Conference News

TON January 2016 Vol 9 No 1

In This Article

Teamwork Improves Palliative Care and Saves Money

San Antonio, TX-An innovative model program for end-of-life (EOL) care for patients with cancer improved symptom management, reduced hospitalizations and in-hospital deaths, and increased use of hospice care. Moreover, the model saved about $7000 per patient in costs of care.

Interim analysis of the first few years of this model also showed that rapid palliative radiation therapy with shorter, higher doses of radiotherapy (ie, hypofractionation) led to pain relief from bone metastases within 1 week for a substantial proportion of patients.

The model, introduced in 2012, had 3 components: CARE Track, a data-driven palliative care team that meets weekly and develops coordinated care plans; MY COURSE, a patient-reported outcomes program integrated into electronic health records that triggers e-mail alerts to the CARE Track team for patients in declining status; and STAT RAD, a same-day, conformal, palliative radiation program with the goal of treating painful bone metastases within 3 to 4 hours.

"This shows that if we listen to our patients carefully, talk to them about their changing medical and emotional needs, and develop rapid and coordinated treatment plans based on their feedback, we can improve their quality of life and reduce the need for hospitalization and symptom management at the EOL," said lead author Paul W. Read, MD, PhD, Professor of Radiation Oncology at the University of Virginia Health System, Charlottesville. Dr Read presented the interim data at the recent annual meeting of the American Society for Radiation Oncology.

The program was based on the recognized need for earlier integration of palliative care into management of patients with advanced-stage cancer. "There is a shortage of palliative care specialists in the [United States], so we needed to innovate and collaborate," he explained. "Our solution is collaborative care, with 3 programs to target patients with the highest symptom burdens."

A total of 646 patients with cancer were enrolled in the CARE Track program. Interim results were based on a comparison of EOL care for 368 CARE Track patients versus 198 patients in a control group.

CARE Track enrollment led to significantly fewer EOL hospitalizations compared with the control group: in the final 90 days of life, 48.3% were hospitalized versus 64% of controls (P = .0004). Hospice care was delivered to more CARE Track patients: 69.6% compared with 47% of controls (P < .0001), leading to fewer hospital deaths for CARE Track patients (8.4 % vs 38.5 %, respectively; P < .0001). Moreover, CARE Track reduced the total costs of care per patient during the last 90 days of life by $7317 compared with controls (P = .0128).

STAT RAD was developed to improve time to response for initiating pain control in patients with bone metastases. The goal of this workflow effort was to transform a 2- to 3-week treatment program into a 1-day procedure to reduce treatment-related toxicity by using highly focused radiation.

A pilot trial enrolled 28 patients with 1 to 3 painful bone metastases; 37 target lesions were treated with radiotherapy of 5 to 10 Gy per fraction, for between 2 and 5 fractions (mean of 26.1 Gy in 3.1 fractions).

Using International Bone Metastases Consensus Working Party criteria to assess pain response at 3 weeks, partial or complete pain relief was achieved in 80% to 90% of patients. Using the Functional Assessment of Cancer Therapy-Bone Pain scale, quality of life was significantly improved from baseline through 26 weeks posttreatment.

A second clinical trial is planned to evaluate a more condensed schedule of radiation so it can be completed in a single 3- to 4-hour procedure.

Dr Read said that all the components of this model are readily available across the country. "Therefore, these programs can all be adopted into clinical practice at most health systems, with minimal cost, training, or education."

Reference

Read PW, Blackhall LJ, Stukenborg GJ, et al. Outcomes of a re-engineered palliative care and radiation therapy care model. Presented at: 2015 Annual Meeting of the American Society for Radiation Oncology; October 18-21, 2015; San Antonio, TX.

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Scan, Treat, and Repeat: Living with Long-Term Metastatic Disease

San Francisco, CA-In the 12 years that have passed since Shirley A. Mertz, MA, JD, President of the Metastatic Breast Cancer Network, first received a diagnosis of metastatic breast cancer, median survival has improved. However, less than a quarter of patients remain alive 5 years after diagnosis.1

At the 2015 Breast Cancer Symposium, Ms Mertz discussed the progress made in the treatment of metastatic disease while highlighting the long road that lies ahead for patients and providers.2

"For providers, it's really important to offer newly diagnosed patients information about the disease that will help you, as you sit down with them, select the best treatments," she said. "Whether patients are newly diagnosed or long-term like myself, we all need psychological and emotional support."

According to Ms Mertz, several factors have contributed to the growing number of long-term patients: increased use of biopsies and attention to biologic markers, research about growth factors, targeted therapies with tolerable toxicities, patient access to quality therapies, and improved patient engagement.

"In 2003, when the median survival was 1 to 2 years, the words 'long-term metastatic breast cancer' were not mentioned in the clinic," she said. "Twelve years later, there has been a slight improvement-perhaps more so in some subtypes-but every day, 110 people still die from this disease."

The ceaseless, repetitive nature of the disease and its treatments are also a source of emotional and physical fatigue. As Ms Mertz explained, despite the length of her survivorship, being a long-term patient still involves confronting feelings of fear, anxiety, and loss of control.

"Three words typify what this disease is about for patients: scan, treat, and repeat. That is our life," she said. "I hate to tell you how many [computer tomography] scans and [positron emission tomography] scans I've had in my 12 years."

What Is Needed

As a substitute for scans, Ms Mertz stressed the need to develop blood biomarkers to measure disease progression or treatment efficacy.

Lack of public understanding regarding metastatic breast cancer was also cause for concern. A 2014 poll revealed that 72% of the population believe that breast cancer in advanced stages is curable if the disease is diagnosed early.3

To enable patients with long-term metastatic breast cancer to live longer, Ms Mertz suggested several policy and regulatory reforms.

"We should expand Medicaid coverage to the states that have rejected it, so that more patients can have access to treatment," she said. "We need to address rising drug and co-pay costs, and we need increased funding for research focused on metastatic breast cancer, which is currently only 7% of funded grants."

She also spoke of the need to seek US Food and Drug Administration (FDA) approval for different drug end points for metastatic clinical trials. Drugs that prevent further spread or outgrowth of the disease are important, she explained, yet the FDA does not allow this as an end point.

Ms Mertz concluded her talk with a call to action. "Together, we must educate people about the difference between early and metastatic breast cancer," she told the audience. "I also ask you to vote for policy makers who believe in the benefit of scientific research, and will undertake legislation to make healthcare affordable for all people."

References

1. American Cancer Society. Cancer treatment & survivorship facts & figures 2014-2015. www.cancer.org/acs/groups/content/@research/documents/document/acspc-042801.pdf. Published 2014. Accessed November 19, 2015.
2. Mertz SA. Long-term metastatic breast cancer. Presented at: 2015 Breast Cancer Symposium; September 25-27, 2015; San Francisco, CA.
3. Pfizer Oncology. National omnibus survey overview. www.pfizer.com/files/news/OmnibusStudyOne-Pager.pdf. Accessed November 19, 2015.

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APN-Led Clinic Improves Outcomes and Lowers Costs of Treating Head and Neck Cancer

San Antonio, TX-Although chemoradiation with or without surgery is effective treatment for many patients with head and neck cancer, it may leave them with acute and long-term side effects that are difficult to tolerate and compromise quality of life. These include pain, difficulty swallowing, tooth decay, nausea, fatigue, and mouth or throat sores, and may result in an increased risk for infections and complications.

A new study presented at the recent annual meeting of the American Society for Radiation Oncology shows that frequent follow-up conducted by advance practice nurses (APNs) in an outpatient clinic enabled more intensive symptom management, which led to fewer postoperative emergency department (ED) visits and hospital admissions compared with traditional management. The specialized clinic is a model for improving value of care, said experts.

"This study illustrates an important role for APNs in radiation oncology. APNs are in a unique position to provide more intensive follow-up care, allowing them to better manage the posttreatment symptoms of high-risk head and neck cancer patients. This led to greater patient satisfaction, and is a more cost-effective way to avoid [ED] or hospital admissions," said lead author Bridgett Harr, CNP, Department of Radiation Oncology at the Cleveland Clinic in Ohio.

The APN outpatient clinic was initiated in 2014 for symptom management in the 90-day period following chemoradiotherapy. The clinic focused on high-risk patients with head and neck cancer, defined as those who had limited social support, resided in a nursing home or other facility, required multiple hydrations during treatment, had received a second course of stereotactic body radiation therapy, and/or had a feeding tube.

The study included 49 patients. Of these patients, 90% had stage IV or recurrent cancer. All patients had been treated with either intensity-modulated radiation therapy or stereotactic body radiation therapy. Twenty-two (45%) patients had radiation therapy alone, and 27 (55%) were treated with concomitant, cisplatin- or cetuximab-based chemoradiation.

Patients treated in the APN-led clinic (n = 25) were seen 2 weeks earlier than those with standard management (n = 24), and seen twice as often.

A total of 18 patients experienced 26 adverse events that required ED visits or hospitalization; 12 (50%) patients in the standard follow-up group versus 6 (24%) patients managed in the APN-led clinic.

The difference between the 2 groups was restricted to patients who were treated with radiation alone. In these patients, the rate of adverse events was 60% for standard management versus 16.7% in the APN-led clinic (P = .010).

No difference was observed in patients receiving concomitant chemoradiation therapy, because medical oncology provided intensive postradiation follow-up, Ms Harr said.

"The clinic provides mutually beneficial care. It improves healthcare for head and neck cancer patients while at the same time reduces costs to the healthcare system," Ms Harr stated. "This practice model can help improve healthcare value for these patients."

"This team-based approach shows that we don't always need high-tech interventions to improve care. The goal is to improve the value of care-that is, the quality of care provided divided by the costs encountered," said Brian Kavanagh, MD, University of Colorado, Denver, who moderated the press conference where this abstract was discussed.

Reference

Harr B. Advanced practice nurse follow-up clinic reduces emergency room visits and admissions in high-risk patients after chemoradiation therapy for head and neck cancer. Presented at: 2015 Annual Meeting of the American Society for Radiation Oncology; October 18-21, 2015; San Antonio, TX.

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Coping with Body Image: An Ongoing Process for Patients and Providers

San Francisco, CA-Body image is a critical psychosocial issue for patients with breast cancer, yet research has shown a strong disconnect between breast cancer care providers and patients regarding this struggle. According to a presentation at the 2015 Breast Cancer Symposium, negative body image for patients is associated with many adverse psychosocial outcomes, including depression, poor quality of life, and sexual dysfunction.

"Body image disruption is among the most common psychosocial concerns reported by women with breast cancer," said Michelle Cororve Fingeret, PhD, Associate Professor of Behavioral Science and Director of the Body Image Therapy Program at The University of Texas MD Anderson Cancer Center. "More needs to be done to reduce the disconnect between patients and their healthcare providers on this issue. Engaging patients in a discussion of body image issues, and addressing body image concerns, are an important part of comprehensive care."

As Dr Fingeret explained, body image is not just about physical appearance. Rather, it's a complex construct, encompassing the relationships among perceptions, cognitions, behaviors, and emotions regarding the body and its functions.

"We need to make sure we're educating patients about what to expect in terms of appearance and functional outcomes," she said. "However, we first should be able to take a step back and understand the patient experience. It's important to allow patients to express their concerns or worries about body image....Then, we can help them understand what to expect."

Body image exists on a continuum, Dr Fingeret reported, with extreme preoccupation with intrusive thoughts about the body on one end, and a genuine lack of concern about bodily changes on the other. The former group is in need of intensive therapy to cope with clinical levels of anxiety and depression, whereas the latter group-those who deny the existence of body image concerns-should give us pause for thought.

"There are some patients who see their scars as a badge of honor, and really do adapt in a positive way," she said. "I'm more concerned about those who are minimizing their body image concerns to healthcare providers because they feel ashamed or guilty."

In this situation, the role of the provider is to help normalize and validate these concerns, said Dr Fingeret, who offered practical approaches to having conversations with patients about body image.

"Before you start your assessment, my recommendation would be to let your patients know that body image concerns are very common for women with breast cancer," she said. "The minute I tell my patients it's okay to have these concerns, most will start crying right away and say that no one has talked to them about this before."

The next step is to address specific concerns, although it's important not to focus on concerns about physical appearance. Many patients, for example, mention fear of losing a nipple or losing sensation in a nipple.

Finally, the patient's understanding of the consequences are critical-how body image can affect relationships, cause discomfort in social situations, and even create occupational difficulties.

"This conversation can be a brief part of your clinical assessment," she said. "It is one aspect to trying to understand the patient's psychosocial concerns."

Although the initial conversation may be brief, Dr Fingeret emphasized that it's only the start of a continuing dialogue.

"This is a conversation you have to have repeatedly," she concluded. "Body image is an ongoing process for patients that changes over time. That's what makes this so challenging."

Reference

Fingeret MC. The patient experience-quality of life and survivorship: body image. Presented at: 2015 Breast Cancer Symposium; September 25-27, 2015; San Francisco, CA.

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