Long-Term Engagement of Patients With Advanced Cancer: Results From the EPAC Randomized Clinical Trial.

Importance: The long-term effect of interventions that assist patients with establishing their end-of-life care preferences among patients with cancer remain relatively unknown. Objective: To evaluate the association of a long-term intervention of a lay health worker-led advance care planning intervention among patients with advanced stages of cancer with overall survival and end-of-life health care use and costs. Design, Setting, and Participants: This follow-up study of the EPAC randomized clinical trial conducted between August 2013 and February 2015 used data from 9.4 years after the first patient was enrolled with a data cut-off date of February 1, 2023. Overall, 213 participants with stage 3 or 4 or recurrent cancer in the US Veterans Affairs Palo Alto Health Care System were included. Interventions: A 6-month lay health worker-led education and support intervention to assist patients with establishing their end-of-life preferences vs usual care. Main Outcomes and Measures: The outcomes of interest were overall survival, risk of death, restricted mean survival time, and palliative care, hospice, and acute care use in the final 30 days before death for participants who died. Results: Among 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years; 211 (99.1%) were male, 2 (0.90%) were female. There were no demographic or clinical characteristic imbalances at enrollment. As of February 1, 2023, 188 had died. The intervention group had a 25% reduction in risk of death (hazard ratio, 0.75; 95% CI, 0.56-0.98); more palliative care (44 [50.0%] vs 35 [35.0%]) and hospice use (64 [72.7%] vs 53 [53.0%]); and lower emergency department use (20 [22.7%] vs 47 [47.0%]), hospitalizations (17 [19.3%] vs 46 [46.0%]), and median (IQR) total health care costs (median [IQR], $1637 [$383-$9026] vs $18 520 [$4790-$50 729]) than control group participants. Conclusions and Relevance: The effects of the lay health worker-led intervention remain durable, with nearly complete follow-up, supporting integration into routine cancer care. Trial Registration: ClinicalTrials.gov Identifier: NCT02966509.

Health Care Professionals' Perspectives on Implementation, Adoption, and Maintenance of a Community Health Worker-Led Advance Care Planning and Cancer Symptom Screening Intervention: A Qualitative Study.

PURPOSE: Advance care planning (ACP) and symptom screening are nationally recommended for all patients with advanced stages of cancer. Yet, routine delivery of such care remains challenging because of multilevel barriers. We hired and trained community health workers (CHWs) to assist with delivery of these services across the United States. The aim of this study was to explore health care professionals' perspectives on barriers and facilitators to these team-based approaches. METHODS: We conducted semistructured interviews with 44 health care professionals in 21 cancer clinics in seven US cities using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. We recorded, transcribed, and analyzed interviews using the framework analysis approach. RESULTS: Participants noted barriers and facilitators to implementation, adoption, and maintenance of CHW-led ACP and symptom management approaches. Participants were initially skeptical; however, they noted a positive shift in their views over time because of personal experiences and effectiveness in their clinics. There was significant variation in adoption with some using a prescriptive top-down approach and others a bottom-up approach. Most agreed that the combination of top-down and bottom-up approaches would be most efficient and effective for promoting team-based care. All participants discussed implementation and provided suggestions for maintenance including organizational support, leadership, and CHW retention. CONCLUSION: CHW-led ACP and proactive symptom management interventions are effective and accepted by cancer care professionals at scale. Tailoring on the basis of organization and local contexts is required to ensure successful adoption, implementation, and maintenance of these effective team-based care delivery approaches.

Perspectives of Low-Income and Minority Populations With Lung Cancer: A Qualitative Evaluation of Unmet Needs.

PURPOSE: Lung cancer is the second most common cancer and the leading cause of cancer death in the United States. Persistent disparities remain in the incidence, mortality, and quality of lung cancer care received among minorities and populations with low income. This study aims to evaluate perspectives of low-income and minority patients with lung cancer on health system-level barriers and facilitators to high-quality lung cancer care delivery. METHODS: Informed by community-based participatory research, we conducted semistructured interviews with 48 patients with lung cancer in the San Francisco Peninsula and Central Coast regions of California. We recorded, transcribed, and analyzed interviews using thematic analysis. RESULTS: Participants described four major structural and process barriers in current lung cancer care: unmet psychosocial support needs, lack of understanding of precision medicine, undertreated symptoms, and financial concerns about cancer, which exacerbate concerns regarding families' well-being. Participants described that trusting relationship with their cancer care team members was a facilitator for high-quality care and suggested that proactive integration of proactive psychosocial and community-based peer support could overcome some of the identified barriers. CONCLUSION: This study identified modifiable health system lung cancer care delivery barriers that contribute to persistent disparities. Opportunities to improve care include integration of community-based peer support.

Missed opportunities to counsel patients with malignant pleural mesothelioma about causation and potential compensation.

INTRODUCTION: Malignant pleural mesothelioma (MPM) is a lethal malignancy strongly associated with occupational exposure to asbestos. The aims of this study were to assess the quality of counseling provided to patients with MPM about the causation of MPM and the potential for compensation. METHODS: The authors conducted a structured retrospective chart review of patients with a diagnosis of MPM. They abstracted demographic data, occupational and environmental history and exposure data. They also searched for documentation of patient education and counseling. RESULTS: The authors identified 16 patients with a new diagnosis of MPM during the study period. A job title was documented at least once in the records of 12 (75%) patients. Documentation of occupational exposure to asbestos was found in the records of 12 (75%) patients. Two patients (13%) were presumed to have had bystander exposure to asbestos. Education about MPM causation and counseling about opportunities for compensation were documented in the record of 1 patient (6%). CONCLUSIONS: Among patients with MPM, documentation of some elements of an occupational history, including an occupational asbestos exposure history, was common. Advice to pursue compensation for potential occupation related MPM was rare. Physicians may be missing opportunities to provide beneficial information to patients with newly diagnosed MPM regarding potential legal redress and compensation.

Occupational history quality in patients with newly documented, clinician-diagnosed chronic bronchitis.

BACKGROUND: Approximately 15% of cases of COPD, including chronic bronchitis, is attributable to occupational exposures. An occupational history is essential to identify exposures responsible for work-related chronic bronchitis. METHODS: We conducted a structured retrospective analysis of the medical records of veterans, 18 to 70 years of age, newly diagnosed with chronic bronchitis in order to achieve the following: (1) to assess the quality of documented occupational histories; and (2) to characterize the management of patients with a history of exposure to a potentially hazardous respiratory substance. We also analyzed occupational exposure data reported by patients on a structured questionnaire. RESULTS: Sixty patients were included in the final analysis. A total of 6,150 notes were reviewed. Occupational status was documented in the records of 54 patients (90%). A description of occupational duties was recorded in 32 records (53%), and work exposure data in 26 records (43%). Clinicians concluded that occupational exposures potentially contributed to chronic bronchitis in three patients (5%). A recommendation for exposure avoidance was documented for six patients (10%). On the questionnaire, most patients reported a history of occupational exposure to respirable substances and symptoms of cough and/or shortness of breath. CONCLUSIONS: Details about job duties and occupational respiratory exposures were documented in the records of approximately half of patients with newly diagnosed chronic bronchitis. Patient self-reports of occupational exposures and respiratory symptoms were common. A determination that occupational exposures contributed to chronic bronchitis was rare. Few patients were counseled to take measures to avoid occupational exposures. Work-related chronic bronchitis may be incompletely assessed and undermanaged by clinicians.

Enhanced acute responses in an experimental exposure model to biomass smoke inhalation in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary diseases (COPD) may increase air pollution-related mortality. The relationship of immune mechanisms to mortality caused by fine particulates in healthy and COPD populations is incompletely understood. The objective of this study was to determine whether fine particulates from a single biomass fuel alter stress and inflammation biomarkers in people with COPD. Healthy and COPD subjects were exposed to smoke in a controlled indoor setting. Immune responses were quantified by measuring cell surface marker expression with flow-cytometric analysis and mRNA levels with quantitative reverse transcriptase-polymerase chain reactions in whole blood before and after exposure. Preexposure COPD subjects had more leukocytes, mainly CD14(+) monocytes and neutrophils, but fewer CD3(+) T cells. Fifty-seven of 186 genes were differentially expressed between healthy and COPD subjects' peripheral blood mononuclear cells (PBMCs). Of these, only nuclear factor (NF)-kappa B1, TIMP-1, TIMP-2, and Duffy genes were up-regulated in COPD subjects. At 4 hours post smoke exposure, monocyte levels decreased only in healthy subjects. Fifteen genes, particular to inflammation, immune response, and cell-to-cell signaling, were differentially expressed in COPD subjects, versus 4 genes in healthy subjects. The authors observed significant differences in subjects' PBMCs, which may elucidate the adverse effects of air pollution particulates on people with COPD.