Exploring Experiences of Pain Management Among Family Caregivers of Community-Dwelling Older Adults With Dementia.

BACKGROUND: Pain is often underreported and under-treated in older adults with dementia. The role of family caregivers (FCGs) in managing pain for their loved ones with dementia living in community has been significantly burdensome. Surprisingly, research has not delved into the experiences of FCGs' concerning pain management in this context. METHODS: A qualitative descriptive study was conducted to gain a deep understanding of FCGs' experiences in managing pain for their loved ones. Family caregivers participated in semi-structured face-to-face or telephone interviews. Inclusion criterion included being an adult providing care to community-dwelling older adults with dementia. Recruitment stopped upon reaching thematic saturation. Basic demographic characteristics was also collected. Constant comparison analytic method was employed. RESULTS: The study included 25 FCGs in central Virginia, spanning ages from 29 to 95. Participants were predominantly white, female, married, and had a minimum high school education. Most of them were adult children (52%) or the spouses (28%) of the care recipients. Four thematic categories emerged around exploring FCGs' pain management experiences: (1) Values; (2) Barriers; (3) Support; and (4) Adaptation. Each theme included sub-themes. CONCLUSION: Family caregivers follow their values to make decisions in pain management. Barriers existed for effective pain management. Adaptation and support from professional or formal caregivers greatly improved FCGs' perception of their competence in pain management. The finding underscores the need for further research and the development of interventions aimed at enhancing FCGs' perception of self-efficacy in this crucial aspect of caregiving.

Pathogenic variant profile in DNA damage response genes correlates with metastatic breast cancer progression-free survival in a Mexican-mestizo population.

Introduction: Metastatic breast cancer causes the most breast cancer-related deaths around the world, especially in countries where breast cancer is detected late into its development. Genetic testing for cancer susceptibility started with the BRCA 1 and 2 genes. Still, recent research has shown that variations in other members of the DNA damage response (DDR) are also associated with elevated cancer risk, opening new opportunities for enhanced genetic testing strategies. Methods: We sequenced BRCA1/2 and twelve other DDR genes from a Mexican-mestizo population of 40 metastatic breast cancer patients through semiconductor sequencing. Results: Overall, we found 22 variants -9 of them reported for the first time- and a strikingly high proportion of variations in ARID1A. The presence of at least one variant in the ARID1A, BRCA1, BRCA2, or FANCA genes was associated with worse progression-free survival and overall survival in our patient cohort. Discussion: Our results reflected the unique characteristics of the Mexican-mestizo population as the proportion of variants we found differed from that of other global populations. Based on these findings, we suggest routine screening for variants in ARID1A along with BRCA1/2 in breast cancer patients from the Mexican-mestizo population.

Characterization of triple negative breast cancer gene expression profiles in Mexican patients.

Triple negative breast cancer (TNBC) is an aggressive type of cancer that accounts for ~23% of breast tumors in Mexico. In an attempt to understand in an improved way the behavior of TNBC, throughout the years, gene expression in these tumors has been studied. Lehman et al identified 6 subtypes of gene expression in TNBC with distinct characteristics. In the present study, it was aimed to assess clinical, pathological and prognostic characteristics of TNBC in a Mexican-based cohort. A total of 55 patients diagnosed with TNBC at Mexico's National Institute of Cancer (INCan) were included. Tumor needle biopsy samples were obtained and subjected to microarray analysis. Patients were thus classified into one of the 6 TNBC molecular subtypes. The prognostic, clinical and pathological information of patients was obtained, and differences across molecular subtypes were sought. Out of the 55 included patients, the following subtypes were identified: 9 basal-like-1, 11 basal-like-2 (BSL2), 16 immunomodulatory (IM), 12 mesenchymal, 6 androgen receptor-like and 1 mesenchymal stem-like. Mean follow-up time was 47.1 months. The IM molecular subtype had the best overall survival (OS) (median OS was not reached). BSL2 had the worst OS (15 months). A complete pathologic response to neoadjuvant chemotherapy was obtained more often in the IM subtype (P=0.032). No significant associations were found between any of the clinical or pathological characteristics and the TNBC molecular subtypes. The results obtained from the present study should be considered when seeking to implement a clinical-molecular model for TNBC patient care, particularly in Hispanic-based populations, as they have been frequently underrepresented in clinical studies assessing TNBC molecular subtypes.

LKB-1 Expression and High-Risk Histopathology are Independent Prognostic Factors for Patients with Oral Cavity Carcinoma.

BACKGROUND: The expression of liver kinase B1 (LKB-1) has been associated with prognosis in squamous cell carcinoma of the oral cavity (SCCOC). This study aimed to define the prognostic role of LKB-1 expression for patients with SCCOC and the suitability of its integration into a multivariate prognostic model. METHODS: A retrospective cohort study of patients with SCCOC was conducted in a cancer center. Expression of LKB-1 was evaluated by immunohistochemistry, and multivariate analysis defined prognostic factors associated with recurrence, recurrence-free survival (RFS), and overall survival (OS). The logistic regression model was used to construct a predictive computer software program. RESULTS: Of the 201 patients in this study, 104 (51.7%) experienced recurrence of their disease. Lower expression of LKB-1, high-risk histopathology, and advanced tumor-node-metastasis (TNM) stages were independent factors via multivariate analysis associated with the increased recurrence risk, poor RFS, and poor OS. If lack of LKB-1 expression is considered the reference category, the factors independently associated with recurrence were low (odds ratio [OR], 0.157; 95% confidence interval [CI], 0.044-0.557), intermediate (OR, 0.073; 95% CI, 0.017-0.319), and intense (OR, 0.047; 95% CI, 0.007-0.304) expression of LKB-1. This model permitted construction of a computer software program capable of prediction with receiver operating characteristic analysis (area under the curve, 0.925) and led to the definition of five prognostic groups with a biologic gradient. CONCLUSION: These results suggest that LKB-1 expression in patients with SCCOC is of robust prognostic value and complements the TNM staging system. The proposed model requires external validation in prospective observational studies.

Evaluación de cribado de la calidad de vida en cuidadores primarios informales de pacientes oncológicos / Screening assessment of quality of life in informal primary caregivers of cancer patients

Objetivo: determinar las propiedades psicométricas de un instrumento de CV (CQoLC) y evaluar la calidad de vida (CV) de los cuidadores primarios (CPI) de pacientes con cáncer. Material y método:estudio tres fases: (1) evaluación de CV en CPI con un instrumento validado para población general y de pacientes que requieren atención médica (InCaViSa); (2) adaptación y piloteo del CQoLC y; (3) evaluación de confiabilidad, validez y normas del CQoLC. Se incluyeron 317 CPI de pacientes con diferentes diagnósticos oncológicos. Se realizaron análisis descriptivos de la CV reportada por los CPI. Para piloteo del instrumento se estimó el porcentaje de CPI que tuvieron dificultades para comprender algún reactivo. En la fase de validación se realizó un análisis factorial por ejes principales y la estructura propuesta se sometió a un análisis factorial confirmatorio (AFC). La confiabilidad se obtuvo a través del Alfa de Cronbach y el coeficiente Omega de McDonald’s. Finalmente, se estimaron los parámetros para calificación del CQoLC. Resultados: los CPI obtuvieron puntajes de “baja” a “muy baja” CV en la mayoría de las subescalas del InCaViSa. El CQoLC no mostró dificultades para su comprensión y se obtuvo una versión de nueve reactivos, distribuidos en cuatro indicadores, que explican el 45,62% de la varianza con adecuado ajuste en el AFC y adecuados índices de confiabilidad (Alfas de Cronbach de 0,496 a 0,866 y coeficiente Omega de McDonald’s = 0,868).Conclusiones:la CV de los CPI de pacientes con cáncer se encuentra afectada importantemente. El CQoLC es un instrumento especializado, que demostró ser adecuado como herramienta de cribado en las mediciones de auto-reporte (AU)

Objective: To determine the psychometric properties of a QoL instrument (CQoLC) and to assess the quality of life (QoL) of primary caregivers (PC) of cancer patients. Methods:Three-phase study: (1) assessment of QoL in PC with an instrument validated for general population and patients requiring medical care (InCaViSa); (2) adaptation and piloting of the CQoLC and (3) assessment of reliability, validity, and norms of the CQoLC. A total of 317 PCs of patients with different oncologic diagnoses were included. Descriptive analyses of the QOL reported by the PCs were performed. For piloting the instrument, the percentage of PCs who had difficulties in understanding any item was estimated. Factor analysis by main axes was performed in the validation phase, and the proposed structure was subjected to confirmatory factor analysis (CFA). Reliability was obtained through Cronbach’s Alpha and McDonald’s Omega coefficient. Finally, the parameters for CQoLC scoring were estimated. Results: The PCs obtained “low” to “deficient” QoL scores in most InCaViSa subscales. The CQoLC showed no difficulties in its comprehension, and a version of nine items was obtained, distributed in four indicators, which explain 45,62% of the variance with adequate adjustment in the AFC and adequate reliability indexes (Cronbach’s alphas from 0,496 to 0,866 and McDonald’s Omega coefficient = 0,868). Conclusions: The QoL of the CQoLC of cancer patients is significantly affected. The CQoLC is a specialized instrument, which proved to be adequate as a screening tool in self-report measurements (AU)

Análisis del comportamiento clínico-patológico del cáncer de mama mucinoso: primer estudio multicéntrico en México. Revisión a 10 años / Analysis of the clinical-pathological behaviour of mucinous carcinoma of the breast: First multicentre study in Mexico-review at 10 years

Introducción El carcinoma mucinoso de mama es una histología poco frecuente, al que se le ha atribuido buen pronóstico, sin embargo, hay pocos datos sobre su comportamiento en población mexicana. Material y métodos Estudio retrospectivo, descriptivo y observacional de tres centros oncológicos de referencia en México, se analizaron características clínicas e histopatológicas de pacientes con carcinoma mucinoso de mama en el periodo comprendido de 2007 a 2017. Resultados Se diagnosticaron 152 pacientes con carcinoma mucinoso puro de mama. Mediana de edad de 56 años. Se encontró asociación entre el tamaño tumoral (p = 0,002) y la afección ganglionar (p < 0,001) con la supervivencia global. Para supervivencia libre de enfermedad, se identificó como factor asociado la afección ganglionar y el inmunofenotipo; con una media de supervivencia libre de enfermedad (SLE) de 143,5 meses para luminal A, 115,4 meses para luminal B, 81 meses para triple negativo y 16 meses para Her 2, p < 0,001. Conclusiones La afección ganglionar es un factor de riesgo para recurrencia de cáncer de mama mucinoso. El tamaño tumoral y una mayor afección ganglionar se relacionaron con un pronóstico adverso en la supervivencia global. (AU)

Introduction Mucinous carcinoma of the breast is an infrequent histological type. Prognosis is believed to be good but there are few data on its behaviour in the Mexican population. Material and methods Retrospective, descriptive, observational study performed in 3 oncological referral centres in Mexico. We analysed the clinical and histopathological characteristics of patients with mucinous carcinoma of the breast between 2007 and 2017. Results A total of 152 patients were diagnosed with pure mucinous breast carcinoma. The median age was 56 years. An association was found between tumoural size (p = 0.002) and lymph node involvement (p < 0.001) with overall survival. The factors associated with disease-free survival were lymph node involvement and immunophenotype. Mean disease-free survival was 143.5 months for luminal A, 115.4 months for luminal B, 81 months for triple negative and 16 months for Her 2, p < 0.001. Conclusions Lymph node involvement is a risk factor for recurrence of mucinous carcinoma of the breast. Tumoural size and greater lymph node involvement are related to worse overall survival. (AU)

Effectiveness of ultrasound in the detection of axillary metastasis in patients with breast cancer without clinical evidence of axillary disease: Clinical impact / Efectividad de la ecografía en la detección de metástasis axilares en pacientes con cáncer de mama sin evidencia clínica de enfermedad axilar: impacto clínico

Introduction Preoperative ultrasound in patients with breast cancer without evidence of clinical axillary disease represents an attempt to reliably identify axillary lymph node metastasis. However, the usefulness of ultrasound for the detection of axillary disease should be evaluated. Materials and methods The study included a retrospective cohort of 826 patients with diagnosed invasive breast cancer, treated at the National Cancer Institute of Mexico, from 2014 to 2018. All patients underwent ipsilateral axillary ultrasound for staging purposes. Besides the descriptive analysis of the preoperative ultrasound, findings of the cohort were compared with their corresponding cytology and histopathology reports. Results Diagnostic index for axillary ultrasound was calculated as follows: 32.8% sensitivity, 82.5% specificity, 37.1% positive predictive value (PPV), 79.6% negative predictive value (NPV), 70.6% diagnostic accuracy, 1.86 positive likelihood ratio (LR+), and 0.81 negative likelihood ratio (LR−). Loss of fatty hilum was associated with a higher risk of axillary metastasis on the multivariate analysis (OR 3.645; 95% CI, 1.664–7.985, p<0.001). Conclusions The utility of axillary ultrasound as a method of determining the nodal status prior to surgery in patients with breast cancer without clinical evidence of axillary disease was not demonstrated in this study. (AU)

Introducción La ecografía preoperatoria en pacientes con cáncer de mama sin evidencia de enfermedad clínica axilar representa un intento de identificar de manera confiable metástasis a ganglios linfáticos axilares. Sin embargo, se debe evaluar la utilidad de la ecografía para la detección de la enfermedad axilar. Material y métodos El estudio incluyó una cohorte retrospectiva de 826 pacientes con cáncer de mama invasivo diagnosticado en el Instituto Nacional de Cancerología de México, de 2014 a 2018. Todos los pacientes se sometieron a una ecografía axilar ipsilateral con fines de estadificación. Además del análisis descriptivo de la ecografía preoperatoria, los resultados de la cohorte se compararon con sus correspondientes informes de citología e histopatología. Resultados Los índices diagnósticos para la ecografía axilar fueron: 32,8% de sensibilidad, 82,5% de especificidad, 37,1% de valor predictivo positivo (VPP), 79,6% de valor predictivo negativo (VPN), 70,6% de precisión diagnóstica, 1,86 de razón de verosimilitud positiva (LR+) y 0,81 de razón de verosimilitud negativa (LR−). La pérdida de hilio graso se asoció con un mayor riesgo de metástasis axilares en el análisis multivariado (RM: 3.645; IC al 95%: 1.664-7.985; p<0,001). Conclusiones La utilidad de la ecografía axilar como método para determinar el estado ganglionar antes de la cirugía en pacientes con cáncer de mama sin evidencia clínica de enfermedad axilar no se demostró en este estudio. (AU)

Prognosis of breast cancer diagnosed during pregnancy and early postpartum according to immunohistochemical subtype: A matched case-control study.

PURPOSE: Pregnancy-associated breast cancer (PABC) poses a clinical challenge and its prognosis remains controversial. During the pregnancy and postpartum periods, the breast undergoes biological events that may uniquely influence disease behavior and treatment response. This study aimed to assess if a PABC diagnosis influences survival compared to non-PABC. METHODS: A single-center record review was performed to identify PABC patients diagnosed from January 2007 through June 2018. Two controls were matched to each PABC case by stage, immunohistochemical (IHC) subtype, age (± 3) and year of diagnosis (± 2). Disease-free survival (DFS) and overall survival (OS) were estimated with the Kaplan-Meier method and compared with the log-rank test. Multivariate analysis was used to assess the impact of PABC on outcomes. RESULTS: 125 PABC patients (pregnant: 62; postpartum: 63) and 250 controls were included. Median follow-up was 67.7 and 73.4 months, respectively. 4-year DFS was 62% in pregnant vs 78% in controls (p = 0.010), and 63% in postpartum vs 83% in controls (p = 0.034). Subanalysis by IHC subtype revealed a significantly inferior DFS in PABC with hormone receptor-positive/HER2-negative (p = 0.032) and HER2-positive disease (p = 0.005) compared to corresponding non-PABC patients. 4-year OS was similar between case groups and controls. Multivariate analysis supported the independent impact of pregnant and postpartum status on DFS (p < 0.05). CONCLUSION: Patients diagnosed during pregnancy and early postpartum are at high risk of recurrence. Further research is warranted to better characterize PABC tumor biology and enable the identification of novel therapeutic interventions to improve treatment outcomes.

A systematic review of interventions for family caregivers who care for patients with advanced cancer at home.

OBJECTIVE: To examine the characteristics of interventions to support family caregivers of patients with advanced cancer. METHODS: Five databases (CINAHL, Medline, PsycINFO, Web of Science, and the Cochrane Library) were searched for English language articles of intervention studies utilizing randomized controlled trials or quasi-experimental designs, reporting caregiver-related outcomes of interventions for family caregivers caring for patients with advanced cancer at home. RESULTS: A total of 11 studies met the inclusion criteria. Based on these studies, the types of interventions were categorized into psychosocial, educational, or both. The characteristics of interventions varied. Most interventions demonstrated statistically significant results of reducing psychological distress and caregiving burden and improving quality of life, self-efficacy, and competence for caregiving. However, there was inconsistency in the use of measures. CONCLUSIONS: Most studies showed positive effects of the interventions on caregiver-specific outcomes, yet direct comparisons of the effectiveness were limited. There is a lack of research aimed to support family caregivers' physical health. PRACTICE IMPLICATIONS: Given caregivers' needs to maintain their wellbeing and the positive effects of support for them, research examining long-term efficacy of interventions and measuring objective health outcomes with rigorous quality of studies is still needed for better outcomes for family caregivers of patients with advanced cancer.

Treatment of Unresectable Differentiated Thyroid Carcinoma With Upfront External Radiotherapy and Salvage Surgery: A STROBE-Compliant Retrospective Cohort Study.

INTRODUCTION: In patients with unresectable Differentiated thyroid cancer (DTC), the use of external beam radiation therapy (EBRT), leads mostly to palliation. Our aim is to define the role of upfront EBRT, followed or not by salvage surgery, on Progression-free survival (PFS) or Overall survival (OS) in patients with DTC. METHODS: This is a cohort study of patients with initially unresectable DTC who received EBRT. Cohort A received EBRT followed by rescue surgery and cohort B, EBRT only. The Kaplan-Meier method and Cox model were employed for survival analysis. RESULTS: Thirty-three patients were included; 69.6% females and 30.3% males. Mean age was 60.6 and mean tumor diameter was 10.4 cm; 17 and 16 patients were included in cohorts A and B, respectively. Belonging to cohort A (Hazard ratio [HR] 0.177, 95% CI 0.05-0.7) and use of intensity modulated radiotherapy (HR 0.177, 95% CI 0.03-1.08) were associated to better PFS, while high-risk histopathology (HR 6.6, 95% CI 0.9-50) and EBRT dose (HR 1.05, 95% CI 1.01-1.08) were independently associated with lower PFS. Patients from cohort A (HR 0.061, 95% CI 0.01-0.3) had improved OS, while high-risk histopathology (HR 5.7, 95% CI 1.1-28.6) and EBRT dose (HR 1.05, 95% CI 1.01-1.09) were independently associated to worse OS. CONCLUSION: EBRT, and when feasible, salvage surgery, should be an integral part of the therapeutic strategy in initially unresectable DTC.

Prognostic Impact of Direct 131I Therapy After Detection of Biochemical Recurrence in Intermediate or High-Risk Differentiated Thyroid Cancer: A Retrospective Cohort Study.

Background: Patients treated for intermediate- or high-risk differentiated thyroid carcinoma (DTC) and Thyroglobulin (TG) elevation during follow-up, require a diagnostic whole-body scan (DWBS) and if positive, 131I treatment. This approach can lead to a delay in treatment and increased costs. The purpose of this study is to compare the oncologic outcomes associated to administration of direct therapy with 131I at first biochemical recurrence. Methods: Retrospective cohort study of patients with intermediate- or high-risk DTC treated with total thyroidectomy, 131I ablation and who developed TG elevation during follow-up, between January 2007 and December 2015. Cohort A included patients who underwent a DWBS with 5 mCi of 131I, and if negative an MRI and/or 18FDG PET-CT prior to the therapeutic dosage, and cohort B included those who only received a therapeutic dosage of 131I, without a DWBS or extensive image studies. Main outcomes were second recurrence (SR) and disease-free survival (DFS). The diagnostic accuracy of DWBS was analyzed. Results: Cohorts A and B had 74 and 41 patients, each. By multivariate analysis, age, differentiation grade, TN classification, ablation dose, and performed DWBS (odds ratio 55.1; 95% CI 11.3-269) were associated with SR (p < 0.0001); age, male gender, ablation dose and performed DWBS (hazard ratio 7.79; 95% CI 3.67-16.5) were independent factors associated with DFS (p < 0.0001). DWBS diagnostic accuracy was 36.48%. Conclusion: 131I treatment in patients with DTC biochemical recurrence and no DWBS or extensive image studies is associated with a significantly lower frequency of SR and an increased DFS. The diagnostic accuracy of DWBS is low, and its clinical efficiency should be defined in prospective phase III studies.

miRNA profile obtained by next­generation sequencing in metastatic breast cancer patients is able to predict the response to systemic treatments.

Metastatic breast cancer (MBC) is a challenge for oncologists, and public efforts should focus on identifying additional molecular markers and therapeutic management to improve clinical outcomes. Among all diagnosed cases of breast cancer (BC; approximately 10%) involve metastatic disease; notably, approximately 40% of patients with early­stage BC develop metastasis within 5 years. The management of MBC consists of systemic therapy. Despite different treatment options, the 5­year survival rate is <20%, which may be due to a lack of response with de novo or acquired resistance. MicroRNAs (miRNAs or miRs) are promising biomarkers as they are readily detectable and have a broad spectrum and potential clinical applications. The aim of this study was to identify a miRNA profile for distinguishing patients with MBC who respond to systemic treatment. Patients with MBC were treated according to the National Comprehensive Cancer Network guidelines. We performed miRNA­Seq on 9 primary tumors using the Thermo Fisher Scientific Ion S5 system. To obtain global miRNA profiles, we carried out differentially expressed gene elimination strategy (DEGES) analysis between the responsive and non­responsive patients. The results identified a profile of 12 miRNAs associated with the response to systemic treatment. The data were validated in an independent cohort (TCGA database). Based on the results, the upregulation of miR­342­3p and miR­187­3p was associated with the response to systemic treatment, and with an increased progression­free survival (PFS) and overall survival (OS); by contrast, the downregulation of miR­301a­3p was associated with a higher PFS and OS. On the whole, the findings of this study indicate that these miRNAs may serve as biomarkers for the response to systemic treatment or the prognosis of patients with MBC. However, these data should be validated experimentally in other robust cohorts and using different specimens before implementing these miRNAs as biomarkers in clinical practice to benefit this group of patients.

A Multi-Center Study of BRCA1 and BRCA2 Germline Mutations in Mexican-Mestizo Breast Cancer Families Reveals Mutations Unreported in Latin American Population.

The presence of germline and somatic deleterious mutations in the BRCA1 and BRCA2 genes has important clinical consequences for breast cancer (BC) patients. Analysis of the mutational status in BRCA genes is not yet common in public Latin American institutions; thus, our objective was to implement high-performance technology with highly reliable results with the possibility of analyzing several patients simultaneously, therefore reducing cost and work time. A prospective cohort of 252 unrelated sporadic breast cancer patients from the Mexican-mestizo population were analyzed using next generation sequencing (NGS) based on ion semiconductor sequencing. We found 28 pathogenic mutations (25 in BRCA1 and 13 in BRCA2), 11 of which had not been reported previously in Hispanic or Latin American populations. A total of 38 patients were positive for a pathogenic mutation representing 15% of our Mexican women cohort with breast cancer; 25 for BRCA1; and 13 for BRCA2. Our results revealed that there are mutations not analyzed by mutations panels, and our findings support the suitability of massive sequencing approaches in the public institutions of developing countries. Hence, BRCA screening should be offered to patients with breast cancer regardless of their family history of cancer in order to identify unaffected family carriers.

HPNA 2019-2022 Research Agenda: Development and Rationale.

Building on the strong work of previous research agendas (2009-2012, 2012-2015, 2015-2018), the Hospice and Palliative Nurses Association Research Advisory Council developed the 2019-2022 Research Agenda in consultation with Hospice and Palliative Nurses Association (HPNA) membership and assessment of major trends in palliative nursing. The HPNA Research Advisory Council identified 5 priority areas and asked subject experts in each area to summarize the state of the science, identify critical gaps, and provide recommendations for future research. This document expands the executive summary published on the HPNA website (www.advancingexpertcare.org/hpna/) and provides supporting evidence for the 2019-2022 recommendations. The 5 priority areas are as follows: (1) pediatric hospice and palliative nursing research; (2) family caregiving; (3) interprofessional education and collaborative practice; (4) big data science, precision health, and nursing informatics; and (5) implementation science.

"Planting the Seed": Perceived Benefits of and Strategies for Discussing Long-Term Prognosis with Older Adults.

OBJECTIVES: To characterize the goals and approaches of clinicians with experience discussing long-term prognostic information with older adults. DESIGN: We used a semistructured interview guide containing 2 domains of perceived benefits and strategies to explore why and how clinicians choose to discuss long-term prognosis, defined as life expectancy on the scale of years, with patients. SETTING: Clinicians from home-based primary care practices, community-based clinics, and academic medical centers across San Francisco. PARTICIPANTS: Fourteen physicians, including 11 geriatricians and 1 geriatric nurse practitioner, with a mean age of 40 and a mean 9 years in practice. MEASUREMENTS: Clinician responses were analyzed qualitatively using the constant comparisons approach. RESULTS: Perceived benefits of discussing long-term prognosis included establishing realistic expectations for patients, encouraging conversations about future planning, and promoting shared decision-making through understanding of patient goals of care. Communication strategies included adapting discussions to individual patient preferences and engaging in multiple conversations over time. Clinicians preferred to communicate prognosis in words and with a visual aid, although most did not know of a suitable visual aid. CONCLUSION: Engaging in customized longitudinal discussions of long-term prognosis aids clinicians in anchoring conversations about future planning and preparing patients for the end of life. J Am Geriatr Soc 66:2367-2371, 2018.

Relationship Between Expectation of Death and Location of Death Varies by Race/Ethnicity.

BACKGROUND: Older black and Latino Americans are more likely than white Americans to die in the hospital. Whether ethnic differences in expectation of death account for this disparity is unknown. OBJECTIVES: To determine whether surviving family members' expectation of death has a differential association with site of death according to race or ethnicity. METHODS: We conducted an analysis of decedents from the Health and Retirement Study, a nationally representative study of US older adults. Telephone surveys were conducted with family members for 5979 decedents (decedents were 55% were women, 85% white, 9% black, and 6% Latino). The outcome of interest was death in the hospital; the predictor variable was race/ethnicity, and the intervening variable was expectation of death. Covariates included sociodemographics (gender, age, household net worth, educational attainment level, religion) and health factors (chronic conditions, symptoms, health-care utilization). RESULTS: Decedents' race/ethnicity was statistically related to the expectation of death and death in the hospital. When death was not expected, whites and Latinos were more likely to die in the hospital than when death was expected (49% vs 29% for whites and 55% vs 37% for Latinos; P < .001). There was no difference in site of death according to family's expectation of death among blacks. CONCLUSION: Expectation of death did not fully account for site of death and played a greater role among whites and Latinos than among black Americans. Discussing prognosis by itself is unlikely to address ethnic disparities. Other factors appear to play an important role as well.

[Breast osteosarcoma originating in a phyllodes tumor. Report of one case]. / Tumor Phyllodes con transformación a osteosarcoma.

Phyllodes tumors account for less than 1% of tumors of the mammary gland, have both epithelial and stromal components and are classified as benign, borderline and malignant. The malignant tumors are highly heterogeneous: they can differentiate to liposarcomas, fibrosarcomas, rhabdomyosarcomas, chondrosarcomas or osteosarcomas. The differentiation to osteosarcoma is extremely rare, constitutes 1.3% of cases and is very aggressive. The standard treatment of these tumors is surgical. The role of radiotherapy and chemotherapy is not clear. However, in patients in whom wide surgical margins are not achieved, adjuvant radiotherapy can be of help. We report a 63 years old female with a right breast osteosarcoma with an osteoclastic component, originating in a phyllodes tumor. The tumor was excised surgically and afterwards she was treated with 10 sessions of 50 Gy of radiotherapy in 25 fractions. She has remained free of disease for the last 10 months.

Prognosis Communication in Late-Life Disability: A Mixed Methods Study.

IMPORTANCE: Long-term prognosis informs clinical and personal decisions for older adults with late-life disability. However, many clinicians worry that telling patients their prognosis may cause harm. OBJECTIVE: To explore the safety of and reactions to prognosis communication in late-life disability. DESIGN: Participants estimated their own life expectancy and were then presented their calculated life expectancy using a validated prognostic index. We used a semi-structured interview guide to ask for their reactions. Qualitative data were analyzed using constant comparative analysis. Potential psychological and behavioral outcomes in response to receiving one's calculated prognosis were recorded and re-assessed 2-4 weeks later. SETTING: Community-dwelling older adults age 70+ residing in the San Francisco Bay Area. PARTICIPANTS: Thirty five older adults with a median age of 80 requiring assistance with ≥1 Activity of Daily Living. RESULTS: Self-estimates of life expectancy were similar to calculated results for 16 participants. 15 estimated their life expectancy to be longer than their calculated life expectancy by >2 years, while 4 shorter by >2 years. An overarching theme of, "fitting life expectancy into one's narrative" emerged from qualitative analysis. Discussing life expectancy led participants to express how they could alter their life expectancy (subtheme "locus of control"), how they saw their present health (subtheme "perceived health"), and their hopes and fears for the remaining years of their lives (subtheme "outlook on remaining years"). Feelings of anxiety and sadness in reaction to receiving calculated prognosis were rare. CONCLUSIONS AND RELEVANCE: About half of the disabled older adults' self-estimates of prognosis were similar to calculated estimates. Evidence of sadness or anxiety was rare. These data suggest that in most cases, clinicians may offer to discuss prognosis.

Tumor Phyllodes con transformación a osteosarcoma / Breast osteosarcoma originating in a phyllodes tumor: report of one case

Phyllodes tumors account for less than 1% of tumors of the mammary gland, have both epithelial and stromal components and are classified as benign, borderline and malignant. The malignant tumors are highly heterogeneous: they can differentiate to liposarcomas, fibrosarcomas, rhabdomyosarcomas, chondrosarcomas or osteosarcomas. The differentiation to osteosarcoma is extremely rare, constitutes 1.3% of cases and is very aggressive. The standard treatment of these tumors is surgical. The role of radiotherapy and chemotherapy is not clear. However, in patients in whom wide surgical margins are not achieved, adjuvant radiotherapy can be of help. We report a 63 years old female with a right breast osteosarcoma with an osteoclastic component, originating in a phyllodes tumor. The tumor was excised surgically and afterwards she was treated with 10 sessions of 50 Gy of radiotherapy in 25 fractions. She has remained free of disease for the last 10 months.