Decision Aids for Patients With Head and Neck Cancer: Qualitative Elicitation of Design Recommendations From Patient End Users.

BACKGROUND: Patients with head and neck cancer (HNC) carry a clinically significant symptom burden, have alterations in function (eg, impaired ability to chew, swallow, and talk), and decrease in quality of life. Furthermore, treatment impacts social activities and interactions as patients report reduced sexuality and shoulder the highest rates of depression across cancer types. Patients suffer undue anxiety because they find the treatment incomprehensible, which is partially a function of limited, understandable information. Patients' perceptions of having obtained adequate information prior to and during treatment are predictive of positive outcomes. Providing patient-centered decision support and utilizing visual images may increase understanding of treatment options and associated risks to improve satisfaction with their decision and consultation, while reducing decisional conflict. OBJECTIVE: This study aims to gather requirements from survivors of HNC on the utility of key visual components to be used in the design of an electronic decision aid (eDA) to assist with decision-making on treatment options. METHODS: Informed by a scoping review on eDAs for patients with HNC, screens and visualizations for an eDA were created and then presented to 12 survivors of HNC for feedback on their utility, features, and further requirements. The semistructured interviews were video-recorded and thematically analyzed to inform co-design recommendations. RESULTS: A total of 9 themes were organized into 2 categories. The first category, eDAs and decision support, included 3 themes: familiarity with DAs, support of concept, and versatility of the prototype. The second category, evaluation of mock-up, contained 6 themes: reaction to the screens and visualizations, favorite features, complexity, preference for customizability, presentation device, and suggestions for improvement. CONCLUSIONS: All participants felt an eDA, used in the presence of their oncologist, would support a more thorough and transparent explanation of treatment or augment the quality of education received. Participants liked the simple design of the mock-ups they were shown but, ultimately, desired customizability to adapt the eDA to their individual information needs. This research highlights the value of user-centered design, rooted in acceptability and utility, in medical health informatics, recognizing cancer survivors as the ultimate knowledge holders. This research highlights the value of incorporating visuals into technology-based innovations to engage all patients in treatment decisions.

Review of Palliative Radiation Therapy Patterns of Practice for Adrenal Metastases in British Columbia.

PURPOSE: The adrenal gland is a common site of metastasis in patients with advanced cancer, but it is rarely symptomatic. A subset of patients develop a complex pain syndrome with anorexia, nausea, and poorly localized visceral pain in the back, flank, or epigastric region. These symptoms can affect quality of life and are occasionally challenging to palliate. The role of palliative radiation therapy (PRT) in these patients is unclear. This population-based retrospective study evaluates PRT practices for patients with adrenal metastases and aims to describe treatment response and acute toxicity. METHODS AND MATERIALS: Patients who received PRT to an adrenal metastasis between the years of 1985 and 2015 were identified in a provincial database. Patient demographics, tumor factors, symptom burden, radiation therapy prescriptions, and response to treatment were collected. Variables were summarized using descriptive statistics. The Kaplan-Meier test was used to assess survival. Factors associated with clinical response were evaluated using univariate and logistic regression analysis. Factors associated with survival were evaluated using univariate and Cox proportional hazards model. RESULTS: One hundred patients who received 103 separate courses of PRT were identified. The majority had a lung primary (82%). The most common baseline symptoms were pain (90%) and gastrointestinal upset (13%). Prescriptions ranged from 600 cGy in a single fraction to 4500 cGy in 25 fractions. Seventy percent of patients experienced an improvement in pain (either a complete or partial response). Forty-three percent of patients developed acute toxicity from treatment. Median survival was 3 months. CONCLUSIONS: Compared with other anatomic sites, conventional PRT is uncommonly delivered to adrenal metastases. Despite heterogeneity in tumor histology and radiation therapy prescriptions, treatment was associated with an overall pain response of 70%. Prophylactic antiemetics to decrease radiation-induced nausea are required before treatment. Given the poor prognosis of this population, short fractionations are indicated.

Non-oncologist Physician Knowledge of Radiation Therapy at an Urban Community Hospital.

Radiation therapy (RT) is a crucial part of cancer care, but previous work suggests that many non-radiation oncologist physicians are uncomfortable referring for RT. To evaluate training and understanding of RT, the authors sent invitations to complete an online questionnaire to all physicians at a community hospital in Bronx, NY, which asked about oncology training and self-rated and objective knowledge of RT. Out of 247 invited participants, 87 responded (35%). Among responders, 19 were attending physicians (22%) and 66 (76%) were residents. Seventy-two percent of respondents reported caring for > 5 cancer patients in the past month, but 54% reported never referring patients for RT. Sixty-nine percent of respondents stated they received no radiation oncology training in medical school, and 36% reported no general oncology training. Approximately half believed themselves to be "somewhat knowledgeable" about RT indications (48%), benefits (53%), and side effects (55%). Objective assessment mean score was 6.2/12 (median 7) for all respondents; Respondents with internal medicine specialization scored higher than others (mean 7.7 vs 3.5; p < 0.01). Scores did not differ between attending and resident physicians, resident post-graduate levels, or receiving oncology training in medical school. The factors most commonly cited as affecting RT referral decisions were type of cancer, patient wishes, family wishes, poor functional status, and life expectancy. Many physicians are unaware of RT effectiveness or indications, which may affect referral patterns. Previous oncology training was not associated with higher knowledge scores.

End-of-life discussions in practice: survey among Canadian radiation oncologists.

BACKGROUND: Early end-of-life (EOL) discussions improve patient satisfaction, quality of care, and the cost-effectiveness of care. However, some US studies show that radiation oncologists (ROs) are unlikely to discuss EOL issues until the patients develop significant symptoms or the families initiate the discussion. There have been no prior studies describing the patterns of EOL discussions among Canadian ROs. The objectives of this study were: (I) to describe the patterns of EOL discussions among Canadian ROs; (II) to identify the barriers to EOL conversation among Canadian ROs; (III) to assess the attitudes of Canadian ROs toward Medical Assistance in Dying (MAiD). METHODS: The 22-question online survey was distributed to the members of Canadian Association of Radiation Oncologists (CARO). Demographics, EOL discussion patterns, perception of EOL discussions, barriers, and the impact of MAiD were evaluated. RESULTS: Sixty ROs responded out of 326. Prognosis (57%) and goals of care (58%) were routinely discussed, while advanced directive (40%) and planned site of death (12%) were not. More than 90% felt that early EOL discussions with palliative patients were important. The amount of palliative discussion training was correlated with confidence in EOL discussion (P <0.01), perceived importance of RO role in EOL (P=0.006), and the frequency of planned site of death discussion (P=0.041). The most frequently identified barriers were lack of time, uncertainty about prognosis, and concern for patient disappointment. Many ROs provided MAiD information upon request or case-by-case, but only 3% provided the information routinely. CONCLUSIONS: Canadian ROs recognize the importance of EOL discussions, but they do not routinely incorporate advanced directive or site of death in their discussions. ROs with more palliative discussion training were more confident in EOL discussion and likely to engage in them earlier. Short structured training may improve the confidence and quality of EOL discussion. Time constraint is the number one barrier that may be alleviated by delegation of tasks and patient education tools. Discussion about MAiD is supported but not routine among Canadian ROs.

A systematic review of quality of life in head and neck cancer treated with surgery with or without adjuvant treatment.

Quality of life (QoL) is an important consideration in the management of head and neck cancers (HNC). We systematically reviewed the literature to assess the impact of curative surgical resection (+/- adjuvant therapy) of HNC on QoL. Eligible studies (participants>age 18 years, reported fully in English, and prospectively assessed QoL) were filtered using quality criteria, and classified according to the added value, using a published taxonomy. MEDLINE and EMBASE searching yielded 302 distinct reports, 49 met eligibility, and 26 met quality criteria. Among the eligible studies, achievement of certain quality criteria was poor: a priori hypothesis (8%), statistical accounting of missing data (8%), reporting of assessment interval (35%) and rationale for chosen measure (53%). The most frequent ways QoL added value were: understanding of treatment benefit and risk (100%), comparing treatments for QoL effect (92%) and advancing QoL research methodology (50%). QoL (physical/social functioning and various symptom domains) deteriorated with treatment, gradually recovering to baseline (cancer diagnosis) level. Swallowing, chewing, saliva, taste, eating disruption, and aesthetic deficits may persist. Advanced tumors, extensive surgical resection, need for flap reconstruction, neck dissection, and postoperative radiation are associated with worse QoL outcomes. Knowledge of these trends can be applied in shared decision making, identification of commonly faced QoL issues, and to develop and provide survivorship resources. Future research should focus on routinely incorporating QoL in randomized studies, reporting the result according to guidelines, and following knowledge translation principles to maximize the clinician's and patient's ability to use QoL data.

Health related quality of life in head and neck cancer treated with radiation therapy with or without chemotherapy: a systematic review.

Health-related quality of life (HRQoL) is a subjective measure of patients' experience of disease and treatment. We systematically reviewed the literature to identify high quality manuscripts reporting HRQoL outcomes in adults with squamous cell carcinoma of the head and neck (HNSCC) treated with an organ-sparing curative regimen of radiation therapy with or without chemotherapy. Assessments were performed independently by two reviewers; a third reviewer resolved disputes. High quality reports were reviewed in detail to identify trends in HRQoL outcomes. MEDLINE and EMBASE searching yielded 276 distinct reports, plus 24 added via hand search. Of these, 53 met eligibility criteria and 18 were deemed high quality reports on the basis of a quality assessment tool. HRQoL declines after treatment but recovers to baseline levels, generally within 12months. However, xerostomia-related HRQoL deficits may remain long-term. Combined chemoradiotherapy showed a trend toward worse HRQoL compared with RT alone. Intensity modulated radiotherapy (IMRT) yields better HRQoL compared with conventional or three-dimensional conformal radiotherapy. Baseline HRQoL may independently predict local-regional control and overall survival. Future research should incorporate HRQoL into phase III trials. However, adequate effort and journal space must be afforded to the HRQoL results of these studies to ensure proper reporting methods are followed, allowing clinicians to incorporate HRQoL into patient counseling and clinical decision making.

Do gap junctions play a role in nerve transmissions as well as pacing in mouse intestine?

Varicosities of nitrergic and other nerves end on deep muscular plexus interstitial cells of Cajal or on CD34-positive, c-kit-negative fibroblast-like cells. Both cell types connect to outer circular muscle by gap junctions, which may transmit nerve messages to muscle. We tested the hypotheses that gap junctions transmit pacing messages from interstitial cells of Cajal of the myenteric plexus. Effects of inhibitors of gap junction conductance were studied on paced contractions and nerve transmissions in small segments of circular muscle of mouse intestine. Using electrical field stimulation parameters (50 V/cm, 5 pps, and 0.5 ms) which evoke near maximal responses to nitrergic, cholinergic, and apamin-sensitive nerve stimulation, we isolated inhibitory responses to nitrergic nerves, inhibitory responses to apamin-sensitive nerves and excitatory responses to cholinergic nerves. 18beta-Glycyrrhetinic acid (10, 30, and 100 microM), octanol (0.1, 0.3, and 1 mM) and gap peptides (300 microM of (40)Gap27, (43)Gap26, (37,43)Gap27) all failed to abolish neurotransmission. 18beta-Glycyrrhetinic acid inhibited frequencies of paced contractions, likely owing to inhibition of l-type Ca(2+) channels in smooth muscle, but octanol or gap peptides did not. 18beta-Glycyrrhetinic acid and octanol, but not gap peptides, reduced the amplitudes of spontaneous and nerve-induced contractions. These reductions paralleled reductions in contractions to exogenous carbachol. Additional experiments with gap peptides in both longitudinal and circular muscle segments after N(G)-nitro-l-arginine and TTX revealed no effects on pacing frequencies. We conclude that gap junction coupling may not be necessary for pacing or nerve transmission to the circular muscle of the mouse intestine.