Median Distress Score Research Articles

App-based assessment of patient-reported outcomes in the Molecular Tumor Board in the Center for Personalized Medicine-(TRACE).

Biomarker-based therapies are increasingly used in cancer patients outside clinical trials. Systematic assessment of patient-reported outcomes (PRO) is warranted to take patients' perspectives during biomarker-based therapies into consideration. We assessed the feasibility of an electronic PRO assessment via a smartphone application. An interdisciplinary expert panel developed a smartphone application based on symptom burden and health-related quality of life (HRQoL) metrics reported in a retrospective analysis of 292 neuro-oncological patients. The app included validated assessments of health-related quality of life (HRQoL), the burden of symptoms, and psychological stress. Feasibility and usability were tested in a pilot study. Semi-structured interviews with patients and health care professionals (HCP) were conducted, transcribed, and analyzed according to Mayring´s qualitative content analysis. Furthermore, we assessed compliance and descriptive data of ePROs. A total of 14 patients have been enrolled, (9 female, 5 male). A total of 4 HCPs, 9 patients, and 1 caregiver were interviewed regarding usability/feasibility. The main advantages were the possibility to complete questionnaires at home and comfortable implementation in daily life. Compliance was high, for example, 82% of the weekly distributed NCCN distress thermometer questionnaires were answered on time, however, with interindividual variability. We observed a median distress score of 5 (range 0-10, 197 results, n = 12, weekly assessed) and a median Global health score of 58.3 according to the EORTC QLQ-C30 instrument (range 16.7-100, 77 results, n = 12, monthly assessed). This pilot study proved the feasibility and acceptance of the app. We will therefore expand its application during biomarker-guided therapies to enable systematic PRO assessments.

P22.03.A FEASIBILITY OF AND COMPLIANCE TO ELECTRONIC PATIENT-REPORTED OUTCOME ASSESSMENT IN THE MOLECULAR TUMOR BOARD IN (NEURO-)ONCOLOGICAL PATIENTS UNDER TARGETED THERAPY (TRACE)

Abstract BACKGROUND Comprehensive genomic profiling and biomarker-based therapies are increasingly used in clinical trials and in innovative health care systems including the center for personalized medicine network. Systematic assessments of patient-reported outcomes (PRO) are warranted to gain insight into the perspective of patients during biomarker-based therapies. In the present study, we focused on the feasibility of and compliance to an electronic PRO assessment in patients treated at our center. MATERIAL AND METHODS Based on a retrospective evaluation of symptom burden in 265 neurooncology patients in the Molecular Tumor Board (MTB), we developed an app by 14 expert rounds including validated assessments of health-related quality of life (HRQoL), burden of symptoms und psychological stress, and tested it in a pilot study. After informed consent, patients were introduced to the app by study staff and completed subsequently patient-reported outcomes at several time points (weekly, monthly, and quarterly). We conducted a structured interview with health care personnel and the patients as users after 3 months to assess the app’s usability and feasibility. The interview was transcribed and analyzed according to Mayring´s qualitative content analysis regarding handling, feasibility and applicability in daily routine.Furthermore, we assessed compliance and descriptive data of the ePROs. RESULTS So far, 14 patients and caregivers have been enrolled, (9 female, 5 male). Median age was 50 years (range 28 -79), 3 out of 14 patients dropped out due to death. A total of 4 study staff members, 9 patients and one caregiver were interviewed regarding usability /feasibility. Both evaluated as good (study staff members in total n=40 quotes, patients/caregivers n=112 quotes). Main advantages were the possibility to complete questionnaires at home and the easy implementation in daily life. Compliance to questionnaires was high, e.g., 91% of weekly distributed NCCN Distress Thermometer were answered in time (range 65-100%, assessment duration 5-56 weeks, 262 answers), we observed a median Distress score of 4 (range 0-9, n=262, weekly assessed) and a median Global health score of 66.7 (range 16.7-100, n=69, EORTC QLQ-C30, question 29 and 30, monthly assessed, compliance 94%). CONCLUSION This pilot study proved feasibility and acceptance of the app and might enable PRO assessment during biomarker-guided therapies.

Psycho-oncology/Supportive Care in Head–Neck Cancers Patients Undergoing Radiation Therapy: A Randomized Controlled Trial

An elevated level of distress is associated with poor health-related quality of life (QoL), decreased patient satisfaction, poor treatment compliance, and possible reduced survival. This randomized trial, conducted at a single center in India, enrolled head–neck cancer patients aged > 18 years who were undergoing curative intent radiation therapy, and had significant baseline distress as per the National Comprehensive Cancer Network distress thermometer (distress score ≥ 4). The patients were randomized into the Standard arm (STD), which involved routine assessment by the oncologist, or the Interventional arm (INV), where psycho-oncology/palliative/supportive care referral was done at baseline and every week during treatment. The study's primary endpoint was the proportion of patients having significant distress 6 months' posttreatment. A total of 212 patients were randomized (n = 108 STD, n = 104 INV). At 6 months' post-treatment completion, 90 and 89 were evaluable in the STD and INV, respectively. The median distress score was 2 in both arms at this time point. There was no significant difference in the proportion of patients having significant distress in STD versus INV (9 vs. 15.6%, p = 0.20). There was an improvement in any symptom measured by the Edmonton Symptom Assessment Score (pain, tiredness, drowsiness, nausea, lack of appetite) and the QoL for the entire cohort with no statistically significant difference between arms for symptoms, QoL, or survival endpoints. Psycho-oncology and palliative/supportive care referral did not impact distress, symptom burden, QoL, or survival at 6 months' posttreatment completion significantly in this randomized trial. Clinical Trial Registry of India Registration number: CTRI/2016/01/006549.

Feasibility trial of child care as a therapeutic intervention.

e24196 Background: The incidence rate of cancer among young adults (ages 20-44) has steadily increased over the past decade. Among them, approximately 18% are parents within two years of initial diagnosis. Work as part of our Young Women Surviving support group identified childcare support as an unmet need. We therefore sought to determine the impact of childcare provision on the timeliness of care among young women undergoing chemotherapy for cancer. Methods: We conducted a pilot feasibility study that enrolled a convenience sample inclusive of parents with histologically confirmed invasive breast or gynecologic cancer receiving system chemotherapy and were caring for children 16 years or younger. Following consent, funds were reimbursed for costs related to their preferred childcare resource, including for travel and infusion time. Therapy assessments and an abridged version of the NCCN Distress Thermometer (score ranging from 0-10 with 0 indicating no distress) were administered at each infusion appointment. Feasibility was measured by acceptance of childcare services by > 25% of patients identified as eligible. Results: This study was offered to 26 eligible patients, of which 23 enrolled (88.5%) and 20 have follow-up data. Among study volunteers, 80% were white, 15% were black; Five percent identified as Hispanic or Latino. The median age was 39 years old (range, 31 to 79). The majority of patients (85%) had breast malignancy, while the remaining 15% had gynecological cancers. The median number of treatment events for which babysitting services were paid for were 6 (range, 2-18). Of 19 patients with distress scores, 4 (21%) reported childcare as a stress for them. The median distress score decreased over time, from 5 at first treatment event to a median score of 3 at the eighth event. All participants who completed end of study surveys (16 patients) reported they “agree” or “strongly agree” with the statements “I would participate in child care again” and “Babysitting allowed you to get to your treatment on time.” Over the duration of study, 95% of this cohort did not have any delays in their cancer-directed therapy due to childcare. Conclusions: This is early evidence to suggest providing childcare to patients who are also undergoing chemotherapy is feasible and may be beneficial in improving impact on cancer outcomes and psychological distress. Further studies should include a comparator arm to better clarify the significant of this supportive measure. It is important to continue investigating the impact of supportive services on the quality of life and of care for this unique cohort.

Characterizing digital access in pediatric urology

Virtual medicine has the potential to improve access for underserved populations by facilitating timely remote evaluation. However, challenges in the real-world implementation of this technology may paradoxically exacerbate health disparities. We sought to characterize families' digital access and how social determinants of health may impact virtual medicine access within pediatric urology. We hypothesized that disadvantaged socioeconomic status would be a barrier to virtual medicine access. A digital access screening tool was prospectively developed and launched in July 2021. Schedulers are prompted to complete this optional screening questionnaire at the time of patient intake, for video or in-person encounters. The parent is screened for access to a device and reliable internet or cellular data that could be used to participate in a video visit. These represented the primary study outcomes. A modality preference for an in-person visit, video visit, or no preference was also recorded. Patient demographics were retrospectively evaluated, and socioeconomic status was estimated using the Distressed Communities Index generated for each patient's zip code. For each zip code, the Distressed Communities Index produces a normalized, comparative distress score ranging from 0 ("prosperous") to 100 ("distressed"). 3885 patients were included, with median age of 5 years (IQR 1-11). Almost 74% were male, 71.3% were White, 20.9% had public insurance, and 2.9% required an interpreter. The median distress score was 14.2 (IQR 7.2-27.5). Screening revealed that 136 families (3.5%) lacked digital access. On multivariable logistic regression analysis, insurance type (p=0.0020) and distress score (p=0.0125) were significant predictors of digital access (Summary Table). Those patients who lacked access to a device (p<0.0001) or reliable internet/cellular data (p<0.0001) were more likely to prefer an in-person visit. Family screening revealed that there is a small but significant proportion of families who lack digital access, and this cohort disproportionately represents underserved communities with higher distress scores, likely reflecting lower socioeconomic status. Those families without digital accesswere more likely to prefer an in-person visit. Improved identification of these socially complex "at-risk" patients can assist in the development of more inclusive health care strategies. Despite the chance for virtual medicine to expand access for underserved populations, lack of digital tools may hinder its potential impact on health disparities in pediatric urology. Ongoing digital access screening and further studies are needed to design interventions tailored to the specific needs of our patients, allowing for more equitable pediatric urological care.

Distress screening in endometrial cancer leads to disparity in referral to support services

ObjectivesRacial disparities in survival from endometrial cancer (EC) are well known. Cancer distress has also been associated with worse clinical outcomes. We characterized the association between race/ethnicity, patient distress reported on the National Comprehensive Cancer Network Distress Thermometer and Problem List (NCCN DT & PL), referral to support services, time to surgery, and acceptance of adjuvant therapy in patients with EC. MethodsWe included patients presenting at an academic gynecologic oncology practice from 1/2013–6/2020 who had not received prior EC-directed treatment. Demographics, NCCN DT scores, and treatment details were abstracted from the electronic medical record. Difference in initial DT scores by race/ethnicity and treatment type was tested using general linear modeling. The significance of interaction effects was tested using linear mixed models and logistic regression. Results393 non-Hispanic White (NHW) and 134 non-Hispanic Black (NHB) patients were included. Median distress scores were higher in NHW patients compared to NHB patients (4 vs. 2, p < 0.001); 51% of NHW patients qualified for referral to support services compared to 40% of NHB patients (p = 0.03). Distress scores were highest at initial appointment and declined over time in NHW patients regardless of treatment, but were initially low and remained low over time in NHB patients. There was no association of initial distress score with time to surgery or acceptance of adjuvant treatment (p-values >0.25). ConclusionsAn observed difference in NCCN DT leads to racial disparities in referral to support services. The NCCN DT may not adequately measure distress in NHB women with EC.

A Comparison of Overall Patient Reported Distress Levels in Appalachian Cancer Patients From Economically Distressed vs. Non-Economically Distressed Counties Receiving Radiation Therapy for Thoracic Malignancies

<h3>Purpose/Objective(s)</h3> Appalachia has historically been an impoverished region. Higher levels of poverty are positively correlated with poorer cancer outcomes, particularly with areas that had a strong coal mining industry. Our medical center primarily serves 21 counties located entirely within Appalachian, 11 of which are economically classified as having a "Distressed" or "At Risk" by the Appalachian Regional Commission (ARC). The patients traveling from these counties usually have longer commute times and reliable access to care can be challenging. The remaining 10 counties are deemed "Transitional" and no county is designated in ARC's economically successful "Competitive" or "Attainment" categories. Considering the correlation between poverty level and outcomes, we hypothesized that patients from the "Distressed" or "At Risk" counties would have higher overall distress levels compared to "Transitional" counties. <h3>Materials/Methods</h3> Of 479 patients receiving radiotherapy (RT) at our institution for lung cancer in 2019 and 2020, 79 sequential patients treated with RT without definitive surgery were identified who had their overall distress level prospectively measured using the NCCN distress instrument prior to starting RT. Patient demographics, tumor and treatment characteristics, and overall distress data were collected and mean values of distress between groups were assessed using Pearson's chi-squared test. <h3>Results</h3> There were no statistically significant differences in patient, tumor, or treatment characteristics between distressed and non-distressed counties, with the exception of cancer stage. 84% of patients coming from distressed counties had Stage I lung cancers (p=0.04). Patients coming from economically "At Risk'' and "Distressed" counties had a median distress score of 2.8 (range 0 to 9); patients from "Transitional" counties had a median distress score of 3.3 (p-value = 0.5). <h3>Conclusion</h3> Our study did not find a statistically significant difference in overall distress levels between patients coming from areas of economic hardship. We hypothesize that a lung cancer diagnosis is one of many stressors facing our Appalachian patients coming from economically distressed regions. Additionally, the majority of patients referred for radiotherapy had Stage I cancers that were asymptomatic. Lung and heart diseases are also more prevalent in these poorer counties and may lead to an earlier subsequent diagnosis of lung cancer incidentally at an earlier age in some patients, which may in turn also result in a better cancer prognosis and prevent distress in the population we studied.

Improving the Initial Breast Cancer Consultation.

Research shows providing cancer patients with adequate information has many benefits, but how do nurse practitioners know whether the initial consultation meets the information needs of their patients? Furthermore, how can the initial consultation be improved? A low-cost continuous quality improvement process centered on decreasing distress and increasing information satisfaction was piloted to determine its effectiveness and feasibility. Immediately before and after an initial consultation with a breast cancer surgeon, 59 women completed a questionnaire to measure distress and specific problems they were having. They then completed a questionnaire to measure information satisfaction. Pre-post changes in the distress score and number of problems were analyzed, as was information satisfaction. Feasibility was qualitatively examined. For the study sample, pre-post median distress scores decreased significantly (from 5 to 3, Chi-square = 5.73, p < .017). Information dissatisfaction scales were identified. The process was deemed feasible. This effective and feasible process may help the nurse practitioner continuously improve the initial consultation process. (a) the initial breast cancer consultation is important, (b) a novel process for improving the initial breast cancer consultation is proposed, and (c) this feasible, low-cost process should be embedded into normal practice operations.

Fear of COVID-19: Effects on mental health in under-resourced patients with cancer.

152 Background: Given the high risk of COVID-19 mortality, patients with cancer are not only vulnerable to physical consequences of COVID-19 infection, but also to adverse psychological outcomes, including fear of COVID-19. Without intervention, psychological distress in patients with cancer can lead to worsening symptoms, poor quality of life, and lower survival. We sought to evaluate the association between fear of COVID-19 and psychological distress for under-resourced patients with cancer during the pandemic. Methods: This observational, longitudinal survey study, fielded during early (May 20- July 11, 2020) and later pandemic (December 2-December 23, 2020), evaluated the pandemic’s impact on patients with cancer receiving Patient Advocate Foundation (PAF) services from July 2019 – April 2020. Questions focused on individual experiences with COVID-19 and psychological, emotional, physical, and material effects from the pandemic. The validated Fear of COVID-19 Scale was used to determine fear of COVID-19. Psychological distress was determined using a four-item questionnaire by Holingue et al. (score range 4 – 16). Means and 95% confidence intervals (CI) were estimated using generalized estimating equation modeling with repeated measures to assess the effect of fear of COVID-19 on psychological distress early and later in the pandemic. Models adjusted for age, sex, race/ethnicity, region, annual household income, household size, marital status, employment status, Area Deprivation Index category, Rural-Urban Commuting Code category, cases per 100,000 in county of residence, cancer type, and number of comorbidities. Results: Amongst 1199 survey respondents, 94% considered themselves high risk for COVID-19. 448 respondents completed both the first and second survey. The majority of respondents were female (72%) and age 56-75 (55%); 40% were Black, Indigenous, or Persons of Color. In adjusted models of respondents who completed the early pandemic survey, respondents with more fear of COVID-19 had a higher mean psychological distress score (10.21; 95% CI 9.38-11.03) compared to respondents with less fear (7.55; 95% CI 6.75-8.36). Among those who completed the later pandemic survey, median fear of COVID-19 decreased (20 vs 19)median distress scores remained the same (8); respondents with more fear of COVID-19 had a higher mean psychological distress score (9.98; 95%CI 9.04-10.92) compared to respondents with less fear (7.87; 95%CI 6.98-8.76). Conclusions: Fear of COVID-19 was linked to psychological distress and persisted throughout the pandemic among under-resourced patients with cancer. Timely psychosocial support is critical to meet increased care needs experienced by patients with cancer during the COVID-19 pandemic. Given these results, fear of COVID-19 could be considered as a trigger to integrate psychological interventions in patients with cancer to treat psychological distress.

Racial differences in patient-reported distress among women with endometrial cancer

Objectives: There are established racial disparities in mortality from endometrial cancer (EC). In addition, distress from cancer diagnosis and treatment is associated with lower compliance and more frequent use of emergency services. Differences in distress by race/ethnicity in EC have not been previously explored. Here we characterize the association between race/ethnicity, distress scores and stressors reported by patients on the National Comprehensive Cancer Network Distress Thermometer and Problem List (NCCN DT), and referral to support services in women with EC. Methods: Patients presenting to a single academic outpatient gynecologic oncology practice for initial evaluation of known EC from January 2013-May 2020 were included. The electronic health record was used to abstract demographics, NCCN DT scores, and stressor categories (physical, emotional, spiritual, practical, and family) from the initial encounter. At our institution, patients are referred to support services for an NCCN DT score ≥4. We excluded women who received prior cancer-directed therapy and those without an NCCN DT score recorded at their initial appointment. Summary statistics were tabulated for demographics. Mann-Whitney U tests were used for inter-group difference on continuous variables and 2-sample tests for equality of proportions were used for binary variables. Results: 412 non-Hispanic White (NHW, mean age 63) and 149 non-Hispanic Black (NHB, mean age 65) women were included in our analysis. More NHB women presented with high-grade EC (53.7%) vs NHW women (21.9%) and fewer NHB women were privately insured (32% vs 52%). Median distress scores were higher in NHW women compared to their NHB counterparts (4 vs. 2, p Conclusions: The NCCN DT, a widely used tool in cancer clinics, may fail to adequately measure distress in NHB women presenting with a diagnosis of EC, despite >30% more high risk histology cancers in this cohort. This phenomenon appears to be driven by the greater frequency of ‘0’ distress scores reported by NHB women. This difference leads to disparities in referral to additional support services, which may affect quality of care and quality of life. Additional research is needed to better understand how women of different races and ethnicities approach the NCCN DT.

92741 Racial differences in patient-reported distress among women with endometrial cancer

ABSTRACT IMPACT: This work will inform and improve the way we assess and treat distress in women with endometrial cancer. OBJECTIVES/GOALS: Distress from cancer is associated with worse processes of care. Differences in outcomes by race/ethnicity in endometrial cancer (EC) are well documented, but differences in distress have not been previously explored. Here we characterize the association between race/ethnicity, distress scores, and stressors reported by patients with EC. METHODS/STUDY POPULATION: Patients presenting to a single academic outpatient gynecologic oncology practice for initial evaluation of known EC from January 2013-May 2020 were included. The electronic health record was used to abstract demographics, National Comprehensive Cancer Network Distress Thermometer and Problem List (NCCN DT) scores and stressor categories (physical, emotional, spiritual, practical, and family) from the initial encounter. Referral to support services occurs at NCCN DT score ≥4. We excluded women who received prior cancer-directed therapy and those without an initial NCCN DT score. Summary statistics were tabulated for demographics. Mann-Whitney U tests were used for inter-group difference on continuous variables and 2-sample tests for equality of proportions were used for binary variables. RESULTS/ANTICIPATED RESULTS: 412 non-Hispanic White (NHW, mean age 63) and 149 non-Hispanic Black (NHB, mean age 65) women were included in our analysis. More NHB women presented with high-grade EC (53.7%) vs NHW women (21.9%) and fewer NHB women were privately insured (32% vs 52%). Median distress scores were higher in NHW women compared to their NHB counterparts (4 vs. 2, p&lt;0.001) and NHB women were more likely to report a distress score of 0 compared to their NHW counterparts (32% vs 19%, p=0.001). 50.5% NHW women had a score ≥4 and thus qualified for referral to services compared to 20.7% of NHB women (p=0.02). Of those referred, NHB and NHW women declined referral to support services at similar rates (35.1% vs 34.5%; NS). There was a significant difference in the median number of stressors reported by NHW and NHB women, (4 vs 3 stressors; p=0.02). DISCUSSION/SIGNIFICANCE OF FINDINGS: The NCCN DT, a widely used tool in cancer clinics, may fail to adequately measure distress in NHB women presenting with a diagnosis of EC, despite &gt;30% more high-risk histology cancers in this cohort. This difference leads to disparities in referral to additional support services, which may affect quality of care and quality of life.

The patient experience of ABVD treatment in Hodgkin lymphoma: a retrospective cohort study of patient-reported distress.

Psychological distress is prevalent in Hodgkin lymphoma (HL). Many patients, regardless of prognosis, receive ABVD chemotherapy as first-line treatment, but few studies have specifically examined the nature of distress during this shared treatment experience. We conducted a retrospective study of patient-reported distress in HL patients receiving ABVD treatment at a single tertiary care facility. Distress was measured using the National Comprehensive Cancer Network Distress Thermometer and Problem List (PL). We used descriptive statistics and generalized estimating equations to assess the prevalence of distress and specific problem items during treatment and associations with patient- and disease-related factors. We collected data from 50 patients comprising 467 unique encounters, with 369/467 (79.0%) reporting a distress thermometer score. Median distress score was 2 (IQR: 0-5), but actionable distress (distress thermometer ≥4) was noted for 118/369 (32.0%) encounters. Actionable distress was only related to having a prior cancer, which conferred lower odds of actionable distress (OR 0.23, 95% CI 0.07-0.74, p=0.01) Physical and emotional problems were reported for 287/369 (77.8%) and 125/369 (33.9%) visits, respectively. Female patients had greater odds of both physical (OR 3.17, 95% CI 1.32-7.66, p=0.01) and emotional (OR 3.31, 95% CI 1.25-8.73, p=0.02) problems. ABVD treatment is associated with a high frequency of actionable distress, with physical and emotional problems acting as primary drivers. Female patients may be particularly vulnerable, while cancer survivors may be uniquely resilient. These findings demonstrate the need to thoroughly screen for and appropriately tailor distress management strategies for HL patients during treatment with ABVD.

Delayed Urological Cancer Care during the COVID-19 Pandemic: Urologists' Experience.

The arrival of coronavirus disrupted health care systems and forced delays in cancer treatment. We explored the experience of urologists who had to delay their patients' cancer care. Urologists who treat prostate, bladder, and renal cancers, selected through purposive sampling, responded to a survey about cancer treatment delay. They were asked about their practice setting, decision making and interactions with patients, and they were asked to reflect on their personal experience. A 0 to 10 point scale, modeled on the National Comprehensive Cancer Network' Distress Thermometer (NCCN-DT), validated for cancer patients with cancer, was used to estimate physician distress. We used descriptive statistics to analyze survey results. Of the 64 participating urologists, 98% delayed surgical treatment; fewer delayed cases of advanced cancers (42% for ≥T3/T4 or Gleason ≥8 prostate cancers, 58% for muscle invasive bladder cancer, 61% for ≥T2 renal cancers). They reported feeling anxious (44%) and helpless (29%), and their median distress score was 5 (range 0-10). They relied on their own risk assessments (67%) and consulted colleagues (56%) and national guidelines (53%) when making treatment deferral decisions. They identified a number of concerns as they resumed surgeries. Based on a comparison to the NCCN-DT clinical cutoff distress level of 4, urologists experienced moderately high levels of distress as they delayed cancer care during the COVID-19 pandemic and expressed concerns going forward. While the focus on patient care is paramount in a pandemic, it is important to recognize physician distress and develop practical and psychological strategies for distress mitigation.

Severity of Neuropsychiatric Symptoms and Distress in Dementia among Older People in Central Africa (EPIDEMCA Study).

Neuropsychiatric symptoms are common in dementia. Limited data are available concerning their association with dementia in developing countries. Our aim was to describe the severity of neuropsychiatric symptoms among older people, evaluate the distress experienced by caregivers, and assess which neuropsychiatric symptoms were specifically associated with dementia among older adults in Central Africa. This study is part of the EPIDEMCA program, a cross-sectional multicenter population-based study. The EPIDEMCA program was conducted from November 2011 to December 2012 in urban and rural areas of the Central African Republic and the Republic of the Congo. Participants were older people (≥65 y) included in the EPIDEMCA program who underwent a neuropsychiatric evaluation. The sample included overall 532 participants, of whom 130 participants had dementia. Neuropsychiatric symptoms were assessed with the brief version of the Neuropsychiatric Inventory including the evaluation of severity and associated distress. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision, criteria were followed to diagnose dementia. A logistic regression model was used to identify associated neuropsychiatric symptoms. The prevalence of neuropsychiatric symptoms was 89.9% (95% confidence interval = 84.6-95.1) among people living with dementia. The overall median severity score for neuropsychiatric symptoms was 9 [interquartile range [IQR] = 6-12], and the overall median distress score was 7 [IQR = 4-10]. Overall median scores of both severity and distress were significantly increased with the number of neuropsychiatric symptoms, the presence of dementia, and dementia severity. Depression, delusions, apathy, disinhibition, and aberrant motor behavior were associated with dementia after multivariate analysis. This report is one of the few population-based studies on neuropsychiatric symptoms among older people with dementia in Sub-Saharan Africa and the first one evaluating the severity of those symptoms and distress experienced by caregivers. Individual neuropsychiatric symptoms were strongly associated with dementia in older people and require great attention considering their burden on populations. J Am Geriatr Soc 68:180-185, 2019.

Distress Screening in Head and Neck Cancer Patients Undergoing Active Cancer Directed Treatment and Impact of Referral to Psycho-Oncology and Palliative Care

To estimate the prevalence of clinically significant distress (Distress score > or equal to 4) in Head and Neck cancer patients treated with a radical intent using the NCCN Distress thermometer (DT) and to evaluate the impact of referral to psycho-oncology and palliative care. This is a prospective study evaluating distress in head and neck cancer patients and patients were accrued from February 2016 to May 2017 (CTRI No. : CTRI/2016/01/006549). The study was conducted in two parts (Parts A and B). Part A: Total of 600 patients undergoing curative radiation therapy, aged more than 18 years, aware of their diagnosis and treatment plan ECOG 2 or less and signed inform consent were considered for accrual. Patients were screened for distress using DT at baseline. Part B: This is a prospective randomized controlled trial and 212 patients of Part A with score= 4 were randomly assigned to the control (care as usual by the treating physician) or intervention group (referral to psycho-oncology and palliative care). All patients were administered the DT with NCCN problem check list, Edmonton symptom assessment system (ESAS) and EORTC QLQ-C-30 and HN35 questionnaires at baseline and 6 month post treatment. Intention to treat analysis was done for Part B. Part A: Six hundred and twenty one patients were screened for the study and 600 patients were accrued in the study. The median distress score of entire cohort was 4 (IQR: 3-5) and clinically significant distress (score = 4) was seen in 340 patients (56.7%). At a median follow up of 15 months, patients with clinically significant distress had inferior survival (2 year: 91% v/s 96%; p=0.04). Part B: 340 patients with a distress score of 4 or more were screened for the Part B study and 212 patients were accrued in the study. The median distress score at baseline in both groups was 6 (IQR: 5-8). At 6 month follow up, the median distress score in both groups was 2 (IQR: 2-3). At 6 month follow up, there was no difference in clinically significant distress (4 or more) between the two groups (16% v/s 9.3%; p= 0.19). There was no difference in the distress checklist domains (physical, practical, family, spiritual and emotional) between the 2 groups. At 6 months follow up, there was reduction in all symptoms as measured by ESAS and improvement in quality of life (QOL) both groups however not statistically significant. At a median follow up of 23.5 months, 1 year and 2 year overall survival (OS) and disease free survival (DFS) rates were 87%, 66% and 75%, 65% respectively. There was no difference in OS, DFS and locoregional control between the arms. Clinically significant distress was seen in 56% of all head and neck cancer patients treated with a curative intent and the survival was significantly poor. Although there was improvement in the distress scores, symptom scores and QOL domains with psycho-oncology and palliative care referral, there was no statistically significant difference. The survival outcomes were similar between the groups.

Patient-Reported Outcomes–Secondary Analysis of the SCORE-2 Trial Comparing 4 Gy × 5 to 3 Gy × 10 for Metastatic Epidural Spinal Cord Compression

To compare 4 Gy × 5 (1 week) to 3 Gy × 10 (2 weeks) in relieving pain and distress in patients with metastatic epidural spinal cord compression (MESCC). The randomized SCORE-2 trial compared 4 Gy × 5 (n = 101) to 3 Gy × 10 (n = 102) for MESCC. In this additional analysis, these regimens were compared for their effect in relieving pain and distress. Distress was evaluated with the distress-thermometer (0 = no distress, 10 = extreme distress) and pain on a linear scale (0 = no pain, 10 = worst pain). Relief of distress was defined as decrease of ≥2 points; complete and partial pain relief were defined as achieving a score of 0 points and a decrease ≥2 points, respectively, without increase of analgesic use. This prospective secondary analysis of the SCORE-2 trial aimed to show that 4 Gy × 5 was not inferior to 3 Gy × 10 regarding distress and pain relief. Analyses were performed using the unconditional test of noninferiority for binomial differences based on restricted maximum likelihood estimates (noninferiority margin: -20%). Evaluations were performed before, directly after, and 1, 3, and 6 months after radiation therapy. (ClinicalTrials.gov: NCT02189473). At baseline, median distress scores were 8 (2-10) points in the 4 Gy × 5 group and 8 (2-10) points in the 3 Gy × 10 group. At 1 month, distress relief rates were 58.1% (43/74) and 62.7% (47/75) (difference: -4.6%; 95% confidence interval, -20.0% to +11.1%; P = .025). At baseline, median pain scores were 7 (2-10) and 7 (2-10) points, respectively. At 1 month, complete pain relief rates were 23.5% (16/68) versus 20.0% (14/70) (difference, +3.5%; 95% confidence interval, -10.4% to +17.5%; P < .001), and overall pain relief rates were 52.9% (36/68) versus 57.1% (40/70) (difference, -4.2%; 95% confidence interval, -20.5% to +12.3%; P = .029). Distress and pain relief rates after 4 Gy × 5 were largely comparable to 3 Gy × 10 at all time points. Associated 95% confidence intervals did not point toward any relevant differences. In patients with MESCC and poor to intermediate survival prognoses, 4 Gy × 5 appeared noninferior to 3 Gy × 10 regarding pain and distress relief.

Identifying psychosocial distress in cancer patients in a community center.

e23193 Background: Psychosocial distress is common in cancer patients. It can cause decreased treatment adherence, lesser treatment satisfaction, low quality of life, and lower survival rate. Distress management is critical to improving cancer survivorship. National Comprehensive Cancer Network (NCCN) Distress Thermometer (DT) is widely used to assess psychosocial problems in cancer patients in five categories - practical, family, emotional, spiritual and physical problems. The aim of our study is to identify the distress pattern in cancer patients undergoing chemotherapy in our center using DT adapted from the NCCN. Methods: This is a retrospective study. Total 192 cancer patients undergoing chemotherapy were included, who were screened with DT at initial visit. Patients were asked to rate their level of distress from 0-10 on DT and select categories. We collected data on distress score, selected categories, age, gender, and primary cancer site. Distress score &lt; 4 were defined as low and = &gt; 4 as high. Our objective was to evaluate distress categories and if distress level (high vs low) is dependent on age ( &lt; 65 vs = &gt; 65), gender, and primary cancer site (top 7 cancer types in our clinic by volume). Statistical test used - Chi-square. Results: Median age - 66.5 years (range: 29-96); Gender: Male/Female - 44.3%/55.7%. Median distress score - 3. Low distress was reported by 55.2% and high distress by 44.8%. Cancer types: Breast (29.7%); Lung (17.7%); Prostate (10.9%); Hematological malignancies (7.3%); Lymphoma (6.7%); Urothelial (6.7%); Head and Neck (6.2%); Others (13.4%). Overall, physical problems were the most common (63.5%) followed by emotional (56.3%), practical and family (32.3%), and spiritual (2.1%). Among patients with high distress, 84.9% reported emotional problems, while 83.7% reported physical problems. Distress level was not dependent on age, gender and primary cancer site. Conclusions: Emotional and physical problems are the most common problems among our study population with high distress level which requires further interventions/referrals. Identifying psychosocial needs of cancer patients with DT can help optimize their care.

The maternal childbirth experience more than a decade after delivery

Maternal satisfaction with the birth experience is multidimensional and influenced by many factors, including mode of delivery. To date, few studies have investigated maternal satisfaction outside of the immediate postpartum period. This study investigated whether differences in satisfaction based on mode of delivery are observed more than a decade after delivery. This was a planned, supplementary analysis of data collected for the Mothers' Outcomes after Delivery study, a longitudinal cohort study of pelvic floor disorders in parous women and their association with mode of delivery. Obstetric and demographic data were obtained through patient surveys and obstetrical chart review. Maternal satisfaction with childbirth experience was assessed via the Salmon questionnaire, administered to Mothers' Outcomes after Delivery study participants >10 years from their first delivery. This validated questionnaire yields 3 scores: fulfillment, distress, and difficulty. These 3 scores were compared by mode of delivery (cesarean prior to labor, cesarean during labor, spontaneous vaginal delivery, and operative vaginal delivery). In addition, the impact of race, age, education level, parity, episiotomy, labor induction, and duration of second stage of labor on maternal satisfaction were examined. Among 576 women, 10.1-17.5 years from delivery, significant differences in satisfaction scores were noted by delivery mode. Salmon scale scores differed between women delivering by cesarean and those delivering vaginally: women delivering vaginally reported greater fulfillment (0.40 [-0.37 to 0.92] vs 0.15 [-0.88 to 0.66], P < .001) and less distress (-0.34 [-0.88 to 0.38] vs 0.20 [-0.70 to 0.93], P < .001) than those who delivered by cesarean. Women who delivered by cesarean prior to labor reported the greatest median fulfillment scores and the lowest median difficulty scores. Median distress scores were lowest among those who delivered by spontaneous vaginal birth. Among women who underwent cesarean delivery, labor induction and prolonged second stage were associated with higher difficulty scores. These factors did not affect satisfaction scores among women who delivered vaginally. Among women who delivered vaginally, operative vaginal delivery was associated with less favorable scores across all 3 scores. Maternal satisfaction with childbirth is influenced by mode of delivery. The birth experience leaves an impression on women more than a decade after delivery.

Using the symptom distress thermometer (SDT) in patients with breast cancer to identify psychosocial supportive needs.

200 Background: Psychological distress is common among cancer patients. In order to optimize patient care there is a need to understand the type of patient problems contributing to distress. SDT is a well-recognized tool for assessing distress in 5 broad problem categories including, practical, family, emotional, spiritual/religious, and physical (NCCN distress guidelines: Cancer 2005). The objective of this study was to evaluate categories of distress commonly experienced by breast cancer patients undergoing radiation therapy (RT). Methods: This is a retrospective study on patient symptoms of distress as recorded on SDT surveys. Patients completing SDT have the opportunity to score distress on a scale of 0-10 and list the category of distress. For the purpose of this study, we defined low distress score to be ≤ 3, and high distress score of ≥ 4 requiring referral/intervention. Patient population included 121 patients receiving a 3-6 week course of breast RT and who completed ≥ 2 weekly surveys during therapy. A total of 433 surveys were reviewed for score and category of distress. Results: Median age was 56 years (range 32-88). Each patient completed an average of 3.58 surveys. The median distress score was 3 (range 0-10). Overall distribution of any distress by problem category was 1.6% spiritual/religious, 3.7% family, 10.6% practical, 23.3% emotional, and 60.8% physical. Further, we noted that 63 patients (53%) described a high distress score (≥ 4). Among this cohort, 47 patients (74.6%) reported that their distress was secondary to emotional problems. We observed no association between high distress score and patient age or stage of disease. Conclusions: Physical problems were the most common symptom reported on SDT in our study population. However, among the patients identified to have high distress score, emotional problems emerged as the most common cause of distress. These observations suggest that although patients undergoing treatment have many physical complaints, the more significant symptoms requiring referral/intervention were in the emotional category. The identification of more significant problems experienced by patients would help optimize their psychosocial supportive needs.

Self-assessment and Screening for Palliative Care Need in Patients with Chronic Heart Failure

Objective: Patients with chronic heart failure (CHF) rarely receive palliative care today. Methods: In a cross-sectional pilot study we evaluated feasibility of self-assessment and physician-directed screening for palliative care need in CHF patients. Patients answered German versions of the “Minimal Documentation system for patients in palliative care” (MIDOS), “Distress-Thermometer” (DT), and the “Patient Health Questionnaire” (PHQ4). A modified version of the “Five-Item Palliative Care Screening Tool” was used to screen for palliative care need by the treating cardiologists. Results: 218 patients were asked to participate and 148 (67%) completed all questionnaires. Median symptom burden (MIDOS) was 7 out of 30 points (SD 4.868), overall wellbeing was two of 5 (SD 0.902), and median distress score was 6 of 10 (SD 2.318). Most frequent moderate or severe symptoms were dyspnea (52%), weakness (51%), and tiredness (49%). Significant distress (DT score>5) was indicated by 106 patients (72%). Exhaustion (79%), sleeping problems (75%), and problems with breathing (69%) were most frequent problems. Only 11% and 14% of patients presented with significant anxiety and depression, respectively (PHQ4-score>3). Palliative care need was scored with mean 6.8 out of 12 points (SD 2.223). Using a cut-off value of >5, 113 patients (76%) would have needed palliative care. Objective parameters for palliative care need (symptom burden 43%, distress 68%, decision-making 67%) were indicated, but request for palliative care by the patients, their relatives (5%) or the cardiology team (5%) was rare. Symptom burden and palliative care screening showed significant, but not clinically relevant interaction. Conclusion: This pilot study, feasibility of palliative care self-assessment and the modified screening instrument could be demonstrated in CHF patients. For comprehensive screening, both perspectives have to be included. First results indicate significant symptom burden, psychological distress and a high need for additional palliative care in CHF patients.