Severe Symptom Burden Research Articles

Abstract 4911: Collaboration on quality of life in myeloproliferative neoplasms: Analysis of body mass index and symptom burden

Abstract Introduction BMI increases the risk of Philadelphia-chromosome negative myeloproliferative neoplasms (MPN) development. Patients with MPN often suffer from a severe symptom burden reduced quality of life. The aim of this study was to examine the association between BMI and symptom burden. Methods A comprehensive analysis of data from two large cross-sectional surveys of health-related quality of life in MPN patients was done by merging data from the Danish Population-based Study with data from the international Fatigue Study. Both surveys included the validated MPN-SAF questionnaire and questions addressing lifestyle. Results Comparing Danish patients with US patients, Danish patients were significantly older (69.2y vs 60.9y, P < 0.001), a smaller proportion were female (56.5%, vs 67.3% P < 0.001) and less patients worked (24.8%, vs 43.3% P < 0.001). In both the US and the Danish (DK) dataset Normal Weight was most frequent (DK/US=52.4/46.3%), followed by Overweight (DK/US=31.7/30.5%), Obese (DK/US=13.2/21.7%) and least frequent Underweight (DK/US=2.7%/1.5%). Interestingly, we observed a U-shaped association between BMI and Symptom Burden in both datasets with significant higher values of total symptom score for underweight and obese patients relative to normal weight. Furthermore, significant higher scores for Underweight or Obese patients were observed for most individual symptoms (Table 1). Conclusion Despite significant differences in demographics, the U-shaped relation between BMI and symptom burden reflects a general pattern of many variables consistent across countries. Weight alteration might be considered as a therapeutic strategy to alter symptom burden in MPN patients, bearing in mind that unintentional weight loss has been demonstrated in some MPN subtypes to be predictive of worsened survival. Further analysis for possible confounders are planned. Table 1.MPN patients’ assessment of symptom severity by BMI category and CountryDenmark (n=2064)Median [IQR]USA (n=894)Median [IQR]BMIUnder-weight(<18.5)Normal Weight(18.5-24.9)Over-weight(25.0-29.9)Obese(≥ 30)P-valueUnder-weight(<18.5)Normal Weight(18.5-24.9)Over-weight(25.0-29.9)Obese(≥ 30)P-valueFatigue (BFI)3 [0-6]3 [0-5]3 [0-5]3 [1-7]0.0278 [5-9]6 [4-8]7 [5-8]7 [6-9]<0.001Early satiety4 [1-5]2 [0-5]2 [0-5]2 [0-5]0.0013 [0-5]2 [0-5]2 [0-5]3 [0-5]0.494Abdominal pain0 [0-2]0 [0-2]0 [0-2]0 [0-2]0.1681 [0-3]0 [0-2]0 [0-3]1 [0-4]<0.001Abdominal discomfort1 [0-4]0 [0-3]1 [0-3]1 [0-3]0.2963 [1-4]1[0-3]1 [0-4]2 [0-5]0.001Inactivity3 [0-5]1 [0-4]1 [0-4]2 [0-5]0.0034 [1-6]2 [0-5]3 [1-6]5 [3-7]<0.001Headache0 [0-2]0 [0-2]0 [0-3]0 [0-3]0.4012 [0-5]1 [0-4]1 [0-4]2 [0-6]<0.001Concentration problem2 [0-5]1 [0-4]1 [0-4]1 [0-5]0.3110 [0-7]3 [0-6]4 [1-6]5 [2-7]<0.001Dizziness3 [1-5]1 [0-4]1 [0-4]1 [0-4]0.0680 [0-3]1 [0-4]1 [0-5]3 [0-6]0.001Numbness3 [0-5]1 [0-4]1 [0-4]2 [0-5]0.0014 [0-7]1 [0-5]2 [0-5]3 [0-6]0.003Insomnia2 [0-5]2 [0-5]1 [0-5]3 [0-6]0.0035 [3-8]3 [1-6]4 [1-7]5 [2-7]0.004Sad mood2 [0-4]1 [0-3]1 [0-3]1 [0-4]0.5551 [0-5]2 [0-5]3 [0-6]4 [2-6]<0.001Sexuality problems1 [0-5]2 [0-6]3 [0-7]3 [0-8]0.0574 [0-7]3 [0-7]4 [0-7]6 [1-8]0.001Cough2 [0-6]0 [0-3]1 [0-3]1 [0-4]<0.0010 [0-4]0 [0-2]0 [0-3]1[0-5]0.001Night sweats1 [0-4]1 [0-4]2 [0-5]2 [0-5]0.0210 [0-2]1 [0-4]1 [0-5]3 [0-6]<0.001Itching1 [0-3]1 [0-3]1 [0-4]1 [0-4]0.0100 [0-5]1 [0-4]2 [0-5]2 [0-7]<0.001Bone pain1 [0-5]0 [0-3]0 [0-3]1 [0-5]0.0081 [0-4]0 [0-4]0 [0-5]3 [0-6]<0.001Fever0 [0-0]0 [0-0]0 [0-0]0 [0-0]0.2940 [0-0]0 [0-0]0 [0-0]0 [0-0]0.013Weight loss4 [0-7]0 [0-1]0 [0-0]0 [0-0]<0.0012 [0-5]0 [0-1]0 [0-0]0 [0-0]<0.001QoL3 [1-5]2 [1-5]2 [1-5]2 [1-5]0.1154 [3-5]3 [1-5]4 [2-5]4 [3-6]<0.001TSS22 [12-37]16[7-30]16[7-29]21[10-33]0.00126[23-41]22[12-34]26[13-40]32[23-44]<0.001 Citation Format: Sarah F. Christensen, Robyn M. Scherber, Martin Goros, Jonathan Gelfond, Nana Brochmann, Christen L. Andersen, Esben M. Flachs, Hans C. Hasselbalch, Ruben A. Mesa. Collaboration on quality of life in myeloproliferative neoplasms: Analysis of body mass index and symptom burden [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4911.

PF676 BODY MASS INDEX AND TOTAL SYMPTOM BURDEN IN MYELOPROLIFERATIVE NEOPLASMS – DISCOVERY OF A U‐SHAPED ASSOCIATION

Background:Elevated Body Mass Index (BMI) is a growing health problem worldwide, leading to enhanced mortality and increased risk of several cancers including the Philadelphia‐chromosome negative myeloproliferative neoplasms (MPN) (Leal, Int J Cancer. 2014). MPN patients often suffer from a severe symptom burden and reduced quality of life (Qol) (Mesa, Cancer. 2007). Furthermore, evidence states that BMI is associated with severity of symptom burden among cancer patients (Fang, Breast Cancer Res Treat. 2013), a finding that has only sparsely been investigated in an MPN context.Aims:To examine whether deviations from a normal BMI in an MPN population are associated with higher symptom burden and reduced QoL.Methods:A combined analysis of data (n = 3114) from two large cross‐sectional surveys, the Danish Population‐based Study, MPNhealthSurvey (n = 2044) and the international Fatigue Study (N = 1070) was done. Symptom burden and quality of life were assessed using the validated MPN‐SAF questionnaire (Scherber, Blood. 2011). BMI was split into underweight (<18.5), normal weight (18.5–24.9), overweight (25.0–29.9) and obese (≥ 30), and analysis of covariance was used to estimate the effects of different BMI categories on symptom scores while adjusting for age, gender and MPN subtype.Results:The two study populations were significantly different; The Fatigue Study had a higher proportion of females (66.0% vs 56.3%, P < 0.0001), the participants were younger (58.8y vs 69.0, P < 0.0001) and a higher percentage were newly diagnosed (5.1 vs 0.6 P < 0.0001). For both studies Normal Weight was most frequent (total 50.3%), followed by Overweight (total 31.6%), then Obese (total 15.8%) and least frequent Underweight (2.3%). Despite differences in baseline characteristics, a U‐shaped association between BMI and Total Symptom Burden (TSS) was observed in both dataset with significant higher mean scores for underweight and obese patients relative to normal weight (Figure 1). Furthermore, the U‐shaped pattern was also found for several of the single symptoms: early satiety (increase: underweight 48.8%/obese 12.4%), inactivity (increase: underweight 32.8% /obese 51.3%), cough (increase: underweight 57.8%/obese 47.8%) and impaired QoL as well (increase: underweight 26.6%/ obese 17.9%). Finally, our data showed that obese patients had significant higher mean scores (range 12.4–52.7%) compared to patients with normal BMI for nearly the entire spectrum of MPN‐SAF symptoms (difference in mean: fatigue = 0.95 P < .001, early satiety = 0.32 P = .02, abdominal pain = 0.46 P < .001, abdominal discomfort = 0.46 P < .001, inactivity = 1.22 P < .001, headache = 0.40 P = .002, concentration problems = 0.71 P < .00, dizziness = 0.52 P < .001, numbness = 0.90 P < .001, insomnia = 0.77 P < .001, sad mood = 0.64 P < .001, sexuality problems = 0.89 P < .001, cough = 0.77 P < .001, night sweats = 0.81 P < .001, itching = 0.86 P < .001, bone pain = 0.97 P < .001, QoL = 0.52 P < .001, and TTS = 5.70 P < .001) with fever and weight loss as the only exceptions.Summary/Conclusion:In two large cross‐sectional studies, a U‐shaped relationship between BMI and total symptom burden, several single symptoms and not least QoL was found; A pattern that was consistent both in the combined and separate analysis, remaining significant after adjusting for age, gender and MPN‐subtype. Bearing in mind, that other confounders may be present this is a critical finding as BMI is a modifiable factor in the care of MPN patients with the potential of safe interventions to contribute to reduced symptom burden and improved QoL among MPN patients.image

PF675 JAK2V617F AND MPL MUTATIONS ARE ASSOCIATED WITH WORSENED SYMPTOM BURDEN THAN CALR IN THE MYELOPROLIFERATIVE NEOPLASMS: FINDINGS FROM THE MYMPN PATIENT REGISTRY

Background: The myeloproliferative neoplasms (MPNs), including essential thrombocythemia (ET), polycythemia vera (PV), and myelofibrosis (MF) are types of hematologic malignancies accompanied by excessive symptom burden that can contribute to worsened quality of life (Blood 2011). Specific driver mutations (i.e., Jak2V617F, Calreticulin (CalR), myeloproliferative leukemia virus (MPL)) have been associated with disease features, including risk of thrombosis, blood counts and overall survival (Haematologica 2017). However, no studies have yet investigated the role of driver mutations on symptom burden profiles. Aims: In this analysis, we address this gap by utilizing the myMPN Patient Registry to investigate the relationship of symptoms to driver mutational status. Methods: The myMPN patient registry was created by the MPN Research Foundation's myMPN steering committee. Utilizing the Genetic Alliance platform, patients can register and complete questions regarding their MPN as well as authorize disclosures. Patients reported variables including disease features and genetic mutations were collected in the registry.The MPN10 score (JCO 2012) was used to assess patient reported symptom burden. If multiple MPN10 surveys were completed, the mean score was calculated between all completed surveys. ANOVA, Levene's test for equality of variances, and T-tests were used to analyze statistical significance. Results: Participants: Since its initiation in September 2017, the registry comprises a total of 789 unique participants. A total of 583 participants have entered genetic driver mutation data to date (including 474 with JAKV617F, 89 with CALR, and 20 with MPL). The frequencies of driver mutations reported by participants were similar to previously reported studies for ET (73% JAK2V617F, 22% CALR, 4% MPL), PV (99% JAK2V617F, <1% CALR), and MF (67% JAK2V617F, 26% CALR, 7% MPL). Mean age was lower for CALR (56.7 years) than for JAK2V617F (60.6 years) or MPL (59.3 years, ANOVA p = 0.08). Symptom Scores: Participants have completed a mean of 2.1 MPN10 surveys (range 1–50 surveys). As demonstrated in Figure 1, MPN10 scores for CALR patients were significantly less symptomatic than JAK2V617F and MPL patients. When evaluating individual symptom scores, fatigue was significantly different among mutation subtypes (1.1 CALR, 5.3 MPL, 4.5 JAK2V617F, ANOVA p < 0.001). When comparing specific mutations, patients harboring CALR mutations were significantly less symptomatic than those with JAK2V617F mutations for items of fatigue (1.1 vs 4.4, t-test p = 0.001), weight loss (0.3 vs 0.7, t-test p = 0.003), and night sweats (1.1 vs 1.9, t-test p = 0.02). CALR patients had worse early satiety than JAK2V617F patients (2.1 vs 1.5, t-test p = 0.007). CALR patients also reported less symptomatic weight loss (0.3 vs 0.8, t-test p = 0.03) than MPL patients.Summary/Conclusion: This represents the first analysis to identify that genetic mutations may be a contributor to specific symptom phenotypes in MPN populations. This fits with the generally known trend towards a younger age at diagnosis and more indolent clinical course of CALR mutated MPNs, however, the lower age in this cohort may also be a cofounder of less severe symptom burden. The role of symptom etiologies, including thrombotic events, comorbidities, and inflammation, and modifying mutations (i.e., ASXL1), would be ideally investigated in an independently validated database. Although the validity of patient-reported registries may be a caveat to their use, data reported in the myMPN registry mirrors closely with previously published and validated MPN populations.

Patient-reported outcomes during hospitalization for patients with late discharge after an open surgery for GYN tumors.

e18078 Background: Using patient-reported outcomes (PRO) in perioperative care is increasingly common in patients undergoing major surgery. Few reports relate the patient’s symptomatic status using validated PROs during hospitalization with other outcomes, such as length of stay (LOS). Methods: Patients with GYN tumors scheduled for open surgery at MD Anderson Cancer Center were recruited prospectively. The MD Anderson Symptom Inventory gynecology perioperative care module (MDASI-PeriOp-GYN) was used to assess symptoms daily during hospitalization. Longitudinal analysis compared patient’s PROs between groups who were discharged within and beyond the median LOS. Results: From Feb 2018–Dec 2018, 83 patients were evaluable. The median LOS was 3 days. 70% of patients were discharged within 3 days, and 30% were hospitalized longer (defined as late discharge group, range 4-10 days). The median LOS for the two groups was 5.64 vs. 2.41 days, P &lt; .0001. Compared to patients who were discharged within 3 days, late discharge patients had longer surgical time (310 min vs. 209 min, P &lt; .0001), and greater operative blood loss (668mL vs. 289 mL, P &lt; .001). Additionally, more patients in the late discharge group had a worse performance status (ECOG PS 2-3: 24% vs. 3.5%, P &lt; .05), and higher comorbidity (Charlson comorbidity Index &gt; 1: 92% vs. 69%, P &lt; .05), and more used opioids within 6 month pre-surgery (16% vs. 1.7%, P &lt; .05). For all patients, the 5 worst symptoms during the first 3 hospital days were pain, fatigue, drowsiness, dry mouth, bloating. Late discharge patients reported significant more severe pain, distress, dry mouth, and interference with walking during the first 3 days post-surgery (all P &lt; .05). Conclusions: Despite all patients undergoing standardized perioperative care on an Enhanced Recovery pathway, this study demonstrates how baseline and intraoperative factors are associated with longer LOS and more severe symptom burden, especially pain and interference with walking.

Using a Patient-Centered Approach to Identify Symptom Clusters Among Adolescents With Cancer.

Prior studies identifying symptom clusters used a symptom-centered approach to demonstrate the relationship among symptoms. Latent profile analysis (LPA) is a patient-centered approach that classifies individuals from a heterogeneous population into homogeneous subgroups, helping prioritize interventions to focus on clusters with the most severe symptom burden. The aim of this study was to use LPA to determine the best-fit models and to identify phenotypes of severe symptom distress profiles for adolescents with cancer who are undergoing treatment and in survivorship. We used estimated means generated by the LPA to predict the probability of an individual symptom occurring across on- and off-treatment groups for 200 adolescents with cancer. The 3-profile solution was considered the best fit to the data for both on- and off-treatment groups. Adolescents on treatment and classified into the severe profile were most likely to report distress in appetite, fatigue, appearance, nausea, and concentration. Adolescents off treatment and classified into the severe profile were most likely to report distress in fatigue, pain frequency, and concentration. Latent profile analysis provided a cluster methodology that uncovered hidden profiles from observed symptoms. This made it possible to directly compare the phenotypes of severe profiles between different treatment statuses. The co-occurring 13-item Symptom Distress Scale symptoms found in the severe symptom distress profiles could be used as items in a prespecified severe symptom distress cluster, helping evaluate a patient's risk of developing varying degrees of symptom distress.

Symptomatic Profiles of 173 Chinese Patients with Essential Thrombocythemia

To explore the symptomatic burden of patients with essential thrombocythemia (ET) and its relation with clinical characteristics including the mutation status, therapeutic protocols and sex. Total of 173 Chinese ET patients were selected and grouped on the basis of disease characteristics (mutation status, therapeutic pro to- cols, and sex). All the groups showed low-to-high symptom burden, with the highest in the Hu (hydroxyurea)-group (total symptom score [TSS], 14.7; range, 7.6-14.7). In the JAK2V617F-positive, Hu-treated, and female groups TSS and independent symptom scores were higher than those in the control group. The CALR-positive and IFN-α-treated groups had lower overall and individual scores as compared with groups lacking the corresponding characteristics. As the number of characteristics (JAK2V617F-positive, Hu-treated, and female) increases, the severity of symptoms gradually increased. The different characteristics have various effects on symptom burden in ET patients. The accumulation of certain characteristics will lead to more severe symptom burden, thus the patient＇s symptom burden should be considered comprehensively when making up the treatment schemes and prognosis.

Ketamine Assisted Psychotherapy (KAP): Patient Demographics, Clinical Data and Outcomes in Three Large Practices Administering Ketamine with Psychotherapy

ABSTRACTCurrently, ketamine is the only legal psychedelic medicine available to mental health providers for the treatment of emotional suffering. Over the past several years, ketamine has come into psychiatric use as an intervention for treatment resistant depression (TRD), administered intravenously without a psychotherapeutic component. In these settings, ketamine’s psychedelic effects are viewed as undesirable “side effects.” In contrast, we believe ketamine can benefit patients with a wide variety of diagnoses when administered with psychotherapy and using its psychedelic properties without need for intravenous (IV) access. Its proven safety over decades of use makes it ideal for office and supervised at-home use. The unique experience that ketamine facilitates with its biological, experiential, and psychological impacts has been tailored to optimize office-based treatment evolving into a method that we call Ketamine Assisted Psychotherapy (KAP). This article is the first to explore KAP within an analytical framework examining three distinct practices that use similar methods. Here, we present demographic and outcome data from 235 patients. Our findings suggest that KAP is an effective method for decreasing depression and anxiety in a private practice setting, especially for older patients and those with severe symptom burden.

Palliative Care for Stroke Patients and Their Families: Barriers for Implementation.

Stroke is a leading cause of death, disability and is a symptom burden worldwide. It impacts patients and their families in various ways, including physical, emotional, social, and spiritual aspects. As stroke is potentially lethal and causes severe symptom burden, a palliative care (PC) approach is indicated in accordance with the definition of PC published by the WHO in 2002. Stroke patients can benefit from a structured approach to palliative care needs (PCN) and the amelioration of symptom burden. Stroke outcome is uncertain and outlook may change rapidly. Regarding these challenges, core competencies of PC include the critical appraisal of various treatment options, and openly and respectfully discussing therapeutic goals with patients, families, and caregivers. Nevertheless, PC in stroke has to date mainly been restricted to short care periods for dying patients after life-limiting complications. There is currently no integrated concept for PC in stroke care addressing the appropriate moment to initiate PC for stroke patients, and the question of how to screen for symptoms remains unanswered. Therefore, PC for stroke patients is often perceived as a stopgap in cases of unfavorable prognosis and very short survival times. In contrast, PC can provide much more for stroke patients and support a holistic approach, improve quality of life and ensure treatment according to the patient's wishes and values. In this short review we identify key aspects of PC in stroke care and current barriers to implementation. Additionally, we provide insights into our approach to PC in stroke care.

Magnesium for the Management of Chronic Noncancer Pain in Adults: Protocol for a Systematic Review.

BackgroundChronic pain is a highly prevalent and complex health problem that is associated with a severe symptom burden, as well as substantial economic and social impact. Many patients with chronic pain still suffer from unrelieved or undertreated pain due to the incomplete efficacy and dose-limiting adverse effects of current therapies. Long-term and high-dose opioid use has considerably increased in the past 20 years despite limited evidence supporting its effectiveness in several chronic pain conditions, and serious concerns have emerged regarding adverse effects and potential misuse. Until recently, the steady increase in opioid prescribing rates has been associated with rising opioid-related mortality and other serious problems, emphasizing the need for better nonopioid therapies. Emerging evidence supports the safe use of magnesium in controlling chronic pain, but its overall efficacy and safety is still unclear.ObjectiveThis paper aims to assess the efficacy and safety of magnesium compared with a placebo for the treatment of chronic noncancer pain.MethodsWe will conduct a detailed search on Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE from their inception until the date the searches are run to identify relevant randomized controlled trials. The reference lists of retrieved studies as well as Web-based trial registries will also be searched. We will include randomized double-blind trials comparing magnesium (at any dose, frequency, or route of administration) with placebo using participant-reported pain assessment. Two reviewers will independently evaluate studies for eligibility, extract data, and assess trial quality and potential bias. Risk of bias will be assessed using criteria outlined in the Cochrane Handbook for Systematic Review of Interventions. Primary outcomes for this review will include any validated measure of pain intensity or pain relief. Dichotomous data will be used to calculate the risk ratio and number needed to treat or harm. The quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.ResultsThis protocol is grant-funded and has undergone a peer-review process through the Queen’s University Department of Anesthesiology and Perioperative Medicine Vandewater Endowed Studentship. This project is also supported, in part, by the Chronic Pain Network of the Canadian Institutes of Health Research Strategy for Patient-Oriented Research. The electronic database search strategies are currently being developed and modified. The entire review is expected to be completed by January 1, 2019.ConclusionsThe completion of this review is expected to identify available high-quality evidence describing the efficacy and safety of magnesium for the treatment of chronic noncancer pain.International Registered Report Identifier (IRRID)PRR1-10.2196/11654

Symptoms during chemotherapy in colorectal cancer patients.

Colorectal cancer (CRC) patients experience several physical and psychological co-occurring symptoms, but little is known about symptom variation during chemotherapy cycles. Therefore, the aims were (1) to assess the occurrence and severity of frequently occurring symptoms (worrying, lack of energy, numbness/tingling, nausea, and pain) at multiple time points during chemotherapy, (2) to investigate differences in symptom trajectories between chemotherapy groups, and (3) to determine whether selected patient and clinical characteristics are associated with symptom severity throughout the treatment trajectory. In total, 120 CRC patients receiving chemotherapy with curative or palliative intent completed the Memorial Symptom Assessment Scale (MSAS), Self-Administered Comorbidity Questionnaire (SCQ-19), and Karnofsky Performance Status (KPS) scale eight times, during two cycles of chemotherapy and 3 and 6months after enrolment. Data were analyzed using linear mixed models for repeated measures to assess the effects of selected variables on outcomes over time. The patients experienced greatest symptom severity in the days following the administration of chemotherapy; these were lack of energy, numbness/tingling (oxaliplatin group), and nausea. Palliative patients reported significantly higher pain scores compared with curative patients over time, whereas the severity of worrying decreased over time in both treatment groups. Age, sex, educational level, performance status, treatment intent and type of chemotherapy were significantly associated with symptom severity throughout the chemotherapy trajectory. Clinicians can use these findings to identify and inform patients about risk for more severe symptom burden, in order to offer supportive care at the right time during the chemotherapy treatment.

Managing myelofibrosis (MF) that "blasts" through: advancements in the treatment of relapsed/refractory and blast-phase MF.

Myelofibrosis (MF) is the most aggressive form of Philadelphia chromosome-negative myeloproliferative neoplasm, and it is complicated by severe symptom burden, thrombotic events, infections, cytopenias, and transformation to acute myeloid leukemia (AML). Ruxolitinib, the first-line therapy for symptomatic or intermediate- and high-prognostic risk MF, has improved overall survival for this population. However, approximately one-half of MF patients will discontinue ruxolitinib by the first few years of therapy due to a spectrum of resistance, intolerance, relapse, or progression to blast phase disease. Danazol, erythropoietin-stimulating agents, and spleen-directed therapies can be useful in the ruxolitinib-resistant setting. In the ruxolitinib-refractory or -intolerant setting, commercial and novel therapies, either alone or in combination with ruxolitinib, have shown clinical utility. For blast-phase MF, the recent advancements in available AML therapies have increased the options with targeted and more tolerable therapies. In this article, we will discuss our paradigm for the management of relapsed/refractory and blast-phase MF in the context of therapeutic advancements in both AML and MF.

Removal and insertion of central venous catheters in cancer patients is associated with high symptom burden

ABSTRACTObjectives: To assess the symptom burden associated with CVC removal and insertion in cancer patients.Methods: We collected patient-reported symptom-burden outcomes for 60 consecutive cancer patients: 30 undergoing CVC removal and 30 undergoing CVC insertion. Cancer patients self-administered the MD Anderson Symptom Inventory to rate the severity of 21 different symptoms immediately after the procedureResults: Symptoms were present in up to 57% to 67% of patients undergoing CVC insertion and removal respectively. Nineteen patients (32%) were moderately symptomatic with a symptom burden of four or more: ten insertion and nine removal patients. Symptoms with a score of 4 or more clustered around physical symptoms (pain, pressure or burning) or more generalized symptoms (fatigue, sleep, distress, dry mouth, and drowsiness). Nine (15%) patients rated at least one symptom as eight or more, five (17%) being insertion patients.Conclusions: CVCs are essential for the management of cancer patients. However, they can become infected and may need to be removed. Catheter removal and insertion produced moderate to severe symptom burden in cancer patients. Safe interventions that would salvage the vascular access without worsening the infectious outcome should be explored to alleviate morbidity associated with the symptom burden of removal and re-insertion.

Palliative Care - not just for the final phase. A rewiev of evidence

Palliative Care - not just for the final phase. A rewiev of evidence Abstract. Already in early stages of their disease, patients with incurable, advanced cancer and non-cancer disease suffer from a range of limitations of their quality of life due to symptoms (i. e. pain, dyspnoea) or psychical, social or spiritual problems. Palliative Care aims to maintain the patients' quality of life and is applicable already early in the disease trajectory and not only at the end of life. As providers of general (basic) palliative care, all health care providers from all disciplines should therefore hold basic expertise in symptom control and communication. Also, they should be aware of psychical, social and spiritual dimensions of suffering. The integration and cooperation of health care services should be driven by the actual needs and demands of the individual patient. In addition to general palliative care, specialist palliative care is provided by multi-professional teams, for example, as specialist palliative home care teams or palliative care services in hospitals. In the future, it will be paramount to routinely identify patients with complex needs and severe (symptom) burden who will benefit most from early integration of specialist palliative care.

Development and validation of a clinically applicable score to classify cachexia stages in advanced cancer patients.

BackgroundCachexia is a multifactorial syndrome that is highly prevalent in advanced cancer patients and leads to progressive functional impairments. The classification of cachexia stages is essential for diagnosing and treating cachexia. However, there is a lack of simple tools with good discrimination for classifying cachexia stages. Therefore, our study aimed to develop a clinically applicable cachexia staging score (CSS) and validate its discrimination of clinical outcomes for different cachexia stages.MethodsAdvanced cancer patients were enrolled in our study. A CSS comprising the following five components was developed: weight loss, a simple questionnaire of sarcopenia (SARC‐F), Eastern Cooperative Oncology Group, appetite loss, and abnormal biochemistry. According to the CSS, patients were classified into non‐cachexia, pre‐cachexia, cachexia, and refractory cachexia stages, and clinical outcomes were compared among the four groups.ResultsOf the 297 participating patients, data from 259 patients were ultimately included. Based on the CSS, patients were classified into non‐cachexia (n = 69), pre‐cachexia (n = 68), cachexia (n = 103), and refractory cachexia (n = 19) stages. Patients with more severe cachexia stages had lower skeletal muscle indexes (P = 0.002 and P = 0.004 in male and female patients, respectively), higher prevalence of sarcopenia (P = 0.017 and P = 0.027 in male and female patients, respectively), more severe symptom burden (P < 0.001), poorer quality of life (P < 0.001 for all subscales except social well‐being), and shorter survival times (P < 0.001).ConclusionsThe CSS is a simple and clinically applicable tool with excellent discrimination for classifying cachexia stages. This score is extremely useful for the clinical treatment and prognosis of cachexia and for designing clinical trials.

Prevalence of Physical Problems Detected by the Distress Thermometer and Problem List in Patients With Myeloproliferative Disorders

Background: Patients with myeloproliferative neoplasms (MPNs) can have a severe physical symptom burden over an extended disease trajectory that contributes to decreased quality of life. Few studies, however, have characterized which patients most frequently consider physical symptoms a problem. This study describes the physical symptoms of patients with MPNs and the relationship of these symptoms to patient characteristics. Methods: Patients with MPNs (N=117) completed questionnaires in a dedicated academic medical center MPN clinic. Patients reported demographics (age, race/ethnicity, sex, marital status, employment status), disease characteristics (MPN type, time with MPN), and whether they were bothered by any of 22 variables in the "Physical Problems" list in the Distress Thermometer and Problem List (DT&PL). Results: The median number of physical problems endorsed by patients was 2 (median, 2.26; SD, 3.18), with a range from 0 to 20. Two-fifths endorsed no physical problems, one-fifth endorsed 1 problem, and two-fifths endorsed ≥2 problems, with fatigue (35.5%), sleep (27.1%), pain (21.5%), dry skin/pruritus (18.7%), and memory/concentration (16.8%) being the most commonly reported. Non-Caucasian participants reported more problems with sleep (P=.050), pain (P=.016), and tingling (P=.026). Patients with polycythemia vera (PV) reported more issues with tingling (P=.046) and sexual problems (P=.032). Conclusions: Patients with MPNs are more likely to report physical symptom bother than to report no bother with multiple physical problems on the DT&PL. Patients of minority race/ethnicity and those with PV, however, showed heightened prevalence of physical problems-characteristics which may be used to triage patients for more intensive symptom management.

The impact of remission status on patients' experiences with acute myeloid leukemia (AML): an exploratory analysis of longitudinal patient-reported outcomes data.

Shared decision-making in acute myeloid leukemia (AML) requires understanding patients' longitudinal experiences of illness, but little is known about the impact of remission status on patient-reported outcomes (PROs). We aimed to explore the association between remission status and PROs 6-12months following induction chemotherapy. Forty-two patients completed three validated instruments characterizing symptom burden (Patient Care Monitor v2.0), distress (NCCN Distress Thermometer), and QOL (FACT-Leu), as part of a longitudinal observational study. We used regression models to explore the relationship between remission status and PROs, and explore differences by initial disease type (de novo versus secondary/relapsed AML). Those with secondary or relapsed AML at study onset had marked impairments in all measures compared to de novo AML patients. After 6months, their mean distress score was 4.8 (> 4.0 warrants intervention), they reported a mean of 14.1 moderate/severe symptoms and had a mean QOL score of 113.6, compared to 1.0, 1.7, and 155.2, respectively, for those with de novo AML (p < .0001). Similarly, patients in relapse had a mean distress score of 5.3, a mean of 12.8 moderate/severe symptoms, and a mean QOL score of 113.4, compared to 1.8, 5.7, and 143.8, respectively, among those in remission (p < .005). These patterns persisted after adjusting for baseline differences (p < .0001). Remission is associated with markedly better patient well-being in AML. Patients with secondary or relapsed AML face more severe symptom burden, distress, and QOL issues after induction. Interventions are needed to improve AML patients' experiences of illness.

Hearing loss and tinnitus in survivors with chemotherapy-induced neuropathy.

The purpose of this study was to evaluate for differences in demographic, clinical, and pain characteristics, as well as measures of sensation, balance, perceived stress, symptom burden, and quality of life (QOL) among survivors who received neurotoxic chemotherapy (CTX) and who reported only chemotherapy-induced neuropathy (CIN, n=217), CIN and hearing loss (CIN/HL, n=69), or CIN, hearing loss, and tinnitus (CIN/HL/TIN, n=85). We hypothesized that as the number of neurotoxicities increased, survivors would have worse outcomes. Survivors were recruited from throughout the San Francisco Bay area. Survivors completed self-report questionnaires for pain and other symptoms, stress and QOL. Objective measures were assessed at an in person visit. Compared to survivors with only CIN, survivors with all three neurotoxicities were less likely to be female and less likely to report child care responsibilities. In addition, survivors with all three neurtoxicities had higher worst pain scores, greater loss of protective sensation, and worse timed get up and go scores. These survivors reported higher state anxiety and depression and poorer QOL. For some outcomes (e.g., longer duration of CIN, self-reported balance problems), significantly worse outcomes were found for the survivors with CIN/HL and CIN/HL/TIN compared to those with only CIN. Our findings suggest that compared to survivors with only CIN, survivors with CIN/HL/TIN are at increased risk for the most severe symptom burden, significant problems associated with sensory loss and changes in balance, as well as significant decrements in all aspects of QOL.

Stability and Priority of Symptoms and Symptom Clusters Among Allogeneic HSCT Patients Within a 5-Year Longitudinal Study

ContextDue to toxicity and invasiveness, allogeneic hematopoietic stem cell transplantation causes severe and longstanding symptom burden. Longitudinal studies on symptoms and symptom clusters (SC) would be helpful to optimize symptom control but are rare to date. ObjectivesThe objective of this study was to investigate stability of symptoms, extract time stable SC, and determine their priority in symptom management. MethodsIn this multicenter study, patients diagnosed with hematologic cancer were assessed before conditioning (T0) and three months (T1), one year (T2), and five years (T3) after transplantation. Symptoms were assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30). Symptoms were stable when rated as present at three consecutive time points. Applying factor analysis, stable SC were composed of symptoms loading on the same factor across all time points. Priority in symptom management was derived from a combination of severity and predictive power for quality of life (QoL). ResultsTwo hundred thirty-nine patients participated at T0, 150 (63%) at T1, 102 (43%) at T2, and 45 (19%) at T3. We identified three stable SC, composed of rest-tired-weak-dyspnea-loss of appetite (exhausted), tense-worried-irritable-depressed (affective), and nausea-vomiting (gastrointestinal). Fatigue was most persistent and also most severe and predictive for QoL, both as symptom and in cluster (exhausted). ConclusionGiven its high stability, severity, and impact on QoL, fatigue should have priority in symptom management. The treatment of this symptom could be enhanced by also incorporating interventions addressing dyspnea and loss of appetite.

Modified Glasgow prognostic score in a North American population of metastatic lung cancer patients: Baseline characteristics from the SNAP trial.

e13072 Background: There is a growing body of evidence that implicates inflammation as a mechanism of disease progression and reduced survival in patients with advanced cancer (Laird B et al. Oncologist 2013;18:1050-5.). Specifically, elevated c-reactive protein (CRP) levels have been associated with a severe symptom burden including pain, dyspnea, fatigue, nausea/vomiting, impaired quality of life, and inferior overall survival (Laird B et al. Oncologist 2013;18:1050-5.). The Modified Glasgow Prognostic Score (mGPS) is a composite inflammatory score based on CRP and serum albumin with proven prognostic value in patients with advanced lung cancer (Simmons CP et al. Lung Cancer 2015;88:304-309.). There is a significant body of evidence supporting the use of the mGPS in both Europe and Asia but the significance of the mGPS in a North American population has not been completely elucidated. We present preliminary data from a group of patients from Eastern North Carolina. Methods: Serum albumin and CRP were drawn at baseline and patients were followed for clinical course and overall survival. Patients with a dx of cancer were included regardless of stage. Clinicopathological features were abstracted from the chart and compared to a similar population from Europe (Simmons CP et al. Lung Cancer 2015;88:304-309.). Statistical comparisons were done by chi-squared test. Results: Two-hundred and twenty seven patients were eligible. Of these, 110 had either stage IV NSCLC (N= 97) or extensive stage small cell lung cancer (n=13). Median CRP was 21.9 mg/L (0.01 - 329.5). Median serum albumin was 3.4 g/dl (2.3-4.6). The number of patients with mGPS of 0, 1, and 2 were 27 (24.5%), 37 (33.6%) and 46 (41.8%), respectively. As compared to the population from Europe, the chi squared statistic was 10.1229 (p = 0.0063). There was no significant association between mGPS and race (p = 0.2277) or gender (p=0.0607). Conclusions: Lung cancer patients in Eastern North Carolina possess a strikingly poor inflammatory signature with significant implications for quality of life and survival. [Table: see text]

Utilizing patient reported outcomes for patients recieving oral chemotherapy.

190 Background: Management of oral chemotherapy presents many challenges to oncology practitioners. The purpose of this study is to describe how incorporation of patient reported outcomes (PRO) for patients receiving oral chemotherapy can identify those patients who are experiencing moderate to severe symptom burden and nonadherence. Methods: As part of a statewide quality collaborative, we wished to improve our monitoring of patients receiving oral chemotherapy. The quality collaborative created a PRO assessment that includes a revised Edmonton Symptom Assessment Scale (ESAS), a single-item adherence question, reasons for nonadherence, the patient’s most bothersome symptom and questions related to patient confidence. Our medical assistants provide the assessment to the patient before each appointment. Results: Patients completing the PRO during the first 3 months (7/7/16 – 9/27/16) were evaluated. We had 32 assessments completed by 23 patients. The oral chemotherapy prescribed were capecitabine (48%), erlotinib (13%), temozolomide (13%), and not recorded (26%). Of the 29 completed ESAS assessments, 72% included at least 1 moderate side effect, and 48% included at least 1 severe side effect. 29% of patients reported low-moderate confidence to self-manage their symptoms. Less than excellent adherence (&lt;80% adherence) was reported in 30% of patients with the most commonly reported reason being related to side effects or concerns about side effects. Conclusions: Use of PROs in our oral chemotherapy population identified a large proportion of patients experiencing moderate to severe side effects. Further assessment of how this compares to what patients report to their oncologist during their visits will be reviewed. In addition, we found that approximately 30% of our patients are nonadherent to their oral chemotherapy. This is consistent with recent publications. We plan to continue assessing patient outcomes and utilizing the data we collect to improve patient self-management support.