strong association between MEDD and levorphanol dose. CONCLUSION This study provided preliminary data that cancer patients could be successfully rotated to levorphanol using an ORR of 8.5. Levorphanol was associated with improved pain and symptom control and was well- tolerated.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Ali Haider
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rony Dev
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kimberson Tanco
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaya Amaram-Davila
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farley Hernandez
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul Chavez
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aline Rozman De Moraes
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jimin Wu
- Department of Biostatistics (J.W.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kristy Nguyen
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ishwaria Subbiah
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Daniel Epner
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marvin Omar Delgado Guay
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tarun Mallipeddi
- University of Tennessee Health Science Center College of Medicine (T.M.), Memphis, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine (A.R., A.H., J.A. D.H., S.D., R.D., K.T., J.A-D., F.H., P.C., A.R.D.M., K.N., I.S., D.E., Z.S., M.O.D.G., E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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4
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Hui D, Puac V, Shelal Z, Dev R, Hanneman SK, Jennings K, Ma H, Urbauer DL, Shete S, Fossella F, Liao Z, Blumenschein G, Chang JY, O'Reilly M, Gandhi SJ, Tsao A, Mahler DA, Bruera E. Effect of dexamethasone on dyspnoea in patients with cancer (ABCD): a parallel-group, double-blind, randomised, controlled trial. Lancet Oncol 2022; 23:1321-1331. [PMID: 36087590 PMCID: PMC10618956 DOI: 10.1016/s1470-2045(22)00508-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Systemic corticosteroids are commonly prescribed for palliation of dyspnoea in patients with cancer, despite scarce evidence to support their use. We aimed to assess the effect of high-dose dexamethasone versus placebo on cancer-related dyspnoea. METHODS The parallel-group, double-blind, randomised, controlled ABCD (Alleviating Breathlessness in Cancer Patients with Dexamethasone) trial was done at the at the University of Texas MD Anderson Cancer Center and the general oncology clinic at Lyndon B Johnson General Hospital (both in Houston, TX, USA). Ambulatory patients with cancer, aged 18 years or older, and with an average dyspnoea intensity score on an 11-point numerical rating scale (NRS; 0=none, 10=worst) over the past week of 4 or higher were randomly assigned (2:1) to receive dexamethasone 8 mg orally every 12 h for 7 days followed by 4 mg orally every 12 h for 7 days, or matching placebo capsules for 14 days. Pharmacists did permuted block randomisation with a block size of six, and patients were stratified by baseline dyspnoea score (4-6 vs 7-10) and study site. Patients, research staff, and clinicians were masked to group assignment. The primary outcome was change in dyspnoea NRS intensity over the past 24 h from baseline to day 7 (±2 days). Analyses were done by modified intention-to-treat (ie, including all patients who were randomly assigned and started the study treatment, regardless of whether they completed the study). Enrolment was stopped after the second preplanned interim analysis, when the futility criterion was met. This study is registered with ClinicalTrials.gov (NCT03367156) and is now completed. FINDINGS Between Jan 11, 2018, and April 23, 2021, we screened 2867 patients, enrolled 149 patients, and randomly assigned 128 to dexamethasone (n=85) or placebo (n=43). The mean change in dyspnoea NRS intensity from baseline to day 7 (±2 days) was -1·6 (95% CI -2·0 to -1·2) in the dexamethasone group and -1·6 (-2·3 to -0·9) in the placebo group, with no significant between-group difference (mean 0 [95% CI -0·8 to 0·7]; p=0·48). The most common all-cause grade 3-4 adverse events were infections (nine [11%] of 85 patients in the dexamethasone group vs three [7%] of 43 in the placebo group), insomnia (seven [8%] vs one [2%]), and neuropsychiatric symptoms (three [4%] vs none [0%]). Serious adverse events, all resulting in hospital admissions, were reported in 24 (28%) of 85 patients in the dexamethasone group and in three (7%) of 43 patients in the placebo group. No treatment-related deaths occurred in either group. INTERPRETATION High-dose dexamethasone did not improve dyspnoea in patients with cancer more effectively than placebo and was associated with a higher frequency of adverse events. These data suggest that dexamethasone should not be routinely given to unselected patients with cancer for palliation of dyspnoea. FUNDING US National Cancer Institute.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of General Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Veronica Puac
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeena Shelal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rony Dev
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sandra K Hanneman
- Cizik School of Nursing at UTHealth, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kristofer Jennings
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hilary Ma
- Department of General Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana L Urbauer
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanjay Shete
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Frank Fossella
- Department of Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George Blumenschein
- Department of Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joe Y Chang
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael O'Reilly
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Saumil J Gandhi
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anne Tsao
- Department of Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA; Respiratory Services, Valley Regional Hospital, Claremont, NH, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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5
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Reddy A, Sinclair C, Crawford GB, McPherson ML, Mercadante S, Hui D, Haider A, Arthur J, Tanco K, Dalal S, Dev R, Amaram-Davila J, Adile C, Liu D, Schuler U, Jammi S, Shelal Z, Del Fabbro E, Davis M, Bruera E. Opioid Rotation and Conversion Ratios Used by Palliative Care Professionals: An International Survey. J Palliat Med 2022; 25:1557-1562. [PMID: 35930252 PMCID: PMC9836667 DOI: 10.1089/jpm.2022.0266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 01/22/2023] Open
Abstract
Background: The opioid rotation ratios (ORRs) and conversion ratios (CRs) used worldwide among palliative care (PC) professionals to perform opioid rotations (ORs) and route conversions may have a wide variation. Methods: We surveyed PC professionals on opioid ratios used through email to the Multinational Association of Supportive Care in Cancer's PC study group and Twitter and Facebook posts between September and November 2020. Results: We received 370 responses from respondents from 53 countries: 276 (76%) were physicians, 46 (13%) advanced practice providers, 39 (11%) pharmacists, and 9 respondents did not report their profession. There were statistically significant variations in median CR from intravenous (IV) to oral morphine (2-3), IV to oral hydromorphone (2-4.5), ORR from IV hydromorphone to oral morphine (10-20), and ORR from transdermal fentanyl mcg/hour to oral morphine (2-3.5) across various groups. Conclusion: This survey highlights the wide variation in ORRs and CRs among PC clinicians worldwide and the need for further research to standardize practice.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christian Sinclair
- Division of Palliative Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Gregory B. Crawford
- Northern Adelaide Local Health Network, Adelaide, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Mary Lynn McPherson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ali Haider
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kimberson Tanco
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaya Amaram-Davila
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ulrich Schuler
- Universitätsklinikum Carl Gustav Carus, PalliativCentrum & Medizinische Klinik, Dresden, Germany
| | - Sheetal Jammi
- Candidate for Bachelor of Science in Biology and Bachelor of Science in Psychology, University of Houston, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Egidio Del Fabbro
- Department of Internal Medicine, Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
| | - Mellar Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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6
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Hui D, Puac V, Shelal Z, Dev R, Hanneman S, Jennings K, Ma HY, Urbauer DL, Shete S, Fossella FV, Liao ZX, Blumenschein GR, Chang JY, O'Reilly M, Gandhi S, Tsao AS, Mahler D, Bruera E. Alleviating breathlessness in patients with cancer with dexamethasone (ABCD): A parallel-group, double-blind, randomized clinical trial (RCT). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.12112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12112 Background: Systemic corticosteroids are commonly prescribed for palliation of dyspnea in patients with cancer; however, evidence to support their use is limited. A small RCT suggested that dexamethasone may be efficacious. In this confirmatory RCT, we compared the effect of high dose dexamethasone and placebo on dyspnea in patients with cancer. Methods: This NCI-funded, multi-site, double-blind, parallel group RCT enrolled ambulatory patients with cancer, age ≥18, dyspnea ≥4/10 and randomly assigned them to receive dexamethasone 8 mg orally every 12 hours for 7 days followed by 4 mg orally every 12 hours for 7 days or matching placebo capsules. Permuted block randomization (block size = 6, 2:1) was conducted, stratified by baseline dyspnea and study site. Patients, research staff and clinicians were blinded. The primary outcome was change in average dyspnea intensity assessed with a 0-10 numeric rating scale (0 = none, 10 = worst) between baseline and day 7. Secondary outcomes included the Edmonton Symptom Assessment Scale (ESAS) and adverse effects (CTCAE v4.02). Intention-to-treat analysis was conducted with linear models to compare between groups. The planned sample size of 201 patients provided 80% power to detect a mean difference of 1.0 between treatment groups with a two-sided α of 5%, assuming a standard deviation of 2.0 and 15% attrition. (Clinicaltrials.gov NCT03367156). Results: Between 1/11/2017 and 4/23/2021, we enrolled 149 patients and 128 received the blinded study interventions (dexamethasone n = 85, placebo n = 43). Enrollment was terminated early by the Data Safety Monitoring Board when futility criterion was met in pre-planned interim analysis. The mean change in dyspnea NRS intensity between baseline and day 7 was -1.6 (95% CI -2, -1.2) in the dexamethasone group and -1.6 (95% CI -2.3, -0.9) in the placebo group, with no significant between-group difference (mean 0, 95% CI -0.8, 0.7; P = 0.91). Secondary analyses showed that the dexamethasone group had a significantly better ESAS appetite (mean difference -1.2, 95% CI -2.2, -0.1; P = 0.03) and well being (mean -1, 95% CI -1.8, -0.2; P = 0.02), and worse ESAS anxiety (mean 1.1, 95% CI 0.3, 1.9; P = 0.01) and depression (mean 0.9, 95% CI 0.1, 1.7; P = 0.02) compared to placebo. Similar magnitude of changes in dyspnea and ESAS symptoms were observed by day 14. Adverse effects were reported more frequently in the dexamethasone group (any grade): insomnia (38% v. 12%), neuropsychiatric symptoms (31% vs. 7%), infections (21% v. 12%), dyspepsia (26% v. 12%), edema (18% v. 9%), hiccups (12% v. 7%), flushing (9% v. 5%) and respiratory distress (6% v. 0%). More patients in the dexamethasone group required hospitalization within 30 d of last study medication (25% vs. 7%, P = 0.02). Conclusions: High dose dexamethasone did not improve dyspnea in patients with cancer more than placebo and was associated with more adverse events. Clinical trial information: NCT03367156.
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Affiliation(s)
- David Hui
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Veronica Puac
- Palliative Care, MD Anderson Cancer Center, Houston, TX
| | - Zeena Shelal
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rony Dev
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sandra Hanneman
- Nursing Research, UT Health Science Center at Houston, Houston, TX
| | | | | | | | - Sanjay Shete
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - George R. Blumenschein
- Department of Thoracic and Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Saumil Gandhi
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anne S. Tsao
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX
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7
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Shih KK, Anderson AE, Brown J, Schuren N, Lyles MY, Williams J, Ross Y, Hampton M, Chen M, Cruz VDL, Nelson C, Stanton P, Shelal Z, Bruera E. Stay Home, Work Safe: Attitudes and Beliefs of Members of a Department of Palliative Care, Rehabilitation, and Integrative Medicine Regarding Remote Work during the COVID-19 Pandemic. J Palliat Med 2021; 25:757-767. [PMID: 34847735 DOI: 10.1089/jpm.2021.0343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The coronavirus disease 2019 (COVID-19) pandemic compelled rapid transition to work from home for the University of Texas MD Anderson Cancer Center Palliative, Rehabilitation, and Integrative Medicine (PRIM) department to ensure social distancing and prevention of transmission. Objectives: To survey the attitudes and beliefs of personnel toward remote work during the COVID-19 pandemic. Methods: One hundred forty-eight clinical, research, and administrative PRIM department employees were invited to participate in an anonymous voluntary survey in May 2020, two months after the beginning of the COVID-19 pandemic and transition to work from home in the geographic location of Houston, Texas. The survey comprised 25 questions, including employee demographics and attitudes and beliefs toward working from home and the COVID-19 pandemic. Results: Ninety-four percent (139) of employees responded, with high response rates among all three employee arms. The majority of respondents were female (74%), between the ages of 30 and 59 years (87%), had broadband Internet (93%), and shared office space before working from home (59%). There were overall positive reports of experience (87%) and emotional response (79%) toward working from home, especially for those more concerned about COVID-19 illness and spread, shared office space, and those reporting adequate resources and equipment for remote work. Clinical role, however, was associated with a less positive response (80%), less productivity (29%), and higher levels of stress (62%). Most of the department also reported increased emotional exhaustion (68%). When surveyed about permanently working from home, most of the department responded favorably (69%). Conclusions: The PRIM rapid transition to remote work was associated with positive perceptions by most members of the clinical, research, and administrative teams. Insight from this survey can serve as a model for future rapid transitions in remote work and merits follow-up studies to prepare us for a postpandemic work environment. Clinical Trial Registration number NCI-2021-01265.
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Affiliation(s)
- Kaoswi Karina Shih
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aimee E Anderson
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Natalie Schuren
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marilyn Y Lyles
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Yvette Ross
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marie Hampton
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Minxing Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vera De La Cruz
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christina Nelson
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Penny Stanton
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Hui D, Puac V, Shelal Z, Liu D, Maddi R, Kaseb A, Javle M, Overman M, Yennurajalingam S, Gallagher C, Bruera E. Fixed-Dose Netupitant and Palonosetron for Chronic Nausea in Cancer Patients: A Double-Blind, Placebo Run-in Pilot Randomized Clinical Trial. J Pain Symptom Manage 2021; 62:223-232.e1. [PMID: 33388382 DOI: 10.1016/j.jpainsymman.2020.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/26/2020] [Accepted: 12/29/2020] [Indexed: 11/17/2022]
Abstract
CONTEXT No clinical trials have examined the effect of netupitant/palonosetron (NEPA) on chronic nausea in patients with cancer. OBJECTIVES In this pilot randomized trial, we assessed the efficacy of NEPA and placebo on chronic nausea. METHODS This double-blind, parallel, randomized trial enrolled patients with cancer and chronic nausea for at least 1 month, intensity ≥4/10 and not on moderately or highly emetogenic systemic therapies. Patients started with a placebo run-in period from days 1 to 5; those without a placebo response proceeded to the double-blinded phase between days 6 to 15 (NEPA: placebo 2:1 ratio). The primary outcome was within-group change in average nausea over the 24 hours on a 0-10 numeric rating scale between day 5 and 15. RESULTS Among the 53 enrolled patients, 46 proceeded to placebo run-in and 33 had blinded treatment (22 NEPA and 11 placebo). We observed a statistically significant within-group improvement in nausea numeric rating scale between day 5 and 15 in the NEPA group (mean change, -2.0; 95% CI, -3.1 to -0.8) and the placebo group (mean change, -2.3; 95% CI, -3.9 to -0.7). A complete response was achieved in 8 (38%) patients in the NEPA group and 2 (20%) in the placebo group by day 15. No grade 3-4 toxicities were attributed to NEPA. There were no statistically significant between-group differences for the primary/secondary outcomes. CONCLUSIONS NEPA and placebo were associated with similar magnitude of within-group improvement in chronic nausea without significant between-group differences (Clinicaltrials.gov NCT03040726).
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA.
| | - Veronica Puac
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Rama Maddi
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ahmed Kaseb
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Overman
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Sriram Yennurajalingam
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Colleen Gallagher
- Department of Bioethics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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Subbiah IM, Amaram-Davila JS, Wong A, Shih KK, Anderson AE, Mendoza TR, Williams LA, Reddy AS, Joy MP, Harnden KM, Gaffney ML, Shelal Z, Maddi R, Nelson CLD, De la Cruz VJ, Elder SL, Ray DQ, Subbiah V, Hong DS, Bruera E. Technology-enhanced palliative care for patients with cancer on phase 1 clinical trials. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.tps12136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS12136 Background: Patients w advanced cancer participating in Phase I trials carry a high symptom burden from cancer and prior therapies. Our prior work shows patients on phase I trials w multiple active symptoms impacting their immediate quality of life with implications on toxicities and clinical outcomes on subsequent therapy. To identify an effective scalable approach to comprehensive symptom management for patients w adv cancer on phase I trials, we leveraged the increased technology use to design a technology-enhanced symptom management and palliative care intervention (TEC). Methods: Patients w adv cancer seen in the phase I clinic will be given the Edmonton Symptom Assessment System (ESAS), a validated patient-reported outcomes (PRO) tool of common cancer symptoms to identify those with a high symptom burden defined as ≥4 out of 10 on >1 ESAS symptom and a Global Distress Score (GDS) of ≥20. The GDS, a validated score of overall symptom intensity derived from the ESAS, is comprised of 6 physical (pain, fatigue, nausea, drowsiness, appetite, shortness of breath) & 2 psychosocial symptoms (depression, anxiety), and overall wellbeing. TEC is an innovative patient-centered care program of strategic vigorous symptom management where standard-of-care clinic visits are complemented by proactive symptom monitoring between clinic visits remotely and through provider-initiated calls. In this pilot randomized study, we will determine the effect sizes of High-Intensity TEC (HI-TEC; q3day remote PRO assessments w preset provider-initiated call bw visits), Low-Intensity TEC (LO-TEC; q5day remote PRO assessments w preset provider-initiated call bw visits), and Standard Palliative Care (no preset provider contact bw visits). Our guiding hypothesis is that a comprehensive, proactive, technology-enhanced symptom management program led by a Palliative Care team can mitigate the high symptom burden of patients with advanced cancers enrolling in phase I trials. The primary objective assesses the effect size of each TEC intervention on the GDS measure of symptom burden prior to C1D1 on phase I trial. Our working hypothesis is that HI-TEC and LO-TEC will be associated with a lower overall symptom burden signifying symptom optimization prior to starting on a phase I trial. Secondary objectives aim to estimate the effect size of TEC on the following: Symptom burden over 12 weeks on a phase I trial using ESAS, quality of life using FACIT-Sp, PRO-CTCAE and patient satisfaction using FAMCARE-P13. clinical outcomes at 6 months including OS, treatment outcomes (interruptions, dose reductions, discontinuation, time on trial) and quality metrics for end-of-life (EOL) (chemotherapy in the last 14 days of life, ICU admit in last 30 days of life, death without hospice or < 3d of hospice). Qualitatively assessment of patients’ + caregivers’ perceptions of receiving TEC-based cancer care. Clinical trial information: NCI-2020-07465.
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Affiliation(s)
| | | | - Angelique Wong
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Tito R. Mendoza
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Manju P Joy
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katie M Harnden
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Zeena Shelal
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rama Maddi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Desiree Q Ray
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vivek Subbiah
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David S. Hong
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX
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10
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Hui D, De La Rosa A, Shelal Z, Maxwell JP, Hosain M, De La Cruz MGJ, Vidal M, Reddy AS, Azhar A, Dev R, Tanco KC, Wong A, Heung Y, Delgado Guay M, Zhukovsky DS, Arthur JA, Reddy S, Yennu S, Bruera E. The impact of a web-based prognostic intervention on physicians’ prognostic confidence. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.12106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12106 Background: Clinicians often hesitate to discuss prognosis with patients because of prognostic uncertainty. The use of validated prognostic models may enhance prognostic confidence and/or prognostic accuracy. Prognostic confidence is a novel concept that has not been well studied and may support prognosis-based decision making. We examined the impact of a web-based prognostic intervention on physicians’ prognostic confidence. Methods: In this prospective study, palliative care specialists estimated the prognosis of patients with advanced cancer seen at an outpatient supportive care clinic using the temporal, surprise and probabilistic questions for 6 m, 3 m, 2 m, 1 m, 2 w, 1 w and 3 d survival. They then reviewed information from a web-based prognostic calculator ( www.predictsurvival.com ) that provided survival predictions from 7 validated prognostic scores, including the Palliative Prognostic Score, Palliative Prognostic Index, and Palliative Performance Status. The clinicians then provided their prognostic estimates post-intervention. The primary outcome was prognostic confidence (0-10 numeric rating scale, where 0 = not at all, 10 = most confident) before vs. after the study intervention. Secondary outcomes included (1) confidence to share the prognosis with patients, (2) confidence to make prognosis-based care recommendations (agreement = strongly agree or agree) and (3) prognostic accuracy. With 220 patients, we had 80% power to detect an effect size of 0.66 with 2-sided α 0.05. We compared the pre-post data using the Wilcoxon signed-rank test for the primary outcome and McNemar test for secondary outcomes. Results: 216 patients with advanced cancer (mean age 61, 50% female) were included and 154 (71%) died. The median (IQR) actual survival was 90 (39, 178) days; the median (IQR) predicted survival before and after intervention were 90 (60, 90) and 80 (60, 90) days, respectively. Prognostic confidence significantly increased after the intervention (pre vs. post: median 6 vs. 7, P < 0.001). A significantly greater proportion of clinicians reported that they felt confident enough about their prognostic estimate to share it with patients (44% vs. 74%, P < 0.001) and to formulate care recommendations (80% vs. 94%, P < 0.001) after the intervention. Prognostic accuracy did not differ significantly before and after the intervention, ranging from 72-100% for the temporal question, 45-97% for the surprise questions and 38%-100% for the probabilistic questions (P > 0.05). Conclusions: Among patients with advanced cancer seen at a supportive care clinic, the web-based prognostic intervention was associated with greater prognostic confidence and willingness to discuss prognosis, despite not significantly altering clinicians’ prognostic estimate or prognostic accuracy. Further research is needed to examine how prognostic tools may be able to augment prognostic discussions and clinical decision making.
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Affiliation(s)
- David Hui
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Zeena Shelal
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | - Ahsan Azhar
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rony Dev
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Angelique Wong
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yvonne Heung
- Loma Linda University Medical Center, Loma Linda, CA
| | | | | | | | - Suresh Reddy
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sriram Yennu
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX
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11
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Reddy A, Arthur J, Dalal S, Hui D, Subbiah I, Wu J, Anderson AE, Castro D, Joy M, Nweke C, Gogineni M, Maddi R, Rozman de Moraes A, Shelal Z, Bruera E. Rapid Transition to Virtual Care during the COVID-19 Epidemic: Experience of a Supportive Care Clinic at a Tertiary Care Cancer Center. J Palliat Med 2021; 24:1467-1473. [PMID: 33535019 DOI: 10.1089/jpm.2020.0737] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: COVID-19 pandemic necessitated rapid adoption of telemedicine at our supportive care center (SCC) to ensure continuity of care while maintaining social distancing. Objective: To document the process of transition from in-person to virtual care. Design: The charts of 1744 consecutive patients in our SCC located in the United States were retrospectively reviewed during the four weeks before transition (February 14-March 12), four weeks after transition (March 20-April 16), and transition week (March 13-March 19). Patient demographics, vital aspects of a supportive care visit such as assessments (Edmonton Symptom Assessment Scale-Financial and Spiritual [ESAS-FS], Cut-down, Annoyed, Guilty, Eye-opener Screen-Adapted to Include Drugs [CAGE-AID], and Memorial Delirium Assessment Scale [MDAS]), interdisciplinary team involvement, and visit type were recorded. Results: In total 763 patients were seen before transition, 168 during the transition week, and 813 after transitioning to virtual care. Patient characteristics, ESAS-FS, CAGE-AID, and nurse assessment did not significantly differ among the three groups. The after-transition group had a small reduction in counseling intervention compared with before (20.2% vs. 26.2%; p = 0.0068). MDAS completion was higher after transition (99.6% vs. 98%; p = 0.007). In-person visits decreased from 100% before to 12.7% after transition (p < 0.0001) and virtual visits increased to 49.3% (video) and 38% (telephone). In-person visits decreased to 49% in the week one, 3% in week two, and <2% in week four after transition (p < 0.0001). Conclusions: Our supportive care team transitioned from in-person care to virtual visits within weeks while maintaining a high patient volume, continuity of care, and adherence to social distancing. Our transition can serve as a model for other centers.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ishwaria Subbiah
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jimin Wu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aimee E Anderson
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Debra Castro
- Supportive Care Center, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Manju Joy
- Supportive Care Center, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chinelo Nweke
- Supportive Care Center, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Meghana Gogineni
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rama Maddi
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aline Rozman de Moraes
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Wiley R, Shelal Z, Bernard C, Urbauer D, Toy E, Ramondetta L. Team-Based Learning Module for Undergraduate Medical Education: a Module Focused on the Human Papilloma Virus to Increase Willingness to Vaccinate. J Cancer Educ 2019; 34:357-362. [PMID: 29280059 DOI: 10.1007/s13187-017-1311-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Human papilloma virus (HPV) vaccination rates lag behind other vaccines, primarily because of weak provider recommendations, and are associated with nearly 30,000 new cancer diagnoses a year. Educating medical students about HPV using active, team-centered learning may increase assimilation of information and may increase vaccination rates. A team-based learning (TBL) module focused on HPV for first-year medical students about HPV will better increase knowledge and likeliness to vaccinate than traditional education methods. Baseline HPV knowledge in medical students across Texas was assessed by surveying all 4-year undergraduate medical schools. Students at one medical school then participated in a week-long TBL focused on basic and clinical concepts relating to HPV, and then were re-surveyed upon completion of the course module. At baseline assessment, first-year student at the intervention site performed at the same level as first-year medical students across the state of Texas on knowledge and satisfaction with their HPV-related medical school education. After the TBL implementation, students performed significantly better than similar-year students and equal to graduating seniors, on knowledge of HPV- and HPV-related cancers, and report significantly higher satisfaction with education measures. Students at the intervention site were significantly more likely to recommend the HPV vaccination in future practice. Short-term knowledge and willingness to recommend vaccination are improved with a targeted HPV TBL early in medical education, which may provide a basis of knowledge that could translate into improved vaccination rates.
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Affiliation(s)
- Rachel Wiley
- University of Texas Health Science Center at Houston, 7000 Fannin St., Houston, TX, 77006, USA
| | - Zeena Shelal
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas M.D. Anderson Cancer Center, 1155 Herman Pressler, Unit #1362, Houston, TX, 77030, USA
| | - Carolyn Bernard
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas M.D. Anderson Cancer Center, 1155 Herman Pressler, Unit #1362, Houston, TX, 77030, USA
| | - Diana Urbauer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas M.D. Anderson Cancer Center, 1155 Herman Pressler, Unit #1362, Houston, TX, 77030, USA
| | - Eugene Toy
- University of Texas Health Science Center at Houston, 7000 Fannin St., Houston, TX, 77006, USA
| | - Lois Ramondetta
- University of Texas Health Science Center at Houston, 7000 Fannin St., Houston, TX, 77006, USA.
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas M.D. Anderson Cancer Center, 1155 Herman Pressler, Unit #1362, Houston, TX, 77030, USA.
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13
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Wiley R, Shelal Z, Urbauer D, Bernard C, Ramondetta L. Relationship Between Intent to Vaccinate and the Education and Knowledge of Human Papillomavirus Among Medical School Faculty and Students in Texas. Tex Med 2019; 115:e1. [PMID: 30601572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Little attention has been given to the state of human papillomavirus (HPV) education in medical schools and how this impacts future vaccination practices. We surveyed medical school faculty and students to assess the relationship between knowledge and willingness to recommend HPV vaccination.
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Wiley R, Shelal Z, Bernard C, Urbauer D, Toy E, Ramondetta L. Human Papillomavirus: From Basic Science to Clinical Management for Preclinical Medical Students. MedEdPORTAL 2018; 14:10787. [PMID: 30800987 PMCID: PMC6354799 DOI: 10.15766/mep_2374-8265.10787] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 11/14/2018] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Human papillomavirus (HPV) is associated with 30,000 cancer diagnoses a year, but the HPV vaccination is administered less frequently than other vaccinations. Future providers are a potential target for improving rates, and this flipped classroom module was developed to educate future vaccinators on HPV virology, vaccination, and clinical management. METHODS Designed as a clinical correlation for a basic science curriculum on introductory virology and immunology, this weeklong module consisted of a 1-hour lecture and case presentation, assigned articles, and a 90-minute wrap-up session including individual and group quizzes over the assigned material, a group clinical application exercise, and a 20-minute lecture on the case and real-world applications. A pre-/posttest survey was done on general knowledge of HPV, satisfaction with education, and willingness to recommend vaccination for HPV. RESULTS This module was designed for first-year students, 491 of whom have performed well in it. Pre-/posttest surveys of 243 students indicated that they significantly improved their knowledge of HPV (from 66.3% premodule to 86.3% postmodule, p <.001) and their satisfaction with medical education on vaccination-related topics, as well as increasing their willingness to recommend vaccination (from 58% premodule to 100% postmodule, p <.001). DISCUSSION This module is an effective and satisfactory way to teach first-year medical students about HPV and HPV vaccination and improves reported willingness to recommend vaccination. With limited resources available to effectively teach HPV vaccination to preclinical medical students, this module fills a gap.
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Affiliation(s)
- Rachel Wiley
- Resident, Obstetrics and Gynecology Residency Program, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - Zeena Shelal
- Senior Coordinator, Clinical Studies, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center
| | - Carolyn Bernard
- Senior Systems Analyst, Office of Health Policy, The University of Texas MD Anderson Cancer Center
| | - Diana Urbauer
- Principal Statistical Analyst, Department of Biostatistics, The University of Texas MD Anderson Cancer Center
| | - Eugene Toy
- Assistant Dean for Educational Programs, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - Lois Ramondetta
- Professor, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center
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15
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Dahlstrom KR, Fu S, Chan W, Shelal Z, Ramondetta LM, Lairson DR. Medical Care Costs Associated with Genital Warts for Commercially Insured US Patients. Pharmacoeconomics 2018; 36:1355-1365. [PMID: 30019118 DOI: 10.1007/s40273-018-0691-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Genital warts are caused by infection with human papillomavirus (HPV) and are associated with significant morbidity. Primary prevention of genital warts is possible through HPV vaccination, but vaccination rates remain low in the USA. When deciding to implement HPV vaccination programs, public health officials and policy makers rely on cost-effectiveness studies that accurately reflect costs associated with morbidity and mortality. However, previous information on the cost of treating genital warts was outdated. OBJECTIVES We estimated the mean direct medical care costs associated with genital warts in the USA. METHODS This was a retrospective case-control study of patients diagnosed with genital warts and matched controls. We used commercial healthcare claims data from 2011 through 2014 to estimate total 1- and 2-year costs from date of diagnosis. We used a generalized linear model to identify factors associated with monthly costs. RESULTS We identified 34,686 eligible cases of genital warts during the period 2011-2014. The first 2-year mean direct medical cost differences between cases and controls were US$6737 for the USA. Costs were significantly higher in the first 3 months following diagnosis and were higher among older individuals, women, those with co-morbidities or psychiatric illnesses, and those located in the south and southwest USA. CONCLUSIONS The mean direct cost of treating genital warts is approximately US$6700 in the first 2 years after diagnosis in the USA. These data can assist policy makers in decisions with respect to allocation of resources to implement HPV vaccine programs.
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Affiliation(s)
- Kristina R Dahlstrom
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Shuangshuang Fu
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St., Houston, TX, 77030, USA
| | - Wenyaw Chan
- Department of Biostatistics, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St., Houston, TX, 77030, USA
| | - Zeena Shelal
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Lois M Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - David R Lairson
- Department of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St., Houston, TX, 77030, USA.
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Rice TW, Brock PA, Gonzalez C, Merriman KW, Shelal Z, Bazerbashi H, Granwehr BP. Routine HIV Screening in Cancer Patients in the Emergency Department. Acute Med 2018; 17:91-95. [PMID: 29882559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Treatment of human immunodeficiency virus(HIV) in cancer patients improves outcomes and reduces transmission of this oncogenic virus. HIV testing rates of cancer patients are similar to the general population (15-40%), despite the association with cancer. Our aim was to increase HIV screening in the Emergency Department(ED) of a comprehensive cancer center through a quality initiative. Testing increased significantly during the intervention (p<0.001; 0.15/day to 2.69/day). Seropositive HIV rate was 1.4% (12/852), with incidence of 0.3%. All patients were linked to care. Incident cases were between 36 and 55 years of age. Barriers encountered included confusion regarding the need for written consent for HIV testing, failure to consider ordering the test, and concerns regarding linkage to care.
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Affiliation(s)
- T W Rice
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - P A Brock
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - C Gonzalez
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - K W Merriman
- Department of Tumor Registry, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Z Shelal
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - H Bazerbashi
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - B P Granwehr
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Shelal Z, Urbauer D, Lewis Patterson P, Schultz D, Rohrer A, Sturgis E, Stevens L, Rosenthal C, Ramondetta L. Didn’t you know? Human papillomavirus (HPV) cancer survivors’ knowledge and attitudes towards HPV vaccination. Gynecol Oncol 2017. [DOI: 10.1016/j.ygyno.2017.03.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lairson DR, Fu S, Chan W, Xu L, Shelal Z, Ramondetta L. Mean direct medical care costs associated with cervical cancer for commercially insured patients in Texas. Gynecol Oncol 2017; 145:108-113. [PMID: 28196673 DOI: 10.1016/j.ygyno.2017.02.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the mean cervical cancer medical care costs for patients enrolled in commercial insurance in Texas. Cost is represented by insurer and patient payments for care. METHODS We estimated the mean medical care costs during the first 2years after the index diagnosis date for patients with cervical cancer (cases). Cases were identified using claims-based International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9), diagnosis codes and matched to controls without a claims-based ICD-9 code for cancer using a 2-step propensity score matching method. Index dates for the cases were randomly assigned to potential controls, and cases and controls were matched by index date. Data for cancer cases and controls were obtained from the de-identified 2011-2014 U.S. MarketScan databases. A generalized linear model was employed to compute the cost for censored months during the 2-year follow-up period. Differential costs were assessed by subtracting the medical costs incurred by controls from those incurred by cases. RESULTS During 2011-2014, 475 commercially insured Texas patients with newly diagnosed cervical cancer met the inclusion criteria. The first-year and second-year mean medical costs were $60,828 and $37,721 for cases and $9982 and $10,066 for controls, respectively. The differential costs of cervical cancer for the first and second years were $50,846 and $27,656, respectively. The major correlates of higher monthly cervical cancer costs were higher Charlson Comorbidity Index score during 6months period prior to diagnosis, higher healthcare costs between 6months and 3months prior to diagnosis, and residence in the western region of Texas. Costs for cervical cancer patients decreased steeply between month 1 and month 5 after diagnosis and then were stable, while costs for the control group were stable throughout the follow-up period. CONCLUSIONS Mean direct medical costs associated with cervical cancer in Texas were substantial. These data will serve as key cost parameters in models of costs associated with human papillomavirus (HPV)-related cancers in Texas and the economic evaluation of HPV vaccination dissemination in Texas.
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Affiliation(s)
- David R Lairson
- Department of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St., Houston, TX 77030, USA.
| | - Shuangshuang Fu
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St., Houston, TX 77030, USA.
| | - Wenyaw Chan
- Department of Biostatistics, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St., Houston, TX 77030, USA.
| | - Li Xu
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA.
| | - Zeena Shelal
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA.
| | - Lois Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA.
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Granwehr B, Merriman K, Grimes R, Shelal Z, Bazerbashi H, Brock P, Gonzalez C, Torres H, Rice T. Prospective HIV, HBV, HCV screening in a cancer center emergency department. J Virus Erad 2016. [DOI: 10.1016/s2055-6640(20)31133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Granwehr BP, Merriman KW, Shelal Z, Bazerbashi H, Brock PA, Gonzalez CE, Torres HA, Rice T. HIV-testing in a cancer center emergency department. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.7_suppl.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
225 Background: HIV is a cancer-associated virus classically associated with KS, NHL, and cervical cancer, but more recently with anal cancer, lung, and head and neck cancers. HIV testing and treatment are important for cancer patients for three reasons: 1) HIV treatment is associated with reduced transmission of a cancer-associated virus. 2) HIV treatment is associated with improved outcomes of cancer therapy in many cancers. 3) HIV testing optimizes quality of care, since testing is recommended by the Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force (USPSTF)(A level recommendation) for patients between the ages of 15 and 65 years of age. Since emergency centers (EC’s) commonly provide immunizations and other preventive care, we implemented HIV testing at our cancer center EC. Methods: In our 44 bed cancer center EC with approximately 25,000 annual visits, routine implementation by physician order was implemented in July 2014. EC information technology (IT) assisted in modification of the order sets and facilitated documentation of specific consent for HIV. Educational materials were disseminated to patients and EC providers. A new consent form with integration of HIV consent, including a check box to refuse HIV testing, was implemented on June 19, 2015. Testing results are described through August 2015. Results: HIV testing increased significantly from July 2014 and August 2015. The impact on institutional testing was considerable, increasing from 1.2% of all HIV testing in 2013 to 15.1% to date in 2015. Between July 2014 and August 2015, 1.4% (0.4% incident) of 852 patients screened positive for HIV. Notably, 83% of patients agreed to HIV testing, but less than 20% of patients were actually tested. The highest refusal rate (18.8%) was in patients over age 70 and lowest (9.9%) in those 21-29 years of age. Conclusions: Routine HIV testing is feasible in a comprehensive cancer center ED, but increased awareness is necessary to optimize testing, given the high acceptance rate. Seroprevalence of HIV is comparable to non-cancer center EC’s (0.5-1.2%). These results demonstrate the acceptance by patients of testing for HIV, with implications in reduction of transmission of this cancer-associated virus.
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Affiliation(s)
| | | | | | | | | | | | - Harrys A. Torres
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Terry Rice
- UT MD Anderson Cancer Center, Houston, TX
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