Stage at cancer diagnosis during the COVID-19 pandemic in western Washington state.

145 Background: The COVID-19 pandemic disrupted medical care, including routine cancer screening for breast, colorectal, lung and cervical cancers. We aimed to investigate the impact of the pandemic on stage at diagnosis for cancer patients. Methods: Using data from the Washington State SEER records we compared AJCC stage for patients diagnosed with cancer in 2017-2019 to 2020 for two time periods, March to June (initial pandemic months) and July to December (later pandemic months). Patients were included if they were age 18+, diagnosed with a solid tumor, and not diagnosed at autopsy. Results: In the early phase of the pandemic, March – June 2020, there was a shift to cancers being diagnosed at a later stage compared to the same time period in 2017-2019 (Stage III: 13.5% to 14.9%, Stage IV: 16.2% to 19.7%). There was also a decrease in cancer diagnoses for cancers that are often detected through routine screening. As a percentage of all cancer diagnoses, both melanoma (13.2% to 9.8%) and colon cancer diagnoses (7.2% to. 6.7%) decreased during the early pandemic. In the later phase of the pandemic, July to December 2020, the stage at diagnosis showed an indication of returning to pre-pandemic levels with an increase in the proportion of early stage cancers (In situ: 16.6% to 19.3%, Stage I: 38.8% to 41.1%). Stage at diagnosis trends varied by tumor type. For colorectal cancer, the overall number of diagnoses decreased during the initial pandemic months. Stage I diagnoses decreased and Stage IV cancer diagnoses increased in both early and late stages of the pandemic. Conclusions: In Washington State, the COVID-19 pandemic had an impact on stage at diagnosis potentially caused by delays or interruptions in medical care. Additional studies are needed to understand how this shift in stage at diagnosis impacted treatment and outcomes for patients.

Improving palliative care integration for patients with stage IV lung cancer at UConn Health by initiating a best practice advisory (BPA) in the electronic medical record (EMR).

331 Background: The American Society of Clinical Oncology (ASCO) practice updates on the integration of palliative care into standard oncology practice provides a key recommendation that patients with advanced cancer should receive palliative care services. Specifically, ASCO recommends that all patients with stage IV cancer receive a referral to an interdisciplinary palliative care team early in their course of disease and within 8 weeks of diagnosis. At UConn Health, it has been previously documented that only 28% of patients with stage IV cancer receive a referral to the palliative care team. To improve the quality of cancer care, a BPA with standardized criteria for palliative care referral was developed and implemented for patients with stage IV lung cancer. In this pilot study, the goal was to get 80-90% of patients a referral to palliative care team within 8 weeks of stage IV lung cancer diagnosis. Methods: The Model for Improvement using Plan-Do-Study-Act Cycles was completed: 1) created an EMR report to identify patients with stage IV lung cancer; 2) completed a retrospective review of patients with stage IV lung cancer referred to palliative care 6 months prior to BPA implementation; 3) created and implemented BPA; 4) educated providers about palliative care referral and BPA; 5) retrospectively reviewed referrals 6 months following BPA implementation; and 6) evaluated potential barriers. The palliative care EMR BPA was developed in collaboration with information technology specialists. The BPA alert populates the EMR when the provider opens a patient chart or visit encounter for all patients with 1) diagnosis of lung cancer; 2) stage IV disease; and 3) does not have a current order for palliative care referral. Results: Prior to BPA implementation (January 1, 2020- July 31, 2020), 8 of 28 patients (32%) with stage IV lung cancer were referred to palliative care service. The BPA became active on 9/15/2020. Within the six months following BPA implementation, 16 patients were newly diagnosed with stage IV lung cancer. Of these 16 patients, 81% of them had a referral to palliative care made within 8 weeks of clinical staging. Several barriers were identified with current process, including lack of staging tool use by all providers; lack of documentation of all data required for staging tool to automatically calculate stage, and inability to track patients who declined palliative care appointment. Conclusions: Incorporating a BPA reminding providers to consider a palliative care referral improved referrals of patients with newly diagnosed stage IV lung cancer to the palliative care clinic within 8 weeks of diagnosis, improving compliance with ASCO’s practice guidance on integration of palliative care. Next steps are to address barriers and expand the use of palliative care referral BPA to all patients with stage IV cancer.

Inpatient chemotherapy for patients with advanced solid tumors: A single-center observational study.

158 Background: We sought to identify a population of patients with advanced-stage solid tumor diagnoses for whom inpatient chemotherapy is appropriate. In so doing, we endeavor to define standards of practice in addressing prognostic awareness and goals of therapy prior to treatment. Methods: We identified 124 patients with Stage IV solid tumors who were given at least one dose of inpatient chemotherapy in 2019. We performed manual chart review to collect information on patient demographics, details of cancer diagnosis and chemotherapy regimen, and dates of admission, chemotherapy administration, discharge, readmission, and death. Results: Ninety-four percent of patients studied were admitted for cancer-related reasons. The 30-day mortality for patients with Stage IV cancer given inpatient chemotherapy was 20.2%, including 12 patients (9.7%) who died during the same admission. The 30-day readmission rate was 40.2%. Median overall survival and readmission-free survival were both 15 days (range, 3-510 and 3-642, respectively). Among patients who died within 30 days, 18.2% (4/22) had a serious illness conversation documented prior to chemotherapy administration. Conclusions: This study demonstrates that there is a high mortality and readmission rate among patients with advanced solid tumor malignancies who receive inpatient chemotherapy. Standardizing the expectation of informed consent and/or goals of care discussion prior to treatment is necessary. This may prevent administration of futile chemotherapy to patients requiring hospitalization for advanced cancer.

Significance of descriptive symptoms and signs and clinical parameters as predictors of neuropathic cancer pain

Purpose Evaluation of symptoms and signs for the management of neuropathic cancer pain (NCP) is challenging. This study aimed to identify clinical predictors of NCP and symptoms and signs most relevant of those in Korean patients. Methods This nationwide, descriptive, cross-sectional, multicenter, observational study included 2,003 cancer patients aged ≥20 years who reported a visual analog scale (VAS) score ≥1 for pain and provided informed consent for participation. The Douleur Neuropathic (DN4) questionnaire (score ≥4) was used to determine symptoms and signs as well as the presence of NCP. Results The prevalence of NCP was associated with age <65 years [OR, 1.57; 95% CI, 1.270–1.934], disease duration >6 months (OR, 1.57; 95% CI, 1.232–2.012), stage IV cancer (OR, 0.75; 95% CI, 0.593–0.955), history of chemotherapy (OR, 1.74; 95% CI, 1.225–2.472), and moderate-to-severe cancer pain (OR, 2.05; 95% CI, 1.671–2.524) after multivariate analysis. The most common descriptive symptoms of NCP were tingling, electric shock, and pins and needles. For NCP patients in the presence or absence of the clinical predictors, pins and needles (p = 0.001) and painful cold (p<0.001) symptoms were significantly frequent in patients with moderate-to-severe pain. Tingling, numbness, and touch hypoesthesia (p = 0.022, 0.033, 0.024, respectively) were more frequent in those with longer cancer duration and hyperesthesia (p = 0.024) was more frequent in young patients. Conclusion Age <65 years, disease duration >6 months, stage IV cancer, history of chemotherapy, and moderate-to-severe cancer pain, were identified as predictors of NCP. Some symptoms and signs of NCP were associated with these predictors. Further studies are warranted on the pathogenesis and management of NCP with respect to the symptoms and signs, and factors associated with pain severity in Korean patients.

Treatment of metastatic hepatocellular carcinoma with lenvatinib. Case report and literature review

Hepatocellular carcinoma (HCC) or liver cancer is the most common primary malignant tumor of the liver, which is characterized on the first place by a poor prognosis. HCC was diagnosed in 92 patients (62.6%) in 2019 and the period from January to April 2020 in the Republic of Bashkortostan, and among them, 68.47% had stage IV cancer. International professional guidelines suggest screening for early HCC detection. Systemic drug therapy is the treatment of choice for inoperable HCC according to professional guidelines. Inhibition of the VEGF pathway is one of the current methods of therapy for advanced HCC. Lenvatinib is a tyrosine kinase inhibitor for the treatment of advanced HCC that is not subject to local interventions. This article provides a description of a clinical case of successful treatment of a 67-year-old patient with advanced hepatocellular carcinoma. He was appointed for targeted therapy with lenvatinib for HCC that was not subject to local interventions, which led to long-term stabilization. There was a positive trend in the patients condition from the first weeks of therapy. The working capacity was restored. The therapy showed a satisfactory tolerability profile.

Exploratory Study of Advance Care Discussions Among Chinese American and White Stage IV Cancer Patients at an American Tertiary Medical Center

Purpose: Timely advance care discussions are essential components of quality care for diverse populations; however, little is known about these conversations among Chinese American cancer patients. This exploratory study describes differences in advance care discussions and planning between Chinese American and White advanced cancer patients. Methods: We collected data for 63 Chinese American and 63 White stage IV cancer patients who died between 2013 and 2018. We compared: frequency and timing of prognosis, goals of care (GOC), and end-of-life care (EOLC) discussions in the final year of life; family inclusion in discussions; healthcare proxy (HCP) identification; do not resuscitate (DNR) order, do not intubate (DNI) order, and other advance directive (AD) completion. We did not conduct statistical tests due to the study’s exploratory nature. Results: Among Chinese American and White patients, respectively, 76% and 71% had prognosis, 51% and 56% had GOC, and 89% and 84% had EOLC discussions. Prognosis, GOC, and EOLC discussions were held a median of 34.0, 15.5, and 34.0 days before death among Chinese American and 17.0, 13.0, and 24.0 days before death among White patients. Documentation rates among Chinese American and White patients were 79% and 76% for DNRs, 81% and 71% for DNIs, 79% and 81% for HCPs, and 52% and 40% for other ADs. Conclusions: Findings suggest that Chinese Americans had similar rates of advance care discussions, completed conversations earlier, and had similar to higher rates of AD documentation compared to White patients. Further studies are needed to confirm our preliminary findings.

Polypharmacy, chemotherapy receipt, and medication-related out-of-pocket costs at end of life among commercially insured adults with advanced cancer

Background Polypharmacy raises the risk of drug-drug interactions and adverse events among patients with cancer. Most polypharmacy research has focused on adults age 65 or older enrolled in Medicare insurance. To better inform pharmacy practice and cancer care delivery, data are needed on polypharmacy among commercially insured patients with cancer and those younger than 65. Methods We performed a retrospective analysis of insurance enrollment and claims files linked to the Puget Sound Cancer Surveillance System for adults age 18 and older who were commercially insured, diagnosed with stage IV cancer, survived 30+ days after diagnosis, and did not enroll in hospice. We describe the prevalence of polypharmacy, chemotherapy use, and medication-related out-of-pocket (OOP) costs in the last month of life. Results Of 606 patients, 390 (64%) experienced polypharmacy (i.e. 5+ medications) in the last 30 days of life. Almost half (n = 297, 49%) received chemotherapy or targeted agents; chemotherapy was associated with significantly higher odds of polypharmacy (odds ratio (OR) 2.93, 95% confidence interval (CI) 2.04–4.20). The most commonly prescribed medications at end of life were opioids, benzodiazepines and anti-emetics. Among 484 patients (80%) incurring medication-related costs in the last month of life, median total OOP cost was $82 (interquartile range $30–$200). Seven patients (1%) had total costs above $5,000. The median chemotherapy-related OOP cost was $446 (IQR $150–$1896); 32 patients (7%) had chemotherapy-related OOP costs between $1,000 and $5,000. Conclusion Most patients with advanced cancer experienced polypharmacy at end of life, although most medications observed herein are commonly used for supportive care. Patients receiving chemotherapy had higher medication-related OOP costs, and chemotherapy was significantly associated with polypharmacy at end of life. Evaluation of polypharmacy at end of life may represent an important opportunity to improve quality of life and reduce costs for patients and families.

How well do documented goals-of-care discussions for patients with stage IV cancer reflect communication best practices?

Background Written clinical communication regarding patients’ disease understanding and values may facilitate goal-concordant care, yet little is known about the quality of electronic health record (EHR) documentation. We sought to (1) describe frequency of communication best practices in EHR-documented goals-of-care discussions, and (2) assess whether templated notes improve quality of documentation. Methods Researchers pulled text of EHR-documented goals-of-care discussions for hospitalized patients with Stage IV cancer from admission to 60-days follow-up. Text was included when in a single encounter the clinician addressed: (a) prognosis and/or illness understanding; and (b) goals and/or treatment options. Researchers qualitatively coded text based on guidelines for communication best practices, and noted if an EHR template was used. Results Forty-two percent (206/492) of patients had EHR-documented goals-of-care discussions. Text frequently described communication of cancer progression (89%), though rarely included prognosis (22%). Text often included patients’ goals and values (83%), and at least on specific treatment decision (82%). Communication about treatments was included for 98% of patients; common examples included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Clinicians documented making recommendations for 40% of patients. Text addressing patient emotional and spiritual concerns was uncommon (15%). Compared to free text, use of a template was associated with increased documentation of goals and values (80% vs. 61%, p < 0.01), but not other best practices. Conclusion Insights from the study can be used to guide future training and research to study and improve the quality of documentation about goal of care, and its impact on goal-concordant care.

The clinically validated viral superinfection therapy (SIT) platform technology could cure early cases of COVID-19 disease

Currently, SARS-CoV-2 infection which is the causative agent for COVID-19 disease is a worldwide pandemic with more than 100 million global cases and more than 2.0 million deaths (as of January, 2021). While several vaccines for prevention of COVID-19 have already been registered by the regulatory authorities, the problem is that the substitution rate of this virus is estimated to be one change per 2 weeks, thus mutations could arise that threaten the efficacy of vaccines. Unfortunately, there is no current evidence from random clinical trials to recommend any specific post-exposure treatment for patients with suspected or confirmed COVID-19 disease. Here we propose an innovative superinfection therapeutic (SIT) strategy, which could complement the development of prophylactic vaccines. SIT is based on clinical observations that unrelated harmless viruses might interact in patients infected with pathogenic virus. During SIT, the patient benefits from superinfection with an apathogenic double-stranded RNA (dsRNA) virus such as the infectious bursal disease virus (IBDV), which is a powerful activator of the interferon-dependent antiviral gene program. An attenuated vaccine strain of IBDV was already successfully administered to resolve acute and persistent infections induced by two completely different viruses, the hepatitis B (DNA) and C (RNA) viruses (HBV/HCV). The safety of orally administered acid-resistant IBDV strain R903/78 reverse engineered viral drug candidate was demonstrated in 10 stage IV cancer patients who exhausted all conventional therapy. Following repeated oral administration of the virus up to 109 infectious units (IU)/ dose, only mild flu-like side effects were reported in some patients. Proof-of-principle efficacy was demonstrated in an early COVID-19 patient who was successfully treated with 3x106 IU of an attenuated IBDV vaccine. A small scale dose-finding Phase I safety study is proposed.