Publications by authors named "Janet L Williams"

96 Publications

Do research participants share genomic screening results with family members?

J Genet Couns 2021 Oct 19. Epub 2021 Oct 19.

Division of Genetics and Genomics and the Manton Center for Orphan Diseases Research, Boston Children's Hospital, Boston, MA, USA.

The public health impact of genomic screening can be enhanced by cascade testing. However, cascade testing depends on communication of results to family members. While the barriers and facilitators of family communication have been researched following clinical genetic testing, the factors impacting the dissemination of genomic screening results are unknown. Using the pragmatic Electronic Medical Records and Genomics Network-3 (eMERGE-3) study, we explored the reported sharing practices of participants who underwent genomic screening across the United States. Six eMERGE-3 sites returned genomic screening results for mostly dominant medically actionable disorders and surveyed adult participants regarding communication of results with first-degree relatives. Across the sites, 279 participants completed a 1-month and/or 6-month post-results survey. By 6 months, only 34% of the 156 respondents shared their results with all first-degree relatives and 4% did not share with any. Over a third (39%) first-degree relatives were not notified of the results. Half (53%) of participants who received their results from a genetics provider shared them with all first-degree relatives compared with 11% of participants who received their results from a non-genetics provider. The most frequent reasons for sharing were a feeling of obligation (72%) and that the information could help family members make medical decisions (72%). The most common reasons indicated for not sharing were that the family members were too young (38%), or they were not in contact (25%) or not close to them (25%). These data indicate that the professional returning the results may impact sharing patterns, suggesting that there is a need to continue to educate healthcare providers regarding approaches to facilitate sharing of genetic results within families. Finally, these data suggest that interventions to increase sharing may be universally effective regardless of the origin of the genetic result.
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http://dx.doi.org/10.1002/jgc4.1511DOI Listing
October 2021

Penetrance of Breast Cancer Susceptibility Genes From the eMERGE III Network.

JNCI Cancer Spectr 2021 Aug 8;5(4):pkab044. Epub 2021 May 8.

Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA.

Background: Unbiased estimates of penetrance are challenging but critically important to make informed choices about strategies for risk management through increased surveillance and risk-reducing interventions.

Methods: We studied the penetrance and clinical outcomes of 7 breast cancer susceptibility genes (, , , , , , and ) in almost 13 458 participants unselected for personal or family history of breast cancer. We identified 242 female participants with pathogenic or likely pathogenic variants in 1 of the 7 genes for penetrance analyses, and 147 women did not previously know their genetic results.

Results: Out of the 147 women, 32 women were diagnosed with breast cancer at an average age of 52.8 years. Estimated penetrance by age 60 years ranged from 17.8% to 43.8%, depending on the gene. In clinical-impact analysis, 42.3% (95% confidence interval = 31.3% to 53.3%) of women had taken actions related to their genetic results, and 2 new breast cancer cases were identified within the first 12 months after genetic results disclosure.

Conclusions: Our study provides population-based penetrance estimates for the understudied genes , , and and highlights the importance of using unselected populations for penetrance studies. It also demonstrates the potential clinical impact of genetic testing to improve health care through early diagnosis and preventative screening.
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http://dx.doi.org/10.1093/jncics/pkab044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8346699PMC
August 2021

Anamorelin combined with physical activity, and nutritional counseling for cancer-related fatigue: a preliminary study.

Support Care Cancer 2021 Jul 31. Epub 2021 Jul 31.

Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA.

Purpose: Cancer-related fatigue (CRF) is the most frequent and debilitating symptom in patients with advanced cancer. There are limited effective treatments for CRF. The objective of this prospective longitudinal study was to evaluate the change in CRF at Day 43 after treatment with combination therapy of oral Anamorelin 100 mg daily with physical activity and nutrition counseling.

Methods: In this study, patients with CRF [≤ 34 Functional Assessment of Chronic Illness Therapy-Fatigue subscales(FACIT-F)] received Anamorelin 100 mg orally daily with standardized physical activity and nutrition counseling for 43 days. Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Anorexia Cachexia(FAACT-ACS), Multidimensional Fatigue Symptom Inventory-Short Form(MFSI-SF), Patient-Reported Outcomes Measurement Information System(PROMIS-Fatigue), body composition, and physical performance tests were assessed at baseline, Day 15, 29, and 43. Frequency and type of side effects were determined by NCI CTAE 4.0.(NCT03035409).

Results: 28/45 (62%) of patients dosed were evaluable at Day 43. The mean, SD for FACIT-F subscale improvement from baseline was 4.89 (± 13.07), P = .058, MFSI-SF (G) - 3.46 (± 6.86), P = 0.013, PROMIS-fatigue - 4.14 (± 7.88), P = 0.010, FAACT ACS 3.48 (± 8.13), P = 0.035. Godin Liesure-Time physical activity questionnaire 7.41 (± 16.50), P = 0.038. Weight (kg) 1.81 (± 2.63), P = 0.005, and Lean Body Mass 1.54 (± 1.85), P = 0.001, IGF-1 36.50 (± 48.76), P = 0.015. There was no significant improvement in physical performance outcomes. No adverse events > grade 3 related to the study drug were reported.

Conclusion: The use of the combination therapy was associated with improvement of CRF (FACIT-F fatigue, PROMIS-fatigue, MFSI-SF-general), activity (Godin-leisure time), anorexia (FAACT), body composition, and IGF-1 levels. Further studies using combination therapy for CRF are justified.
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http://dx.doi.org/10.1007/s00520-021-06463-8DOI Listing
July 2021

What guidance does HIPAA offer to providers considering familial risk notification and cascade genetic testing?

J Law Biosci 2020 Jan-Dec;7(1):lsaa071. Epub 2020 Dec 11.

University of Iowa, College of Law, Iowa City, IA, USA.

Background: It is unclear how the Health Insurance Portability and Accountability Act (HIPAA) should be interpreted in the context of sharing of genomic information between family members.

Methods: The authors analyzed the HIPAA Privacy Rule, reviewed the literature and constructed a clinical scenario to inform how HIPAA can be interpreted for multiple forms of patient- and provider-mediated genetic risk notification.

Results: Under HIPAA, healthcare providers can lawfully notify relatives to recommend genetic risk assessment using multiple approaches, including supporting the patient telling their own relatives, contacting relatives directly with the patient's authorization, or contacting a relative's provider directly.

Conclusions: Multiple forms of patient- or provider-mediated contact of relatives are already legally permissible under HIPAA, are consistent with ethical obligations of care to patients and their families, and could result in improved population health through identification of clinically actionable disease risk. Unanswered questions remain about implementation and impacts of provider-mediated programs.
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http://dx.doi.org/10.1093/jlb/lsaa071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8249115PMC
December 2020

Genetic Factors Associated With Pain Severity, Daily Opioid Dose Requirement, and Pain Response Among Advanced Cancer Patients Receiving Supportive Care.

J Pain Symptom Manage 2021 10 10;62(4):785-795. Epub 2021 Apr 10.

Department of Palliative care, Rehabilitation Medicine, and Integrative Medicine UT MD Anderson Cancer Center (S.Y., C.R.-G., Z.L., J.L.W., S.-C.Y., A.E.A., E.B.), Houston, Texas.

Background: Current understanding of genetic factors associated with pain severity, and improvement of pain with opioids in advanced cancer patients (AC) is inadequate for delivery of personalized pain therapy (PPT). Therefore, the aim of this study was to determine the genetic factors associated with pain severity, daily opioid dose, and pain response in AC patients receiving supportive care.

Methods: In this prospective study, AC patients were eligible if they had cancer pain ≥4/10 on Edmonton Symptom Assessment Scale (ESAS) - Pain Item and needed opioid rotation for pain control by specialist at the outpatient supportive care center. Association of genetic factors with pain phenotype was assessed using logistic regression models and SKATO (Gene-block) analysis.

Results: About 174/178 (98%) patient samples were analyzed. After adjustment for demographic and clinical variables, pain severity was negatively associated with intron variant alleles in OPRM1 rs9322446, P = 0.02; rs2270459, P = 0.038; rs62052210, P = 0.038. Opioid daily dose was positively associated NFKBIA rs2233419, P = 0.008; rs2233417, P = 0.007; rs3138054, P = 0.008; rs1050851, P = 0.015; ORPM1 rs9479759, P = 0.046; rs2003185, P = 0.047; rs636433, P = 0.044; COMT (rs9306234, P = 0.014; rs165728, P = 0.014; rs2020917, P = 0.036; rs165728, P = 0.034); ARRB2 (rs1045280, P = 0.045); and pain response to opioids was negatively associated OPRM1 rs1319339, P = 0.024; rs34427887, P = 0.048; and COMT rs4646316, P = 0.03; rs35478083, P = 0.028, respectively. SKATO analysis showed association between pain severity and CXCL8 (P = 0.0056), and STAT6 (P = 0.0297) genes respectively, and pain response with IL-6 (P = 0.00499).

Conclusions: This study identified that SNPs of OPRM1, COMT, NFKBIA, CXCL8, IL-6, STAT6, and ARRB2 genes were associated with pain severity, opioid daily dose, and pain response in AC receiving supportive care. Additional studies are needed to validate our findings for PPT.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.03.024DOI Listing
October 2021

Exercise Barriers and Adherence to Recommendations in Patients With Cancer.

JCO Oncol Pract 2021 07 19;17(7):e972-e981. Epub 2021 Mar 19.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: The American College of Sports Medicine exercise guidelines for cancer survivors encourage a combination of 150 minutes of moderate-intensity aerobic activity and 2-3 weekly sessions of strength training. Cancer survivors often experience more barriers to meeting recommended guidelines because of side effects from cancer treatments. Our aim was to measure the cancer survivors' adherence and barriers with these recommendations.

Methods: Two hundred adult cancer survivors completed surveys (Stanford Patient Education Research Center Exercise Behaviors Survey and an exercise barrier scale) reporting their physical activity, barriers to physical activity, and symptom assessment.

Results: A total of 68/200 participants (34%) reported adhering to the recommended physical activity guidelines of 150 minutes or more per week. Those who adhered to the guidelines reported fewer barriers to exercise (mean of 2.44 compared with 4.15 barriers, < .0001). Female participants ( = .01), higher number of barriers, and feeling of poor well-being were less likely to report at least 60 or 150 minutes of exercise time. Lack of interest ( = .003) and self-discipline ( = .001) were reported as barriers. These participants were more likely to report high symptom burden of pain ( = .007) and fatigue ( = .005). Participants who reported < 60 minutes of exercise reported lack of enjoyment ( = .03), lack of equipment ( = .01), and symptoms of poor appetite, poor well-being, and increased dyspnea.

Conclusion: Although recommendations are given for exercise, adherence to recommendations is low. Issues of motivation, including lack of interest and self-discipline, and symptoms of pain and fatigue were some of the main reported barriers to adhering to the recommended exercise guidelines. Therefore, interventions aimed at increasing motivation and treating symptoms could improve cancer survivor adherence to recommended exercise guidelines.
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http://dx.doi.org/10.1200/OP.20.00625DOI Listing
July 2021

An Integrated Approach to Selecting a Prepared Medical Decision-Maker.

J Pain Symptom Manage 2021 06 24;61(6):1305-1310. Epub 2020 Dec 24.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Background: We implemented a systematic multidisciplinary process to engage new outpatients with cancer in selecting and preparing a medical decision-maker.

Measures: Templated advance care planning notes and medical power of attorney documents were used in the electronic health record by the third office visit.

Intervention: Patients were coached to meet with social work from a "culture of yes," viewed a video about the importance of selecting a prepared medical a decision-maker in English or in Spanish, and referenced cards containing simple explanations of advance directives when responding to advance directive questions.

Outcomes: A total of 351 patients were evaluated. By visit 3, there was no increase in documented social work advance care planning notes in intervention or scanned medical power of attorney documents in the electronic health record.

Conclusions/lessons Learned: This systematic multidisciplinary approach did not engage new outpatients with cancer in preparing a medical decision-maker. More active physician involvement and varied ways of engagement are needed.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.12.006DOI Listing
June 2021

Empowering the Health and Well-Being of the Palliative Care Workforce: Evaluation of a Weekly Self-Care Checklist.

J Pain Symptom Manage 2021 04 23;61(4):817-823. Epub 2020 Sep 23.

Department of Palliative Care, Rehabilitation and Integrative Medicine, Houston, Texas, USA. Electronic address:

Background: Workplace interventions are needed to prevent burnout and support the well-being of the palliative care workforce.

Measures: We conducted a survey of all palliative care clinical staff to evaluate the usefulness and feasibility of checklist items and the checklist itself. We collected demographics, perceptions of professional satisfaction and burnout, and qualitative feedback aimed at improving the checklist.

Intervention: We implemented a 13-item self-care checklist, included in a handbook on palliative care carried in the laboratory coat of all clinical personnel, to remind them to care of their own well-being.

Outcomes: Of 39 personnel contacted, 32 (82%) responded. Most (20; 62%) found the checklist useful. Exercise was the most highly ranked item, whereas watching visual arts was the lowest ranked item.

Conclusions/lessons Learned: Numerous opportunities were identified to improve the checklist and facilitate achievement of checklist items. Survey data will be used in the next checklist version.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.09.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7510423PMC
April 2021

Cancer Patients' Perception of Usefulness of Wearable Exercise Trackers.

PM R 2021 08 20;13(8):845-851. Epub 2020 Oct 20.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Objective: To determine the feasibility and perception of usefulness of wearable trackers in inpatient and outpatient cancer rehabilitation patients.

Design: Prospective study.

Setting: Acute inpatient rehabilitation and outpatient clinic at a tertiary cancer center.

Participants: Adult cancer patients (N = 100).

Interventions: Participants were provided with wearable trackers for the duration of the study.

Main Outcome Measures: Survey regarding feasibility (as defined as equal or more than two-thirds of participants reporting use of the wearable tracker) and usefulness of the wearable tracker and Edmonton Symptom Assessment Scale (ESAS-FS) in both inpatient and outpatient populations. Activity minutes, number of steps, heart rate, and sleep data were collected from the wearable tracker.

Results: Patients reported the use of a wearable tracker is feasible, with 48/50 (96%) outpatients and 47/50 (94%) inpatients reported wearing the wearable tracker daily and 37/49 (76%) outpatients and 29/50 (58%) inpatients reported that they would continue to wear the wearable tracker after this study. The majority of cancer patients (41/49 [84%] of outpatient and 33/50 [66%] of inpatient patients) reported that the wearable tracker was useful and 41/49 (84%) outpatients and 27/50 (54%) inpatients perceived the wearable tracker as helping to increase physical activity.

Conclusions: The use of wearable trackers in cancer patients is feasible and patients perceive wearable trackers as useful in both the inpatient and outpatient rehabilitation setting. Physical activity in these patients was better in the outpatient population, as expected because of less medical acuity.
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http://dx.doi.org/10.1002/pmrj.12475DOI Listing
August 2021

The development of a nomogram to determine the frequency of elevated risk for non-medical opioid use in cancer patients.

Palliat Support Care 2021 02;19(1):3-10

Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.

Objective: Non-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center.

Method: 3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. "+risk" was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk.

Results: 731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. The C-index was 0.8. A nomogram was developed and can be accessed at https://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1.

Significance Of Results: We established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.
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http://dx.doi.org/10.1017/S1478951520000322DOI Listing
February 2021

Effects of Center-Based Delivery of Tai Chi and Qi Gong Group Classes on Self-Reported Symptoms in Cancer Patients and Caregivers.

Integr Cancer Ther 2020 Jan-Dec;19:1534735420941605

The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

There is increasing interest in complementary approaches such as Tai Chi (TC) and Qi Gong (QG) in oncology settings. We explored the effects of TC/QG delivered in group classes at a comprehensive cancer center. Patients and caregivers who participated in TC or QG completed assessments before and after an in-person group class. Assessments included questions about expectancy/satisfaction and common cancer symptoms (Edmonton Symptom Assessment Scale [ESAS]). ESAS distress subscales analyzed included global (GDS), physical (PHS), and psychosocial (PSS). Three hundred four participants (184 patients, 120 caregivers) were included in the analysis. At baseline, caregivers had a greater expectancy for change in energy level as a result of class participation compared with patients (22.9% vs 9.9%). No significant difference was observed between baseline patient and caregiver PSS. Clinically significant improvement in well-being was observed among patients in TC classes (1.0) and caregivers in QG classes (1.2). For fatigue, patients (1.4) and caregivers (1.0) participating in QG experienced clinically significant improvement. Both TC and QG classes were associated with clinically significant improvements (ESAS GDS decrease ≥3) in global distress for patients (TC = 4.52, SD= 7.6; QG = 6.05, SD = 7.9) and caregivers (TC = 3.73, SD = 6.3; QG = 4.02, SD = 7.8). Eighty-nine percent of participants responded that their expectations were met. Patients and caregivers participating in TC or QG group classes were satisfied overall and experienced significant improvement in global distress. Additional research is warranted to explore the integration of TC and QG in the delivery of supportive cancer care.
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http://dx.doi.org/10.1177/1534735420941605DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374530PMC
August 2021

Cancer Patients' Perceived Difficulties Filling Opioid Prescriptions After Receiving Outpatient Supportive Care.

J Pain Symptom Manage 2020 11 20;60(5):915-922. Epub 2020 Jun 20.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA. Electronic address:

Context: Limited access to opioids for patients with cancer has been reported as a potential unintended consequence of recent regulations restricting opioid use and prescribing practices. To our knowledge, there are a limited number of peer-reviewed studies that evaluate the perceived difficulties of the patients with cancer when filling their opioid prescription. To understand these difficulties, we surveyed patients receiving opioids in our outpatient supportive care center (SCC).

Objectives: The primary objective of this study was to evaluate cancer patients' perceptions of overall difficulties when filling their opioid prescription. Secondary objectives included determining associations between patient characteristics and difficulty and comparing difficulty between filling opioid and nonopioid prescriptions.

Methods: Patients with cancer receiving opioids that had been seen two times or more at our SCC were asked to complete a survey. The information collected included patient demographics, clinical characteristics, and patients' experiences filling their opioid prescription.

Results: The patients' median age was 60 years; 54% were female and 69% were white. Forty-four patients (32%) reported that they have experienced difficulty filling their opioid prescription. More than 25% of those 44 patients perceived difficulty from interactions with the pharmacy and/or pharmacist. Forty-six patients (33%) reported more difficulty filling their opioid prescriptions than filling their nonopioid prescriptions.

Conclusion: This study provides evidence that patients with cancer visiting our SCC perceived difficulties obtaining their opioid prescriptions. The results suggest that negative interactions with the pharmacy and/or pharmacist contribute to their perceived difficulty. Additional research is needed to further characterize the contributors of the difficulties patients with cancer face in filling their opioid prescriptions.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.06.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305512PMC
November 2020

Understanding the Return of Genomic Sequencing Results Process: Content Review of Participant Summary Letters in the eMERGE Research Network.

J Pers Med 2020 May 13;10(2). Epub 2020 May 13.

Genomic Medicine Institute, Geisinger, Danville, PA 17822, USA.

A challenge in returning genomic test results to research participants is how best to communicate complex and clinically nuanced findings to participants in a manner that is scalable to the large numbers of participants enrolled. The purpose of this study was to examine the features of genetic results letters produced at each Electronic Medical Records and Genomics (eMERGE3) Network site to assess their readability and content. Letters were collected from each site, and a qualitative analysis of letter content and a quantitative analysis of readability statistics were performed. Because letters were produced independently at each eMERGE site, significant heterogeneity in readability and content was found. The content of letters varied widely from a baseline of notifying participants that results existed to more detailed information about positive or negative results, as well as materials for sharing with family members. Most letters were significantly above the Centers for Disease Control-suggested reading level for health communication. While continued effort should be applied to make letters easier to understand, the ongoing challenge of explaining complex genomic information, the implications of negative test results, and the uncertainty that comes with some types of test and result makes simplifying letter text challenging.
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http://dx.doi.org/10.3390/jpm10020038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354464PMC
May 2020

Positive impact of genetic counseling assistants on genetic counseling efficiency, patient volume, and cost in a cancer genetics clinic.

Genet Med 2020 08 30;22(8):1348-1354. Epub 2020 Apr 30.

Geisinger, Danville, PA, USA.

Purpose: Cancer genetics clinics have seen increasing demand, challenging genetic counselors (GCs) to increase efficiency and prompting some clinics to implement genetic counseling assistants (GCAs). To evaluate the impact of GCAs on Geisinger's cancer genetics clinic, we tracked GC time utilization, new patient volume, and clinic cost per patient before and after implementing a GCA program.

Methods: GCs used time-tracking software while completing preappointment activities. Electronic health records were reviewed for appointment length and number of patients per week. Internal salary data for GCs and GCAs were used to calculate clinic costs per patient.

Results: Time spent by GCs completing each preappointment activity (21.8 vs. 15.1 minutes) and appointment length (51.6 vs. 44.5 minutes) significantly decreased after GCA program implementation (p values < 0.001). New patients per week per GC significantly increased (7.9 vs. 11.4, p < 0.001). Weekly clinic cost per patient significantly decreased ($233 vs. $176, p = 0.03).

Conclusion: Implementing a GCA program increased GC efficiency in preappointment activities and clinic appointments, increased patient volume, and decreased clinic cost per patient. Such a program can improve access to GC services and assist GCs in focusing on the direct patient care for which they are specially trained.
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http://dx.doi.org/10.1038/s41436-020-0797-2DOI Listing
August 2020

Returning Results in the Genomic Era: Initial Experiences of the eMERGE Network.

J Pers Med 2020 Apr 27;10(2). Epub 2020 Apr 27.

Genomic Medicine Institute, Geisinger, Danville, PA 17822, USA.

A goal of the 3rd phase of the Electronic Medical Records and Genomics (eMERGE3) Network was to examine the return of results (RoR) of actionable variants in more than 100 genes to consenting participants and their healthcare providers. Each of the 10 eMERGE sites developed plans for three essential elements of the RoR process: Disclosure to the participant, notification of the health care provider, and integration of results into the electronic health record (EHR). Procedures and protocols around these three elements were adapted as appropriate to individual site requirements and limitations. Detailed information about the RoR procedures at each site was obtained through structured telephone interviews and follow-up surveys with the clinical investigator leading or participating in the RoR process at each eMERGE3 institution. Because RoR processes at each of the 10 sites allowed for taking into account differences in population, disease focus and institutional requirements, significant heterogeneity of process was identified, including variability in the order in which patients and clinicians were notified and results were placed in the EHR. This heterogeneity in the process flow for eMERGE3 RoR reflects the "real world" of genomic medicine in which RoR procedures must be shaped by the needs of the patients and institutional environments.
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http://dx.doi.org/10.3390/jpm10020030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354592PMC
April 2020

Place-of-death preferences among patients with cancer and family caregivers in inpatient and outpatient palliative care.

BMJ Support Palliat Care 2020 Apr 6. Epub 2020 Apr 6.

Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Objective: Meeting the preferences of patients is considered an important palliative care outcome. Prior studies reported that more than 80% of patients with terminally ill cancer prefer to die at home. The purpose of this study was to determine place-of-death preference among palliative care patients in the outpatient centre and the palliative care unit (PCU) of a comprehensive cancer centre.

Methods: A cross-sectional anonymous questionnaire was administered to patients with advanced cancer and caregivers (PCU and outpatient centre) between August 2012 and September 2014. PCU patients responded when there was no delirium and the primary caregiver responded when the patient was unable to respond. In the case of outpatients, dyads were assessed. The survey was repeated 1 month later.

Results: Overall, 65% preferred home death. There was less preference for home death among PCU patients (58%) than among outpatients (72%). Patient and caregiver agreement regarding preferred place of death for home was 86%. After 1 month, outpatients were significantly more likely than PCU patients to have the same preferred place of death as they had 1 month earlier (96% vs 83%; p=0.003).

Conclusions: Although home was the preferred place of death in our group of patients with advanced cancer and their caregivers, a substantial minority preferred hospital death or had no preference. We speculate that PCU patients' higher preference for hospital death is likely related to more severe distress because they had already tried home care. Personalised assessment of place of death preference for both patient and caregiver is needed.
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http://dx.doi.org/10.1136/bmjspcare-2019-002019DOI Listing
April 2020

Randomized Feasibility Study of Meditative Practices in Hospitalized Cancer Patients.

Integr Cancer Ther 2020 Jan-Dec;19:1534735420909903

The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

There is limited research regarding the benefits of mind-body practices such as meditation in hospitalized patients with an active diagnosis of any cancer type. We conducted a prospective, randomized, clinical trial (NCT03445572) comparing 2 meditative practices-Isha Kriya (IK) and meditative slow breathing (MSB)-versus wait-list controls in hospitalized cancer patients. Our aim was to determine the feasibility of meditation practice in cancer inpatients. Feasibility was defined as recruitment of more than 50% of the eligible patients approached and at least 60% of the patients having meditated at least 4 days by day 7. Acceptability was assessed on day 7 as a positive response on at least 2 questions on the modified Global Symptom Evaluation (GSE) scale. Forty patients (39% of the eligible patients approached) consented to participate in the study and were randomly assigned to the MSB (n = 13), IK (n = 14), or wait-list (n = 13) groups. Of the 27 patients assigned to receive MSB and IK meditations, day 7 data were available for 18 patients. Fifteen of the 18 patients meditated at least once in the first 7 days, and most (12/15) responded positively on the GSE. Both IK and MSB meditations were acceptable among the hospitalized cancer patients. Feasibility for enrollment and practice was likely not achieved due to limited uninterrupted time for daily meditation, high levels of morbidity in some participants, and limited research staff support. Shorter term outcomes should be explored in future meditation studies involving hospitalized cancer patients.
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http://dx.doi.org/10.1177/1534735420909903DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065431PMC
March 2021

Challenging the Status Quo of Physician Attire in the Palliative Care Setting.

Oncologist 2020 07 19;25(7):627-637. Epub 2020 Feb 19.

Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Background, Aim, And Hypothesis: This randomized controlled trial aimed to compare the impact of a physician's attire on the perceptions of patients with cancer of compassion, professionalism, and physician preference. Our hypothesis was that patients would perceive the physician with formal attire as more compassionate than the physician wearing casual attire.

Materials And Methods: One hundred five adult follow-up patients with advanced cancer were randomized to watch two standardized, 3-minute video vignettes with the same script, depicting a routine physician-patient clinic encounter. Videos included a physician in formal attire with tie and buttoned-up white coat and casual attire without a tie or white coat. Actors, patients, and investigators were all blinded to the purpose and videos watched, respectively. After each video, patients completed validated questionnaires rating their perception of physician compassion, professionalism, and their overall preference for the physician.

Results: There were no significant differences between formal and casual attire for compassion (median [interquartile range], 25 [10-31] vs. 20 [8-27]; p = .31) and professionalism (17 [13-21] vs. 18 [14-22]; p = .42). Thirty percent of patients preferred formal attire, 31% preferred casual attire, and 38% had no preference. Subgroup analysis did not show statistically significant differences among different cohorts of age, sex, marital status, and education level.

Conclusion: Doctors' attire did not affect the perceptions of patients with cancer of physician's level of compassion and professionalism, nor did it influence the patients' preference for their doctor or their trust and confidence in the doctor's ability to provide care. There is a need for more studies in this area of communications skills. Clinical trial identification number. NCT03168763 IMPLICATIONS FOR PRACTICE: The significance of physician attire as a means of nonverbal communication has not been well characterized. It is an important element to consider, as patient preferences vary geographically, are influenced by cultural beliefs, and may vary based on particular care settings. Previous studies consisted of nonblinded surveys and found increasing confidence in physicians wearing a professional white coat. Unfortunately, there are no randomized controlled trials, to the authors' knowledge, to confirm the survey findings. In this randomized, blinded clinical trial the researchers found that physician's attire did not affect patients' perception of the physician's level of compassion and professionalism. Attire also did not influence the patients' preferences for their doctor or their trust and confidence in the doctor's ability to provide care.
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http://dx.doi.org/10.1634/theoncologist.2019-0568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356715PMC
July 2020

Sleep disturbance in patients with cancer: a feasibility study of multimodal therapy.

BMJ Support Palliat Care 2021 Jun 10;11(2):170-179. Epub 2020 Jan 10.

Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Background: Our aim was to determine feasibility and effect sizes of bright light therapy (BLT), melatonin (MLT), methylphenidate (MP) and eight combinations (BLT+MLT+MP, BLT+MLT, BLT+MP, BLT alone, MLT+MP, MLT alone, MP alone, placebo for BLT, MLT and MP) defined as multimodal therapy (MMT), to improve sleep quality (SQ) (Pittsburgh Sleep Quality Index (PSQI)) from baseline to day 15. We also examined the effects of MMT on insomnia, fatigue, depression, quality of life and actigraphy.

Methods: Patients with advanced cancer with poor SQ (PSQI ≥5) were eligible. Using a double-blind randomised factorial study design, patients were randomised into 1 of the 8 arms for 2 weeks. Feasibility and effect sizes were assessed.

Results: 81% (54/67) of randomised patients completed the study. There were no differences in the demographics and SQ between groups. The adherence rates for BLT, MLT and MP were 93%, 100% and 100%, respectively. BLT+MLT+placebo of MP; BLT+placebo of MLT+placebo of MP; BLT+MLT+MP showed an effect size (Cohen's d) for change in PSQI scores of 0.64, 0.57 and 0.63, respectively. PSQI change using linear regression showed BLT (n=29) has effect size of 0.46, p=0.017; MLT (n=26), 0.24, p=0.20; MP (n=26), 0.06, p=0.46. No significant differences were observed in scores for insomnia, fatigue, depression, quality of life and actigraphy. There were no differences in adverse events by groups(p=0.80).

Conclusions: The use of MMT to treat SQ disturbance was feasible. BLT+MLT showed the most promising effect size in improvement in SQ, and additional larger studies are needed.

Trial Registration Number: NCT01628029.
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http://dx.doi.org/10.1136/bmjspcare-2019-001877DOI Listing
June 2021

Enhancing palliative care patient access to psychological counseling through outreach telehealth services.

Psychooncology 2020 01 10;29(1):132-138. Epub 2019 Nov 10.

Department of Palliative Care, Rehabilitation and Integrative Medicine, Houston, Texas.

Context: Palliative care encompasses an interdisciplinary team, including mental health care professionals, to address psychological distress of cancer patients.

Objectives: To present the implementation of an outreach counseling program via videoconferencing or telephone to patients receiving care in an outpatient palliative care clinic and to compare patients using this service to those who only received psychological counseling in our outpatient clinic.

Methods: We conducted a retrospective chart review of cancer patients seen for psychology counseling services in an outpatient supportive care center between June 2015 and March 2017.

Results: We reviewed 2072 unique patients (52% of the total patients seen at the outpatient Supportive Care Center), who had 4567 total counseling encounters across outreach and outpatient settings. A total of 452 (22%) patients participated in a combination of outpatient and outreach counseling services. Patients who participated in outreach services had significantly more encounters (311 [69%] had two to five sessions) compared with those who had outpatient services only (1137 [70%] had one session only) (P < .001). Outreach patients also had shorter times between the initial and follow-up encounters (median 14 days) compared with those who had outpatient services only (median 30 days) (P < .0001).

Conclusions: Outreach telehealth counseling services was found to enhance palliative care patient access to psychological counseling. These services represent an additional modality for providing continuous psychological care.
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http://dx.doi.org/10.1002/pon.5270DOI Listing
January 2020

Systematic Approach to Selecting and Preparing a Medical Power of Attorney in the Gynecologic Oncology Center.

J Oncol Pract 2019 12 15;15(12):e1092-e1097. Epub 2019 Oct 15.

The University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: Advance care planning (ACP) supports national priorities of patient engagement, person-centered care, and safety. A systematic approach is uncommon in most care settings. Our institution offers all patients with cancer new to the institution an opportunity to select and prepare a medical decision maker (MDM) after social work counseling. The goals of this study were to determine the success of a systematic institutional process for selecting a prepared MDM. The primary objectives were that (1) 70% or more of new patients would have one or more documented social work ACP discussions by the third office visit within 4 months, and (2) there would be a two-fold increase in scanned medical power of attorney (MPOA) documents available in the electronic health record (EHR). The secondary objectives were (1) improved surrogate preparedness for medical decision making, and (2) to determine whether patients with metastatic disease demonstrated greater readiness for selection of an MDM than those with localized disease.

Materials And Methods: We conducted a retrospective chart review of consecutive gynecology oncology outpatients.

Results: Of 133 patients, 93 (70%) had metastatic disease. The median number of visits was two (one to three). Forty-seven patients (39.3%) met with social work by visit 3. Review of ACP notes suggested that most patients were in the early stages of selecting a prepared MDM. At visit 1, 39 (29.3%) reported having an advance directive document; 14 (10.5%) had an MPOA in the EHR. There was no increase by visit 3. Fewer patients with metastatic disease than those with localized cancer (32.3% 67.5%; = .001) had three visits; no other parameter, including presence of MPOA documents in the EHR, achieved statistical significance between groups.

Conclusion: Current processes fail to engage patients in selecting and preparing an MDM.
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http://dx.doi.org/10.1200/JOP.19.00109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846063PMC
December 2019

Concurrent use of opioids with benzodiazepines or nonbenzodiazepine sedatives among patients with cancer referred to an outpatient palliative care clinic.

Cancer 2019 Dec 28;125(24):4525-4531. Epub 2019 Aug 28.

Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: The concurrent use of opioids with benzodiazepines (BZD) or nonbenzodiazepine sedatives (S) recently was found to be associated with an increased risk of overdose death compared with the use of opioids alone. In the current study, the authors examined the frequency and trend of concurrent opioid/BZD-S use and its associated risk factors among patients with cancer.

Methods: Data regarding the frequency and trend of concurrent opioid/BZD-S use were extracted for 1500 randomly selected patients referred to the outpatient palliative care clinic at The University of Texas MD Anderson Cancer Center between the calendar years of 2011 and 2016. To explore associated risk factors, the authors compared the demographic and clinical predictors of 418 patients each in the concurrent opioid/BZD-S group and opioids-only group.

Results: In 2011, at the time of referral to the palliative care clinic, 96 of 221 patients with cancer (43%) were prescribed concurrent opioids/BZD-S. This rate progressively declined to 67 of 217 patients (31%) by 2016 (P = .0008). Patients in the concurrent opioid/BZD-S group had a higher percentage of females (233 individuals; 55% [P = .007]) and whites (323 individuals; 77% [P = .002]), and patients reported higher scores regarding depression (P = .0001), anxiety (P ≤ .0001), drowsiness (P = .048), and worst feeling of well-being (P = .001). The morphine equivalent daily dose was significantly higher in concurrent opioid/BZD-S group (median of 67.5 mg/day [interquartile range (IQR), 30-135 mg/day] vs 60 mg/day [IQR, 30-105 mg/day]; P = .034). Multivariate analysis demonstrated that anxiety (P ≤ .0001), white race (P = .0092), and poor Eastern Cooperative Oncology Group performance status (P = .0017) were significantly associated with concurrent use.

Conclusions: The concurrent use of opioids with BZD-S has declined but continues to be frequent among patients with cancer. Anxiety, white race, and poor Eastern Cooperative Oncology Group performance status were associated with its use. More research is needed to explore which medications can replace these agents.
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http://dx.doi.org/10.1002/cncr.32484DOI Listing
December 2019

Extension for Community Healthcare Outcomes-Palliative Care in Africa Program: Improving Access to Quality Palliative Care.

J Glob Oncol 2019 07;5:1-8

University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: There is limited access to quality palliative care (PC) for patients with advanced cancer in sub-Saharan Africa. Our aim was to describe the development of the Project Extension for Community Healthcare Outcomes-Palliative Care in Africa (ECHO-PACA) program and describe a preliminary evaluation of attitudes and knowledge of participants regarding the ability of the program to deliver quality PC.

Methods: An interdisciplinary team at the MD Anderson Cancer Center, guided by experts in PC in sub-Saharan Africa, adapted a standardized curriculum based on PC needs in the region. Participants were then recruited, and monthly telementoring sessions were held for 16 months. The monthly telementoring sessions consisted of case presentations, discussions, and didactic lectures. Program participants came from 14 clinics and teaching hospitals in Ghana, Kenya, Nigeria, South Africa, and Zambia. Participants were surveyed at the beginning, midpoint, and end of the 16-month program to evaluate changes in attitudes and knowledge of PC.

Results: The median number of participants per session was 30. Thirty-three (83%) of 40 initial participants completed the feedback survey. Health care providers' self-reported confidence in providing PC increased with participation in the Project ECHO-PACA clinic. There was significant improvement in the participants' attitudes and knowledge, especially in titrating opioids for pain control ( = .042), appropriate use of non-opioid analgesics ( = .012), and identifying and addressing communication issues related to end-of-life care ( = .014).

Conclusion: Project ECHO-PACA was a successful approach for disseminating knowledge about PC. The participants were adherent to ECHO PACA clinics and the completion of feedback surveys. Future studies should evaluate the impact of Project ECHO-PACA on changes in provider practice as well as patient outcomes.
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http://dx.doi.org/10.1200/JGO.19.00128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6776016PMC
July 2019

Integration of a Mandatory Palliative Care Education Into Hematology-Oncology Fellowship Training in a Comprehensive Cancer Center: A Survey of Hematology Oncology Fellows.

J Oncol Pract 2019 11 3;15(11):e934-e941. Epub 2019 Jul 3.

The University of Texas, MD Anderson Cancer Center, Houston, TX.

Purpose: The primary aim of this study was to determine the attitudes and beliefs of hematology and medical oncology (HMO) fellows regarding palliative care (PC) after they completed a 4-week mandatory PC rotation.

Methods: The PC rotation included a 4-week standardized curriculum covering all PC domains. HMO fellows were provided educational materials and attended all didactic sessions. All had clinical rotation in an acute PC unit and an outpatient clinic. All HMO fellows from 2004 to 2017 were asked to complete a 32-item survey on oncology trainee perception of PC.

Results: Of 105 HMO fellows, 77 (73%) completed the survey. HMO fellows reported that PC rotation improved assessment and management of symptoms (98%); opioid prescription (89%), opioid rotation (78%), and identification of opioid adverse effects (87%); communication with patients and families (91%), including advance care planning discussion (88%) and do-not-resuscitate discussion (88%); and they reported comfort with discussing ethical issues (74%). Participants reported improvement in knowledge of symptom assessment and management (n = 76; 98%) as compared with efficacy in ethics (n = 57 [74%]; = .0001) and for coping with stress of terminal illness (n = 45 [58%]; = .0001). The PC rotation educational experience was considered either far better or better (53%) or the same (45%) as other oncology rotations. Most respondents (98%) would recommend PC rotations to other HMO fellows, and 95% felt rotation should be mandatory.

Conclusion: HMO fellows reported PC rotation improved their attitudes and knowledge in all PC domains. PC rotation was considered better than other oncology rotations and should be mandatory.
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http://dx.doi.org/10.1200/JOP.19.00056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846059PMC
November 2019

Corrected QT Interval Prolongation in Pediatric and Young Adult Patients on Methadone for Cancer-Related Pain.

J Pain Symptom Manage 2019 10 11;58(4):678-684. Epub 2019 Jun 11.

Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA.

Context: Methadone has been reported to prolong the corrected QT (QTc) interval and increase the risk of torsades de pointes.

Objectives: Our study examined the frequency of QTc prolongation among pediatric and young adult patients starting methadone for cancer pain.

Methods: All patients followed a standardized protocol. Electrocardiograms (ECGs) were obtained at baseline (methadone starting day to 14 days prior), 1-2 weeks, and 4-6 weeks later. QTc values were manually calculated using the Bazett formula. QTc prolongation was defined as ≥460 milliseconds (ms) for prepubertal children, ≥470 ms for pubertal males, and ≥480 ms for pubertal females.

Results: Baseline ECGs were completed in 42 patients. Follow-up ECGs were completed in 38 of 42 (91%) and 31 of 42 (74%) patients at 1-2 weeks and 4-6 weeks, respectively. No patients had prolongation of the QTc at baseline, and 1 of 38 (3%) patients had a prolonged QTc at weeks 1-2. This patient had a history of prolonged QTc that the family did not initially report. No patients had prolongation of the QTc at weeks 4-6. No patients had torsades de pointes or ventricular fibrillation, and none died suddenly. Median (interquartile range [IQR]) baseline QTc was 391 (377-400) ms; median (IQR) 1-2 week follow-up QTc was 399 (374-411) ms (P = .05), and median (IQR) 4-6 week follow-up QTc was 393 (379-423) ms (P = .01).

Conclusion: Clinically significant prolongation of the QTc interval occurred only in one patient who had a history of prolonged QTc. Prolonged QTc is rare in this population.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.05.021DOI Listing
October 2019

Patients' Perspective of Timeliness and Usefulness of an Outpatient Supportive Care Referral at a Comprehensive Cancer Center.

J Pain Symptom Manage 2019 08 25;58(2):275-281. Epub 2019 Apr 25.

Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Context: Current guidelines recommend early referral to palliative care for patients with advanced cancer; however, no studies have examined the optimal timing of referral from the patients' perspective.

Objectives: To examine patients' perceptions of timeliness of referral and its association with survival among patients with advanced cancer referred to an outpatient supportive care (SC) clinic.

Methods: This cross-sectional prospective study in an SC clinic at a comprehensive cancer center included patients aged 18 years or older with locally advanced, recurrent, or metastatic cancer. Patients were asked to complete an anonymous survey regarding the timeliness and perceived usefulness of SC referral within four weeks of their first SC consultation.

Results: Of 253 eligible patients, 209 (83%) enrolled in the study and 200 completed the survey. Median survival was 10.3 months. Most patients (72%) perceived that referral occurred "just in time," whereas 21% felt it was "late," and 7% felt "early." A majority (83%) found the referral useful, and 88% would recommend it to other patients with cancer. The perception of being referred early was associated with lower reported levels of pain (P = 0.043), fatigue (P = 0.004), drowsiness (P = 0.005), appetite loss (P = 0.041), poor well-being (P = 0.041), and lower physical (P = 0.001) and overall symptom distress (P = 0.001). No other associations were found between perceived timeliness and usefulness and patients' baseline characteristics.

Conclusion: Most patients with a median survival of 10 months perceived that SC referral was timely and useful. Patient care needs rather than the timing of advanced cancer diagnosis drove this perception of referral timing. Lower symptom burden was associated with the perception of being referred to early.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.04.027DOI Listing
August 2019

Frequency of Concomitant Use of Opioids and Psychoactive Medications Among Cancer Patients Referred to Outpatient Palliative Care.

J Pain Symptom Manage 2019 06 13;57(6):e7-e10. Epub 2019 Mar 13.

Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

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http://dx.doi.org/10.1016/j.jpainsymman.2019.03.004DOI Listing
June 2019

The effects of inpatient music therapy on self-reported symptoms at an academic cancer center: a preliminary report.

Support Care Cancer 2019 Nov 1;27(11):4207-4212. Epub 2019 Mar 1.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.

Purpose: Music therapy has shown benefits for reducing distress in individuals with cancer. We explore the effects of music therapy on self-reported symptoms of patients receiving inpatient care at a comprehensive cancer center.

Methods: Music therapy was available as part of an inpatient integrative oncology consultation service; we examined interventions and symptoms for consecutive patients treated by a board-certified music therapist from September 2016 to May 2017. Patients completed the Edmonton Symptom Assessment Scale (ESAS, 10 symptoms, scale 0-10, 10 most severe) before and after the intervention. Data was summarized by descriptive statistics. Changes in ESAS symptom and subscale scores (physical distress (PHS), psychological distress (PSS), and global distress (GDS)) were evaluated by Wilcoxon signed rank test.

Results: Data were evaluable for 96 of 100 consecutive initial, unique patient encounters; 55% were women, average age 50, and majority with hematologic malignancies (47%). Reasons for music therapy referral included anxiety/stress (67%), adjustment disorder/coping (28%), and mood elevation/depression (17%). The highest (worst) symptoms at baseline were sleep disturbance (5.7) and well-being (5.5). We observed statistically and clinically significant improvement (means) for anxiety (- 2.3 ± 1.5), drowsiness (- 2.1 ± 2.2), depression (- 2.1 ± 1.9), nausea (- 2.0 ± 2.4), fatigue (- 1.9 ± 1.5), pain (- 1.8 ± 1.4), shortness of breath (- 1.4 ± 2.2), appetite (- 1.1 ± 1.7), and for all ESAS subscales (all ps < 0.02). The highest clinical response rates were observed for anxiety (92%), depression (91%), and pain (89%).

Conclusions: A single, in-person, tailored music therapy intervention as part of an integrative oncology inpatient consultation service contributed to the significant improvement in global, physical, and psychosocial distress. A randomized controlled trial is justified.
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http://dx.doi.org/10.1007/s00520-019-04713-4DOI Listing
November 2019
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