Supportive Oncology Clinic Research Articles

Integrated supportive oncology program and outcomes for cancer patients at the end of life.

240 Background: Patients with advanced cancer are often exposed to acute medical care that does not improve quality of life or restore health. Further, the cost of care during the terminal phase defined as the last 30 days of life is substantially higher with the vast majority related to acute care services. We established an integrated outpatient supportive oncology service to improve quality of life for patients with advanced cancer. The embedded program provides same day access, longitudinal symptom management, and advanced care planning services. Here, we looked at our institutional outcomes of those patients managed by the integrated supportive oncology program. Methods: A retrospective cohort analysis was performed on patients with metastatic cancer treated at Intermountain Medical Center who died between January 1, 2022 and December 31, 2022. The study population included patients who were seen in the integrated supportive oncology clinic. Hospitalizations, length of stay, and deaths in the hospital during the last 30 days of life were recorded. We used Medicare and commercial insurance claims data to calculate the cost of these end-of-life hospitalizations. Results: Of 164 patients with cancer who died in 2022, 111 (67%) received longitudinal care from the supportive oncology clinic. Hospitalization rate in the last 30 days of life was lower in the study population compared to the control cohort (26% vs 50%) as were in-hospital deaths (7% vs 19%). The median cost of an end-of-life hospitalization was $20,648. Conclusions: An integrated supportive oncology service decreases the rates of end of life hospitalizations and in-hospital deaths for patients with advanced cancer. This is associated with a cost savings.

Telemedicine Utilization in the Ambulatory Palliative Care Setting: Are There Disparities?

ContextGiven a shortage of specialty palliative care clinicians and geographic variation in availability, telemedicine has been proposed as one way to improve access to palliative care services for patients with cancer. However, the enduring digital divide raises questions about whether unequal access will exacerbate healthcare disparities. ObjectivesTo examine factors associated with utilization of telemedicine as compared to in-person visits by patients with cancer in the ambulatory palliative care setting. MethodsWe collected data on patients seen in Supportive Oncology clinic by palliative care clinicians with an in-person or telemedicine visit from March 1 to December 30, 2020. A logistic regression with generalized estimating equation was fit to assess the association between visit type and patient characteristics. ResultsA total of 491 patients and 1783 visits were identified, including 1061 (60%) in-person visits and 722 (40%) telemedicine visits. Female patients were significantly more likely to utilize telemedicine than male patients (OR 1.46; 95% CI 1.11–1.90). Spanish-speaking patients (OR 0.32, 95% CI 0.17–0.61), those without insurance (OR 0.28, 95% CI 0.15–0.52), and those without an activated patient portal (Inactivated: OR 0.46, 95% CI 0.26–0.82; Pending Activation: OR 0.29, 95% CI 0.18–0.48) were less likely to utilize telemedicine. ConclusionOur study reveals disparities in telemedicine utilization in the ambulatory palliative care setting for patients with cancer who are male, Spanish-speaking, uninsured, or do not have an activated patient portal. In the wake of the COVID-19 pandemic, we can better meet the palliative care needs of patients with cancer through telemedicine only if equity is kept at the forefront of our discussions.

Central Pain in Patient with Cancer (GP789)

• Understand what central pain is and why it is important to recognize it.• Review the results from a small survey study designed to assess the prevalence of central pain in an advanced cancer population. Despite the current efforts to manage cancer pain with opioids, a significant number of cancer patients still experience pain. One reason may be that such patients have pain that comes from problems with the brain’s processing of pain rather than nociception, neuropathy, or inflammation. Pain related to aberrant central nervous system processing is called “central pain.” Central pain is the key pathway in many chronic pain syndromes (e.g. fibromyalgia). To demonstrate that central pain is common among cancer patients receiving palliative care. To demonstrate that cancer patients with greater severity of centralization also have elevated levels of other symptoms as well. This was a small observational study of data routinely gathered during visits to the Supportive Oncology Clinic at the University of Michigan. Patients were administered the 2011 Fibromyalgia Survey (2011 FMS) which is used to diagnose central pain and grade its severity. Patients also received the ESAS. Patients were classified as having central pain (y/n) based on 2016 American College of Rheumatology criteria for fibromyalgia and further grouped into terciles based on their 2011 FM Score. Among 55 subjects, 13 (24%) met established criteria for central pain. Subjects with central pain had the same number of symptoms and severity of pain as those without central pain, but higher severity (0-10) of anxiety (5.4 vs. 3.6), cognitive difficulties (3.6 vs. 2.7), memory difficulties (4.5 vs. 3.0), and depressed mood (4.7 vs. 3.6). Higher terciles of central pain associated with constipation (coef. 0.182 P=0.040), fatigue (coef. 1.368, P=0.010), and dyspnea (coef. 0.243, P=0.010). There is evidence of central pain among patients with cancer seen in Supportive Oncology

Advancing supportive oncology care via collaboration between psycho-oncology and integrative medicine.

As survival after cancer diagnosis increases, patients are increasingly turning toward integrative therapies (e.g., yoga, acupuncture, massage) to manage acute and chronic concerns related to cancer treatment and survivorship. As such, integrative medicine programs devoted to combining conventional Western cancer care with complementary treatments such as yoga, acupuncture, botanicals, and homeopathy are increasingly common in cancer communities around the world. However, few integrative medicine programs have included psycho-oncology providers in order to systematically evaluate and treat psychological and behavioral health factors affecting adjustment to cancer. A pilot program was initiated at a large academic medical center to explore benefits of a collaborative clinic visit conducted with psycho-oncology and integrative medicine within an existing supportive oncology clinic. Collaborative medical and psychological interventions were provided to enhance patient quality of life and reduce symptom burden. Forty-nine patients were seen via the dyadic consultation model. Sixty-eight percent of patients rated their emotional distress at or above clinical cutoffs, indicating unmet supportive care needs. The majority of patients seen were White, non-Hispanic, and female. Many cancer patients and survivors report persistent emotional distress and chronic physical problems associated with their diagnosis and treatment. The types of patients seen in this pilot program raise concern about ongoing inequalities in access to integrative medicine and psycho-oncology services, which may contribute to downstream health disparities and poorer clinical outcomes. Future directions will explore billing practices, financial sustainability, and methods to increase access to this type of program for demographically diverse individuals across cancer populations.

Supportive Oncology Clinic Broadens Care for Cancer Patients

Supportive Oncology Clinic Broadens Care for Cancer Patients

3447 Effects of intranasal ketamine on uncontrolled cancer related pain

3447 Effects of intranasal ketamine on uncontrolled cancer related pain

Impact of an initial supportive oncology clinic visit on hospitalizations and emergency department visits.

150 Background: Hospitalizations and emergency department (ED) visits can be frequent, costly and discordant with stated goals-of-care for cancer patients. Little is known about the impact of outpatient palliative care and supportive oncology on hospitalizations and ED visits. Our aim was to investigate the impact of an initial visit at an outpatient supportive oncology clinic (SOC) on patient hospitalizations and ED visits. Methods: New patients were referred to a SOC from our health system’s oncologists from November 1, 2014 through January 31, 2015. Visits include a structured symptom assessment and personalized treatment plan from the clinic’s physician and/or nurse practitioner. Data were collected 90 days retrospectively and 90 days prospectively from 134 consecutive initial SOC visits. Descriptive statistics were calculated. We used the Wilcoxon signed rank test to compare the mean number of hospitalizations and ED visits in the 90 days prior and 90 days post a patient’s first SOC visit. Results: Mean patient age at first SOC visit was 55.6 (SD = 16.4). 51.2% of patients were female. The most common cancers were breast, lung, head and neck. Mean number of hospitalizations per patient was significantly (p < 0.05) decreased: 1.3 (SD = 1.6) in the 90 days prior to initial SOC visit vs. 0.7 (SD = 0.7) in the 90 days post initial SOC visit. There was a non-significant reduction in mean ED visits per patient: 0.9 (SD = 0.9) in the 90 days prior to initial SOC visit vs. 0.7 (SD = 0.7) in the 90 days post initial SOC visit. Conclusions: Hospitalizations were significantly decreased and ED visits were reduced after the first visit to a small-scale SOC. This provides evidence that outpatient supportive care including aggressive symptom management may reduce patient crises, preventing ED visits and hospitalizations, and will likely lead to cost savings and improve quality of life for patients during and after cancer therapy. The decrease in hospitalizations and ED visits may be underestimated if disease was progressing and overestimated if disease was shrinking, but this data was not available for this study.

Symptom Clustering Among Patients Visiting a Supportive Oncology Clinic (FR435-D)

Objectives Describe a supportive oncology clinic and its patient population. Identify symptoms that compose psychological, treatment-related, and gastrointestinal clusters within a supportive oncology population. Original Research Background: Multiple symptoms are common and often severe in patients with cancer. Identification of symptoms that cluster may serve to elucidate the pathophysiology of the disease and aid in symptom management. Research Objectives: Our aim was to define symptom clusters occurring among cancer outpatients receiving chemotherapy. Methods: November 2011 through May 2014 completed the Condensed Memorial Symptom Assessment Scale plus a sexual dysfunction structured assessment. Data were collected prospectively from 323 consecutive initial visits. Patients rated from 0-4 how

Reduced Symptom Burden After Visiting an Outpatient Supportive Oncology Clinic (S709)

Reduced Symptom Burden After Visiting an Outpatient Supportive Oncology Clinic (S709)

Symptom clustering among patients visiting a supportive oncology clinic.

188 Background: Multiple symptoms are common and often severe in patients with cancer. Identification of symptoms which cluster may serve to elucidate the pathophysiology of the disease and aid in symptom management. Our aim was to define symptom clusters occurring among cancer outpatients receiving chemotherapy. Methods: New and returning patients referred to a supportive oncology clinic (SOC) from our health system’s oncologists from November 2011 through May 2014 completed the Condensed Memorial Symptom Assessment Scale plus a sexual dysfunction structured assessment. Data were collected prospectively from 323 consecutive initial visits. Patients rated from 0-4 how bothersome 15 cancer symptoms were; symptoms were then graded as present (1+) or absent (0). Hierarchical cluster analysis with average linkage was used to identify symptom clusters. The absolute value of the correlation between symptoms was used as the measure of similarity between pairs of symptoms. A correlation of ≥0.6 was used to define the final clusters. A symptom cluster was defined as two or more symptoms that predictably occur together. Results: Three clusters were identified: 1. Psychological (worrying, feeling sad, feeling nervous); 2. Treatment-related (lack of energy, feeling drowsy, difficulty concentrating, dry mouth, constipation); 3. Gastrointestinal (weight loss, lack of appetite, nausea). Pain, difficulty sleeping, shortness of breath, and loss of interest did not cluster with any symptom. Gastrointestinal symptoms are important within the clusters. The prevalence of worrying, feeling sad, and feeling nervous did not cluster with lack of energy or difficulty in sleeping, nor pain with worrying or feeling sad. Conclusions: Three symptom clusters were identified as showing high absolute correlation: a psychological cluster, treatment-related cluster, and gastrointestinal cluster. Identifying symptom clusters may promote our understanding of the pathophysiology of cancer, help prioritize effective pharmacotherapies, and identify drugs likely to help more than one symptom.

Reduced symptom burden after visiting an outpatient supportive oncology clinic.

204 Background: Outpatient palliative care in supportive oncology clinics (SOC) is growing and has shown promise in controlling symptoms. We sought toinvestigate the impact on symptom burden of a SOC in a National Cancer Institute-designated Comprehensive Cancer Center. Methods: New and returning SOC patients referred from our health system’s oncologists from November 2011 through May 2014 completed the Condensed Memorial Symptom Assessment Scale plus a sexual dysfunction structured assessment. Visits include a structured symptom assessment and personalized treatment plan from the clinic’s part-time physician and/or nurse practitioner. Patients rated from 0-4 how bothersome 15 cancer symptoms were. Descriptive statistics were calculated. We used the Wilcoxon signed rank test to compare symptom scores at patients’ first and second visits. Results: 135 patients had multiple SOC visits. Mean age was 54.7 (SD 12.5) years. 55.3% were female. The most common cancers were breast, lung, and head and neck (18.1% each). Median time between visits was 29 days (mean: 52.8, range: 2-446). The most bothersome symptoms at baseline were pain (mean 3.1, SD 1.3), lack of energy (2.4, SD 1.3), and difficulty sleeping (2.1, SD 1.6). Least bothersome were dyspnea (0.8, SD 1.1), sexual problems (0.9, SD 1.4), and nausea (1.0, SD 1.3). Energy, pain, drowsiness, constipation, sleep, worrying, sadness, and nervousness were significantly improved at follow-up with reductions between 0.2 (drowsiness) and 0.5 (pain) points (all p<0.05). Weight loss trended toward improved (p=0.053). Conclusions: 8 of 15 symptoms significantly improved after the first visit to a small-scale SOC. These reductions may underestimate the SOC’s effect if disease was progressing or overestimate differences if disease was shrinking, but such data were unavailable. Larger multi-site trials with well-defined interventions and control groups are needed.

Symptom Burden and Complementary Medicine Assessment in an Outpatient Supportive Oncology Clinic (S725)

19% reported gathering this knowledge while working. 68% wanted more formal education around terminal patient care. 11 RTs (23%) reported sometimes being uncomfortable with terminal extubations, but 10 of these 11 said they rarely or never got the option not to perform an uncomfortable extubation. Conclusions. RTs are rarely involved in end of life discussions despite a desire to be, and they experience situations that generate discomfort. There is demand for more formal RT training around care for terminal patients. Implications for research, policy, or practice. RTs are rarely involved in end of life discussions despite a desire to be, and they experience situations that generate discomfort. There is demand for more formal RT training around care for terminal patients.

Medication therapy management (MTM) in a multidisciplinary supportive oncology clinic.

30 Background: Patients with advanced cancer experience significant symptom burden and psychosocial distress from the onset of their diagnosis and throughout treatment shifting the paradigm of supportive care. In addition, most cancer patients have multiple co-morbidities and are at high risk of poly-pharmacy. One in three ambulatory cancer patients are at risk of drug-drug interactions. Methods: In June 2010, a multidisciplinary supportive oncology clinic, modeled after the Massachusetts General Hospital article by Temel et al., was started and staffed by a pharmacist, a nurse, a social worker and a dietitian and lead by a nurse practitioner. A chart audit was conducted for all patients seen in the clinic between June 2010 and March 2012. Pharmacy assessment entries were evaluated for diagnosis, medication issues and total time spent with patients. Duplicate therapy was defined as an unnecessary duplication in therapy for a single symptom and/or two medications in the same class. Drug-Interactions were assessed utilizing Micromedex 2.0 Drug-Interaction Checker and Lexicomp Lexi-Interact Online drug-interaction analysis program. All major kinetic interactions were recorded and pharmacodynamic interactions were recorded if they required intervention. Results: From June 2010 to May 2012, 153 patients were seen in the clinic. The most common diagnoses were pancreatic, lung, breast and head and neck. Use of a standardized pharmacy assessment identified duplicate therapies in 45.1% of patients, drug-drug interactions in 35.3%, side-effects in 83%, lack of efficacy in 88.9% and untreated conditions 68.6%. The pharmacists spent an average of 44.1 minutes (range 15-90 min) with patients. Conclusions: Pharmacist-initiated MTM identifies a higher rate of poly-pharmacy, drug-drug interactions and side effects than found in literature. Identification allows for referral to other disciplines within the clinic for work-up. Gastrointestinal related issues were referred to a dietitian, psychosocial issues including adherence issues to a social worker and medication related issues to the nurse practitioner for follow-up. Initial identification of these issues has allowed for more long-term follow-up in these patients.

Implementing a Standardized Pharmacist Assessment and Evaluating the Role of a Pharmacist in a Multidisciplinary Supportive Oncology Clinic

Supportive care, or palliative care, in oncology patients has been a shifting paradigm in the last few years. Patients with advanced cancer experience significant symptom burden and psychosocial distress from the onset of their diagnosis and throughout treatment. The focus on cancer treatment often defers the integration of palliative care to a more "reactive" vs "proactive" approach, which can hinder symptom management. Many cancer centers are integrating palliative care programs in their practice; however, the scope of services and degree of intervention varies widely, especially with regard to the pharmacist's role. The purpose of this article is to describe the operational aspects of a multidisciplinary supportive oncology clinic at St. Luke's Mountain States Tumor Institute (MSTI). The MSTI supportive oncology clinic is a half-day clinic where complex patients are seen by a multidisciplinary team led by a nurse practitioner. The team also includes a nurse, a pharmacist, a dietitian, and a social worker. The pharmacist is responsible for medication reconciliation, which includes assessment for drug interactions, adverse effects, duplications in therapy, lack of efficacy, and untreated conditions. Within the first year of the supportive oncology clinic's operation, we saw a total of 75 patients. Use of a standardized pharmacy assessment helped to elucidate and address medication issues such as duplicate therapies (46.7% of patients), drug interactions (44%), side effects (74.7%), lack of efficacy (94.7%), and untreated conditions (73.3%). Pharmacists are uniquely trained in medication therapy management, and a thorough medication therapy review has been shown to assist other disciplines in their own assessments.