Yael Schenker

Patients with advanced pancreatic cancer suffer from high morbidity and mortality. Specialty palliative care may improve quality of life. Assess the feasibility, acceptability, and perceived effectiveness of early specialty physician-led palliative care for patients with advanced pancreatic cancer and their caregivers. A mixed-methods pilot randomized controlled trial in which patient-caregiver pairs were randomized (2:1) to receive specialty palliative care, in addition to standard oncology care versus standard oncology care alone. At a National Cancer Institute-designated comprehensive cancer center in Western Pennsylvania, 30 patients with advanced pancreatic adenocarcinoma and their caregivers (N = 30), oncologists (N = 4), and palliative care physicians (N = 3) participated. Feasibility (enrollment, three-month outcome-assessment, and intervention completion rates), acceptability, and perceived effectiveness (process interviews with patients, caregivers, and physicians). Consent:approach rate was 49%, randomized:consent rate 55%, and three-month outcome assessment rate 75%. Two patients and three caregivers withdrew early. The three-month mortality rate was 13%. Patients attended a mean of 1.3 (standard deviation 1.1) palliative care visits during the three-month period. Positive experiences with palliative care included receiving emotional support and symptom management. Negative experiences included inconvenience, long travel times, spending too much time at the cancer center, and no perceived palliative care needs. Physicians suggested embedding palliative care within oncology clinics, tailoring services to patient needs, and facilitating face-to-face communication between oncologists and palliative physicians. A randomized trial of early palliative care for advanced pancreatic cancer did not achieve feasibility goals. Integrating palliative care within oncology clinics may increase acceptability and perceived effectiveness.

110 Background: Palliative care trials face implementation barriers. We describe challenges encountered in a pilot trial of early specialty palliative care for patients with pancreatic cancer. Methods: We conducted a mixed-methods pilot randomized controlled trial of early specialty physician-led palliative care in advanced pancreatic cancer. Recently diagnosed patients with borderline, locally-advanced, or metastatic pancreatic cancer and their caregivers (total N=60) were recruited from clinic at a comprehensive cancer center and randomized (2:1) to receive monthly specialty palliative care visits for 3 months in addition to standard oncology care vs. standard oncology care alone. Feasibility assessments included enrollment and intervention completion rates. Acceptability and perceived effectiveness were assessed via drop-out rates and semi-structured participant interviews. Results: The enrollment target was reached after 50 weeks, with a randomized: approached rate of 27%. Mean patient age was 63 (SD 11) and 50% were male. Mean caregiver age was 62 (SD 12), 47% were male, and 80% were the spouse or partner of a patient. 70% of participants in the intervention group completed at least one specialty palliative care visit and 15% completed 3 palliative care visits within the 3-month time period. Two patients and 3 caregivers withdrew, and 4 patients died prior to 3 months. Enrollment barriers included patients not planning to continue receiving care from a participating oncologist and feeling too overwhelmed at the time of diagnosis to consider research participation. In semi-structured interviews, patients and caregivers noted that long travel times to the cancer center, difficulty scheduling palliative care visits at a convenient time, and lengthy study assessments posed burdens. Oncologists and palliative care physicians recommended more in-person communication between clinicians and tailoring palliative care visit content and schedules to match patient needs. Conclusions: Future palliative care intervention trials must consider implementation challenges related to recruitment, retention, intervention fidelity, and participant burden. Clinical trial information: NCT01885884.

109 Background: Rates of early specialty palliative care utilization remain low, despite increasing familiarity and favorable attitudes amongst cancer center oncologists. In this context, understanding organizational barriers to specialty palliative care use becomes critical. Methods: We conducted a qualitative interview study with 74 medical oncologists practicing at 3 U.S. academic cancer centers with well-established specialty palliative care clinics. The in-depth interview guide elicited experiences and views related to outpatient palliative care. For this analysis, we focused on organizational factors influencing palliative care use, defined as the structural arrangements and social patterns that facilitate or impede implementation of best practices in healthcare. The team conducted mixed deductive and inductive coding, using Cabana’s quality improvement framework as a starting point. Key concepts were iteratively refined with interdisciplinary input. Two coders applied the final codebook to all transcripts, with disagreements reviewed and resolved by team consensus. Results: Participating oncologists were 68% male, specialized in solid tumors (61%), hematologic malignancies (32%), or both (7%), and had been practicing oncology for a mean of 17 (SD 12) years. Organizational factors impeding early specialty palliative care utilization included: the perceived burden on patients from spending more time at clinic appointments, which was balanced against the value added from specialty palliative care; social, financial, and disease-related factors interfering with patients’ ability to attend additional specialty visits; the clinic name, with concern that patients equated ‘palliative care’ with death, dying or giving up; an unwieldy referral process without availability of same-day appointments; and inadequate communication between oncologists and palliative care specialists. Conclusions: Even when oncologists are aware of the evidence and agree with recommended practices, organizational factors may impede adherence to oncologic and palliative care guidelines. Addressing these barriers could improve use of outpatient specialty palliative care.

In the United States, cancer centers commonly advertise clinical services directly to the public. Potential benefits of such advertising include informing patients about available treatments and reducing the stigma of cancer.^1,2 Potential risks include misleading vulnerable patients and creating false hopes, increasing demand for unnecessary tests and treatments, adversely affecting existing physician-patient relationships, and increasing health care costs.^3,4 Understanding the trends in the advertising spending of cancer centers and the characteristics of the centers that spend the most can inform the debate about the effect of their advertisements. We hypothesized that advertising spending by cancer centers has increased and is concentrated among for-profit cancer centers.

This Viewpoint urges the development of systems to help patients with serious illness and their families understand palliative care options.

Conducting a Google search for a disease is how many people get information about their illness and possible treatments. In a national survey sponsored by the P

Background: Specialty palliative care is not accessible for many patients with advanced cancer. There is a need to find alternative palliative care strategies in oncology clinics. Objective: The objective of the study was to assess the feasibility, acceptability, and perceived effectiveness of an oncology nurse-led care management approach to improve primary palliative care. Methods: The study design was a single-arm pilot trial of the C are M anagement by O ncology N urses (CONNECT) intervention, in which registered oncology nurses receive specialized training and work closely with oncologists to (1) address symptom needs; (2) engage patients and caregivers in advance care planning; (3) provide emotional support; and (4) coordinate care. The subjects were 23 patients with advanced cancer, 19 caregivers, and 5 oncologists from a community oncology clinic in western Pennsylvania. Feasibility was assessed through enrollment rates, outcome assessment rates, and visit checklists. Patients, caregivers, and oncologists completed three-month assessments of acceptability and perceived effectiveness. Results: The consent-to-approach rate was 86% and enrolled-to-consent rate, 77%. CONNECT was implemented according to protocol for all participants. No participants withdrew after enrollment. Four patients died during the study; three-month outcome assessments were completed with all remaining participants (83%). Patients and caregivers reported high satisfaction with CONNECT and perceived the intervention as helpful in addressing symptoms (85%), coping (91%), and planning for the future (82%). Oncologists unanimously agreed that CONNECT improved the quality of care provided for patients with advanced cancer. Conclusion: An oncology nurse-led care management intervention is feasible, acceptable, and was perceived to be effective for improving provision of primary palliative care. A randomized trial of CONNECT is warranted.