Background: An international panel achieved consensus on 9 need-based and 2 time-based major referral criteria to identify patients appropriate for outpatient palliative care referral. To better understand the operational characteristics of these criteria, we examined the proportion and timing of patients who met these referral criteria at our Supportive Care Clinic. Methods:We retrieved data on consecutive patients with advanced cancer who were referred to our Supportive Care Clinic between January 1, 2016 and February 18, 2016. We examined the proportion of patients who met each major criteria and its timing.Results: Among 200 patients (mean age 60, 53% female), the median overall survival from outpatient palliative care referral was 14 (95% confidence interval 9.2, 17.5) months. A majority (n=170, 85%) of patients met at least 1 major criteria; specifically, 28%, 30%, 20% and 8% met 1, 2, 3, and ≥4 criteria, respectively. The most commonly met need-based criteria were severe physical symptoms (n=140, 70%), emotional symptoms (n=36, 18%), decision making needs (n=26, 13%) and brain/leptomeningeal metastases (n=25, 13%). For time-based criteria, 54 (27%) were referred within 3 months of diagnosis of advanced cancer and 63 (32%) after progression from ≥2 lines of palliative systemic therapy. The median duration from patient first meeting any criterion to palliative care referral was 2.4 (interquartile range 0.1, 8.6) months. Conclusions:Patients were referred early to our palliative care clinic and a vast majority (85%) of them met at least one major criteria. Standardized referral based on these criteria may facilitate even earlier referral.Terms of use and reuse: academic research for non-commercial purposes, see here for full terms. http://www.springer.com/gb/openaccess/authors-rights/aam-terms-v1

The landscape of healthcare delivery has considerably changed due to the emergence of coronavirus disease 2019 (COVID-19). This is nowhere more evident than in the care of advanced cancer patients receiving palliative care. This population is susceptible to the severe complications of COVID-19, and immediate measures had to be taken to ensure their safety. Thus, the adoption of telemedicine as a health care delivery model emerged. This model provides many benefits, such as improved access to care while maintaining social distancing; however, there exist challenges to this model, including health care disparities, reimbursement, and monitoring of opioids in high-risk populations. This narrative review provides an overview of the unique benefits and barriers of telemedicine in palliative care patients.

Background There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics. Methods Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient's risk potential for NMOU. Targeted UDT was ordered on the basis of a physician's estimation of a patient's risk for NMOU. Results In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener–Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01). Conclusions Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.

Background Recognizing and managing existential suffering remains challenging. We present two cases demonstrating how existential suffering manifests in patients and how to manage it to alleviate suffering. Case description Case 1: A 69-year-old man with renal cell carcinoma receiving end-of-life care expressed fear of lying down “as he may not wake up.” He also expressed concerns of not being a good Christian. Supportive psychotherapy and chaplain support were provided, with anxiolytic medications as needed. He was able to express his fear of dying and concern about his family, and Edmonton Symptom Assessment System scores improved. He died peacefully with family at bedside. Case 2: A 71-year-old woman presented with follicular lymphoma and colonic obstruction requiring nasogastric drain of fecaloid matter. Initially, she felt that focusing on comfort rather than cure symbolized giving up but eventually felt at peace. Physical symptoms were well-controlled but emotionally she became more distressed, repeatedly asking angrily, “Why is it taking so long to die?.” She was supported by her family through Bible readings and prayers, but she was distressed about being a burden to them. An interdisciplinary approach involving expressive supportive counseling, spiritual care, and integrative medicine resulted in limited distress relief. Owing to increasing agitation, the patient and family agreed to titrate chlorpromazine to sedation. Her family was appreciative that she was restful until her death. Conclusion Existential suffering manifests through multiple domains in each patient. A combination of pharmacologic and non-pharmacologic techniques may be needed to relieve end-of-life suffering.

During the past 10 years, many organizations have implemented quality metrics for end-of-life care. One of the most important is inpatient hospital mortality, 1 which is typically reported as a mortality ratio, ie, observed vs expected deaths, and is used by many major organizations to rank hospitals 1,2 ; its use is supported by survey studies that have found that most patients express the desire to die at home. 1,3,4 However, it is not clear whether patients in these studies have understood the complexity of end of life at home.Patients with cancer and their caregivers may not be aware of the burden of care that would fall on them or the limited support delivered at home by hospices. 1 Patients with cancer who live alone will need to move in with a relative, or a relative will need to move in with them. Caregivers are usually the same age as the patient (mid-60s), 5 and the vast majority do not have any medical or nursing training. They will now be responsible for the following: administering multiple regular medications, making decisions about needed medications for different symptom problems, providing hygiene, helping the patient with elimination, assisting the patient with repositioning as he or she progressively becomes completely bedridden, and providing around-the-clock physical and emotional support. For the most part, they will be alone with the patient at the moment of death. There are side effects to a home death for patients and their loved ones. Failure to disclose those will result in less-reliable consent. Also, in some cultures, a home death is not seen favorably, and universally enforcing it could lead to culturally callous care.Patients enrolled in hospice care this year during the last week of life received a nursing visit on approximately 40% of the days (whether the visitors were registered nurses or nursing assistants was not specified), they received a visit from a social worker or counselor on approximately 9% of the days, and the vast majority of them never saw a physician during their last week of life. 4 This level of care may be enough for some patients with very stable chronic conditions. It also may be seriously deficient for patients with cancer unless they have minimal discomfort or are able to afford considerable family or private duty support.Patients with cancer frequently develop devastating physical and psychosocial symptoms before death. At the time of great profit margin (approximately 17% from 2017 through 2019), for-profit hospice organizations have provided very limited, and not increasing, care. 4 Perhaps for these reasons, care for patients with cancer decreased from more than 90% of the hospice patient population at the inception of the Medicare hospice benefit in 1983 to less than 26% in 2019. 4

Dacomitinib (PF-00299804) is a second-generation irreversible HER tyrosine kinase inhibitor (TKI). In preclinical studies, dacomitinib has demonstrated anti-tumor activity in lung cancer cell lines with sensitive and resistant EGFR mutations (including the T790 mutation). Safety and well tolerability of dacomitinib were demonstrated in Phase I studies with stomatitis, diarrhea and skin toxicities being the dose-limiting toxicities. The maximum tolerated dose was established to be 45 mg/day. In Phase II and III studies, dacomitinib has shown clinical activity in both HER tyrosine kinase-naive and HER tyrosine kinase failure settings. Further clinical trials are underway to evaluate the efficacy of dacomitinib in non-small-cell lung cancer.

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