Greater Symptom Burden Research Articles

Relationship processes and symptom burden in couples coping with metastatic lung cancer.

169 Background: Attachment style is a complex behavioral control system rooted in neurophysiological processes which guides a person’s ability to elicit and respond to emotional closeness in an intimate relationship. Patients with high attachment anxiety and/or avoidance may engage in interpersonal behaviors that exacerbate their stress response and perhaps symptom burden. We hypothesized that, while patients’ insecure attachment is associated with increased symptom burden, partners’ positive relationship behaviors may protect against this association. Methods: Patients with metastatic NSCLC and their partners completed cross-sectional surveys assessing attachment (ECR) and emotional closeness during cancer-related discusssions (PAIR). Patients completed the MDASI to measure cancer-related symptoms. We used multi-level modeling for the dyadic analyses. Results: 54 patients (51% female; 80% White; µ age = 65 yrs) and their partners (51% female; 68% White; µ age = 64 years; µ relationship length = 27 years) participated. Patients with high attachment avoidance reported significantly higher cancer symptoms compared to those with secure attachment (MDASI µ’s: 2.14 vs .21, respectively; P<.05). Cancer symptoms were also significantly higher for patients whose partners reported low compared to high closeness during cancer-related discussions (MDASI µ’s: 1.08 vs .42, respectively; P<.05). In fact, there was a significant interaction between partners’ perceptions of closeness and patients’ attachment avoidance (P<.01) so that only patients with high avoidance reported significantly greater symptom burden if their partners reported low closeness (high avoidance and low closeness: MDASI µ = 2.73; high avoidance and high closeness: MDASI µ = 1.32). Conclusions: Patients’ attachment avoidance is significantly associated with their symptom burden. Partners who are able to maintain closeness during cancer-related discussions may protect patients with high attachment avoidance from experiencing increased symptom burden. Teaching partners of patients with insecure attachment to stay emotionally connected during cancer-related discussions may be an important target for psychosocial interventions.

Characteristics of individuals who prefer branded innovator over generic medicines: a New Zealand general population survey

Although generic medicines provide a safe and economical treatment for many illnesses, negative attitudes towards generics are common and branded innovator drugs are often preferred to generic drugs. The current study examined differences between individuals preferring branded innovator drugs compared with individuals preferring generic drugs or having no preference. We investigated differences in terms of demographics, perceived sensitivity to medicines, symptom burden, and other clinical variables. A representative general population sample (n = 1000) was recruited using random digit dialling. In a telephone interview, participants were asked about their preferences for and attitudes toward innovator versus generic drugs, perceived sensitivity to medicines, recent symptoms, and other clinical variables, such as the number of general practitioner (GP) visits, and medicine-related information-seeking behaviour. Univariate logistic regression analyses showed that individuals preferring branded innovator medicines reported lower levels of education, more negative attitudes toward generic medicines, higher perceived sensitivity to medicines, a greater symptom burden and more frequent GP visits. There were no between-group differences in whether participants were currently prescribed drugs, or in participants’ medicine-related information-seeking behaviour. Entering all variables into a multivariate logistic regression model confirmed the findings of the univariate models, apart from perceived sensitivity of medicine and symptom burden. The multivariate analysis also confirmed non-European NZ ethnicity and having no current medication prescription to be significantly associated with a preference for branded medicines. Clinicians should be especially aware that the preference for a branded innovator medicine is higher in patients with lower education, higher perceived sensitivity to medicines, higher levels of symptom burden, higher levels of healthcare utilization and not currently taking any prescription medication.

The importance of incorporating smoking cessation into lung cancer screening.

Lung cancer is the leading cause of cancer-related death in the United States (U.S.) and is the second most common non-skin cancer among men and women, accounting for about 30% of cancer-related deaths. There is clear and accumulating evidence that continued tobacco use has multiple adverse effects on cancer treatment outcomes, including greater probability of recurrence, second primary malignancies, reduced survival, greater symptom burden, and poorer quality of life (QOL). Recent findings suggest an avenue to significantly mitigate the impact of smoking on lung cancer mortality rates through the use of low-dose computed tomography (LDCT) lung cancer screening. Based on the reviewed evidence (type B), the U.S. Preventive Services Task Force (USPSTF) guidelines of 2015 recommend screening combined with smoking cessation interventions for high-risk heavy smokers and recent quitters. These practice changes offer opportunities to develop novel smoking cessation strategies tailored to highly specific settings that aim to amplify the survivorship gains expected from screening alone. However, there is a paucity of research and data that speaks to the feasibility and efficacy of providing smoking cessation treatment specifically within the context of the LDCT lung cancer screening environment. While some studies have attempted to characterize the parameters within which smoking cessation interventions should be implemented in this context, further research is needed to explore relevant factors such as the format, components, and timing of interventions, as well as the influence of risk perceptions and results of the screening itself on motivation and ability to quit smoking.

Patient-Reported Functional Status in Outpatients With Advanced Cancer: Correlation With Physician-Reported Scores and Survival

ContextPerformance status measures are increasingly completed by patients in outpatient cancer settings, but are not well validated for this use. ObjectivesWe assessed performance of a patient-reported functional status measure (PRFS, based on the Eastern Cooperative Oncology Group [ECOG]), compared with the physician-completed ECOG, in terms of agreement in ratings and prediction of survival. MethodsPatients and physicians independently completed five-point PRFS (lay version of ECOG) and ECOG measures on first consultation at an oncology palliative care clinic. We assessed agreement between PRFS and ECOG using weighted Kappa statistics, and used linear regression to determine factors associated with the difference between PRFS and ECOG ratings. We used the Kaplan-Meier method to estimate the patients' median survival, categorized by PRFS and ECOG, and assessed predictive accuracy of these measures using the C-statistic. ResultsFor the 949 patients, there was moderate agreement between PRFS and ECOG (weighted Kappa 0.32; 95% CI: 0.28–0.36). On average, patients' ratings of performance status were worse by 0.31 points (95% CI: 0.25–0.37, P < 0.0001); this tendency was greater for younger patients (P = 0.002) and those with worse symptoms (P < 0.0001). Both PRFS and ECOG scores correlated well with overall survival; the C-statistic was higher for the average of PRFS and ECOG scores (0.619) than when reported individually (0.596 and 0.604, respectively). ConclusionPatients tend to rate their performance status worse than physicians, particularly if they are younger or have greater symptom burden. Prognostic ability of performance status could be improved by using the average of patients and physician scores.

Abstract P1-11-01: Effectiveness, safety and quality of life (QoL) results from the German multicenter AVANTI study of 1st-line bevacizumab (BEV)-containing therapy in &amp;gt;2000 patients (pts) with advanced breast cancer (aBC)

Abstract Background: In Europe, BEV is approved with either paclitaxel (PAC) or capecitabine (CAP) as 1st-line therapy for HER2-negative aBC. These regimens are being evaluated in routine oncology practice in the German AVANTI (ML22452) observational study. Methods: Eligible pts had received no prior chemotherapy (CT) for aBC and had no BEV contraindications. CT schedule, diagnostics and frequency of follow-up are at the physician's discretion. Data are collected for 1 y after starting BEV, with 6-monthly follow-up for 1.5 y thereafter. QoL is assessed using EORTC QLQ-C30. Data cutoff for the 3rd interim analysis was Dec 1, 2016. Results: Between Oct 2009 and Feb 2015, 2056 eligible pts at &amp;gt;300 centers began treatment with BEV+PAC (n=1658) or BEV+CAP (n=398). Median follow-up was 12.7 (range &amp;lt;0.1–50.9) mo. Median treatment duration was 4.4 (95% CI 4.2–4.6) mo for CT and 6.0 (95% CI 5.8–6.5) mo for BEV. Table 1 summarizes PFS. In the overall population, grade 3/4 AEs were reported in 20% of pts (20% BEV+PAC; 22% BEV+CAP) and led to treatment discontinuation in 5% (5% and 5%, respectively). Mean QLQ-C30 scores were relatively stable over time both overall and in subgroups aged &amp;lt;65 vs ≥65 y, indicating maintained QoL during therapy; no relevant QoL differences between age groups were seen (Table 2). To characterize 'long responders', we identified 459 pts with PFS ≥15 mo (410 BEV+PAC; 49 BEV+CAP). Of these, 33% were aged ≥65 y, 15% had triple-negative aBC (TNBC) and 25% had ≥3 metastatic sites. Median treatment duration was 5.1 mo for CT and 10.8 mo for BEV. Table 1. PFS by subgroupPtsNo. of events/pts (%)Median PFS (95% CI), moAll1121/2042 (55)14.2 (13.5–15.3)BEV+PAC902/1646 (55)15.2 (14.0–16.2)BEV+CAP219/396 (55)10.9 (10.1–13.4)TNBC187/429 (44)12.6 (10.7–14.3)Non-TNBC677/1486 (46)14.7 (13.6–16.1)&amp;lt;65 y577/1325 (44)15.1 (13.6–16.2)≥65 y344/717 (48)13.5 (12.5–14.9)&amp;lt;3 metastatic sites678/1522 (45)14.4 (13.6–15.8)≥3 metastatic sites254/534 (48)13.5 (11.7–15.5) Table 2. Mean QoL scores over time, selected scalesScaleTimepointAll pts&amp;lt;65 y≥65 y nMean scorenMean scorenMean scoreGlobal health statusaBL84046.555747.128345.4 Wk 986744.057044.229743.7 Wk 3352043.335543.716542.4 Wk 5434244.622845.111443.6Physical functioningaBL83668.555570.328164.7 Wk 986360.956864.329554.4 Wk 3351360.335263.316153.8 Wk 5434161.622862.411359.9Social functioningaBL82761.455559.727264.8 Wk 985654.456655.429052.5 Wk 3351455.435156.516353.2 Wk 5433758.122555.811262.8FatiguebBL83548.955548.128050.6 Wk 986059.156756.329364.6 Wk 3351656.135254.516459.7 Wk 5434055.822855.711255.9PainbBL83537.855638.027937.2 Wk 986438.556937.029541.3 Wk 3351746.935345.616449.8 Wk 5434046.922848.111244.5BL=baseline. aHigher score=better QoL/functioning. bHigher score=greater symptom burden. Conclusions: More mature results from AVANTI show median PFS of 14.2 mo, favorable tolerability and maintained QoL, supporting 1st-line use of BEV for aBC. The subgroup with prolonged disease control (PFS &amp;gt;15 mo) was heterogeneous; further analyses of these pts are ongoing. Citation Format: Müller V, Jakob A, Aktas B, Grafe A, März W, Fett W, Bruch H-R, Klare P, Hoefflin S, Schneeweiss A. Effectiveness, safety and quality of life (QoL) results from the German multicenter AVANTI study of 1st-line bevacizumab (BEV)-containing therapy in &amp;gt;2000 patients (pts) with advanced breast cancer (aBC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-11-01.

Symptom Burden and Palliative Care Among Patients with Multi-Morbidity (S746)

•Identify patient-level predictors of high symptom burden.•Describe strategies to implement and evaluate standardization of symptom assessment and management protocols in primary care settings. Palliative care research has largely focused on patients with disease specific conditions. As patients age, they often accumulate diseases that increase their risk of death that is not attributable to a single condition. We assessed symptom burden and quality of life among patients with >3 chronic conditions to determine whether patients receive assessment and treatment consistent with palliation of symptoms. We hypothesized a higher number of comorbidities would be associated with greater symptom burden and poorer quality of life. We identified patients at high risk of hospitalization or death using a prognostic model. We administered cross-sectional surveys (Memorial Symptom Assessment Scale and Veterans-Rand 12) to randomly selected patients enrolled in primary care clinics in the VA Health Care System from May-December 2015. We asked patients if their most bothersome symptom was addressed and being treated during their recent appointment. Regression models identified patient-level predictors of high symptom burden and poor self-perceived health status. Patients (n=503) were white (74%), males (97%), aged 71+11.2 years. Patients reported 10.6+5.5 active symptoms and poor quality of life (28.6+11.4) (physical component scale 0-100, higher score=better health). Pain and dyspnea were the most burdensome symptoms (n=145, 29%; n=57, 11%) respectively. Among patients, 348 (74%) perceived their clinician assessed their most bothersome symptom and 330 (70%) reported they were receiving treatment for it. Younger patients (p=0.01) and those with a greater number of multi-morbidities (p<0.001) reported higher symptom burden than older patients and those with fewer multi-morbidities. Younger patients (p=0.002) and those with a greater number of multi-morbidities (p<0.001) perceived themselves as having worse physical health than older patients and those with fewer multi-morbidities. Our findings support standardization of symptom assessment and management in primary care settings for patients with multi-morbidities. Ameliorating symptoms may result in patients’ higher perceived quality of life.

Sociodemographic predictors of patients with brain metastases treated with stereotactic radiosurgery.

BackgroundPatient sociodemographic factors such income, race, health insurance coverage, and rural residence impact a variety of outcomes in patients with cancer. The role of brain metastasis at presentation and its subsequent outcomes have not been well characterized in this patient population.ResultsMultivariate analysis revealed that median income lower than $50,000 was associated with higher presenting symptom grade for brain metastasis (mean RTOG grade 1.2 vs 1.0, SE = 0.1, p = 0.04) and higher chronic symptom grade (mean RTOG grade 1.3 vs 0.9, SE = 0.1, p = 0.002). Higher area-level median income was associated with a lower symptom grade at diagnosis of brain metastasis (p = 0.0008) and likelihood of hospitalization (p = 0.004). Other sociodemographic factors were not significantly associated with survival, neurologic death, or patterns of failure after stereotactic radiosurgery for brain metastases.ConclusionsLower median income was associated with a greater symptom burden at the time of diagnosis and need for hospitalization for patients with brain metastases, suggesting a delayed time to presentation. These differences in symptom burden persisted during treatment.MethodsBetween January 2000 and December 2013, we identified 737 patients treated with stereotactic radiosurgery for brain metastases. They were characterized by 4 sociodemographic factors: median income, race, rural-urban residence, and health insurance status. Clinical outcomes included stage at diagnosis, symptom grade at presentation, likelihood of hospitalization from brain metastasis, overall survival, local failure, distant brain failure, and neurologic death. Multivariate cox proportional hazards model for each outcome was performed controlling for age, sex, number of brain metastases, and dose to brain metastases.

Do differences in patient-provider relationships explain racial differences in side effect burden among women with breast cancer in the pathways study?

48 Background: Prior research suggests that black patients with cancer report a greater burden of symptoms compared to white patients. Differences in patient-provider relationships may be an underlying and modifiable factor in these observed disparities. We examined differences in side effect burden by race/ethnicity and tested the hypothesis that patient-provider communication and trust may partly explain differences in symptom burden among women with breast cancer (BC). Methods: We conducted a cross-sectional analysis of data collected from 4,505 women diagnosed with BC from 2005-2013 at Kaiser Permanente Northern California. Women were asked two months post-diagnosis how much they were bothered by treatment side effects (FACT-B). Using modified Poisson regression, we assessed the association of race/ethnicity with side effect bother, adjusting for clinical characteristics, socioeconomic status (SES), and patient-provider communication and patients’ trust in providers in a step-wise fashion. Provider communication and trust were measured using the Interpersonal Processes of Care survey and a one-item assessment of patients’ trust in providers, respectively. Results: Before adjustment, Black, Hispanic, and Asian patients were at least 75% more likely than white patients to report high (vs. low) side effect bother (p &lt; 0.0001). Bivariate associations of communication and trust with side effect bother and race/ethnicity were statistically significant. For example, patients with high (vs. low) scores for shared decision-making were more likely to be white than black (46% vs. 39%) and less likely to experience high vs. low side effect bother (10% vs. 14%, p &lt; 0.0001 for both comparisons). However, after adjusting for clinical and SES characteristics in a multivariable analysis, the addition of patient-provider communication and trust to the model did not substantially alter disparity estimates. Conclusions: In our sample, patient-provider communication did not modify racial disparities in side effect bother. Further research is needed to explore additional modifiable factors underlying potential disparities in side effect management.

An Evaluation of the Specificity of Executive Function Impairment in Developmental Psychopathology

Deficits in executive function (EF) are common in neuropsychiatric disorders, but the specificity of these deficits remains unclear. The aim of the present study was to elucidate the pattern of EF impairment across psychopathologies in children and adolescents. Associations among components of EF with dimensions of psychopathology, including an overall psychopathology factor, were assessed. Participants (8-21 years) were from the Philadelphia Neurodevelopmental Cohort (N= 9,498). Data from a structured clinical screening interview were reduced to 5 dimensional domains using factor analyses: overall psychopathology, anxious-misery, fear, externalizing, and psychosis. EF components of attentional vigilance, response inhibition, conceptual flexibility, and working memory were assessed. Associations of clinical dimensions with general EF ability and with specific EF components were examined. EF ability showed common and domain-specific associations with clinical symptoms. General EF was directly associated with the general psychopathology, anxious-misery, and psychosis domains but not with the fear or externalizing domains. For the EF subcomponents, differences emerged in the magnitude and direction of the association between components and clinical domains. Poorer EF was typically associated with increased symptoms across clinical domains; however, in some instances, better EF ability was associated with greater symptom burden, particularly in the fear domain. EF has widespread associations with psychopathology in youth. Findings showed some overlap in the type of EF impairment across clinical phenotypes, as indicated by similar patterns of associations between some clinical symptoms and EF. However, findings also showed domain-specific associations with EF that differed across EF components and clinical domains.

Interleukin-6 is independently associated with right ventricular function in pulmonary arterial hypertension

An elevated serum level of interleukin-6 (IL-6) in pulmonary arterial hypertension (PAH) patients results in a greater symptom burden and increased mortality; however, the mechanisms underlying these observations remain unclear. Because both pre-clinical and clinical data associate elevated IL-6 levels with impaired cardiac function, we hypothesized that the adverse effects of IL-6 in PAH result, in part, from right ventricular (RV) dysfunction. We analyzed the relationship between IL-6 and RV function in 40 patients with PAH identified in our institutional PAH registry. Serum IL-6 levels was quantified by enzyme-linked immunoassay. PAH patients had higher IL-6 levels than age- and gender-matched controls. Circulating IL-6 levels correlated inversely with echocardiography-based measures of RV function and RV-pulmonary artery (RV-PA) coupling. When dividing PAH patients by median IL-6 level, patients with higher IL-6 had significantly worse RV function (fractional area change [FAC] 23 ± 12% vs 38 ± 11%, tricuspid annular plane systolic excursion [TAPSE] 1.3 ± 0.3 cm vs 2.1 ± 0.5 cm), impaired RV-PA coupling (0.6 ± 0.5%/mm Hg vs 0.9 ± 0.5%/mm Hg), higher right atrial pressure (13 ± 7 mm Hg vs 9 ± 5 mm Hg), reduced cardiac index (2.0 ± 0.5 liters/min/m2 vs 2.8 ± 1.0 liters/min/m2) and lower stroke volume (48 ± 20 ml vs 70 ± 28 ml). In contrast, the relationships between IL-6 and mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR) and pulmonary arterial compliance (PAC) were not significant. Finally, IL-6 was independently associated with RV function and RV-PA coupling after adjusting for static (PVR) and pulsatile (PAC) after-load on the RV. Serum IL-6 levels are independently associated with RV function and RV-PA coupling in PAH. Patients with higher IL-6 levels have more severe RV dysfunction and diminished RV-PA coupling despite a comparable severity of pulmonary vascular disease.

2041

OBJECTIVES/SPECIFIC AIMS: Traditional hospice focuses on symptoms and quality of life (QOL) at the very end of life. Clinical symptoms and QOL in the last 1–2 years of life are also important and may be affected by dementia. Our objective was to characterize how symptoms differ between people with and without dementia in the last years before death and whether symptoms impact social dimensions of QOL. METHODS/STUDY POPULATION: We studied 1270 community-dwelling participants who died between 2011 and 2015 in the National Health and Aging Trends Study, a nationally representative cohort of older adults. From the last interview before death, we examined sensory (vision; hearing), physical (pain; problems with breathing, chewing/swallowing, speaking, upper or lower extremity strength/movement, and balance/coordination), and psychiatric (depression; anxiety; insomnia) symptoms by dementia status. We examined associations between symptoms and participation restrictions (visiting family/friends, attending religious services, participating in clubs/activities, going out for enjoyment, and engaging in favorite activity). RESULTS/ANTICIPATED RESULTS: Low energy (69%), pain (59%), and lower extremity strength/movement problems (56%) were most common. People with dementia (37.3% of decedents) had higher prevalence of all symptoms (p≤0.01), except pain, breathing problems, and insomnia. Dementia and greater symptom burden were independently associated with greater odds of participation restrictions (p&lt;0.05). Problems speaking were significantly associated with limitations in all activities except for attending religious services. Balance/coordination, energy, and strength/movement problems were associated with limitations in 3 activities. DISCUSSION/SIGNIFICANCE OF IMPACT: Sensory, physical, and psychiatric symptoms are common in the year before death, with greater symptom prevalence in people with dementia. Both dementia and symptoms are associated with restrictions in participation. Older patients may benefit not only from earlier emphasis on palliative care but also programs and assistive devices that accommodate physical impairments.

High Symptom Burden and Low Functional Status in the Setting of Multimorbidity.

To enhance understanding of the relationship between multimorbidity, symptom burden, and functional status in individuals with life-limiting illness. Secondary analysis of baseline data from a randomized clinical trial conducted in the Palliative Care Research Cooperative Group. Group differences were tested using a t-test; multivariate regression analysis was used to determine the effect of multiple variables on functional status and symptom burden. Fifteen Palliative Care Research Cooperation sites. Adults who participated in a parent statin-discontinuation clinical trial were included in the analysis (N = 381). Inclusion criteria were diagnosis of a life-limiting illness, statin use for 3 months or longer, life expectancy longer than 1 month, and declining functional status. Cancer diagnosis (solid organ and hematologic malignancies), multimorbidity (Charlson Comorbidity Index (CCI) score), symptom burden (Edmonton Symptom Assessment Scale (ESAS) score, number of symptoms with ESAS severity score >4), functional status (Australia-modified Karnofsky Performance Scale (AKPS)). Fifty-one percent had a primary diagnosis of cancer; mean age 74.1 ± 11.6. Participants had multiple comorbid illnesses (CCI score 4.9 ± 2.8), multiple symptoms (ESAS score 27.2 ± 15.9), and poor functional status (AKPS = 53 ± 13). In univariate and multivariate analyses, multimorbidity was associated with greater symptom burden (4.2 vs 3.1 moderate or severe symptoms (t = -3.2, P = .002), 12% vs 6% with severe symptoms (t = -3.7, P < .001)), but cancer diagnosis was not. In univariate and multivariate analyses, higher symptom burden was associated with poorer functional status (F = 11.6, P < .001), but multimorbidity was not. Symptoms cannot be attributed solely to a diagnosis of cancer. The association between symptom burden and functional status underscores the importance of clinical attention to symptoms in individuals with multimorbidity.

Association between patients' perception of the comorbidity burden and symptoms in outpatients with common solid tumors.

Cancer patients' symptom burden is commonly attributed to their cancer and treatment. Increasingly, cancer patients have many other chronic comorbid conditions. However, the degree to which these comorbid conditions may contribute to the patient-reported symptom burden is unclear. This study explored the relations between the presence of comorbid conditions, the symptom experience and burden, and the perceived bother from cancer or comorbid conditions in 3106 cancer patients. The associations between the number of comorbidities (identified from current medications), the patient-reported symptom burden (the number of symptoms scored as ≥7 on the 13-item MD Anderson Symptom Inventory physical scale), the patient-reported bother from comorbid conditions and from cancer (from "not at all" to "extremely"), and the clinician-reported difficulty in caring for patients' symptoms were examined. According to medication lists, 19% of the patients had at least 5 of 12 comorbid conditions. Approximately 39% rated at least 1 symptom as ≥ 7, and this proportion increased with an increasing number of comorbid conditions (48% with ≥ 5 comorbid conditions vs 36% with 1 comorbid condition). One-third of the patients reported moderate or worse bother, and this was significantly associated with an increased number of comorbid conditions (odds ratio [OR], 2.4) and an increased symptom burden (OR, 1.22). Clinician ratings of difficulty in managing patients' symptoms were significantly associated with bother from cancer (OR, 2.0), comorbid conditions (OR, 1.6), and symptom burden (OR, 1.1). Comorbidity is common in cancer patients and is associated with a greater symptom burden and clinician reports of difficulty in managing patients' symptoms. Greater attention to comorbid conditions is needed to optimize the symptom management of cancer patients with multimorbidity. Cancer 2017;123:3835-3842. © 2017 American Cancer Society.

Patients With Co-Occurring Bipolar Disorder and Posttraumatic Stress Disorder: A Rapid Review of the Literature.

To summarize the current literature on epidemiology, clinical correlates, and treatment of individuals with co-occurring bipolar disorder and posttraumatic stress disorder (PTSD). We conducted a focused, time-sensitive review called "rapid review" in November 2015, using keyword searches (including keywords bipolar disorder, post-traumatic stress disorder, PTSD, and others) in PubMed for studies of adults with co-occurring bipolar disorder and PTSD. Results were sorted and systematically searched. An article was excluded if it did not describe adult patients with co-occurring PTSD and bipolar disorder or did not report original data on epidemiology, clinical correlates, or treatment. Information on study characteristics including population studied and key findings were extracted onto a data collection tool. Thirty-two articles were included. Over two-thirds of articles reported epidemiology of co-occurring bipolar disorder and PTSD. Prevalence of PTSD among individuals with bipolar disorder ranged from 4% to 40%, with women and those with bipolar I versus bipolar II disorder experiencing higher prevalence of PTSD. Prevalence of bipolar disorder among individuals with PTSD ranged from 6% to 55%. Baseline PTSD or bipolar disorder was associated with incidence of the other illness. Individuals with co-occurring bipolar disorder and PTSD experienced high symptom burden and low quality of life. No studies evaluated prospective treatment of patients with co-occurring bipolar disorder and PTSD. Bipolar disorder and PTSD commonly co-occur and result in greater symptom burden than either condition alone. Few published treatment strategies exist for patients with both conditions.

Symptom burden and hospital length of stay among patients with curable cancer.

6579 Background: Prolonged hospital admissions are often inconsistent with patients’ preferences and incur significant costs. While patients’ symptoms may result in hospitalizations, the relationship between patients’ symptom burden and their hospital length-of-stay (LOS) has not been fully explored in patients with curable cancers. Methods: We prospectively enrolled patients with curable cancer and unplanned hospital admissions between 8/2015 and 12/2016. Within the first 5 days of admission, we assessed patients’ physical (Edmonton Symptom Assessment System [ESAS]; scored 0-10 with higher scores indicating greater symptom burden) and psychological symptoms (Patient Health Questionnaire 4 [PHQ-4]; scored categorically and continuous with higher scores indicating greater distress). We created summated ESAS total and physical symptom variables. To assess the relationship between patients’ symptom burden and their hospital LOS, we used separate linear regression models adjusted for age, sex, marital status, education level, time since cancer diagnosis, and cancer type. Results: We enrolled 452 of 497 (91%) approached patients (mean age = 61.9 years; 188 [42%] female). Over half had hematologic cancers (n = 249, 55%). Mean hospital LOS was 8.3 days. Over one-tenth of patients screened positive for PHQ-4 depression (n = 74, 16%) and anxiety (n = 60, 13%) symptoms. Mean ESAS symptom scores were highest for fatigue (6.6), drowsiness (5.4), pain (4.9), and lack of appetite (4.8). In multivariable regression analysis, patients’ physical and psychological symptoms were associated with longer hospital LOS (table). Conclusions: Patients with curable cancer and unplanned hospital admissions experience a substantial symptom burden, which predicts for prolonged hospitalizations. Importantly, patients’ symptoms are modifiable risk factors that, if properly addressed, can improve care delivery and may have the potential to help decrease prolonged hospitalizations. [Table: see text]

Unmet supportive care needs of older adults with advanced cancer.

10040 Background: Cancer disproportionately affects older adults, yet research defining the supportive care needs of these patients is lacking. We sought to examine associations between geriatric impairments, quality of life (QOL), and physical and psychological symptom burden in older adults with newly diagnosed incurable gastrointestinal (GI) cancer. Methods: We prospectively enrolled patients age ≥70 within 8 weeks of diagnosis of incurable GI cancer at Massachusetts General Hospital from 10/2015-11/2016. We used surveys to assess geriatric impairments (Vulnerable Elders Survey-13 [range 0-10, scores ≥3 identify patients with impairments), QOL (EORTC QLQ-C30 [range 0-100, higher scores indicate better QOL]), physical symptoms (Edmonton Symptom Assessment System [range 0-10, higher scores indicate greater symptom burden]) and psychological symptoms (Geriatric Depression Scale, [range 0-15, higher scores indicate greater depression symptoms]). We used descriptive statistics to determine differences in patient characteristics by the presence or absence of geriatric impairments. We used linear regression adjusted for age, employment, cancer type, and comorbidity to examine associations between geriatric impairments, QOL, and physical and psychological symptom burden. Results: We enrolled 50 of 58 (86%) patients approached (mean age = 78.7; 52% with pancreatic cancer). Nearly half (46%) screened positive for geriatric impairments; these patients were older (81.7 vs 76.1, p &lt; .01) and had more comorbid conditions (2.4 vs 1.2, p = .01). On linear regression, patients with geriatric impairments reported worse QOL across all domains (General QOL: B = -28.3, p &lt; .01; Physical: B = -36.8, p &lt; .01; Role: B = -36.8, p &lt; .01; Emotional: B = -30.1, p &lt; .01; Cognitive: B = -17.8, p = .03; Social: B = -39.7, p &lt; .01), higher depression scores (B = 5.1, p &lt; .01) and worse fatigue (B = 4.6, p &lt; .01), drowsiness (B = 4.0, p &lt; .01), appetite (B = 3.8, p &lt; .01), and pain (B = 2.7, p = .02). Conclusions: Older adults with advanced cancer experience considerable unmet supportive care needs, particularly those with geriatric impairments. Future research is needed to assess older patients for geriatric impairments and address their unique palliative and supportive care needs.

Switching tumor necrosis factor inhibitors in the treatment of axial spondyloarthritis.

To assess the impact of switching tumor necrosis factor (TNF)-alpha inhibitors on patients with axial spondyloarthritis (axSpA). PubMed literature searches were conducted using combinations of search terms including ankylosing spondylitis, spondyloarthropathy, spondyloarthritis, switch/switching, drug survival, and TNF/tumor necrosis factor to identify published articles with data on outcomes related to switching biologic therapies in patients with axSpA. Of the 134 studies screened, 21 were identified as reporting data on switching TNF inhibitors in patients carrying a diagnosis of axSpA or ankylosing spondylitis. The most common reasons for switching from the first TNF inhibitor were lack of efficacy (14-68%), loss of efficacy (13-61%), and adverse events/poor tolerability (13-57%). Switching TNF inhibitors was beneficial for a substantial proportion of patients with axSpA who failed to respond to initial or even second TNF inhibitor therapy and adverse effects were not enhanced. Drug survival rates were generally lower for the second (47-72% at 2 years) or third TNF inhibitor (49% at 2 years) than for the first TNF inhibitor (58-75% at 2 years). Predictors of responses in TNF-naïve patients included HLA-B27 positivity, absence of enthesitis, age ≤40 years, elevated C-reactive protein level, good functional status, and shorter disease duration. Predictors of drug survival included male sex and peripheral arthritis. Common characteristics of patients who switched TNF inhibitors included female sex, older age, more severe disease, greater symptom burden, higher erythrocyte sedimentation rate, complete ankyloses, and enthesitis. When the first or even the second TNF inhibitor fails, switching to an alternate one is not an unreasonable clinical therapeutic decision.

Emotional Problems, Quality of Life, and Symptom Burden in Patients With Lung Cancer

ObjectivesLung cancer is associated with a greater symptom burden than other cancers, yet little is known about the prevalence of emotional problems and how emotional problems may be related to the physical symptom burden and quality of life in newly diagnosed patients with lung cancer. This study aimed to identify the patient and disease characteristics of patients with lung cancer experiencing emotional problems and to examine how emotional problems relate to quality of life and symptom burden. Patients and MethodsA total of 2205 newly diagnosed patients with lung cancer completed questionnaires on emotional problems, quality of life, and symptom burden. ResultsEmotional problems at diagnosis were associated with younger age, female gender, current cigarette smoking, current employment, advanced lung cancer disease, surgical or chemotherapy treatment, and a lower Eastern Cooperative Oncology Group performance score. Additionally, strong associations were found between greater severity of emotional problems, lower quality of life, and greater symptom burden. ConclusionCertain characteristics place patients with lung cancer at greater risk for emotional problems, which are associated with a reduced quality of life and greater symptom burden. Assessment of the presence of emotional problems at the time of lung cancer diagnosis provides the opportunity to offer tailored strategies for managing negative mood, and for improving the quality of life and symptom burden management of patients with lung cancer.

The Course of Concussion Recovery in Children 6-12 Years of Age: Experience From an Interdisciplinary Rehabilitation Clinic

BackgroundCurrent concussion evidence is derived largely from teenagers and adults. Concussion in younger children occurs within the context of neuromaturation, with differing age-based pathophysiological responses to injury. Therefore, our current understanding of concussion in older children and adults is unlikely to directly apply to younger children. ObjectiveTo describe patient variables, clinical course, and factors associated with time to discharge from concussion care in children 6-12 years of age with concussion treated in an interdisciplinary rehabilitation-based concussion clinic. DesignRetrospective chart review. SettingInterdisciplinary concussion clinic at an academically affiliated rehabilitation center. PatientsChildren aged 6-12 years (n = 105; mean 10.8 years of age, 70% male) seen within 60 days of concussive injury. Main Outcome MeasurementsDescriptive statistics explored demographic, injury, and clinical features. The primary outcome measure, time to discharge from concussion care, was estimated with survival-analysis methods based on the date of discharge from the clinic. Multivariate models were used to examine factors associated with longer time to discharge. ResultsMedian time to discharge was 34 days postinjury (range 5-192 days); 75% of children were discharged within 60 days of injury. A minority reported persisting symptoms at discharge. Younger age and increased symptom burden at initial evaluation predicted longer time to discharge. ConclusionsAlthough children 6-12 years old treated in a specialty concussion clinic show variability in time to discharge from concussion care, most were discharged within 2 months after injury. Risk factors for prolonged recovery, such as younger age and greater symptom burden at initial visit, can be used when counseling families and planning interventions. There may be varying contributions, including psychosocial stressors, to ongoing symptoms in children who experience persisting symptoms after other concussion-related concerns have resolved. Future work focused on the subset of children who report persisting symptoms will be useful for developing an evidence base related to their care. Level of EvidenceII

Comparing the symptom experience of cancer patients and non-cancer patients.

Symptom burden is an established concept in oncology encompassing the presence and severity of symptoms experienced by cancer patients. Few studies have examined differences in symptom burden between cancer patients and non-cancer patients. This study seeks to examine the differences in symptom burden between cancer patients (CP) and non-cancer patients (NCP) in order to better understand symptom burden in both populations. Two groups of patients completed the Memorial Symptom Assessment Scale: 301 patients from a general medical clinic and 558 cancer patients from a cancer tumor registry. Participants provided demographic information-age, race/ethnicity, and sex and completed the Memorial Symptom Assessment Scale. Medical comorbidity was also measured. Most symptoms were more common in CP, except for pain, which was more prevalent in the NCP (45% of CP vs. 54% of NCP, p<.05). There was no difference in prevalence for the following symptoms: dry mouth, mouth sores, feeling nervous, worry, cough, and dizziness. The CP had greater mean MSAS Total scores (0.53 vs. 0.43, p<.01), number of symptoms (9.11 vs. 6.13, p<.01), and psychological subscale scores (0.77 vs. 0.64, p<.05). There was no difference by group in the physical nor the GDI subscale scores. The results of this study support the perception that cancer patients have greater symptom burden. There were some unexpected results, particularly in terms of pain, which was more common in NCP and other symptoms that were experienced equally in both patient populations.