Decision-Making Preferences among Advanced Cancer Patients in a Palliative Setting in Jordan.

Understanding patients' decision-making preferences is crucial for enhancing patients' outcomes. The current study aims to identify Jordanian advanced cancer patients' preferred decision-making and to explore the associated variables of the passive decision-making preference. We used a cross-sectional survey design. Patients with advanced cancer referred to the palliative care clinic at a tertiary cancer center were recruited. We measured patients' decision-making preferences using the Control Preference Scale. Patients' satisfaction with decision-making was assessed with the Satisfaction with Decision Scale. Cohen's kappa statistic was used to assess the agreement between decision-control preferences and actual decision-making, and the bivariate analysis with 95% CI and the univariate and multivariate logistic regression were used to examine the association and predictors of the demographical and clinical characteristics of the participants and the participants' decision-control preferences, respectively. A total of 200 patients completed the survey. The patients' median age was 49.8 years, and 115 (57.5%) were female. Of them, 81 (40.5%) preferred passive decision control, and 70 (35%) and 49 (24.5%) preferred shared and active decision control, respectively. Less educated participants, females, and Muslim patients were found to have a statistically significant association with passive decision-control preferences. Univariate logistic regression analysis showed that, being a male (p = 0.003), highly educated (p = 0.018), and a Christian (p = 0.006) were statistically significant correlates of active decision-control preferences. Meanwhile, the multivariate logistic regression analysis showed that being a male or a Christian were the only statistically significant predictors of active participants' decision-control preferences. Around 168 (84%) of participants were satisfied with the way decisions were made, 164 (82%) of patients were satisfied with the actual decisions made, and 143 (71.5%) were satisfied with the shared information. The agreement level between decision-making preferences and actual decision practices was significant (ⱪ coefficient = 0.69; 95% CI = 0.59 to 0.79). The study's results demonstrate that a passive decision-control preference was prominent among patients with advanced cancer in Jordan. Further studies are needed to evaluate decision-control preference for additional variables, such as patients' psychosocial and spiritual factors, communication, and information sharing preferences, throughout the cancer trajectory so as to inform policies and improve practice.

Validation of the Arabic Version of the Edmonton Symptom Assessment System.

Quality cancer care is a team effort. In addition, patients' symptoms change over the course of treatment. As such, the Edmonton Symptom Assessment System (ESAS) is a simple tool designed to quickly monitor symptom change. Here, we present the results from a two-phase study aimed at validating the Arabic version of the ESAS (ESAS-A). Phase one involved the creation of two versions of the ESAS with both reverse and forward translations by bilingual, native Arabic speakers as well as evaluation by an expert panel. The reconciled version was then administered to 20 patients as a pilot from which to create the final version, which was then used with 244 patients. Phase two for the ESAS-involved an ESAS-based validation of 244 adults aged 18 years and older who were diagnosed with advanced cancer; then, further validation was completed in conjunction with two other symptom survey tools, the EORTC-Pal 15 and the HADS. The ESAS-A items possessed good internal consistency with an average Cronbach's alpha of 0.84, ranging from 0.82 to 0.85. Moreover, the results of ESAS-A showed good agreement with those of EORTC QLQ- 15 PAL (r = 0.36 to 0.69) and HADS (r = 0.60 and 0.57) regarding anxiety and depression. We found the ESAS-A to be responsive to symptom change and a median time to completion of 3.73 min. The results of our study demonstrate that the ESAS-A is a reliable, valid, and feasible tool for the purposes of monitoring symptom change over the course of cancer treatment.

Development and assessment of a natural language processing model to identify residential instability in electronic health records' unstructured data: a comparison of 3 integrated healthcare delivery systems.

OBJECTIVE: To evaluate whether a natural language processing (NLP) algorithm could be adapted to extract, with acceptable validity, markers of residential instability (ie, homelessness and housing insecurity) from electronic health records (EHRs) of 3 healthcare systems. MATERIALS AND METHODS: We included patients 18 years and older who received care at 1 of 3 healthcare systems from 2016 through 2020 and had at least 1 free-text note in the EHR during this period. We conducted the study independently; the NLP algorithm logic and method of validity assessment were identical across sites. The approach to the development of the gold standard for assessment of validity differed across sites. Using the EntityRuler module of spaCy 2.3 Python toolkit, we created a rule-based NLP system made up of expert-developed patterns indicating residential instability at the lead site and enriched the NLP system using insight gained from its application at the other 2 sites. We adapted the algorithm at each site then validated the algorithm using a split-sample approach. We assessed the performance of the algorithm by measures of positive predictive value (precision), sensitivity (recall), and specificity. RESULTS: The NLP algorithm performed with moderate precision (0.45, 0.73, and 1.0) at 3 sites. The sensitivity and specificity of the NLP algorithm varied across 3 sites (sensitivity: 0.68, 0.85, and 0.96; specificity: 0.69, 0.89, and 1.0). DISCUSSION: The performance of this NLP algorithm to identify residential instability in 3 different healthcare systems suggests the algorithm is generally valid and applicable in other healthcare systems with similar EHRs. CONCLUSION: The NLP approach developed in this project is adaptable and can be modified to extract types of social needs other than residential instability from EHRs across different healthcare systems.

Clinicopathological Characteristics And Treatment Outcomes Of Breast Cancer Among Adolescents And Young Adults In A Developing Country.

PURPOSE: Compared to Western societies, breast cancer diagnosis in our region is usually made at a younger age and at a more advanced stage. Breast cancer in younger patients tends to be more aggressive, and may result in a higher likelihood of long-term treatment-related toxicity and unique psychosocial problems. This study highlights the clinicopathological features and treatment outcomes in this age-group in a developing country like ours. METHODS: Consecutive patients aged 40 years or younger with a pathologically confirmed diagnosis of breast cancer treated and followed up at our institution were included. Medical records and hospital databases were searched for patients' characteristics and treatment outcomes. RESULTS: A total of 417 patients were enrolled. Median age at diagnosis was 35 (21-40) years. On presentation, 63 (15.1%) patients had metastatic disease, 50 (79.4%) with visceral metastasis. Patients with nonmetastatic disease had poor pathological features, including node-positivity (66.9%), grade III (51.4%), lymphovascular invasion (48.6%) and positive HER2 (31.5%). Breast-conserving surgery was performed on 32.9%, and only 36.5% of women had breast-reconstruction surgery. At a median follow-up of 59 months, 5-year overall survival for the whole group was 72%: 84% for nonmetastatic and 13% for those with metastatic disease. On Cox regression, nodal metastasis (adjusted HR 3.46, 95% CI 1.48-8.10; p=0.004) and grade III disease (HR 1.97, 95% CI 1.14-3.39; p=0.015) were associated with poor outcome. CONCLUSION: Adolescents and young Jordanian adults with breast cancer present with more advanced-stage disease and more aggressive pathological features that reflect poorly on treatment outcomes.

Intensity of Cancer Care Near the End of Life at a Tertiary Care Cancer Center in Jordan.

CONTEXT: Chemotherapy use in the last month of life is an indicator of poor quality of end-of-life care. OBJECTIVES: We assessed the frequency of chemotherapy use at the end of life at our comprehensive cancer center in Jordan and identified the factors associated with chemotherapy use. METHODS: We conducted a retrospective chart review to examine the use of chemotherapy in the last 30 days and 14 days of life in consecutive adult patients with cancer seen at King Hussein Cancer Center (KHCC) who died between January 1, 2010, and December 31, 2012. We collected data on patient and disease characteristics, palliative care referral, and end-of-life care outcome indicators. RESULTS: Among the 1714 decedents, 310 (18.1%) had chemotherapy use in the last 30 days and 142 (8.3%) in the last 14 days of life. Over half (910; 53.1%) had a palliative care referral. Chemotherapy use in the last 30 and 14 days of life were associated with younger age (odds ratio [OR] 0.99/yr, P = 0.01, and OR 0.99/yr, P = 0.01, respectively) and hematological malignances (OR 1.98, P < 0.001, and OR 2.85, P < 0.001, respectively). Palliative care referral was significantly associated with decreased use of chemotherapy in the last 30 (OR 0.30, P < 0.001) and 14 (OR 0.15, P < 0.001) days of life. CONCLUSIONS: A sizable minority of patients with cancer at KHCC received chemotherapy at the end of life. Younger patients and those with hematological malignancies were more likely to receive chemotherapy, whereas those referred to palliative care were significantly less likely to receive chemotherapy at the end of life.

Four cycles of adriamycin and cyclophosphamide followed by four cycles of docetaxel (NSABP-B27) with concomitant trastuzumab as neoadjuvant therapy for high-risk, early-stage, HER2-positive breast cancer patients.

BACKGROUND: The majority of breast cancer patients in Jordan are diagnosed at a young age and present with metastatic or locally advanced disease. The National Surgical Adjuvant Breast and Bowel Project Protocol B27 (NSABP-B27) (four cycles of adriamycin and cyclophosphamide [AC] followed by four cycles of docetaxel) is a standard neoadjuvant regimen in our institution. In this study, we report the efficacy of adding trastuzumab to docetaxel in this regimen for high-risk human epidermal growth factor receptor 2 (HER2)-positive early-stage disease. PATIENTS AND METHODS: Consecutive HER2-positive breast cancer patients treated with this regimen were included. Treatment was given at standard doses and schedules as reported in NSABP-B27. Trastuzumab was given with docetaxel and then continued for 1 year. RESULTS: A total of 121 patients (mean age 45.4 years) were included. The majority had high-risk features including large tumor size, positive axillary lymph nodes, and grade III disease. Three patients did not complete the planned cycles of AC due to a lack of response. Eight (6.6%) patients missed at least one cycle of docetaxel. Following neoadjuvant therapy, 119 patients underwent surgery, of whom 59 (49.6%) patients achieved pathological complete response. The response was higher in node-negative patients (64.0 vs 45.7%; P=0.03) and in hormone receptor-negative disease patients (69.7 vs 41.9%; P=0.018). Breast-conserving surgery was performed in 21.5% of the patients. The median disease-free survival (DFS) for the whole group was not reached while the 3- and 5-year DFS rates were 84.2 and 74.1%, respectively. CONCLUSION: Trastuzumab added to the NSABP-B27 regimen is a unique combination. When used in high-risk patients, as in our study, outcomes similar to reported data were achieved without unexpected toxicities.

The Application of Current Proposed Venous Thromboembolism Risk Assessment Model for Ambulatory Patients With Cancer.

Venous thromboembolism (VTE) is a commonly encountered problem in patients with cancer. In recent years, cancer treatment paradigm has shifted with most therapy offered in ambulatory outpatient settings. Excess of half VTEs in patients with cancer occur in outpatient settings without prior hospitalization, where current practice guidelines do not recommend routine prophylaxis. Risk assessment models (RAMs) for VTE in such patients were recently introduced. This study aims to assess the practical application of one of these models in clinical practice. Medical records and hospital electronic database were searched for patients with cancer having VTE. Known risk factors were collected, and risk assessment was done using the Khorana RAM. Over a 10-year period, 346 patients developed VTE in ambulatory settings. Median age was 57 and 59.0% were females. Lower extremities were involved in 196 (56.6%), while 96 (27.7%) had pulmonary embolism. Most (76.6%) patients had stage IV disease, only 9.0% had stage I or II disease. Only 156 (45.1%) patients were on active chemotherapy, for whom Khorana risk assessment score was calculated. In these patients, high risk was identified in 31 (19.9%) patients, while 81 (51.9%) had intermediate risk and 44 (28.2%) had low risk. No patients were on prophylaxis prior to VTE. Most ambulatory patients with cancer who developed VTE were not on chemotherapy, and many of those who were on active treatment had low Khorana risk scores. This illustrates the need to modify the model or develop a new one that takes into consideration this group of patients.

From clinical trials to clinical practice: outcome of NSABP-B27 neoadjuvant chemotherapy regimen for high-risk early-stage breast cancer.

PURPOSE: Majority of Jordanian breast cancer patients present at a relatively young age and with locally advanced disease highlight the importance of neoadjuvant chemotherapy. This study evaluated the efficacy and safety of NSABP-B27 regimen in high-risk patients in daily clinical practice. METHODS: Patients' medical records and hospital database were searched for all consecutive patients treated at our institution for breast cancer using neoadjuvant NSABP-B27 chemotherapy regimen. Chemotherapy was given at standard doses and schedule as originally reported in the NSABP-B27. RESULTS: 346 female patients (median age 51 years) were treated using this regimen. Majority had high-risk features including larger tumor size (>4 cm in 68.5%), positive axillary lymph nodes (78.3%), and Grade III disease (47.4%). While most patients tolerated and completed planned chemotherapy, 41 (11.8%) patients failed to complete all four cycles of docetaxel. Following neoadjuvant chemotherapy, complete pathological response (pCR) was achieved in 84 (25.0%) evaluable patients; pCR was higher in hormone receptor-negative disease (40.0 vs. 22.1%, p = 0.002), in patient with tumor size ≤4 cm (28.3 vs. 23.5%, p = 0.024) and in patients with node-negative disease (41.2 vs. 20.7%, p = 0.002). Age (<50 vs. ≥50) had no effect, with pCR of 24.2 and 26.4%, respectively (p = 0.607). Breast-conserving surgery was performed in 85 (24.6%). CONCLUSIONS: NSABP-B27 is an effective neoadjuvant regimen. Despite including higher risk patients, pCR is similar to the original NSABP-B27 and many other anthracycline-taxane-based regimens. Tumor size, LN status, hormone receptors status, but not age, were significant factors in achieving pCR.