Edmonton Symptom Assessment System Assessment Research Articles

Radiation Toxicity Profile Difference in p16+ vs. p16- Oropharyngeal Cancer Patients

p16+ oropharyngeal squamous cell carcinoma is radiosensitive and has better prognosis than p16-ve. However, the correlation between p16 reactivity and radiation toxicity profile in these patients has not been studied. Edmonton Symptom Assessment System (ESAS) is a generic patient reported symptom scale validated for patient reported outcome (PRO) assessments in head and neck cancer patients. We sought to review the ESAS and its psychometric properties in oropharyngeal cancer patients treated with concurrent chemoradiation (CCRT) stratified by their HPV status. To evaluate differences in magnitude and temporal trends in PRO before, during and after radiation treatments in both p16+ and p16-ve oropharyngeal cancer patients using ESAS scores. Prospectively collected ESAS scores for oropharyngeal cancer patients treated at a safety net hospital with CCRT were analyzed. Longitudinal variation in pain, depression, appetite and family distress scores before, during and up to 36 weeks after CCRT were evaluated at seven time points: prior to treatment, 1-3, 4-6, 7-10, 11-15, 16-20 and 20-36 weeks. Statistical analysis focused on data collected through repeated measurements for patients using ANOVA mixed regression analysis using p16 status as between subjects factor for each symptom. Three hundred fifty-five ESAS assessments were analyzed for each symptom for 64 oropharyngeal cancer patients treated with CCRT. Subsites identified were 21 (32.8%) tonsil, 15 (23.4%) base of tongue, 22 (34.4%) soft palate, and 6 (9.4%) oropharynx not specified. We identified 35 (54.7%) p16+ and 29 (45.3%) p16-ve patients. The median age of the cohort was 60 (range: min 39 - max 88); the median age was 59 for p16+ and 61 for p16-ve. Median total radiation dose was 6996 Gy. Pain scores peaked at 7-10 weeks for both groups but p16-ve had delayed peak 11-15 weeks as well. Depression scores stayed <4 for both populations but family distress, pain and appetite scores peaked for p16-ve between 11-15 weeks. Mean pain scores were similar for both populations and peak during CCRT for both however p16-ve patients have another peak after completion of CCRT. Family distress and decreased appetite also heighten during this post CCRT time for p16-ve patients which warrants a planned early intervention at 11-15 weeks for these patients to improve their quality of life.

Gaps in Depression Symptom Management for Patients With Head and Neck Cancer.

To understand practice patterns and identify care gaps within a large-scale depression screening program for patients with head and neck cancer (HNC). Retrospective cohort study. This was a population-based study of adults diagnosed with a HNC between January 2007 and October 2020. Each patient was observed from time of first symptom assessment until end of study date, or death. The exposure of interest was a positive depressive symptom screen on the Edmonton Symptom Assessment System (ESAS). Outcomes of interest included psychiatry/psychology assessment, social work referral, or palliative care assessment. Cause specific hazard models with a time-varying exposure were used to investigate the exposure-outcome relationships. Of 14,054 patients with HNC, 9016 (64.2%) reported depressive symptoms on at least one ESAS assessment. Within 60 days of first reporting depressive symptoms, 223 (2.7%) received a psychiatry assessment, 646 (7.9%) a social work referral, and 1131 (13.9%) a palliative care assessment. Rates of psychiatry/psychology assessment (HR 3.15 [95% CI 2.67-3.72]), social work referral (HR 1.83 [95% CI 1.64-2.02]), and palliative care assessment (HR 2.34 [95% CI 2.19-2.50]) were higher for those screening positive for depression. Certain patient populations were less likely to receive an assessment including the elderly, rural residents, and those without a prior psychiatric history. A high proportion of head and neck patients report depressive symptoms, though this triggers a referral in a small number of cases. These data highlight areas for improvement in depression screening care pathways. 3 Laryngoscope, 133:2638-2646, 2023.

Symptom Assessment Following Surgery for Lung Cancer: A Canadian Population-based Retrospective Cohort Study.

To conduct a population-level analysis of temporal trends and risk factors for high symptom burden in patients receiving surgery for non-small cell lung cancer (NSCLC). A population-level overview of symptoms after curative intent surgery is necessary to inform decision making and supportive care for patients with lung cancer. Retrospective cohort study of patients receiving surgery for stages I to III NSCLC between January 2007 and September 2018. Prospectively collection Edmonton Symptom Assessment System (ESAS) scores, linked to provincial administrative data, were used to describe the prevalence, trajectory, and predictors of moderate-to-severe symptoms in the year following surgery. A total of 5350 patients, with 28,490 unique ESAS assessments, were included in the analysis. Moderate-to-severe tiredness (68%), poor wellbeing (63%), and shortness of breath (60%) were the most common symptoms reported. The rise and fall in the proportion of patients experiencing moderate-to-severe symptoms after surgery coincided with the median time to first (58 days, interquartile range: 47-72) and last cycle of chemotherapy (140 days, interquartile range: 118-168), respectively. There was eventual stabilization, albeit above the preoperative baseline, within 6 to 7 months after surgery. Female sex (relative risk [RR] 1.09- 1.26), lower income (RR 1.08-1.23), stage III disease (RR 1.15-1.43), adjuvant therapy (RR 1.09-1.42), chemotherapy within 2 weeks of an ESAS assessment (RR 1.14-1.73), and pneumonectomy (RR 1.05-1.15) were associated with moderate-to-severe symptoms following surgery. Knowledge of population-level prevalence, trajectory, and predictors of moderate-to-severe symptoms after surgery for NSCLC can be used to facilitate shared decision making and improve symptom management throughout the course of illness.

Association of Patient-Reported Outcomes With Subsequent Nonfatal Self-injury After a New Cancer Diagnosis

Nonfatal self-injury (NFSI) is a patient-centered manifestation of severe distress occurring in 3 out of 1000 patients after cancer diagnosis. How to identify patients at risk for NFSI remains unknown. To examine the associations between patient-reported outcome measures and subsequent NFSI in patients with cancer. This population-based matched case-control study included adults with a new cancer diagnosis reporting an Edmonton Symptom Assessment System (ESAS) score within 36 months of diagnosis in Ontario, Canada, 2007 to 2019. Data analysis was performed January 2007 to December 2019. Cases included patients with NFSI, and controls were patients without NFSI. Cases and controls were matched 1:4. Multivariable conditional logistic regression assessed the association between moderate to severe ESAS symptom scores and total ESAS (t-ESAS, range 0-90) score with NFSI in the subsequent 180 days. Of 408 858 patients reporting 1 or more ESAS assessments, 425 patients experienced NFSI and reported an ESAS score in the preceding 180 days. Of those, 406 cases were matched to 1624 control patients without an NFSI. Cases reported a higher proportion of moderate to severe symptoms and higher t-ESAS score than controls prior to the event. After adjustment, moderate to severe anxiety (odds ratio [OR], 1.61; 95% CI, 1.14-2.27), depression (OR, 1.66; 95% CI, 1.20-2.31), and shortness of breath (OR, 1.65; 95% CI, 1.18-2.31) and each 10-point increase in t-ESAS score (OR, 1.51; 95% CI, 1.40-1.63) were independently associated with higher odds of subsequent NFSI. In this case-control study, reporting moderate to severe anxiety, depression, and shortness of breath and an increasing t-ESAS score after cancer diagnosis were associated with higher odds of NFSI in the following 180 days. These data support the prospective use of routine ESAS screening as a means of identifying patients at higher risk for NFSI to improve supportive care.

587 PATIENT-REPORTED SYMPTOMS FOR ESOPHAGEAL CANCER PATIENTS UNDERGOING CURATIVE INTENT TREATMENT

Abstract Esophageal cancer (EC) patients experience considerable symptom burden from treatment. This study utilized population-level patient-reported Edmonton Symptom Assessment System (ESAS) scores collected as part of standard clinical care to describe symptom trajectories and characteristics associated with severe symptoms for patients undergoing curative intent EC treatment. Methods EC patients treated with curative intent at regional cancer centers and affiliates between 2009–2016 and assessed for symptoms in the 12 months following diagnosis were included. ESAS measures nine common patient-reported cancer symptoms. The outcome was reporting of severe (≥7/10) symptom scores. Multivariable analyses were used to identify characteristics associated with severe symptom scores. Results 1,751 patients reported a median of 7 (IQR 4–12) ESAS assessments in the year following diagnosis, for a total of 14,953 unique ESAS assessments included in the analysis. The most frequently reported severe symptoms were lack of appetite (n = 918, 52%), tiredness (n = 787, 45%) and poor wellbeing (713, 40.7%). The highest symptom burden is within the first five months following diagnosis, with moderate improvement in symptom burden in the second half of the first year. Characteristics associated with severe scores for all symptoms included female sex, high comorbidity, lower socioeconomic status, urban residence, and symptom assessment temporally close to diagnosis. Conclusion This study demonstrates a high symptom burden for EC patients undergoing curative intent therapy. Targeted treatment of common severe symptoms, and increased support for patients at risk for severe symptoms, may enhance patient quality of life.

Patient-Reported Symptom Burden as a Predictor of Emergency Department Use and Unplanned Hospitalization in Head and Neck Cancer: A Longitudinal Population-Based Study.

To determine the association between patient-reported symptom burden and subsequent emergency department use and unplanned hospitalization (ED/Hosp) in a head and neck cancer (HNC) patient population. This was a population-based study of patients diagnosed with HNC who had completed at least one outpatient Edmonton Symptom Assessment System (ESAS) assessment between January 2007 and March 2018 in Ontario, Canada. Logistic regression models were used to determine the relationship between outpatient ESAS scores and subsequent 14-day ED/Hosp use. A generalized estimating equation approach with an exchangeable correlation structure was incorporated to account for patient-level clustering. There were 11,761 patients identified, completing a total of 73,282 ESAS assessments and experiencing 5,203 ED/Hosp events. Six of the nine ESAS symptom scores were positively associated with ED/Hosp use, with pain, appetite, shortness of breath, and tiredness demonstrating the strongest associations. A global ESAS score was calculated by selecting the highest individual symptom score (h-ESAS). Among patients reporting a maximum h-ESAS score of 10, 15.1% had an ED/Hosp event within 14 days compared with 1.5% for those with the lowest possible score of zero. In adjusted analysis, the odds of ED/Hosp use increased with h-ESAS (1.23 per one-unit increase [95% CI, 1.22 to 1.25]). When treated as a categorical variable, patients with the maximum h-ESAS score of 10 had 9.23 (95% CI, 7.22 to 11.33) higher odds of ED/Hosp use, relative to the minimum score of zero. ESAS scores are strongly associated with subsequent ED/Hosp events in patients with HNC. Clinician education around how ESAS data might inform patient care may enhance symptom detection and management.

The impact of routine Edmonton symptom assessment system use on receiving palliative care services: results of a population-based retrospective-matched cohort analysis

BackgroundIn 2007, Cancer Care Ontario began standardised symptom assessment as part of routine care using the Edmonton Symptom Assessment System (ESAS).AimThe purpose of this study was to evaluate the impact...

Multistate Models for Examining the Progression of Intermittently Measured Patient-Reported Symptoms Among Patients With Cancer: The Importance of Accounting for Interval Censoring

ContextPatients with cancer in Ontario, Canada, receive symptom monitoring in a standardized fashion using the Edmonton Symptom Assessment System (ESAS). These measurements can be used to understand symptom progression during the cancer trajectory. ObjectivesThis study demonstrates the implementation of multistate models for examining symptom progression, while appropriately accounting for intermittent observation. We also compare the estimates when the panel nature of the data is ignored. MethodsThis was a population-based retrospective cohort study using linked administrative health-care databases. The cohort consisted of patients who were newly diagnosed with a primary cancer and had at least one ESAS assessment completed between 2007 and 2015 in Ontario, Canada. A 5-state model was developed to examine the progression of symptom severity, where estimation was conducted with and without accommodating for the panel nature of the symptom data. ResultsThe study cohort consisted of 212,615 patients diagnosed with cancer, collectively having 1,006,360 ESAS assessments within the first year after diagnosis. The median (interquartile range) of the number of ESAS assessments per patient was 3 (1–6), and the average gap time between consecutive assessments was approximately three months. The estimated mean sojourn time in each state was consistently and significantly greater when ignoring interval censoring than when accounting for it. This held true for all states and symptoms. ConclusionOur work demonstrates the use of multistate models and the importance of accommodating for intermittent observation when examining symptom progression using ESAS among patients with cancer. This work serves as a methodological guide for applied researchers interested in modeling disease progression under the presence of intermittent observation.

Impact of Standardized Edmonton Symptom Assessment System Use on Emergency Department Visits and Hospitalization: Results of a Population-Based Retrospective Matched Cohort Analysis.

The Edmonton Symptom Assessment System (ESAS) is a validated instrument whose use has been standardized in the Ontario cancer system to measure symptoms among ambulatory patients with cancer. The objective was to examine the effect of ESAS exposure on visits to the emergency department (ED) and hospitalizations. This was a retrospective matched cohort study conducted in Ontario, Canada. The study included patients ≥ 18 years of age diagnosed with cancer between 2007 and 2015. Patients were considered exposed if they were screened with ESAS at least once during the study period, and their first ESAS screening date was defined as the index date. Each exposed patient was matched randomly to a patient with cancer without ESAS assessment using a combination of hard matching (birth year ± 2 years, cancer diagnosis date ± 1 year, cancer type, and sex) and propensity score matching (14 variables, including cancer stage, treatments received, and comorbidities). A multivariable Andersen-Gill recurrent event model was used to evaluate the effect of ESAS on the rate of health care use. The analysis included 128,893 matched pairs that were well balanced on baseline measures. After adjusting for other variables, patients with ESAS had lower rates of both ED visits (relative rate [RR], 0.92; 95% CI, 0.91 to 0.93) and hospitalizations (RR, 0.86; 95% CI, 0.85 to 0.87) compared with patients without ESAS. ESAS exposure is independently associated with decreased rates of ED visits and hospitalizations. This provides real-world evidence of one potential positive impact of standardized symptom assessment in cancer care.

Symptom burden as a predictor of emergency room use and unplanned hospitalization in patients with head and neck cancer: A population-based study.

12084 Background: Symptoms are common in oncology patients, though they remain undetected and untreated by clinicians in up to 50% of cases. Integrating patient reported outcomes (PRO) within routine clinical practice has been suggested as a way to improve detection. In order to inform an effective and efficient PRO symptom screening program, we sought to determine whether outpatient symptom scores could predict emergency room use and unplanned hospitalization (ER/Hosp) in a cancer patient population. Methods: This was a population-based study of patients diagnosed with head and neck cancer who had completed at least one outpatient Edmonton Symptom Assessment System (ESAS) assessment between January 2007 and March 2018 in Ontario. Logistic regression models were used to determine the relationship between reported outpatient ESAS scores and ER/Hosp use in the 14-day period following ESAS completion. A generalized estimating equations approach was incorporated to account for possible patient-level clustering. Results: There were 11,761 unique patients identified with a total of 73,282 ESAS assessments. There were 5,203 ER/Hosp outcome events. In adjusted analysis, the odds of ER/Hosp use increased log linearly with ESAS score (1.23 per 1 unit increase in index ESAS score, [95% confidence interval (CI) 1.22 – 1.25]). This corresponds to a 9.23 (95%CI 7.22-11.33) higher odds of ER/Hosp use for the maximum index ESAS score of 10. Seven of the nine ESAS symptom scores were significantly associated with ER/Hosp use with pain, appetite and shortness of breath demonstrating the strongest association. Conclusions: ESAS scores are independently associated with 14-day ER/Hosp in head and neck cancer patients. Appropriate and timely management of symptom burden may reduce rates of ER/Hosp. [Table: see text]

Patient-reported symptoms following diagnosis in esophagus cancer patients treated with palliative intent.

The majority of patients with esophagus cancer have advanced-stage disease without curative options. For these patients, treatment is focused on improving symptoms and quality of life. Despite this, little work has been done to quantify symptom burden for incurable patients. We describe symptoms using the Edmonton Symptom Assessment System (ESAS) among esophagus cancer patients treated for incurable disease. This retrospective cohort study linked administrative datasets to prospectively collected ESAS data of non-curatively treated adult esophagus cancer patients diagnosed between January 1, 2009 and September 30, 2016. ESAS measures nine common cancer-related symptoms: anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and impaired well-being. Frequency of severe symptoms (score ≥ 7/10) was described by month for the 6months from diagnosis for all patients and by treatment type (chemotherapy alone, radiotherapy alone, both chemotherapy and radiotherapy, and best supportive care). A sensitivity analysis limited to patients who survived at least 6months was performed to assess robustness of the results to proximity to death and resulting variation in follow-up time. Among 2,989 esophagus cancer patients diagnosed during the study period and meeting inclusion criteria, 2,103 reported at least one ESAS assessment in the 6months following diagnosis and comprised the final cohort. Patients reported a median of three (IQR 2-7) ESAS assessments in the study period. Median survival was 7.6 (IQR 4.1-13.7) months. Severe lack of appetite (53.1%), tiredness (51.1%), and impaired well-being (42.7%) were the most commonly reported symptoms. Severe symptoms persisted throughout the 6months after the diagnosis. Subgroup analysis by treatment showed no worsening of symptoms over time in those treated by either chemotherapy alone, or both chemotherapy and radiation. Results followed a similar pattern on sensitivity analysis. Patients diagnosed with incurable esophagus cancer experience considerable symptom burden in the first 6months after diagnosis and the frequency of severe symptoms remains high throughout this period. Patients with this disease require early palliative care and psychosocial support upon diagnosis and support throughout the course of their cancer journey.

Patient-Reported Symptoms for Esophageal Cancer Patients Undergoing Curative Intent Treatment

Esophageal cancer (EC) patients experience considerable symptom burden from treatment. This study utilized population-level patient-reported Edmonton Symptom Assessment System (ESAS) scores collected as part of standard clinical care to describe symptom trajectories and characteristics associated with severe symptoms for patients undergoing curative intent EC treatment. EC patients treated with curative intent at regional cancer centers and affiliates between 2009 and 2016 and assessed for symptoms in the 12 months after diagnosis were included. The ESAS measures 9 common patient-reported cancer symptoms. The outcome was report of a severe symptom score (score ≥7 our of 10). Multivariable analyses were used to identify characteristics associated with severe symptom scores. A total of 1751 patients reported a median of 7 (interquartile range, 4-12) ESAS assessments in the year after diagnosis, for a total of 14,953 unique ESAS assessments included in the analysis. The most frequently reported severe symptoms were lack of appetite (n= 918, 52%), tiredness (n= 787, 45%), and poor well-being (n= 713, 41%). The highest symptom burden was within the first 5 months after diagnosis, with moderate improvement in symptom burden in the second half of the first year. Characteristics associated with severe scores for all symptoms included female sex, high comorbidity, lower socioeconomic status, urban residence, and symptom assessment temporally close to diagnosis. This study demonstrates a high symptom burden for EC patients undergoing curative intent therapy. Targeted treatment of common severe symptoms and increased support for patients at risk for severe symptoms may enhance patient quality of life.

Patient-Reported Symptom Severity Among 22,650 Cancer Outpatients in the Last Six Months of Life

ContextUnderstanding the magnitude and risk factors for symptom burden of patients with cancer at the end of life is critical to guiding effective patient- and system-level interventions. ObjectivesWe aimed to estimate the prevalence of severe patient-reported symptoms among cancer outpatients during the six months before death and to identify patient groups at a higher risk for reporting severe symptoms. MethodsThis was a retrospective cohort study of cancer decedents at regional cancer centers from 2010 to 2016. Patient-reported Edmonton Symptom Assessment System (ESAS) scores from the last six months of life were linked to administrative databases. The proportion of patients reporting severe symptom scores (≥7) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and overall well-being during the six months before death was described. Multivariable modified Poisson regression analyses were used to identify risk factors for reporting severe symptom scores. ResultsOf 39,084 cancer decedents, 22,650 had one or more symptom assessments recorded in the last six months of life, resulting in 92,757 ESAS assessments. Severe scores were highest for tiredness (56%), lack of appetite (46%), and impaired well-being (45%). The proportion of patients reporting severe symptom scores was stable before progressively increasing at three months before death. Elderly, women, patients with high comorbidity, immigrants, and living in urban areas or with high material deprivation were at increased risk of reporting severe scores. ConclusionsDespite an integrated symptom screening program, rates of severe patient-reported symptom scores before death were high for outpatients with cancer. Patient subgroups at increased risk of severe symptom burden may benefit from targeted interventions. Ongoing review of routinely collected symptom data may be used to assess the supportive care needs and guide targeted interventions at the health-system level.

Patient-Reported Symptoms Improve Performance of Risk Prediction Models for Emergency Department Visits Among Patients With Cancer: A Population-Wide Study in Ontario Using Administrative Data

ContextPrior work shows measurements of symptom severity using the Edmonton Symptom Assessment System (ESAS) which are associated with emergency department (ED) visits in patients with cancer; however, it is not known if symptom severity improves the ability to predict ED visits. ObjectivesTo determine whether information on symptom severity improves the ability to predict ED visits among patients with cancer. MethodsThis was a population-based study of patients who were diagnosed with cancer and had at least one ESAS assessment completed between 2007 and 2015 in Ontario, Canada. After splitting the cohort into training and test sets, two ED visit risk prediction models using logistic regression were developed on the training cohort, one without ESAS and one with ESAS. The predictive performance of each risk model was assessed on the test cohort and compared with respect to area under the curve and calibration. ResultsThe full cohort consisted of 212,615 unique patients with a total of 1,267,294 ESAS assessments. The risk prediction model including ESAS was superior in sensitivity, specificity, accuracy, and discrimination. The area under the curve was 73.7% under the model with ESAS, whereas it was 70.1% under the model without ESAS. The model with ESAS was also better calibrated. This improvement in calibration was particularly noticeable among patients in the higher deciles of predicted risk. ConclusionThis study demonstrates the importance of incorporating symptom measurements when developing an ED visit risk calculator for patients with cancer. Improved predictive models for ED visits using measurements of symptom severity may serve as an important clinical tool to prompt timely interventions by the cancer care team before an ED visit is necessary.

The impact of routine ESAS use on overall survival: Results of a population-based retrospective matched cohort analysis.

6509 Background: The study objective was to examine the impact of routine Edmonton Symptom Assessment System (ESAS) use on overall survival among adult cancer patients. We hypothesized that patients exposed to ESAS would have better overall survival rates than those who didn’t have ESAS. Methods: The effect of ESAS screening on survival was evaluated in a retrospective matched cohort study. The cohort included all Ontario patients aged 18 or older who were diagnosed with cancer between 2007 and 2015. Patients completing at least one ESAS assessment during the study were considered exposed. The index date was the day of their first ESAS assessment. Follow up time for each patient was segmented into one of three phases: initial, continuing, or palliative care. Exposed and unexposed patients were matched 1:1 using hard (birth year ± 2 years, cancer diagnosis date ± 1 year, cancer type and sex) and propensity-score matching (14 measures including cancer stage, treatments received, and comorbidity). Matched patients were followed until death or the end of study at Dec 31, 2015. Kaplan-Meier curves and multivariable Cox regression were used to evaluate the impact of ESAS on survival. Results: There were 128,893 pairs well matched on all baseline characteristics (standardized difference &lt; 0.1). The probability of survival within the first 5 years was higher among those exposed to ESAS compared to those who were not (73.8% vs. 72.0%, P-value &lt; 0.0001). In the multivariable Cox regression model, ESAS assessment was significantly associated with a decreased mortality risk (HR: 0.49, 95% CI: 0.48-0.49) and this protective effect was seen across all phases. Conclusions: ESAS exposure is associated with improved survival in cancer patients, in all phases of care. To the extent possible, extensive matching methods have mitigated biases inherent to observational data. This provides real world evidence of the impact of routine symptom assessment in cancer care.

Symptom burden of patients with advanced pancreas cancer (APC): A provincial cancer institute observational study.

384 Background: Patients (pts) with advanced pancreatic cancer (APC) experience many disease-related symptoms. The Edmonton Symptom Assessment System (ESAS) measures the severity of 9 separate domains, and is completed by pts at each visit at our provincial cancer institute. The aim of this study was to describe symptom burden at baseline and over time for chemotherapy (CT) treated pts with APC, using ESAS. Methods: Pts diagnosed with APC between 2012-2016 and treated with at least 1 cycle of CT were identified. ESAS scores were extracted from the electronic medical record. Descriptive statistics were used to report the most common symptoms of pts with APC. A joint model was used to describe the trajectory of ESAS during follow-up while controlling for death. Multivariable Cox regression was used to identify independent predictors of death. Results: Of 123 pts identified, 61% had metastatic disease, 82.1% had a baseline ECOG of 0-1, with an average age of 64.8. 1608 clinic visits had an ESAS score documented and 87% of pts completed ≥ 2 ESAS assessments. Median overall survival was 10.2 months. Median progression free survival was 6.7 months. At baseline, the 10th percentile, median and 90th percentile for total symptom distress (TSD) score were 6.2, 24 and 53 respectively. 86% of pts had at least one ESAS score of ≥ 4 at baseline, with the most common being: fatigue, nausea, anxiety, and shortness of breath. Using a joint model, average TSD scores for the cohort improved for the first 4 to 5 months after starting CT and started to rise after 6 months. Average TSD scores at 15 to 18 months were similar to scores at baseline. Controlling for metastatic disease and CT type, for every increase of 10 in baseline TSD score, there was a 5% increased risk of death. Conclusions: The ESAS tool reflects the heavy burden of cancer-associated symptoms in APC. Symptoms improve months after starting CT and eventually worsen. The impact of early intervention to address symptom management is an important area of investigation in APC.

The impact of routine ESAS use on receiving palliative care services: Results of a population-based retrospective matched cohort analysis.

191 Background: In 2007 Cancer Care Ontario began standardized symptom assessment as part of routine clinical care using the Edmonton Symptom Assessment System (ESAS). The purpose of this project was to evaluate the impact of this program on referrals to palliative care. We hypothesized that patients exposed to ESAS would be more likely to be referred. Methods: A retrospective matched cohort study was conducted to examine the impact of ESAS screening on the initiation of palliative care services provided by physician or homecare nurse among newly diagnosed cancer patients in Ontario, Canada. The study included all adult patients who were diagnosed with cancer between 2007 and 2015. Exposure was defined as completing ≥1 ESAS during the study period. Using four hard matched variables and propensity-score matching with 14 variables, cancer patients exposed to ESAS were matched 1:1 to those who were not. Matched patients were followed from first ESAS until initiation of palliative care, death or the end of study at Mar 31, 2017. Results: The final cohort consisted of 204,688 matched patients with no prior palliative care consult. The pairs were well matched. The probability of receiving palliative care within the first 5 years was higher among those exposed to ESAS compared to those who were not (20.6% vs. 15.2%, p &lt; .0001). The risk of death without receipt of palliative care within the same period was low in both groups. In the adjusted cause-specific Cox proportional hazards model, ESAS assessment was associated with a 6% increase in palliative care services (HR: 1.06, 95% CI: 1.04-1.08). Conclusions: Cancer patients who completed ESAS were more likely to initiate palliative care services than those who didn’t. ESAS screening may help identify patients who would benefit from a palliative approach to care earlier in their clinical course.

Performance Status and Symptom Scores of Women With Gynecologic Cancer at the End of Life

The Palliative Performance Scale (PPS), which measures performance status (100 = best performance to 0 = dead), and the Edmonton Symptom Assessment System (ESAS), which measures severity of 9 symptoms, are routinely collected at ambulatory cancer visits in Ontario. This study describes the trajectory of scores in patients with gynecologic cancer in the last 6 months of life. An observational study was conducted between 2007 and 2010. Patients had ovarian/fallopian tube, uterine, and cervical cancer and required 1 or more PPS or ESAS assessment in the 6 months before death. Outcomes were the average PPS and ESAS scores per week before death. Using logistic regression, we analyzed the odds ratio of reporting a moderate to severe score for each symptom. Seven hundred ninety-five (PPS) and 1299 (ESAS) patients were included. The average PPS score started at 70 and ended at 30, rapidly declining in the last 2 months. For ESAS symptoms, drowsiness, decreased well-being, lack of appetite, and tiredness increased in severity closer to death and were prevalent in more than 70% of patients in the last week of life. Patients with cervical cancer had increased odds of moderate to severe pain (1.74; 95% confidence interval, 1.30-2.32) compared with ovarian cancer. Trajectories of mean performance status had not reached the "end-of-life" phase until 1 week before death. A large proportion of the gynecologic cancer patients reported moderate to severe symptom scores as death approached. Pain was uniquely elevated in the cervical cancer cohort as death approached. Adequately managing the symptom burden appears to be a significant issue in end-of-life gynecologic care.

Predictive Factors for Well-being in Advanced Cancer Patients Referred for Palliative Radiotherapy

AimWell-being falls within a broad category of quality of life indicators and encompasses both physical and emotional factors. Identification of the most important factors affecting overall well-being may allow health care practitioners to target these symptoms and improve patients’ quality of life. The purpose of this study was to determine factors most predictive of well-being in advanced cancer patients. Materials and methodsPatients referred to the Rapid Response Radiotherapy Program completed the Edmonton Symptom Assessment System (ESAS) at consultation. ESAS scores and demographics were analysed for their predictive ability for well-being via regression analysis of the raw and categorical scores. ResultsIn total, 1439 ESAS assessments were analysed; the median age was 69 years (range 21–95). The most common primary cancers were of the lung (36%), breast (21%) and prostate (18%). Greater distress in all ESAS items, lower Karnofsky performance status (KPS) and referral for bone metastases significantly predicted for worse well-being (all P < 0.0001). However, referral for brain metastases predicted for better well-being. In multivariate analysis, the most predictive factors for worse well-being were lower KPS (P = 0.003) and greater distress in drowsiness (P = 0.01), pain (P < 0.0001), fatigue (P < 0.0001), depression (P < 0.0001) and appetite loss (P < 0.0001). Repeated analyses with categorical scores led to similar results. ConclusionGreater distress in physical and emotional symptoms assessed by ESAS contributes significantly to poorer well-being. Management for patients with advanced cancer should be directed towards these symptoms, as they form the basis for well-being. Although emotional symptoms may be scored lower than physical symptoms by patients, both significantly affect well-being.

Do patient-reported symptoms predict for emergency department visits? A population-based analysis.

6039 Background: Since 2007 in Ontario, Canada, the Edmonton Symptom Assessment System (ESAS) has been routinely used to assess symptoms in cancer patients in both ambulatory and home-care settings. The purpose of this study was to determine the relationship between individual patient symptoms, and their severity, with the likelihood of an emergency department (ED) visit. Methods: The cohort includes all cancer patients in Ontario who completed an ESAS assessment between January 2007 and March 2009. We linked multiple provincial health databases to describe the cohort and determine if an ED visit occurred within 7 days of the patient’s first ESAS. Multivariate logistic regression was used to determine the association between symptom scores (absent: score 0; mild: 1-3; moderate: 4-7; severe: 8-10) and the likelihood of an ED visit. Results: The cohort included 45,118 unique patients whose first assessment contributes to the study. 3.8% (n=1732) had an ED visit. The patients with ED visits were more likely to be men, to have lung or gastro-intestinal cancer, to have had recent radio or chemotherapy, and to have a shorter survival. The proportion of patients with ED visits increased from 2% to 10-12% as individual symptom scores increased from 0 to 10. Anxiety and depression were not associated with ED visits in the model, regardless of severity. Pain, nausea, drowsiness, appetite and shortness of breath with moderate or severe scores were associated with ED visits. Tiredness and wellbeing were the only symptoms to show a significant association for mild, moderate and severe scores. A well being score of 7-10 (reference score=0) had the highest odds ratio of 1.8 (95% CI 1.4-2.3). Conclusions: Worsening symptoms clearly contribute to ED visits. While specific symptoms like pain are obvious targets for management in the outpatient setting, constitutional symptoms like wellbeing or fatigue are associated with even higher odds. Though difficult to manage, such symptoms also warrant detailed assessment in order to optimize patient outcomes.