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AbstractBackgroundPurposeMethodsResultsConclusions\nIMPLICATIONS FOR REHABILITATIONPersisting Symptoms after Concussion (PSaC) are common and difficult to treat. Mindfulness-based interventions can support recovery but are rarely included in rehabilitative care. We developed OWNMindfulness, an eight-week live-video mindfulness-based group for PSaC.To assess feasibility and preliminary clinical effects of OWNMindfulness.Fourteen individuals with PSaC enrolled in this mixed-methods single-arm feasibility study. We assessed enrollment/retention, adherence, fidelity, instrument completion, safety, and satisfaction. We evaluated preliminary trends in the impact of the intervention on mindfulness (CAMS-R), concussion symptoms (PCSS), and QOL (WHOQOL-BREF). Qualitative analysis of exit interviews explored participants’ perceptions of the effects of the intervention, and framework analysis assessed adequacy of the quantitative measures to capture perceived effects.Feasibility results met a priori benchmarks. Mindfulness, concussion symptoms, and QOL scores improved (CAMS-R: adjusted p = 0.01, large effect size; PCSS: adjusted p = 0.03, moderate effect size; WHOQOL-BREF: not significant, small effect size). Qualitative analysis of interview data found benefits including validation, compassion, self-awareness, self-efficacy, concussion symptoms, resilience, life participation, social relationships, and QOL. Framework analysis demonstrated that quantitative tools captured change in concussion symptoms but did not comprehensively assess the other benefits identified through qualitative methods.OWNMindfulness shows preliminary feasibility and promise for improving clinical outcomes. Results suggest the need for additional quantitative tools for comprehensive measurement of the effects and may point to potential mechanisms of action.Integration of mindfulness-based interventions in standard rehabilitation care for persistent concussion symptoms has potential to boost recovery for this difficult to treat population.OWNMindfulness, a live-video mindfulness-based group intervention, can be delivered in a clinical education setting.People with persistent concussion symptoms may benefit from validation from providers and peers, self-compassion, self-awareness, and self-efficacy to support resilience and recovery.Integration of mindfulness-based interventions in standard rehabilitation care for persistent concussion symptoms has potential to boost recovery for this difficult to treat population.OWNMindfulness, a live-video mindfulness-based group intervention, can be delivered in a clinical education setting.People with persistent concussion symptoms may benefit from validation from providers and peers, self-compassion, self-awareness, and self-efficacy to support resilience and recovery. [ABSTRACT FROM AUTHOR]

Purpose: Many older breast cancer survivors experience long-term disability due to cancer and cancer-related treatments. However, less than 20% of older breast cancer survivors utilize cancer rehabilitation services to address cancer-related disability. Further understanding of survivor experiences may reveal strategies to improve uptake cancer rehabilitation services in the USA. Methods: Older breast cancer survivors were recruited from university-based registries, previous breast cancer research studies at our institution, community support groups, and geriatric oncology clinics. Participants completed a brief online survey to capture demographic and clinical characteristics. Semi-structured telephone-based interviews were recorded, transcribed, and thematically analyzed. Interviews facilitated conversation about access to rehabilitation and indications for cancer rehabilitation. Results: Participants (n = 14) were, on average, 71 years old, primarily White, and an average of 36.5 months post-diagnosis. Five participants had formally received rehabilitation for a cancer-related concern. Participants described seven factors that influenced utilization of cancer rehabilitation services: (1) emerging awareness of disability; (2) coping styles; (3) comparison of cancer experience with others; (4) provider interaction; (5) perceptions of cancer diagnosis; (6) social support; and (7) cost of rehabilitation. Conclusions: Older breast cancer survivors consider multiple factors when determining utilization of cancer rehabilitation services. Development of shared decision-making tools addressing the seven described factors may enhance communication and referral to cancer rehabilitation services. Intervention research should adopt frameworks that enhance healthcare accessibility to improve relevance of intervention content and delivery features for older breast cancer survivors. [ABSTRACT FROM AUTHOR]

Background: Virtual Learning Collaboratives (VLC), learning communities focused on a common purpose, are used frequently in healthcare settings to implement best practices. Yet, there is limited research testing the effectiveness of this approach compared to other implementation strategies. This study evaluates the effectiveness of a VLC compared to Technical Assistance (TA) among community oncology practices implementing ENABLE (Educate, Nurture, Advise, Before Life Ends), an evidence-based, early palliative care telehealth, psycho-educational intervention for patients with newly diagnosed advanced cancer and their caregivers.Methods: Using Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Proctor's Implementation Outcomes Frameworks, this two-arm hybrid type-III cluster-randomized controlled trial (RCT) will compare two implementation strategies, VLC versus TA, among the 48 National Cancer Institute Community Oncology Research Program (NCORP) practice clusters that have not historically provided palliative care to all patients with advanced cancer. Three cohorts of practice clusters will be randomized to the study arms. Each practice cluster will recruit 15-27 patients and a family caregiver to participate in ENABLE. The primary study outcome is ENABLE uptake (patient level), i.e., the proportion of eligible patients who complete the ENABLE program (receive a palliative care assessment and complete the six ENABLE sessions over 12 weeks). The secondary outcome is overall program implementation (practice cluster level), as measured by the General Organizational Index at baseline, 6, and 12 months. Exploratory aims assess patient and caregiver mood and quality of life outcomes at baseline, 12, and 24 weeks. Practice cluster randomization will seek to keep the proportion of rural practices, practice sizes, and minority patients seen within each practice balanced across the two study arms.Discussion: This study will advance the field of implementation science by evaluating VLC effectiveness, a commonly used but understudied, implementation strategy. The study will advance the field of palliative care by building the capacity and infrastructure to implement an early palliative care program in community oncology practices.Trial Registration: Clinicaltrials.gov . NCT04062552; Pre-results. Registered: August 20, 2019. https://clinicaltrials.gov/ct2/show/NCT04062552?term=NCT04062552&draw=2&rank=1. [ABSTRACT FROM AUTHOR]

Purpose: Determine correlations between health-related quality of life (HRQOL), supportive care need, and sociodemographic factors in low-income Latina breast cancer survivors. Methods: A descriptive, survey-based, cross-sectional study was completed with 102 low-income Latina breast cancer survivors at a major public safety net hospital. Correlation coefficients were calculated between number of unmet supportive care needs (per Supportive Care Needs Survey), HRQOL (per SF-36), and sociodemographic variables. Results: Unmet supportive care needs were correlated with lower HRQOL in all domains (r > −0.40; p < 0.0001). Lower income was significantly associated with lower HRQOL (r > 0.21; p < 0.05) and more supportive care needs (r = −0.22; p < 0.05). Multimorbidity was significantly associated with decreased HRQOL (r > −0.23; p < 0.05) and greater supportive care need (r = 0.19; p < 0.05). Conclusions: Identifying and addressing unmet supportive care needs may improve HRQOL in low-income Latina breast cancer survivors. Rehabilitation interventions that address barriers to accessing supportive care related to low SES and multimorbidity may also improve health outcomes in this population. The dual effect of multimorbidity on both quality of life and level of supportive care need in this population warrants further investigation. Screening for unmet supportive care needs may be an important step in improving health-related quality of life during cancer rehabilitation. Challenges accompanying multimorbidity and lower socioeconomic status may prevent low-income cancer patients from accessing adequate supportive care. Rehabilitation interventions for socioeconomically disadvantaged cancer survivors should compensate for both socioeconomic status and the presence of comorbidities in order to reduce disparities in quality of life during survivorship. [ABSTRACT FROM AUTHOR]

The article discusses study that aimed to gain a deeper understanding of participants' perspectives of the intervention and palliative care trial participation and compares their benefits and burdens. It also discusses design and analysis of data followed standard procedures of descriptive thematic analysis. Results were drawn and it was concluded that the benefits of the intervention and the positive aspects of trial participation outweighed the burdens.

Prpose/Objectives: To describe the natural pace and pattern of activity resumption in the first six months after stem cell transplantation (SCT).Design: Longitudinal, descriptive survey.Setting: Bone marrow transplantation program of a National Cancer Institute-designated comprehensive cancer center in the northeastern United States.Sample: 18 men and 18 women who underwent either autologous (83%) or allogeneic (17%) transplantation.Methods: Participants were surveyed 30 days, 100 days, and six months after SCT. Descriptive statistics were followed by exploratory linear mixed modeling with factors of time, gender, and the interaction between time and gender.Main Research Variables: A modified checklist version of the Activity Card Sort was used to measure activity retention.Findings: Participants generally were performing 49% of their usual activities 30 days after transplantation, 70% of their premorbid activities 100 days after transplantation, and 77% of their premorbid activities six months after transplantation. Level of activity engagement increased over time, with the greatest changes observed from 30-100 days after SCT. Men retained more of their activities than women in the domains of low physical-demand leisure and social activities.Conclusions: Rehabilitation screening may be most helpful in the period from 100 days to six months, when activity levels begin to plateau. Activity recovery may differ for men and women; future research should explore how this could affect rehabilitation needs.Implications for Nursing: Nurses can use structured surveys to explore and promote patients' satisfaction with and ability to engage in daily activities and ensure appropriate referrals to rehabilitation during recovery from SCT. [ABSTRACT FROM AUTHOR]

The article focuses on a randomized controlled trial which determined the effect of a nursing-led intervention on quality of life, symptom intensity, mood, and resource use in patients with advanced cancer. The trial used 322 patients with advanced cancer in a rural, National Cancer Institute-designated comprehensive cancer center in New Hampshire and affiliated outreach clinics and a Veterans Affairs (VA) medical center in Vermont. The study found that the patients receiving nursing-led intervention have higher scores for quality of life and mood compared to those receiving usual oncology. But these patients did not have improvements in symptom intensity scores or reduced days in the hospital or intensive care units or emergency department visits.

Abstract: The Functional Assessment of Chronic Illness Therapy (FACIT) system provides a general, multidimensional measure of health-related quality of life (FACT-G) that can be augmented with disease or symptom-specific subscales. The 19-item palliative care subscale of the FACIT system has undergone little psychometric evaluation to date. The aim of this paper is to report the internal consistency, factor structure, and construct validity of the instrument using the palliative care subscale (FACIT-Pal). Two hundred fifty-six persons with advanced cancer in a randomized trial testing a palliative care psychoeducational intervention completed the 46-item FACIT-Pal at baseline. Internal consistency was greater than 0.74 for all subscales and the total score. Seventeen of the 19 palliative care subscale items loaded onto the four-factor solution of the established core measure (FACT-G). As hypothesized, total scores were correlated with measures of symptom intensity (r =−0.73, P <0.001) and depression (r =−0.75, P <0.001). The FACIT-Pal was able to discriminate between participants who died within three months of completing the baseline and participants who lived for at least one year after completing the baseline assessment (t =−4.05, P <0.001). The functional well-being subscale discriminated between participants who had a Karnofsky performance score of 70 and below and participants with a Karnofsky performance score of 80 and above (t =3.40, P <0.001). The findings support the internal consistency reliability and validity of the FACIT-Pal as a measure of health-related quality of life for persons with advanced cancer. [Copyright &y& Elsevier]

Abstract: Research on palliative care presents some unique sampling challenges. The purpose of this paper is to articulate the sampling challenges that palliative care researchers face during phases of study design, conduct, and the reporting of results. Challenges include identifying a target population, avoiding selection bias in the face of clinician and patient denial of serious illness, developing eligibility criteria for a seriously ill population, minimizing high patient refusals due to illness, and accurate reporting of all screened and eligible participants. These challenges are explored within the context of a randomized clinical trial testing a palliative care intervention. Suggestions for improving scientific rigor in sampling design include 1) defining a target population that is consistent with research goals; 2) identifying eligibility criteria that are objective and understandable to clinicians to yield the desired sample; and 3) reporting results about the target population, sample eligibility/exclusions, and participation using standardized criteria. [Copyright &y& Elsevier]

Objective: To explore the extent to which practitioners effectively use cues from clients' verbal descriptions of their favourite activities to form accurate impressions of the personality of clients with Parkinson's disease. Participants: Ninety-nine practitioners from disciplines of occupational, physical and speech therapy, nursing or medicine. Procedure: Six men and six women with Parkinson's disease completed a self-report measure of personality and were individually interviewed regarding their favourite activities. The practitioners viewed 2-min segments of those videotaped interviews and provided judgements of the clients' personality. Measure: The NEO-Five Factor Inventory and a coding scheme to describe characteristics of clients' favourite activities. Analysis: Clients' self-reported personality was correlated with the activity characteristics to identify the degree to which each characteristic was a cue of personality. Practitioners' judgements of personality were correlated with the activity characteristics to identify how heavily the practitioners weighted each cue. These two sets of weightings were compared using Pearson's correlations to determine whether practitioners used an appropriate cue strategy related to the activity descriptions. Results: Practitioners appropriately used the personality cues found in the clients' favourite activity descriptions to assess the traits of Openness to Experience, Agreeableness and Conscientiousness (r = 0.66, r = 0.60, and r = 0.55, respectively, all p ≤ 0.02). Practitioners appeared to use less effective cue strategies for the traits of Neuroticism and Extraversion. Conclusion: Clients with Parkinson's disease appear to express their personality in their descriptions of favourite activities, and practitioners appear to make use of these expressive verbal cues effectively for some aspects of personality. [ABSTRACT FROM AUTHOR]

Objective: To explore rehabilitation practitioners' use of observable cues of personality to form accurate impressions of persons with Parkinson's disease. Participants: Ninety-nine practitioners from disciplines of occupational, physical, and speech therapy and nursing and medicine. Procedure: Participants viewed excerpts of videotaped interviews of 6 men and 6 women with mild-to-moderate Parkinson's disease and formed impressions of the targets' personality. Main Outcome Measure: NEO Five Factor Inventory personality test. Analysis: Brunswik lens model correlational analysis of the associations between expressive behavior and personality judgments. Results: Practitioners were accurate in judging Openness to Experience, Agreeableness, and Conscientiousness but were unable to detect interparticipant differences in levels of Extraversion and Neuroticism. Conclusion: Accuracy in judging some traits suggests that future research may identify interventions, such as sensitizing practitioners to valid behavioral cues or modifying contextual features, to maximize a practitioner's ability to understand a client's personality. [ABSTRACT FROM AUTHOR]

Numerous self-management training programs have been created for persons with chronic illness to assist them in cultivating the skills and confidence to promote their own health and well-being. However, self-management training is rarely explicitly discussed regarding the population of people who have Parkinson's disease. This paper reviews published theoretical and empirical literature to identify guidelines that should be considered when developing and evaluating self-management training programs for persons with Parkinson's disease. Self-management of disease is presented as one aspect of a collaborative management approach to healthcare in which patients, caregivers, and healthcare practitioners are all working in concert toward explicit, shared, and specific goals. [ABSTRACT FROM AUTHOR]

Background: While evidence shows that occupational therapists can play a key role in the care of people with palliative care needs, more knowledge about effective occupational therapy interventions for this group is needed. Aim: To identify, organise and prioritise intervention components considered to be effective within occupational therapy for people with palliative care needs from the perspective of occupational therapy clinicians, managers and researchers. Design: Group Concept Mapping utilising a mixed methods participatory approach. Using a focus prompt, participants brainstormed, sorted, labelled and rated generated statements about effective occupational therapy intervention components. Multidimensional scaling analysis and cluster analysis were conducted. Setting/Participants: Snowball recruitment was used to recruit participants. Participants included occupational therapists worldwide who were able to read and write in English and were working as clinicians, managers and/or researchers with occupational therapy interventions for people with palliative care needs. Results: Seventy-two occupational therapists from 15 countries participated in the study representing Asia (n = 3, 20%), Europe (n = 8, 53%), Oceania (n = 2, 13%) and North America (n = 2, 13%). A total of 117 statements were identified and organised into five clusters: (1) being client-centred, (2) promoting occupational engagement to optimise quality of life, (3) involving the social and relational environment, (4) enabling occupations and (5) facilitating occupational adaptation. Conclusions: Five clusters of core occupational therapy intervention components were considered to be effective when supporting people with palliative care needs. Research should use this knowledge to inform future occupational therapy interventions for this group of people. [ABSTRACT FROM AUTHOR]

Purpose Cervical cancer is a leading cause of cancer-related mortality in low- and middle-income countries (LMICs) and screening in LMICs is extremely limited. We aimed to implement on-site highrisk human papillomavirus (hrHPV) DNA testing in cohorts of women from an urban factory and from a rural village. Methods A total of 802 women were recruited for this study in partnership with La Liga Contra el Cancer through the establishment of women’s health resource fairs at two locations in Honduras: a textile factory (n = 401) in the city of San Pedro Sula and the rural village of El Rosario (n = 401) in Yoro. Participants received a routine cervical examination during which three sterile cytobrushes were used to collect cervical samples for testing. hrHPV genotyping was performed using a hrHPV genotyping assay and a realtime polymerase chain reaction instrument. Results hrHPV status across all participants at both sites was 13%hrHPV positive and 67%hrHPV negative. When hrHPV status was compared across all three testing sites, hrHPV-positive rates were approximately equal among the factory (13%), village (12%), and confirmatory testing at Dartmouth-Hitchcock Medical Center (Lebanon, NH; 14%). hrHPV genotype was compared across sites, with HPV 16 showing the highest infection rate (15%), followed by HPV 59 (12%), and HPV 68 (11%). There was a low prevalence of HPV 18 observed in both populations compared with the hrHPV-positive population in the United States. Conclusion In collaboration with oncologists and pathologists from La Liga Contra el Cancer, we were able to provide a continuum of care once health-fair testing was performed. We established a method and implementation plan for hrHPV testing that is sustainable in LMICs. [ABSTRACT FROM AUTHOR]

Purpose: Cervical cancer is a leading cause of cancer-related mortality in low- and middle-income countries (LMICs) and screening in LMICs is extremely limited. We aimed to implement on-site high-risk human papillomavirus (hrHPV) DNA testing in cohorts of women from an urban factory and from a rural village. Methods: A total of 802 women were recruited for this study in partnership with La Liga Contra el Cancer through the establishment of women's health resource fairs at two locations in Honduras: a textile factory (n = 401) in the city of San Pedro Sula and the rural village of El Rosario (n = 401) in Yoro. Participants received a routine cervical examination during which three sterile cytobrushes were used to collect cervical samples for testing. hrHPV genotyping was performed using a hrHPV genotyping assay and a real-time polymerase chain reaction instrument. Results: hrHPV status across all participants at both sites was 13% hrHPV positive and 67% hrHPV negative. When hrHPV status was compared across all three testing sites, hrHPV-positive rates were approximately equal among the factory (13%), village (12%), and confirmatory testing at Dartmouth-Hitchcock Medical Center (Lebanon, NH; 14%). hrHPV genotype was compared across sites, with HPV16 showing the highest infection rate (15%), followed by HPV59 (12%), and HPV68 (11%). There was a low prevalence of HPV18 observed in both populations compared with the hrHPV-positive population in the United States. Conclusion: In collaboration with oncologists and pathologists from La Liga Contra el Cancer, we were able to provide a continuum of care once health-fair testing was performed. We established a method and implementation plan for hrHPV testing that is sustainable in LMICs. [ABSTRACT FROM AUTHOR]

Purpose: To build consensus around an optimal patient-reported outcome measure of cancer symptoms and patient needs to facilitate patient-provider communication and trigger referrals to supportive services. Methods and materials: The Grid-Enabled Measures platform was used to crowdsource and facilitate collaboration to achieve consensus. Respondents were invited to nominate and independently rate the usefulness of measures that: (1) have been actively used at a healthcare institution, (2) have a multiple choice or yes/no type format, (3) are applicable to adults with cancer, (4) are patient-reported, and 5) have psychometric data if possible. Discussion boards within the GEM workspace allowed respondents to identify barriers to implementing patient assessment and referral systems. Results: 166 individuals from various disciplines from 25 organizations participated. Six instruments were nominated, and 553 rating surveys were submitted. The three most highly-rated overall instruments were the Distress Thermometer, the James Supportive Case Screening, and the Functional Assessment of Cancer Therapy-General. Participants noted that wide-scale implementation of this process requires both identifying problems and providing clinicians with algorithms to facilitate appropriate referrals. Conclusions: Consensus reported three most highly-related measures as optimal for comprehensive screening and identification for referral by assessing multiple domains of functioning and quality of life. Gaining consensus on the best patient reported outcome measures is an important step towards improving access to cancer rehabilitation services. A consensus agreed on several measures to use for cancer rehabilitation screening. Functional Assessment of Cancer Therapy-General, National Comprehensive Cancer. Network Distress Thermometer and the James Instrument. The selected measures do not put undue burden on clinicians and patients. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to explore the feasibility, acceptability and perceived utility of the provision of a wearable fitness device and an exercise prescription from a surgeon, prior to surgery for lung cancer. Methods: A single‐arm, pre–post feasibility study was conducted with 30 participants scheduled for surgery to treat stage I, II or III lung cancer. Participants were given a Garmin Vivoactive HR device and a prescription for 150 min of moderately to vigorous exercise per week. Participants completed assessments on four occasions and completed a semi‐structured interview on two occasions. Descriptive statistics were used to assess the feasibility and acceptability of study procedures, including synchronising the Garmin device and engaging in study assessments. Results: Seventy‐nine per cent of enrolled participants completed the pre‐operative study activities. Seventy‐one per cent of enrolled participants successfully synchronised their device during the pre‐operative period. Data were transmitted from the device to the study team for an average of 70% of the pre‐operative days. Conclusion: This pilot study demonstrated the feasibility and acceptability of a pre‐operative exercise program for patients scheduled to undergo surgery for lung cancer. Trial Registration: The study protocol was registered with ClinicalTrials.gov prior to the initiation of participant recruitment (NCT03162718). [ABSTRACT FROM AUTHOR]

Evidence-based interventions often need to be adapted to maximize their implementation potential in low-to middle-income countries. A single-arm feasibility study was conducted to determine the feasibility and acceptability of a telephone-delivered, nurse-led, symptom management intervention for adults undergoing chemotherapy in Honduras. Over the course of 6 months, nurses engaged 25 patients undergoing chemotherapy in the intervention. Each participant received an average of 16.2 attempts to contact them for telephone sessions (SD = 8.0, range = 2-28). Collectively, the participants discussed 24 different types of symptoms. The most commonly discussed symptoms were pain (12%), nausea (7%), and constipation (5%). Qualitative and quantitative data were used to identify treatment manual modifications (i.e., adding content about different symptoms and addressing scheduling of treatment) and workplace modifications (i.e., dedicated nurse time and space) that are needed to optimize implementation of the intervention. [ABSTRACT FROM AUTHOR]

Purpose: This study investigated the supportive care needs of a sample of low-income Latina breast cancer survivors.Methods: Ninety-nine Spanish-speaking breast cancer survivors who self-identified as Latina and reported an income below the US Census Bureau low-income threshold were recruited from the oncology clinic of a major public safety net hospital. Eligible participants completed the supportive care needs survey (SCNS-SF34) and a demographic questionnaire.Results: Ninety-three percent of respondents had unmet needs. The majority of frequently reported unmet needs involved (1) access to and delivery of health-related information and (2) physical function. These findings appear to contrast with those of other studies of supportive care needs in heterogeneous cancer survivors, most of which describe psychological concerns as most urgent.Conclusions: Participants espoused information-related needs with a higher frequency than many other samples of cancer survivors. This study population may also require a particularly high level of assistance with overcoming participation restrictions. Further research is needed to understand these discrepancies and to address unmet needs across all domains. [ABSTRACT FROM AUTHOR]

We conducted a randomized controlled trial (RCT) of an early palliative care intervention (ENABLE: Educate, Nurture, Advise, Before Life Ends) for persons with advanced cancer and their family caregivers. Not all patient participants had a caregiver coparticipant; hence, we explored whether there were relationships between patient survival, having an enrolled caregiver, and caregiver outcomes prior to death. One hundred and twenty-three patient-caregiver dyads and 84 patients without a caregiver coparticipant participated in the ENABLE early versus delayed (12 weeks later) RCT. We collected caregiver quality-of-life (QOL), depression, and burden (objective, stress, and demand) measures every 6 weeks for 24 weeks and every 3 months thereafter until the patient's death or study completion. We conducted survival analyses using log-rank and Cox proportional hazards models. Patients with a caregiver coparticipant had significantly shorter survival (Wald = 4.31, HR = 1.52, CI: 1.02-2.25, P = 0.04). After including caregiver status, marital status (married/unmarried), their interaction, and relevant covariates, caregiver status (Wald = 6.25, HR = 2.62, CI: 1.23-5.59, P = 0.01), being married (Wald = 8.79, HR = 2.92, CI: 1.44-5.91, P = 0.003), and their interaction (Wald = 5.18, HR = 0.35, CI: 0.14-0.87, P = 0.02) were significant predictors of lower patient survival. Lower survival in patients with a caregiver was significantly related to higher caregiver demand burden (Wald = 4.87, CI: 1.01-1.20, P = 0.03) but not caregiver QOL, depression, and objective and stress burden. Advanced cancer patients with caregivers enrolled in a clinical trial had lower survival than patients without caregivers; however, this mortality risk was mostly attributable to higher survival by unmarried patients without caregivers. Higher caregiver demand burden was also associated with decreased patient survival. [ABSTRACT FROM AUTHOR]

A response by M. Bakitas and colleagues to a letter to the editor about their article "Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced Cancer: The Project ENABLE II Randomized Controlled Trial" in the 2009 issue is presented.

Context: There are few randomized controlled trials on the effectiveness of palliative care interventions to improve the care of patients with advanced cancer.Objective: To determine the effect of a nursing-led intervention on quality of life, symptom intensity, mood, and resource use in patients with advanced cancer.Design, Setting, and Participants: Randomized controlled trial conducted from November 2003 through May 2008 of 322 patients with advanced cancer in a rural, National Cancer Institute-designated comprehensive cancer center in New Hampshire and affiliated outreach clinics and a VA medical center in Vermont.Interventions: A multicomponent, psychoeducational intervention (Project ENABLE [Educate, Nurture, Advise, Before Life Ends]) conducted by advanced practice nurses consisting of 4 weekly educational sessions and monthly follow-up sessions until death or study completion (n = 161) vs usual care (n = 161).Main Outcome Measures: Quality of life was measured by the Functional Assessment of Chronic Illness Therapy for Palliative Care (score range, 0-184). Symptom intensity was measured by the Edmonton Symptom Assessment Scale (score range, 0-900). Mood was measured by the Center for Epidemiological Studies Depression Scale (range, 0-60). These measures were assessed at baseline, 1 month, and every 3 months until death or study completion. Intensity of service was measured as the number of days in the hospital and in the intensive care unit (ICU) and the number of emergency department visits recorded in the electronic medical record.Results: A total of 322 participants with cancer of the gastrointestinal tract (41%; 67 in the usual care group vs 66 in the intervention group), lung (36%; 58 vs 59), genitourinary tract (12%; 20 vs 19), and breast (10%; 16 vs 17) were randomized. The estimated treatment effects (intervention minus usual care) for all participants were a mean (SE) of 4.6 (2) for quality of life (P = .02), -27.8 (15) for symptom intensity (P = .06), and -1.8 (0.81) for depressed mood (P = .02). The estimated treatment effects in participants who died during the study were a mean (SE) of 8.6 (3.6) for quality of life (P = .02), -24.2 (20.5) for symptom intensity (P = .24), and -2.7 (1.2) for depressed mood (P = .03). Intensity of service did not differ between the 2 groups.Conclusion: Compared with participants receiving usual oncology care, those receiving a nurse-led, palliative care-focused intervention addressing physical, psychosocial, and care coordination provided concurrently with oncology care had higher scores for quality of life and mood, but did not have improvements in symptom intensity scores or reduced days in the hospital or ICU or emergency department visits.Trial Registration: clinicaltrials.gov Identifier: NCT00253383. [ABSTRACT FROM AUTHOR]

Background: Each year, greater than a half million people die of cancer in the U.S. Despite progress in increasing access to palliative oncology services, end-of-life care still needs improvement. Measuring the quality of the end-of-life experience is difficult because of patient debility and reduced consciousness as death approaches. Family proxies have been proposed as valuable informants regarding the quality of end-of-life care. This article describes family proxy perspectives concerning care at the end of life in patients who died of advanced cancer.Methods: In the context of a novel outpatient palliative care demonstration project, 125 family proxy respondents completed a structured survey by telephone 3 months to 6 months after the patient's death from breast, lung, or gastrointestinal cancer. Four key quality of care indicators were measured: decision-making and physician communication, location of death, hospice involvement, and end-of-life symptoms.Results: Proxies reported that 78% to 81% of patients completed at least 1 form of advance directive and approximately half of them were helpful in guiding care. Communication with physicians regarding end-of-life treatment wishes occurred in 67% of cases, but only 57% of the patients actually made a plan with their physician to ensure that their wishes were followed. The majority of patients died in their location of choice, most often at home, and greater than half had hospice involvement for an average of 41.8 days before death. During the last week of life, the majority of patients experienced troublesome physical and emotional symptoms.Conclusions: Measurement of proxy perspectives is feasible as an indicator of the quality of end-of-life care, and the results of the current study provide actionable data for areas of improvement in palliative oncology care. [ABSTRACT FROM AUTHOR]