BACKGROUND: Adolescent and young adult oncology (AYAO) patients and caregivers may experience significant psychosocial dysfunction and financial toxicity. Understanding early risk factors is critical to improving survivorship trajectories. METHODS: The authors conducted a cross-sectional study of baseline survey data from a prospective cohort of AYAO patient-caregiver dyads enrolled within 1 month of medical oncology treatment initiation. Posttraumatic stress symptoms (PTSS) were measured by the Impacts of Events Scale-Revised, and financial toxicity was measured with the Comprehensive Score (COst). The authors fit models of linear association between PTSS, financial toxicity, and other end points and pairwise associations of PTSS and financial toxicity within dyads. RESULTS:The analytic cohort contained 41 patients, 37 caregivers, and 34 complete dyads. Clinically-concerning PTSS were observed among patients (44%) and caregivers (52%). The median COst scores were 20.0 for patients (quartiles, 12.5-29.5) and 22.0 for caregivers (quartiles, 12.8-26.0), which were consistent with high financial toxicity (patients, 46%; caregivers, 44%). PTSS were positively associated with financial toxicity (P = .013 for patients, P = .039 for caregivers), subjective distress (P < .001 for all), depressive (P < .001 for all) and anxiety symptoms (P = .005 for patients, P = .024 for caregivers), and poorer quality of life (P < .001 for patients, P = .003 for caregivers). A significant paired association was not found in PTSS (Pearson correlation coefficient [PCC], 0.23; 95% confidence interval [CI], −0.15 to 0.56). Financial toxicity was positively associated within dyads (PCC, 0.65; 95% CI, 0.36-0.83). CONCLUSIONS: At diagnosis, AYAO patients and caregivers exhibit substantial PTSS, which are associated with greater financial toxicity and other psychosocial distress.
With their study, Seow et al 1 call attention to the complementary role that patients play in shaping end-of-life (EOL) care and the potential utility of a patient-oriented prognostic tool in influencing their experience. The investigators sought to develop a prognostic tool that is geared toward patients and families, making excellent use of a large and representative data set from Ontario, Canada, that is unique for its longitudinal measurement of patient-reported outcomes and symptom scores that are not available in most other cancer registries. Using the Edmonton Symptom Assessment Scale and Palliative Performance Scale to predict mortality, along with various other clinical factors, the investigators created a novel model for predicting mortality among patients with cancer irrespective of cancer type and laboratory values.Despite increased attention to quality of EOL care, patients with cancer continue to receive aggressive care near death and experience poor EOL outcomes. 2 Although 80% of patients prefer to die at home, most die in hospitals and without a prior goals-of-care conversation, 3,4 and nearly 25% of patients with cancer receive chemotherapy within 2 weeks of death. 2 Outcomes are shaped by multiple factors, including poor physician prognostic awareness and optimism bias. With advances in therapeutics, patients and practitioners may anchor on the explanation of advanced cancer as treatable but not curable but neglect the harder discussions of how declining functional status and the biological limits of late-line therapies will inevitably limit the value of additional treatments. Therefore, physicians have been the focus of recent attempts to improve prognostication and palliative care implementation through electronic health record automation and machine learning methods. 3,4 Efforts to develop and standardize patient-facing prognostic tools to help patients understand their own mortality and disease trajectory, as well as tools to empower patients and families to advocate for care consistent with their goals and values, are also necessary. Patients substantially overestimate their own likely survival, and discordance between physician and patient understanding is substantial, including on fundamental issues, such as whether cure is likely. 5 Furthermore, heterogeneity of physician practice, as opposed to relevant clinical factors, often determines the timing and likelihood of EOL discussions. 6 A prognosis framework based on functional decline and symptoms is intuitive and conceptually useful in orienting patients and practitioners toward linking the day-to-day changes that patients and families experience to their larger prognostic significance. Of note, the study's finding that any change in appetite is predictive of mortality is an important one, highlighting the critical need for further research into cancer-related cachexia. Although some of the other metrics used in the model are circular, such as receiving EOL home care, this not an inherent weakness in a patient-oriented model. As dis...
In their article "Assessment of Time-to-Treatment Initiation and Survival in a Cohort of Patients with Common Cancers," Cone et al 1 bring to the forefront an important and topical issue about the risks of delays in cancer care. They focus on delays in time-to-treatment initiation (TTI) with curative-intent therapy following diagnosis in a retrospective cohort study leveraging the National Cancer Database for nonmetastatic prostate, breast, and colon, and stages I and II lung cancer treated from 2004 to 2015. They find evidence that longer TTI is associated with higher mortality across cancer types, most significantly in colon cancer and early-stage lung cancer.
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