The experience of financial toxicity among advanced melanoma patients treated with immunotherapy.

Purpose To measure financial toxicity and explore its association with quality of life (QOL) in an emerging population of survivors: advanced melanoma patients treated with immunotherapy. Design Cross-sectional survey and medical record review. Sample 106 survivors (39% response). Median time since start of immunotherapy was 36.4 months (range: 14.2-133.9). Methods The Comprehensive Score for Financial Toxicity measured financial toxicity, and the EORTC-QLQ30 assessed QOL and functioning across five domains. Data were collected online, by phone, or in clinic. Findings: Younger patients (<65 years) reported higher financial toxicity (p < .001) than older patients. Controlling for age, financial toxicity was correlated with QOL (p < .001), financial difficulties (p < .001), and EORTC-QLQ30 functioning subscales. Conclusions Given the demonstrated association between financial toxicity and QOL, our study highlights the importance of addressing financial toxicity, particularly among patients receiving high-cost treatments. Implications for Psychosocial Providers: Providers should educate patients and their caregivers about cost-management techniques, link them with available resources, and provide psychosocial counseling to alleviate related distress.

The Hospitalist Model and Oncology: Oncologist Opinions About Inpatient Cancer Care Delivery.

Hospitalists, rather than oncologists, are increasingly providing inpatient medical care to hospitalized patients with cancer, yet the opinions of oncologists regarding this model of care delivery are unknown. A survey was conducted assessing these opinions and experiences with inpatient cancer care delivery at a tertiary cancer center. Only 30% of oncologists agreed that caring for hospitalized patients with cancer was an efficient use of their time, and most believed a hospitalist service allowed them to pursue other interests. Most had a positive experience with hospitalists, agreeing that hospitalists can diagnose and manage toxicities of cancer therapy, exhibit professionalism, and communicate with them and their patients appropriately. Hematologic malignancy specialists were more likely to value inpatient service time and had less confidence in the ability of hospitalists. Overall, the hospitalist model was generally accepted by oncologists and will continue to be an important part of oncologic care delivery.

The Clinical Challenge of Clonal Hematopoiesis, a Newly Recognized Cardiovascular Risk Factor.

Importance: Despite current standards of cardiovascular care, a considerable residual burden of risk remains in both primary and secondary prevention. Clonal hematopoiesis of indeterminate potential (CHIP) has recently emerged as a common, potent, age-associated, independent risk factor for myocardial infarction, stroke, heart failure events, and survival following percutaneous aortic valve intervention. The presence of CHIP results from the acquisition of somatic mutations in a small number of leukemia driver genes found in bone marrow stem cells, leading to the expansion of leukocytes clones in peripheral blood. The association between CHIP and cardiovascular disease likely involves activation of the inflammasome pathway. More common DNA sequencing identifies individuals with CHIP who then seek advice regarding management of their cardiovascular risk. Observations: Using clinical vignettes based on real encounters, we highlight some of the diverse presentations of CHIP, ranging from incidental identification to that detected during cancer care, that have brought patients to the attention of cardiovascular practitioners. We illustrate how we have applied a consensus-based approach to the evaluation and management of cardiovascular risk in specific patients with CHIP. Since we currently lack evidence to guide the management of these individuals, we must rely on expert opinion while awaiting data to furnish a firmer foundation for our recommendations. Conclusions and Relevance: These vignettes illustrate that the management of CHIP should involve an individualized plan based on features such as comorbidities, life expectancy, and other traditional cardiovascular risk factors. Because individuals with CHIP will increasingly seek advice from cardiovascular specialists regarding management, these examples provide a template for approaches based on a multidisciplinary perspective. The current need for reliance on expert opinion illustrates a great need for further investigation into the management of this newly recognized contributor to residual cardiovascular risk, both in patients who are apparently well and those with established cardiovascular or malignant disease.

Quality of life in long-term survivors of advanced melanoma treated with checkpoint inhibitors.

BACKGROUND: Immune checkpoint inhibitors (CIs) have revolutionized treatment of advanced melanoma, leading to an emerging population of long-term survivors. Survivors' quality of life (QOL) and symptom burden are poorly understood. We set out to evaluate symptom burden and QOL in patients with advanced melanoma alive more than 1 year after initiating CI therapy. METHODS: Cross-sectional surveys, accompanied by chart review of patients with advanced melanoma treated with CIs at Memorial Sloan Kettering Cancer Center, completed therapy, and were alive >1 year after treatment initiation. Surveys were administered between February and August 2018. Surveys included: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, EuroQOL, items from Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events and Fatigue Severity Scale. RESULTS: We included 90 patients. The most common CI regimens were ipilimumab plus nivolumab (53%) and pembrolizumab (41%); most patients (71%) were not treated in clinical trials. Median time from CI therapy initiation was 40 months and from last dose was 28 months. Fatigue was reported by 28%, with higher fatigue scores in women than men; 12% reported difficulty sleeping. Aching joints (17%) and muscles (12%) were fairly common. Level of functioning was generally high. Overall QOL was excellent though 40% reported 'some or moderate' problems with anxiety/depression and 31% with pain/discomfort. CONCLUSIONS: After CI therapy, long-surviving advanced melanoma patients commonly report fatigue but otherwise have moderate symptom burden and good QOL. Ensuring appropriate symptom management will optimize clinical outcomes for these patients.

The Clinical Management of Clonal Hematopoiesis: Creation of a Clonal Hematopoiesis Clinic.

The acquisition of mutations in hematologic stem cells (clonal hematopoiesis) is common with normal aging and can be identified as an incidental finding through clinical genetic testing. Clonal hematopoiesis is associated with a heightened risk of developing hematologic neoplasms (especially myeloid) and accelerated atherosclerotic cardiovascular disease. This article discusses a multidisciplinary clinical approach to the management of patients with clonal hematopoiesis. Key areas of research needed to establish evidence-based clinical care guidelines and intervention strategies for individuals with clonal hematopoiesis are discussed.

Clonal Hematopoiesis: Crossroads of Aging, Cardiovascular Disease, and Cancer: JACC Review Topic of the Week.

A novel, common, and potent cardiovascular risk factor has recently emerged: clonal hematopoiesis of indeterminate potential (CHIP). CHIP arises from somatic mutations in hematopoietic stem cells that yield clonal progeny of mutant leukocytes in blood. Individuals with CHIP have a doubled risk of coronary heart disease and ischemic stroke, and worsened heart failure outcomes independent of traditional cardiovascular risk factors. The recognition of CHIP as a nontraditional risk factor challenges specialists in hematology/oncology and cardiovascular medicine alike. Should we screen for CHIP? If so, in whom? How should we assess cardiovascular risk in people with CHIP? How should we manage the excess cardiovascular risk in the absence of an evidence base? This review explains CHIP, explores the clinical quandaries, strives to provide reasonable recommendations for the multidisciplinary management of cardiovascular risk in individuals with CHIP, and highlights current knowledge gaps.

Cardiovascular Complications Associated with Mediastinal Radiation.

PURPOSE OF REVIEW: Radiation-induced heart disease (RIHD) encompasses a broad range of pathologies and is a significant source of morbidity and mortality among cancer survivors. Increased awareness of the early and late consequences of mediastinal radiation has led to the development of strategies for cardiac risk reduction to improve outcomes through active surveillance and early detection of RIHD. This review aims to discuss the current knowledge on the presentation, diagnosis, and management of RIHD. RECENT FINDINGS: Decades' worth of cohort data demonstrates an increased risk of RIHD as cancer survivors age. Additionally, interventional/surgical management of irradiated patients poses unique considerations and can be technically challenging. Used in conjunction with echocardiography, multimodality imaging for morphologic and functional assessment adds complementary value in screening, surveillance, and targeted symptom investigation in patients at risk for RIHD. Furthermore, sensitive imaging parameters and biomarkers have shown potential in detecting subclinical RIHD. Despite the development of techniques which minimize cardiac exposure to ionizing radiation, their effects on the long-term development of RIHD remain to be seen. Due to the morbidity and mortality associated with RIHD, both patients and clinicians should be aware of the lifelong cardiovascular risks of mediastinal radiation exposure. RIHD surveillance should be a consideration throughout the survivorship period. Studies to evaluate the clinical consequences of contemporary radiation therapy strategies aimed at minimizing cardiac doses and the value of novel, more sensitive metrics for the early detection or prognostication of RIHD are ongoing.

Comparison of Magnetic Resonance Imaging-stratified Clinical Pathways and Systematic Transrectal Ultrasound-guided Biopsy Pathway for the Detection of Clinically Significant Prostate Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

CONTEXT: Recent studies suggested that magnetic resonance imaging (MRI) followed by targeted biopsy ("MRI-stratified pathway") detects more clinically significant prostate cancers (csPCa) than the systematic transrectal ultrasound-guided prostate biopsy (TRUS-Bx) pathway, but controversy persists. Several randomized clinical trials (RCTs) were recently published, enabling generation of higher-level evidence to evaluate this hypothesis. OBJECTIVE: To perform a systematic review and meta-analysis of RCTs comparing the detection rates of csPCa in the MRI-stratified pathway and the systematic TRUS-Bx pathway in patients with a suspicion of prostate cancer (PCa). EVIDENCE ACQUISITION: PubMed, EMBASE, and Cochrane databases were searched up to March 18, 2019. RCTs reporting csPCa detection rates of both pathways in patients with a clinical suspicion of prostate cancer were included. Relative csPCa detection rates of the MRI-stratified pathway were pooled using random-effect model. Study quality was assessed using the Cochrane risk of bias tool for randomized trials. A comparison of detection rates of clinically insignificant PCa (cisPCa) and any PCa was also performed. EVIDENCE SYNTHESIS: Nine RCTs (2908 patients) were included. The MRI-stratified pathway detected more csPCa than the TRUS-Bx pathway (relative detection rate 1.45 [95% confidence interval {CI} 1.09-1.92] for all patients, and 1.42 [95% CI 1.02-1.97] and 1.60 [95% CI 1.01-2.54] for biopsy-naïve and prior negative biopsy patients, respectively). Detection rates were not significantly different between pathways for cisPCa (0.89 [95% CI 0.49-1.62]), but higher in the MRI-stratified pathway for the detection of any PCa (1.39 [95% CI 1.05-1.84]). CONCLUSIONS: The MRI-stratified pathway detected more csPCa than the systematic TRUS-guided biopsy pathway in men with a clinical suspicion of PCa, for both biopsy-naïve patients and those with prior negative biopsy. The detection rate of any PCa was higher in the MRI-stratified pathway, but not significantly different from that of cisPCa. PATIENT SUMMARY: Our meta-analysis of clinical trials shows that the magnetic resonance imaging-stratified pathway detects more clinically significant prostate cancers than the transrectal ultrasound-guided prostate biopsy pathway in men with a suspicion of prostate cancer.

Acupuncture versus medication for pain management: a cross-sectional study of breast cancer survivors.

AIM OF THE STUDY: Breast cancer survivors who take aromatase inhibitors (AI) often suffer from chronic pain. Emerging evidence supports the use of acupuncture as an effective pain management strategy for this condition, but its acceptability among cancer survivors is unknown. We evaluated breast cancer survivors' preferences for acupuncture as compared with medication use and identified factors predictive of this preference. METHODS: We conducted a cross-sectional study among breast cancer survivors who were currently, or had been, taking an AI. The primary outcome was degree of preference for acupuncture as compared with medication for pain management. We conducted multivariate logistic regression analyses to evaluate the effects of socioeconomic status (SES) factors and health beliefs on treatment preference. RESULTS: Among 592 participants, 160 (27.0%) preferred acupuncture, 153 (25.8%) preferred medication and 279 (47.1%) had no clear preference. In a multivariate analysis that only included SES, higher education and white race were significantly associated with greater preference for acupuncture. When health beliefs were added, SES effects were attenuated, while greater expectation of acupuncture's effect, lower perceived barriers to its use, higher social norm (endorsement from family members and healthcare professionals) related to acupuncture and higher holistic health beliefs were associated with greater preference for acupuncture. CONCLUSION: We found similar rates of preference for acupuncture versus medication among breast cancer survivors for pain management. Specific attitudes and beliefs predicted such preferences, highlighting the importance of a patient-centred approach to align patient beliefs and preferences with therapeutic options for more effective pain management. TRIAL REGISTRATION NUMBER: NCT01013337; Results.

Influence of family on expected benefits of complementary and alternative medicine (CAM) in cancer patients.

BACKGROUND: Cancer patients often use complementary and alternative medicine (CAM) based on recommendations from family. However, the relationship between family endorsement of CAM and the patient's expectation of its benefits has never been quantified. METHODS: Between 2010 and 2011, we conducted a cross-sectional survey study among patients with a diagnosis of cancer recruited from thoracic, breast, and gastrointestinal medical oncology clinics at a single academic cancer center. We performed multivariate linear regression analyses to evaluate the relationship between perceived family endorsement of and expected benefits from CAM, adjusting for covariates. RESULTS: Among the 962 participants, 303 (31.3%) reported family endorsement of CAM use. Younger patients and those who had college or higher education were more likely to report family endorsement (both p < 0.05). Patients with family support had expectation scores that were 15.9 higher than patients without family support (coefficient 15.9, 95% CI 13.5, 18.2, p < 0.001). Participants with family encouragement of CAM use were also more likely to expect CAM to cure their cancer (12 vs. 37%) and prolong their life (24 vs. 61%). These relationships remained highly significant after adjusting for covariates). CONCLUSIONS: Family endorsement of CAM use is strongly associated with patient expectation of its clinical efficacy, including expectations for cure and improved survival. These findings underscore the importance of including family in counseling and education on CAM use in order to achieve realistic patient expectations, maximize benefits, and avoid potential medical adverse effects through herb-drug interactions or rejections of conventional care.

Improving Hepatitis C Virus Screening Rates in Primary Care: A Targeted Intervention Using the Electronic Health Record.

PURPOSE: With the advent of effective treatments for hepatitis C virus (HCV), it has become a public health priority to increase the identification of HCV carriers and link them to systems of care. As a result, in 2012, the Centers for Disease Control and Prevention recommended that all adults born between 1945 and 1965 should receive one-time testing for HCV. In response to this mandate, we sought an effective nonintrusive means to increase HCV screening rates in our busy primary care practices. METHODS: We designed an HCV testing decision support module that was integrated into the electronic health record (EHR) and triggered an automatic test order for eligible patients at the time of visit. Rates of HCV screening for eligible patients were measured before and after implementation. RESULTS: Hepatitis C virus screening rates increased by 254% after implementation of this tool. CONCLUSION: Incorporating a clinical reminder into the EHR effectively and appropriately increased the hepatitis C testing rates among primary care patients with no previous testing. Such tools can be an effective means to operationalize health system-wide testing efforts.

Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction.

BACKGROUND: While there are numerous benefits of smartphone use for physicians, little is known about the negative effects of using these devices in the context of patient care. OBJECTIVE: To assess resident and faculty smartphone use during inpatient attending rounds and its potential as a source of distraction during transfer of clinical information. DESIGN: Cross-sectional survey. SETTING: University-affiliated public teaching hospital. PARTICIPANTS: All housestaff and inpatient faculty in the departments of Medicine and Pediatrics. METHODS: Participants were asked about smartphone ownership, usage patterns during attending rounds, and whether team members had ever missed important data during rounds due to distraction from smartphones. Attendings were asked whether policies should be established for smartphone use during rounds. RESULTS: The overall response rate was 73%. Device ownership was prevalent (89% residents, 98% faculty), as was use of smartphones during inpatient rounds (57% residents, 28% attendings). According to self-reports, smartphones were used during rounds for patient care (85% residents, 48% faculty), reading/responding to personal texts/e-mails (37% residents, 12% faculty), and other non-patient care uses (15% residents, 0% faculty). Nineteen percent of residents and 12% of attendings believed they had missed important information because of distraction from smartphones. Residents and faculty agreed that smartphones "can be a serious distraction during attending rounds," and nearly 80% of faculty believed that smartphone policies should be established. CONCLUSIONS: Smartphone use during attending rounds is prevalent and can distract users during important information transfer. Attendings strongly favored the institution of formal policies governing appropriate smartphone use during inpatient rounds.

"The MICU is full": one hospital's experience with an overflow triage policy.

BACKGROUND: Coronary care units (CCUs) are designed and staffed to care for patients with cardiovascular disease, while medical intensive care units (MICUs) are specially organized and staffed for the care of patients with noncardiovascular critical illness. Because the demand for MICU beds often exceeds their availability, patients in need of critical care often experience delays in admission and transfer to such specialized units, which may result in preventable harm. In response to this challenge, during times of MICU bed nonavailability Jacobi Medical Center (Bronx, New York) activates a policy whereby patients with noncardiovascular critical illness are admitted to a cardiology-staffed CCU for critical care to be delivered in a timely manner. A study was conducted to determine the impact of this novel overflow policy on patient outcomes and patient safety metrics. METHODS: A retrospective analysis was performed of all 1,104 patients discharged from the CCU with a noncardiovascular primary diagnosis between January 1, 2006, and December 31, 2009. Patient demographics, overall hospital length of stay (LOS,) ICU LOS, in-hospital mortality, 30-day hospital readmission status, and severity of illness were compared with a reference cohort of 2,041 patients who were discharged from the MICU during the same period. RESULTS: The severity-adjusted in-hospital mortality rate, 30-day readmission rate, ICU LOS, overall LOS, and patient safety outcomes for the CCU cohort were similar to those of the MICU cohort. CONCLUSIONS: A policy that directed critically ill patients to a CCU instead of an MICU during times of bed nonavailability appeared to be a safe practice. With careful planning, CCU bed resources might be an acceptable alternative for the delivery of critical care in an environment of constrained MICU bed access.

Using a computerized sign-out system to improve physician-nurse communication.

BACKGROUND: Communication problems among health care workers are a common, preventable source of hospital-related morbidity and mortality. Internal medicine residents at Jacobi Medical Center (Bronx, NY) began using an electronic sign-out program that had been incorporated into the computerized medical record. This new system had been developed to improve the quality of information transfer between cross-covering residents. Eighteen months later, a pilot study was initiated to explore the potential benefits of offering inpatient nurses access to this sign-out data. METHODS: Nursing staff members were provided electronic access to the residents' sign-out information. Nurses received printouts of the computerized sign-outs at the start of each shift and were asked to use the sign-out program as a basis for their care plans and nursing change-of-shift "report." RESULTS: The 19 (of 20) nurses who completed the survey agreed that using the resident sign-out program positively affected their ability to care for their patients. In addition, the intervention improved nurses' understanding of the patients' reason for admission, helped to improve communication between physicians and nurses, and raised nursing morale. DISCUSSION: Incorporation of a housestaff electronic sign-out system into nursing daily workflow demonstrated multiple benefits and facilitated the transfer of valuable patient information from housestaff to nurses.

A look at the pediatrician as parent: experiences with the introduction of varicella vaccine.

Many physicians voiced reservations about routine use of the varicella vaccine for healthy children after its licensing in 1995. Anecdotal evidence suggested that some pediatricians who were parents themselves were electing not to vaccinate their own children against chickenpox. Little has been written about pediatrician-parents' behaviors in caring for their own children, and how these practices may differ from the behavior that these same pediatricians apply in practice. Pediatricians' tacit attitudes toward medical interventions might be better understood from their behaviors as parents than from their clinical practices, which may be influenced by a sense of responsibility to follow guidelines of professional organizations. Varicella vaccination practices were examined to determine whether pediatricians' behaviors in parenting their own children differed from their recommendations for their patients. A mail survey was sent to 1,762 New York State pediatricians selected randomly from the membership directory of the American Academy of Pediatrics. The response rate was 43% (764/1,762); 63% of responding pediatricians were parents. Eighty-five percent of pediatricians recommended varicella vaccine routinely in practice. Of the pediatricians' own eligible children, 88% (256/291) had been vaccinated against chickenpox. We found a high overall rate of compliance with recommendations for routine use of varicella vaccine. Pediatricians who were parents were just as likely as nonparent pediatricians to recommend the vaccine routinely for their patients. Importantly, pediatrician-parents demonstrated no "double standard"; at the time of the study, 88% of pediatricians' own eligible children had been vaccinated against varicella.

The internal medicine subinternship: a curriculum needs assessment.

Despite broad acceptance of the internal medicine subinternship rotation by the undergraduate medical education community, only a small fraction of programs provide students with explicit learning objectives. To design a curriculum for the medical subinternship, we surveyed 3 different groups of educational stakeholders--subinternship directors, residency program directors, and housestaff--in order to identify and prioritize the competencies that should be learned during this rotation. This study provides a starting point for the development of a structured curriculum for the fourth-year subinternship rotation.