Background. Early palliative care for advanced cancer patients improves quality of life and survival, but less is known about its effect on intensive care unit (ICU) use at the end of life. This analysis assessed the effect of a comprehensive early palliative care program on ICU use and other outcomes among patients with advanced cancer. Patients and Methods. A retrospective cohort of patients with advanced cancer enrolled in an early palliative care program (n 5 275) was compared with a concurrent control group of patients receiving standard care (n 5 195) during the same time period by using multivariable logistic regression analysis. The multidisciplinary outpatient palliative care program used early end-of-life care planning, weekly interdisciplinary meetings to discuss patient status, and patient-reported outcomes assessment integrated within the electronic health record.

Navigating the biomedical, emotional, and logistical complexity of end-of-life (EOL) care requires seamless interprofessional teamwork. Unfortunately, EOL care, interprofessional collaboration, and the role of support services such as hospice are not adequately emphasized in nursing and medical curricula. This article describes a student-run program, entitled the "HeArt of Medicine", which was designed to foster a reflective and collaborative approach to EOL care. The program consists of three workshops with a novel blend of art, science, and practical information, highlighting the need for interprofessional teamwork. Participants were surveyed before and after the workshops on their attitudes toward EOL care. Composite participant scores after workshops demonstrated increased comfort with and knowledge of EOL care topics (p = 0.001). The results show that this program has had a positive impact on participants' knowledge, comfort, and collaboration in EOL settings.

Neoadjuvant therapy is integral to the treatment of early-stage breast cancer. Goals of treatment include surgical downstaging of the tumor, rendering inoperable tumors resectable, and de-escalating axillary surgery in those with clinically positive nodes. Additionally, response to treatment provides important prognostic information regarding risk of recurrence and guides future adjuvant treatment. Although chemotherapy serves as the backbone of neoadjuvant treatment, an increased understanding of the tumor's clinical course as well as its molecular and genetic make-up aids in individualizing treatment and developing novel agents. This review summarizes current clinical approaches and the future direction to the management of breast cancer patients in the neoadjuvant setting.

Age is one of the most important risk factors for the development of breast cancer. Nearly a third of all breast cancer cases occur in older women (aged ≥70 years), with most cases being oestrogen receptor-positive (ER+). Such tumours are often indolent and unlikely to be the ultimate cause of death for older women, particularly when considering other comorbidities. This Review focuses on unique clinical considerations for screening, detection, and treatment regimens for older women who develop ER+ breast cancers—specifically, we focus on recent trends for de-implementation of screening, staging, surgery, and adjuvant therapies along the continuum of care. Additionally, we also review emerging basic and translational research that will further uncover the unique underlying biology of these tumours, which develop in the context of systemic age-related inflammation and changing hormone profiles. With prevailing trends of clinical de-implementation, new insights into mechanistic biology might provide an opportunity for precision medicine approaches to treat patients with well tolerated, low-toxicity agents to extend patients’ lives with a higher quality of life, prevent tumour recurrences, and reduce cancer-related burdens.

25 Background: The “Surprise Question” — Would I be surprised if this patient died in the next 12 months? — was developed to help clinicians predict when patients are nearing the end of life. Limited data has shown that the “Surprise Question” is modestly predictive of mortality (CMAJ 2017 Apr 3;189(13):E484-E493), though its performance seems to be superior among cancer patients (Palliat Med 2014 Jul;28(7):959-964). Via Oncology Pathways, a platform used by UPMC Hillman Cancer Center and other institutions nationwide to guide treatment decisions, asks physicians the “Surprise Question” when a new treatment plan is implemented for patients with metastatic cancer. We assessed the “Surprise Question’s” ability to predict survival among Hillman Cancer Center patients with select stage IV diagnoses. Methods: We queried the UPMC Hillman Cancer Center Registry Information and Reporting Services for cases of colorectal, non-small cell lung, prostate, pancreatic, and breast cancer with clinic visits between 1/1/2016 and 12/31/2017 and residence in Allegheny County, the primary referral base for the UPMC Hillman Cancer Center network’s flagship facility. Results: The “Surprise Question” was completed for 1,584 patients with metastatic disease of the 5,330 patients that were screened. “No” was the response for 891 patients (56.3%). Mortality at 12 months for patients for whom the answer to the “Surprise Question” was “no” was 63.1%, compared to 32.5% for patients for whom the answer was “yes” (P < 0.0001). The sensitivity of the “Surprise Question” was 71.4% (95% CI 69.0 – 73.8%), and the specificity was 58.7% (95% CI 56.3 – 61.0%). The positive predictive value was 63.1% (95% CI 60.9 – 65.2%) and negative predictive value 67.5% (64.8% – 70.2%). Finally, the positive likelihood ratio was 1.73 (95% CI 1.58 – 1.89) and negative likelihood ratio 0.49 (0.43 – 0.55). Conclusions: While a “no” response to the “Surprise Question” for UPMC oncology patients with select stage IV diagnoses was more likely to predict 12-month mortality than a “yes” response, the “Surprise Question” was only modestly predictive of 12-month mortality. Future work will focus on determining if there are patient populations for whom the “Surprise Question” is more predictive and assessing the ability of the “Surprise Question” to predict other clinical outcomes, such as ED visits and hospitalizations.