Characteristics and Impact of Post-Transplant Interdisciplinary Palliative Care Consultation in Older Allogeneic Hematopoietic Cell Transplant Recipients.

Context and Objectives: The myriad of benefits of early palliative care (PC) integration in oncology are well established, and emerging evidence suggests that PC improves symptom burden, mood, and quality of life for hematopoietic cell transplant (HCT) recipients. Specific impact of PC consultation on outcomes of older allogeneic HCT (allo-HCT) recipients, a historically high-risk population vulnerable to transplant-related complications and mortality, has not been explored. Design and Methods: In this single institution, retrospective analysis of 527 first allo-HCT recipients aged ≥60 years, we characterized 75 patients who had received post-HCT PC consultation and its association with geriatric vulnerabilities identified by pre-HCT geriatric assessment. We also examined end-of-life care outcomes among patients who died within one-year of allo-hematopoietic cell transplantation. Results: In multivariate analysis, higher disease risk, female gender, and, importantly, pre-HCT functional limitation (hazard ratio 2.35, 95% confidence interval, 1.35-4.09, p = 0.003) were associated with post-HCT PC utilization. Within one-year of hematopoietic cell transplantation, 127 patients died; among those, recipients of early PC consultation had significantly higher rates of hospice enrollment (25% vs. 9%, p = 0.019) and lower rates of hospital death (71% vs. 90%, p = 0.013), intensive care unit admission (44% vs. 75%, p = 0.001), and high-intensity medical care in last 30 days of life (46% vs. 77%, p = 0.001). Conclusions: Our results highlight important pre-HCT risk factors associated with increased PC needs posthematopoietic cell transplantation and benefits of PC involvement for older allo-HCT recipients at the end of life. Prospective studies should examine the optimal timing of PC consultation and its multidimensional benefits for older allo-HCT patients.

Information Framing Reduces Initial Negative Attitudes in Cancer Patients' Decisions About Hospice Care.

BACKGROUND: Negative attitudes toward hospice care might prevent patients with cancer from discussing and choosing hospice as they approach end of life. When making a decision, people often naturally focus on either expected benefits or the avoidance of harm. Behavioral research has demonstrated that framing information in an incongruent manner with patients' underlying motivational focus reduces their negative attitudes toward a disliked option. OBJECTIVE: Our study tests this communication technique with cancer patients, aiming to reduce negative attitudes toward a potentially beneficial but often-disliked option, that is, hospice care. METHODS: Patients (n = 42) with active cancer of different types and/or stages completed a paper survey. Participants read a vignette about a patient with advanced cancer and a limited prognosis. In the vignette, the physician's advice to enroll in a hospice program was randomized, creating a congruent message or an incongruent message with patients' underlying motivational focus (e.g., a congruent message for someone most interested in benefits focuses on the benefits of hospice, whereas an incongruent message for this patient focuses on avoiding harm). Patients' attitudes toward hospice were measured before and after receiving the physician's advice. RESULTS: Regression analyses indicated that information framing significantly influenced patients with strong initial negative attitudes. Patients were more likely to reduce intensity of their initial negative attitude about hospice when receiving an incongruent message (b = -0.23; P < 0.01) than a congruent one (b = -0.13; P = 0.08). CONCLUSION: This finding suggests a new theory-driven approach to conversations with cancer patients who may harbor negative reactions toward hospice care.

Sequential cytoprotective responses to Sigma1 ligand-induced endoplasmic reticulum stress.

The Sigma1 receptor (Sigma1) is an endoplasmic reticulum (ER) integral membrane protein that is highly expressed in a number of cancer cell lines. Small molecule compounds targeting Sigma1 (Sigma1 ligands) inhibit cancer cell proliferation and induce apoptotic cell death in vitro and inhibit tumor growth in xenograft experiments. However, the cellular pathways activated by Sigma1 protein-ligand interaction are not well defined. Here, we find that treatment with some Sigma1 ligands induces ER stress and activates the unfolded protein response (UPR) in a dose- and time-responsive manner in a range of adenocarcinoma cell lines. Autophagy is engaged after extended treatment with Sigma1 ligands, which suggests that protracted UPR results in autophagy as a secondary response. Inhibition of UPR by RNAi-mediated knockdown of inositol-requiring enzyme 1α and activating transcription factor 4 abrogates autophagosome formation, as does knockdown of essential autophagy gene products Beclin1 and autophagy protein 5. Knockdown of Sigma1 also suppresses IPAG [1-(4-iodophenyl)-3-(2-adamantyl) guanidine] induced UPR marker and autophagosome levels, indicating that this response is indeed Sigma1-mediated. We find that UPR activation precedes autophagosome formation and autophagy precedes apoptosis in Sigma1 ligand-treated cells. These processes are reversible, and washout of IPAG before cell death results in a return of autophagosomes and UPR markers toward basal levels. However, inhibition of Sigma1 ligand-induced UPR or autophagy accelerates apoptotic cell death. Together, these data suggest that UPR and autophagy are engaged as primary and secondary cytoprotective responses, respectively, to Sigma1 ligand-induced disruption of cancer cell protein homeostasis.

Palliative care in the outpatient oncology setting: evaluation of a practical set of referral criteria.

BACKGROUND: The National Comprehensive Cancer Network's (NCCN) palliative care (PC) guidelines recommend screening all patients for PC issues at the first visit with their oncologist and at subsequent, clinically relevant times. Criteria for referral to a PC specialist are also part of the guideline. We evaluated the feasibility of screening for PC needs in outpatients attending one GI oncology practice specializing in colorectal cancer and neuroendocrine tumors. METHODS: All patients attending clinic during a 3-week period were screened by the office practice nurse (OPN). A one-page screening tool based on the NCCN guidelines was developed, giving a score from 0 to 13. The OPN also evaluated the NCCN referral criteria. RESULTS: There were 152 clinic visits by 125 patients during the surveillance period; 119 were screened. Median age was 61 years; half were male. Eighty percent had colorectal cancer, and two thirds had advanced disease. Screening took approximately 3 to 5 minutes per patient. Depending on the PC definition used, between 7% and 17% of patients screened positive; all met the NCCN referral criteria. Psychosocial distress was commoner than physical symptoms. The maximum screening score was 8. A cut point of 5 had the best predictive value for specialist referral, and would result in 13% patients having PC consultations. CONCLUSION: Screening identified 7% to 17% of patients in this busy clinic as having PC issues and 13% who might benefit from specialist referral. But even this simple method adds considerably to the clinic workload, so the benefits of implementing routine screening need to be carefully evaluated.

Calcium binding sequences in calmyrin regulates interaction with presenilin-2.

Calmyrin is a myristoylated calcium binding protein that contains four putative EF-hands. Calmyrin interacts with a number of proteins, including presenilin-2 (PS2). However, the biophysical properties of calmyrin, and the molecular mechanisms that regulate its binding to different partners, are not well understood. By site-directed mutagenesis and Ca2+ binding studies, we found that calmyrin binds two Ca2+ ions with a dissociation constant of approximately 53 microM, and that the two C-terminal EF-hands 3 and 4 bind calcium. Using ultraviolet spectroscopy, circular dichroism (CD), and NMR, we found that Ca(2+)-free and -bound calmyrin have substantially different protein conformations. By yeast two-hybrid assays, we found that both EF-hands 3 and 4 of calmyrin must be intact for calmyrin to interact with PS2-loop sequences. Pulse-chase studies of HeLa cells transfected with calmyrin expression constructs indicated that wild-type (Wt) calmyrin has a half-life of approximately 75 min, whereas a mutant defective in myristoylation turns over more rapidly (half-life of 35 min). By contrast, the half-lives of calmyrin mutants with a disrupted EF-hand 3 or EF-hand 4 were 52 and 170 min, respectively. Using immunofluorescence staining of HeLa cells transfected with Wt and mutant calmyrin cDNAs, we found that both calcium binding and myristoylation are important for dynamic intracellular targeting of calmyrin. Double immunofluorescence microscopy indicated that Wt and myristoylation-defective calmyrin proteins colocalize efficiently and to the same extent with PS2, whereas calmyrin mutants defective in calcium binding display less colocalization with PS2. Our results suggest that calmyrin functions as a calcium sensor and that calcium binding sequences in calmyrin are important for interaction with the PS2 loop.