Palliative Treatment Intent Research Articles

Identification of Palliative Care Needs in Cancer Patients in a Surgical Emergency Center

BackgroundAdvanced cancer is associated with a significant symptom burden, and timely identification of palliative care (PC) needs, and provision of appropriate PC can improve treatment outcomes, reduce healthcare cost, and enhance patient and family satisfaction with care. Several tools have been used to identify PC needs in different clinical settings and patient groups. ObjectiveThe primary objective was to determine the prevalence and associated characteristics of PC needs among cancer patients admitted to the surgical emergency center (SEC) of a large academic hospital in South Africa (SA). The association between PC needs and early death were explored as a secondary outcome. Design: This was a cross-sectional observational study that included all patients with known malignancy admitted through the SEC for acute surgical emergencies. The validated Supportive and Palliative Care Indicators Tool (SPICT™) was applied to patients’ files on admission to the SEC. In addition, attending physicians were asked to estimate the 1 year survival probability of these patients by answering The Surprise Question (SQ). SettingA tertiary level, public, academic hospital in Cape Town, SA. ResultsOne hundred and twelve admissions were included with a median age of 58 years. Fifty-two admissions (46.4%) were for metastatic patients and 60.7% were known with palliative treatment intent. The prevalence of SPICT- and SQ-defined PC needs was 46.4% and 54.7% respectively. Pain was the most prevalent presenting symptom and bowel obstruction the most prevalent presenting diagnosis. SPICT-positivity was a significant predictor of death before discharge and death within 6 months of first admission. Proportional agreement in predicting for PC needs of greater than 70% was shown between the two tools. ConclusionPatients with PC needs comprise a significant proportion of SEC cancer admissions. This study shows the clear need for investment in staff and infrastructure to provide integrated palliative and end-of-life care as part of surgical services. The SPICTTM and SQ were shown to predict for early death in this cohort. Further validation of PC needs assessment tools is needed to guide the cost-effective implementation of PC services in low resource settings.

Clinical outcomes in cancer patients with COVID-19 in Sweden

Background The results of studies on the relationship between cancer and COVID-19 have been conflicting and therefore further studies are needed. We aimed to examine the incidence of COVID-19 among patients at one of the largest oncology departments in Sweden, and to evaluate and identify risk factors for poor outcomes, hospital care and death, associated with COVID-19 among cancer patients. Material and methods This retrospective study included cancer patients at a single center who tested positive for SARS-CoV-2 by PCR either in hospital, primary health care center or commercial laboratory between 1 March and 14 August 2020. Clinical and demographic data were collected from the medical records. Logistic regression analysis was used to identify variables that associated the primary outcomes of need for hospital care and death within 30 days of positive test. Results Of 10,774 patients from the Department of Oncology at Sahlgrenska University Hospital, 135 tested positive for SARS-CoV-2 (1.3%). Twenty-eight patients were excluded from further the data collection since they did not meet the inclusion criteria. Altogether, 107 cancer patients were included and the case fatality rate (CFR) was 12% (13) within 30 days of confirmed SARS-CoV-2 infection by PCR. Increasing years of age (OR 1.10; CI 95% 1.03–1.18), palliative treatment intent (OR 15.7; CI 95% 1.8–135.8), and transition to end-of-life care (OR 52.0; CI 95% 3.7–735.6) were associated with increased odds of death within 30 days. Male sex was associated with needing hospital care (OR 3.7; CI 95% 1.50–9.1). Conclusion As in the general population, male sex was found to be at greater risk of needing hospital care for COVID-19, with terminal cancer disease, and older age increasing the odds of fatality. Compared to the general population, slightly more cancer patients had COVID-19. The CFR was within the lower range of others reported in cancer patients.

Impact of pretreatment second look 18FDG-PET/CT on stage and treatment changes in head and neck cancer

BackgroundPatients diagnosed with locoregionally advanced head and neck squamous cell carcinoma (LAHNSCC) regularly undergo staging with 18F-FDG PET/CT in our center. In cases of delays in radiotherapy (RT) planning CT more than 4 weeks after initial PET/CT or clinically suspected progress, PET/CT is repeated for restaging and as an RT planning reference. Our aim was to determine the impact of second-look PET/CT on stage migration, treatment change and RT planning. MethodsConsequent treatment changes were categorized as minor and major. Minor changes were defined as PET/CT-based modifications of RT plans, e.g., the addition of anatomical compartments, changes in high- and low-risk dose levels or both. Major changes included changes from curative to palliative treatment intent and alterations of interdisciplinary treatment plans, such as the addition of induction chemotherapy, switch to primary surgery, no treatment and/or the necessity of additional diagnostic work-up resulting in the postponement or cancellation of treatment. ResultsThirty-two newly diagnosed LAHNSCC patients who were treated between 2014 and 2018 underwent second-look PET/CT (median interval 42.5 days). Second-look PET/CT led to locoregional and distant upstaging in 3/32 and 1/32 patients, respectively. In 1/32 patients (3%), second-look PET/CT led to a palliative approach with systemic treatment. New lymph node metastases were discovered in 16 patients, 6 of whom also showed significant progression of the primary tumor, resulting in minor changes in 16 of the remaining 31 patients (52%) who were treated curatively. ConclusionIf RT treatment planning of LAHNSCC was delayed by more than 4 weeks after initial PET/CT staging or when progression was clinically suspected, a second look at 18FDG-PET/CT was performed. This led to changes in treatment planning in more than half of the cases, which is expected to directly influence oncologic outcomes.

The effects of geriatric assessment on oncologist-patient communication regarding functional status and physical performance in older adults with cancer: A secondary analysis of a 541-subject nationwide URCC NCORP (NCI Community Oncology Research Program) cluster randomized trial.

12010 Background: Despite high prevalence of functional status (FS) and physical performance (PP) impairments among older adults with cancer, standardized assessments and interventions are not routinely used in oncology care. This study characterized how oncologist knowledge of Geriatric Assessment (GA) results influenced conversations and GA-guided recommendations addressing FS and PP concerns. Methods: Data were from a NCORP funded (UG1CA189961) nationwide cluster randomized controlled trial (ClinicalTrials.gov: NCT02107443; PI: Mohile), with inclusion criteria: age ≥70, stage III/IV solid tumor or lymphoma with palliative treatment intent, and ≥1 GA domain impairment. All subjects underwent baseline GA including standardized FS ([instrumental] activities of daily living) and PP (Timed Up and Go, Short Physical Performance Battery, Older Americans Resources and Services Physical Health scale, falls in past 6 months) measures. Oncologists in Intervention arm practices received full GA results and validated recommendations for each patient, while those in the usual care (UC) arm were only notified of depression or severe cognitive impairment. One clinical encounter per patient within 4 weeks of GA was audio-recorded, transcribed and blind coded using a priori content-analysis scheme to categorize conversations and oncologist response (dismissed, acknowledged, or addressed with recommendation) by GA domain. Frequencies, raw and adjusted (for site using generalized linear mixed models) proportions were compared using the Chi square test. Results: 541 patients (mean age: 77, range 70-96) were included. More FS and PP conversations occurred in Intervention (PP=532, FS=164) than UC (PP=183, FS=87) arm (p<.0001). The adjusted proportion of all patients having one or more FS or PP conversations reached 85.8% in the Intervention arm but only 58.6% in UC (p<.0001). Intervention oncologists were more likely to address FS and PP concerns than UC oncologists (42.6% vs 16.5%, p=0.0003), and to use referrals (Intervention=23.5%, UC=5.0%, p<.0001) or information (Intervention=22.3%, UC=3.8%, p=0.0006) to address them. Conclusions: Providing oncologists a GA report with recommended interventions enhances oncologist-patient communication regarding FS and PP-related concerns in older adults with advanced cancer. FS and PP-related issues were more likely to be addressed by those oncologists receiving the GA report, demonstrating the utility of GA as a tool in creating tailored interventions for FS and PP concerns. Our findings support use of GA as an important tool in caring for patients with impairments in physical performance and function. Funding: NIH/NCI UG1CA189961, T32CA102618. Clinical trial information: NCT02107443.

Electrochemotherapy in Mucosal Cancer of the Head and Neck: A Systematic Review.

Simple SummaryElectrochemotherapy is a topical ablative treatment based on the formation of electropores in the cell membrane exposed to an external electric field. The consequent intracellular accumulation of hydrophilic bleomycin or cisplatin molecules greatly increases their cytotoxicity. Currently, electrochemotherapy is recognized as an effective treatment for tumors of different histological types and also for some deep-seated tumors. In mucosal cancer of the head and neck, experience with electrochemotherapy is limited, primarily due to the anatomical complexity of the region and the poor accessibility of tumors, as well as the design limitations of the electrodes used to create an electric field. A systematic review of the literature and subsequent analysis of 164 patients from 16 studies treated between 1998 and 2020 confirmed that electrochemotherapy is an effective and safe treatment for mucosal cancer of the head and neck as well.Electrochemotherapy (ECT) is a local ablative treatment that is based on the reversible electroporation and intracellular accumulation of hydrophilic drug molecules, which greatly increases their cytotoxicity. In mucosal head and neck cancer (HNC), experience with ECT is limited due to the poor accessibility of tumors. In order to review the experience with ECT in mucosal HNC, we undertook a systematic review of the literature. In 22 articles, published between 1998 and 2020, 16 studies with 164 patients were described. Curative and palliative intent treatment were given to 36 (22%) and 128 patients (78%), respectively. The majority of tumors were squamous cell carcinomas (79.3%) and located in the oral cavity (62.8%). In the curative intent group, complete response after one ECT treatment was achieved in 80.5% of the patients, and in the palliative intent group, the objective (complete and partial) response rate was 73.1% (31.2% and 41.9%). No serious adverse events were reported during or soon after ECT and late effects were rare (19 events in 17 patients). The quality-of-life assessments did not show a significant deterioration at 12 months post-ECT. Provided these preliminary data are confirmed in randomized controlled trials, ECT may be an interesting treatment option in selected patients with HNC not amenable to standard local treatment.

163P Gastrointestinal stromal tumours (GIST) in adolescents and young adults (AYA) in an Asian institution from 2002 to 2018

GIST is not common in AYA patients and the data on AYA GISTs are limited. In our institution, the typical adult GIST patient is male (52.9%), with mutations in KIT (53.6%) or PDGFR (4.2%), has gastric as the primary location (54.4%), and a five-year overall survival (OS) of 51%. We studied the clinical and genetic characteristics and prognoses of AYA GISTs. All GIST patients diagnosed between the ages of 16-39 at National Cancer Centre Singapore from 1 January 2002 to 31 December 2018 were included. We retrospectively studied their clinico-molecular characteristics and outcomes. 41 AYA GIST patients were seen with a median age of 34 years old. 25 patients (61.0%) were male. 27 patients (65.9%) were Chinese. 9 (22.0%) had metastatic disease at diagnosis. The tumours were primarily in the jejunum/ileum (41.5%, n=17) or stomach (34.1%, n=14). 25 patients (61.0%) had tumor mutation testing performed. Of these, 19 (76%) had KIT and one (4%) had PDFGRA. 5 (20%) were KIT/PDGFR wildtype. Of those with KIT mutations, 17 (89.5%) were in exon 11, while 2 (10.5%) were in exon 9. The PDGFRA mutation was in exon 18. No data is available on genetic syndromes. 24 patients (58.4%) received curative-intent treatment with 3 (12.5%) subsequently had local recurrences. 14 (58.3%) received imatinib in a neoadjuvant/adjuvant setting. 17 patients (41.5%) received palliative-intent treatment with 13 (76.4%) receiving palliative imatinib. 9 (52.9%) had Sunitinib after progression. The median follow-up was 48 months (0-165). 6 patients (14.6%) had demised. Median OS for all patients was 162.0 months (95% CI: 80.8– 243.2) with no significant differences with regards to age (p=0.07), gender (p=0.91), presence of a sensitising mutation (KIT Exon 9 and 11) (p=0.26), and treatment intent (p=0.2). A significant OS difference was found between patients undergoing curative or palliative intent (162.0 vs 65.0 months, p=0.001) and in patients with different primary tumor location (p=0.029). Out of the 6 patients with uncommon primary tumor locations, 3 had demised. AYA GISTs differ from adult GIST. In our series, 61.0% had tumor mutation analysis performed. AYA GIST also has a higher rate of small intestine primary. Further studies are needed to evaluate the low mutation and genetic testing and clinico-molecular differences to better understand how these affect outcomes.

Effect of ethnicity and rurality on treatment delays in patients with colorectal cancer in Northland, New Zealand

Ethnic and rural disparities in medical treatment and outcomes have been demonstrated across a range of conditions, including colorectal cancer. Timely treatment and investigation of symptoms in patients with suspicion of cancer is likely to improve outcomes and patient experience. Achieving equity in timeliness of care is important in achieving the goal of equitable cancer outcomes outlined in the New Zealand cancer action plan. The aim of this study was to compare treatment times in patients with colorectal cancer, between Māori and non-Māori patients as well as urban and rural patients in Northland, New Zealand. All adult patients diagnosed with colorectal adenocarcinoma from 2011 to 2016 were identified using hospital coding. Further information on the primary cohort was then obtained using the hospitals electronic results system, CONCERTO. The primary outcomes of interest were differences in delays to treatment between Māori and non-Māori as well as Urban versus rural residence. Secondary outcomes of interest included rate of emergency admission and treatment by curative intent in different groups. A total of 511 patients formed the primary cohort; 12% were Māori and were on average 6 years younger than non-Māori. Māori had a 6% higher emergency admission rate and a 5% higher rate of palliative treatment intent. No significant difference in treatment delay times was seen between different ethnicities or different domiciles. Ethnicity and rurality were not shown to affect treatment delays. Further research in this area is needed to help attain equitable outcomes for patients with colorectal cancer in New Zealand.

How many patients with heart failure are eligible for cardiac contractility modulation therapy?

Increasing evidence exists suggesting that cardiac contractility modulation therapy (CCM) improves symptoms in heart failure patients if various selection criteria are fulfilled. The aim of this study is to analyse an unselected sample of heart failure patients to establish what percentage of patients would meet the current criteria for CCM therapy. All patients admitted to two district general hospitals in the UK in 2018 with a diagnosis of heart failure were audited for eligibility for CCM therapy. The selection criteria were (a) ejection fraction (EF) 25%-45%, (b) QRS duration less than 130ms, (c) New York Heart Association (NYHA) class 3-4 and (d) treated for heart failure for at least 90days and on stable medications. Exclusion criteria included: (a) significant valvular disease, (b) permanent or persistent atrial fibrillation, (c) biventricular pacing system implanted or QRS duration more than 130ms and (4) patients not suitable for device therapy as a result of palliative treatment intent. A total of 475 patients were admitted with heart failure during the study period. From this group, 24 (5.1%) patients fulfilled the criteria for CCM therapy. The mean age and ejection fraction were 70.8±10.2 and 32.5%±7.4%. The majority of patients were men (71%) and had an ischaemic cardiomyopathy (75%). If patients with atrial fibrillation were included, an additional 18 (3.8%) patients potentially may be eligible for CCM. Only 5.1% of all patients presenting with heart failure might benefit from cardiac CCM. This is a small proportion of the overall heart failure population. However, this population has no other current option for device therapy of their condition.

Successful Anatomic Resection of Tumor-Bearing Portal Territory Delays Long-Term Stage Progression of Hepatocellular Carcinoma.

Optimal choice of surgical procedure for hepatocellular carcinoma (HCC) remains inconclusive. This study seeks to investigate the oncological superiority of anatomic resection (AR) of the tumor-bearing portal territory and potential mechanism of survival benefit for patients undergoing AR. In 203 patients who underwent curative resection for primary solitary HCC measuring ≤ 5cm in diameter, which was resectable either by AR or limited resection (non-AR), long-term outcomes were compared with propensity score adjustment. Advantages of AR in local tumor control and postprogression survival were then evaluated by a multivariate analysis and a Markov model. The AR group showed better recurrence-free survival [hazard ratio (HR), 0.51; 95% CI, 0.28-0.91; P = 0.023), time-to-interventional failure (TIF) (HR, 0.08; 95% CI, 0.01-0.60; P = 0.014), and overall survival (HR, 0.11; 95% CI, 0.01-0.79, P = 0.029) than the non-AR group. Competing-risks regression revealed that AR significantly decreases local recurrence (HR, 0.13; 95% CI, 0.02-0.97; P = 0.047) and is correlated with smaller number and size of recurrent lesions, both of which were predictors for better TIF and postprogression survival. A Markov model demonstrated that annual transition rate from the early recurrence stage (i.e., curative-intent treatment indicated) to the intermediate stage (i.e., only palliative-intent treatment indicated) was significantly lower (9.0% versus 35.6%, P = 0.027) when AR was completed at the initial hepatectomy. AR is oncologically advantageous for patients with primary solitary HCC. Initial choice of surgical procedure may have significant influence on the pattern of recurrence and postprogression clinical course that may affect overall survival of patients with HCC.

Trends in patient misperception and decisional regret during treatment for advanced cancer: A prospective study.

e24190 Background: Cancer patients receiving palliative therapy often misperceive the likelihood of benefits and toxicity. Change in misperception during treatment and decisional regret after has not been studied. We assessed shifts in perception of treatment outcomes and decisional regret after treatment in a single-center prospective study. Methods: We enrolled patients with advanced solid cancer starting palliative intent treatment. At baseline, both patients and their treating physicians were asked about their perceived likelihood of treatment response, symptom palliation, survival benefit, and treatment toxicity on scale of 0-100% at start of treatment and at follow-up. The Signed Rank tested whether patient perception changed significantly over time. After treatment, patients alive and not in hospice were asked about their decision to undergo treatment. Results: Of 122 patients with baseline estimates, 65% completed at least one follow-up survey while undergoing treatment. At enrollment, respondents’ mean age was 65 years (range: 32–89); 54% were male. Compared to baseline, there was no change in patients’ perceptions of treatment response, survival benefit, toxicity (all P≥0.52) at follow-up; a trend toward change in perceived curative potential (P = 0.06); an increase (of 7 points) of perceived likelihood of symptom relief (P = 0.04). Perceived likelihood of treatment response and symptom relief increased (both P < 0.03) among patients whose baseline estimates of treatment response were lower than or similar to their physicians’ estimates. Conversely, perceived likelihood of treatment response (P = 0.01) and curative potential (P = 0.02) decreased among patients with more optimistic estimates than their physicians’. Of the surviving 63 patients, 33 (52%) completed the end of treatment survey, 24 were unreachable and 6 declined. Median time of survey response was at 41.2 weeks (IQR: 36.4 – 47.9). Nearly all (95%) agreed that treatment was the right decision. None regretted their choice; 79% agreed they would make the same choice if they had to do it again; 12% agreed that treatment did them a lot of harm. Conclusions: Patients’ perceptions of treatment response converged during therapy as compared to their physicians at baseline. Of surviving patients surveyed, none regretted their decision to receive palliative cancer treatment. Treatment expectations evolve over time, highlighting opportunities for enhanced communication and patient education beyond initial consent procedures.

Real World Outcomes in Patients With Relapsed/Refractory Diffuse Large B-cell Lymphoma Receiving Palliative Intent Therapies

BackgroundOutcomes in patients with relapsed/refractory (R/R) diffuse large b-cell lymphoma (DLBCL) who are ineligible for and/or fail high-dose chemotherapy and autologous stem cell transplantation in the second line are poor. There is no preferred palliative-intent treatment for patients in this setting. Patients and MethodsA retrospective cohort study was performed using the nationwide de-identified electronic health record-derived Flatiron Health database. Event-free survival (EFS) and overall survival (OS) was evaluated for patients with R/R DLBCL who were ineligible for and/or failed autologous stem cell transplantation in the second line and received bendamustine, gemcitabine, or lenalidomide. ResultsThree hundred eighty-three patients were included. Therapy received was bendamustine in 158 patients, gemcitabine in 142 patients, and lenalidomide in 83 patients. The median EFS and OS for all patients was 4.1 months and 8.7 months, respectively. Compared with patients receiving bendamustine or gemcitabine, those receiving lenalidomide demonstrated significantly longer median EFS (6.8 vs. 3.8 months; P = .006) and median OS (15.4 vs. 7.7 months; P = .045). Survival outcomes were also improved for lenalidomide-treated patients specifically in the second- as well as third- or fourth-line settings. ConclusionUse of lenalidomide resulted in prolonged EFS and OS as compared with bendamustine or gemcitabine in this cohort of patients with R/R DLBCL receiving palliative therapy. This first large-scale analysis of real-world outcomes for this patient population may guide current clinical management as well as serve as a benchmark for survival outcomes in the standard-of-care setting, which may aid in the design of future clinical trials.

Applicability of scoring systems predicting outcome of transarterial chemoembolization for hepatocellular carcinoma

PurposeSeveral scoring systems have been proposed to predict the outcome of transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). However, the application of these scores to a bridging to transplant setting is poorly validated. Evaluation of the applicability of prognostic scores for patients undergoing TACE in palliative intention vs. bridging therapy to liver transplantation (LT) is necessary.MethodsBetween 2008 and 2017, 148 patients with HCC received 492 completed TACE procedures (158 for bridging to transplant; 334 TACE procedures in palliative treatment intention at our center and were analyzed retrospectively. Scores (ART, CLIP, ALBI, APRI, SNACOR, HAP, STATE score, Child–Pugh, MELD, Okuda and BCLC) were calculated and evaluated for prediction of overall survival. ROC analysis was performed to assess prediction of 3-year survival and treatment discontinuation.ResultsIn patients receiving TACE in palliative intention most scores predicted OS in univariate analysis but only mSNACOR score (p = 0.006), State score (p < 0.001) and Child–Pugh score (p < 0.001) revealed statistical significance in the multivariate analysis. In the bridging to LT cohort only the BCLC score revealed statistical significance (p = 0.002).ConclusionsClinical usability of suggested scoring systems for TACE might be limited depending on the individual patient cohorts and the indication. Especially in patients receiving TACE as bridging to LT none of the scores showed sufficiently applicability. In our study Child–Pugh score, STATE score and mSNACOR score showed the best performance assessing OS in patients with TACE as palliative therapy.

Skeletal muscle mass is an imaging biomarker for decreased survival in patients with oropharyngeal squamous cell carcinoma.

Low skeletal muscle mass (SMM) and sarcopenic obesity (co-presence of low SMM and obesity) are emerging prognosticators in oncology, but the prevalence and prognostic value in oropharyngeal squamous cell carcinoma (OPSCC) is not yet known. Patients with OPSCC, curative treatment intention and pre-treatment diagnostic imaging of the head and neck area were included. Patients with unknown HPV-status, palliative treatment intention or unavailable imaging were excluded, Relevant demographic and clinical characteristics were collected between 2009 and 2016. Patients were stratified into a low-, intermediate-, and high-risk group according to HPV-status, amount of pack-years, tumor and nodal stage. SMM was radiologically measured and cutoff values were determined by optimal stratification. The prognostic value of low SMM and sarcopenic obesity for overall survival (OS) and disease-free survival (DFS) was determined by Cox regression analysis and Kaplan Meier survival curves. In 216 patients, low SMM and sarcopenic obesity were present in 140 (64.8%) and 13 (6.0%) patients, respectively. On multivariate analysis, stratification into a high-risk group (HPV-negative status with ≥10-pack-years or T4-stage) was a prognostic factor for OS and DFS (HR 2.93, p<0.01) (HR 4.66, p<0.01). Of specific interest, sarcopenic obesity was a strong negative prognostic factor for OS and DFS (HR 4.42, p<0.01 and (HR 3.90, p<0.05), independent from other well-known prognostic factors such as HPV-status. Low skeletal muscle mass is highly prevalent in OPSCC patients. Sarcopenic obesity is a novel pretreatment prognosticator for OS and DFS in OPSCC and should therefore be considered in clinical decision making.

Analgesic requirement as a predictor of mortality to guide ceilings of care discussions for oncology patients in the emergency room.

188 Background: Discussing an oncology patient’s ceiling of care in the emergency room (ER) is a high-stakes and time-pressured challenge. Discussions and consensus for ceilings are warranted when patients are acutely unwell with sepsis. We explored whether daily oral morphine equivalent (OME) was predictive of outcome and could therefore assist in ceiling of care decision making or advanced resuscitation planning (ARP). Methods: Oncology patients presenting with infection or sepsis to a quaternary hospital ER between October 2008 and April 2011 were included. Hospital electronic databases and medical records were manually reviewed to extract data on patient demographics, OME at time of presentation to ER, illness severity (SOFA scores), whether patients had a pre-existing formalised ARP vs acute ARP documented within the ER and 90-day mortality from ER presentation. Descriptive statistics were reported. Results: A total of 91 patients were identified with median age 64 years, 60% were male, 62% were undergoing palliative-intent treatment and 70% were receiving first-line chemotherapy. There were 54 patients taking no analgesia (OME 0) and 37 patients with an OME &gt; 0. Of the 37 patients with OME &gt; 0, 6 patients (16.2%) had an ARP documented in the ER. A further 14 patients with OME &gt; 0 had an ARP documented at some point during their admission. The median total SOFA scores for patients with OME &gt; 0 was 3 and OME of 0 was also 3. The 90- day mortality from ER presentation was higher for patients with an OME &gt; 0 compared to those with an OME of 0 (Chi-square = 5.02, p = 0.03). There were 15/37 patients (40.5%) with an OME &gt; 0 who were deceased within 90 days compared with 10/54 patients (18.5%) with an OME of 0. Conclusions: Patients with higher OME use at ER presentation had poorer outcomes and this may be useful to guide clinicians in ceilings of care decisions. Daily OME should signal a need for timely, formalised advanced care planning with patients and their treating oncologists.

Stage III Non-small Cell Lung Cancer Management in England

AimsWe present the first analysis of the management and outcomes of stage III non-small cell lung cancer (NSCLC) conducted in England using National Lung Cancer Audit data. Materials and methodsPatients diagnosed with stage III NSCLC in 2016 were identified. Linked datasets (including Hospital Episode Statistics, the National Radiotherapy Dataset, the Systemic Anti-Cancer Dataset, pathology reports and death certificate data) were used to categorise the treatment received. Kaplan–Meier survival curves were obtained, with survival defined from the date of diagnosis to the date of death. ResultsIn total, 6276 cases of stage III NSCLC were analysed: 3827 stage IIIA and 2449 stage IIIB; 1047 (17%) patients were treated with radical radiotherapy with 676 (11%) of these also receiving chemotherapy. Twenty per cent of patients with stage IIIA disease underwent surgery, with half of these also receiving chemotherapy, predominantly delivered in the adjuvant setting. Of note, 2148 (34%) patients received palliative-intent treatment and 2265 (36%) received no active anti-cancer treatment. The 1-year survival was 32.9% (37.4% for stage IIIA), with the highest survival seen for those patients receiving chemotherapy and surgery. ConclusionsWe highlight important gaps in the optimal care of patients with stage III NSCLC in England. Multimodality treatment with either surgery or radical radiotherapy combined with chemotherapy was delivered to less than one-fifth of patients, even though these regimens are considered optimal. Timely access to specialist resources and staff, the practice of effective shared decision making and challenging preconceptions have the potential to optimise management.

Treatment and survival of locally recurrent rectal cancer: A cross-sectional population study 15 years after the Dutch TME trial

IntroductionOptimized treatment of primary rectal cancer might have influenced treatment characteristics and outcome of locally recurrent rectal cancer (LRRC). Subgroup analysis of the Dutch TME trial showed that preoperative radiotherapy (PRT) for the primary tumour was an independent poor prognostic factor after diagnosis of LRRC. This cross-sectional population study aimed to evaluate treatment and overall survival (OS) of LRRC patients, stratified for prior preoperative radiotherapy (PRT) and intention of treatment of LRRC. MethodsAll patients developing LRRC were selected from a collaborative Snapshot study on 2095 surgically treated rectal cancer patients from 71 Dutch hospitals in the year 2011. Cox proportional hazard analysis was performed to determine predictors for OS. ResultsA total of 107 LRRC patients (5.1%) were included, of whom 88 (82%) underwent PRT for their primary tumour. LRRC was treated with initial curative intent in 31 patients (29%), with eventual resection in 20 patients (19%). Median OS was 22 and 8 months after curative and palliative intent treatment, respectively (p < 0.001). Initial CRM positivity and palliative intent treatment were associated with worse OS after LRRC, while prior PRT was not. ConclusionsThis cross-sectional study revealed that rectal cancer patients, who underwent curative resection in the Netherlands in 2011 and subsequently developed local recurrence, were amenable for again curative intent treatment in 29%, with a corresponding median survival of 22 months. Prior PRT was not significantly associated with survival after diagnosis of LRRC.

Factors associated with early mortality in non-small cell lung cancer patients following systemic anti-cancer therapy: A 10 year population-based study

ObjectivesTo investigate how clinical, demographic and treatment-related factors in non-small cell lung cancer (NSCLC) patients impact the risk of mortality in the 30 days following receipt of systemic anti-cancer therapies (SACT), and undertake a comprehensive review of the treatment decisions and experiences of a real-world population. Materials and methodsWe reviewed NSCLC patients receiving SACT from 2005 to 2014, and captured in the Glans-Look Lung Cancer Database, which contains demographic, clinical, pathological, treatment and outcome data. The 30-day post-SACT mortality rate was calculated, and regimen changes in the last 14 days of life were identified. Univariate analysis and multivariate logistic regression were used to identify demographic, tumor and treatment-related factors that correlated with mortality risk. Results1044 patients receiving ≥ 1 cycle of SACT in 2005–2014 were identified. 233 (22.3%) deaths occurred ≤ 30 days following SACT receipt; 32 (13.7%) of which had new SACT regimens ≤ 14 days prior to death. Risk of 30-day mortality and regimen changes at the end of life increased in association with being male [OR: 1.48 (1.12–1.95), p = 0.005], advanced disease at diagnosis [OR: 1.85 (1.19–2.88), p = 0.006], palliative-intent treatment [OR: 6.75 (3.88–11.77), p < 0.001], and use of EGFR-targeting agents [OR: 4.5 (3.27–6.18) p < 0.001]. Risk of early mortality decreased for never-smokers [OR: 0.62 (0.41–0.95), p = 0.028], and those receiving SACT in more recent years (2010–2014) [OR: 0.65 (0.49–0.86), p = 0.002]. ConclusionOur findings identified several factors that affected the risk of early mortality in NSCLC patients following SACT. These results from a representative population provide insights regarding the benefits and risks of SACT and can serve to inform clinical and palliative best practices.

Safety analysis of long-term phenazopyridine use for radiation cystitis.

Phenazopyridine is a urinary tract analgesic indicated for short-term treatment of irritation in the lower urinary tract. Despite the lack of evidence for extended use, it is often used in varying durations for supportive care for cancer patients with radiation-induced cystitis. The objective of this study was to compare the incidence of adverse drug reactions in patients with radiation cystitis receiving long-term phenazopyridine (>14-day supply) compared to a matched comparator group. This retrospective cohort study compared adverse events among cancer patients with and without phenazopyridine exposure. Included patients received radiation and at least one chronic medication between 1 July 2008 and 30 June 2017. The phenazopyridine group also received >14-day supply of phenazopyridine during the study period. Patients were matched based on gender, age (±5 years), cancer diagnosis, and palliative or curative treatment intent. Data collection occurred at baseline, during the time of presumed exposure, and through the end of the study period for surveillance purposes. A total of 272 patients received phenazopyridine for >14-day supply during the study period. Of these, 90 patients were included and matched to an equal number of patients in the comparator group. The included patients were similar between groups and were largely male with a diagnosis of prostate cancer. Most patients received between a 30- and 60-day supply of phenazopyridine. There were a total of 13 adverse drug reactions in the phenazopyridine group and 18 in the comparator group (p = 0.32). No differences were identified between the phenazopyridine and comparator groups for the incidence of individual adverse drug reactions, emergency department visits, hospitalizations, or new diagnoses of hepatocellular or colorectal cancer. There was no difference in adverse drug reactions among patients receiving phenazopyridine for >14 days compared to a matched comparator group. The overall incidence of adverse events in both groups was low.

Palliative intent treatment for head and neck cancer: an analysis of practice and outcomes

There is little consensus on how best to manage head and neck cancer with palliative intent. Predicting outcome is difficult and reported survival varies. The present study sought to delineate local practice and outcomes in patients treated with palliative intent. The clinical records of all head and neck cancer patients treated with palliative intent presenting between 2015 and 2016 to our multidisciplinary team were reviewed. Eighty-four patients (21.5 per cent) were treated with palliative intent. All had squamous cell carcinoma. Mean survival time was 151 days (standard deviation = 121.1; range, 8-536 days). Of the patients, 83.3 per cent had a palliative care referral; 74.1 per cent had a hospice referral. Patients received a variety of interventions, and there was an associated complication in 8.2 per cent. The mean number of days spent in hospital for interventions was 11.9 days (standard deviation = 12.5; range, 0-41 days). Different interventions are used to manage head and neck cancer patients with palliative intent, and these may be associated with significant morbidity. Survival time is variable, often several months; thus, any treatment must take into account morbidity in conjunction with the patient's wishes.

Real-World Outcomes of Older Patients with Primary Central Nervous System Lymphoma (PCNSL): Methotrexate Dose Intensity and Combination with Cytarabine Correlate with Response and Survival

INTRODUCTION Primary central nervous system lymphoma (PCNSL) in patients (pts) over 65 years old have poorer outcome compared to younger cohorts, as comorbidities, baseline performance status and susceptibility to iatrogenic toxicity impede adequate drug delivery (Kasenda et al, Ann Oncol, 2015). Balancing toxicity against treatment benefits remains a challenge in this age group. Recent trials have attempted to rationalize treatment aiming for reduced toxicity whilst maintaining CNS penetration. Efficacy of additional agents, such as oral alkylators (Fritsch et al, Leukemia 2017) has also been demonstrated. Most clinical trial cohorts underrepresent elderly pts and thus analysis of real-world outcomes and therapeutic practice is warranted. METHODS Consecutively diagnosed pts between 01/10/12 and 01/10/17, ≥65 years old in 14 tertiary UK centres were analysed retrospectively. Radiological exclusion of systemic disease and histological diagnosis were mandatory. Pts receiving any form of 1st line treatment including palliative (whole-brain radiotherapy [WBRT]/oral chemotherapy), best supportive care (BSC) or clinical trial were included. Diagnostic and referral pathways were audited. Baseline patient characteristics and treatment received was recorded in order to document current UK practice. Pts. were stratified into 4 treatment groups: single agent MTX; MTX with oral alkylator; high-intensity HI-MTX (MTX/AraC and MATRix) or palliative intent treatment (WBRT/oral alkylator/BSC). The study primary outcome was overall response rate (ORR) after induction. Secondary outcomes were PFS and OS. Additional variables were MTX clearance and the relative dose intensity (RDI) of MTX normalised with a reference of 14mg/m2. UV/MVA for ORR and Cox-regression for PFS and OS were used for identification of baseline predictors of response and survival. RESULTS 244 pts were included in the analysis with median age 71yrs (range 65-91) and 123 (50%) male. LDH (Elevated:104, 42%) and ECOG performance score (PS) (3-4: 87, 36%) were the only prognostic markers recorded. Median time from presenting scan to treatment was 33 days (IQR 22-48). Demographic characteristics are summarised in table 1. 80% of pts (n=192) received MTX based chemotherapy. 68% of pts >70yr and 50% >75yr received >1 cycle of MTX. MTX median cumulative dose delivered was 10.6 g/m2 (range 1.5-21), median number of cycles was 4 (range 1-6). Dose reductions of MTX occurred in 53/176 pts. (30%). Median time to MTX clearance was 3 days (range 1-18) and median RDI was 0.75 (range 0.11-1.5). TRM for MTX treated pts was 7.2%. 112 pts received rituximab (46%; 11% pre-2015 vs. 64% post-2015). 73 pts. (38%) received ORR after induction was 63%. HI-MTX (HR 3.4; CI 95% 1.5 - 7.6; p=0.003) was independently associated with superior ORR compared to HD-MTX alone (Table 1). Median follow up for survival was 25 months. 2-yr PFS and OS were both 39%, median OS after progression was 80 days. MTX RDI (HR 0.18; p 52 pts (21%) received upfront palliative treatment and compared to MTX cohort, were older (median 76y vs. 70y), had a poorer PS (ECOG 3-4: 62% vs. 28%) and higher incidence of impaired renal function (GFR CONCLUSION MTX can be delivered to the majority of pts >70 years with manageable TRM rates. Notably, early treatment discontinuation was relatively frequent with outcomes in this group comparable to palliative care. By contrast, pts who completed >3 cycles of HI-MTX and underwent consolidation experienced comparable outcomes to younger trial cohorts. MTX combination chemotherapy and MTX dose intensity were the strongest predictors of survival whilst rituximab was not a covariate for response or survival despite an increase in its use. Maximising cumulative MTX dose, particularly within more intensive protocols, may translate into improved ORR and survival in older pts with PCNSL. Disclosures Kassam:AbbVie: Equity Ownership. Culligan:Merck Sharp & Dohme (MSD): Honoraria; Celgene: Other: Support to attend conferences; Daiichi-Sankyo: Other: Support to attend conferences; JAZZ: Honoraria; Abbvie: Other: Support to attend conferences; Takeda: Honoraria, Other: Support to attend conferences; Pfizer: Honoraria. McKay:Epizyme: Consultancy, Honoraria. Eyre:Roche: Consultancy; Janssen: Consultancy, Other: travel support; Gilead: Consultancy, Other: travel support; Abbvie: Consultancy, Other: travel support; Celgene: Other: travel support. Osborne:Roche: Consultancy, Honoraria, Speakers Bureau; Pfizer: Honoraria, Speakers Bureau; Servier: Consultancy; MSD: Consultancy; Celgene: Consultancy; Takeda: Consultancy, Honoraria, Speakers Bureau; Novartis: Other: Travel to conference. Yallop:Servier: Other: Travel funding; Pfizer: Consultancy. Fox:Janssen: Consultancy, Other: Personal fees and non-financial support, Speakers Bureau; AbbVie: Consultancy, Other: Travel support, Research Funding, Speakers Bureau; Celgene: Consultancy, Other: Travel support, Speakers Bureau; Sunesis: Consultancy; Roche: Consultancy, Other: Travel support, Research Funding, Speakers Bureau; Gilead: Consultancy, Other: Travel support, Research Funding, Speakers Bureau. Cwynarski:Roche: Consultancy, Other: Conferences/Travel support, Speakers Bureau; Autolus: Consultancy; Kite: Consultancy; Gilead: Consultancy, Other: Conferences/Travel support, Speakers Bureau; Janssen: Other: Conferences/Travel support.