User login
Many women with cancer not told about impaired fertility risk
BOSTON – Less than half of all women of child-bearing age who are diagnosed with cancer discuss with their physicians the potential effects of cancer therapy on fertility, and even fewer are referred to reproductive specialists, investigators reported at the conjoint meeting of the International Federation of Fertility Societies and the American Society for Reproductive Medicine.
A survey of 1,282 female survivors of various cancers showed that more than 50% did not have a discussion with their oncologists about the possible deleterious effects of chemotherapy or radiation on fertility, and few patients received referrals to reproductive specialists, said Penelope P. Howards, Ph.D., assistant professor of epidemiology at Emory University’s Rollins School of Public Health in Atlanta.
"In our cohort, which was women who were diagnosed between 1990 and 2009, a large proportion is not getting the message about how treatments may affect their fertility," Dr. Howards said in an interview.
The likelihood that women would have been counseled about fertility varied by the type of cancer and by the typical treatment approach. For example, nearly 70% of women with cervical cancer said they had talked about fertility with their physicians, whereas women with cancers more typically managed by surgery – such as melanoma and thyroid cancer – were the least likely to be informed about potentially compromised fertility.
Only 60% of women with uterine cancers and 42% of women with ovarian cancers were told about the effects of treatment on fertility, despite having cancers of the reproductive system. Among women with breast cancer, the most common cancer type represented in the study, only 44% said they received fertility counseling.
Women who had at least one child by the time of diagnosis were less likely to be counseled than were women with no children (42% vs. 50%, respectively), and women aged 20-24 years were less likely to be informed about potentially compromised fertility than were women in their 30s, the investigators found.
Dr. Howards speculated that oncologists may assume that younger cancer patients are less likely to need counseling because they have a longer time to recover reproductive function than women who are approaching the age of menopause. Additionally, they may observe that young women who are rendered amenorrheic by cancer treatment may eventually resume menses, and wrongly assume that a return to menstruation indicates a return to full reproductive health.
Of those women who reported having a fertility discussion, 33% said they had initiated it themselves, 44% said that their oncologists had brought it up, and 23% said someone else initiated the discussion.
Dr. Howards and her colleagues searched the Georgia Cancer Registry to identify and interview women with a first diagnosis of cancer between the ages of 20 and 35 years. The interviews included questions about their reproductive histories, whether they had discussed with a clinician how cancer therapies might affect their fertility, and whether they had received a referral to a fertility specialist.
Factors that significantly predicted which women would be less likely to be counseled about infertility included having a child at diagnosis (adjusted odds ratio, 1.7), younger age at diagnosis (aOR, 1.5), being African American vs. white (aOR, 1.2), and not receiving chemotherapy or radiation (aOR, 3.1).
Of those women who did have a fertility discussion, only 6% of those with a child and 19% of those without children were referred to a fertility specialist.
An investigator who was not involved in the study said that the problem is not limited to women.
"With regard to men who get a diagnosis of cancer, we have seen that the discussion about their fertility status is not often had prior to getting a therapy that would affect their fertility status, such as chemotherapy, radiotherapy, or surgery," said Dr. Anand Shridharani, a urologist at the Erlanger Health System in Chattanooga, Tenn.
The study was supported by a grant from the Eunice Kennedy Shriver National Institute for Child Health and Development. Dr. Howards and Dr. Shridharani reported having no relevant disclosures.
BOSTON – Less than half of all women of child-bearing age who are diagnosed with cancer discuss with their physicians the potential effects of cancer therapy on fertility, and even fewer are referred to reproductive specialists, investigators reported at the conjoint meeting of the International Federation of Fertility Societies and the American Society for Reproductive Medicine.
A survey of 1,282 female survivors of various cancers showed that more than 50% did not have a discussion with their oncologists about the possible deleterious effects of chemotherapy or radiation on fertility, and few patients received referrals to reproductive specialists, said Penelope P. Howards, Ph.D., assistant professor of epidemiology at Emory University’s Rollins School of Public Health in Atlanta.
"In our cohort, which was women who were diagnosed between 1990 and 2009, a large proportion is not getting the message about how treatments may affect their fertility," Dr. Howards said in an interview.
The likelihood that women would have been counseled about fertility varied by the type of cancer and by the typical treatment approach. For example, nearly 70% of women with cervical cancer said they had talked about fertility with their physicians, whereas women with cancers more typically managed by surgery – such as melanoma and thyroid cancer – were the least likely to be informed about potentially compromised fertility.
Only 60% of women with uterine cancers and 42% of women with ovarian cancers were told about the effects of treatment on fertility, despite having cancers of the reproductive system. Among women with breast cancer, the most common cancer type represented in the study, only 44% said they received fertility counseling.
Women who had at least one child by the time of diagnosis were less likely to be counseled than were women with no children (42% vs. 50%, respectively), and women aged 20-24 years were less likely to be informed about potentially compromised fertility than were women in their 30s, the investigators found.
Dr. Howards speculated that oncologists may assume that younger cancer patients are less likely to need counseling because they have a longer time to recover reproductive function than women who are approaching the age of menopause. Additionally, they may observe that young women who are rendered amenorrheic by cancer treatment may eventually resume menses, and wrongly assume that a return to menstruation indicates a return to full reproductive health.
Of those women who reported having a fertility discussion, 33% said they had initiated it themselves, 44% said that their oncologists had brought it up, and 23% said someone else initiated the discussion.
Dr. Howards and her colleagues searched the Georgia Cancer Registry to identify and interview women with a first diagnosis of cancer between the ages of 20 and 35 years. The interviews included questions about their reproductive histories, whether they had discussed with a clinician how cancer therapies might affect their fertility, and whether they had received a referral to a fertility specialist.
Factors that significantly predicted which women would be less likely to be counseled about infertility included having a child at diagnosis (adjusted odds ratio, 1.7), younger age at diagnosis (aOR, 1.5), being African American vs. white (aOR, 1.2), and not receiving chemotherapy or radiation (aOR, 3.1).
Of those women who did have a fertility discussion, only 6% of those with a child and 19% of those without children were referred to a fertility specialist.
An investigator who was not involved in the study said that the problem is not limited to women.
"With regard to men who get a diagnosis of cancer, we have seen that the discussion about their fertility status is not often had prior to getting a therapy that would affect their fertility status, such as chemotherapy, radiotherapy, or surgery," said Dr. Anand Shridharani, a urologist at the Erlanger Health System in Chattanooga, Tenn.
The study was supported by a grant from the Eunice Kennedy Shriver National Institute for Child Health and Development. Dr. Howards and Dr. Shridharani reported having no relevant disclosures.
BOSTON – Less than half of all women of child-bearing age who are diagnosed with cancer discuss with their physicians the potential effects of cancer therapy on fertility, and even fewer are referred to reproductive specialists, investigators reported at the conjoint meeting of the International Federation of Fertility Societies and the American Society for Reproductive Medicine.
A survey of 1,282 female survivors of various cancers showed that more than 50% did not have a discussion with their oncologists about the possible deleterious effects of chemotherapy or radiation on fertility, and few patients received referrals to reproductive specialists, said Penelope P. Howards, Ph.D., assistant professor of epidemiology at Emory University’s Rollins School of Public Health in Atlanta.
"In our cohort, which was women who were diagnosed between 1990 and 2009, a large proportion is not getting the message about how treatments may affect their fertility," Dr. Howards said in an interview.
The likelihood that women would have been counseled about fertility varied by the type of cancer and by the typical treatment approach. For example, nearly 70% of women with cervical cancer said they had talked about fertility with their physicians, whereas women with cancers more typically managed by surgery – such as melanoma and thyroid cancer – were the least likely to be informed about potentially compromised fertility.
Only 60% of women with uterine cancers and 42% of women with ovarian cancers were told about the effects of treatment on fertility, despite having cancers of the reproductive system. Among women with breast cancer, the most common cancer type represented in the study, only 44% said they received fertility counseling.
Women who had at least one child by the time of diagnosis were less likely to be counseled than were women with no children (42% vs. 50%, respectively), and women aged 20-24 years were less likely to be informed about potentially compromised fertility than were women in their 30s, the investigators found.
Dr. Howards speculated that oncologists may assume that younger cancer patients are less likely to need counseling because they have a longer time to recover reproductive function than women who are approaching the age of menopause. Additionally, they may observe that young women who are rendered amenorrheic by cancer treatment may eventually resume menses, and wrongly assume that a return to menstruation indicates a return to full reproductive health.
Of those women who reported having a fertility discussion, 33% said they had initiated it themselves, 44% said that their oncologists had brought it up, and 23% said someone else initiated the discussion.
Dr. Howards and her colleagues searched the Georgia Cancer Registry to identify and interview women with a first diagnosis of cancer between the ages of 20 and 35 years. The interviews included questions about their reproductive histories, whether they had discussed with a clinician how cancer therapies might affect their fertility, and whether they had received a referral to a fertility specialist.
Factors that significantly predicted which women would be less likely to be counseled about infertility included having a child at diagnosis (adjusted odds ratio, 1.7), younger age at diagnosis (aOR, 1.5), being African American vs. white (aOR, 1.2), and not receiving chemotherapy or radiation (aOR, 3.1).
Of those women who did have a fertility discussion, only 6% of those with a child and 19% of those without children were referred to a fertility specialist.
An investigator who was not involved in the study said that the problem is not limited to women.
"With regard to men who get a diagnosis of cancer, we have seen that the discussion about their fertility status is not often had prior to getting a therapy that would affect their fertility status, such as chemotherapy, radiotherapy, or surgery," said Dr. Anand Shridharani, a urologist at the Erlanger Health System in Chattanooga, Tenn.
The study was supported by a grant from the Eunice Kennedy Shriver National Institute for Child Health and Development. Dr. Howards and Dr. Shridharani reported having no relevant disclosures.
AT THE JOINT IFFS/ASRM MEETING
Major finding: Less than half of all women of reproductive age with a diagnosis of cancer were told by physicians that treatment might affect their fertility.
Data source: Telephone-based survey of 1,282 women in a cancer registry.
Disclosures: The study was supported by a grant from the Eunice Kennedy Shriver National Institute for Child Health and Development. Dr. Howards and Dr. Shridharani reported having no relevant disclosures.
Use of the JAK1/JAK2 inhibitor ruxolitinib in the treatment of patients with myelofibrosis
Myelofibrosis (MF), including primary MF and MF secondary to polycythemia vera or essential thrombocythemia, is a chronic, clinically heterogeneous hematologic malignancy characterized by inefficient hematopoiesis, bone marrow fibrosis, and shortened survival. Typical clinical manifestations include progressive splenomegaly, debilitating symptoms, and anemia. MF is associated with dysregulation of Janus kinase (JAK)-signal transducer and activator of transcription (JAK/STAT) pathway affecting hematopoiesis and inflammation. Ruxolitinib, an oral JAK1/JAK2 inhibitor, was approved for the treatment of patients with intermediate or high-risk MF based on the results of 2 phase 3 studies (Controlled MyeloFibrosis Study with Oral JAK Inhibitor Treatment [COMFORT]-I and COMFORT-II). In these trials, ruxolitinib treatment was associated with reductions in spleen size and symptom burden, and improvements in quality of life. The most common adverse events were dose-dependent cytopenias, which were managed by dose modifications, treatment interruptions, and red blood cell transfusions (for anemia). Ruxolitinib was effective regardless of MF type, risk status, or JAK2V617F mutation status, and across various other MF subpopulations. Two-year follow-up data from the COMFORT trials also demonstrate that ruxolitinib has durable efficacy and may be associated with a survival advantage relative to placebo and best available therapy. Preliminary data from ongoing studies support possible dosing strategies for patients with low platelet counts.
Click on the PDF icon at the top of this introduction to read the full article.
Myelofibrosis (MF), including primary MF and MF secondary to polycythemia vera or essential thrombocythemia, is a chronic, clinically heterogeneous hematologic malignancy characterized by inefficient hematopoiesis, bone marrow fibrosis, and shortened survival. Typical clinical manifestations include progressive splenomegaly, debilitating symptoms, and anemia. MF is associated with dysregulation of Janus kinase (JAK)-signal transducer and activator of transcription (JAK/STAT) pathway affecting hematopoiesis and inflammation. Ruxolitinib, an oral JAK1/JAK2 inhibitor, was approved for the treatment of patients with intermediate or high-risk MF based on the results of 2 phase 3 studies (Controlled MyeloFibrosis Study with Oral JAK Inhibitor Treatment [COMFORT]-I and COMFORT-II). In these trials, ruxolitinib treatment was associated with reductions in spleen size and symptom burden, and improvements in quality of life. The most common adverse events were dose-dependent cytopenias, which were managed by dose modifications, treatment interruptions, and red blood cell transfusions (for anemia). Ruxolitinib was effective regardless of MF type, risk status, or JAK2V617F mutation status, and across various other MF subpopulations. Two-year follow-up data from the COMFORT trials also demonstrate that ruxolitinib has durable efficacy and may be associated with a survival advantage relative to placebo and best available therapy. Preliminary data from ongoing studies support possible dosing strategies for patients with low platelet counts.
Click on the PDF icon at the top of this introduction to read the full article.
Myelofibrosis (MF), including primary MF and MF secondary to polycythemia vera or essential thrombocythemia, is a chronic, clinically heterogeneous hematologic malignancy characterized by inefficient hematopoiesis, bone marrow fibrosis, and shortened survival. Typical clinical manifestations include progressive splenomegaly, debilitating symptoms, and anemia. MF is associated with dysregulation of Janus kinase (JAK)-signal transducer and activator of transcription (JAK/STAT) pathway affecting hematopoiesis and inflammation. Ruxolitinib, an oral JAK1/JAK2 inhibitor, was approved for the treatment of patients with intermediate or high-risk MF based on the results of 2 phase 3 studies (Controlled MyeloFibrosis Study with Oral JAK Inhibitor Treatment [COMFORT]-I and COMFORT-II). In these trials, ruxolitinib treatment was associated with reductions in spleen size and symptom burden, and improvements in quality of life. The most common adverse events were dose-dependent cytopenias, which were managed by dose modifications, treatment interruptions, and red blood cell transfusions (for anemia). Ruxolitinib was effective regardless of MF type, risk status, or JAK2V617F mutation status, and across various other MF subpopulations. Two-year follow-up data from the COMFORT trials also demonstrate that ruxolitinib has durable efficacy and may be associated with a survival advantage relative to placebo and best available therapy. Preliminary data from ongoing studies support possible dosing strategies for patients with low platelet counts.
Click on the PDF icon at the top of this introduction to read the full article.
The demands of cancer survivorship: the who, what, when, where, why, and how
With an exponential increase in the number of cancer survivors over the past few decades, we have an opportunity and responsibility to effectively manage cancer survivors across the continuum of cancer care. The delivery of survivorship care requires realistic deliverables with defined outcomes that focus on cost, impact on disease management and prevention, and integration within a health care delivery model. Building a framework using defined time-points and definitions can be helpful. Due to the complex nature of delivering cancer survivorship care, it is necessary to establish collaborations with specialty providers including cardiologists, reproductive specialists, endocrinology, ophthalmology, allied health professionals and cancer rehab, to name a few. Strengthening relationships with primary care providers will enhance the transition from cancer care to primary care. Essential tools to help fulfill these goals and achieve national standards include using expert recommended treatment summaries and survivorship care plans. These tools support a shared care model with the goal of high quality, coordinated healthcare for the survivorship population. With limited evidence to guide the delivery of survivorship care and national standards looming, how do we meet the demands of cancer survivorship? This article explores the “the who, what, when, where, why and how?” of cancer survivorship care.
Click on the PDF icon at the top of this introduction to read the full article.
With an exponential increase in the number of cancer survivors over the past few decades, we have an opportunity and responsibility to effectively manage cancer survivors across the continuum of cancer care. The delivery of survivorship care requires realistic deliverables with defined outcomes that focus on cost, impact on disease management and prevention, and integration within a health care delivery model. Building a framework using defined time-points and definitions can be helpful. Due to the complex nature of delivering cancer survivorship care, it is necessary to establish collaborations with specialty providers including cardiologists, reproductive specialists, endocrinology, ophthalmology, allied health professionals and cancer rehab, to name a few. Strengthening relationships with primary care providers will enhance the transition from cancer care to primary care. Essential tools to help fulfill these goals and achieve national standards include using expert recommended treatment summaries and survivorship care plans. These tools support a shared care model with the goal of high quality, coordinated healthcare for the survivorship population. With limited evidence to guide the delivery of survivorship care and national standards looming, how do we meet the demands of cancer survivorship? This article explores the “the who, what, when, where, why and how?” of cancer survivorship care.
Click on the PDF icon at the top of this introduction to read the full article.
With an exponential increase in the number of cancer survivors over the past few decades, we have an opportunity and responsibility to effectively manage cancer survivors across the continuum of cancer care. The delivery of survivorship care requires realistic deliverables with defined outcomes that focus on cost, impact on disease management and prevention, and integration within a health care delivery model. Building a framework using defined time-points and definitions can be helpful. Due to the complex nature of delivering cancer survivorship care, it is necessary to establish collaborations with specialty providers including cardiologists, reproductive specialists, endocrinology, ophthalmology, allied health professionals and cancer rehab, to name a few. Strengthening relationships with primary care providers will enhance the transition from cancer care to primary care. Essential tools to help fulfill these goals and achieve national standards include using expert recommended treatment summaries and survivorship care plans. These tools support a shared care model with the goal of high quality, coordinated healthcare for the survivorship population. With limited evidence to guide the delivery of survivorship care and national standards looming, how do we meet the demands of cancer survivorship? This article explores the “the who, what, when, where, why and how?” of cancer survivorship care.
Click on the PDF icon at the top of this introduction to read the full article.
How to begin a survivorship program in your community oncology practice
In 2012, the United States had an estimated 12 million cancer survivors.1 In November 2005 the Institute of Medicine (IOM) issued a call to action on cancer survivorship for health care professionals to recognize challenges, treat conditions, and support our patients more comprehensively after their diagnosis with cancer.2 This support begins with educating patients about their disease and treatment, their follow-up plan, and potential complications. It involves an assessment for potential complications of disease and treatment, and intervention when warranted. Survivorship programs have emerged throughout the country, but the composition of the programs and operational process by which they are implemented are widely varied. There is some divergence about what defines a cancer survivor, though most current programs treat individuals who have undergone early stage disease treatment through palliation. The site of service where survivorship programs are delivered varies from hospital to center to clinic. The structure of the delivery mechanism can be as a consultation, assuming individuals will have usually 1 survivorship visit, or as longitudinal, setting the precedent that patients will follow up at some regular interval for continued survivorship care. The most striking variation in survivorship programs is the depth and breadth of services that they provide to their patients.
*Click on the links to the left for PDFs of the full article and related article and Commentary.
In 2012, the United States had an estimated 12 million cancer survivors.1 In November 2005 the Institute of Medicine (IOM) issued a call to action on cancer survivorship for health care professionals to recognize challenges, treat conditions, and support our patients more comprehensively after their diagnosis with cancer.2 This support begins with educating patients about their disease and treatment, their follow-up plan, and potential complications. It involves an assessment for potential complications of disease and treatment, and intervention when warranted. Survivorship programs have emerged throughout the country, but the composition of the programs and operational process by which they are implemented are widely varied. There is some divergence about what defines a cancer survivor, though most current programs treat individuals who have undergone early stage disease treatment through palliation. The site of service where survivorship programs are delivered varies from hospital to center to clinic. The structure of the delivery mechanism can be as a consultation, assuming individuals will have usually 1 survivorship visit, or as longitudinal, setting the precedent that patients will follow up at some regular interval for continued survivorship care. The most striking variation in survivorship programs is the depth and breadth of services that they provide to their patients.
*Click on the links to the left for PDFs of the full article and related article and Commentary.
In 2012, the United States had an estimated 12 million cancer survivors.1 In November 2005 the Institute of Medicine (IOM) issued a call to action on cancer survivorship for health care professionals to recognize challenges, treat conditions, and support our patients more comprehensively after their diagnosis with cancer.2 This support begins with educating patients about their disease and treatment, their follow-up plan, and potential complications. It involves an assessment for potential complications of disease and treatment, and intervention when warranted. Survivorship programs have emerged throughout the country, but the composition of the programs and operational process by which they are implemented are widely varied. There is some divergence about what defines a cancer survivor, though most current programs treat individuals who have undergone early stage disease treatment through palliation. The site of service where survivorship programs are delivered varies from hospital to center to clinic. The structure of the delivery mechanism can be as a consultation, assuming individuals will have usually 1 survivorship visit, or as longitudinal, setting the precedent that patients will follow up at some regular interval for continued survivorship care. The most striking variation in survivorship programs is the depth and breadth of services that they provide to their patients.
*Click on the links to the left for PDFs of the full article and related article and Commentary.
Survivorship in the community oncology practice
In this issue of Community Oncology, we have a focus on cancer survivorship. While oncologists are knowledgeable of the need for survivorship programs to enhance quality of care along the patient care continuum, the processes of implementation of survivorship programs outside of larger organizational systems of care delivery has been limited. For those community oncologists outside of larger care delivery systems, there is a need for tools and processes to facilitate survivorship care planning. We discuss some of those issues in this month’s issue. Jennifer Klemp has done tremendous work with survivorship care training to prepare practitioners to deliver focused survivorship care. She does this by using educational videos and tools to provide education around the needs of the cancer survivor. In addition, there is an article out of my group in Texas Oncology discussing the practical steps of implementing a survivorship care program in a community practice. We discuss key steps in implementation and highlight several free and publicly available tools to assist oncologists in the process of providing survivorship care.
*Click on the links to the left for PDFs of the full Commentary and related articles.
In this issue of Community Oncology, we have a focus on cancer survivorship. While oncologists are knowledgeable of the need for survivorship programs to enhance quality of care along the patient care continuum, the processes of implementation of survivorship programs outside of larger organizational systems of care delivery has been limited. For those community oncologists outside of larger care delivery systems, there is a need for tools and processes to facilitate survivorship care planning. We discuss some of those issues in this month’s issue. Jennifer Klemp has done tremendous work with survivorship care training to prepare practitioners to deliver focused survivorship care. She does this by using educational videos and tools to provide education around the needs of the cancer survivor. In addition, there is an article out of my group in Texas Oncology discussing the practical steps of implementing a survivorship care program in a community practice. We discuss key steps in implementation and highlight several free and publicly available tools to assist oncologists in the process of providing survivorship care.
*Click on the links to the left for PDFs of the full Commentary and related articles.
In this issue of Community Oncology, we have a focus on cancer survivorship. While oncologists are knowledgeable of the need for survivorship programs to enhance quality of care along the patient care continuum, the processes of implementation of survivorship programs outside of larger organizational systems of care delivery has been limited. For those community oncologists outside of larger care delivery systems, there is a need for tools and processes to facilitate survivorship care planning. We discuss some of those issues in this month’s issue. Jennifer Klemp has done tremendous work with survivorship care training to prepare practitioners to deliver focused survivorship care. She does this by using educational videos and tools to provide education around the needs of the cancer survivor. In addition, there is an article out of my group in Texas Oncology discussing the practical steps of implementing a survivorship care program in a community practice. We discuss key steps in implementation and highlight several free and publicly available tools to assist oncologists in the process of providing survivorship care.
*Click on the links to the left for PDFs of the full Commentary and related articles.
Hospice usage up but not delivered soon enough, study finds
LEBANON, N.H. – Medicare patients with advanced cancer are more likely to receive hospice care than in previous years, although it is still too late in their treatment to deliver the full benefits of palliative care, according to a report issued by the Dartmouth Institute for Health Policy and Clinical Practice.
The report also states that geography and the treatment styles favored by individual health systems, rather than patient preferences, drive the level of intensive, end-of-life treatments used.
The findings are part of the Dartmouth Atlas Project, which uses Medicare data to examine how health care resources are allocated nationally. The report is the institute’s first longitudinal analysis of trends in end-of-life care for advanced cancer patients across regions, academic medical centers, and National Cancer Institute–designated cancer centers.
Controlling for patient age, sex, race, tumor type, and non–cancer-related comorbidities, the investigators found that, when compared with similar data collected from 2003 to 2007 and published by the institute in 2010, the number of advanced cancer patients on Medicare dying in the hospital decreased by an average of 28.8% during 2003-2007 to 24.7% in 2010. An increase from 54.6% to 61.3% in the number of patients who were enrolled in hospice in the last month of life was also found. The number of patients for whom hospice was initiated during the last 3 days of life increased from 8.3% during 2003-2007 to 10.9% in 2010.
When asked in an interview about the importance of starting hospice sooner in terminal care, Dr. Lorenzo Norris, director of psycho-oncology services at George Washington University Medical Center in Washington, said, "The biggest misconception is that hospice is strictly for end of life. Palliative care is just good medicine. If you limit the hospice care to the last 3 days, you’ve already limited the options a patient has. If you offer palliative care 5 or 6 months out, you can start reducing symptom burdens and increase a patient’s quality of life, which is very important because during that last year to 6 months is when patients are finishing unresolved financial and relationship issues. Palliative care allows them to more fully engage in their life."
When viewed according to the medical center delivering the care, between 13% and 50% of Medicare patients with advanced cancer died in a hospital in 2010, rather than in a hospice setting – typically the patient’s home. These figures include data from NCI-designated cancer centers. Hospice treatment in the last month of life for patients treated in mid- and northwestern states such as Oregon and Iowa trended as much as nearly 50% higher than in places such as Alaska and New York City.
Addressing the reasons for regional variations in care, Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., wrote in an accompanying editorial that, "Previous research has also shown that regional supply of health care resources, such as hospital and intensive care beds and imaging equipment, is one driver of the intensity of care, irrespective of the patient’s particular condition or illness level."
The analysts found the overall rate of ICU admissions for treatments such as intubation, a feeding tube, or cardiopulmonary resuscitation during the last month of life increased from 23.7% in the period between 2003 and 2007 to 28.8% in 2010. The number of days patients spent in the ICU in the last month of life varied more than fivefold across all centers, the analysts wrote.
"Our research continues to find that patients with advanced cancer are often receiving aggressive care until their final days, when we know that most patients would prefer care directed toward a better quality of life through hospice and palliative services. The increase in patients admitted to hospice care only days before death suggests that hospice services are often provided too late to provide much benefit," Dr. David C. Goodman, coprincipal investigator for the Dartmouth Atlas Project, said in a statement.
When asked why some oncologists are not referring their patients to hospice sooner, Dr. Clifford Hudis, president of the American Society of Clinical Oncology said, "There are many circumstances, based on culture, family dynamics, and patient’s wishes, where it is hard to communicate the value of hospice services. Some patients remain fearful of the very word and, in some situations, there is an unwillingness to acknowledge the severity of illnesses. These barriers can often be overcome through an increase in communication between doctors and patients about care goals and wishes."
When asked about the potential economic implications of the data, Dr. Goodman said, "The goal of better end-of-life care is to improve patient well-being. Often, it is less expensive to provide good care that patients want, [rather] than the usual care that patients receive."
The report also indicated that the number of patients who saw 10 or more different physicians during the last six months of their lives rose from 46.2% to 58.5%. The analysts interpreted this to mean "more patients may have experienced fragmented care."
In a statement Dr. Hudis encouraged the oncology community to "keep striving to deliver the right care at the right time." In an e-mail interview, Dr. Hudis wrote that, "The overall trend is a good one because it is concordant with the overall goals of ASCO: to make sure that every patient has access to the highest quality care throughout their disease experience."
Dr. Goodman and Dr. Byock report no relevant disclosures. The report was principally funded by the Robert Wood Johnson Foundation, with support from a consortium of funders including the WellPoint Foundation, the United Health Foundation, and the California HealthCare Foundation.
LEBANON, N.H. – Medicare patients with advanced cancer are more likely to receive hospice care than in previous years, although it is still too late in their treatment to deliver the full benefits of palliative care, according to a report issued by the Dartmouth Institute for Health Policy and Clinical Practice.
The report also states that geography and the treatment styles favored by individual health systems, rather than patient preferences, drive the level of intensive, end-of-life treatments used.
The findings are part of the Dartmouth Atlas Project, which uses Medicare data to examine how health care resources are allocated nationally. The report is the institute’s first longitudinal analysis of trends in end-of-life care for advanced cancer patients across regions, academic medical centers, and National Cancer Institute–designated cancer centers.
Controlling for patient age, sex, race, tumor type, and non–cancer-related comorbidities, the investigators found that, when compared with similar data collected from 2003 to 2007 and published by the institute in 2010, the number of advanced cancer patients on Medicare dying in the hospital decreased by an average of 28.8% during 2003-2007 to 24.7% in 2010. An increase from 54.6% to 61.3% in the number of patients who were enrolled in hospice in the last month of life was also found. The number of patients for whom hospice was initiated during the last 3 days of life increased from 8.3% during 2003-2007 to 10.9% in 2010.
When asked in an interview about the importance of starting hospice sooner in terminal care, Dr. Lorenzo Norris, director of psycho-oncology services at George Washington University Medical Center in Washington, said, "The biggest misconception is that hospice is strictly for end of life. Palliative care is just good medicine. If you limit the hospice care to the last 3 days, you’ve already limited the options a patient has. If you offer palliative care 5 or 6 months out, you can start reducing symptom burdens and increase a patient’s quality of life, which is very important because during that last year to 6 months is when patients are finishing unresolved financial and relationship issues. Palliative care allows them to more fully engage in their life."
When viewed according to the medical center delivering the care, between 13% and 50% of Medicare patients with advanced cancer died in a hospital in 2010, rather than in a hospice setting – typically the patient’s home. These figures include data from NCI-designated cancer centers. Hospice treatment in the last month of life for patients treated in mid- and northwestern states such as Oregon and Iowa trended as much as nearly 50% higher than in places such as Alaska and New York City.
Addressing the reasons for regional variations in care, Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., wrote in an accompanying editorial that, "Previous research has also shown that regional supply of health care resources, such as hospital and intensive care beds and imaging equipment, is one driver of the intensity of care, irrespective of the patient’s particular condition or illness level."
The analysts found the overall rate of ICU admissions for treatments such as intubation, a feeding tube, or cardiopulmonary resuscitation during the last month of life increased from 23.7% in the period between 2003 and 2007 to 28.8% in 2010. The number of days patients spent in the ICU in the last month of life varied more than fivefold across all centers, the analysts wrote.
"Our research continues to find that patients with advanced cancer are often receiving aggressive care until their final days, when we know that most patients would prefer care directed toward a better quality of life through hospice and palliative services. The increase in patients admitted to hospice care only days before death suggests that hospice services are often provided too late to provide much benefit," Dr. David C. Goodman, coprincipal investigator for the Dartmouth Atlas Project, said in a statement.
When asked why some oncologists are not referring their patients to hospice sooner, Dr. Clifford Hudis, president of the American Society of Clinical Oncology said, "There are many circumstances, based on culture, family dynamics, and patient’s wishes, where it is hard to communicate the value of hospice services. Some patients remain fearful of the very word and, in some situations, there is an unwillingness to acknowledge the severity of illnesses. These barriers can often be overcome through an increase in communication between doctors and patients about care goals and wishes."
When asked about the potential economic implications of the data, Dr. Goodman said, "The goal of better end-of-life care is to improve patient well-being. Often, it is less expensive to provide good care that patients want, [rather] than the usual care that patients receive."
The report also indicated that the number of patients who saw 10 or more different physicians during the last six months of their lives rose from 46.2% to 58.5%. The analysts interpreted this to mean "more patients may have experienced fragmented care."
In a statement Dr. Hudis encouraged the oncology community to "keep striving to deliver the right care at the right time." In an e-mail interview, Dr. Hudis wrote that, "The overall trend is a good one because it is concordant with the overall goals of ASCO: to make sure that every patient has access to the highest quality care throughout their disease experience."
Dr. Goodman and Dr. Byock report no relevant disclosures. The report was principally funded by the Robert Wood Johnson Foundation, with support from a consortium of funders including the WellPoint Foundation, the United Health Foundation, and the California HealthCare Foundation.
LEBANON, N.H. – Medicare patients with advanced cancer are more likely to receive hospice care than in previous years, although it is still too late in their treatment to deliver the full benefits of palliative care, according to a report issued by the Dartmouth Institute for Health Policy and Clinical Practice.
The report also states that geography and the treatment styles favored by individual health systems, rather than patient preferences, drive the level of intensive, end-of-life treatments used.
The findings are part of the Dartmouth Atlas Project, which uses Medicare data to examine how health care resources are allocated nationally. The report is the institute’s first longitudinal analysis of trends in end-of-life care for advanced cancer patients across regions, academic medical centers, and National Cancer Institute–designated cancer centers.
Controlling for patient age, sex, race, tumor type, and non–cancer-related comorbidities, the investigators found that, when compared with similar data collected from 2003 to 2007 and published by the institute in 2010, the number of advanced cancer patients on Medicare dying in the hospital decreased by an average of 28.8% during 2003-2007 to 24.7% in 2010. An increase from 54.6% to 61.3% in the number of patients who were enrolled in hospice in the last month of life was also found. The number of patients for whom hospice was initiated during the last 3 days of life increased from 8.3% during 2003-2007 to 10.9% in 2010.
When asked in an interview about the importance of starting hospice sooner in terminal care, Dr. Lorenzo Norris, director of psycho-oncology services at George Washington University Medical Center in Washington, said, "The biggest misconception is that hospice is strictly for end of life. Palliative care is just good medicine. If you limit the hospice care to the last 3 days, you’ve already limited the options a patient has. If you offer palliative care 5 or 6 months out, you can start reducing symptom burdens and increase a patient’s quality of life, which is very important because during that last year to 6 months is when patients are finishing unresolved financial and relationship issues. Palliative care allows them to more fully engage in their life."
When viewed according to the medical center delivering the care, between 13% and 50% of Medicare patients with advanced cancer died in a hospital in 2010, rather than in a hospice setting – typically the patient’s home. These figures include data from NCI-designated cancer centers. Hospice treatment in the last month of life for patients treated in mid- and northwestern states such as Oregon and Iowa trended as much as nearly 50% higher than in places such as Alaska and New York City.
Addressing the reasons for regional variations in care, Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., wrote in an accompanying editorial that, "Previous research has also shown that regional supply of health care resources, such as hospital and intensive care beds and imaging equipment, is one driver of the intensity of care, irrespective of the patient’s particular condition or illness level."
The analysts found the overall rate of ICU admissions for treatments such as intubation, a feeding tube, or cardiopulmonary resuscitation during the last month of life increased from 23.7% in the period between 2003 and 2007 to 28.8% in 2010. The number of days patients spent in the ICU in the last month of life varied more than fivefold across all centers, the analysts wrote.
"Our research continues to find that patients with advanced cancer are often receiving aggressive care until their final days, when we know that most patients would prefer care directed toward a better quality of life through hospice and palliative services. The increase in patients admitted to hospice care only days before death suggests that hospice services are often provided too late to provide much benefit," Dr. David C. Goodman, coprincipal investigator for the Dartmouth Atlas Project, said in a statement.
When asked why some oncologists are not referring their patients to hospice sooner, Dr. Clifford Hudis, president of the American Society of Clinical Oncology said, "There are many circumstances, based on culture, family dynamics, and patient’s wishes, where it is hard to communicate the value of hospice services. Some patients remain fearful of the very word and, in some situations, there is an unwillingness to acknowledge the severity of illnesses. These barriers can often be overcome through an increase in communication between doctors and patients about care goals and wishes."
When asked about the potential economic implications of the data, Dr. Goodman said, "The goal of better end-of-life care is to improve patient well-being. Often, it is less expensive to provide good care that patients want, [rather] than the usual care that patients receive."
The report also indicated that the number of patients who saw 10 or more different physicians during the last six months of their lives rose from 46.2% to 58.5%. The analysts interpreted this to mean "more patients may have experienced fragmented care."
In a statement Dr. Hudis encouraged the oncology community to "keep striving to deliver the right care at the right time." In an e-mail interview, Dr. Hudis wrote that, "The overall trend is a good one because it is concordant with the overall goals of ASCO: to make sure that every patient has access to the highest quality care throughout their disease experience."
Dr. Goodman and Dr. Byock report no relevant disclosures. The report was principally funded by the Robert Wood Johnson Foundation, with support from a consortium of funders including the WellPoint Foundation, the United Health Foundation, and the California HealthCare Foundation.
EXPERT ANALYSIS FROM THE DARTMOUTH ATLAS PROJECT
Minimizing cancer’s impact on bone with denosumab: current and future perspectives
Bone metastasis is a serious complication of advanced cancer. It is most commonly observed in patients with metastatic breast and prostate cancers, but also occurs in most other metastatic solid cancers. Without treatment, patients may experience complications including intractable bone pain, hypercalcemia, fracture, spinal cord compression and/or a requirement for surgical or radiotherapeutic intervention. In 2010, denosumab, a fully human monoclonal antibody that inhibits RANK ligand (RANKL) and subsequent osteoclast-mediated bone destruction, was approved by the Food and Drug Administration for the prevention of skeletal-related events (SREs) in patients with bone metastases from solid tumors. This article reviews the role of denosumab in preventing SREs due to bone metastases, treating bone loss due to hormone-ablative cancer therapies, and describes denosumab’s safety profile and potential future indications under investigation.
Click on the PDF icon at the top of this introduction to read the full article.
Bone metastasis is a serious complication of advanced cancer. It is most commonly observed in patients with metastatic breast and prostate cancers, but also occurs in most other metastatic solid cancers. Without treatment, patients may experience complications including intractable bone pain, hypercalcemia, fracture, spinal cord compression and/or a requirement for surgical or radiotherapeutic intervention. In 2010, denosumab, a fully human monoclonal antibody that inhibits RANK ligand (RANKL) and subsequent osteoclast-mediated bone destruction, was approved by the Food and Drug Administration for the prevention of skeletal-related events (SREs) in patients with bone metastases from solid tumors. This article reviews the role of denosumab in preventing SREs due to bone metastases, treating bone loss due to hormone-ablative cancer therapies, and describes denosumab’s safety profile and potential future indications under investigation.
Click on the PDF icon at the top of this introduction to read the full article.
Bone metastasis is a serious complication of advanced cancer. It is most commonly observed in patients with metastatic breast and prostate cancers, but also occurs in most other metastatic solid cancers. Without treatment, patients may experience complications including intractable bone pain, hypercalcemia, fracture, spinal cord compression and/or a requirement for surgical or radiotherapeutic intervention. In 2010, denosumab, a fully human monoclonal antibody that inhibits RANK ligand (RANKL) and subsequent osteoclast-mediated bone destruction, was approved by the Food and Drug Administration for the prevention of skeletal-related events (SREs) in patients with bone metastases from solid tumors. This article reviews the role of denosumab in preventing SREs due to bone metastases, treating bone loss due to hormone-ablative cancer therapies, and describes denosumab’s safety profile and potential future indications under investigation.
Click on the PDF icon at the top of this introduction to read the full article.
Improving access with a collaborative approach to cancer genetic counseling services: a pilot study
Background Limited access to cancer genetic counselors (GC) may result in the lack of patient identification and/or failure to show due to travel distance and complicated treatment schedules.
Objective We hypothesized that access would improve when a GC collaborated with distant nongenetics health care providers to provide services locally.
Methods Patients at a collaborative site were offered a risk assessment survey that was reviewed remotely by a licensed, boardcertified GC. Patients were triaged such that the onsite registered nurse (RN) provided basic risk assessment and offered genetic testing for straight-forward hereditary breast and ovarian cases. Ongoing training and support was provided by the GC. Followup and complex cases were scheduled with the GC during a monthly outreach visit to the collaborative site.
Results During the 1-year study period, the total number of patients who accessed genetic counseling services from the target region was 4 times greater than the previous year. Ten of 17 patients who were triaged for genetic counseling and testing underwent genetic risk assessment services as a result of this identification and triage protocol.
Conclusion This defines a workable approach for patient identification and triage for hereditary cancer risk assessment and genetic counseling in a community setting. This collaborative approach may be applicable to centers that do not have access to a board-certified GC, especially important in light of the 2012 Commission on Cancer Standards that require cancer risk assessment, genetic counseling and testing services on site or by referral.
Click on the PDF icon at the top of this introduction to read the full article.
Background Limited access to cancer genetic counselors (GC) may result in the lack of patient identification and/or failure to show due to travel distance and complicated treatment schedules.
Objective We hypothesized that access would improve when a GC collaborated with distant nongenetics health care providers to provide services locally.
Methods Patients at a collaborative site were offered a risk assessment survey that was reviewed remotely by a licensed, boardcertified GC. Patients were triaged such that the onsite registered nurse (RN) provided basic risk assessment and offered genetic testing for straight-forward hereditary breast and ovarian cases. Ongoing training and support was provided by the GC. Followup and complex cases were scheduled with the GC during a monthly outreach visit to the collaborative site.
Results During the 1-year study period, the total number of patients who accessed genetic counseling services from the target region was 4 times greater than the previous year. Ten of 17 patients who were triaged for genetic counseling and testing underwent genetic risk assessment services as a result of this identification and triage protocol.
Conclusion This defines a workable approach for patient identification and triage for hereditary cancer risk assessment and genetic counseling in a community setting. This collaborative approach may be applicable to centers that do not have access to a board-certified GC, especially important in light of the 2012 Commission on Cancer Standards that require cancer risk assessment, genetic counseling and testing services on site or by referral.
Click on the PDF icon at the top of this introduction to read the full article.
Background Limited access to cancer genetic counselors (GC) may result in the lack of patient identification and/or failure to show due to travel distance and complicated treatment schedules.
Objective We hypothesized that access would improve when a GC collaborated with distant nongenetics health care providers to provide services locally.
Methods Patients at a collaborative site were offered a risk assessment survey that was reviewed remotely by a licensed, boardcertified GC. Patients were triaged such that the onsite registered nurse (RN) provided basic risk assessment and offered genetic testing for straight-forward hereditary breast and ovarian cases. Ongoing training and support was provided by the GC. Followup and complex cases were scheduled with the GC during a monthly outreach visit to the collaborative site.
Results During the 1-year study period, the total number of patients who accessed genetic counseling services from the target region was 4 times greater than the previous year. Ten of 17 patients who were triaged for genetic counseling and testing underwent genetic risk assessment services as a result of this identification and triage protocol.
Conclusion This defines a workable approach for patient identification and triage for hereditary cancer risk assessment and genetic counseling in a community setting. This collaborative approach may be applicable to centers that do not have access to a board-certified GC, especially important in light of the 2012 Commission on Cancer Standards that require cancer risk assessment, genetic counseling and testing services on site or by referral.
Click on the PDF icon at the top of this introduction to read the full article.
Reconciling patient access to care
One of the major features of the Patient Protection and Affordable Care Act is its potential to insure some of the estimated 35 million Americans who are currently uninsured, without regard to whether or not they have pre-existing conditions. Of course, that will stress our already overburdened health system to provide both care and caregivers. To that end, Renteria and colleagues describe the access to care and treatment of locally advanced pancreatic cancer in a socio-economically challenged population. Their analyses reveal that it can be done but it requires, in their words, “intense supportive services,” which highlights how those with poor or little insurance can still have the outcomes similar to those in clinical trials if the system rises to the occasion and makes the extra effort to deliver the appropriate care and treatment. One can only imagine what things will be like when those 35 million have guaranteed insurance-based access to care.
*Click on the links to the left for PDFs of the full Editorial and related articles.
One of the major features of the Patient Protection and Affordable Care Act is its potential to insure some of the estimated 35 million Americans who are currently uninsured, without regard to whether or not they have pre-existing conditions. Of course, that will stress our already overburdened health system to provide both care and caregivers. To that end, Renteria and colleagues describe the access to care and treatment of locally advanced pancreatic cancer in a socio-economically challenged population. Their analyses reveal that it can be done but it requires, in their words, “intense supportive services,” which highlights how those with poor or little insurance can still have the outcomes similar to those in clinical trials if the system rises to the occasion and makes the extra effort to deliver the appropriate care and treatment. One can only imagine what things will be like when those 35 million have guaranteed insurance-based access to care.
*Click on the links to the left for PDFs of the full Editorial and related articles.
One of the major features of the Patient Protection and Affordable Care Act is its potential to insure some of the estimated 35 million Americans who are currently uninsured, without regard to whether or not they have pre-existing conditions. Of course, that will stress our already overburdened health system to provide both care and caregivers. To that end, Renteria and colleagues describe the access to care and treatment of locally advanced pancreatic cancer in a socio-economically challenged population. Their analyses reveal that it can be done but it requires, in their words, “intense supportive services,” which highlights how those with poor or little insurance can still have the outcomes similar to those in clinical trials if the system rises to the occasion and makes the extra effort to deliver the appropriate care and treatment. One can only imagine what things will be like when those 35 million have guaranteed insurance-based access to care.
*Click on the links to the left for PDFs of the full Editorial and related articles.
How can social media improve oncology care?
Social media is a broad term that can include many types of “media.” Broadly speaking, media may be defined as “tools used to store and deliver information or data,” and social media is “media disseminated through social interaction.”1 So social media is more than just Twitter or Facebook posts, it includes all sorts of socially interactive information exchange. Kaplan and Haenlein described 6 types of social media (see Table 1).2 A similar social media organizational structure is used on the HowTo.gov site, a US government Web site best described as a resource to help government workers deliver a better customer experience to citizens (see Table 2 for a glossary of social media terms3).
*Click on the link to the left for a PDF of the full article.
Social media is a broad term that can include many types of “media.” Broadly speaking, media may be defined as “tools used to store and deliver information or data,” and social media is “media disseminated through social interaction.”1 So social media is more than just Twitter or Facebook posts, it includes all sorts of socially interactive information exchange. Kaplan and Haenlein described 6 types of social media (see Table 1).2 A similar social media organizational structure is used on the HowTo.gov site, a US government Web site best described as a resource to help government workers deliver a better customer experience to citizens (see Table 2 for a glossary of social media terms3).
*Click on the link to the left for a PDF of the full article.
Social media is a broad term that can include many types of “media.” Broadly speaking, media may be defined as “tools used to store and deliver information or data,” and social media is “media disseminated through social interaction.”1 So social media is more than just Twitter or Facebook posts, it includes all sorts of socially interactive information exchange. Kaplan and Haenlein described 6 types of social media (see Table 1).2 A similar social media organizational structure is used on the HowTo.gov site, a US government Web site best described as a resource to help government workers deliver a better customer experience to citizens (see Table 2 for a glossary of social media terms3).
*Click on the link to the left for a PDF of the full article.