Symptom Management Recommendations Research Articles

AI-Generated Content in Cancer Symptom Management: A Comparative Analysis Between ChatGPT and NCCN

BackgroundArtificial intelligence-driven tools, like ChatGPT, are prevalent sources for online health information. Limited research has explored the congruity between AI-generated content and professional treatment guidelines. This study seeks to compare recommendations for cancer-related symptoms generated from ChatGPT with guidelines from the National Comprehensive Cancer Network (NCCN). InterventionWe extracted treatment recommendations for nine symptoms from NCCN, separated into four full Supportive Care sections and five subsections of the Palliative Care webpage. We entered "How can I reduce my cancer-related [symptom]" into ChatGPT- 3.5 for these same symptoms and extracted its recommendations. A comparative content analysis focused on recommendations for medications, consultations, and non-pharmacological strategies. We compared word count and Flesch-Kincaid Grade Level (FKGL) readability for each NCCN and ChatGPT section. OutcomesThe mean percent agreement between NCCN and ChatGPT recommendations was 37.3% (range 16.7%–81.8%). NCCN offered more specific medication recommendations. ChatGPT did recommend medications in the constipation and diarrhea sections that were not recommended by NCCN. Significant differences in word count (P=0.03) and FKGL (P<0.01) were found for NCCN Supportive Care webpages, with ChatGPT having lower word count and reading level. In the NCCN Palliative Care webpage subsections, there was no significant difference in word count (P=0.076), but FKGL was significantly lower with ChatGPT (P<0.01). Conclusions/Lessons LearnedWhile ChatGPT provides concise, accessible supportive care advice, discrepancies with guidelines raise concerns for patient-facing symptom management recommendations. Future research should consider how AI can be used in conjunction with evidence-based guidelines to support cancer patients’ supportive care needs.

Exploring AI-generated content and professional guidelines in cancer symptom management: A comparative analysis between ChatGPT and NCCN guidelines.

e13610 Background: Artificial intelligence (AI)-driven tools, like ChatGPT, have become widely-available sources for online health information. Limited research has explored the congruity between AI-generated content and professional treatment guidelines. This study seeks to compare recommendations for cancer-related symptoms generated from ChatGPT with guidelines from National Comprehensive Cancer Network (NCCN), a provider focused source requiring users to log in or register to access its recommendations. Utilizing a provider-focused source like NCCN serves as a benchmark to assess whether ChatGPT recommendations align with the standards typically endorsed by clinicians. Methods: We extracted treatment recommendations from four NCCN Supportive Care webpages (Cancer Pain, Antiemesis, Cancer-Related Fatigue, and Distress Management) and five subsections of the NCCN Palliative Care webpage (dyspnea, constipation, diarrhea, sleep disturbances, and anorexia/cachexia). We then entered "How can I reduce my cancer-related [symptom]" into ChatGPT 3.5 and extracted its recommendations. We calculated and compared word count and Flesch-Kincaid Grade Level readability for each NCCN and ChatGPT section. We completed a comparative content analysis focusing on recommendations for medications, consultations, and non-pharmacological strategies. Results: Across the nine NCCN Supportive Care and Palliative Care webpages, the mean word count was 2393.8 (SD=2601.4) and the mean Flesch-Kincaid Grade Level was 17.3 (SD=1.4) vs 382.4 (SD=29.6) and 11.6 (SD=0.8) for ChatGPT. The mean percent agreement between NCCN and ChatGPT recommendations was 44.6% (range 14.3%-81.8%). ChatGPT and NCCN guidelines shared fewer than half of their symptom-related recommendations in all but one section, fatigue. NCCN offered specific medication recommendations across all sections. ChatGPT's recommendations lacked the specificity observed in NCCN's guidelines including often not suggesting any medications. ChatGPT recommended specific medications in the shortness of breath and diarrhea sections that were not recommended by NCCN. NCCN's guidelines often did not include recommendations related to spirituality or palliative care consults, areas that ChatGPT addressed. Conclusions: While ChatGPT provides concise, accessible supportive care advice including many non-medical support recommendations, discrepancies with guidelines raise concerns for patient-facing symptom management recommendations. Overall, AI-generated content like ChatGPT can assist in providing preliminary information but should be researched in conjunction with comprehensive, evidence-based guidance provided by healthcare professionals. Healthcare providers should work with AI developers to ensure data sources are high-quality and accurate.

A qualitative analysis of algorithm-based decision support usability testing for symptom management across the trajectory of cancer care: one size does not fit all

BackgroundAdults with cancer experience symptoms that change across the disease trajectory. Due to the distress and cost associated with uncontrolled symptoms, improving symptom management is an important component of quality cancer care. Clinical decision support (CDS) is a promising strategy to integrate clinical practice guideline (CPG)-based symptom management recommendations at the point of care.MethodsThe objectives of this project were to develop and evaluate the usability of two symptom management algorithms (constipation and fatigue) across the trajectory of cancer care in patients with active disease treated in comprehensive or community cancer care settings to surveillance of cancer survivors in primary care practices. A modified ADAPTE process was used to develop algorithms based on national CPGs. Usability testing involved semi-structured interviews with clinicians from varied care settings, including comprehensive and community cancer centers, and primary care. The transcripts were analyzed with MAXQDA using Braun and Clarke’s thematic analysis method. A cross tabs analysis was also performed to assess the prevalence of themes and subthemes by cancer care setting.ResultsA total of 17 clinicians (physicians, nurse practitioners, and physician assistants) were interviewed for usability testing. Three main themes emerged: (1) Algorithms as useful, (2) Symptom management differences, and (3) Different target end-users. The cross-tabs analysis demonstrated differences among care trajectories and settings that originated in the Symptom management differences theme. The sub-themes of “Differences between diseases” and “Differences between care trajectories” originated from participants working in a comprehensive cancer center, which tends to be disease-specific locations for patients on active treatment. Meanwhile, participants from primary care identified the sub-theme of “Differences in settings,” indicating that symptom management strategies are care setting specific.ConclusionsWhile CDS can help promote evidence-based symptom management, systems providing care recommendations need to be specifically developed to fit patient characteristics and clinical context. Findings suggest that one set of algorithms will not be applicable throughout the entire cancer trajectory. Unique CDS for symptom management will be needed for patients who are cancer survivors being followed in primary care settings.

Pilot Study of a Mobile Phone Chatbot for Medication Adherence and Toxicity Management Among Patients With GI Cancers on Capecitabine.

Capecitabine is an oral chemotherapy used to treat many gastrointestinal cancers. Its complex dosing and narrow therapeutic index make medication adherence and toxicity management crucial for quality care. We conducted a pilot study of PENNY-GI, a mobile phone text messaging-based chatbot that leverages algorithmic surveys and natural language processing to promote medication adherence and toxicity management among patients with gastrointestinal cancers on capecitabine. Eligibility initially included all capecitabine-containing regimens but was subsequently restricted to capecitabine monotherapy because of challenges in integrating PENNY-GI with radiation and intravenous chemotherapy schedules. We used design thinking principles and real-time data on safety, accuracy, and usefulness to make iterative refinements to PENNY-GI with the goal of minimizing the proportion of text messaging exchanges with incorrect medication or symptom management recommendations. All patients were invited to participate in structured exit interviews to provide feedback on PENNY-GI. We enrolled 40 patients (median age 64.5 years, 52.5% male, 62.5% White, 55.0% with colorectal cancer, 50.0% on capecitabine monotherapy). We identified 284 of 3,895 (7.3%) medication-related and 13 of 527 (2.5%) symptom-related text messaging exchanges with incorrect recommendations. In exit interviews with 24 patients, participants reported finding the medication reminders reliable and user-friendly, but the symptom management tool was too simplistic to be helpful. Although PENNY-GI provided accurate recommendations in >90% of text messaging exchanges, we identified multiple limitations with respect to the intervention's generalizability, usefulness, and scalability. Lessons from this pilot study should inform future efforts to develop and implement digital health interventions in oncology.

Annual cost and implementation of remote oncology pharmacist order review within a network of community oncology practices.

30 Background: The US Oncology Network’s ClinReview program employs a team of centralized clinical pharmacists providing remote services to community oncology practices. Literature demonstrating the clinical impact of the oncology pharmacist has been well established. However, comprehensive data supporting the financial value compensating these clinical services continues to prove challenging. The aim of this study is to evaluate the annual cost-avoidance realized by the ClinReview program through clinical and quality interventions. Methods: A team of 6 oncology clinical pharmacists electronically reviewed chemotherapy orders within 9 community oncology practices. The pharmacist identified opportunities to optimize oncology regimens by performing clinical treatment plan reviews, identifying orders requiring dose modifications, symptom management recommendations, clinical consultations, regimen entry, or drug interaction reviews. Recommendations were discussed with the treating provider or modified if permitted by approved practice policies. A retrospective, observational study was performed utilizing clinical intervention data entered by ClinReview pharmacists from October 2022 through March 2023. Interventions were allocated to specific cost-avoidance values based on previously validated studies and extrapolated to an annualized value. Results: During the 6-month study period, a total of 10,195 interventions were documented and categorized as treatment plan management (2,434, 24%), medication regimen/dosing change (6,365, 62%), symptom management (1,145, 11%), drug information consultation (103, 1%), regimen entry, (69, 1%), and drug interaction management (90, 1%). Based on previously validated cost-savings estimates, annualized cost avoidance realized from the ClinReview program was $2,247,818. Taking into account the cost of pharmacist time, the 6-month intervention data demonstrated an annualized net cost-avoidance of $1,896,164. Conclusions: The integration of the ClinReview program into community oncology practices delivers significant quality, safety, and financial benefits, with approximately $1.9 million in annual net cost-savings benefit. [Table: see text]

Capturing the patient’s voice to inform advanced clinical decision support for guideline-based cancer symptom management.

510 Background: Electronic patient reported outcomes (ePROs) have become routine in cancer care; however, ePROs alone do not provide sufficient information to enable informed symptom management. Informed symptom management requires an awareness of patient context to reduce inappropriate or erroneous advice. In this project we asked: how can information be collected directly from patients to provide clinicians with detailed, contextually-informed, patient-specific, evidence-based recommendations to manage distressing symptoms, especially among patients with complex comorbidities. Methods: The literature states that text messages are the most effective way to engage patients in clinical data collection. We texted patients a link that led them to a Web-based questionnaire that asked them about their common cancer symptoms. Prototypes were tested with 9 cancer patients through structured interviews and think aloud sessions from which themes were identified. Feedback from these interviews was used to develop a patient data collection questionnaire that we iteratively refined through think aloud sessions with 9 cancer patients to achieve universal patient acceptance. We also engaged 28 oncology clinicians in semi-structured interviews to assess the clinical impact of the additional contextual information on the symptom recommendations they received. Results: Formative evaluation identified four themes: 1) make instructions brief, 2) use intuitive navigation buttons with labels, 3) focus on multiple-choice style questions, and 4) extract data from the medical record for patient verification instead of free text entry by patients (e.g., medications). Developers incorporated “more detailed” questions into the patient data collection questionnaire; additional questions were presented if the patient indicated moderate or greater severity of a given symptom. These detailed questions focused on characteristics of the symptoms (e.g. neuropathic or somatic pain), remedies a patient had already initiated for self treatment (e.g., laxatives for constipation), and comorbid conditions that could impact the safety of recommendations (e.g., fall risk). Clinicians indicated that the additional data collected from patients increased the value of the tailored recommendations for enhanced symptom management. Conclusions: Additional data collection from patients using standard text messaging enables clinical decision support algorithms to provide more individually tailored cancer symptom management recommendations. This study is limited in that the design enhancements have been tested with a small number of end-users in a laboratory setting. Acknowledgements: This project was 100% funded using Cancer Moonshot funding through Phase I and II SBIR contracts from the National Cancer Institute, Contract #75N91018C00022 and #75N91020C00019, respectively.

Abstract P5-07-12: Patient-Reported Symptom Burden in Women Undergoing Treatment for Early Stage and Metastatic Breast Cancer

Abstract Background: Women undergoing treatment for breast cancer experience both disease- and treatment-related symptoms. Remote symptom management programs allow real time symptom documentation, earlier intervention, and opportunities to improve quality of life and decrease symptom burden. This study describes patient-reported outcomes (PROs) in women undergoing treatment for early stage and metastatic breast cancer. Methods: Women with breast cancer using Carevive’s remote symptom management (RSM) program completed weekly surveys to assess the presence of 14 common symptoms over 16 weeks. Symptoms assessed were anxiety, decreased appetite, fatigue, general pain, mouth sores, muscle pain, nausea, vomiting, numbness, sadness, shortness of breath, diarrhea, constipation, and insomnia. When a symptom was reported, additional questions were asked regarding symptom severity, frequency, and interference using the National Cancer Society’s Patient Reported Outcomes-Common Terminology Criteria for Adverse Events (PRO-CTCAE). The PRO-CTCAE produced composite scores, which classified each symptom reporting event as mild, moderate-severe, or severe. A mild symptom classification generates an electronic care plan with recommendations for symptom management; moderate-severe and severe classifications trigger an alert to the care team. Descriptive analyses summarize PROs for early stage and metastatic patients. Symptom burden was assessed by calculating the frequency distribution of each patient’s highest reported composite score for each symptom by month (Table 1). Results: Between September 2020 and April 2022, 280 women enrolled in the RSM program; 201 of these women had complete staging information for analysis. 80% (n=160) had early stage (0-III) and 20% (n=41) had metastatic (IV) disease. 32% (n=64) were less than 50 years old and 68% (n=137) were age 50 or older. 58% (n=116) were hormone receptor (HR) positive/HER2 negative, 22% (n=45) HR+ or -/HER2+ and 19% (n=39) HR-/HER2-. In Month 1, patients with metastatic disease most frequently reported moderate to severe symptoms for general pain (51%), nausea (32%), decreased appetite (22%), and diarrhea (29%). In Month 1, patients with early stage disease most frequently reported moderate to severe symptoms for general pain (32%) and diarrhea (28%). In Month 1, general pain was the most frequently reported symptom for both early stage (34%) and metastatic (51%) groups. In both groups over 16 weeks, nausea, diarrhea, and constipation were among the five most reported symptoms along with muscle pain for early stage patients and shortness of breath for metastatic patients. The frequency of all symptoms decreased over 16 weeks, but there remained cases of moderate-severe and severe symptom intensity through Week 16 for several symptoms. Conclusion: Women with metastatic and early stage breast cancer both report severe symptoms during treatment. Early stage patients may have different symptom profiles and unmet needs not captured by common PROs. Future work should further evaluate symptom profiles of early stage patients to understand how to best use PRO monitoring in the curative intent setting. Percentage of Moderate-Severe and Severe Symptom Reports By Month and Symptom for Women with Early Stage and Metastatic Breast Cancer MO=Month Citation Format: Tara Kaufmann, Aaron Galaznik, Nicholas Coombs, Gabrielle B. Rocque. Patient-Reported Symptom Burden in Women Undergoing Treatment for Early Stage and Metastatic Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-07-12.

An augmented intelligence mobile phone chatbot for medication adherence and toxicity management among patients with gastrointestinal cancers on capecitabine.

424 Background: Capecitabine (cape), an oral chemotherapy, is the treatment backbone for many GI cancers. Its complex dosing and narrow therapeutic index make medication adherence and toxicity management crucial for quality patient care. Methods: We conducted a feasibility study of “Penny,” an augmented intelligence mobile phone chatbot that leverages algorithmic surveys and natural language processing (NLP) to engage with patients in conversational, bi-directional text messages. Penny provides patients with medication reminders tailored to their prescribed doses and schedules, sends weekly check-in messages, manages low-grade symptoms in real time, and escalates high-grade symptoms for resolution by the clinical team. Patients ≥18 years old receiving cape for the treatment of a GI cancer were accrued in sequential cohorts of 20 for participation over a three-month period. Feasibility was assessed during planned interim analyses and was predefined as the completion of a 20-patient cohort without a safety event, defined as the communication of incorrect medication or symptom management recommendations as ascertained by two independent clinician reviewers (Κ = 0.89). Secondary outcomes included patient-reported adherence and engagement with the chatbot’s weekly check-in messages. At study completion, all patients were invited to participate in structured interviews to provide feedback on the platform. Results: The first cohort of 20 patients was enrolled from 8/2021 to 4/2022; the median age was 57 years, and patients were primarily female (55%), white (65%), commercially insured (55%), and had colorectal cancer (55%). Chemotherapy regimens included cape with oxaliplatin (50%), concurrent RT (30%), temozolomide (5%), and monotherapy (15%). A total of 2,149 text messaging exchanges were reviewed with 150 (7%) medication-related and 9 (0.4%) symptom-related safety events identified. Most medication-related safety events were due to misalignment with prescribed chemotherapy schedules (55%) and doses (32%). Symptom-related safety events were primarily due to the misinterpretation of patient messages by Penny’s NLP functionality (89%). Average patient-reported adherence was 67% (SD 27%), and patients engaged with 27% (SD 24%) of the chatbot’s weekly check-in messages. In post-study interviews with 12 patients, participants reported that the medication reminders were reliable and user-friendly, whereas the symptom management tool was too simplistic to be helpful. Conclusions: Although Penny has not yet met its feasibility endpoint, the lessons learned from this first cohort have informed further refinements to the platform. Ongoing efforts aim to integrate Penny with the electronic health record and further train the chatbot’s NLP functionality to minimize medication- and symptom-related safety events, respectively. Clinical trial information: NCT05113264.

Perspectives of Patients, Nurses, and Nephrologists About Electronic Symptom Monitoring With Feedback in Hemodialysis Care

Patients receiving hemodialysis experience high symptom burden and low quality of life (QOL). Electronic patient-reported outcome measures (e-PROMs) monitoring with feedback to clinicians may be an acceptable intervention to improve health-related QOL for patients receiving hemodialysis. This study explored patient and clinician perspectives on e-PROMs monitoring with feedback to clinicians. Qualitative study. 41 participants (12 patients, 13 nephrologists, 16 dialysis nurses) who participated in a 6-month feasibility pilot study of adults receiving facility-based hemodialysis across 4 Australian units. The intervention consisted of electronic symptom monitoring with feedback to clinicians, who also received evidence-based symptom management recommendations to improve health-related QOL. Semistructured interviews and focus group discussions explored the feasibility and acceptability of e-PROMs monitoring with feedback to clinicians. We conducted a thematic analysis of transcripts. We identified 4 themes: enabling efficient, systematic, and multidisciplinary patient-centered care; experiencing limited data and options for symptom management; requiring familiarity with technology and processes; and identifying barriers and competing priorities. While insufficient patient engagement, logistic/technical challenges, and delayed symptom feedback emerged as barriers to implementation, active engagement by nurses in encouraging and supporting patients during survey completion and clinicians' prompt action after symptom feedback were considered to be facilitators to implementation. Limited generalizability due to inclusion of English-speaking participants only. Patients, nurses, and nephrologists considered e-PROMs monitoring with feedback to clinicians feasible for symptom management in hemodialysis. Clinician engagement, patient support, reliable technology, timely symptom feedback, and interventions to address symptom burden are likely to improve its implementation within research and clinical settings.

Optimising symptom management in children with cancer using a novel mobile phone application: protocol for a controlled hybrid effectiveness implementation trial (RESPONSE)

BackgroundIntense and aggressive treatment regimens for most children’s cancer have achieved vast improvements in survival but are also responsible for both a high number and burden of symptoms. The use of Patient Reported Outcome Measures (PROMs) demonstrates a range of benefits for improved symptom management in adults with cancer. There are, however, multiple barriers to integrating PROMs into routine care in children and adolescents with cancer. This study aims to evaluate: (1) the effectiveness of electronic PROMs to generate stratified alerts, symptom management recommendations and graphical summaries (the RESPONSE system) to improve health outcomes and (2) the implementation of the RESPONSE system by assessing feasibility, acceptability, satisfaction, and sustainability.MethodsA pragmatic hybrid II effectiveness-implementation controlled trial, using mixed methods, will be undertaken, advancing both knowledge of the effectiveness of the intervention and implementation factors. One-hundred and sixty children with cancer receiving active treatment will be recruited 1:1 to a non-randomised study involving two groups with an equal number of participants in each group. The intervention group (n = 80) will be prospectively recruited to receive the RESPONSE system intervention over eight weeks, versus the historical matched control group (n = 80) who will complete the ePROMs without access to the RESPONSE system. The primary outcome of the effectiveness trial is change between groups in total symptom burden. Secondary outcomes include child health-related quality-of-life and implementation outcomes. Trial data will be analysed using linear mixed-effects models. Formative implementation evaluation is informed by CFIR and ERIC frameworks and implementation outcomes will be mapped to the RE-AIM framework and include interviews, field notes, as well as administrative data to evaluate feasibility, acceptability, satisfaction and sustainability.Trial registration numberACTRN12621001084875. Retrospectively Registered 16 August 2021.

Impact of the COVID-19 pandemic on obstructive sleep apnea: recommendations for symptom management

In the context of the current COVID-19 pandemic situation, we address the following important questions: (1) How can patients be identified for possible OSA while sleep clinic testing is temporarily unavailable or limited? and (2) What measures can be suggested to improve sleep health until proper diagnosis and treatment become safe and available again? As a proxy for home or in-laboratory testing, validation of a symptom-based measure of OSA risk is presented, based on an ongoing larger prospective study of 156 family medicine patients with OSA (88 women, 68 men; mean age, 57 years) and 60 control participants (36 women, 24 men; mean age, 54 years) recruited from the community. Participants completed the Sleep Symptom Checklist (SSC) and a range of other self-report measures; primary care patients also underwent a polysomnographic sleep study. Results showed that (1) individuals with OSA reported more symptoms on the SSC related to insomnia, daytime symptoms, sleep disorders, and psychological maladjustment than did the control group (all P < .001), and (2) their sleep-related symptoms were significantly more severe than those of the control patients. In addition, several polysomnographic indices in recently diagnosed untreated individuals with OSA were significantly correlated with SSC measured sleep disorder symptoms, and SSC scores significantly distinguished participants with OSA from control participants. Our findings suggest that family practitioners can effectively prescreen patients for possible OSA by inquiring about 5 items that form the SSC sleep disorders subscale. If OSA is suspected, then we can recommend a range of behavioral techniques to improve symptoms. The current pandemic causes us to reflect that the provisional targeting of symptoms and guidance regarding mitigation strategies while waiting for specialist care could serve patients well at any time.

Development of the SPARK family member web pages to improve symptom management for pediatric patients receiving cancer treatments

BackgroundSupportive care Prioritization, Assessment and Recommendations for Kids (SPARK) is a web-based application that facilitates symptom screening and access to supportive care clinical practice guidelines (CPGs) for children and adolescents receiving cancer treatments. Objective was to develop SPARK family member web pages for pediatric patient family members accessing: (1) proxy symptom screening and symptom reports, and (2) care recommendations for symptom management based on CPGs.MethodsSPARK family member web pages were developed and included access to symptom screening and care recommendations sections. Care recommendations for fatigue and mucositis were created. These were iteratively refined based upon cognitive interviews with English-speaking family members ≥16 years of age until less than two participants incorrectly understood sections as adjudicated by two independent raters.ResultsA total of 100 family members were enrolled who evaluated the SPARK family member web pages (n = 40), fatigue care recommendation (n = 30) and mucositis prevention care recommendation (n = 30). Among the last 10 participants, none said that the SPARK family member web pages were hard or very hard to use, one incorrectly understood one web page, none said either care recommendation was hard to understand and none were incorrect in their understanding of the care recommendations.ConclusionsWe successfully developed SPARK web pages for use by family members of pediatric patients receiving cancer treatments. We also developed a process for translating CPG recommendations designed for healthcare professionals to lay language. The utility of SPARK family member web pages after clinical implementation could be a focus for future research.

An Overview of Premenstrual Voice Syndrome: Definition, Treatment, and Future Trajectories.

For classical singers, performing in peak condition is optimal at all times in an industry which demands excellence. The slightest variability in a singer's physiology can influence sound quality and production; in severe instances, a singer's career longevity may be compromised. Researchers have observed an effect of menstrual cycle hormone variability on the voice, compromising tone quality, agility, and stamina. For a subset of these singers, the effect of hormone variability on voice production is especially severe. This phenomenon has been termed premenstrual voice syndrome (PMVS) among singers, although there has been little empirical research on PMVS, which complicates matters related to defining, taxonomizing, and treating the condition. This article offers an overview of existing research related to PMVS, identifies gaps in definitional and categorical boundaries between PMVS and premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), and offers recommendations for symptom management as well as suggestions for pedagogues and teachers to better educate themselves and their students about PMVS.

QOLP-19. A NEW MODEL OF CARE FOR PATIENTS WITH CENTRAL NERVOUS SYSTEM CANCERS

Abstract Patients (pts) with primary or metastatic central nervous system (CNS) cancers often have multiple physical, psychosocial, and spiritual needs. Neurological impairments can transform relationship dynamics with caregivers. These issues are difficult to address within a single outpatient oncology clinic. The Neurological Multidisciplinary Care Clinic (MdCC) at Memorial Sloan Kettering Cancer Center was a pilot study from 08/2017 to 04/2019 to foster a new model of care for complex pts with CNS cancers to identify and address their needs. The MdCC team: a neurologist, nurse, physiatrist (RM), physical therapist, social worker (SW), case manager (CM), dietitian (RD), and chaplain saw each pt/caregiver during a 3-hour visit. Since 11/2017 participants completed validated surveys on unmet needs, financial strain, and home equipment prior to their visit and satisfaction surveys afterward. Descriptive statistics were used to analyze results. Seventy-eight pts were seen: 39 were female, median age 59. Of these 78 pts, 65 had primary CNS cancers; predominantly glioblastoma (52%) and high-grade glioma (29%). Over 60% had never seen a SW, CM, RD, or physiatrist prior to MdCC. Seventy-six pts (97%) received symptom management recommendations. Prognosis/coping with cancer was discussed with 72 (92%) which increased signed health care proxy forms by 17% and DNR orders by 6% at time or within a month post MdCC. New/updated physical therapy was ordered for 48 pts (61%), orthotics for 8 (10%), and new equipment for 12 (15%). 25 pts (32%) continued following with physiatrists. Forty-eight pts completed a satisfaction survey; of these, 96% were highly satisfied, and would recommend MdCC to others. Pts’/caregivers’ unmet needs were effectively identified and addressed in this new model, The presence of these providers at time of MdCC allows for real time assessment of pts’/caregivers’, their support system, multidisciplinary team collaboration, planning, coordination of community services and implementation of a safe patient centered plan of care.

New model of care for patients with central nervous system cancers.

87 Background: Patients (pts) with primary or metastatic central nervous system (CNS) cancers often have multiple physical, psychosocial, and spiritual needs. Likewise, neurological impairments can transform pts’ relationship dynamics with caregivers. These issues, along with prognosis and end of care planning, are difficult to address within a single outpatient oncology clinic. Methods: The Neurological Multidisciplinary Care Clinic (MdCC) at Memorial Sloan Kettering Cancer Center was a pilot study from 8/2017 to 6/2019 to foster a new model of care for complex pts with CNS cancers to identify and address their needs. Twice a month between 8/2017- 6/2019, a team comprised of a neurologist, nurse, physiatrist (RM), physical therapist, social worker (SW), case manager (CM), dietitian (RD), and chaplain (C) saw patients with neurological deficits and KPS ≤80. Within a 3 hour-visit, providers rotated in to see patients and their caregivers. Since 11/2017 participants completed validated surveys on unmet needs, financial strain, and home equipment prior to their visit, and satisfaction surveys afterward. Descriptive statistics were used to analyze results. Results: Eighty-two pts with advanced cancer were seen: 40 were female, median age 59. Of these 82 pts, 66 had primary CNS cancers, predominantly high-grade glioma/glioblastoma (79%). Over 60% had never seen a CM, RM, RD or C prior to MdCC. Seventy-eight pts (95%) received symptom management recommendations. Prognosis/coping with cancer was discussed with 75 pts (91%) which increased signed health care proxy forms by 16% and DNR orders by 6% at time or within a month post-MdCC. New/updated physical therapy was ordered for 50 pts (61%), orthotics for 10 (12%), and new equipment for 14 (17%). Forty-nine pts completed a satisfaction survey: of these, 96% were highly satisfied, and would recommend MdCC to others. Conclusions: Pts’/caregivers’ unmet needs were effectively identified and addressed within a single MdCC visit. The presence of several providers through MdCC allows for the assessment of pts’/caregivers’ needs and coping skills in real time. The MdCC also facilitates discussing pts’ goals of care, assessing their support system, and implementing a safe patient-centered plan of care.

A new model of care for patients with central nervous system cancers.

e18029 Background: Patients (pts) with primary or metastatic central nervous system (CNS) cancers often have multiple physical, psychosocial, and spiritual needs. Neurological impairments can transform relationship dynamics as loved ones become caregivers. These issues are difficult to address within a single outpatient oncology clinic. Methods: The Neurological Multidisciplinary Care Clinic (MdCC) at Memorial Sloan Kettering Cancer Center was a pilot study from 08/2017 to 01/2019 to foster a new model of care for complex pts with CNS cancers to identify and address their needs. The MdCC team, comprised of a neurologist, nurse, physiatrist, physical therapist, social worker(SW), case manager(CM), dietitian(RD), and chaplain. During a 3-hour visit, MdCC providers saw each pt/caregiver. Since 11/2017 participants completed validated surveys on unmet needs, financial strain, and home equipment prior to their visit and satisfaction surveys afterward. Descriptive statistics were used to analyze results. Results: Seventy-six pts were seen: 37 were female, median age 60. Of these 76 pts, 63 had primary CNS cancers; glioblastoma (51%) and high-grade glioma (HGG) (29%). Fifty-five were receiving cancer-directed therapy at the time of MdCC. Over 70% had never seen a SW, CM, RD, or physiatrist prior to MdCC. Pts’ most commonly reported need was “not being able to do the things I used to do”; for caregivers it was “I need my partner to have an ongoing CM.” Seventy-four pts (97%) received symptom management recommendations. Prognosis/coping with cancer was discussed with 70 (92%) which increased signed health care proxy forms by 11% and DNR orders by 3%. New/updated physical therapy was ordered for 48 pts (61%), orthotics for 8 (10%), and new equipment for 12 (15%). Five pts were referred to a food assistance program. Forty-five pts completed a satisfaction survey; of these, 96% were highly satisfied, and would recommend MdCC to others. Conclusions: Pts’/caregivers’ unmet needs were effectively identified and addressed in this new model, and an emphasis on supportive and coordinated care contributed to high pt/caregiver satisfaction. We therefore propose to offer this clinic for all pts with HGG to improve pts’ well-being, quality of care, and increase pt/caregiver satisfaction.

Body- and symptom-related concerns in women diagnosed with polycystic ovary syndrome: A gap in symptom management.

Polycystic ovary syndrome is the most common endocrine disorder among women aged from 18 to 40 years. Its debilitating menstrual/obesity-related symptoms challenge conceptions of femininity. To date, age-related differences in women's body esteem and physicians' symptom management recommendations have not been investigated. Age moderated the relationships between symptom concerns and both sexual attractiveness and physical condition, but only for midlife, not for emerging adult women. Midlife women received holistic management information from physicians, while emerging adult women received weight management information. This study highlights the need for physician training to manage women's health and age-targeted body acceptance interventions for women diagnosed with polycystic ovary syndrome.

Discontinuing ECMO Support–An Interdisciplinary Approach

Extracorporeal membrane oxygenation (ECMO) is a temporary means of providing mechanical support in patients with severe respiratory or cardiac failure. Patients who are on ECMO also tend to be on multiple other life-sustaining modalities such as renal replacement therapy (RRT), ventilator support, vasopressors and anticoagulation. When a decision is made to discontinue ECMO support, knowing how and when to discontinue the other multiple life-sustaining measures can be challenging. Palliative providers may not be familiar with the ECMO circuit and the surgical intensive care unit (SICU) and surgical teams may not be comfortable with withdrawing of life support. We present a case where an interdisciplinary approach was crucial in ensuring that the patient's comfort and dignity were preserved during the process of withdrawing multiple life-sustaining modalities. CH was a 34-year-old woman with a history of left ventricle dysfunction and thrombus. She presented to the hospital with chest pain and was found to have an ST elevation myocardial infarction. She underwent catheterization and three-vessel stent placement. This was complicated by ventricular fibrillation and cardiogenic shock, requiring intubation, intra-aortic balloon pump, multiple vasopressors, and ultimately ECMO. Her course was complicated by abdominal compartment syndrome, retroperitoneal hematomas, and cerebral infarcts. Our palliative consult service was consulted to facilitate goals of care discussions and after several family meetings, the family decided to withdraw life-sustaining measures. Our team worked closely with the surgical team, SICU team, bedside nursing, respiratory therapist and ECMO perfusionist to formulate a timeline of discontinuing the ECMO support, RRT, vasopressors, anticoagulation and ventilator support, along with recommendations for symptom management for end of life care. We have found that using this interdisciplinary approach not only ensures good symptom management and a smoother transition to comfort care, but also provides clarity and understanding for all members of the treatment team.

Abstract P5-11-04: Technology as a change agent for improving breast cancer quality care

Abstract Background: With rapid advances in research, clinicians often struggle to remain current with evolving care guidelines and to implement current national quality standards (NQS) relevant to breast cancer management. Adherence to NQS is driving reimbursement for cancer services, but clinical workflow processes and IT solutions are lacking to effectively document adherence. The Carevive Care Planning SystemTM (CPS), an evidence-based, patient assessment and care planning software, is designed to close gaps in quality cancer care by marrying clinical and patient-reported data with evidence-based algorithms to help centers improve and document their adherence rates to quality care standards. Methods: This study enrolled 30 non-metastatic breast cancer patients presenting to an NCI-designated comprehensive cancer center for no greater than their second medical oncology visit, and compared provider adherence to quality metrics for these patients with 30 matched historical controls who were seen prior to the study intervention. All were planned for chemotherapy treatment. The two part study intervention included 1) Provider participation in certified continuing medical education (CME) on evidence-based assessment, decision-making, and management strategies for breast cancer and 2) Use of the Carevive CPS with intervention subjects, each of whom who completed a electronic survey assessing current symptoms and concerns prior to their visit, and then received a provider-approved care plan including tailored recommendations for symptom management and referrals. The primary aim was to compare provider adherence to select quality metrics between historical controls (pre-test) and post-intervention subjects. Analysis/Results: Patient enrollment began in July 2015 and an earlier report of control data showed improved provider knowledge post-CME and opportunities to improve adherence. Median age and distribution of race, ethnicity, breast cancer stage, and HER2/ER status was not statistically different between the groups. Provider adherence to quality standards from pre to post-test is shown below: Quality Standard MetricsQuality StandardNPrePostChi-squarepAssessed emotional well being6020%50%6.190.045Addressed emotional well being2133.3%93.3%8.510.004Pain quantified by second visit60100%100%N/AN/APain plan documented1137.533.3%&amp;lt;10.90Opioid assesssed post treatment2791.0%100%1.510.22Opioid induced constipation assessed2718.2%9.3%&amp;lt;10.33 Conclusions:Provider adherence to quality metrics for emotional wellbeing increased from pre- to post- intervention, but did not for pain assessment and management. This was largely due to ceiling effect, but opportunities exist for continued improvement in pain management, at least in documentation. The Carevive CPS plus CME has the potential to allow institutions an patient-centered and user-friendly approach to both improve and document adherence to quality metrics. Citation Format: Hathaway A, Stricker C, Halilova KI, Hammelef KJ, Wujcik D, Dudley WN, Rocque G. Technology as a change agent for improving breast cancer quality care [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-11-04.

Lack of Patient-Clinician Concordance in Cancer Patients: Its Relation With Patient Variables

ContextPatients with cancer are bothered by its diagnosis, treatment, and associated uncertainty. Lack of concordance (LOC) of patients' reporting of their symptoms and quality of life (QOL) with that of their clinicians has been observed in cancer care. However, information regarding the reporting of patients' bother due to aspects of cancer experience and their clinicians' assessment is lacking. ObjectivesThe objective was to describe cancer patients' bother due to aspects of their disease experience and explore the concordance (LOC) or a lack thereof between patients' and clinicians' reporting of patients' bother and factors associated with it. MethodsData from a prospective study of cancer patients' symptoms were analyzed. LOC was defined as any discrepancy between patient-clinician pairs in reporting patients' bother due to disease, cancer treatment, comorbidity, and side effects of symptom management. The relation of LOC to patients' QOL and distress was also explored. ResultsOf the 2597 patients analyzed, a perfect concordance was observed in 37%–42%. Clinicians underestimated the severity of bother in 62%–76% of discordant cases. LOC was significantly associated with patient-reported distress and poor QOL. Referral for symptom management was associated with the clinician's rating of patients' bother, and LOC was associated with likelihood of poor compliance with recommendations for symptom management. ConclusionMajority of clinicians tended to underestimate cancer patients' bother, and this was associated with poor QOL of cancer patients and their distress. Future studies should examine the LOC and its correlates to confirm the results of this study.