Burden of Pancreatic Cancer: From Epidemiology to Practice.

Pancreatic cancer is the seventh leading cause of cancer-related deaths worldwide with 432,242 related deaths in 2018. Unlike other cancers, the incidence of pancreatic cancer continues to increase, with little improvement in survival rates. We review the epidemiologic features of pancreatic cancer, covering surveillance and early detection in high-risk persons. We summarize data on worldwide incidence and mortality and analyze the 1975-2016 data from 9 registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results study, on the overall burden of pancreatic cancer as well as age-, sex-, and race-specific incidence, survival rates and trends. It is important to increase our knowledge of the worldwide and regional epidemiologic features of and risk factors for pancreatic cancer, to identify new approaches for prevention, surveillance, and treatment.

Medical Podcasting in Low- and Middle-Income Countries: A Needs Assessment and Vision for the Future.

Phenomenon: Physician shortages in low- and middle-income countries (LMIC) have led to increased interest in using e-learning tools for training. Organic digital education (ODE)-digital scholarship largely created outside of formal medical curricula-has increased in popularity over the past decade. Medical podcasting has become one of the most prominent asynchronous ODE sources for learners in high-income (HI) countries; there have been no previous attempts to characterize their use in LMIC. Approach: Listener data from a 2-year period from three major internal medicine podcasts-Bedside Rounds, Core IM, and The Curbsiders-were aggregated, 188 episodes in total. These data were subdivided into country by top-level domain, normalized by population, and grouped together by World Bank income levels and English-speaking status. This methodology was also repeated to compare individual episodes on topics more versus less relevant to learners in LMIC. Findings: Over a 2-year period, the three podcasts had a total of 2.3 million unique downloads and were listened to in 192 of 207 countries worldwide. Overall, 91.5% of downloads were in HI countries, with 8.2% in LMIC. A total of 86.1% of listens were in countries with English as an official or unofficial listed language, whereas 13.8% were in countries without. Normalized for population, listeners in HI countries represented 970.5 listens per million population compared with 12.4 per million in LMIC. An analysis of individual episodes by topic showed that material more relevant to learners in LMIC had significantly more listeners from these countries. Insights: Compared with other forms of ODE, medical podcasting has much lower uptake in LMIC. However, there are considerable opportunities for growth. Medical podcasters in HI countries should be aware of a potential global audience and should take concrete steps to ensure a diversity of content and to periodically audit their data. Medical educators in LMIC should consider podcasting as a potentially powerful form of teaching. International medical educational organizations as well as podcasting organizations should provide resources for educators in these countries.

Opportunity Strikes for Reducing Cancer Drug Waste: Bortezomib as an Example of Vial Mis-Sizing in Oncology.

Mis-sized packaging leads to millions of dollars in drug waste annually. Now is the time to act.

What do patients think about palliative care? A national survey of hematopoietic stem cell transplant recipients.

Palliative care (PC) benefits patients undergoing hematopoietic stem cell transplantation (HSCT), but it remains underutilized. Although transplant physicians report concerns regarding how patients perceive PC, HSCT recipients' perceptions about PC remain unaddressed. We conducted a multisite, cross-sectional survey of autologous and allogeneic HSCT recipients 3 to 12 months after transplant to assess their familiarity, knowledge, and perception of PC, as well as their unmet PC needs. We computed a composite score of patients' perceptions of PC and used a generalized linear regression model to examine factors associated with these perceptions. We enrolled 69.6% (250/359) of potential participants (median age = 58.1; 63.1% autologous HSCT). Overall, 44.3.8% (109/249) reported limited knowledge about PC and 52% (127/245) endorsed familiarity with PC. Most patients felt hopeful (54%) and reassured (50%) when they heard the term PC; 83% saw referral as a sign their doctor cared about what was happening to them. In multivariate analyses, patients who were more knowledgeable about PC were more likely to have positive perceptions of PC (B = 7.54, standard error = 1.61, P < .001). Patients' demographics, HSCT features, quality of life, and symptom burden were not significantly associated with perceptions of PC. HSCT recipients have positive perceptions of PC, though many have limited knowledge about its role. Patients who were more knowledgeable about PC were more likely to have positive perceptions of PC. These data do not support transplant physicians' negative concerns about how patients perceive PC and underscore the need to further educate patients and transplant physicians about PC.

Code status transitions in patients with high-risk acute myeloid leukemia.

Patients with high-risk acute myeloid leukemia (AML) often experience intensive medical care at the end of life (EOL), including high rates of hospitalizations and intensive care unit (ICU) admissions. Despite this, studies examining code status transitions are lacking. We conducted a mixed-methods study of 200 patients with high-risk AML enrolled in supportive care studies at Massachusetts General Hospital between 2014 and 2021. We defined high-risk AML as relapsed/refractory or diagnosis at age ≥60. We used a consensus-driven medical record review to characterize code status transitions. At diagnosis, 86.0% (172/200) of patients were "full code" (38.5% presumed, 47.5% confirmed) and 8.5% had restrictions on life-sustaining therapies. Overall, 57.0% of patients experienced a transition during the study period. The median time from the last transition to death was 2 days (range, 0-350). Most final transitions (71.1%) were to comfort measures near EOL; only 60.5% of patients participated in these last transitions. We identified 3 conversation types leading to transitions: informative conversations focusing on futility after clinical deterioration (51.0%), anticipatory conversations at the time of acute deterioration (32.2%), and preemptive conversations (15.6%) before deterioration. Younger age (B = 0.04; P = .002) and informative conversations (B = -2.79; P < .001) were associated with shorter time from last transition to death. Over two-thirds of patients were "presumed full code" at diagnosis of high-risk AML, and most experienced code status transitions focused on the futility of continuing life-sustaining therapies near EOL. These results suggest that goals-of-care discussions occur late in the illness course for patients with AML and warrant interventions to increase earlier discussions regarding EOL preferences.

Financial toxicity in cancer care: origins, impact, and solutions.

Financial toxicity describes the financial burden and distress that can arise for patients, and their family members, as a result of cancer treatment. It includes direct out-of-pocket costs for treatment and indirect costs such as travel, time, and changes to employment that can increase the burden of cancer. While high costs of cancer care have threatened the sustainability of access to care for decades, it is only in the past 10 years that the term "financial toxicity" has been popularized to recognize that the financial burdens of care can be just as important as the physical toxicities traditionally associated with cancer therapy. The past decade has seen a rapid growth in research identifying the prevalence and impact of financial toxicity. Research is now beginning to focus on innovations in screening and care delivery that can mitigate this risk. There is a need to determine the optimal strategy for clinicians and cancer centers to address costs of care in order to minimize financial toxicity, promote access to high value care, and reduce health disparities. We review the evolution of concerns over costs of cancer care, the impact of financial burdens on patients, methods to screen for financial toxicity, proposed solutions, and priorities for future research to identify and address costs that threaten the health and quality of life for many patients with cancer.

Rapid Rectal Polyposis Development in a Patient With Familial Adenomatous Polyposis.

Familial adenomatous polyposis (FAP) is a well-described genetic condition that results in the development of multiple benign and malignant lesions throughout the gastrointestinal tract. The development of colorectal cancer is nearly universal in classic FAP, and total proctocolectomy after polyp development is recommended. We present a patient with FAP who was unable to undergo proctectomy. Despite careful removal of all rectal polyps before subtotal colectomy with ileorectal anastomosis, he developed 12 rectal polyps, including 4 advanced neoplastic lesions, within 73 days after initial endoscopic removal. This case highlights the rapid regrowth rate of colorectal adenomas in FAP.

Characteristics of U.S. Nursing Homes with COVID-19 Cases.

BACKGROUND/OBJECTIVES: The 2019 coronavirus disease (COVID-19) has been documented in a large share of nursing homes throughout the United States, leading to high rates of mortality for residents. To understand how to prevent and mitigate future outbreaks, it is imperative that we understand which nursing homes are more likely to experience COVID-19 cases. Our aim was to examine the characteristics of nursing homes with documented COVID-19 cases in the 30 states reporting the individual facilities affected. DESIGN: We constructed a database of nursing homes with verified COVID-19 cases as of May 11, 2020, via correspondence with and publicly available reports from state departments of health. We linked this information to nursing home characteristics and used regression analysis to examine the association between these characteristics and the likelihood of having a documented COVID-19 case. SETTING: All nursing homes from 30 states that reported COVID-19 cases at the facility-level. PARTICIPANTS: Nursing home residents in states reporting data. MEASUREMENTS: Whether a nursing home had a reported COVID-19 case (yes/no), and conditional on having a case, the number of cases at a nursing home. RESULTS: Of 9,395 nursing homes in our sample, 2,949 (31.4%) had a documented COVID-19 case. Larger facility size, urban location, greater percentage of African American residents, non-chain status, and state were significantly (P < .05) related to the increased probability of having a COVID-19 case. Five-star rating, prior infection violation, Medicaid dependency, and ownership were not significantly related. CONCLUSION: COVID-19 cases in nursing homes are related to facility location and size and not traditional quality metrics such as star rating and prior infection control citations. J Am Geriatr Soc 68:1653-1656, 2020.

Factors Influencing Family Burden in Pediatric Hematology/Oncology Encounters.

PURPOSE: Caring for a child with cancer or hematologic disease places unique stress on a family unit. Families' subjective experience of this care-related burden mediates the relationship between cost and health-related outcomes. While financial costs are well described for families of pediatric hematology/oncology patients, it is unclear how cost and other factors each contribute to families' overall experience of care-related burden. This study identifies and groups the challenges that families report and describes their association with overall reported burden. METHODS: This mixed-methods analysis of a cross-sectional single-center study was conducted via structured, self-administered questionnaire provided to inpatient and outpatient caregivers of pediatric hematology/oncology patients. Respondents rated their perception of burden associated with that day's medical encounter on a 5-point Likert scale. The questionnaire included an open-ended prompt for caregivers about areas they deemed most burdensome. Primary themes were extracted and categorized. RESULTS: A total of 278 outpatient and 42 inpatient caregivers participated. Six thematic categories emerged: logistics, life disruption, care delivery system, parking, financial burden, and emotional burden. Outpatient caregivers reported more burden than inpatient caregivers for the first three categories, while inpatient caregivers reported more burden for the last three. Salient subthemes associated with higher and lower overall burden were identified in each theme category. CONCLUSIONS: These data establish theme categories for future study of caregiver-perceived burden in pediatric hematologic/oncologic encounters, demonstrate that certain components of cost contribute disproportionately to caregivers' overall sense of care-related burden, and identify areas within each of the 6 burden categories that can be best targeted to alleviate caregiver burden.

Reviewing Systems.

This poster represents the experience of a clinician-in-training with a diagnostic screening method typically called "review of systems." Although at times executing this method can feel onerous, it is intended to reveal key symptoms, promote inquiry, and enhance communication. It also sometimes generates unexpected and important insights, and that experience is conveyed here with a combination of text and images.

Incidence of gastric cancer in the USA during 1999 to 2013: a 50-state analysis.

BACKGROUND: The incidence of gastric cancer, while declining in many places worldwide, is characterized by considerable geographical variability. The USA has large racial, ethnic and regional variation; we collected data from all 50 states to better characterize recent changes in gastric cancer incidence nationwide. METHODS: Annual gastric cancer incidence rates from 1999 to 2013 were extracted from the United States Cancer Statistics (USCS) registry. Secular trends of gastric cancer incidence were examined overall and by sociodemographic factors and states. We used Joinpoint regression to compute annual percent change (APC) and average annual percent change (AAPC) and corresponding 95% confidence intervals (CIs). SEER 13 registries data were extracted to examine the secular trends by cardia and non-cardia gastric cancers. RESULTS: Overall gastric cancer incidence decreased until 2007 (APC = -1.55, 95% CI: -1.88, -1.21), and remained stable thereafter (APC = -0.32, 95% CI: -0.84, 0.20). However, rates increased among persons <50 years of age (AAPC = 0.89, 95% CI: 0.61, 1.16), especially among non-Hispanic white females and Hispanic females. Incidence of non-cardia gastric cancer increased among persons <50 years of age (AAPC = 0.69, 95% CI: -0.06, 1.44), whereas rates of gastric cardia cancer remained unchanged. States with rapid increases in high-risk population groups (e.g. Hispanic females aged <50), including California and Texas, had highest annual increases in gastric cancer incidence. CONCLUSIONS: Divergent trends for gastric cancer incidence were observed in the USA. Incidence rates, particularly for non-cardia gastric cancer, were stable or increasing among persons aged <50 years.