Supportive Care Clinic Research Articles

Patient considerations of social media account management after death.

Social media is widely used but few studies have examined how patients with advanced cancer want their accounts managed after death. The objective of this study was to determine the proportion of our patients with advanced cancer who have discussed the post-mortem management of their social media accounts with their family or friends. This was a cross-sectional survey in which patients with advanced cancer at an outpatient Supportive Care Clinic at a tertiary cancer center completed a novel survey on social media use that assessed patients' social media use practices, attitudes and preferences, and reactions to the survey. Of 117 patients, 72 (61.5%) were women, and the mean age was 56.4years old. We found that 24 (21%) of our patients have discussed their preferences for management of their social media accounts after death. Patients with a lower annual income were significantly more likely to report having such conversations (p = 0.0036). Completing the survey motivated 76 patients (67%) to discuss their social media accounts and 82 patients (71.3%) to explore how social media will be managed after their death. Half of our study participants reported social media as an important source of coping. Few patients have had conversations on the management of their accounts after death, although more were interested in exploring their options further. More research is needed to examine the role of social media as a digital legacy and a coping tool for patients with advanced cancer.

Attitudes and beliefs regarding sexual dysfunction among patients with advanced cancer receiving palliative care.

12054 Background: Sexual dysfunction (SD) is highly prevalent among patients with advanced cancer, but it is not regularly assessed by palliative care (PC) specialists. This study aims to investigate the frequency of SD, and its impact in PC patients with cancer, as well as the barriers they face to have an open communication with PC providers. Methods: AdultPC patients with cancer seen at the outpatient Supportive Care Clinic were invited to participate in a 25-item questionnaire about SD. The survey was voluntary and anonymous. Results: A total of 100 patients (54 women and 46 men) completed the survey. The mean age was 55 (range 24-78), 90% were Caucasians, 16% Hispanics and 77% were married or lived with a partner. In the month and within six months before the survey, the patients received treatment with chemotherapy (44 and 37%), radiation (14 and 13%), or surgery (4 and 20%), respectively. Only 29 patients (29%) would like to discuss their SD with a provider -this was consistent across gender ( p= 0.827) and age groups ( p= 0.194)-, even though 81% had experienced SD in the previous year and merely 45% were satisfied with their sexual function. Only 20 (20%) reported that their clinician had ever asked them about SD. Most of the patients (79%) responded that it was appropriate for the clinician to inquire about SD but only 32% thought that clinicians should always ask. Patients "strongly agreed or agreed" that the SD worsened their depression (39%), anxiety (28%), pain (14%), fatigue (13%), and wellbeing (39%). Factors that worsened the current sexual desire included medications in 33/59 participants, treatments (chemotherapy, radiation or surgery) in 61/80, miscommunication with the partner in 31/66, urinary incontinence in 17/24, weigh loss in 18/36, body image in 45/64, tube/lines (nephrostomy, colostomy, urinary catheter, etc) in 12/18, and oxygen in 4/12. When asked why they did not discuss SD, 64% said that discussing other symptoms was more important, 35% said that they wanted to keep it private, 29% because a family member was present, and 17% because of lack of time. Conclusions: SD is very common among PC patients with cancer and it worsens their emotional and physical symptoms as well as their overall wellbeing. About only a third of the respondents said they would want to discuss it with their provider, and almost two-thirds said that talking about other symptoms was more important. Our findings do not support the notion that PC specialists should always initiate a discussion about SD with their PC patients with cancer. Future studies should try to better identify which PC patients are open to talk about SD and exploring its therapies.

Patient and caregiver satisfaction of a palliative care chronic diseases clinic during COVID lockdowns.

To assess the quality assurance of a specialist palliative care clinic focused on chronic diseases and explore the satisfaction and acceptability of the telemedicine model amongst patients and caregivers. A cross-sectional 23-item survey was developed by the clinical team, approved by ethics and distributed to patients and caregivers. Data collection ran between September 2021 and February 2022, and SPSS was used for data analysis. Demographics were collected from hospital records. Thirty-five surveys were returned. The cohort had a median age of 82 years, and the most common primary diagnosis was renal failure. Participants rated telemedicine as easier to access than face-to-face appointments due to convenience. Telemedicine was rated highly for future utility, with video consultations being perceived as more useful than telephone consultations. Participants responded overwhelmingly well towards the clinic. Findings demonstrated high levels of satisfaction with the Supportive Care Clinic model and for telemedicine. However, logistical challenges and the desire for face-to-face appointments were also identified. The study highlights the importance of offering a range of modalities for patient engagement in healthcare services and suggests that telemedicine should complement, rather than replace, face-to-face consultations. Future investigations should explore patient and caregiver sentiment towards telemedicine platforms alongside patient deterioration.

Frequency of malnutrition and anorexia-cachexia syndrome in patients with advanced cancer evaluated in an outpatient supportive care clinic.

257 Background: Patients with cancer are at risk for malnutrition and the development of anorexia-cachexia syndrome, which is often under-treated. The objective of our study was to determine the frequency of these conditions in advanced cancer patients who were evaluated in an outpatient Supportive Care Clinic (SCC). Methods: Advanced cancer patients seen in SCC were prospectively enrolled to complete a cross-sectional one-time survey. We collected patient demographics, weight history and height, cancer history, the Functional Assessment of Anorexia Therapy – Anorexia/Cachexia Subscale (FAACT-A/CS) questionnaire, Edmonton Symptom Assessment Scale (ESAS), the Patient Generated Subjective Global Assessment – short form (PG-SGA SF), and a Body Image Scale (BIS) questionnaire. Malnutrition was indicated by a PG-SGA cut-off of ≥ 5, and loss of appetite, anorexia, was defined as either ESAS ≥ 3 or FAACT-ACS ≤ 37. Results: Of 165 cancer patients that were approached, 100 (61%) completed the prospective survey. The average (SD) age was 61.6 years old (11.5). The majority of patients were female gender (52%), Caucasian (75%), were married (80%), and the most common cancers were gastrointestinal (22%) and genitourinary (21%). At the time of the survey, 14% of patients were noted to have a BMI < 20, 60% of patients reported anorexia (ESAS ≥ 3), 53% patients screened positive for the FAACT-A/CS (≤ 37), 69% were malnourished (PGSGA ≥ 5), and 55% had body image dissatisfaction (BIS ≥ 4). Documented weight loss of >10% in the medical records was recorded in 59% of patients with an average (SD) of -12.8% (15.3). Patient self-reported weight loss of > 5% over 6 months and > 10% over a lifetime was noted in 56% and 62% of the patients, respectively. Conclusions: Advanced cancer patients seen in an outpatient SCC are at high risk of malnutrition and roughly 60% experience complications of anorexia-cachexia syndrome. Routine screening for malnutrition and weight loss should be incorporated into all Supportive Care encounters, and nutritional counseling and support should be offered to the majority of cancer patients.

EHR-based process to reduce no-shows at the outpatient supportive care clinic at a tertiary cancer center.

263 Background: No-Shows are pervasive across healthcare systems and are associated with interrupted clinical workflows, increased cost, healthcare utilization, and increased morbidity, and mortality. In palliative care, patients who miss their appointments are more likely to have uncontrolled symptoms, frequent Emergency Room visits, and unplanned hospitalization. There is an ongoing need to reduce no-shows to improve patient outcomes. Methods: The aim of this quality improvement (QI) project, launched in September 2022 at the outpatient supportive care center (SCC) at the University of Texas MD Anderson Cancer Center, was to reduce overall no-shows by process improvement in the targeted areas. We developed a process map and Ishikawa diagram to outline workflow and reasons for no-shows. Based on the results of a previous study from our center, 8% of no-shows were due to hospitalization. We used the Plan Do Study Act (PDSA) tool. We developed an electronic query for the Electronic Health Record (EHR) to identify hospitalized patients with an upcoming appointment at SCC in the next 10 days. We redesigned the clinical workflow to generate a daily list of such appointments which were canceled and replaced by patients on the waitlist. We assessed overall no-show rate and rate specific to hospitalizations for our center monthly for eight months. This QI project was approved by the Quality Improvement Assurance Board at the University of Texas MD Anderson Cancer Center. Results: Overall no-show rate was 12% before intervention (BI) and decreased to 8% after intervention (AI), measured at 8 months. No-show rate due to hospitalizations decreased from 9% BI to 2% AI. Telehealth visits had a lower rate of no-shows (5.9%) than in person visits (10.4%). No-show rates did not differ based on days of the week (median 7.4%, SD 0.3%), and the type of visit - consult vs. follow-up (8% vs. 7%). Conclusions: Clinical workflow redesign using EHR at our SCC decreased no-shows due to hospitalization, thereby reducing overall no-show rate by 33% of the original. However, most no-shows are due to reasons other than hospital stays, and more research is needed to identify these patient and system level factors.

Factors associated with quality of life in patients with kidney failure managed conservatively and with dialysis: a cross-sectional study

BackgroundLater stage chronic kidney disease (CKD) is associated with poorer self-perceived health-related quality of life (HRQOL), a major consideration for many patients. Psychological factors such as depression and anxiety have been linked with poorer HRQOL. We aimed to determine if anxiety or depressive symptoms are significantly associated with self-perceived health-related quality of life, in patients with CKD Stage 5. The secondary aim was to determine which patient-associated factors are associated with HRQOL in patients with CKD Stage 5.MethodsThis retrospective cross-sectional study included patients that attended the St George Hospital Kidney Supportive Care (KSC) clinic between 1 and 2015 and 30 June 2022 with CKD Stage 5 (either conservatively-managed or receiving dialysis). Patients completed surveys of their functional ‘domains’ and quality of life (EQ-5D-5L) and symptom surveys (IPOS-Renal) at their first visit. We performed multivariable linear regression analysis with the outcome of interest being HRQOL, measured using the EQ-VAS, a continuous 100-point scale, for patients undergoing conservative management or dialysis. Pre-specified variables included age, sex, eGFR (for those conservatively-managed), “feeling depressed” (IPOS-Renal), “feeling anxious” (IPOS-Renal) and “anxiety/depression” (EQ-5D-5L).ResultsWe included 339 patients. 216 patients received conservative kidney management (CKM) and 123 patients received dialysis. Patients receiving CKM were significantly older than those on dialysis, (median age 83 years vs. 73 years, p < 0.001). For conservatively-managed patients, variables independently associated with poorer EQ-VAS were difficulty performing usual activities (EQ-5D-5L), drowsiness (IPOS-Renal) and shortness of breath (IPOS-Renal). For patients receiving dialysis, variables that were independently associated with poorer EQ-VAS were reduced ability to perform self-care (EQ-5D-5L) and lack of energy (IPOS-Renal). Anxiety and depressive symptoms were not significantly associated with poorer EQ-VAS for either group of patients.ConclusionsSymptoms associated with reduced HRQOL include shortness of breath, drowsiness and impaired functional ability. Optimization of multidisciplinary teams focusing on these issues are likely to be of benefit.

Implementation of Patient Reported Outcomes in Outpatient Palliative Care: From Paper to Computer.

This quality improvement project aimed to transition completion of Edmonton Symptom Assessment System (ESAS) at our supportive care clinic from paper to electronic format. Proportion of patients who completed electronic ESAS (eESAS). Starting July 2018, patients could complete eESAS 24h before check-in (eESAS-before), eESAS after check-in (eESAS-after) or on paper (pESAS). A total of 6631 cancer patients had 25,767 clinic visits between July 13, 2018 and November 5, 2021. The ESAS completion rate was 100%. eESAS uptake gradually increased over time, first reaching ≥75% eESAS completion in 5/2019 (eESAS-after 61.9%; eESAS-before 14.0%; pESAS 24.1%). We observed a sharp uptake in eESAS-before since adoption of telehealth during the pandemic (May 2020) and the ≥75% eESAS target was consistently achieved from November 2020 onwards (eESAS-after 0.6%; eESAS-before 76.7%; pESAS 22.7%). In an anonymous survey, we identified several modifiable barriers to implementing eESAS. Transition to eESAS was a gradual process and was catalyzed by the pandemic.

Frequency of vaccine hesitancy among patients with advanced cancer.

Vaccine hesitancy has become prevalent in society. Vulnerable populations, such as those with cancer, are susceptible to increased morbidity and mortality from diseases that may have been prevented through vaccination. Our objective was to determine patient perception of vaccine efficacy and safety and sources of information that influence decisions. This study was a prospective cross-sectional survey trial conducted from March 10, 2022, to November 1, 2022, at a Supportive Care Clinic. Patients completed the survey with a research assistant or from a survey link. Vaccine hesitancy was defined as a response of 2 or more on the Parent Attitudes About Childhood Vaccines (PACV-4). Perception on vaccine safety and efficacy along with the importance of sources of information were determined by a questionnaire. Of the 72 patients who completed the PACV-4, 30 were considered vaccine-hesitant (42%). Of those who completed the survey alone (35), 23 (66%) were vaccine-hesitant; and of those who completed the survey with the help of a study coordinator (37), 7 (19%) were vaccine-hesitant. The most important source for decision-making was their doctor (82%, 95% CI 73-89), followed by family (42%, 95% CI 32-52), news/media (31%, 95% CI 22-41), and social media (9%, 95% CI 4-16). Clinical and demographic factors including age, gender, race/ethnicity, education level, and location of residence were not associated with vaccine hesitancy. Vaccine hesitancy is present among patients with advanced cancer. The high value given to the doctor's recommendation suggests that universal precautions regarding vaccine recommendation may be an effective intervention.

#2929 FACTORS ASSOCIATED WITH QUALITY OF LIFE IN KIDNEY FAILURE MANAGED CONSERVATIVE AND WITH DIALYSIS: A RETROSPECTIVE CROSS-SECTIONAL STUDY

Abstract Background and Aims Internationally, chronic kidney disease (CKD) affects over 10% of the general population. As patients approach CKD Stage 5, they are faced with the decision of whether to proceed with dialysis or conservative, non-dialysis, kidney management (CKM). Regardless of pathway, worsening CKD is associated with poorer self-perceived health-related quality of life (HRQOL). Psychological factors such as depression and anxiety have been linked with poorer HRQOL. Quality of life is a major consideration for many patients. Patients’ experiences of disease and significant contributors to HRQOL should be recognised as an important area for healthcare providers to identify, understand and target. The primary aim is to determine if anxiety or depressive symptoms are significantly associated with HRQOL, in patients with CKD Stage 5. The secondary aim is to determine which patient-associated factors (such as comorbidities, symptoms or biochemical parameters) are associated with HRQOL in patients with CKD Stage 5. Method Patients that attend the St George Hospital Kidney Supportive Care (KSC) clinic complete surveys of their functional ‘domains’ and quality of life (EQ-5D-5L, EuroQOL Research Foundation, 2019) and symptom surveys (IPOS-Renal, Cicely Saunders Institute, 2016) at the beginning of each clinic visit. Demographic data, comorbidities and biochemical data are also obtained from the St George Hospital electronic medical records system and entered into the KSC database, with corresponding survey data. We included all patients from St George and Sutherland Hospitals that attended the KSC Clinic between 1 July 2015 and 30 June 2022 with CKD Stage 5, who were managed with either CKM or dialysis, and completed EQ5D5L and IPOS-Renal surveys at their first KSC visit. The primary outcome is self-perceived health-related quality of life score, measured using EQ-VAS, a continuous 100-point scale on the EQ-5D-5L survey. We performed multivariable linear regression analysis with pre-specified variables including age, sex, eGFR (for those on CKM), “Feeling depressed,” (IPOS-Renal) “Feeling anxious” (IPOS-Renal) and “Anxiety/depression” (EQ5D5L), for the CKM and dialysis pathways. Statistical analyses were performed with IBM SPSS Statistics V26.0. p-values of &amp;lt;0.05 were regarded as significant. Results We included 339 patients (216 patients on CKM and 123 patients on dialysis). Patients receiving CKM were significantly older than those on dialysis, with a median age of 83 years, compared to 73 years. Most patients on dialysis received haemodialysis (85.4%). For patients receiving CKM, variables independently associated with poorer EQ-VAS were difficulty performing usual activities (EQ5D5L), drowsiness (IPOS-Renal) and shortness of breath (IPOS-Renal) (Figure 1). For patients receiving dialysis, variables independently associated with poorer EQ-VAS were reduced ability to perform self-care (EQ5D5L) and lack of energy (IPOS-Renal) (Figure 2). Anxiety and depressive symptoms were not significantly associated with poorer EQ-VAS for either CKM or dialysis patients. Conclusion We did not find an association between anxiety and depressive symptoms and poorer EQ-VAS for patients with CKD Stage 5. For patients receiving CKM, symptoms that significantly reduce EQ-VAS include shortness of breath and drowsiness. Impaired functional ability significantly reduced EQ-VAS in patients with CKD Stage 5 managed with and without dialysis. Optimization of multidisciplinary teams within KSC units are likely to be of benefit.

Helpfulness of Question Prompt Sheet for Patient-Physician Communication Among Patients With Advanced Cancer

There are few robust evaluations of disease-specific question prompt sheets (QPS) in patient-physician communication among patients with advanced cancer. To compare the patient perception of helpfulness, global evaluation, and preference for the QPS vs a general information sheet (GIS), and to examine the effect of the QPS on participants' anxiety, participants' speaking time, number of questions asked, and length of the clinical encounter. This controlled, double-blind randomized clinical trial was conducted at an outpatient palliative and supportive care clinic in a cancer center in the US. Eligible patients were 18 years or older, had a cancer diagnosis, and were undergoing their first outpatient consultation visit with a palliative care physician from September 1, 2017, to May 31, 2019. Data analysis used a modified intention-to-treat design. Data were analyzed from May 18 to June 27, 2022. QPS, a 25-item list of questions developed by expert palliative care clinicians using a Delphi process and tested among ambulatory advanced cancer patients. The control was GIS, generic information material given routinely to patients seen at the supportive care clinic. The main outcome was patient perception of helpfulness. Secondary outcomes included global evaluation and preference of QPS compared with GIS immediately after the encounter. A total of 130 patients (mean [SD] age, 58.6 [13.3] years; 79 [60.8%] female) were randomized to receive either QPS (67 patients [51.5%]) or GIS (63 patients [48.5%]). Patients considered QPS and GIS equally helpful, with no statistically significant difference (mean [SD] helpfulness score, 7.2 [2.3] points vs 7.1 [2.7] points; P = .79). The QPS group, compared with the GIS group, had a higher global positive view of the material (mean [SD] global perception score, 7.1 [1.3] vs 6.5 [1.7]; P = .03) and felt it prompted them more to generate new questions (mean [SD] rating, 7.0 [2.9] vs 5.3 [3.5]; P = .005). Of 47 patients asked their preference between the items, more participants preferred the QPS to the GIS in communicating with their physicians (24 patients [51.1%] vs 7 patients [14.9%]; P = .01) at the 4-week follow-up. No significant differences between the QPS and GIS groups were observed regarding participant anxiety, speaking time, number of questions asked, or consultation length (eg, mean [SD] anxiety rating, 2.3 [3.7] vs 1.6 [2.7]; P = .19). In this randomized clinical trial, participants perceived both QPS and GIS as equally helpful, but they had a more positive global view of and preferred the QPS. QPS facilitated generation of new questions without increasing patient anxiety nor prolonging the consultation. The findings provide support for increased adoption and integration of QPS into routine oncologic care. ClinicalTrials.gov Identifier: NCT03287492.

Quality of Life in Patients with Chronic Kidney Disease Managed with or without Dialysis: An Observational Study

Emerging research suggests that quality of life (QOL) outcomes, such as maintenance of independence, rather than length of life, are the main priority for many patients with end stage kidney disease (ESKD). There is therefore a need to focus on whether QOL for older patients on dialysis differs significantly from conservative kidney management (CKM). This study aimed to describe the QOL trajectory for patients with ESKD, comparing CKM to dialysis and transplantation. This retrospective, observational study included all patients who attended the Kidney Supportive Care Clinic at St. George Hospital and had one or more EuroQOL (EQ5D5L) questionnaires between July 2014 and May 2020. Kruskal-Wallis tests compared QOL scores between groups at baseline and 12 months. Wilcoxon signed rank tests compared QOL scores from baseline to 18 months within groups. Chi-squared tests compared proportions of patients reporting problems with QOL "domains" between the groups at baseline and 12 months. McNemar's tests compared changes in proportions of patients reporting problems with QOL "domains" within groups from baseline to 12 months. A total of 604 patients had an initial survey. At baseline, patients who were managed conservatively reported more problems with mobility, self-care, and ability to perform usual activities. However, pain/discomfort and anxiety/depression were no higher in the conservative population. CKM patients reported no significant decline in mobility, self-care, ability to perform their usual activities, pain/discomfort, or anxiety/depression after 12 months or in QOL scores after 18 months compared with the other groups. QOL scores or symptom burdens did not change significantly in patients receiving CKM compared with dialysis, suggesting that appropriately supported CKM can maintain patients' QOL.

The Supportive Care Clinic: A Novel Model of Embedded Pediatric Palliative Oncology Care.

Pediatric palliative care (PPC) improves quality of life and end-of-life outcomes for children with cancer, but often occurs late in the disease course. The Supportive Care Clinic (SCC) was launched in 2017 to expand outpatient PPC access. To describe the inaugural four years (2017-2021) of an academic, consultative, embedded SCC within pediatric oncology. Descriptive statistics (demographic, disease, treatment, visit, and end-of-life) and change over time were calculated. During the first four years, 248 patients (51.6% male; 58.1% White; 35.5% Black; 13.7% Hispanic/Latino) were seen in SCC, totaling 1,143 clinic visits (median 4, IQR 2,6), including 248 consultations and 895 follow-up visits. Clinic visits grew nearly 300% from year one to four. Primary diagnoses were central nervous system tumor (41.9%), solid tumor (37.5%), and leukemia/lymphoma (17.3%). The first point of PPC contact became SCC (70.6%) for most referred patients. Among the 136 deceased patients (54.8%), 77.9% had a do-not-resuscitate or Physician Orders for Life Sustaining Treatment in place, and 72.8% received hospice care. When known (n=112), 89.3% died in their preferred location. The time from SCC consultation to death increased from 74 to 226 days over the four years (P < 0.0001). The proportion of SCC consultations that occurred greater than 90 days from death increased from 39.1% in year one to 85.0% in year four. Embedded SCC clinics can be successful, achieve steady growth, improve referrals and timing of PPC, and enhance end-of-life care for children with cancer. Large pediatric cancer centers should include SCC outpatient services.

Patient reported outcomes in advanced penile cancer.

Patient reports of their symptom burden (i.e., patient-reported outcomes or PROs) have been shown to direct clinicians' ability to personalize care and improve outcomes. A disciplined assessment of PRO in the population of patients with advanced penile cancer (PeCa) has not previously been undertaken. Our center leveraged a significant cadre of patients with PeCa and a significant experience with a well-established PRO: the Edmonton Symptom Assessment Scale (ESAS). After IRB approval, we screened ESAS surveys of 14,781 patients completed between February 2017 and February 2021; these were collected in the Supportive Care and Radiation Oncology clinics. Of these, those with PeCa were divided into 3 cohorts: (A) Those after any partial penectomy procedure without lymph node dissection (LND); (B) Those after partial penectomy procedure with LND; and (C) Those after total penectomy and LND. Patients with recurrent disease were analyzed separately (D). ESAS scores were collated and compared both by individual symptom and cumulatively. Twenty-two PeCa patients completed 122 ESAS surveys in this time and are included in this analysis: a median of 4 ESAS surveys (mean = 5, range = 1-19) were completed by each patient. The symptom with the highest median ESAS score was Tiredness (3.00). Patients with recurrent disease had the highest cumulative symptom score (median score = 30). Patients after total penectomy with LND had a higher cumulative symptom score (14.4) than those with partial penectomy and LND (7.9). Patients with partial penectomy without LND had a cumulative score of 22. PROs provide an insight into the morbidity of therapies for advanced PeCa, and the most symptoms are reported by patients with recurrent disease.

Bevacizumab, With Sorafenib and Cyclophosphamide Provides Clinical Benefit for Recurrent or Refractory Osseous Sarcomas in Children and Young Adults.

ObjectiveChildren and adolescents with recurrent and metastatic solid tumors have a poor outcome. A previous phase 1 study (ANGIO1) targeting angiogenesis with bevacizumab, sorafenib, and cyclophosphamide, demonstrated a signal of activity in a subset of patients. Here we report the results of a cohort of pediatric and young adult patients treated at the recommended phase 2 doses.MethodsElectronic medical records of patients with refractory or recurrent solid tumors who received ANGIO1 therapy were reviewed. Treatment cycles lasted 21 days and included bevacizumab, sorafenib, and cyclophosphamide. Toxicities were assessed using Common Terminology Criteria for Adverse Events, v5.0. Responses were evaluated using Response Evaluation Criteria in Solid Tumors (RECIST1.1).ResultsThirty-nine patients (22 male, 17 female; median age 15 years; range 1-22 years) received the treatment regimen. The most common diagnoses included bone sarcomas (n=21; 14 Ewing sarcoma, 7 osteosarcoma) and soft tissue sarcomas (n=9; 2 rhabdomyosarcoma, 3 synovial sarcoma, 2 desmoplastic small round cell tumors, and 2 high-grade sarcoma). The most common Grade 3 non-hematologic toxicities included hypertension (2, 5.4%) and hematuria (2, 5.4%). Five patients (13.5%) had a pneumothorax (3 at progressive disease, 1 post lung biopsy, and 1 spontaneous). Common Grade 3/4 hematologic toxicities were lymphopenia (19, 51%) and leukopenia (13, 35%). Sixteen patients (43.2%) developed palmar-plantar erythrodysesthesia Grade 2 or less. A total of 297 cycles were administered. Twenty-three patients required a dose reduction of cyclophosphamide, sorafenib or bevacizumab during therapy, all of whom continued to have clinical benefit following dose modification. One patient (Ewing sarcoma) achieved a complete response after 11 cycles; 2 patients (Ewing sarcoma, high grade sarcoma) achieved a partial response following cycles 2 and 4, respectively and 20 patients had stable disease as a best response.ConclusionsIntravenous bevacizumab combined with oral sorafenib and metronomic cyclophosphamide was tolerated and required minimal supportive care or additional clinic visits. Disease stabilization for prolonged time periods was observed in greater than half of the treated patients. Patients with bone sarcoma demonstrated a signal of activity suggesting possible benefit from incorporation of the therapy as a maintenance regimen in upfront setting, or as a palliative regimen.

Impact of Early Supportive Care Assessment on treatment decision in head and neck cancer before concomitant chemoradiotherapy.

To assess the impact of a global pretherapeutic comprehensive supportive care assessment performed in an outpatient supportive care clinic (OSCC) and early supportive care interventions on oncological treatment choice in patients with chemoradiation (CRT) indication for head and neck cancer (HNC). In this monocentric prospective observational study, we included all patients considered for CRT (exclusive or post-operative) for HNC from February 2019 to March 2020. The following frailty indicators were assessed: comorbidities (Charlson index), nutritional status, altered functional ability (ADL and IADL), social precarity (EPICES score), cognitive impairment (MoCA score), addictive habits and pain. OSCC led to a change in treatment for 13.7% of patients, mainly de-escalations. Ninety-three percent of patients had at least one altered domain, including 50% with three or more altered domains. Cognitive function was the most frequently altered domain (66.7%). Altered functional ability was significantly associated with treatment de-escalation after OSCC. Treatment interruptions were significantly associated with treatment de-escalation and social precarity. De-escalation was also associated with a significantly poorer PFS (median of 23.2 mos. vs 8.8 mos., HR = 2.18 95%IC[1.02-4.63] p = 0.037)) and a non-significant trend towards worse OS (median 23.3mos. vs not reached (HR = 2.16 95%CI[0.88-5.31] p = 0.0836). We strongly encourage the creation of OSCC for patients treated with chemoradiation for HNC. This practice, through an exhaustive assessment, favours therapeutic adaptation, personalized follow-up and optimization of supportive care.

Early palliative/supportive care in acute myeloid leukaemia allows low aggression end-of-life interventions: observational outpatient study

ObjectivesEarly palliative supportive care has been associated with many advantages in patients with advanced cancer. However, this model is underutilised in patients with haematological malignancies. We investigated the presence and...

Cannabidiol: Knowledge, Beliefs, and Experiences of Patients With Cancer.

Cannabidiol (CBD) is purported to work for a variety of therapeutic indications. Interest in CBD products has significantly increased as patients with cancer seek ways to improve symptom control and quality of life. The purpose of this study was to explore patients' knowledge of and experience with CBD. A panel of oncology nurse practitioners, an oncologist, and oncology pharmacy specialists developed a survey to capture information about patient knowledge and use of CBD. The initial survey was pilot tested and further refined, resulting in the final item survey. The final survey was administered to 100 participants undergoing or having completed cancer treatment and being followed in a supportive oncology care clinic at a large academic medical center. Most patients learned about CBD through a family member or friend. The majority of patients had never tried CBD. The most common reported indications were pain, anxiety, and nausea. Of those who had not tried CBD, the most common reasons included lack of knowledge about CBD and providers not recommending CBD.

Comparison of opioid rotation on pain, symptoms, and daily opioid dose in a supportive care clinic.

Opioid rotation (OR) is used to decrease patients' cancer-related pain and mitigate opioid-induced adverse effects. There is limited evidence regarding its effect on symptoms and morphine equivalent daily dose (MEDD). The objective of this study was to investigate the effects of OR on pain scores, Edmonton Symptom Assessment Score (ESAS), and MEDD in patients with cancer. Retrospective observational study in an outpatient supportive care clinic using a within-subject design to analyze data collected over 34 months. Study included 676 patients with 217 rotations identified in 128 patients at supportive care clinic at a National Cancer Institute (NCI) Cancer Center. OR were identified and analysis compared the pre-visit data with the subsequent post-visit data following OR using paired t-tests. Primary endpoints included pain scores, total ESAS, and MEDD for OR and these endpoints were compared amongst rotations to specific opioid analgesics. Following OR, there was a statistically significant reduction in mean pain scores from 6.25 at the pre-visit to 5.75 following OR. Of the 194 ORs, 29.90% were successful in reducing patients' pain by either 30% or by 2-points. Only rotations to morphine, oxycodone, and methadone correlated with significant decreases in pain scores. Overall, OR did not correlate with significant changes in ESAS or MEDD. Only rotations to methadone correlated with a significant reduction in MEDD. These findings suggest OR is associated with decreased pain scores without increasing MEDD. Of the agents compared, only rotations to methadone correlated with both a significant reduction in pain scores and in MEDD.

Adaptive and maladaptive coping strategies among patients with advanced cancer.

e24129 Background: Few studies have examined the coping mechanisms among patients with advanced cancer seen by palliative care. The objective of the study was to evaluate coping strategies in advanced cancer patients and identity risk factors for maladaptive coping. Methods: The authors conducted a secondary analysis of a cross-sectional survey on chemical coping. We prospectively enrolled patients with advanced cancer from a Supportive Care Clinic and documented the patient demographics, symptom expression (Edmonton Symptom Assessment System), Zubrod performance status, substance use history including tobacco, and coping strategies (the Brief COPE Questionnaire). Univariate and multivariate analyses were performed to identify risk factors for the use of maladaptive coping strategies. Results: Among 399 patients, the most common malignancies were gastrointestinal (21%) and breast (19%). Cancer patients frequently incorporated adaptive coping strategies including acceptance (86.7%), emotional support (79.9%), religion (69.4%), active coping (62.4%), instrumental support (48.4%), positive reframing (48.6%), planning (49.6%), and infrequently, humor (18.5%). Common maladaptive strategies included self-distraction (36.6%) and venting (14.5%), while self-blame (6.3%), denial (4.5%), behavioral disengagement (1.8%), and substance use (1.0%) were infrequently reported. On univariate analysis, venting was significantly associated with anxiety and depression, female gender, and tobacco use; and self-distraction was significantly associated with younger age, gender, depression, dyspnea, and a post-secondary education (P&lt;0.05 for all). On multivariate analysis, male gender (OR -1.22, p&lt;0.0001) and smoking (non-smoker vs everyday OR -1.9, P=0.008 ) remained significant for maladaptive venting; and age (HR -0.026, p=0.005), male gender (OR -0.65, p=0.004), dyspnea (OR -0.12, p=0.01) and post-secondary education (OR 0.596, p=0.022) remained significant for self-distraction. Conclusions: The vast majority of patients with advanced cancer seen by palliative care reported using adaptive coping strategies. We identified subgroup of patients who may be more likely to use maladapative coping strategies and may benefit from further psychological support.

The impact of a web-based prognostic intervention on physicians’ prognostic confidence.

12106 Background: Clinicians often hesitate to discuss prognosis with patients because of prognostic uncertainty. The use of validated prognostic models may enhance prognostic confidence and/or prognostic accuracy. Prognostic confidence is a novel concept that has not been well studied and may support prognosis-based decision making. We examined the impact of a web-based prognostic intervention on physicians’ prognostic confidence. Methods: In this prospective study, palliative care specialists estimated the prognosis of patients with advanced cancer seen at an outpatient supportive care clinic using the temporal, surprise and probabilistic questions for 6 m, 3 m, 2 m, 1 m, 2 w, 1 w and 3 d survival. They then reviewed information from a web-based prognostic calculator ( www.predictsurvival.com ) that provided survival predictions from 7 validated prognostic scores, including the Palliative Prognostic Score, Palliative Prognostic Index, and Palliative Performance Status. The clinicians then provided their prognostic estimates post-intervention. The primary outcome was prognostic confidence (0-10 numeric rating scale, where 0 = not at all, 10 = most confident) before vs. after the study intervention. Secondary outcomes included (1) confidence to share the prognosis with patients, (2) confidence to make prognosis-based care recommendations (agreement = strongly agree or agree) and (3) prognostic accuracy. With 220 patients, we had 80% power to detect an effect size of 0.66 with 2-sided α 0.05. We compared the pre-post data using the Wilcoxon signed-rank test for the primary outcome and McNemar test for secondary outcomes. Results: 216 patients with advanced cancer (mean age 61, 50% female) were included and 154 (71%) died. The median (IQR) actual survival was 90 (39, 178) days; the median (IQR) predicted survival before and after intervention were 90 (60, 90) and 80 (60, 90) days, respectively. Prognostic confidence significantly increased after the intervention (pre vs. post: median 6 vs. 7, P &lt; 0.001). A significantly greater proportion of clinicians reported that they felt confident enough about their prognostic estimate to share it with patients (44% vs. 74%, P &lt; 0.001) and to formulate care recommendations (80% vs. 94%, P &lt; 0.001) after the intervention. Prognostic accuracy did not differ significantly before and after the intervention, ranging from 72-100% for the temporal question, 45-97% for the surprise questions and 38%-100% for the probabilistic questions (P &gt; 0.05). Conclusions: Among patients with advanced cancer seen at a supportive care clinic, the web-based prognostic intervention was associated with greater prognostic confidence and willingness to discuss prognosis, despite not significantly altering clinicians’ prognostic estimate or prognostic accuracy. Further research is needed to examine how prognostic tools may be able to augment prognostic discussions and clinical decision making.