Aggressive Symptom Management Research Articles

Breast cancer survivorship among younger patients: challenges and opportunities-narrative review.

Young women with breast cancer (YWBC) face unique survivorship challenges due to being diagnosed at a more vulnerable stage in life and receiving gonadotoxic and/or antiestrogen therapy during their reproductive years. The purpose of this article is to elaborate on these challenges and demonstrate how specialized supportive care programs tailored specifically for YWBC, can greatly facilitate the provision of interventions to address these challenges. The databases used were PubMed and Medline. Articles included those that involve young women with breast cancer and survivorship care needs. Compared to older breast cancer patients, YWBC generally require more aggressive treatments and are more likely to have a hereditary basis for their disease. Common challenges include childbearing concerns, premature menopause, body image issues, excessive fear of cancer recurrence, difficulties with intimate relationships, and financial toxicity. A possible solution to addressing these needs are longitudinal care in a specialized supportive care program, such as the PYNK Program for Young Women with Breast Cancer in Toronto, Ontario, Canada. Examples of such interventions include fast-tracking fertility preservation, aggressive management of symptoms of iatrogenic menopause, peer support groups, as well as individualized psycho-social support for the patient and her family. By addressing the unique needs of this population, supportive care programs can play a crucial role in empowering young women with breast cancer to cope with the physical, emotional, and practical challenges they may face during and after treatment. The limitation lies in resource availability and funding for sustainability. Ongoing research is required to better understand the needs of YWBC patients in survivorship and ensure the sustainability of programs designed to address these challenges.

Severely Painful and Pruritic Forearm Rash: A Case of Caterpillar Envenomation in South Florida.

The asp caterpillar (Megalopyge opercularis) is endemic to the southeastern United States, with most sightings in Florida, Texas, and Louisiana. A few hundred caterpillar envenomations are reported annually with most cases occurring in July-November. Asp caterpillars have hollow spines along their backs that contain venom. Contact with these spines is what produces the characteristic "sting" resulting in contact dermatitis and a localized hypersensitivity reaction collectively referred to as lepidopterism. Symptoms of lepidopterism may include severe burning pain, pruritis, edema, nausea, vomiting, abdominal pain, and headache. Symptoms are often self limited, and treatment should focus on expedited removal of implanted spines and aggressive symptom management. We present the case of a patient presenting to the emergency department (ED) with acute-onset severe left forearm pain with associated pruritic rash incurred while working in a retail store. Initial therapeutic management included administration of analgesics, antihistamines, and steroids. After obtaining a comprehensive history and consulting with the Poison Control Center, we suspected an asp caterpillar envenomation. Following extraction of the caterpillar spines with silk tape, the patient's symptoms improved. After a period of observation in the ED, the patient was discharged home without any known sequelae. Although asp caterpillars typically inhabit trees and foliage, human exposure to the caterpillar may occur in developed environments. Effective history-taking, prompt communication with toxicologic experts, and complete removal of intact spines are essential for early identification and effective clinical management of asp caterpillar envenomation.

Relationship Between Overactive Bladder and Bone Fracture Risk in Female Patients.

Overactive bladder (OAB) has recently been recognized as an independent risk factor for falls and fractures. This study aimed to predict fracture risk in female patients with OAB symptoms. We assessed and compared the fracture risk in newly diagnosed female patients with OAB to those without OAB using the Fracture Risk Assessment Tool (FRAX), and investigated the relationship between fracture risk and OAB severity. The present single-center, cross-sectional study included 177 female participants (79 with OAB, 98 without OAB). The OAB group was older (p=0.033) and shorter (p=0.010) compared to the non-OAB group. Compared to the non-OAB group, the OAB group had more patients with hypertension (p<0.001) and diabetes mellitus (p=0.011), as well as higher risks for major fractures (non-OAB group: 15.2±13.2%; OAB group: 23.6±14.1%; p<0.001) and hip fractures (non-OAB group: 6.3±11.0%; OAB group: 10.6±10.0%; p=0.007). In addition, those with moderate/severe OAB had the most significantly elevated risks for both major fractures (non-OAB group: 15.2±13.2%, mild-OAB: 17.6±12.5%, moderate/sever-OAB: 26.4±14.0%; p<0.001) and hip fractures (non-OAB group: 6.3±11.0%, mild-OAB: 6.5±7.6%, moderate/sever-OAB: 12.5±10.4%; p<0.001). Among the OAB symptoms, nocturia had the strongest correlation with fracture risk (major fracture, ρ=0.534; hip fracture, ρ=0.449; all p<0.001). Patients with severe OAB, and particularly severe nocturia, should be closely monitored with timely and aggressive symptom management; however, an interventional study incorporating the management of OAB symptoms is required to confirm whether the proactive management of OAB symptoms reduces the risk of fractures in older females.

Integrated Memory Care: Primary Care for Persons Living with Dementia

AbstractThe Integrated Memory Care (IMC) program is a nurse practitioner led, physician‐supported primary care model which serves individuals living with Alzheimer’s disease and related dementias (ADRD) and their care partners living in the community. Individualized care plans align with patients’ goals, and patients benefit from care coordination provided by an expert team that includes nurses, social workers, occupational therapists, and dementia care assistants, all working directly with primary care providers. The IMC adds a palliative care perspective as well, emphasizing aggressive symptom management and advance care planning, thereby providing holistic care for individuals living with ADRD.Over 2000 patients and family care partners have received care at IMC since 2015. The average age of the patient population is 78.6 years; 65% of patients are female; 42% of patients are non‐white. The practice has developed and tested dementia‐specific workflows that can be implemented in a fee‐for‐service primary care environment. Successful completion of dementia quality measures, such as documentation of dementia type and stage, as well as assessment of cognitive, functional, and behavioral symptoms, is &gt;90%. The ambulatory care sensitive admission rate of patients enrolled in the program is 0.5‐0.9%, well below published rates of 13% to 15%. In a case‐matched control group of patients, the IMC relative risk of hospitalization was one‐half those managed in usual primary care.The IMC represents a novel model of care for individuals living with ADRD and their care partners, achieving superior patient outcomes and representing a financially sustainable model for this growing population. Its primary care systems and processes provide an integrated pathway to quality care, thereby facilitating the identification of patients in the primary care setting who are living with ADRD.

Emergency Palliative Care: Hospice Patients in the Emergency Department.

In this segment of the emergency department (ED) palliative care (PC) case series, we discuss a patient on hospice who presented to the ED for the management of acute symptoms and potential procedural intervention. Hospice patients frequently visit the ED and can challenge typical ED paradigms of care that often include resuscitative efforts and broad workups. Our patient had a history of advanced liver cancer, and his ED presentation was prompted by worsening abdominal pain from ascites requiring serial paracentesis. PC consultation was requested to help address the patient's symptoms and create a plan of care. The PC clinician played an important role in supporting aggressive symptom management, re-evaluating goals of care, addressing concerns about hospice, and facilitating changes in code status requested for a procedure.

Association of Sarcopenia With Toxicity-Related Discontinuation of Adjuvant Endocrine Therapy in Women With Early-Stage Hormone Receptor–Positive Breast Cancer

Sarcopenia, an age-related decline in muscle mass and physical function, is associated with increased toxicity and worse outcomes in women with breast cancer (BC). Sarcopenia may contribute to toxicity-related early discontinuation of adjuvant endocrine therapy (aET) in women with hormone receptor-positive (HR+) BC but remains poorly characterized. This multicenter, retrospective cohort study included consecutive women with stage 0-II HR+ BC who received breast conserving therapy (lumpectomy and radiation therapy) and aET from 2011 to 2017 with a 5-year follow-up. Skeletal muscle index (SMI, cm2/m2) was analyzed using a deep learning model on routine cross-sectional radiation simulation imaging; sarcopenia was dichotomized according to previously validated reports. The primary endpoint was toxicity-related aET discontinuation; logistic regression analysis evaluated associations between SMI/sarcopenia and aET discontinuation. Cox regression analysis evaluated associations with time to aET toxicity, ipsilateral breast tumor recurrence (IBTR), and disease-free survival (DFS). A total of 305 women (median follow-up, 89 months) were included with a median age of 67 years and early-stage BC (12% stage 0, 65% stage I). A total of 60 (20%) women experienced toxicity-related aET discontinuation. Sarcopenia was associated with toxicity-related early discontinuation of aET (odds ratio, 2.18; P=.036) and shorter time to aET toxicity (hazard ratio [HR], 1.62; P=.031). SMI or sarcopenia were not independently associated with IBTR or DFS; toxicity-related aET discontinuation was associated with worse IBTR (HR, 9.47; P=.002) and worse DFS (HR, 4.53; P=.001). Among women with early-stage HR+ BC who receive adjuvant radiation therapy and hormone therapy, sarcopenia is associated with toxicity-related early discontinuation of aET. Further studies should validate these findings in women who did not receive adjuvant radiation therapy. These high-risk patients may be candidates for aggressive symptom management and/or alternative treatment strategies to improve outcomes.

Pre-Diagnosis Pain in Patients With Pancreatic Cancer Signals the Need for Aggressive Symptom Management.

This study assessed the impact of pancreatic cancer (PC) pain on associated symptoms, activities, and resource utilization from 2016 to 2020 in an online patient registry. Responses from PC patient volunteers (N = 1978) were analyzed from online surveys in a cross-sectional study. Comparisons were performed between PC patient groups reporting, (1) the presence vs. absence of pre-diagnosis PC pain, (2) high (4-8) vs. low (0-3) pain intensity scores on an 11-point numerical rating scale (NRS), and (3) year of PC diagnosis (2010-2020). Descriptive statistics and all bivariate analyses were performed using Chi-square or Fisher's Exact tests. PC pain was the most frequently reported pre-diagnosis symptom (62%). Pre-diagnostic PC pain was reported more frequently by women, those with a younger age at diagnosis, and those with PC that spread to the liver and peritoneum. Those with pre-diagnostic PC pain vs. those without reported higher pain intensities (2.64 ± 2.54 vs.1.56 ± 2.01 NRS mean ± SD, respectively, P = .0039); increased frequencies of post-diagnosis symptoms of cramping after meals, feelings of indigestion, and weight loss (P = .02-.0001); and increased resource utilization in PC pain management: (ER visits N = 86 vs. N = 6, P = .018 and analgesic prescriptions, P < .03). The frequency of high pain intensity scores was not decreased over a recent 11-year span. PC pain continues to be a prominent PC symptom. Patients reporting pre-diagnosis PC pain experience increased GI metastasis, symptoms burden, and are often undertreated. Its mitigation may require novel treatments, more resources dedicated to ongoing pain management and surveillance to improve outcomes.

Distinct Profiles of Morning and Evening Fatigue Co-Occurrence in Patients During Chemotherapy.

Morning and evening fatigue are distinct and distressing symptoms experienced during chemotherapy that demonstrate a large amount of interindividual variability. The objectives of this study were to identify subgroups of patients with distinct morning and evening fatigue co-occurrence profiles and evaluate for differences among these subgroups in demographic, clinical, and symptom characteristics and quality of life. Oncology patients ( n = 1,334) completed the Lee Fatigue Scale to self-report morning and evening fatigue, six times over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct morning and evening physical fatigue profiles. Four distinct morning and evening fatigue profiles were identified (i.e., Both Low, Low Morning + Moderate Evening, Both Moderate, and Both High). Compared to the Both Low profile, the Both High profile was significantly younger, less likely to be married or partnered, more likely to live alone, had a higher comorbidity burden, and lower functional status. The Both High profile had higher levels of anxiety, depressive symptoms, sleep disturbance, and pain and lower levels of quality of life. The variability in the morning and evening severity scores among the four profiles supports the hypothesis that morning and evening fatigue are distinct but related symptoms. Clinically meaningful levels of both morning and evening fatigue were reported by 50.4% of our sample, which suggests that the co-occurrence of these two symptoms is relatively common. Patients in Both Moderate and Both High profiles experienced an extremely high symptom burden that warrants ongoing assessments and aggressive symptom management interventions.

Abstract P2-03-01: Sarcopenia on baseline imaging is associated with toxicity-related discontinuation of endocrine therapy in women with early-stage hormone-positive breast cancer

Abstract Background Adjuvant endocrine therapy (ET) is standard of care in women with hormone receptor-positive (HR+) breast cancer (BC) with the goal to reduce recurrence. However, early discontinuation of ET occurs in 30-40% of women, largely attributable to toxicity, and leads to increased recurrence risk. There is considerable overlap in risk factors that predict toxicity from ET and chemotherapy, including age, co-morbidities, and geriatric conditions. Baseline low skeletal muscle area (SMA) on chest computed tomography (CT) is a surrogate marker for sarcopenia and predicts for significant toxicity and intolerance to chemotherapy in women with BC. No study has assessed the association of sarcopenia with toxicity-related discontinuation of ET in women with early-stage HR+ BC. Methods This single center retrospective cohort study included consecutive women with Stage 0-II HR+ BC who received ET and adjuvant radiotherapy (RT) from 01/2011-12/2017. Inclusion required a minimum of 5-year clinical follow-up after diagnosis. We used a validated deep learning pipeline to quantify SMA (cm2) at the tenth thoracic (T10) vertebral body on existing RT planning CT. The skeletal muscle index (SMI [cm2/m2] = SMA/(patient height (m))2) was calculated to adjust for patient height. Sarcopenia was defined as SMI&amp;lt; 32.3 cm2/m2, based on a previously validated independent cohort of young healthy women. The primary endpoint was toxicity-related discontinuation of ET less than 60 months after initiation of ET. Secondary endpoints included any NCI CTCAE v5.0 Grade 3-5 toxicity from ET and ipsilateral breast tumor recurrence. We assessed associations between ET discontinuation and SMI (continuous), as well as thoracic sarcopenia (dichotomous), using logistic regression adjusting for baseline characteristics. We used cox proportional hazards regression to assess disease-free survival (DFS), defined as ipsilateral breast tumor recurrence, locoregional recurrence, or distant metastasis adjusting for baseline and treatment characteristics. Results A total of 265 women (median age 67 years) met inclusion criteria. The majority of women had a comorbidity index of 0-1 (89%) and were Caucasian (89%). The median follow-up was 82 months, 5-year overall survival was 96% and 5-year DFS was 94%. Diagnoses included DCIS (12%), IDC (76%), or ILC (12%); most were T1 (69%) or T2 (18%) and N0 (85%), ER-positive (100%), PR-positive (85%), or HER2-negative (9%). Most common ET type was anastrozole (63%), letrozole (16%), and tamoxifen (17%). SMI (continuous) was not associated with older age, Charlson Comorbidity Index (CCI), race, or tumor stage. A total of 64 (24%) women experienced toxicity-related early discontinuation of ET. On multivariate analysis (MVA), lower SMI was associated with increased toxicity-related early discontinuation of ET (Odds Ratio [OR] 0.89 per 1 cm2/m2 SMI, p=0.001) independent of age, CCI, ET type, or receipt of adjuvant chemotherapy. Lower SMI was associated with higher risk of grade 3-5 toxicity from ET (OR 0.89 per 1 unit SMI, p=0.001) independent of age, CCI, ET type, or receipt of adjuvant chemotherapy. On MVA, sarcopenia was associated with higher risk of toxicity-related early discontinuation of ET (OR 2.43, p=0.019). DFS was associated with toxicity-related early discontinuation of ET (HR 8.06, p=0.005), grade 3 histology (HR 1.42, p=0.042), and multifocal disease (HR 2.55, p=0.040), but not age, histology, stage, or lymphovascular invasion (p&amp;gt;.05 for all). Conclusion Low baseline thoracic skeletal muscle is associated with toxicity-related early ET discontinuation in women with early-stage HR+ BC. Further studies should attempt to generalize this association to all HR+ BC who are candidates for ET. High-risk patients may be candidates for aggressive symptom management or alternative adjuvant therapies. Citation Format: Anurag Saraf, Ismail Tahir, Bonnie Hu, Anna-Sophia Dietrich, Paul Erik Tonnesen, Greg Sharp, Gayle Tillman, Florian Fintelmann, Rachel Jimenez. Sarcopenia on baseline imaging is associated with toxicity-related discontinuation of endocrine therapy in women with early-stage hormone-positive breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-03-01.

BIOM-37. EVALUATION OF TEMPORALIS MUSCLE THICKNESS WITH TOXICITY AND SURVIVAL IN GLIOBLASTOMA PATIENTS RECEIVING CHEMORADIATION

Abstract BACKGROUND Treatment-related toxicity is common in patients with glioblastoma (GBM) receiving chemotherapy and radiotherapy (RT). Temporalis muscle thickness (TMT) is a biomarker associated with sarcopenia and worse clinical outcomes in GBM, however its relation to treatment toxicity is less studied. We hypothesize that TMT may predict toxicity and survival in GBM patients. METHODS We reviewed consecutive patients with IDH-wildtype GBM treated from 2014-2019 at a single academic center. TMT was retrospectively assessed on T1-weighted MRI scans and dichotomized based upon previously validated sex-specific cutoff values. TMT was measured on baseline MRI scan at time of diagnosis. Cox regression multivariable analysis (MVA) was used to assess survival. RESULTS We evaluated 351 patients with median age of 60y (range 20-94) and median follow-up of 14mo. Most patients were male (59%), baseline KPS &amp;gt;70 (95%), and MGMT unmethylated (55%). After maximal safe resection, most patients received standard (90%) or hypofractionated (10%) RT with concurrent systemic therapy (89%). On MVA, baseline low TMT (HR 1.93, p=0.01), age &amp;gt;65y, baseline KPS, and MGMT-unmethylated status were associated with worse OS. On MVA, baseline low TMT (HR 1.95, p=0.01), age &amp;gt;65y, MGMT-unmethylated status, and discontinuing systemic therapy were associated with worse profession-free survival (PFS). 21 patients did not complete anticipated treatment course of chemoradiation and adjuvant systemic therapy due to toxicity, primarily thrombocytopenia, associated with worse OS on MVA (HR 1.99, p&amp;lt; 0.01). Low TMT was associated with higher risk of stopping treatment due to adverse events (OR 5.25, p&amp;lt; 0.01) independent of age, sex, extent of resection, RT dose on MVA. CONCLUSION Baseline low TMT was associated with worse PFS and OS, and it was associated with treatment interruption due to treatment toxicity in GBM patients. While further validation is needed, TMT may help identify patients who will benefit from aggressive symptom management or treatment deintensification.

Association of Skeletal Muscle Area with Toxicity and Treatment Tolerance in Patients Receiving Chemoradiation for Advanced Lung Cancer

<h3>Purpose/Objective(s)</h3> Significant toxicity is common in the treatment of advanced non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) and can be associated with adverse events, such as chemotherapy delay or dose reduction, and worse clinical outcomes. Baseline low skeletal muscle (SM) area is a marker of sarcopenia and has been associated with worse survival in other malignancies, but the association of SM area and toxicity in lung cancer is less studied. <h3>Materials/Methods</h3> Patients with locally advanced or oligo-metastatic NSCLC and extensive-stage SCLC treated with concurrent chemoradiation (CRT) from 2002-2013 at a single institution were reviewed. A deep-learning pipeline utilized existing pre-treatment computed tomography scans to calculate SM area at the 3^rd lumbar vertebral level. Gold standard SM index (SMI) was calculated, adjusting for height, sex, and dichotomized per previously validated cutoff values. Grade 3 or higher (G3+) toxicity, per NCI CTCAE v5.0, was assessed within 21-days of first chemotherapy cycle. Multivariate analysis (MVA) of toxicity endpoints with SMI and baseline characteristics were analyzed by logistic regression analysis, and with overall survival (OS) using Cox regression analysis. <h3>Results</h3> A total of 455 patients met inclusion criteria, with median follow-up of 23.0mo (range 1.0-193.0mo) and median age of 63y (range 29-88y). Among 387 patients with NSCLC, most were clinical stage (AJCC 7th edition) IIIA (43%), IIIB (29%), or IV (11%), while 11% had upfront surgery and adjuvant CRT. Most common chemotherapy regimen was cisplatin-based (48%). Patients with low SMI were more likely to be older (median age 70y vs 62y), ECOG performance status (PS) >0 (75% vs 60%), lower BMI (median BMI 23.3 vs 27.7), and not receive cisplatin-based regimen (39% vs 56%). There was no difference in histology, stage, surgery, or every 3-week (q3w) chemotherapy dosing. On MVA, low SMI was associated with increased risk of G3+ toxicity (OR 1.72, p<0.01) and chemotherapy delay or dose reduction (OR 1.99, p = 0.029). G3+ toxicity was also associated with surgery, but not age, PS, q3w dosing, or regimen. Chemotherapy delay or dose reduction was not associated with age, PS, surgery, and q3w dosing, or regimen. In patients with NSCLC, median OS was 26.2m. G3+ toxicity (HR 1.56, p=0.016), stage 4 (HR 1.280, p=0.003), and cisplatin (HR 1.65, p=0.013) were associated with worse OS on Cox regression, but not low SMI (HR 1.25, p = 0.11), PS, surgery, or regimen. In patients with SCLC, SMI or toxicity were not associated with OS. <h3>Conclusion</h3> Low SMI predicted higher risk of G3+ toxicity during first cycle of chemotherapy in lung cancer. High-risk patients with low SMI experienced significant adverse events and should be considered for more aggressive symptom management or alternative treatment strategies.

Assessment of Nutritional and Imaging Biomarkers to Predict PEG Tube Placement in Non-HPV-Associated Head and Neck Patients Undergoing Concurrent Chemoradiotherapy

<h3>Purpose/Objective(s)</h3> Patients with head and neck cancers undergoing chemoradiotherapy may require percutaneous endoscopic gastrostomy (PEG) tube placement because of dehydration or significant weight loss from their locally-advanced disease or treatment. Modifiable risk factors, such as sarcopenia, may identify high-risk populations who could benefit from intervention. Objective measures of sarcopenia include skeletal muscle index (SMI), skeletal muscle density (SMD), and skeletal muscle gauge (SMG), a novel measure which incorporates both SMI and SMD. We reviewed our institutional experience to assess pretreatment risk factors for nutritional deficiency with respect to serum and skeletal muscle biomarkers. <h3>Materials/Methods</h3> Definitive and post-operative patients undergoing concurrent chemoradiotherapy for locally advanced (AJCC 7^th edition Stage III-IVB) non-human papilloma virus (HPV)-associated head and neck cancer at an academic medical center between 2011 and 2016 were reviewed. Imaging analysis was assessed with three different skeletal muscle measures: SMI, SMD, and SMG. Measurements were obtained from radiation planning computed tomography scans by contouring muscles with an axial slice at the C3 vertebral body. Association between patient factors and PEG tube placement were calculated in univariate and multivariate analyses. <h3>Results</h3> A total 129 patients were included consisting of mostly males (91.5%) with primary tumors located in the larynx/hypopharynx (45.7%) and oropharynx (29.5%). Mean age was 62 years old (range 19-87) with a majority former or current smokers (80.6%) with ECOG performance status 0-1 (83.0%). 70% were treated with definitive chemoradiation and 30% were treated post-operatively. PEG tube was placed in 87/129 (67.4%) patients. Weight loss ≥10% was less common in patients with versus without PEG (30.0% vs 45.2%, p=0.086). Predictive factors on univariate analysis for PEG tube included older age (p=0.01), Caucasian race (p<0.01), former and current smoking status (p<0.01), low SMI (p=0.01), low SMD (p=0.04), deficiency of all 3 skeletal muscle measures (p<0.01), and low pretreatment albumin (p<0.01). On multivariate analysis, factors that persisted included Caucasian race (OR 5.13, p=0.01), current smoking status (OR 6.06, p<0.01), and low pretreatment albumin (OR 4.88, p<0.01). A receiver operating characteristic curve to estimate multivariate model sensitivity and specificity provided an area under the curve of 0.814 (95% CI, 0.738-0.890). <h3>Conclusion</h3> Pretreatment albumin level may serve as a predictive and modifiable pretreatment characteristic of head and neck patients receiving PEG tube placement for treatment. This evaluation identifies patients needing aggressive nutritional guidance, targeted supplementation, and early symptom management as a component of their care.

Dilemas éticos de pediatras ao administrar sedação paliativa em crianças no Brasil

Abstract This study aims to analyze the use of pediatric palliative sedation and understand how it is connected to medical training and the doctor-patient relationship in Brazil. This is a cross-sectional exploratory study using an online survey targeted at pediatricians working in Brazil to evaluate concepts of palliative sedation and aggressive symptom management. The lack of specific training, protocols, and institutionalized guidelines can create uncertainties in palliative care. This also contributes to the increased end-of-life suffering those children and their families face. Improving education in pediatric palliative care is an urgent and pressing need in Brazil.

Low skeletal muscle area and association with toxicity and hospitalization with chemotherapy in advanced non–small cell lung cancer.

8532 Background: Significant toxicity is common in the treatment of advanced non-small cell lung cancer (NSCLC) and can be associated with adverse events, such as unplanned hospitalization, and worse clinical outcomes. Baseline low skeletal muscle (SM) area is a marker of sarcopenia and has been associated with worse survival in other malignancies, but the association of SM area and toxicity in NSCLC is less studied. Methods: Patients with locally advanced or oligo-metastatic NSCLC treated with combined chemotherapy and radiotherapy with or without surgery from 2002-2013 at a single institution were reviewed. A deep-learning pipeline utilized existing pre-treatment computed tomography scans to calculate SM area at the 3rd lumbar vertebral level. Gold standard SM index (SMI) was calculated, adjusting for height, sex, and dichotomized per previously validated cutoff values. Grade 3 or higher hematologic (G3+ heme) toxicity, was assessed per NCI CTCAE v5.0, within 21-days of first chemotherapy cycle. Hospital use was defined as unplanned ED visit or inpatient hospitalization during chemotherapy. Multivariate analysis (MVA) of toxicity endpoints with SMI and baseline characteristics were analyzed by logistic regression analysis, and with overall survival (OS) using Cox regression analysis. Results: A total of 369 patients met inclusion criteria with median follow-up of 23.0mo (range 1-193mo), median age of 64y (range 29-88y), and were mostly male (51%). Most were clinical stage (AJCC 7th edition) IIIA (44%), IIIB (31%), or IV (10%), while 10% had upfront surgery and adjuvant chemotherapy. Most common regimen was cisplatin-based (48%). Median OS was 25.5mo and PFS was 14.0mo. Patients with low SMI were more likely to be younger (median age 70y vs 62y), ECOG performance status (PS) &gt; 0 (74% vs 59%), lower BMI (median BMI 23.3 vs 27.7), and not receive cisplatin-based regimen (35% vs 53%). There was no difference in histology, stage, surgery, or every 3-week (q3w) chemotherapy dosing. On MVA, low SMI was associated with increased risk of G3+ heme toxicity (OR 1.74, p = 0.04) and increased hospital use (OR 1.79, p = 0.04). G3+ heme toxicity was also associated with surgery and q3w dosing, but not age, PS, BMI, or regimen. Hospital use was also associated with BMI, surgery, and cisplatin-based regimen, but not age, PS, or q3w dosing. G3+ heme toxicity (HR 1.48, p &lt; 0.01), older age (HR 1.02, p = 0.02), and stage 4 (HR 3.32, p &lt; 0.01) were associated with worse survival on MVA, but not low SMI (HR 1.25, p = 0.11), PS, BMI, surgery, or regimen. Conclusions: Low SMI predicted higher risk of G3+ toxicity during first cycle of chemotherapy. High-risk patients with low SMI experienced significant adverse events and should be considered for more aggressive symptom management or alternative treatment strategies.

Characterization of avoidable hospital admissions in patients with lung cancer in the immunotherapy and targeted therapy era.

e21133 Background: Hospitalization is the second largest contributor of cancer care spending, and over 50% of lung cancer patients are admitted to the hospital while receiving treatment. Patients who avoid hospital admission have reduced health care costs with a higher quality of life. This is the first study that characterizes the risk factors and outcomes for avoidable hospital admissions of lung cancer patients. It is the first to examine the extent to which hospitalizations from immunotherapy and targeted therapy could be avoided. Methods: A retrospective chart review of lung cancer patients admitted January 2018 through December 2018 was conducted. Demographics, disease and treatment history, admission characteristics, outcomes, and end-of-life care utilization were recorded. Following a multidisciplinary consensus review, hospitalizations were determined “avoidable” or “unavoidable.” Generalized estimating equation logistic regression models analyzed risks and outcomes associated with avoidable admissions. Kaplan-Meier estimators examined the median overall survival (mOS) between patients with and without avoidable admissions. Results: We evaluated 319 admissions from 188 patients with a median age of 66 and 16%/84% SCLC/NSCLC. Cancer-related symptoms accounted for 66% of hospitalizations; pneumonia and other infections comprised 34%, and 32% were due to cancer-related pain, vomiting, or failure to thrive (FTT). Common causes of unavoidable hospitalizations were unexpected disease progression causing symptoms, COPD exacerbation, and infection. Of the 47 hospitalizations identified as avoidable (15%), the mOS was 1.6 months; the mOS of unavoidable hospitalizations was 9.7 months (HR 2.07; 95% CI 1.34-3.19; p &lt; 0.001). Significant reasons for avoidable admissions included cancer-related pain (p = 0.021), hypervolemia (p = 0.033), patient desire to initiate hospice services (p = 0.011), and errors in medication reconciliation or distribution (p &lt; 0.001). Errors in medication management caused 26% of the avoidable hospitalizations. Of admissions in patients on immunotherapy (n = 102) or targeted therapy (n = 44), 9% were due to adverse effects of treatment. Patients on immunotherapy and targeted therapy were not more likely to have avoidable hospitalizations compared to patients not on the treatments (p = 0.323 and 0.133, respectively). Patients with avoidable admissions were 3.02 times more likely to enroll in hospice within 30 days of hospitalization compared to unavoidable admissions (95% CI 1.54-5.92; p = 0.001). Conclusions: Patients on immunotherapy or targeted therapy were only rarely admitted due to side effects of treatment. Hospitalizations may be avoided with more aggressive outpatient symptom management, earlier hospice discussion with at-risk patients, and outpatient pharmacist review of medications following hospital discharge.

Integrated memory care clinic: Primary care for people living with dementia

AbstractBackgroundThe Integrated Memory Clinic (IMCC) serves individuals with a dementia diagnosis, such as Alzheimer’s disease or a related disorder, and their care partners who reside in a community setting. The IMCC is America’s first and only comprehensive primary and dementia care practice. The IMCC addresses a primary concern for nearly 6 million Americans living with dementia: How to identify a primary care practice that is knowledgeable about, and sensitive to, the complex medical and social issues associated with a dementia diagnosis and also that can manage the co‐morbidities common in aging. The model takes a primary palliative care perspective, emphasizing aggressive symptom management, advance care planning, and holistic care that focuses on improving the quality of life for the person living with dementia and their care partner. The IMCC’s patient‐centered approach allows patients to receive a broad array of health care services in a single visit from an interdisciplinary team. The IMCC team supports families living with dementia by focusing on the care recipient and care partner well‐being and quality of life, by processes designed to avoid inappropriate acute and emergency care utilization, and through stage‐based support and psychoeducational programs. The IMCC launched a Patient Family Advisory Council simultaneously with enrolling its first patient. The Council meets monthly to review and advise health care providers about clinic operations, communications, billing practices, and sustainability. Currently, four nurse practitioners deliver care to approximately 550 patients. The average age of the patient population is 78 years; 65% of patients are female; 42% of patients are non‐white. The ambulatory care sensitive admission rate ranges from 1.56% to 2.87% for the past 12 months. Performance in hypertension and diabetes management outperforms health system benchmark goals for primary care practices. The IMCC nurse practitioners’ overall patient experience scores are at 97th percentile, representing a meaningful and positive caregiver experience. The IMCC has earned national recognition as a patient‐centered medical home from the National Commission on Quality Assurance. The IMCC represents a novel model of care for people living with dementia and their caregivers and may be a more sustainable model for this growing vulnerable population.

Treatment interruption and discontinuationof hormonal therapy in hormone receptor-positive breast cancer patients.

To investigate predictors of treatment interruption and early discontinuation of adjuvant hormonal therapy (HT) in a retrospective cohort of women with newly diagnosed hormone receptor-positive (HR +) breast cancer. Eligible cases were identified from a single institutional tumor registry from 2009 to 2015. Patients were followed from initiation of adjuvant HT for a minimum of one year through December 1, 2016. Predictors of treatment interruption or early discontinuation were analyzed with Cox proportional hazards regression models. With a median follow-up time of 3.0years (IQR 1.5-4.5), 22 women (10.9%) discontinued HT early and 47 (23.4%) had at least one treatment interruption of > 14days. Adjusted Cox proportional hazards regression models showed that women with pre-existing affective disorders were more likely to discontinue therapy early (HR 3.15; 95% CI 1.35-7.37), while those with pre-existing chronic pain disorders were at increased risk for treatment interruption (HR 2.24; 95% CI 1.20-4.19). HT-related symptoms were the most commonly reported reason for HT interruption or discontinuation. Women who experienced severe treatment-related symptoms were at increased risk for both HT interruption (HR 2.64; 95% CI 1.07-6.50) and HT discontinuation (HR 3.48; 95% CI 1.20-10.1). This study showed that HT interruptions and discontinuation were common, often associated with HT-related symptoms. Clinicians caring for breast cancer patients on HT should monitor closely for treatment-emergent symptoms, especially women with pre-existing disorders, and support them to continue therapy through aggressive symptom management and other patient-centered approaches.

Symptom burden and characteristics of patients who die in the acute palliative care unit of a tertiary cancer center.

Acute palliative care unit (APCU) is a novel inpatient program in a tertiary cancer center that provides aggressive symptom management and assists with the transition to hospice. However, patients often die in the APCU before successfully transferring to hospice. The aim of this study was to evaluate the symptom burden and characteristics of advanced cancer patients who died in the APCU. We retrospectively reviewed the medical records of all advanced cancer patients admitted to the APCU between April 2015 and March 2016 at a tertiary cancer center in Korea. Basic characteristics and symptom burden assessed by the Edmonton Symptom Assessment System (ESAS) were retrieved. Statistical analyses were conducted to compare patients who died in the APCU with those who were discharged alive. Of the 267 patients, 87 patients (33%) died in the APCU. The median age of the patients was 66 years (range, 23-97 years). The most common primary cancer types were lung (21%), stomach (17%), and colorectal cancer (15%). Patients who died in the APCU had higher ESAS scores for drowsiness (6 vs. 5, P=0.002), dyspnea (4 vs. 2, P=0.001), anorexia (8 vs. 6, P=0.014) and insomnia (6 vs. 4, P=0.002) compared to patients who were discharged alive. The total symptom distress score (SDS) was also significantly higher (47 vs. 40, P=0.001) in patients who died in the APCU. In the multivariate analysis, patients who died in the APCU were more likely to be male [odds ratio (OR) 2.63, 95% confidence interval (CI): 1.49-4.64, P=0.001] and have higher ESAS scores for drowsiness (OR 2.08, 95% CI: 1.08-3.99, P=0.029) and dyspnea (OR 2.19, 95% CI: 1.26-3.80, P=0.005). Patients who died in the APCU showed significantly shorter survival after APCU admission (7 vs. 31 days, P<0.001). Advanced cancer patients who die in the APCU were more likely to be male and have significantly higher symptom burden including drowsiness and dyspnea. These patients showed rapid clinical deterioration after APCU admission. More proactive and timely end-of-life care is needed for these patients.

Physical and Functional Impairment Among Older Adults With a History of Traumatic Brain Injury.

To examine the association of lifetime history of traumatic brain injury (TBI) with later-life physical impairment (PI) and functional impairment (FI) and to evaluate the impact of neurobehavioral symptoms that frequently co-occur with TBI on these relations. A total of 1148 respondents to the 2014 Wave of the Health and Retirement Study, a nationally representative survey of older community-dwelling adults, randomly selected to participate in a TBI exposure survey. They reported no prior TBI (n = 737) or prior TBI (n = 411). Cross-sectional survey study. Physical impairment (self-reported difficulty with ≥1 of 8 physical activities); FI (self-reported difficulty with ≥1 of 11 activities of daily living); self-reported current neurobehavioral symptoms (pain, sleep problems, depression, subjective memory impairment); The Ohio State University TBI Identification Method (OSU-TBI-ID)-short form. Stepwise logistic regression models ([1] unadjusted; [2] adjusted for demographics and medical comorbidities; [3] additionally adjusted for neurobehavioral symptoms) compared PI and FI between TBI groups. Traumatic brain injury-exposed (mean: 33.6 years postinjury) respondents were younger, less likely to be female, and reported more comorbidities and neurobehavioral symptoms. Although TBI was significantly associated with increased odds of PI and FI in unadjusted models and models adjusted for demographics/comorbidities (adjusted odds ratio, 95% confidence interval: PI 1.62, 1.21-2.17; FI 1.60, 1.20-2.14), this association was no longer statistically significant after further adjustment for neurobehavioral symptoms. History of TBI is associated with substantial PI and FI among community-dwelling older adults. Further research is warranted to determine whether aggressive management of neurobehavioral symptoms in this population may mitigate long-term PI and FI in this population.

Symptom burden and characteristics of patients who die in the acute palliative care unit of a tertiary cancer center.

53 Background: Acute Palliative Care Units (ACPUs) are novel inpatient programs in tertiary care centers that provide aggressive symptom management and assist transition to hospice. However, patients often die in the APCU before successfully transferring to hospice. The aim of this study was to evaluate the symptom burden and characteristics of advanced cancer patients who die in the APCU. Methods: We retrospectively reviewed the medical records of all advanced cancer patients admitted to the APCU between April, 2015 and March, 2016 at a tertiary cancer center in Korea. Basic characteristics and symptom burden assessed by the Edmonton Symptom Assessment System (ESAS) were obtained from consultation upon APCU admission. Statistical analyses were conducted to compare patients who died in the APCU with those who were discharged alive. Results: Of the 267 patients analyzed, 87 patients (33%) died in the APCU. The median age of patients was 66 (range, 23-97). Patients who died in the APCU had higher ESAS scores of drowsiness (6 vs 5, P = 0.002), dyspnea (4 vs 2, P = 0.001), anorexia (8 vs 6, P = 0.014) and insomnia (6 vs 4, P = 0.001) compared to patients who discharged alive. Total symptom distress scores (SDS) were also significantly higher (47 vs 40, P = 0.001). Patients who died in the APCU were more likely to be male (odds ratio [OR] for female patients 0.38, 95% confidence interval [CI] 0.22-0.67, P &lt; 0.001) and have higher ESAS scores of drowsiness (OR 2.08, 95% CI, 1.08-3.99, P = 0.029) and dyspnea (OR 2.19, 95% CI 1.26-3.80, P = 0.005). These patients showed significantly shorter survival after APCU admission (7 days vs 31 days, P &lt; 0.001). Conclusions: Advanced cancer patients who die in the APCU are more likely to be male and have significantly higher symptom burden that include drowsiness and dyspnea. These patients show rapid clinical deterioration after APCU admission. More proactive and timely end-of-life care is needed for these patients.