Long-term opioid use in patients treated with head and neck intensity-modulated radiotherapy.

PURPOSE: Acute and chronic pain during and after radiotherapy is an important driver of poor quality of life. We aimed to identify risk factors associated with increased chronic opioid use in head and neck squamous cell cancer survivors. METHODS: We performed a retrospective cohort analysis on head and neck squamous cell cancer patients treated with definitive or adjuvant intensity-modulated radiotherapy. We tracked their oncologic opioid prescription profile from initial presentation to the last follow-up date. We determined the incidences of 1- and 2-year opioid use and performed multivariate logistic regression for both outcomes. RESULTS: Our analytic cohort consisted of 403 head and neck squamous cell cancer survivors. The numbers of patients requiring opioids at 3 months, 6 months, and 1 year after treatment were 316 (78%), 203 (50%), and 102 (25%), respectively. On multivariate logistic regression, positive smoking history (95% CI 1.86 [1.03, 3.43], p = 0.04), unemployment (95% CI 2.33 [1.16, 4.67], p = 0.02), prior psychiatric illness (95% CI 2.15 [1.05, 4.40], p = 0.03), and opiate use before radiotherapy (95% CI 2.75 [1.49, 5.20], p = 0.01) were independently associated with significantly greater odds of opioid use at 1 year. CONCLUSIONS: Our institutional analysis has shown that a substantial amount of head and neck cancer survivors are chronically dependent on opioids following radiotherapy. We have identified a cohort at highest risk for long-term use, for whom early interventions should be targeted.

NCCN Guidelines® Insights: Palliative Care, Version 2.2021.

Palliative care has evolved to be an integral part of comprehensive cancer care with the goal of early intervention to improve quality of life and patient outcomes. The NCCN Guidelines for Palliative Care provide recommendations to help the primary oncology team promote the best quality of life possible throughout the illness trajectory for each patient with cancer. The NCCN Palliative Care Panel meets annually to evaluate and update recommendations based on panel members' clinical expertise and emerging scientific data. These NCCN Guidelines Insights summarize the panel's recent discussions and highlights updates on the importance of fostering adaptive coping strategies for patients and families, and on the role of pharmacologic and nonpharmacologic interventions to optimize symptom management.

Top Ten Tips Palliative Care Clinicians Should Know About Leveraging the Electronic Health Record for Data Collection and Quality Improvement.

As palliative care (PC) programs rapidly grow and expand across settings, the need to measure, improve, and standardize high-quality PC has also grown. The electronic health record (EHR) is a key component of these efforts as a central hub of care delivery and a repository of patient and system data. Deliberate efforts to leverage the EHR for PC quality improvement (QI) can help PC programs and health systems improve care for patients with serious illnesses. This article, written by clinicians with experience in QI, informatics, and clinical program development, provides practical tips and guidance on EHR strategies and tools for QI and quality measurement.

Early Palliative Care Is Associated With Reduced Emergency Department Utilization in Pancreatic Cancer.

OBJECTIVES: Most patients with pancreatic cancer have high symptom burden and poor outcomes. Palliative care (PC) can improve the quality of care through expert symptom management, although the optimal timing of PC referral is still poorly understood. We aimed to assess the association of early PC on health care utilization and charges of care for pancreatic cancer patients. MATERIALS AND METHODS: We selected patients with pancreatic cancer diagnosed between 2000 and 2009 who received at least 1 PC encounter using the Surveillance, Epidemiology, and End Results (SEER)-Medicare. Patients who had unknown follow-up were excluded. We defined "early PC" if the patients received PC within 30 days of diagnosis. RESULTS: A total of 3166 patients had a PC encounter; 28% had an early PC. Patients receiving early PC were more likely to be female and have older age compared with patients receiving late PC (P<0.001). Patients receiving early PC had fewer emergency department (ED) visits (2.6 vs. 3.0 visits, P=0.004) and lower total charges of ED care ($3158 vs. $3981, P<0.001) compared with patients receiving late PC. Patients receiving early PC also had lower intensive care unit admissions (0.82 vs. 0.98 visits, P=0.006) and total charges of intensive care unit care ($14,466 vs. $18,687, P=0.01). On multivariable analysis, patients receiving early PC were significantly associated with fewer ED visits (P=0.007) and lower charges of ED care (P=0.018) for all patients. CONCLUSIONS: Early PC referrals were associated with lower ED visits and ED-related charges. Our findings support oncology society guideline recommendations for early PC in patients with advanced malignancies such as pancreatic cancer.

Telehealth and Palliative Care for Patients With Cancer: Implications of the COVID-19 Pandemic.

It has been reported that the incidence of SARS-CoV-2 infection is higher in patients with cancer than in the general population and that patients with cancer are at an increased risk of developing severe life-threatening complications from COVID-19. Increased transmission and poor outcomes noted in emerging data on patients with cancer and COVID-19 call for aggressive isolation and minimization of nosocomial exposure. Palliative care and oncology providers are posed with unique challenges due to the ongoing COVID-19 pandemic. Telepalliative care is the use of telehealth services for remotely delivering palliative care to patients through videoconferencing, telephonic communication, or remote symptom monitoring. It offers great promise in addressing the palliative and supportive care needs of patients with advanced cancer during the ongoing pandemic. We discuss the case of a 75-year-old woman who was initiated on second-line chemotherapy, to highlight how innovations in technology and telehealth-based interventions can be used to address patients' palliative and supportive care needs in the ongoing epidemic.

End-of-Life Care in Cystic Fibrosis: Comparing Provider Practices Based on Lung Transplant Candidacy.

Background: The optimal timing to introduce palliative care (PC) and end-of-life (EOL) conversations into the lives of people with cystic fibrosis (CF) has not been established. Objective: Compare EOL care practices for people with CF who died without a lung transplant (LT), are living without an LT, and those who received an LT. Design: Retrospective chart review. Setting/Subjects: People with CF who received care from 2012 to 2017 at the University of Texas Southwestern Medical Center. Measurements: Primary outcomes were (1) EOL discussion with a pulmonologist, (2) time of EOL discussion before death or LT, (3) evaluation by PC, and (4) documentation of advanced directive or medical power of attorney. Results: Twenty-three patients died without LT, 40 patients received an LT, and 222 were living without an LT. Among LT recipients, 10% had EOL conversations compared with 74% of deceased patients and 5% of living patients without LT (p = 0.001). Among deceased patients, 39% had EOL conversations more than six months before death, while 5% of transplanted patients had EOL conversation more than six months before LT (p < 0.001). Deceased patients were more likely to have seen PC (57%) than either patients who received LT (2%) or those living without LT (3%, p = 0.0001). Conclusions: Patients who died without LT were more likely to have seen PC and had an EOL conversation than patients who received LT or who are living without LT. Further research should explore the optimal timing to discuss EOL care and the best timing to involve PC.

Double-balloon endoscopy and Peutz-Jeghers syndrome: a new look at an old disease.

Peutz-Jeghers syndrome is a rare disease characterized by mucocutaneous hyperpigmentation and intestinal hamartomatous polyposis. Life-threatening complications include intestinal obstruction and increased risk of gastrointestinal malignancies. While colonoscopy continues to serve as the gold standard for examination of the colon, newer techniques such as capsule endoscopy and double-balloon endoscopy (DBE) are now being applied to both treatment and surveillance of this disease. Capsule endoscopy serves as a minimally invasive means of locating and characterizing polyps in symptomatic patients but is limited to detection only. DBE allows physicians to visit areas of the small bowel that were previously unreachable by older techniques and to treat lesions that are found. By using DBE to treat polyposis, hemorrhagic ulcers, angiodysplasia, strictures, and cancers, the number of small bowel resections can be decreased in these patients.