- Email: [email protected]
Symptom Burden in Gynecologic Oncology Outpatients (411-B)
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Schedule with Abstracts
of men with prostate cancer receiving concurrent palliative and oncologic care. Background. Prostate cancer is the most common solid organ cancer among men. Little is known about the efficacy of interventions to improve palliative outcomes among outpatients undergoing treatment for localized or metastatic disease. Research objectives. Assess the impact on symptoms of outpatient palliative care comanagement of patients undergoing prostate cancer treatment. Methods. Since 2007, 96 men with prostate cancer at a comprehensive cancer center were referred to an outpatient palliative care comanagement clinic. The clinic provides palliative care concurrently with patients’ surgical and chemotherapeutic treatments. Patients completed the Edmonton Symptom Assessment Scale and the Steinhauser spirituality screen at each palliative care visit. Data are summarized with descriptive statistics and paired t-tests. Results. Patients’ mean age was 67 years. Most (57%) had metastatic disease. Sixteen (17%) died over the 3-year study period. The two most common reasons for referral to the service were depression and pain. Patients with metastatic disease were more likely to report mortality concerns (p ¼ 0.02). Nevertheless, 43% of men with localized disease still reported worry about dying from their cancer. The severity of pain, fatigue, depression, anxiety, and spiritual distress was similar among men with metastatic versus localized disease, however, men with metastatic disease reported lower quality of life (p ¼ 0.02). Compared to baseline (pre-visit) surveys, 2-month follow-up surveys demonstrated improvements in fatigue (p ¼ 0.02), anxiety (p < 0.01), depression (p < 0.01), quality of life (p < 0.01), and spiritual well-being (p < 0.01). There was no significant change in pain. Conclusion. Regardless of their disease stage, men with prostate cancer suffer numerous physical, emotional, and existential symptoms. An outpatient palliative care clinic offering symptom comanagement concurrent with usual oncologic and surgical care was associated with improvement in multiple symptoms across multiple domains. Implications for research, policy, or practice. These findings should be explored in a randomized, controlled trial, especially to understand the lack of impact on pain. Domain Physical Aspects of Care
Vol. 41 No. 1 January 2011
Symptom Burden in Gynecologic Oncology Outpatients (411-B) Carolyn Casey, MD MPH, University of California San Francisco, San Francisco, CA. Michael Rabow, MD, University of California San Francisco, San Francisco, CA. Alexander Sherman, BA, University of California San Francisco, San Francisco, CA. Bethan Powell. John Chan. Lee-may Chen, MD, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA. (All speakers for this session have disclosed no relevant financial relationships with the following exception: Chan is on the speakers bureau and received an honorarium from Centocor Ortho Biotech, Inc.) Objectives 1. Identify patterns of symptom burden in gynecologic oncology outpatients. 2. Identify gynecologic oncology outpatients likely to benefit from outpatient palliative care services concurrent with their oncologic care. Background. Outpatient services are an important frontier in palliative medicine. Symptom research in outpatient gynecologic oncology is mostly limited to ovarian cancer patients on chemotherapy. Research objectives. We sought to identify symptom prevalence among gynecologic oncology outpatients, assess demographic and clinical features associated with high symptom burden, and identify patients most likely to benefit from outpatient palliative care concurrent with their oncologic treatment. Methods. Descriptive study with a convenience sample of gynecologic oncology patients at a comprehensive cancer center between August 2007 and March 2009. Patients completed the Edmonton Symptom Assessment Scale survey on pain, fatigue, anxiety, and depression. Severity score > 3-4 out of 10 considered clinically significant. Disease and treatment information abstracted from medical records. Descriptive and t-test statistics were used. Results. We reviewed 188 surveys: 39% ovarian cancer, 36% uterine, 20% cervical, and 4% vulvar/vaginal. Of the participants, 53% had stage I/II disease and 47% stage III/IV. Thirty-four percent had completed treatment and had no evidence of disease. Prevalence of clinically significant pain (36%), fatigue (44%), anxiety (51%), and depression (34%). Younger patients (<55 years) had more
Vol. 41 No. 1 January 2011
Schedule with Abstracts
pain (41% vs 27%, p ¼ 0.032), fatigue (47% vs 34%, p ¼ 0.042), and depression (41% vs 27%, p ¼ 0.046). Patients with no evidence of disease had less fatigue (27% vs 52%, p ¼ 0.002), anxiety (36% vs 60%, p ¼ 0.003), and depression (24% vs 39%, p ¼ 0.016). Patients with history of anxiety, depression, or chronic pain had more pain (56% vs 30%, p ¼ 0.003), fatigue (60% vs 39%, p ¼ 0.016), anxiety (68% vs 47%, p ¼ 0.021), and depression (48% vs 30%, p ¼ 0.046). No significant differences in symptom burden by cancer type or stage. Conclusion. Gynecologic oncology outpatients have a high symptom burden, especially fatigue and anxiety, regardless of cancer type and stage. Symptom burden is higher among younger patients and patients with history of depression, anxiety, or chronic pain. Implications for research, policy, or practice. Consideration should be given to targeting these patients for outpatient palliative care services. Domain Physical Aspects of Care
Lessons from Rural Volunteer Hospices: Thinking Outside the Medicare Box (411-C) Solomon Liao, MD FAAHPM, University of California Irvine, Orange, CA. Jared Garrison-Jakel, MD MPH, Santa Rosa Family Medicine Residency, Santa Rosa, CA. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Discuss creative approaches to providing hospice and palliative care to under-served populations. 2. Describe the volunteer hospice model. 3. Discuss the current state of rural hospices in California. Background. Once the only form of hospice in the United States, volunteer hospices have, since the Medicare hospice benefits, become a small minority. Little is known about their current model of care. Research objectives. Describe the current structure and practice of volunteer hospices in California. Methods. Qualitative, semi-structured, keyinformant interviews of four volunteer hospice programs in a rural county in California Results. Volunteer hospices have developed innovative ways to provide comprehensive end-of-
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life care without Medicare hospice benefits, involving community partnerships, efficient resource utilization, and funding support from their community. Since volunteer hospices in the study were prohibited from providing skilled nursing, they focused on care-coordination; education and training of caregivers, volunteers, and the community; and provision of spiritual and bereavement care. Their utilization of existing nursing and pharmacy resources and community support allowed them to successfully provide care to rural, under-served, and low-resource areas. However, volunteer hospices felt alienated from the larger hospice community. Conclusion. The volunteer hospice model, without a reliance on Medicare hospice benefits, offers creative approaches to providing hospice and palliative care to under-served populations, such as the under-insured and those in nursing homes and rural areas. More engagement of volunteer hospices is needed in research and in national organizations. Implications for research, policy, or practice. Medicare-certified hospices can use the same approaches currently used by volunteer hospices to provide care to under-served populations not covered by or inadequately covered by their insurances. Domain Structure and Processes of Care
Managing Opioid Misuse in Palliative Care Settings: How Prepared Do Hospice and Palliative Medicine Fellows Feel? (412-A) Julie Childers, MD, University of Pittsburgh Medical Center, Pittsburgh, PA. Robert Arnold, MD, University of Pittsburgh, Pittsburgh, PA. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Describe the percentage of hospice and palliative medicine fellows who had encountered a patient at risk for opioid misuse within a 2week period. 2. Describe the domains in which hospice and palliative medicine expressed particular challenges in treating patients at risk for opioid misuse. 3. Rate education in substance use disorders and opioid misuse as an important objective for future palliative medicine specialists. Background. As palliative care becomes integrated earlier in patients’ diseases, palliative
Schedule with Abstracts
of men with prostate cancer receiving concurrent palliative and oncologic care. Background. Prostate cancer is the most common solid organ cancer among men. Little is known about the efficacy of interventions to improve palliative outcomes among outpatients undergoing treatment for localized or metastatic disease. Research objectives. Assess the impact on symptoms of outpatient palliative care comanagement of patients undergoing prostate cancer treatment. Methods. Since 2007, 96 men with prostate cancer at a comprehensive cancer center were referred to an outpatient palliative care comanagement clinic. The clinic provides palliative care concurrently with patients’ surgical and chemotherapeutic treatments. Patients completed the Edmonton Symptom Assessment Scale and the Steinhauser spirituality screen at each palliative care visit. Data are summarized with descriptive statistics and paired t-tests. Results. Patients’ mean age was 67 years. Most (57%) had metastatic disease. Sixteen (17%) died over the 3-year study period. The two most common reasons for referral to the service were depression and pain. Patients with metastatic disease were more likely to report mortality concerns (p ¼ 0.02). Nevertheless, 43% of men with localized disease still reported worry about dying from their cancer. The severity of pain, fatigue, depression, anxiety, and spiritual distress was similar among men with metastatic versus localized disease, however, men with metastatic disease reported lower quality of life (p ¼ 0.02). Compared to baseline (pre-visit) surveys, 2-month follow-up surveys demonstrated improvements in fatigue (p ¼ 0.02), anxiety (p < 0.01), depression (p < 0.01), quality of life (p < 0.01), and spiritual well-being (p < 0.01). There was no significant change in pain. Conclusion. Regardless of their disease stage, men with prostate cancer suffer numerous physical, emotional, and existential symptoms. An outpatient palliative care clinic offering symptom comanagement concurrent with usual oncologic and surgical care was associated with improvement in multiple symptoms across multiple domains. Implications for research, policy, or practice. These findings should be explored in a randomized, controlled trial, especially to understand the lack of impact on pain. Domain Physical Aspects of Care
Vol. 41 No. 1 January 2011
Symptom Burden in Gynecologic Oncology Outpatients (411-B) Carolyn Casey, MD MPH, University of California San Francisco, San Francisco, CA. Michael Rabow, MD, University of California San Francisco, San Francisco, CA. Alexander Sherman, BA, University of California San Francisco, San Francisco, CA. Bethan Powell. John Chan. Lee-may Chen, MD, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA. (All speakers for this session have disclosed no relevant financial relationships with the following exception: Chan is on the speakers bureau and received an honorarium from Centocor Ortho Biotech, Inc.) Objectives 1. Identify patterns of symptom burden in gynecologic oncology outpatients. 2. Identify gynecologic oncology outpatients likely to benefit from outpatient palliative care services concurrent with their oncologic care. Background. Outpatient services are an important frontier in palliative medicine. Symptom research in outpatient gynecologic oncology is mostly limited to ovarian cancer patients on chemotherapy. Research objectives. We sought to identify symptom prevalence among gynecologic oncology outpatients, assess demographic and clinical features associated with high symptom burden, and identify patients most likely to benefit from outpatient palliative care concurrent with their oncologic treatment. Methods. Descriptive study with a convenience sample of gynecologic oncology patients at a comprehensive cancer center between August 2007 and March 2009. Patients completed the Edmonton Symptom Assessment Scale survey on pain, fatigue, anxiety, and depression. Severity score > 3-4 out of 10 considered clinically significant. Disease and treatment information abstracted from medical records. Descriptive and t-test statistics were used. Results. We reviewed 188 surveys: 39% ovarian cancer, 36% uterine, 20% cervical, and 4% vulvar/vaginal. Of the participants, 53% had stage I/II disease and 47% stage III/IV. Thirty-four percent had completed treatment and had no evidence of disease. Prevalence of clinically significant pain (36%), fatigue (44%), anxiety (51%), and depression (34%). Younger patients (<55 years) had more
Vol. 41 No. 1 January 2011
Schedule with Abstracts
pain (41% vs 27%, p ¼ 0.032), fatigue (47% vs 34%, p ¼ 0.042), and depression (41% vs 27%, p ¼ 0.046). Patients with no evidence of disease had less fatigue (27% vs 52%, p ¼ 0.002), anxiety (36% vs 60%, p ¼ 0.003), and depression (24% vs 39%, p ¼ 0.016). Patients with history of anxiety, depression, or chronic pain had more pain (56% vs 30%, p ¼ 0.003), fatigue (60% vs 39%, p ¼ 0.016), anxiety (68% vs 47%, p ¼ 0.021), and depression (48% vs 30%, p ¼ 0.046). No significant differences in symptom burden by cancer type or stage. Conclusion. Gynecologic oncology outpatients have a high symptom burden, especially fatigue and anxiety, regardless of cancer type and stage. Symptom burden is higher among younger patients and patients with history of depression, anxiety, or chronic pain. Implications for research, policy, or practice. Consideration should be given to targeting these patients for outpatient palliative care services. Domain Physical Aspects of Care
Lessons from Rural Volunteer Hospices: Thinking Outside the Medicare Box (411-C) Solomon Liao, MD FAAHPM, University of California Irvine, Orange, CA. Jared Garrison-Jakel, MD MPH, Santa Rosa Family Medicine Residency, Santa Rosa, CA. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Discuss creative approaches to providing hospice and palliative care to under-served populations. 2. Describe the volunteer hospice model. 3. Discuss the current state of rural hospices in California. Background. Once the only form of hospice in the United States, volunteer hospices have, since the Medicare hospice benefits, become a small minority. Little is known about their current model of care. Research objectives. Describe the current structure and practice of volunteer hospices in California. Methods. Qualitative, semi-structured, keyinformant interviews of four volunteer hospice programs in a rural county in California Results. Volunteer hospices have developed innovative ways to provide comprehensive end-of-
227
life care without Medicare hospice benefits, involving community partnerships, efficient resource utilization, and funding support from their community. Since volunteer hospices in the study were prohibited from providing skilled nursing, they focused on care-coordination; education and training of caregivers, volunteers, and the community; and provision of spiritual and bereavement care. Their utilization of existing nursing and pharmacy resources and community support allowed them to successfully provide care to rural, under-served, and low-resource areas. However, volunteer hospices felt alienated from the larger hospice community. Conclusion. The volunteer hospice model, without a reliance on Medicare hospice benefits, offers creative approaches to providing hospice and palliative care to under-served populations, such as the under-insured and those in nursing homes and rural areas. More engagement of volunteer hospices is needed in research and in national organizations. Implications for research, policy, or practice. Medicare-certified hospices can use the same approaches currently used by volunteer hospices to provide care to under-served populations not covered by or inadequately covered by their insurances. Domain Structure and Processes of Care
Managing Opioid Misuse in Palliative Care Settings: How Prepared Do Hospice and Palliative Medicine Fellows Feel? (412-A) Julie Childers, MD, University of Pittsburgh Medical Center, Pittsburgh, PA. Robert Arnold, MD, University of Pittsburgh, Pittsburgh, PA. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Describe the percentage of hospice and palliative medicine fellows who had encountered a patient at risk for opioid misuse within a 2week period. 2. Describe the domains in which hospice and palliative medicine expressed particular challenges in treating patients at risk for opioid misuse. 3. Rate education in substance use disorders and opioid misuse as an important objective for future palliative medicine specialists. Background. As palliative care becomes integrated earlier in patients’ diseases, palliative