Trajectories of Health Care Contact Days for Patients With Stage IV Non-Small Cell Lung Cancer.

Importance: Patients with stage IV non-small cell lung cancer (NSCLC) experience substantial morbidity and mortality. Contact days (ie, the number of days with health care contact outside the home) measure how much of a person's life is consumed by health care, yet little is known about patterns of contact days for patients with NSCLC. Objective: To describe the trajectories of contact days in patients with stage IV NSCLC and how trajectories vary by receipt of cancer-directed treatment in routine practice. Design, Setting, and Participants: A retrospective, population-based decedent cohort study was conducted in Ontario, Canada. Participants included adults aged 20 years or older who were diagnosed with stage IV NSCLC (January 1, 2014, to December 31, 2017) and died (January 1, 2014, to December 31, 2019); there was a maximum 2-year follow-up. Data analysis was conducted from February 22 to August 16, 2023. Exposure: Systemic cancer-directed therapy (yes or no) and type of therapy (chemotherapy vs immunotherapy vs targeted therapy). Main Outcomes and Measures: Contact days (days with health care contact, outpatient or institution-based, outside the home) were identified through administrative data. The weekly percentage of contact days and fitted models with cubic splines were quantified to describe trajectories from diagnosis until death. Results: A total of 5785 decedents with stage IV NSCLC were included (median age, 70 [IQR 62-77] years; 3108 [53.7%] were male, and 1985 [34.3%] received systemic therapy). The median overall survival was 108 (IQR, 49-426) days, median contact days were 36 (IQR, 21-62), and the median percentage that were contact days was 33.3%. A median of 5 (IQR, 2-10) days were spent with specialty palliative care. Patients who did not receive systemic therapy had a median overall survival of 66 (IQR, 34-130) days and median contact days of 28 (IQR, 17-44), of which a median of 5 (IQR, 2-9) days were spent with specialty palliative care. Overall and for subgroups, normalized trajectories followed a U-shaped distribution: contact days were most frequent immediately after diagnosis and before death. Patients who received targeted therapy had the lowest contact day rate during the trough (10.6%; vs immunotherapy, 15.4%; vs chemotherapy, 17.7%). Conclusions and Relevance: In this cohort study, decedents with stage IV NSCLC had a median survival in the order of 3.5 months and spent 1 in every 3 days alive interacting with the health care system outside the home. These results highlight the need to better support patients and care partners, benchmark appropriateness, and improve care delivery.

Care Coordination Between Family Physicians and Palliative Care Physicians for Patients With Cancer: Results of a Quality Improvement Initiative.

PURPOSE: At our institution's cancer palliative care (PC) clinic, new referrals from oncologists were scheduled for consultation and ongoing follow-up by PC physicians without input from the patients' family physicians (FPs). FPs reported that they felt out of the loop. We implemented a quality improvement (QI) initiative aimed at systematically facilitating care coordination between FPs and PC physicians. METHODS: A coordination toolkit was sent from the PC physician to the FP whenever the PC physician received a consultation request from an oncologist. The toolkit included an introduction to the PC physician team; an opportunity for the FP to choose how best to collaborate with PC physicians to meet the patient's PC needs; and contact information for access to 24/7 PC physician support. Responses from FPs regarding their preferred level of engagement with PC determined further care planning in the clinic. We measured feasibility, response rate, and qualitative surveys of FPs about the usefulness of the intervention. RESULTS: Two hundred fourteen new consultations were eligible for a standardized letter over the 6-month implementation period. Feasibility for sending the toolkit was 90.0% and response rate for collaborative care preference from FPs was 86.0%, with median response time of 3-4 days. 78.9% of FPs indicated they would prefer ongoing consultative care by the PC physician, while 18.6% indicated that PC physician consultation was not needed, or that the FP would provide primary PC after a one-time PC physician consultation. CONCLUSION: We successfully implemented a QI initiative to improve care coordination between FPs and PC physicians for patients with cancer. The coordination toolkit can protect the patient-FP primary PC relationship and optimize specialist PC resource utilization for complex patients.

Impact on costs and outcomes of multi-gene panel testing for advanced solid malignancies: a cost-consequence analysis using linked administrative data.

Background: To date, economic analyses of tissue-based next generation sequencing genomic profiling (NGS) for advanced solid tumors have typically required models with assumptions, with little real-world evidence on overall survival (OS), clinical trial enrollment or end-of-life quality of care. Methods: Cost consequence analysis of NGS testing (555 or 161-gene panels) for advanced solid tumors through the OCTANE clinical trial (NCT02906943). This is a longitudinal, propensity score-matched retrospective cohort study in Ontario, Canada using linked administrative data. Patients enrolled in OCTANE at Princess Margaret Cancer Centre from August 2016 until March 2019 were matched with contemporary patients without large gene panel testing from across Ontario not enrolled in OCTANE. Patients were matched according to 19 patient, disease and treatment variables. Full 2-year follow-up data was available. Sensitivity analyses considered alternative matched cohorts. Main Outcomes were mean per capita costs (2019 Canadian dollars) from a public payer's perspective, OS, clinical trial enrollment and end-of-life quality metrics. Findings: There were 782 OCTANE patients with 782 matched controls. Variables were balanced after matching (standardized difference <0.10). There were higher mean health-care costs with OCTANE ($79,702 vs. $59,550), mainly due to outpatient and specialist visits. Publicly funded drug costs were less with OCTANE ($20,015 vs. $24,465). OCTANE enrollment was not associated with improved OS (restricted mean survival time [standard error]: 1.50 (±0.03) vs. 1.44 (±0.03) years, log-rank p = 0.153), varying by tumor type. In five tumor types with ≥35 OCTANE patients, OS was similar in three (breast, colon, uterus, all p > 0.40), and greater in two (ovary, biliary, both p < 0.05). OCTANE was associated with greater clinical trial enrollment (25.4% vs. 9.5%, p < 0.001) and better end-of-life quality due to less death in hospital (10.2% vs. 16.4%, p = 0.003). Results were robust in sensitivity analysis. Interpretation: We found an increase in healthcare costs associated with multi-gene panel testing for advanced cancer treatment. The impact on OS was not significant, but varied across tumor types. OCTANE was associated with greater trial enrollment, lower publicly funded drug costs and fewer in-hospital deaths suggesting important considerations in determining the value of NGS panel testing for advanced cancers. Funding: T.P H holds a research grant provided by the Ontario Institute for Cancer Research through funding provided by the Government of Ontario (#IA-035 and P.HSR.158) and through funding of the Canadian Network for Learning Healthcare Systems and Cost-Effective 'Omics Innovation (CLEO) via Genome Canada (G05CHS).

Improving Access and Timeliness of Early Palliative Care Specialist Assessment for Patients With Advanced Lung Cancer in a Rapid Assessment Clinic.

Background: Integrating palliative care in the management of patients with lung cancer improves quality of life, patient satisfaction, and overall survival. However, few patients receive timely palliative care consultation. The Lung Diagnostic Assessment Program (LDAP) in Southeastern Ontario is a multidisciplinary rapid assessment clinic that expedites the diagnosis and management of patients with suspected lung cancer. Objectives: We sought to increase the percentage of LDAP patients with stage IV lung cancer receiving palliative care consultation within three months of diagnosis. Design: We integrated a palliative care specialist in LDAP to facilitate in-person, same-visit consultation for patients with a new lung cancer diagnosis. Setting/Subjects: Five hundred fifty patients in a Canadian academic center (154 initial baseline, 104 COVID baseline, 292 post-palliative care integration). Measurements: Baseline data were established using retrospective chart review (February-June 2020 and December 2020-March 2021 due to COVID-19 pandemic). Data were collected prospectively to assess improvement (March-August 2021). Statistical Process Control charts assessed for special cause variation; chi-square tests assessed for differences between groups. Results: The percentage of patients with stage IV lung cancer seen by palliative care within three months increased from 21.8% (12/55) during early-COVID baseline to 49.2% (32/65) after palliative care integration (p < 0.006). Palliative care integration in LDAP reduced mean time from referral to consultation from 24.8 to 12.3 days, including same-day consultation for 15/32 (46.8%) patients with stage IV disease. Conclusions: Integrating palliative care specialists into LDAP improved the timeliness of palliative care assessment for patients with stage IV lung cancer.

Pharmacovigilance in hospice/palliative care: Net effect of amitriptyline or nortriptyline on neuropathic pain: UTS/IMPACCT Rapid programme international consecutive cohort.

BACKGROUND: Real-world effectiveness of interventions in palliative care need to be systematically quantified to inform patient/clinical decisions. Neuropathic pain is prevalent and difficult to palliate. Tricyclic antidepressants have an established role for some neuropathic pain aetiologies, but this is less clear in palliative care. AIM: To describe the real-world use and outcomes from amitriptyline or nortriptyline for neuropathic pain in palliative care. DESIGN: An international, prospective, consecutive cohort post-marketing/phase IV/pharmacovigilance/quality improvement study of palliative care patients with neuropathic pain where the treating clinician had already made the decision to use a tricyclic antidepressant. Data were entered at set times: baseline, and days 7 and 14. Likert scales graded benefits and harms. SETTING/PARTICIPANTS: Twenty-one sites (inpatient, outpatient, community) participated in six countries between June 2016 and March 2019. Patients had clinician-diagnosed neuropathic pain. RESULTS: One hundred and fifty patients were prescribed amitriptyline (110) or nortriptyline (40) of whom: 85% had cancer; mean age 73.2 years (SD 12.3); mean 0-4 scores for neuropathic pain at baseline were 1.8 (SD 1.0). By day 14, doses of amitriptyline were 57 mg (SD 21) and nortriptyline (48 mg (SD 21). Fifty-two (34.7%) patients had pain improvement by day 14 (amitriptyline (45/110 (43.3%); nortriptyline (7/40 (18.9%)). Thirty-nine (27.7%) had new harms; (amitriptyline 29/104 (27.9%); nortriptyline 10/37 (27.0%); dizziness (n = 23), dry mouth (n = 20), constipation (n = 14), urinary retention (n = 10)). Benefits without harms occurred (amitriptyline (26/104 (25.0%); nortriptyline (4/37 (10.8%)). CONCLUSIONS: Benefits favoured amitriptyline while harms were similar for both medications.

Developing and Implementing a Web-Based Psychotherapy Program to Address Mental Health Challenges Among Patients Receiving Oncologic and Palliative Care: Protocol for an Open-Label Randomized Controlled Trial.

BACKGROUND: The demand for mental health care, particularly for depression and anxiety, is 3-fold greater among patients receiving oncologic and palliative care than for the general population. This population faces unique barriers, making them more susceptible to mental health challenges. Various forms of psychotherapy have been deemed effective in addressing mental health challenges in this population, including supportive psychotherapy, cognitive behavioral therapy, problem-based therapy, and mindfulness; however, their access to traditional face-to-face psychotherapy resources is limited owing to their immunocompromised status, making frequent hospital visits dangerous. Additionally, patients can face hospital fatigue from numerous appointments and investigations or may live in remote areas, which makes commutes both physically and financially challenging. Web-based psychotherapy is a promising solution to address these accessibility barriers. Moreover, web-based psychotherapy has been proven effective in addressing depression and anxiety in other populations and may be implementable among patients receiving oncologic and palliative care. OBJECTIVE: The study will investigate the feasibility and effectiveness of web-based psychotherapy among patients receiving oncologic and palliative care, who have comorbid depression or anxiety. We hypothesized that this program will be a viable and efficacious treatment modality compared to current treatment modalities in addressing depression and anxiety symptoms in this population. METHODS: Participants (n=60) with depression or anxiety will be recruited from oncology and palliative care settings in Kingston (Ontario, Canada). Participants will be randomly allocated to receive either 8 weeks of web-based psychotherapy plus treatment as usual (treatment arm) or treatment as usual exclusively (control arm). The web-based psychotherapy program will incorporate cognitive behavioral therapy, mindfulness, and problem-solving skills, and homework assignments with personalized feedback from a therapist. All web-based programs will be delivered through a secure platform specifically designed for web-based psychotherapy delivery. To evaluate treatment efficacy, all participants will complete standardized symptomology questionnaires at baseline, midpoint (week 4), and posttreatment. RESULTS: The study received ethics approval in February 2021 and began recruiting participants in April 2021. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, 11 participants (treatment, n=5; control, n=4; dropout, n=2) have been recruited. Data collection and analysis are expected to conclude by December 2021 and January 2022, respectively. Linear regression (for continuous outcomes) will be conducted with interpretive qualitative methods. CONCLUSIONS: Our findings can be incorporated into clinical policy and help develop more accessible mental health treatment options for patients receiving oncologic and palliative care. Asynchronous and web-based psychotherapy delivery is a more accessible, scalable, and financially feasible treatment that could have major implications on the health care system. TRIAL REGISTRATION: ClinicalTrials.gov NCT04664270; https://clinicaltrials.gov/ct2/show/NCT04664270. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30735.

Coping during COVID-19: a mixed methods study of older cancer survivors.

PURPOSE: Older cancer survivors are among the most vulnerable to the negative effects of COVID-19 and may need specific survivorship supports that are unavailable/restricted during the pandemic. The objective of this study was to explore how older adults (≥ 60 years) who were recently (≤ 12 months) discharged from the care of their cancer team were coping during the pandemic. METHODS: We used a convergent mixed method design (QUAL+quan). Quantitative data were collected using the Brief-COPE questionnaire. Qualitative data were collected using telephone interviews to explore experiences and strategies for coping with cancer-related concerns. RESULTS: The mean sample age (n = 30) was 72.1 years (SD 5.8, range 63-83) of whom 57% identified as female. Participants' Brief-COPE responses indicated that they commonly used acceptance (n = 29, 96.7%), self-distraction (n = 28, 93.3%), and taking action (n = 28, 93.3%) coping strategies. Through our descriptive thematic analysis, we identified three themes: (1) drawing on lived experiences, (2) redeploying coping strategies, and (3) complications of cancer survivorship in a pandemic. Participants' coping strategies were rooted in experiences with cancer, other illnesses, life, and work. Using these strategies during the pandemic was not new-they were redeployed and repurposed-although using them during the pandemic was sometimes complicated. These data were converged to maximize interpretation of the findings. CONCLUSIONS: Study findings may inform the development or enhancement of cancer and non-cancer resources to support coping, particularly using remote delivery methods within and beyond the pandemic. Clinicians can engage a strengths-based approach to support older cancer survivors as they draw from their experiences, which contain a repository of potential coping skills.

Older survivors of cancer in the COVID-19 pandemic: Reflections and recommendations for future care.

PURPOSE: Although the year after cancer treatment is challenging for all cancer survivors, older adults (≥60 years) face additional challenges due to age-related decline and high rates of comorbidity. There is a paucity of research on how health service interruptions from the COVID-19 pandemic have impacted the experience of older cancer survivors. In this study we explore older cancer survivors' reflections on the pandemic and their suggestions for future care delivery when traditionally offered resources are not available. METHODS: We conducted 1:1 telephone interviews with adults 60 years and older previously diagnosed with breast and colorectal cancer and recently (≤12 months) discharged from their cancer care team. We analyzed the data using descriptive thematic analysis. RESULTS: The mean sample (n = 30) age was 72.1 years (SD 5.8, Range 63-83) of whom 57% identified as female. Participants described personal and societal implications of the pandemic. that affected their ability to navigate social support, and public and clinical landscapes. These reflections informed their suggestions for future health care delivery, such as how they could have been better prepared to self-manage their post-cancer treatment journey. Participants recommendations were grouped into four sub-themes: 1) enhanced baseline information; 2) facilitate caregiver support and engagement; 3) greater technology integration; and 4) sustained use and public appreciation of personal protective equipment. CONCLUSION: Older cancer survivors appreciate the needed shift to virtual appointments and services during the COVID-19 pandemic. Specific strategies to bolster older adults existing strengths and improve their readiness to engage in these measures are critical.

Parental attitudes regarding analgesic use for children: differences in ethnicity and language.

PURPOSE: The aim of this study was to identify the impact of ethnicity and language on parental attitudes regarding analgesic use to treat children's pain. METHODS: A total of 206 parents of children undergoing outpatient surgery were recruited to complete the Medication Attitudes Questionnaire, a measure of parental beliefs about using analgesic medications to treat children's pain. Parents were grouped into one of 3 categories according to ethnicity and primary language spoken: English-speaking white, English-speaking Hispanic, and Spanish-speaking Hispanic. Group differences in pain medication attitudes were examined. RESULTS: After controlling for socioeconomic status, English-speaking Hispanic parents endorsed higher levels of misconceptions about pain medication use, including a tendency to avoid analgesic use for children, compared with English-speaking white and Spanish-speaking Hispanic parents. CONCLUSIONS: This study highlights parental characteristics, including ethnicity and language, which may place children at higher risk for undertreatment of acute pain based on misconceptions about analgesic use for children. Specifically, English-speaking Hispanic parents may be most likely to undertreat children's pain at home. Future studies are needed to identify the most appropriate means of providing education to counter parental misconceptions and support optimal pain management of children's pain in the home setting.

Desire for perioperative information and parental ethnicity.

OBJECTIVES: To examine the role of ethnicity, language, and socioeconomic variables in parental desire for information regarding children's surgery. AIM: To compare anesthetic and surgical information desired between English- and Spanish-speaking White and Hispanic mothers of children undergoing outpatient surgery. BACKGROUND: Parents report wanting to receive detailed information regarding children's preoperative care; however, variables such as parent ethnicity and language spoken have not been accounted for in understanding desire for information. METHODS/MATERIALS: One hundred and eighty-one mothers of children undergoing outpatient surgery, elective surgery, and general anesthesia were recruited and categorized into one of three groups: English-speaking White (ESW, n=79), English-speaking Hispanic (ESH, n = 63), and Spanish-speaking Hispanic (SSH, n = 39). In addition to providing demographic questionnaire, mothers completed the Parental Desire for Information (PDI) questionnaire, a 14-item measure of surgery and anesthesia-related statements. RESULTS: Overall, mothers desired receiving information about the majority of the items on the PDI. As compared to ESW mothers, SSH mothers and ESH mothers were overrepresented in the 'have a right to know' response option, with significant differences existing in items concerning alternative methods of anesthesia, details of needles used, and location of PACU and OR. CONCLUSIONS: Anesthesiologists should tailor the provision of preoperative information based on ethnicity and language of mothers involved. Ethnic and language differences shown in this study may exist in other populations as well.