Publications by authors named "Madeline Li"

60 Publications

Request for medical assistance in dying from a geriatric patient in primary care: Understanding eligibility and promoting a patient-centred approach.

Can Fam Physician 2021 09;67(9):675-677

Clinician scientist in the Department of Supportive Care and Head of Psychosocial Oncology at Princess Margaret Cancer Centre in Toronto, and developed the medical assistance in dying service at the University Health Network.

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http://dx.doi.org/10.46747/cfp.6709675DOI Listing
September 2021

Phase II Trial of Symptom Screening With Targeted Early Palliative Care for Patients With Advanced Cancer.

J Natl Compr Canc Netw 2021 Sep 7:1-10. Epub 2021 Sep 7.

12Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.

Background: Routine early palliative care (EPC) improves quality of life (QoL) for patients with advanced cancer, but it may not be necessary for all patients. We assessed the feasibility of Symptom screening with Targeted Early Palliative care (STEP) in a phase II trial.

Methods: Patients with advanced cancer were recruited from medical oncology clinics. Symptoms were screened at each visit using the Edmonton Symptom Assessment System-revised (ESAS-r); moderate to severe scores (screen-positive) triggered an email to a palliative care nurse, who called the patient and offered EPC. Patient-reported outcomes of QoL, depression, symptom control, and satisfaction with care were measured at baseline and at 2, 4, and 6 months. The primary aim was to determine feasibility, according to predefined criteria. Secondary aims were to assess whether STEP identified patients with worse patient-reported outcomes and whether screen-positive patients who accepted and received EPC had better outcomes over time than those who did not receive EPC.

Results: In total, 116 patients were enrolled, of which 89 (77%) completed screening for ≥70% of visits. Of the 70 screen-positive patients, 39 (56%) received EPC during the 6-month study and 4 (6%) received EPC after the study end. Measure completion was 76% at 2 months, 68% at 4 months, and 63% at 6 months. Among screen-negative patients, QoL, depression, and symptom control were substantially better than for screen-positive patients at baseline (all P<.0001) and remained stable over time. Among screen-positive patients, mood and symptom control improved over time for those who accepted and received EPC and worsened for those who did not receive EPC (P<.01 for trend over time), with no difference in QoL or satisfaction with care.

Conclusions: STEP is feasible in ambulatory patients with advanced cancer and distinguishes between patients who remain stable without EPC and those who benefit from targeted EPC. Acceptance of the triggered EPC visit should be encouraged. ClinicalTrials.gov identifier: NCT04044040.
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http://dx.doi.org/10.6004/jnccn.2020.7803DOI Listing
September 2021

Phase II Trial of Symptom Screening With Targeted Early Palliative Care for Patients With Advanced Cancer.

J Natl Compr Canc Netw 2021 Sep 7:1-10. Epub 2021 Sep 7.

12Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.

Background: Routine early palliative care (EPC) improves quality of life (QoL) for patients with advanced cancer, but it may not be necessary for all patients. We assessed the feasibility of Symptom screening with Targeted Early Palliative care (STEP) in a phase II trial.

Methods: Patients with advanced cancer were recruited from medical oncology clinics. Symptoms were screened at each visit using the Edmonton Symptom Assessment System-revised (ESAS-r); moderate to severe scores (screen-positive) triggered an email to a palliative care nurse, who called the patient and offered EPC. Patient-reported outcomes of QoL, depression, symptom control, and satisfaction with care were measured at baseline and at 2, 4, and 6 months. The primary aim was to determine feasibility, according to predefined criteria. Secondary aims were to assess whether STEP identified patients with worse patient-reported outcomes and whether screen-positive patients who accepted and received EPC had better outcomes over time than those who did not receive EPC.

Results: In total, 116 patients were enrolled, of which 89 (77%) completed screening for ≥70% of visits. Of the 70 screen-positive patients, 39 (56%) received EPC during the 6-month study and 4 (6%) received EPC after the study end. Measure completion was 76% at 2 months, 68% at 4 months, and 63% at 6 months. Among screen-negative patients, QoL, depression, and symptom control were substantially better than for screen-positive patients at baseline (all P<.0001) and remained stable over time. Among screen-positive patients, mood and symptom control improved over time for those who accepted and received EPC and worsened for those who did not receive EPC (P<.01 for trend over time), with no difference in QoL or satisfaction with care.

Conclusions: STEP is feasible in ambulatory patients with advanced cancer and distinguishes between patients who remain stable without EPC and those who benefit from targeted EPC. Acceptance of the triggered EPC visit should be encouraged. ClinicalTrials.gov identifier: NCT04044040.
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http://dx.doi.org/10.6004/jnccn.2020.7803DOI Listing
September 2021

Medical Assistance in Dying in patients with advanced cancer and their caregivers: a mixed methods longitudinal study protocol.

BMC Palliat Care 2021 Jul 21;20(1):117. Epub 2021 Jul 21.

Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 620 University Avenue, 12th Floor, Toronto, Ontario, M5G 2C1, Canada.

Background: The legal criteria for medical assistance in dying (MAiD) for adults with a grievous and irremediable medical condition were established in Canada in 2016. There has been concern that potentially reversible states of depression or demoralization may contribute to the desire for death (DD) and requests for MAiD. However, little is known about the emergence of the DD in patients, its impact on caregivers, and to what extent supportive care interventions affect the DD and requests for MAiD. The present observational study is designed to determine the prevalence, predictors, and experience of the DD, requests for MAiD and MAiD completion in patients with advanced or metastatic cancer and the impact of these outcomes on their primary caregivers.

Methods: A cohort of patients with advanced or metastatic solid tumour cancers and their primary caregivers will be recruited from a large tertiary cancer centre in Toronto, Ontario, Canada, to a longitudinal, mixed methods study. Participants will be assessed at baseline for diagnostic information, sociodemographic characteristics, medical history, quality of life, physical and psychological distress, attitudes about the DD and MAiD, communication with physicians, advance care planning, and use of psychosocial and palliative care interventions. Measures will subsequently be completed every six months and at the time of MAiD requests. Quantitative assessments will be supplemented by qualitative interviews in a subset of participants, selected using quota sampling methods.

Discussion: This study has the potential to add importantly to our understanding of the prevalence and determinants of the DD, MAiD requests and completions in patients with advanced or metastatic cancer and of the experience of both patients and caregivers in this circumstance. The findings from this study may also assist healthcare providers in their conversations about MAiD and the DD with patients and caregivers, inform healthcare providers to ensure appropriate access to MAiD, and guide modifications being considered to broaden MAiD legislation and policy.
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http://dx.doi.org/10.1186/s12904-021-00793-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8296526PMC
July 2021

A Race to the End: Family Caregivers' Experience of Medical Assistance in Dying (MAiD)-a Qualitative Study.

J Gen Intern Med 2021 Jul 21. Epub 2021 Jul 21.

Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.

Background: The June 2016 legalization of medical assistance in dying (MAiD) provided an added layer of choice to end-of-life care in Canada. Family caregivers play an important role in patient end-of-life decision-making. They may experience unique psychological burden or distress associated with their role. However, we know little about the caregiver experience associated with patient MAiD requests and the nature of psychosocial supports caregivers require before, during, and following MAiD intervention.

Objective: The objective of this study is to better understand the caregiver experience of MAiD within the Canadian legal landscape following Bill C-14.

Design: Caregiver experience was examined based on qualitative, semi-structured interviews.

Participants: A total of 22 caregivers of patients who had requested MAiD were interviewed.

Approach: Transcripts were recorded, transcribed, and analyzed based on grounded theory methodology.

Key Results: The caregiver experience of MAiD within the legal framework was found to be understood as a "race to the end," with the ultimate goal of creating an ideal dying experience for the patient while balancing a threat to capacity that would undermine their access to MAiD. Caregivers can be described within the overarching framework as either co-runners or onlookers. Sources of caregiver distress were linked to these roles.

Conclusions: The "race to the end" theoretical model contributes new knowledge and understanding that can inform the development of tailored support services for caregivers, the impact of legislative changes on this population, and future research examining decision-making near end of life and the caregiver experience.
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http://dx.doi.org/10.1007/s11606-021-07012-zDOI Listing
July 2021

Recent trends in the management of depression in persons with cancer.

Curr Opin Psychiatry 2021 09;34(5):448-459

Division of Psychosocial Oncology, Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network.

Purpose Of Review: Depression is a prevalent comorbidity in cancer that significantly increases the risk for numerous negative health outcomes. This review updates the current evidence base for management of depression in cancer, highlighting new research directions based on the inflammatory hypothesis of depression.

Recent Findings: Research on pharmacotherapy and psychotherapy for depression in cancer has shown mixed efficacy partly because of methodological issues arising from the phenomenology of depression in cancer. After decades of stagnancy, more recent high-quality clinical trials are beginning to provide an evidence base to guide treatment. Inflammatory cytokine-associated depression is a subtype of depression that may have particular relevance in cancer, opening new avenues to explore therapeutic targets and biobehavioral impacts of interventions, which may improve cancer outcomes.

Summary: The continuum of severity in cancer-related depression is important to consider in management approaches. Choice of treatment should be personalized to the patient and their symptom profile as there is currently insufficient evidence to recommend any particular medication or psychotherapy over another. Psychological interventions should be considered first line for mild-to-moderate depression, and pharmacological treatment added for more severe depression, which can be optimally delivered within a collaborative care model.

Video Abstract: http://links.lww.com/YCO/A62.
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http://dx.doi.org/10.1097/YCO.0000000000000727DOI Listing
September 2021

Screening for symptoms of anxiety and depression in patients treated with renal replacement therapy: utility of the Edmonton Symptom Assessment System-Revised.

Qual Life Res 2021 Jun 17. Epub 2021 Jun 17.

Multi-Organ Transplant Program and Division of Nephrology, University Health Network, University of Toronto, 585 University Avenue, Peter Munk Building, Floor 11 Room 188, Toronto, ON, M5G 2N2, Canada.

Purpose: The Edmonton Symptom Assessment System-revised (ESASr) is widely used in clinical oncology to screen for physical and emotional symptoms. The performance of the anxiety and depression items (ESASr-A and ESASr-D, respectively) as screening tools have not been evaluated in patients treated with renal replacement therapy.

Methods: Kidney transplant recipients and patients on dialysis were recruited in Toronto. Patients were classified as having moderate/severe depression and anxiety symptoms using the established cut-off score of ≥ 10 on the Patient Health Questionnaire-9 (PHQ-9) and the General Anxiety Disorder-7 (GAD-7) questionnaires.

Results: This study included 931 participants; 62% male, mean age (SD) 55(16), and 52% White. All participants completed ESASr, however only 748 participants completed PHQ-9 and 769 participants completed GAD-7. Correlation between ESASr item scores and legacy scores were moderately strong (ESASr-D/PHQ-9: 0.61; ESASr-A/GAD-7: 0.64). We found good discrimination for moderate/severe depression and anxiety [area under the receiver operating characteristics curve (95% CI) ESASr-D 0.82(0.78-0.86); ESASr-A 0.87 (0.82, 0.92)]. The cut-off ≥ 2 for ESASr-D [Sensitivity = 0.76; Specificity = 0.77; Likelihood Ratio (LR) + = 3.29; LR - = 0.31] and ≥ 4 for ESASr-A (Sensitivity = 0.75; Specificity = 0.87; LR + = 5.76; LR - = 0.29) had the best combination of measurement characteristics.

Conclusion: The identified ESASr-D and ESASr-A cut-off scores may be used to rule out patients without emotional distress with few false negatives. However, the low sensitivity identified in our analysis suggests that neither ESASr-D or ESASr-A are acceptable as standalone screening tools.
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http://dx.doi.org/10.1007/s11136-021-02910-5DOI Listing
June 2021

Supporting the Needs of Adolescents and Young Adults: Integrated Palliative Care and Psychiatry Clinic for Adolescents and Young Adults with Cancer.

Cancers (Basel) 2021 Feb 12;13(4). Epub 2021 Feb 12.

Department of Supportive Care, University Health Network, Toronto, ON M5G 2C4, Canada.

Clinical guidelines aimed at cancer care for adolescents and young adults (AYAs) encourage early integration of palliative care, yet there are scarce data to support these recommendations. We conducted a retrospective chart review of AYA patients, aged 15 to 39 years, who were referred to the Integrated AYA Palliative Care and Psychiatry Clinic (IAPCPC) at the Princess Margaret Cancer Centre between May 2017 and November 2019 ( = 69). Demographic data, symptom prevalence, change in symptom scores between baseline consultation and first follow-up, and intensity of end-of-life care were collected from the patients' medical charts, analyzed, and reported. Of the 69 patients, 59% were female, and sarcoma was the most common cancer. A majority of patients had at least one symptom scored as moderate to severe; tiredness, pain, and sleep problems were the highest scored symptoms. More than one-third used medical cannabis to manage their symptoms. Symptom scores improved in 61% after the first clinic visit. Out of the 69 patients, 50 (72.5%) had died by October 2020, with a median time between the initial clinic referral and death of 5 months (range 1-32). Three patients (6%) received chemotherapy, and eight (16%) were admitted to an intensive care unit during the last month of life. In conclusion, AYAs with advanced cancer have a high burden of palliative and psychosocial symptoms. Creating a specialized AYA palliative care clinic integrated with psychiatry showed promising results in improving symptom scores and end-of-life planning.
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http://dx.doi.org/10.3390/cancers13040770DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7918814PMC
February 2021

CanDirect: Effectiveness of a Telephone-Supported Depression Self-Care Intervention for Cancer Survivors.

J Clin Oncol 2021 04 8;39(10):1150-1161. Epub 2021 Feb 8.

St Mary's Research Centre, Montreal, QC, Canada.

Purpose: Depression in post-treatment cancer survivors is common and can impair quality of life. CanDirect is a novel, telephone-delivered depression self-care intervention for cancer survivors. We conducted a randomized controlled superiority trial to compare CanDirect with usual care (UC) in this population.

Methods: Participants completing cancer treatment within the past 10 years who had mild-moderate depressive symptoms with or without major depression were recruited from clinical and community settings in Quebec and Ontario. Permuted block random assignment allocated participants to CanDirect plus UC or to UC alone. Assessments of depression severity (Center for Epidemiological Studies-Depression scale [CES-D]; primary outcome) and secondary outcomes health-related quality of life (Short Form Survey-12 mental and physical component summaries), anxiety symptoms (Hospital Anxiety and Depression Scale), activation (Patient Activation Measure), depression diagnosis (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV), and health services (self-report) were conducted at baseline, as well as 3 and 6 months (primary time point). Analyses of outcomes were adjusted for covariates using linear regression and missing data by inverse probability weighting.

Results: Participants recruited between September 2016 and October 2018 were randomly assigned to CanDirect (n = 121) or UC (n = 124). Among 245 participants randomly assigned, 218 (89.0%) completed the primary outcome at 6 months. CanDirect participants reported less severe depressive symptoms on the CES-D than UC participants at 6 months, adjusted effect size (ES) 0.61 (95% CI, 0.33 to 0.88). CanDirect participants also had significantly greater quality of life, lower anxiety, more activation, and lower rates of depression diagnoses, compared with UC. Exploratory analysis suggested that sex was a modifier of the primary outcome (interaction term value = .03); the intervention was less effective in men (ES, 0.12; 95% CI, -0.45 to 0.69).

Conclusion: The findings suggest that CanDirect is an effective method of managing mild-moderate depression symptoms in cancer survivors.
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http://dx.doi.org/10.1200/JCO.20.01802DOI Listing
April 2021

Nonesterified Fatty Acids and Depression in Cancer Patients and Caregivers.

Curr Dev Nutr 2020 Nov 13;4(11):nzaa156. Epub 2020 Oct 13.

Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada.

Background: Nonesterified fatty acids (NEFAs) are known to have inflammatory effects. The inflammatory hypothesis of depression suggests that omega-3 (ω-3) and omega-6 (ω-6) fatty acids might be negatively and positively correlated with depression, respectively.

Objective: An exploratory study was conducted to determine the association between dietary free fatty acids and depressive symptoms in cancer patients and caregivers.

Methods: Associations between depression and the NEFA pool were investigated in 56 cancer patients and 23 caregivers using a combination of nonparametric tests and regularized regression. Plasma NEFAs were measured using thin layer and gas chromatography with flame ionization detection. Depression was characterized both as a continuous severity score using the GRID-Hamilton Depression Rating Scale (GRID Ham-D), and as a categorical diagnosis of major depression by structured clinical interview.

Results: Initial hypotheses regarding the relation between depression and omega-3 or omega-6 fatty acids were not well supported. However, elaidic acid, a -unsaturated fatty acid found in hydrogenated vegetable oils, was found to be negatively correlated with continuous depression scores in cancer patients. No significant associations were found in caregivers.

Conclusions: An unexpected negative association between elaidic acid and depression was identified, supporting recent literature on the role of G protein-coupled receptors in depression. Further research is needed to confirm this result and to evaluate the potential role of G protein agonists as therapeutic agents for depression in cancer patients.
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http://dx.doi.org/10.1093/cdn/nzaa156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792569PMC
November 2020

Validation of the Death and Dying Distress Scale in patients with advanced cancer.

Psychooncology 2021 May 18;30(5):716-727. Epub 2021 Jan 18.

Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.

Background: Distress about dying and death is an important clinical and research outcome in advanced cancer. A 15-item Death and Dying Distress Scale (DADDS) measure has undergone preliminary validation, but full validation in a large sample has not previously been reported. We investigated its psychometric characteristics and responsiveness to a therapeutic intervention.

Methods: This is a secondary analysis of baseline data obtained from a randomized controlled trial of psychotherapeutic intervention for patients with advanced cancer. Participants (n = 386) completed the DADDS, and measures of depression, anxiety, demoralization, quality of life (including preparation for end of life), spirituality, attachment security, and symptom burden.

Results: A confirmatory factor analysis revealed factors related to "Finitude" and to "Dying." Both factors showed good internal consistency (Cronbach α = 0.861-0.949). DADDS scores were significantly higher in females, those with lower income and not working. Construct validity was demonstrated by a positive correlation between DADDS and demoralization (r = 0.569-0.679), and a negative correlation with preparation for the end of life (r = -0.475 to -0.678). At 6 months, intervention participants with moderate DADDS scores at baseline reported significantly lower DADDS scores on both factors compared to usual care.

Conclusions: The DADDS is a valid and brief two-factor measure that assesses distress related to the shortness of time and to the process of dying. The total and factor scores have utility in the clinical and research assessment of death-related distress in patients with advanced cancer.
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http://dx.doi.org/10.1002/pon.5620DOI Listing
May 2021

Is ketamine a litmus test for capacity in assisted dying with depression?

Psychooncology 2021 03 15;30(3):417-420. Epub 2020 Nov 15.

Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1002/pon.5586DOI Listing
March 2021

Inflammatory Biomarkers, Hematopoietic Stem Cells, and Symptoms in Breast Cancer Patients Undergoing Adjuvant Radiation Therapy.

JNCI Cancer Spectr 2020 Oct 8;4(5):pkaa037. Epub 2020 May 8.

Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.

Background: Fatigue and insomnia are common symptoms experienced by breast cancer patients undergoing adjuvant radiation therapy (RT), yet the underlying mechanisms of these symptoms are unclear. In particular, the roles of hematopoietic stem cells (HSCs) and inflammatory cytokines remain to be elucidated.

Methods: Breast cancer patients (n = 147) completed questionnaires to longitudinally assess symptoms before, during, and after adjuvant RT. Phlebotomies were performed prior to RT, at the second and fifth treatment fractions, end of treatment (EOT), and 1 month after completing RT, assessing for CD34, CD45, full hematology, and 17 inflammatory cytokines. The associations between symptoms and all biomarkers were evaluated. All statistical tests were 2-sided.

Results: General fatigue and insomnia worsened with RT, with peak levels observed at EOT, which remained statistically significant even after controlling for anxiety and depression ( < .05 for all). CD34, CD45, white blood cell, and lymphocyte counts decreased, with the lowest levels also observed at EOT ( < .001). Fatigue and insomnia were associated with changes in both interferon γ-induced protein 10 (IP-10) - ( = .03 and  = .01, respectively) and tumor necrosis factor receptor II (TNF-RII) ( = .02 and  = .006, respectively), while mental fatigue was associated with increased matrix metalloproteinases-2 (MMP-2) levels ( = .03). Patients who received prior chemotherapy demonstrated statistically significantly greater severity in all symptoms, with lower baseline HSC levels.

Conclusions: This is the first longitudinal study to examine linkages between symptoms, HSCs, and cytokines, demonstrating that fatigue and insomnia shared associations with increasing serum levels of IP-10 and TNF-RII, and mental fatigue was associated with increasing serum levels of MMP-2. Our findings highlight opportunities for further research into mechanisms and potential interventions for these symptoms.
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http://dx.doi.org/10.1093/jncics/pkaa037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7583146PMC
October 2020

A cross-sectional gender-sensitive analysis of depressive symptoms in patients with advanced cancer.

Palliat Med 2020 12 12;34(10):1436-1446. Epub 2020 Aug 12.

Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network), Toronto, ON, Canada.

Background: Patients with advanced cancer commonly report depressive symptoms. Examinations of gender differences in depressive symptoms in patients with advanced cancer have yielded inconsistent findings.

Aim: The objective of this study was to investigate whether the severity and correlates of depressive symptoms differ by gender in patients with advanced cancer.

Design: Participants completed measures assessing sociodemographic and medical characteristics, disease burden, and psychosocial factors. Depressive symptoms were examined using the Patient Health Questionnaire, and other measures included physical functioning, symptom burden, general anxiety, death related distress, and dimensions of demoralization. A cross-sectional analysis examined the univariate and multivariate relationships between gender and depressive symptoms, while controlling for important covariates in multivariate analyses.

Setting/participants: Patients with advanced cancer ( = 305, 40% males and 60% females) were recruited for a psychotherapy trial from outpatient oncology clinics at a comprehensive cancer center in Canada.

Results: Severity of depressive symptoms was similar for males ( = 7.09,  = 4.59) and females ( = 7.66,  = 5.01), (303) = 1.01,  = 0.314. Greater general anxiety and number of cancer symptoms were associated with depressive symptoms in both males and females. Feeling like a failure ( = 0.192), less death anxiety ( = -0.188), severity of cancer symptoms ( = 0.166), and older age ( = 0.161) were associated with depressive symptoms only in males, while disheartenment ( = 0.216) and worse physical functioning ( = 0.275), were associated with depressive symptoms only in females.

Conclusions: Males and females report similar levels of depressive symptoms but the pathways to depression may differ by gender. These differences suggest the potential for gender-based preventive and therapeutic interventions in this population.
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http://dx.doi.org/10.1177/0269216320947961DOI Listing
December 2020

Measuring financial toxicity incurred after treatment of head and neck cancer: Development and validation of the Financial Index of Toxicity questionnaire.

Cancer 2020 09 30;126(17):4042-4050. Epub 2020 Jun 30.

Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.

Background: The treatment of head and neck cancer (HNC) may cause significant financial toxicity to patients. Herein, the authors have presented the development and validation of the Financial Index of Toxicity (FIT) instrument.

Methods: Items were generated using literature review and were based on expert opinion. In item reduction, items with factor loadings of a magnitude <0.3 in exploratory factor analysis and inverse correlations (r < 0) in test-retest analysis were eliminated. Retained items constituted the FIT. Reliability tests included internal consistency (Cronbach α) and test-retest reliability (intraclass correlation). Validity was tested using the Spearman rho by comparing FIT scores with baseline income, posttreatment lost income, and the Financial Concerns subscale of the Social Difficulties Inventory. Responsiveness analysis compared change in income and change in FIT between 12 and 24 months.

Results: A total of 14 items were generated and subsequently reduced to 9 items comprising 3 domains identified on exploratory factor analysis: financial stress, financial strain, and lost productivity. The FIT was administered to 430 patients with HNC at 12 to 24 months after treatment. Internal consistency was good (α = .77). Test-retest reliability was satisfactory (intraclass correlation, 0.70). Concurrent validation demonstrated mild to strong correlations between the FIT and Social Difficulties Inventory Money Matters subscale (Spearman rho, 0.26-0.61; P < .05). FIT scores were found to be inversely correlated with baseline household income (Spearman rho, -0.34; P < .001) and positively correlated with lost income (Spearman rho, 0.24; P < .001). Change in income was negatively correlated with change in FIT over time (Spearman rho, -0.25; P = .04).

Conclusions: The 9-item FIT demonstrated internal and test-retest reliability as well as concurrent and construct validity. Prospective testing in patients with HNC who were treated at other facilities is needed to further establish its responsiveness and generalizability.
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http://dx.doi.org/10.1002/cncr.33032DOI Listing
September 2020

Personalized symptom management: a quality improvement collaborative for implementation of patient reported outcomes (PROs) in 'real-world' oncology multisite practices.

J Patient Rep Outcomes 2020 Jun 17;4(1):47. Epub 2020 Jun 17.

University Health Network (Princess Margaret Cancer Centre), 610 University Health Network Room 15-617, Toronto, ON, M5G 2M9, Canada.

Background: Little research has focused on implementation of electronic Patient Reported Outcomes (e-PROs) for meaningful use in patient management in 'real-world' oncology practices. Our quality improvement collaborative used multi-faceted implementation strategies including audit and feedback, disease-site champions and practice coaching, core training of clinicians in a person-centered clinical method for use of e-PROs in shared treatment planning and patient activation, ongoing educational outreach and shared collaborative learnings to facilitate integration of e-PROs data in multi-sites in Ontario and Quebec, Canada for personalized management of generic and targeted symptoms of pain, fatigue, and emotional distress (depression, anxiety).

Patients And Methods: We used a mixed-methods (qualitative and quantitative data) program evaluation design to assess process/implementation outcomes including e-PROs completion rates, acceptability/use from the perspective of patients/clinicians, and patient experience (surveys, qualitative focus groups). We secondarily explored impact on symptom severity, patient activation and healthcare utilization (Ontario sites only) comparing a pre/post population cohort not exposed/exposed to our implementation intervention using Mann Whitney U tests. We hypothesized that the iPEHOC intervention would result in a reduction in symptom severity, healthcare utilization, and higher patient activation. We also identified key implementation strategies that sites perceived as most valuable to uptake and any barriers.

Results: Over 6000 patients completed e-PROs, with sites reaching 51%-95% population completion rates depending on initial readiness. e-PROs were acceptable to patients for communicating symptoms (76%) and by clinicians for treatment planning (80%). Patient experience was better than the provincial average. Compared to the pre-population, we observed a significant reduction in levels of anxiety (p = 0.008), higher levels of patient activation (p = 0.045), and reduced hospitalization rates (12.3% not exposed vs 10.1% exposed, p = 0.034). A pre/post population trend towards significance for reduced emergency department visit rates (14.8% not exposed vs 12.8% exposed, p = 0.081) was also noted.

Conclusion: This large-scale pragmatic quality improvement project demonstrates the impact of implementation strategies and a collaborative improvement approach on acceptability of using PROs in clinical practice and their potential for reducing anxiety and healthcare utilization; and improving patient experience and patient activation when implemented in 'real-world' multi-site oncology practices.
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http://dx.doi.org/10.1186/s41687-020-00212-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7300168PMC
June 2020

Could symptom burden predict subsequent healthcare use in patients with end stage kidney disease on hemodialysis care? A prospective, preliminary study.

Ren Fail 2020 Nov;42(1):294-301

Multi-Organ Transplant Program and Division of Nephrology, University Health Network, University of Toronto, Toronto, Canada.

Patients treated with maintenance hemodialysis experience significant symptom burden resulting in impaired quality of life. However, the association of patient reported symptom burden and the risk of healthcare use for patients with end stage kidney disease on hemodialysis has not been fully explored. To investigate if higher symptom burden, assessed by the Edmonton Symptom Assessment System-revised (ESASr), is associated with increased healthcare use in patients with end stage kidney disease on hemodialysis. Prospective, single-center, study of adult patients on HD. Participants completed the ESASr questionnaire at enrollment. Baseline demographic, clinical information as well as healthcare use events during the 12-month following enrollment were extracted from medical records. The association between symptom burden and healthcare use was examined with a multivariable adjusted negative binomial model. Mean (SD) age of the 80 participants was 71 (13) years, 56% diabetic, and 70% male. The median (IQR) dialysis vintage was 2 (1-4) years. In multivariable adjusted models, higher global [incident rate ratio (IRR) 1.02, 95% confidence interval (CI) 1.00-1.04,  = .025] and physical symptom burden score [IRR 1.03, CI 1.00-1.05,  = .034], but not emotional symptom burden score [IRR 1.05, CI 1.00-1.10,  = .052] predicted higher subsequent healthcare use. Our preliminary evidence suggests that higher symptom burden, assessed by ESASr may predict higher risk of healthcare use amongst patients with end stage kidney disease on hemodialysis. Future studies need to confirm the findings of this preliminary study and to assess the utility of ESASr for systematic symptom screening.
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http://dx.doi.org/10.1080/0886022X.2020.1744449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144228PMC
November 2020

Correction.

J Clin Psychiatry 2020 04 22;81(2). Epub 2020 Apr 22.

This corrects the article DOI: 10.4088/JCP.18r12475.
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http://dx.doi.org/10.4088/JCP.20lcx13315DOI Listing
April 2020

The impact of attachment security on death preparation in advanced cancer: The role of couple communication.

Psychooncology 2020 05 26;29(5):833-840. Epub 2020 Feb 26.

Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.

Objective: Attachment security protects psychological well-being in patients with advanced cancer, but its effect on death preparation in this population has not been demonstrated. We examined the relationship of attachment security to death preparation in advanced cancer and tested whether couple communication mediates this relationship and whether gender and age moderate this mediating effect, using longitudinal data from a psychotherapy trial.

Methods: Patients with advanced cancer who lived with a partner (N = 289) completed measures of attachment security (attachment avoidance, attachment anxiety), couple communication, and death preparation (preparation for end of life, life completion) and attendant health involvement (relationship with healthcare provider). A moderated mediation model was evaluated at each time period (baseline, 3 months, and 6 months).

Results: Couple communication mediated the relationship of attachment security to preparation for end of life and life completion (b's = -.06 to -.10). Anxiety × Gender effects on baseline couple communication (P's = .016) indicated that women with greater attachment anxiety reported worse communication than their male counterparts. Couple-communication × Gender × Age effects on baseline preparation for end of life (P = .007-.020) suggested that women showed better preparation with better couple communication. Younger patients reported less preparation than older patients, especially with poorer communication, but their preparation increased with better communication, especially in younger men.

Conclusions: Attachment security supports death preparation in advanced cancer partly through better couple communication. Couple-based psychotherapeutic interventions, especially for younger individuals and women with attachment anxiety, may facilitate constructive conversations and death preparation.
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http://dx.doi.org/10.1002/pon.5354DOI Listing
May 2020

Integration of patient-reported outcomes (PROs) for personalized symptom management in "real-world" oncology practices: a population-based cohort comparison study of impact on healthcare utilization.

Support Care Cancer 2020 Oct 4;28(10):4933-4942. Epub 2020 Feb 4.

ICES, Toronto, Ontario, Canada.

Background: The use of patient-reported outcomes (PROs) for routine cancer distress screening is endorsed globally as a quality-care standard. However, there is little research on the integration of PROs in "real-world" oncology practices using implementation science methods. The Improving Patient Experience and Health Outcome Collaborative (iPEHOC) intervention was established at multisite disease clinics to facilitate the use of PRO data by clinicians for precision symptom care. The aim of this study was to examine if patients exposed to the intervention differed in their healthcare utilization compared with contemporaneous controls in the same time frame.

Methods: We used a PRE- and DURING-intervention population cohort comparison study design to estimate the effects of the iPEHOC intervention on the difference in difference (DID) for relative rates (RR) for emergency department (ED) visits, hospitalizations, psychosocial oncology (PSO), palliative care visits, and prescription rates for opioids and antidepressants compared with controls.

Results: A small significantly lower Difference in Difference (DID) (- 0.223) in the RR for ED visits was noted for the intervention compared with controls over time (0.947, CI 0.900-0.996); and a DID (- 0.0329) for patients meeting ESAS symptom thresholds (0.927, CI 0.869-0.990). A lower DID in palliative care visits (- 0.0097), psychosocial oncology visits (- 0.0248), antidepressant prescriptions (- 0.0260) and an increase in opioid prescriptions (0.0456) in the exposed population compared with controls was also noted. A similar pattern was shown for ESAS as a secondary exposure variable.

Conclusion: Facilitating uptake of PROs data may impact healthcare utilization but requires examination in larger scale "real-world" trials.
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http://dx.doi.org/10.1007/s00520-020-05313-3DOI Listing
October 2020

High prevalence of persistent emotional distress in desmoid tumor.

Psychooncology 2020 02 10;29(2):311-320. Epub 2019 Dec 10.

Department of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Ontario, Canada.

Objective: Clinical experience suggests a high prevalence of emotional distress in patients with desmoid tumor (DT). We examine longitudinal Distress Assessment and Response Tool (DART) scores to estimate prevalence and persistence of distress, and compare cross-sectional data between DT and malignant sarcoma cohorts, to identify predictors of distress.

Methods: Patients with DT completed DART at: T1-diagnosis, T2-during, T3-<6 months, and T4-≥6 months, post-treatment. DART includes patient-reported outcome measures of physical symptoms (ESAS-r), depression (PHQ-9), anxiety (GAD-7), and social difficulties (SDI-21). Descriptive prevalence and persistence of anxiety, depression, and wellbeing are reported, and mixed model regression analyses determine predictors of distress.

Results: Between 2012 and 2018, a total of 152 DART screens from 94 patients with DT were completed (T1: n = 44, T2: n = 31, T3: n = 22, T4: n = 55). Patients had a mean age 40 years, 78% were female and DT locations were abdominal wall (48%), extremity (30%), and mesentery (22%). Moderate to severe ESAS-r scores (≥4) persisted at T4 for anxiety (20%), depression (13%), and poor wellbeing (31%). Compared to 402 patients with malignant sarcoma, patients with abdominal wall sited DT reported severe PHQ-9 and GAD-7 scores twice as frequently. Abdominal wall location, female sex, history of mood problems, and psychosocial concerns were significant predictors of anxiety, depression, and poor wellbeing in DT.

Conclusions: Adults with DT experience persistently high emotional distress compared to patients with malignant sarcoma. Women with abdominal wall DT, prior mood, and current psychosocial concerns need early attention within multidisciplinary treatment settings to reduce persistent distress.
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http://dx.doi.org/10.1002/pon.5250DOI Listing
February 2020

Depression in the medically ill.

Aust N Z J Psychiatry 2020 04 21;54(4):346-366. Epub 2019 Nov 21.

Department of Psychiatry, University of Toronto, Toronto, ON, Canada.

Background: Depressive disorders are significantly more common in the medically ill compared to the general population. Depression is associated with worsening of physical symptoms, greater healthcare utilization and poorer treatment adherence. The present paper provides a critical review on the assessment and management of depression in the medically ill.

Methods: Relevant articles pertaining to depression in the medically ill were identified, reviewed and synthesized qualitatively. A systematic review was not performed due to the large breadth of this topic, making a meaningful summary of all published and unpublished studies not feasible. Notable studies were reviewed and synthesized by a diverse set of experts to provide a balanced summary.

Results: Depression is frequently under-recognized in medical settings. Differential diagnoses include delirium, personality disorders and depressive disorders secondary to substances, medications or another medical condition. Depressive symptoms in the context of an adjustment disorder should be initially managed by supportive psychological approaches. Once a mild to moderate major depressive episode is identified, a stepped care approach should be implemented, starting with general psychoeducation, psychosocial interventions and ongoing monitoring. For moderate to severe symptoms, or mild symptoms that are not responding to low-intensity interventions, the use of antidepressants or higher intensity psychotherapeutic interventions should be considered. Psychotherapeutic interventions have demonstrated benefits with small to moderate effect sizes. Antidepressant medications have also demonstrated benefits with moderate effect sizes; however, special caution is needed in evaluating side effects, drug-drug interactions as well as dose adjustments due to impairment in hepatic metabolism and/or renal clearance. Novel interventions for the treatment of depression and other illness-related psychological symptoms (e.g. death anxiety, loss of dignity) are under investigation.

Limitations: Non-systematic review of the literature.

Conclusion: Replicated evidence has demonstrated a bidirectional interaction between depression and medical illness. Screening and stepped care using pharmacological and non-pharmacological interventions is merited.
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http://dx.doi.org/10.1177/0004867419888576DOI Listing
April 2020

Age-related cytokine effects on cancer-related fatigue and quality of life in acute myeloid leukemia.

J Geriatr Oncol 2020 04 10;11(3):402-409. Epub 2019 May 10.

Department of Psychiatry, University Health Network, Toronto, Canada.

Objectives: We determined whether cytokines are a potential target to improve cancer-related fatigue (CRF) and quality of life (QOL) in acute myeloid leukemia (AML).

Methods: 219 patients age 18+ undergoing intensive chemotherapy for AML were assessed at up to 4 time points (pre-treatment, 1 month, 6 months, 12 months). CRF and QOL were assessed with validated patient-reported outcome measures with minimum clinically important differences (MCID) of 4 and 10 points, respectively. A panel of 31 plasma cytokines was measured. CRF and QOL were regressed against scaled cytokine values, adjusting for age, gender, time, remission status, and hemoglobin in linear models.

Results: 498 cytokine samples were available. For CRF, the model R was 25.3%, with cytokines explaining 6.9% of the variance. For QOL, corresponding values were 27.9% and 7.4%, respectively. A shift from the 30th to 70th centile distribution of all cytokines was associated with an improvement in CRF by 5.2 points and a 10.2-point improvement in QOL. A shift from 5th to 95th centile in TNF-α but no other single cytokine was associated with a change of >MCID in CRF, but there was no similar association with QOL. Cytokines had greater explanatory power for CRF in older versus younger adults and the most influential cytokines differed by age, particularly TNF-α.

Conclusion: Cytokines explain a relatively small amount of CRF and QOL scores in patients with AML and effects differ by age group. For cytokine-targeted therapies to improve either outcome, multiple cytokines may need to be substantially altered and therapeutic targets may vary with age.
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http://dx.doi.org/10.1016/j.jgo.2019.04.009DOI Listing
April 2020

Oral Ketamine for Depression: A Systematic Review.

J Clin Psychiatry 2019 04 16;80(3). Epub 2019 Apr 16.

Mood Disorder Psychopharmacology Unit, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Objective: Intravenous (IV) ketamine has rapid and robust antidepressant effects; however, poor accessibility of the IV route often limits its use. Numerous alternative routes of administration are being investigated. Oral ketamine is particularly appealing for its ease of use with the potential for high accessibility. The objective of the current systematic review, in accordance with PRISMA, is to determine the efficacy, safety, tolerability, and dose range of oral ketamine for bipolar and unipolar depression.

Data Sources: The MEDLINE/PubMed, EMBASE, and Google Scholar databases were systematically searched for relevant articles, written in English, published prior to July 2018 using relevant keywords for all variants of ketamine, oral, and depression.

Study Selection: All clinical studies assessing oral ketamine for bipolar or unipolar depression were included. A total of 13 published articles were identified, of which 2 were proof-of-concept, randomized controlled trials (RCTs); 1 was a prospective open-label trial; 5 were retrospective chart reviews; and 5 were case reports.

Data Extraction: Included articles were qualitatively analyzed to determine antidepressant efficacy, tolerability, safety, dose range, antisuicide effects, time to effect, and efficacy in treatment-resistant depression and study bias.

Results: Both RCTs demonstrated antidepressant efficacy with good tolerability; however, significant changes in depressive symptom severity were observed only after 2-6 weeks of treatment (P < .05). Both RCTs had high risk for bias, due to inadequate intent-to-treat analysis and adverse effect monitoring. Rapid antidepressant effects (ie, within 24 hours), antisuicide effects, and efficacy in treatment-resistant depression were reported only in retrospective studies. Dosages and frequency of administration were variable (ie, 0.5-7.0 mg/kg 3 times daily to once monthly), with most studies providing dosages of 1-2 mg/kg every 1-3 days. No clinically significant adverse effects were reported.

Conclusions: A small number of clinical studies assessed the antidepressant effects of oral ketamine. Initial results suggest that oral ketamine has significant antidepressant effects with good overall tolerability; however, antidepressant effects are not as rapid as those associated with IV ketamine. Antisuicide effects and efficacy in treatment-resistant depression have yet to be demonstrated. Additional well-designed RCTs are warranted.
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http://dx.doi.org/10.4088/JCP.18r12475DOI Listing
April 2019

Validation of the Patient-Reported Outcomes Measurement Information System (PROMIS)-57 and -29 item short forms among kidney transplant recipients.

Qual Life Res 2019 Mar 22;28(3):815-827. Epub 2018 Nov 22.

Division of Nephrology, Multi-Organ Transplant Program, University Health Network and University of Toronto, Toronto, Canada.

Objective: The Patient-Reported Outcomes Measurement Information System (PROMIS) aims to address the lack of generalizable and universal measure of patient-reported outcomes to assess health-related quality of life. It has not been validated for patients with chronic kidney disease. We aim to validate the PROMIS-57 and PROMIS-29 questionnaires among kidney transplant recipients.

Methods: A cross-sectional sample of stable kidney transplant recipients was recruited. Each participant completed PROMIS-57, a 57-question instrument covering seven domains-physical function, anxiety, depression, fatigue, pain, sleep disturbance, and social functioning-alongside validated legacy questionnaires [Patient Health Questionnaire (PHQ9), General Anxiety Disorder (GAD7), Edmonton Symptom Assessment Scale revised (ESASr), and Kidney Disease Quality of Life (KDQoL-36)]. PROMIS-29, a 29-question instrument, is nested within PROMIS-57 and measures the same domains. Structural validity of PROMIS was assessed with confirmatory factor analysis, reported using the Comparative Fit Index (CFI). Construct validity was assessed with known-groups comparisons. Internal consistency was evaluated with Cronbach's α and convergent validity was assessed with Spearman's Rho. Test-retest reliability was assessed through the intraclass correlation coefficient (ICC).

Results: Mean (± SD) age of the 177 participants was 50 (± 17), 57% were male and 55% Caucasian. Internal consistency of each domain was high (Cronbach's α > 0.88). Confirmatory factor analysis showed good structural validity for most domains (CFI > 0.95, RMSEA < 0.05). Test-retest reliability indicated good agreement (ICC > 0.6). Known-groups comparisons by clinical and socio-demographic differences were found as hypothesized.

Conclusions: Our results provide evidence that PROMIS-57 and PROMIS-29 are highly reliable and valid instruments among kidney transplant recipients. We propose it as a valuable tool to assess important domains of the illness experience.
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http://dx.doi.org/10.1007/s11136-018-2058-2DOI Listing
March 2019

Psychosocial Distress and Health Service Utilization in Patients Undergoing Hemodialysis: A Prospective Study.

Psychosomatics 2019 Jul - Aug;60(4):385-392. Epub 2018 Oct 10.

Geri-PARTy Research Group, Jewish General Hospital, Department of Psychiatry, McGill University, Montreal, Canada.

Background: End-stage renal disease is associated with significant morbidity, high-symptom burden, and health care use. Studies have not yet assessed psychosocial distress and health care utilization in this population.

Objective: This study examines psychosocial distress and its association with hospitalization and emergency room (ER) visits in patients on maintenance hemodialysis (HD).

Methods: The Distress Assessment and Response Tool (DART) was administered to 80 adults on HD in a single treatment center. The DART assessed for anxiety, depression, and social distress. Health care utilization data were extracted prospectively from electronic medical charts. The time between psychosocial distress and hospitalization or ER visits during 12-month follow-up was examined using Cox proportional hazard models.

Results: Overall 46% of the sample reported psychosocial distress, with 33% screening above the threshold for depression, 14% for anxiety, and 36% for significant social distress. In multivariable regression adjusting for age, sex, and comorbidity, the presence of psychosocial distress was associated with shorter time to hospitalization (hazard ratio: 2.4 [1.1, 5.0], p = 0.03) during 12-month follow-up. Psychosocial distress was not significantly associated with ER visits in either univariable (hazard ratio: 1.3 [0.7, 2.3], p = 0.5) or multivariable (hazard ratio: 1.4 [0.8, 2.6], p = 0.3) analyses.

Conclusion: Psychosocial distress is frequent in patients undergoing maintenance HD and is associated with shorter time to hospitalization. Future longitudinal studies should examine if health service use can be reduced through routine distress screening and psychosocial distress intervention.
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http://dx.doi.org/10.1016/j.psym.2018.10.001DOI Listing
May 2020

Symptom screening for constipation in oncology: getting to the bottom of the matter.

Support Care Cancer 2019 Jul 30;27(7):2463-2470. Epub 2018 Oct 30.

Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 16th Floor, Room 749, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.

Purpose: This study seeks to determine whether specific screening for constipation will increase the frequency of clinician response within the context of an established symptom screening program.

Methods: A "constipation" item was added to routine Edmonton Symptom Assessment System (ESAS) screening in gynecologic oncology clinics during a 7-week trial period, without additional constipation-specific training. Chart audits were then conducted to determine documentation of assessment and intervention for constipation in three groups of patients, those who completed (1) ESAS (n = 477), (2) ESAS-C with constipation (n = 435), and (3) no ESAS (n = 511).

Results: Among patients who were screened for constipation, 17% reported moderate to severe symptoms. Greater constipation severity increased the likelihood of documented assessment (Z = 2.37, p = .018) and intervention (Z = 1.99, p = .048). Overall rates of documented assessment were 36%, with the highest assessment rate in the no ESAS group (χ = 9.505, p = .006), a group with the highest proportion of late-stage disease. No difference in the rate of assessment was found between the ESAS and ESAS-C groups. Overall rates for documentation of intervention were low, and did not differ between groups.

Conclusions: Specific screening for constipation within an established screening program did not increase the documentation rate for constipation assessment or intervention. The inclusion of specific symptoms in multi-symptom screening initiatives should be carefully evaluated in terms of added value versus patient burden. Care pathways should include guidance on triaging results from multi-symptom screening, and clinicians should pay particular attention to patients who are missed from screening altogether, as they may be the most symptomatic group.
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http://dx.doi.org/10.1007/s00520-018-4520-7DOI Listing
July 2019

Consultation-liaison psychiatry and physician-assisted death.

Gen Hosp Psychiatry 2018 Nov - Dec;55:15-19. Epub 2018 Aug 31.

University Health Network Centre for Mental Health, Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Faculty of Medicine, Canada.

Objective: Consultation-liaison (C-L) psychiatrists are involved in physician-assisted death (PAD) teams in many permitting jurisdictions. This paper will describe our Canadian PAD experience over 2 years, highlighting the role of C-L psychiatrists, at a large hospital network that provides medical assistance in dying (MAID, as this is called in Canada).

Methods: We will describe the Canadian criteria for MAID, our multispecialty MAID team experience and the roles, issues and concerns experienced by C-L psychiatrists. Some brief patient examples will be provided.

Results: Our MAID team has managed 186 MAID inquiries, assessed 95 MAID requests and provided 49 MAID interventions over a 24 month period. The 2 co-leaders of the MAID team, 8 assessors and 1 intervention physician are C-L psychiatrists. Each of the MAID criteria: grievous medical condition, advanced state of irreversible decline, intolerable suffering, natural death reasonably foreseeable, voluntary request, capacity and informed consent pose specific challenges to be resolved in the assessment. Several unique MAID issues, including the role of education and mandatory psychiatric assessment and protocols will also be discussed.

Conclusions: Our experience shows that C-L psychiatrists are well-situated to provide vital expertise and leadership to multispecialty PAD teams.
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http://dx.doi.org/10.1016/j.genhosppsych.2018.08.011DOI Listing
July 2019

Symptom burden in adults with thyroid cancer.

Psychooncology 2018 10 31;27(10):2517-2519. Epub 2018 Aug 31.

Department of Supportive Care, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1002/pon.4853DOI Listing
October 2018

Development and prospective evaluation of CAPLET, a cancer ambulatory patient physical function longitudinal evaluation tool for routine clinical practice.

Support Care Cancer 2019 Feb 8;27(2):521-530. Epub 2018 Jul 8.

Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Departments of Medicine and Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.

Purpose: A patient's physical function is a critical outcome variable for measuring and improving chronic care management. However, patient-reported outcome measures of physical function are not routinely assessed in cancer outpatients, in part due to limitations of tools available. This study presents the development and evaluation of the Cancer Ambulatory Patient Physical Function Longitudinal Evaluation Tool (CAPLET) as an adaptive response tool for routinely screening for physical dysfunction in oncology clinical practice.

Methods: In phase 1, 407 adult outpatients at Princess Margaret Cancer Centre completed the World Health Organization Disability Assessment Schedule (WHODAS) 2.0, Health Assessment Questionnaire Disability Index (HAQ-DI), EuroQuol-5D-3L ( EQ-5D-3L), and patient-reported outcome (PRO)-Eastern Cooperative Oncology Group (ECOG). CAPLET was developed based on a branching logic algorithm navigating patients to appropriate domains of HAQ-DI/WHOAS using their responses to the PRO-ECOG/EQ-5D-3L as screeners. Sensitivity/specificity of CAPLET screeners for HAQ-DI/WHODAS items were reported. In phase 2, CAPLET vs the WHODAS/HAQ-DI were alternatively administrated to 318 adult outpatients in a two-arm trial comparing time to completion and acceptability between the tools.

Results: Using a patient's ECOG status and the sum of the mobility, self-care, and usual activity dimensions of the EQ-5D-3L to dichotomize patients as with or without difficulty, CAPLET achieved a sensitivity > 90% against recommended WHODAS and HAQ-DI cutoffs for significant dysfunction. Sensitivity of screeners for capturing dysfunction in individual WHODAS/HAQ-DI items ranged from 85 to 100%. Compared to the HAQ-DI/WHODAS, CAPLET was associated with a 50% reduction in administration times and improved patient acceptability, while reducing question burden by 84% for half the sample population.

Conclusions: CAPLET improves the feasibility of capturing detailed assessments of patient-reported physical function in cancer outpatients.
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http://dx.doi.org/10.1007/s00520-018-4333-8DOI Listing
February 2019
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