JCO oncology practice最新文献

Medication reconciliation is a critical part of providing safe oncology care. Small errors in medication management can affect patients' outcomes. Optimal cancer care requires multiple disciplines to act in concert. Too often, disciplines do not communicate efficiently or rely on assumptions of patient knowledge to coordinate care. This case study examines one patient's course that was compromised by such assumptions and suggests systems-based improvements which can prevent similar occurrences.

Purpose: Performance status (PS) assessment is used to determine clinical trial eligibility among patients with cancer, but may be inaccurately assessed by oncology clinicians. Wearable accelerometers may allow objective assessment of physical activity, a proxy for PS. In this analysis of two prospective studies, we derive and externally validate objective PS (OPS) by measuring the association between daily physical activity and overall survival among patients with metastatic cancer.

Materials and methods: For the derivation cohort, we prospectively measured daily physical activity using a wearable accelerometer among patients with metastatic cancer during the screening period for a phase 1 clinical trial in Spain. We used univariable survival analysis, AUCs, and Youden's index to derive an OPS cutoff in mean daily distance walked. We used a multivariable Cox model to calculate the association between OPS and 180-day mortality. We subsequently externally validated OPS in a separate prospective trial of patients with metastatic lung and GI cancers receiving chemotherapy at a large academic health center in the United States.

Results: Full data were available for 123 patients (70 derivation; 53 validation). In the derivation cohort, we defined an OPS cutoff at 1,200 m walked per day. Poor OPS was associated with higher mortality than good OPS in the derivation (180-day mortality, 81.6% v 38.4%; adjusted hazard ratio [aHR], 6.82 [95% CI, 3.44 to 13.5]; P < .001) and external validation cohorts (180-day mortality, 36% v 8%; aHR, 7.07 [95% CI, 1.37 to 36.6]; P = .02).

Conclusion: OPS is an independent, externally validated prognostic indicator and could serve as an objective surrogate for traditional methods of PS assessment in clinical trials and choice of therapy for patients with cancer.

Purpose: With increasing use of immune checkpoint inhibitors (ICIs), effective management of immune-related adverse events (irAEs) has become a critical concern. This study aimed to identify the detection triggers of irAEs and provide insights for improving their management.

Methods: This retrospective analysis included 1,237 patients treated with ICIs between 2014 and 2023. irAEs were categorized into three groups based on their detection triggers: symptom-dominant irAEs (>80% of cases identified through subjective symptoms), test-dominant irAEs (>80% of cases detected via clinical examinations), and mixed-type irAEs (meeting neither criterion).

Results: Among the 1,237 patients, 547 (44.2%) experienced 797 irAEs. Symptom-dominant irAEs included skin toxicity (all-grade: 17.3%, grade ≥3: 1.1%), colitis (3%, 1.4%), musculoskeletal toxicity (1.9%, 0.6%), type 1 diabetes (0.6%, 0.6%), nervous system toxicity (0.6%, 0.4%), and ocular toxicity (0.4%, 0%). Test-dominant irAEs included thyroid dysfunction (11.7%, 0.3%), hepatitis (6.5%, 3.2%), nephritis (1.9%, 0.4%), pancreatitis (1.5%, 1.1%), and hematological toxicity (0.6%, 0.3%). Mixed-type irAEs included pneumonitis (10.6%, 2.7%), adrenal insufficiency or hypophysitis (5.2%, 2.5%), and cardiovascular toxicity (0.8%, 0.2%). Mixed-type irAEs were associated with significantly higher rates of grade ≥3 events (33.2%) and unscheduled hospital visits (26.8%) than other irAEs. Furthermore, mixed-type irAEs identified through clinical examination generally exhibited milder severity than those detected based on subjective symptoms.

Conclusion: Considering irAE detection triggers, incidence, and severity, this study highlights skin toxicity, colitis, pneumonitis, and adrenal insufficiency as high-priority conditions for patient education. After treatment initiation, test-dominant irAEs require appropriate diagnostic work-ups, symptom-dominant irAEs emphasize the importance of patient interviews, and mixed-type irAEs benefit from a combination of these strategies. This comprehensive strategy may improve irAE detection and management, ultimately enhancing patient outcomes.

Purpose: Patient portals increase communication, but little is known about response rates or patient characteristics associated with patient responses to portal-enabled questionnaires about health-related values (HRVs).

Methods: We tested feasibility of sending seven HRV questions by portal to medical oncology patients, with responses automatically returned to clinicians. HRV questionnaires were sent 1 week in advance of scheduled follow-up visits. The primary feasibility measure was patient response rate. Secondarily, we assessed patient characteristics associated with responses, and oncology clinicians' impressions.

Results: One thousand five hundred fifty-six HRV questionnaires were sent by portal to as many individual patients of five total clinics between July 2023 and July 2024. Seven hundred thirty questionnaires were returned with at least one of the questions answered (47% response rate). Response rate increased significantly (45%-50%, P = .05) after April 2024 when the portal notification was updated with a personalized message from oncologists and two study clinics were added to the initial 3. Nonresponders either returned a blank questionnaire (133, 9%) or did not return anything (693, 45%). Response rates were significantly different by patient race (P = .05): Asian (51%) and White (48%) versus Black (44%) and Hispanic (41%). Female patient responses were longer than males. Response time was associated with patients' oncology team and shorter after April 2024. Participating clinicians' impressions were consistently favorable.

Conclusion: Automating a patient portal-driven process to broadly scale elicitation of medical oncology outpatients' HRVs and sending aggregated reports of HRVs to oncology teams are feasible and valued by clinicians. Patient characteristics appear to be associated with responses. Ongoing research will investigate technology-supported strategies to optimize response rates across diverse populations (including minoritized patients who may suffer digital health inequity), and measure effects on person-centered communication and care outcomes.

Purpose: Guidelines recommend offering germline testing to patients with advanced prostate cancer (PCa) to inform treatment and personal/familial cancer risk. We asked whether veterans affairs (VA) patients made informed decisions about germline testing after informed consent discussions with oncologists.

Methods: We conducted a mixed-methods study of veterans with advanced PCa at the San Francisco VA. We audio recorded patient-oncologist germline testing discussions to assess oncologist communication concordance with National Comprehensive Cancer Network consent guidelines. Seven days afterward, we administered the Decisional Conflict Scale (DCS) and KnowGene scale to assess decisional conflict and germline testing knowledge, respectively, and interviewed veterans and caregivers to characterize decision making. We separately interviewed VA oncology and genetics providers for their perspectives on veterans' decision making.

Results: Among 41 participants, 35 (85%) agreed to germline testing. The mean DCS score was 25/100 (higher = greater decisional conflict); 19% had scores >37.5, which is associated with decision delay. Recordings and surveys revealed that oncologists often did not communicate, and most patients lacked knowledge about key informed consent elements, particularly about potential harms, testing outcomes, and results disclosure. Interviews with patients, caregivers, and providers identified numerous patient decisional needs (decisional conflict, inadequate knowledge, unrealistic expectations, inadequate support/resources, and complex decision); barriers to patient decision making (inadequate oncologist training/bandwidth, limited access to educational resources, insufficient oncology/genetics workforce, and paternalistic culture); and facilitators (patient-centered communication, caregiver engagement, and trust in VA).

Conclusion: Although decisional conflict about germline testing was low, some patients made uninformed decisions and oncologists did not communicate all elements of informed consent according to guidelines. To promote patient-centered care, we recommend provider training about informed consent and shared decision making, increased oncology/genetics workforce capacity, and tailored patient-facing educational resources.

Purpose: Breast cancer diagnosis and treatment cause psychosocial distress that can worsen the disease course and outcomes. We hypothesized that personalized telephone follow-up would reduce stress and anxiety, enhance patients' feeling of safety, and minimize symptom exacerbation.

Methods: We conducted a randomized controlled trial to determine the effects of personalized psychological management and support for adverse events (AEs) delivered by two telephone calls during chemotherapy cycles. Calls were conducted by oncology nurses and clinical research associates following a protocol to ensure consistent and supportive communication. We measured changes in Profile of Mood States (POMS) scores between baseline and end of the first chemotherapy (primary outcome), and changes after each chemotherapy cycle of POMS, Hospital Anxiety and Depression Scale, and Core Quality of Life Questionnaire scores. The feasibility, acceptability, and appropriateness of the intervention were also analyzed.

Results: Two hundred forty-eight women were randomly assigned to the intervention group or control group. We found no significant differences in POMS scores (P = .23). The intervention's effects varied by educational level, occupation, and treatment, with higher education linked to greater improvement in Vigor, active women showing reduced Depression, and women treated with docetaxel and cyclophosphamide experiencing a larger decrease in Anger. The repeated ANOVA found no significant effect on all scores (P > .06). The intervention was feasible (89% adherence) and well-received (97.7% satisfaction), but had no effect on AEs.

Conclusion: Personalized telephone intervention was feasible and well-received but did not significantly improve emotional well-being, anxiety, depression, quality of life, and toxicity management compared with standard of care. Subgroup analyses suggest that women with higher education, employment, and specific treatment may benefit, emphasizing the need for tailored approaches.