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The COVID-19 pandemic placed the issue of resource utilization front and center. Our comprehensive cancer center developed a Goals of Care Rapid Response Team (GOC RRT) to optimize resource utilization balanced with goal-concordant patient care.Primary study objective was to evaluate feasibility of the GOC RRT by describing the frequency of consultations that occurred from those requested. Secondary objectives included adherence to consultation processes in terms of core team member participation and preliminary efficacy in limiting care escalation.We conducted a retrospective chart review of patients referred to GOC RRT (3/23/2020-9/30/2020). Analysis was descriptive. Categorical variables were compared with Fisher's exact or Chi-Square tests and continuous variables with Mann-Whitney U tests.Eighty-nine patients were referred. Eighty-five percent (76/89) underwent a total of 95 consultations. Median (range) patient age was 61 (49, 69) years, 54% (48/89) male, 19% (17/89) Hispanic, 48% (43/89) White, 73% (65/89) married/partnered and 66% (59/89) Christian. Hematologic malignancies and solid tumors were evenly balanced (53% [47/89] vs 47% [42/89, P=0.199]). Most patients (82%, 73/89) had metastatic disease or relapsed leukemia. Seven percent (6/89) had confirmed COVID-19. Sixty-nine percent (61/89) died during the index hospitalization. There was no statistically significant difference in demographic or clinical characteristics among groups (no consultation, 1 consultation,1 consultation). Core team members were present at 64% (61/95) of consultations. Care limitation occurred in 74% (56/76) of patients.GOC RRT consultations were feasible and associated with care limitation. Adherence to core team participation was fair.

Few studies have assessed interventions aimed at managing nonmedical opioid use (NMOU) behavior among patients with cancer. The authors developed the Compassionate High-Alert Team (CHAT) intervention to manage patients receiving opioids for cancer pain who demonstrate NMOU behavior. The objective of this study was to determine the change in frequency of NMOU behaviors, pain intensity, and opioid requirements among those who received the intervention.A total of 130 patients receiving opioids for cancer pain that had documented evidence of NMOU and received the CHAT intervention were reviewed. Demographic and clinical information such as NMOU behaviors, pain scores, and morphine equivalent daily dose at baseline, 3, and 6 months post-intervention was obtained.NMOU behaviors significantly decreased from a median (interquartile range) of 2 (1-3) at baseline to 0 (0-1) at both 3 and 6 months post-intervention (p .001). A total of 45 of 75 (60%) and 31 of 50 (62%) of CHAT recipients achieved complete response to the intervention at 3 and 6 months, respectively. Higher baseline number of NMOU behaviors was independently associated with patient response to the intervention (odds ratio [OR], 1.97; 95% confidence interval [CI],1.09-4.28, p = .049 at 3 months; OR, 2.5; 95% CI, 1.20-6.47, p = .03 at 6 months). The median pain score decreased from 7 at baseline to 6 at both 3 and 6 months (p = .01). Morphine equivalent daily dose did not significantly change during that same period (143 mg/day vs. 139 mg/day, p = .13).Most patients who received the CHAT intervention improved in their NMOU behaviors and pain intensity scores 3 and 6 months post-intervention. These preliminary findings support the efficacy of CHAT in managing patients receiving opioids for cancer pain who demonstrate NMOU behavior.

Purpose There is limited literature available regards the frequency and characteristics of COVID-19 + ve status among advanced cancer patients referred to an inpatient supportive care consultation(PC) at a tertiary cancer center. Our study aimed to determine the frequency and characteristics of COVID-19 + ve cancer patients seen by PC. Methods Advanced cancer patients seen as a consult by PC between June 15 and September 25, 2020, at MD Anderson Cancer Center were eligible for the study. We evaluated the patient demographics, clinical characteristics including symptoms(ESAS), delirium(MDAS), COVID + status prior to, and after PC referral(converters), and type of PC delivery(in person or virtual care). Results Sixty-six out of 1380 (4.8%) PC consults were COVID-19 + ve: 42 prior to PC (79%), and 14 (21%) were COVID-19 + ve after the PC (converters). COVID-19 + PC patients had lower depression (P = .035), spiritual distress (P = .003), and were more seen frequently virtually (P

Purpose: In this study we aimed to estimate the effectiveness of pharmacological, nutraceutical, and phytopharmaceutical treatments on CRF. Methods: Ovid MEDLINE, Ovid Embase, Ovid Psych info, CINHAHL and Cochrane Library databases were searched up to 30 September 2021. Randomized controlled trials of pharmacological, nutraceutical and phytopharmaceutical interventions for treatment of CRF for at least one week duration and have used valid tool to assess severity of CRF as a primary or secondary outcome were considered. Results: 32 eligible studies (4896 patients) were reviewed. For the overall meta-analysis, the random effect models yielded the treatment effect (95% CI) of −0.29 (−0.48,−0.09), p < 0.001. The meta-analysis did not show significant reduction of CRF with treatment with ginseng (n = 6), guarana (n = 3), megestrol (n = 2), mistletoe (n = 3), psychostimulants (n = 14), SSRI/antidepressants (n = 2). Corticosteroids (n = 2) showed significant reduction in CRF with treatment effects of 0.94 (−1.21, −0.67), p

Despite cancer related fatigue (CRF) being the most common, and debilitating symptom in patients with recently diagnosed acute hematological malignancies (HM), there are limited effective treatments for CRF in HM. The aim of this study was to determine the feasibility of cognitive behavioral therapy (CBT) for CRF in HM.In this preliminary longitudinal prospective study, HM patients diagnosed a median of one month previously with moderate to severe fatigue were enrolled. Patients received CBT in seven weekly sessions for eight weeks. Change in Functional Assessment of Cancer Illness Therapy (FACIT) - Fatigue (primary), FACT-G, Pittsburg Sleep Quality Index (PSQI), Hospital Anxiety Depression Scale (HADS), M.D. Anderson Symptom Inventory - Acute Myeloid Leukemia (MDASI-AML/MDS), and Herth Hope Index (HHI) were analyzed.Twenty-seven of 36 (75 %) patients were evaluable. Adherence and satisfaction rates to the CBT intervention were 78.6% (95% CI 67.2%, 89.9%), and 92% (95% CI 76.7%, 98.3%) respectively. The median age 66, 64% female, the most common HM was AML (60%), median FACIT-F was 27. The mean (SD) improvement at end eight weeks for FACIT-F was 5.5(13.6), Cohen δ 0.4, P=0.046; and for PSQI total was 2.9 (3), Cohen δ -1, P=0.006. We also found significant improvement in HADS anxiety -2.7(4.5), P=0.049, MDASI Sleep -1.8(3.0), P=0.022, MDASI mean module symptom severity -0.7(1.6), P=0.006. However, no significant improvements were found in FACT-G, HHI, and HADS-depression scores.The use of CBT was feasible with improvement of CRF, sleep quality, and anxiety scores in HM. Randomized controlled trials are justified.

ImportanceThere are few robust evaluations of disease-specific question prompt sheets (QPS) in patient-physician communication among patients with advanced cancer.ObjectiveTo compare the patient perception of helpfulness, global evaluation, and preference for the QPS vs a general information sheet (GIS), and to examine the effect of the QPS on participants’ anxiety, participants’ speaking time, number of questions asked, and length of the clinical encounter.Design, Setting, and ParticipantsThis controlled, double-blind randomized clinical trial was conducted at an outpatient palliative and supportive care clinic in a cancer center in the US. Eligible patients were 18 years or older, had a cancer diagnosis, and were undergoing their first outpatient consultation visit with a palliative care physician from September 1, 2017, to May 31, 2019. Data analysis used a modified intention-to-treat design. Data were analyzed from May 18 to June 27, 2022.InterventionQPS, a 25-item list of questions developed by expert palliative care clinicians using a Delphi process and tested among ambulatory advanced cancer patients. The control was GIS, generic information material given routinely to patients seen at the supportive care clinic.Main Outcomes and MeasuresThe main outcome was patient perception of helpfulness. Secondary outcomes included global evaluation and preference of QPS compared with GIS immediately after the encounter.ResultsA total of 130 patients (mean [SD] age, 58.6 [13.3] years; 79 [60.8%] female) were randomized to receive either QPS (67 patients [51.5%]) or GIS (63 patients [48.5%]). Patients considered QPS and GIS equally helpful, with no statistically significant difference (mean [SD] helpfulness score, 7.2 [2.3] points vs 7.1 [2.7] points; P = .79). The QPS group, compared with the GIS group, had a higher global positive view of the material (mean [SD] global perception score, 7.1 [1.3] vs 6.5 [1.7]; P = .03) and felt it prompted them more to generate new questions (mean [SD] rating, 7.0 [2.9] vs 5.3 [3.5]; P = .005). Of 47 patients asked their preference between the items, more participants preferred the QPS to the GIS in communicating with their physicians (24 patients [51.1%] vs 7 patients [14.9%]; P = .01) at the 4-week follow-up. No significant differences between the QPS and GIS groups were observed regarding participant anxiety, speaking time, number of questions asked, or consultation length (eg, mean [SD] anxiety rating, 2.3 [3.7] vs 1.6 [2.7]; P = .19).Conclusions and RelevanceIn this randomized clinical trial, participants perceived both QPS and GIS as equally helpful, but they had a more positive global view of and preferred the QPS. QPS facilitated generation of new questions without increasing patient anxiety nor prolonging the consultation. The findings provide support for increased adoption and integration of QPS into routine oncologic care.Trial RegistrationClinicalTrials.gov Identifier: NCT03287492

To evaluate how the COVID-19 pandemic impacted the quality of end-of-life care for patients with advanced cancer, we compared a random sample of 250 inpatient deaths from 1 April 2019, to 31 July 2019, with 250 consecutive inpatient deaths from 1 April 2020, to 31 July 2020, at a comprehensive cancer center. Sociodemographic and clinical characteristics, the timing of palliative care referral, timing of do-not-resuscitate (DNR) orders, location of death, and pre-admission out-of-hospital DNR documentation were included. During the COVID-19 pandemic, DNR orders occurred earlier (2.9 vs. 1.7 days before death, p = 0.028), and palliative care referrals also occurred earlier (3.5 vs. 2.5 days before death, p = 0.041). During the pandemic, 36% of inpatient deaths occurred in the Intensive Care Unit (ICU) and 36% in the Palliative Care Unit, compared to 48 and 29%, respectively, before the pandemic (p = 0.001). Earlier DNR orders, earlier palliative care referrals, and fewer ICU deaths suggest an improvement in the quality of end-of-life care in response to the COVID-19 pandemic. These encouraging findings may have future implications for maintaining quality end-of-life care post-pandemic.

BACKGROUND: There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics. METHODS: Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient’s risk potential for NMOU. Targeted UDT was ordered on the basis of a physician’s estimation of a patient’s risk for NMOU. RESULTS: In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener–Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01). CONCLUSIONS: Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.

Background: Increasing the total opioid dose is the standard approach for managing uncontrolled cancer pain. Other than simply increasing the opioid dose, palliative care interventions are multidim...

Opioid therapy provides essential pain relief for cancer patients. We used the population-based Surveillance Epidemiology and End Results (SEER) linked with Medicare database to identify the patterns of opioid use and associated factors in pancreatic adenocarcinoma cancer patients 66 years or older.We assessed opioid types, dispensed days, opioid uptake rates, and factors associated with opioid use after pancreatic adenocarcinoma cancer diagnosis in Medicare beneficiaries between 2007 and 2015 from the SEER-Medicare data. Multivariable regression analysis was used to adjust for a variety of patient-related factors.We identified a cohort of 10,745 pancreatic cancer patients with a median age of 76 years old and median survival of 7 months; 75% of patients-initiated opioids after cancer diagnosis. African Americans had the lowest rate of opioid use of 69.1% compared with all other race/ethnicity groups at around 75%. No significant yearly trend of prescribing opioids was detected. Hydrocodone was the most frequently prescribed opioid type. Regression analysis revealed that age ≤80 years, residing in Southern or Western SEER registries, residing in urban/less urban versus big metro areas, having stage IV cancer at diagnosis, longer survival time, and undertaking cancer-directed treatment or using palliative care were positively associated with opioid initiation, more prescribed opioid types, and higher opioid doses.While a range of sociodemographic variables were associated with opioid use in unadjusted analysis, the associations between race/ethnicity, gender, and socioeconomic status with opioid initiation disappeared when sociodemographic factors, tumor characteristics, and cancer treatment were adjusted.Health care professionals' opioid prescription pattern for pancreatic cancer patients does not parallel the U.S. opioid epidemic. Racial/ethnic disparities in opioid treatment were not identified.

PURPOSE: An understanding of opioid prescription and cost patterns is important to optimize pain management for patients with advanced cancer. This study aimed to determine opioid prescription and cost patterns and to identify opioid prescription predictors in patients with advanced cancer who received inpatient palliative care (IPC). MATERIALS AND METHODS: We reviewed data from 807 consecutive patients with cancer who received IPC in each October from 2008 through 2014. Patient characteristics; opioid types; morphine equivalent daily dose (MEDD) in milligrams per day of scheduled opioids before, during, and after hospitalization; and in-admission opioid cost per patient were assessed. We determined symptom changes between baseline and follow-up palliative care visits and the in-admission opioid prescription predictors. RESULTS: A total of 714 (88%) of the 807 patients were evaluable. The median MEDD per patient decreased from 150 mg/d in 2008 to 83 mg/d in 2014 ( P < .001). The median opioid cost per patient decreased and then increased from $22.97 to $40.35 over the 7 years ( P = .03). The median MEDDs increased from IPC to discharge by 67% ( P < .001). The median Edmonton Symptom Assessment Scale pain improvement at follow-up was 1 ( P < .001). Younger patients with advanced cancer (odds ratio [OR[, 0.95; P < . 001) were prescribed higher preadmission MEDDs (OR, 1.01; P < .001) more often in the earlier study years (2014 v 2009: OR, 0.18 [ P = .004] v 0.30 [ P = .02]) and tended to use high MEDDs (> 75 mg/d) during hospitalization. CONCLUSION: The MEDD per person decreased from 2008 to 2014. The opioid cost per patient decreased from 2008 to 2011 and then increased from 2012 to 2014. Age, prescription year, and preadmission opioid doses were significantly associated with opioid doses prescribed to patients with advanced cancer who received IPC.

12006 Background: Despite the high frequency of cancer related fatigue (CRF) in patients with advanced cancer (PAdC), there are no effective pharmacological treatments. Our group previously found that the placebo response was 56% among PAdC participating in CRF trials. There are no clinical trials using open label placebo for CRF in PAdC. The purpose of this study was to determine the effects of open labeled placebo (OLP) compared to waitlist control (WLC) in reducing CRF in PAdC using Functional Assessment of Chronic Illness Therapy-Fatigue subscale (FACIT-F). Methods: In this randomized controlled trial, PAdC with fatigue ≥ 4/10 on ESAS were randomized to OLP one tablet twice a day or WLC for seven days (primary end point). After week 1 in patients of both arms received placebo for 3 weeks. Changes in FACIT-F from baseline to Day 8 (primary outcome), and changes after 21 days of placebo in both arms were assessed. Secondary outcomes included quality of life (QOL)[FACT-G], fatigue dimensions(MFSI-SF), depression(CES-D), and Fatigue cluster(ESAS fatigue, pain, and depression). Results: 82/90(91%) patients were evaluable. The adherence to placebo [mean%(SD)], was 93.6(18.6), and 88.1(20.2) at Day 8 and Day 29 respectively in OLP arm, and 89.9 (73) at Day 29 in WLC arm. The mean(SD) FACIT-F change at day 8 was 6.6 (7.6) after OLP, 2.1 (9.4) after WLC (p = 0.016). On days 15 and 29, when all patients received OLP, there was significant improvement of CRF but not difference between arms. FACT-G Total Score, FACT-G EWB, ESAS Fatigue, and Fatigue cluster score, all showed significant evidence of reduced CRF in the OLP arm on Day 8 of the study (p = 0.002, 0.030, 0.029, and 0.044, respectively). There was no significant difference in adverse events between the two groups. Conclusions: Open labeled placebo was efficacious in reducing CRF, fatigue cluster, and QOL in fatigued advanced cancer patients at the end of one week. The improvement in fatigue was maintained for 4 weeks. Further studies of this intervention are justified. Clinical trial information: NCT03927885.

Background: Despite the high frequency of cancer-related fatigue (CRF) and its debilitating effects on the quality of life of patients with advanced cancer, there are limited treatment options available. Treatments including physical activity (PA) or dexamethasone (Dex) improve CRF; however, they have lower adherence rates (PA) or long-term adverse effects (Dex). The aim of this study was to determine the feasibility of and preliminary results for the combination of PA and Dex in improving CRF. Methods: In this phase II randomized controlled trial, patients with advanced cancer and CRF scores of ≥4/10 on the Edmonton Symptom Assessment Scale were eligible. Patients were randomized to standardized PA for 4 weeks with either 4 mg of Dex (LoDex arm) or 8 mg of Dex (HiDex arm) twice a day for 7 days. Feasibility and change in the Functional Assessment of Cancer Illness Therapy-Fatigue subscale (FACIT-F) from baseline to day 8 and day 29 (primary outcome) were assessed. Secondary outcomes included changes in fatigue dimensions (FACIT-General, Patient-Reported Outcomes Measurement Information System [PROMIS]-Fatigue). Results: A total of 60 of 67 (90%) patients were evaluable. All patients were adherent to study medication. We found that 84% and 65% of patients in the LoDex arm and 96% and 68% of patients in the HiDex arm were adherent to aerobic and resistance exercise, respectively. The FACIT-F effect size in the LoDex arm was 0.90 (PPPP≤.013) and the PROMIS-Fatigue (P≤.003) at days 8 and 29 in both arms. Mixed-model analysis showed a significant improvement in the FACIT-F scores at day 8 (PPP=.002). Changes in the FACIT-F scores were not significantly different between patients in the 2 arms (P=.86). Conclusions: Our study found that the combination therapy of PA with Dex was feasible and resulted in the improvement of CRF. The improvement was seen for up to 3 weeks after the discontinuation of Dex. Further larger studies are justified. ClinicalTrials.gov identifier: NCT02491632.

Background Current understanding of genetic factors associated with pain severity, and improvement of pain with opioids in advanced cancer patients (AC) is inadequate for delivery of personalized pain therapy (PPT). Therefore, the aim of this study was to determine the genetic factors associated with pain severity, daily opioid dose, and pain response in AC patients receiving supportive care. Methods In this prospective study, AC patients were eligible if they had cancer pain ≥4/10 on Edmonton Symptom Assessment Scale (ESAS) - Pain Item and needed opioid rotation for pain control by specialist at the outpatient supportive care center. Association of genetic factors with pain phenotype was assessed using logistic regression models and SKATO (Gene-block) analysis. Results About 174/178 (98%) patient samples were analyzed. After adjustment for demographic and clinical variables, pain severity was negatively associated with intron variant alleles in OPRM1 rs9322446, P = 0.02; rs2270459, P = 0.038; rs62052210, P = 0.038. Opioid daily dose was positively associated NFKBIA rs2233419, P = 0.008; rs2233417, P = 0.007; rs3138054, P = 0.008; rs1050851, P = 0.015; ORPM1 rs9479759, P = 0.046; rs2003185, P = 0.047; rs636433, P = 0.044; COMT (rs9306234, P = 0.014; rs165728, P = 0.014; rs2020917, P = 0.036; rs165728, P = 0.034); ARRB2 (rs1045280, P = 0.045); and pain response to opioids was negatively associated OPRM1 rs1319339, P = 0.024; rs34427887, P = 0.048; and COMT rs4646316, P = 0.03; rs35478083, P = 0.028, respectively. SKATO analysis showed association between pain severity and CXCL8 (P = 0.0056), and STAT6 (P = 0.0297) genes respectively, and pain response with IL-6 (P = 0.00499). Conclusions This study identified that SNPs of OPRM1, COMT, NFKBIA, CXCL8, IL-6, STAT6, and ARRB2 genes were associated with pain severity, opioid daily dose, and pain response in AC receiving supportive care. Additional studies are needed to validate our findings for PPT.

ObjectiveNon-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center.Method3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. “+risk” was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk.Results731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. TheC-index was 0.8. A nomogram was developed and can be accessed athttps://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1.Significance of resultsWe established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.

Background The effect of high-flow oxygen (HFOx) and high-flow air (HFAir) on dyspnea in nonhypoxemic patients is not known. We assessed the effect of HFOx, HFAir, low-flow oxygen (LFOx), and low-flow air (LFAir) on dyspnea. Subjects, Materials, and Methods This double-blind, 4×4 crossover clinical trial enrolled hospitalized patients with cancer who were dyspneic at rest and nonhypoxemic (oxygen saturation >90% on room air). Patients were randomized to 10 minutes of HFOx, HFAir, LFOx, and LFAir in different orders. The flow rate was titrated between 20–60 L/minute in the high-flow interventions and 2 L/minute in the low-flow interventions. The primary outcome was dyspnea numeric rating scale (NRS) “now” where 0 = none and 10 = worst. Results Seventeen patients (mean age 51 years, 58% female) completed 55 interventions in a random order. The absolute change of dyspnea NRS between 0 and 10 minutes was −1.8 (SD 1.7) for HFOx, −1.8 (2.0) for HFAir, −0.5 (0.8) for LFOx, and − 0.6 (1.2) for LFAir. In mixed model analysis, HFOx provided greater dyspnea relief than LFOx (mean difference [95% confidence interval] −0.80 [−1.45, −0.15]; p = .02) and LFAir (−1.24 [−1.90, −0.57]; p < .001). HFAir also provided significantly greater dyspnea relief than LFOx (−0.95 [−1.61, −0.30]; p = .005) and LFAir (−1.39 [−2.05, −0.73]; p < .001). HFOx was well tolerated. Seven (54%) patients who tried all interventions blindly preferred HFOx and four (31%) preferred HFAir. Conclusion We found that HFOx and HFAir provided a rapid and clinically significant reduction of dyspnea at rest in hospitalized nonhypoxemic patients with cancer. Larger studies are needed to confirm these findings (Clinicaltrials.gov: NCT02932332). Implications for Practice This double-blind, 4×4 crossover trial examined the effect of oxygen or air delivered at high- or low-flow rates on dyspnea in hospitalized nonhypoxemic patients with cancer. High-flow oxygen and high-flow air were significantly better at reducing dyspnea than low-flow oxygen/air, supporting a role for palliation beyond oxygenation.

There are limited studies on factors associated with cancer patients' perception of curability.To examine advanced cancer patient's perception of curability and its association with patient's sociodemographic and clinical characteristics, decisional control preference (DCP), symptoms, and end-of-life quality care outcomes.Secondary analysis of a study to determine the DCP and illness understanding of advanced cancer patients receiving palliative care (PC).Data of the Illness Understanding survey, the Control Preference Scale, and demographics, symptoms, and end-of-life quality care outcomes were reviewed.Of 121 patients, 104 (86%) were evaluable. Median age was 56 years, 60% were women, and 64% had a Karnofsky performance status ≤60. Thirty-seven percent inaccurately reported that their cancer was curable. Patients with accurate perception were more likely to choose a passive DCP (20% vs. 2.6%, p = 0.04). An accurate perception of curability was associated with a longer time from advanced cancer diagnosis to PC referral (odds ratio [OR] = 1.04, p = 0.04). There was a trend toward an association between inaccurate perception of curability, male gender (OR = 0.29, p = 0.09), and intensive care unit admission within 30 days of death (OR = 0.26, p = 0.09). No other significant associations between perception of curability and patients' demographics, clinical characteristics, symptoms, or end-of-life quality care outcomes were found.Thirty-seven percent of advanced cancer patients receiving PC inaccurately perceived their disease curable. These patients were more likely to have earlier PC referrals. An accurate perception of curability was associated with passive DCP. Further studies are needed to test effective communication strategies to mitigate this misperception.

BACKGROUND Opioid misuse is a growing crisis. Patients with cancer who are at risk of aberrant drug behaviors are frequently underdiagnosed. The primary objective of this study was to determine the frequency and factors predicting a risk for aberrant opioid and drug use behaviors (ADB) among patients who received an outpatient supportive care consultation at a comprehensive cancer center. In addition, the screening performance of the Cut Down-Annoyed-Guilty-Eye Opener (CAGE) questionnaire adapted to include drug use (CAGE-AID) was compared with that of the 14-item Screener and Opioid Assessment for Patients With Pain (SOAPP-14) tool as instruments for identifying patients at risk for ADB. METHODS In total, 751 consecutive patients with cancer who were referred to a supportive care clinic were reviewed. Patients were eligible if they had diagnosis of cancer and had received opioids for pain for at least 1 week. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), the SOAPP-14, and the CAGE-AID. SOAPP scores ≥7 (SOAPP-positive) were used to identify patients who were at risk of ADB. RESULTS Among the 729 of 751 (97%) evaluable consults, 143 (19.6%) were SOAPP-positive, and 73 (10.5%) were CAGE-AID-positive. Multivariate analysis revealed that the odds ratio of a positive SOAPP score was 2.3 for patients who had positive CAGE-AID scores (P < .0001), 2.08 for men (P = .0013), 1.10 per point for ESAS pain (P = .014), 1.13 per point for ESAS anxiety (P = .0015), and 1.09 per point for ESAS financial distress (P = .012). A CAGE-AID cutoff score of 1 in 4 had 43.3% sensitivity and 90.93% specificity for screening patients with a high risk of ADB. CONCLUSIONS The current results indicate a high frequency of an elevated risk of ADB among patients with cancer. Men and patients who have anxiety, financial distress, and a prior history of alcoholism/illicit drug use are at increased risk of ADB.

Background: Understanding patients’ decision control preferences is important in providing quality cancer care. Patients’ decisional control preference can be either active (patients prefer to make decisions themselves), shared (collaborative between patient, their physician, and/or family), or passive (patients prefer that the decisions are made by either the physician and/or their family). Aim: To determine the frequency and predictors of passive decision control preferences among advanced cancer patients. We also determined the concordance between actual decision-making and decision control preferences and its association with patient satisfaction. Design: In this cross-sectional survey of advanced cancer patients referred to palliative care across 11 countries, we evaluated sociodemographic variables, Control Preference Scale, and satisfaction with the decisions and care. Results: A total of 1490 participants were evaluable. Shared, active, and passive decision control preferences were 33%, 44%, and 23%, respectively. Passive decision control preferences (odds ratio, p value) was more frequent in India (4.34, Conclusion: Passive decision control preferences were less common (23%) than shared and active decision control preference even among developing countries. Significant predictors of passive decision control preferences were performance status, education, and country of origin.

Introduction: In the United States, opioid regulations have become increasingly stringent in recent years. Increased regulatory scrutiny, in part, is related to heightened awareness through literature and a recent media blitz on the opioid prescription epidemic. These regulations have the potential to impact prescription trends by health care providers. Our objective was to evaluate changes in the type and dose of opioid prescriptions among patients who are referred by oncologists to an outpatient palliative care clinic. Materials and Methods: We reviewed the electronic health records of 750 patients who were seen as new consultations at MD Anderson Cancer Center’s outpatient palliative care clinic between January 1 and April 30 each year from 2010 through 2015. Data collected included demographics, cancer type and stage, symptom assessment, performance status, opioid type, and opioid dose defined as the morphine equivalent daily dose (MEDD). Results: Median age was 59 years (interquartile range [IQR], 51 to 67), 383 (51%) were female, 529 (70%) were white, and 654 (87%)of patients had advanced cancer. In 2010, median MEDD before referral was 78 mg/d (IQR, 30 to 150); however, by 2015, the MEDD had progressively decreased to 40 mg/d (IQR, 19 to 80; P = .001). Hydrocodone was the most common opioid prescribed between 2010 and 2015; however, after its reclassification as a schedule II opioid in October 2014, the use of tramadol, a schedule IV opioid, increased ( P < .001). Conclusion: During the past several years, the MEDD prescribed by referring oncologists has decreased. After hydrocodone reclassification, the use of tramadol with less stringent prescription limits has increased.

Background There are limited data on illness understanding and perception of cure among advanced cancer patients around the world. The aim of the study was to determine the frequency and factors associated with inaccurate perception of curability among advanced cancer patients receiving palliative care across the globe. Materials and Methods Secondary analysis of a study to understand the core concepts in end-of-life care among advanced cancer patients receiving palliative care from 11 countries across the world. Advanced cancer patients were surveyed using a Patient Illness Understanding survey and Control Preference Scale. Descriptive statistics and multicovariate logistic regression analysis were performed. Results Fifty-five percent (763/1,390) of patients receiving palliative care inaccurately reported that their cancer is curable. The median age was 58, 55% were female, 59% were married or had a partner, 48% were Catholic, and 35% were college educated. Sixty-eight percent perceived that the goal of therapy was “to get rid of their cancer,” and 47% perceived themselves as “seriously ill.” Multicovariate logistic regression analysis shows that accurate perception of curability was associated with female gender (odds ratio [OR] 0.73, p = .027), higher education (OR 0.37, p Conclusion Inaccurate perception of curability in advanced cancer patients is 55% and significantly differs by gender, education, performance status, employment status, and country of origin. Further studies are needed to develop strategies to reduce this misperception of curability in advanced cancer patients. Implications for Practice The findings of this study indicate that inaccurate perception of curability among advanced cancer patients is 55%. Inaccurate perception of curability significantly differs by gender, education, performance status, employment status, and country of origin. There is great need to facilitate improved patient–physician communication so as to improve health care outcomes and patient satisfaction.

Background: Despite the high frequency, severity, and effects of cancer-related fatigue (CRF) on the quality of life (QoL) of patients with cancer, limited treatment options are available. The primary objective of this study was to compare the effects of oral Panax ginseng extract (PG) and placebo on CRF. Secondary objectives were to determine the effects of PG on QoL, mood, and function. Methods: In this randomized, double-blind, placebo-controlled study, patients with CRF ≥4/10 on the Edmonton Symptom Assessment System (ESAS) were eligible. Based on a pilot study, we randomized patients to receive either 400 mg of standardized PG twice daily or a matching placebo for 28 days. The primary end point was change in the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) subscale from baseline to day 29. Results: Of 127 patients, 112 (88.2%) were evaluable. The mean (SD) FACIT-F subscale scores at baseline, day 15, and day 29 were 22.4 (10.1), 29.9 (10.6), and 30.1 (11.6) for PG (P

IMPORTANCE: The recent parenteral opioid shortage (POS) has potential implications for cancer-related pain management in hospitalized patients. OBJECTIVE: This study compared changes in opioid prescriptions and clinically improved pain (CIP) among patients treated by an inpatient palliative care (PC) team before and after our institution first reported the POS. DESIGN, SETTING, AND PARTICIPANTS: A cohort study of 386 eligible patients with cancer treated at a comprehensive cancer center 1 month before and after the announcement of the POS. We reviewed data from electronic health records, including patient demographics, opioid type, route of administration, and dose. Board-certified palliative care specialists assessed CIP at follow-up day 1. EXPOSURES: The announcement of the POS by the institution’s pharmacy and therapeutics committee on February 8, 2018. MAIN OUTCOMES AND MEASURES: The primary outcome was to measure the change in opioid prescription patterns of physicians, and the secondary outcome was to measure the proportion of patients who achieved CIP before and after announcement of the POS. RESULTS: Of 386 eligible patients, 196 were men (51%), 270 were white (70%), and the median age was 58 years (interquartile range, 46-67 years). Parenteral opioids were prescribed less frequently by the referring oncology teams after the POS (56 of 314 [18%]) vs before the POS (109 of 311 [35%]) (P

IMPORTANCE: One of the main aims of research on nonmedical opioid use (NMOU) is to reduce the frequency of NMOU behaviors through interventions such as universal screening, reduced opioid exposure, and more intense follow-up of patients with elevated risk. The absence of data on the frequency of NMOU behavior is the major barrier to conducting research on NMOU. OBJECTIVE: To determine the overall frequency of and the independent predictors for NMOU behavior. DESIGN, SETTING, AND PARTICIPANTS: In this prognostic study, 3615 patients with cancer were referred to the supportive care center at MD Anderson Cancer Center from March 18, 2016, to June 6, 2018. Patients were eligible for inclusion if they had cancer and were taking opioids for cancer pain for at least 1 week. Patients were excluded if they had no follow-up within 3 months of initial consultation, did not complete the appropriate questionnaire, or did not have scheduled opioid treatments. After exclusion, a total of 1554 consecutive patients were assessed for NMOU behavior using established diagnostic criteria. All patients were assessed using the Edmonton Symptom Assessment Scale, the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Cut Down, Annoyed, Guilty, Eye Opener–Adapted to Include Drugs (CAGE-AID) survey. Data were analyzed from January 6 to September 25, 2020. RESULTS: A total of 1554 patients (median [interquartile range (IQR)] age, 61 [IQR, 52-69] years; 816 women [52.5%]; 1124 White patients [72.3%]) were evaluable for the study, and 299 patients (19.2%) had 1 or more NMOU behaviors. The median (IQR) number of NMOU behaviors per patient was 1 (IQR, 1-3). A total of 576 of 745 NMOU behaviors (77%) occurred by the first 2 follow-up visits. The most frequent NMOU behavior was unscheduled clinic visits for inappropriate refills (218 of 745 [29%]). Eighty-eight of 299 patients (29.4%) scored 7 or higher on SOAPP, and 48 (16.6%) scored at least 2 out of 4 points on the CAGE-AID survey. Results from the multivariate model suggest that marital status (single, hazard ratio [HR], 1.58; 95% CI, 1.15-2.18; P = .005; divorced, HR, 1.43; 95% CI, 1.01-2.03; P = .04), SOAPP score (positive vs negative, HR, 1.35; 95% CI, 1.04-1.74; P = .02), morphine equivalent daily dose (MEDD) (HR, 1.003; 95% CI, 1.002-1.004; P

Context Health care provider education is an effective strategy to improve knowledge and competencies in opioid-prescribing practices. However, there are very few studies regarding this among providers of patients with cancer pain and nonmedical opioid use (NMOU). The aim of our study was to assess participants' attitudes, beliefs, and self-perceived confidence in caring for patients with cancer pain and NMOU before and after attending an opioid educational seminar on the use and nonmedical use of opioids in patients with cancer. Methods An anonymous cross-sectional survey was conducted among health care providers who attended an opioid educational event in April 2018 and May 2019. Results The overall response rate was 63% (129 of 206). Approximately 72% of participants had concerns about NMOU in patients with cancer, 69% felt that such patients are frequently underdetected, and 63% felt that cancer pain is frequently undertreated. At baseline, only 23% reported adequate knowledge and 35% reported confidence in caring for patients with cancer with NMOU-related issues. Among those who completed both the preseminar and postseminar surveys, these numbers improved significantly at the end of the seminar (26% vs. 71% and 43% vs. 84%, respectively; all P Conclusion Most health care providers expressed concerns about underdetection of NMOU and undertreatment of pain among patients with cancer. Many self-reported knowledge and confidence deficits in caring for patients with cancer with NMOU. Seminar participation was associated with an increase in the number of participants with self-perceived knowledge and confidence. Future studies are needed to ascertain the impact of such opioid educational events on patient care practices.

BACKGROUND Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer. METHODS A retrospective chart review was conducted of 1058 patients who attended an outpatient supportive care clinic from March 2014 to November 2015. Sixty-one patients who were receiving chronic opioid therapy and underwent UDTs were identified. A control group of 120 patients who did not undergo UDTs was selected for comparison. RESULTS Sixty-one of 1058 patients (6%) underwent UDTs, and 33 of 61 patients (54%) had abnormal results. Multivariate analysis indicated that the odds ratio for UDT ordering was 3.9 in patients who had positive Cut Down, Annoyed, Guilty, and Eye Opener (CAGE) questionnaire results (P = .002), 4.41 in patients aged

12086 Background: One of the methodological barriers to conducting research on interventions for NOMU (Aberrant Opioid Use Behaviors) among cancer patients is the lack of data on the frequency of this problem. Although the frequency of risk factors has been established by our group and others, not all the patients with risk factors will be diagnosed with having NMOU behaviors, and some patients with no previous risk factors will engage in NMOU. AIM: To characterize the overall frequency of NMOU for a duration of 3 months, as well independent predictors for NMOU. Methods: In this retrospective study, 1558 consecutive patients referred to supportive care clinic (SCC) from 3/18/2016 to 6/6/2018 were reviewed for development of NMOU using established diagnostic criteria. Patients were eligible if they were ≥18 years, had a diagnosis of cancer, and were on opioids for pain for at least a week. All patients were assessed with the Edmonton Symptom Assessment Scale (ESAS), SOAPP-14, and CAGE-AID. Descriptive statistics, spearman correlation coefficient, multivariate analysis were performed. Results: 299 patients (19%) had ≥1 NMOU behavior. The median (IQR) NMOU behavior was 1 (1-2); range 1-10. Most NMOU occurred at 1st and 2nd follow up visits. The most frequent NMOU behavior was unscheduled clinic visit for inappropriate refills. 29/299 (10%) NMOU patients received specialized care for high-risk for aberrant opioid misuse by interdisciplinary team. Results of multivariate logistic regression model showed Marital status (Divorced vs. Married, OR=1.47, 95% CI: 0.98, 2.22, p=0.654 (marginally significant); Single vs. Married, OR=1.68, 95% CI: 1.15, 2.46, p=0.0079), SOAPP (Positive vs. Negative, OR=1.42, 95% CI: 1.05, 1.93, p=0.0238), morphine equivalent daily dose (MEDD) (OR=1.004, 95% CI: (1.003, 1.006), p

e24135 Background: Current ASCO guidelines propose early access to SC in all CP to improve quality of care, quality of life, and symptoms. Very few studies have evaluated patients’ perceived criteria for referral to outpatient SC and perceptions of patients who are referred early in their disease trajectory. Methods: In this study we evaluated CP attitudes and perceptions regarding the role of and access to outpatient Supportive Care clinic (SCC) at a comprehensive cancer center. CP with life expectancy of greater than 6 months (as determined by the oncologist) and who are newly registered at MD Anderson Cancer Center were randomized to either obtain an educational brochure that explained the role of the SCC or no brochure. Both groups then completed a survey regarding the role and access to of outpatient SCC. After completion of the survey, patients were asked if they would like to be seen by the SC team. If so, they were scheduled by their oncologist for a SC consult. Results: 288 patients were evaluable: median age was 63, 43% were female, 84% were Caucasian, and the most common cancer type was lung cancer (39%). Median survival was 15 months. Patients who received a brochure reported more understanding of the role of SC vs those who did not receive a brochure (63% vs 37%, p = 0.04). Both groups felt that SC could help to address physical (47% vs 54%) and psychosocial (50% vs 50%) symptoms. Both groups felt SC could help to address questions regarding prognosis (50% vs 50%) and future care (53% vs 47%). Both groups did not feel that time (50% vs 50%) nor financial concerns (49% vs 51%) would be barriers to access SC. Both groups did not feel that receiving SC would impede their cancer care (60% vs 40%) nor change their oncologists’ perspective of them (25% vs 75%). Both groups felt they could receive SC and cancer care simultaneously (50% vs 50%). Approximately half of the patients in both groups perceived it was not too early for a referral to SC. There were no statistical differences in these groups for these findings. Conclusions: Patients who received a brochure had a better understanding of the role of SC. A very significant proportion in both groups had limited awareness of the value of SC. Oncologist driven referral and education of SC may facilitate better understanding of the value of SC. Further studies are needed.

12077 Background: Dyspnea is common in hospitalized cancer patients and highly distressing. High flow oxygen (HFOx) is administered for oxygenation in this setting; however, its effect on dyspnea has not been well examined, particularly among non-hypoxemic patients. In this phase II trial, we assessed the effect of HFOx, high flow air (HFAir), low flow oxygen (LFOx) and low flow air (LFAir) on dyspnea. We hypothesized that HFO and HFA can alleviate dyspnea. Methods: This double-blind, 4x4 crossover clinical trial enrolled hospitalized patients with cancer who were dyspneic (NRS ≥3 at rest) and non-hypoxemic (SpO2>90% on room air). Patients were randomized to 10 minutes of HFOx, HFAir, LFOx and LFAir in different orders. The flow rate was titrated between 20-60 L/min in the high flow groups and 2 L/min in the low flow groups. The primary outcome was dyspnea 0-10 numeric rating scale (NRS) “now”, where 0=none and 10=worst. Secondary outcomes included modified Borg scale dyspnea intensity and unpleasantness, adverse effects, and overall preference. We compared among the interventions with a linear mixed model adjusting for time, treatment effect, period effect and carryover effect. Results: 17 patients completed 55 interventions in a random order. Mean age 51, 58% female, mean baseline dyspnea NRS 6.3 (SD 1.7). The absolute change of dyspnea NRS between 0 and 10 minutes was -1.8 (SD 1.7) for HFOx, -1.8 (2.0) for HFAir, -0.5 (0.8) for LFOx and -0.6 (1.2) for LFAir. In mixed model analysis, HFOx group provided greater dyspnea relief than LFOx (mean difference [95% CI] -0.80 [-1.45, -0.15], P=0.02) and LFAir (-1.24 [-1.90, -0.57], P

This cohort study assesses the frequency of abnormal urine drug test findings among patients with cancer pain treated with long-term opioid therapy who underwent random and targeted testing.

To determine the timing of palliative care (PC) access, symptoms, and end-of-life (EOL) quality care outcomes of patients with advanced nonsmall cell lung cancer (NSCLC) referred to outpatients embedded palliative care consults (EPC) compared with those of outpatients palliative care consults (OPC).There are no studies comparing the outcomes of outpatients EPC consults with those of stand-alone OPC consults among patients with NSCLC.The design consists of a random sample of OPC consults (January 2009 to July 2012) and EPC consults (August 2012 to June 2013) at MD Anderson Cancer Center. After the initial consult, all EPC follow-ups occurred at the OPC clinic.Patients' characteristics, symptoms (assessed by Edmonton Symptom Assessment Scale), time from referral to first consult, overall survival from consult to death, and EOL quality care outcomes (ICU admissions, emergency center visits, hospitalizations within last 30 days, cancer treatments within last 14 days, hospice referrals, advanced care planning [ACP] discussions, and completion of advanced directives) were reviewed.A total of 340 consults were included (EPC consults = 147). Baseline Eastern Cooperative Oncology Group status (2.2 vs. 1.9, p 0.001) and median pain (6 vs. 5, p = 0.038) were higher among EPC consults. In EPC consults, time from referral to first consult was shorter (median: 0 day vs. 7 days, p 0.001), and ACP discussions occurred more frequently (90% vs. 77%, p = 0.026), and earlier (median: 2 month vs. 1 month before death, p = 0.018). No other significant differences in symptoms, EOL outcomes, or survival were observed.EPC consults plus OPC follow-ups accessed PC earlier, and had more frequent and earlier ACP discussions as compared with OPC consults. Embedded palliative cancer care might not be the ideal model for an initial PC consultation. Further research is necessary.

Opioid misuse is a growing crisis. Patients with cancer who are at risk of aberrant drug behaviors are frequently underdiagnosed. The primary objective of this study was to determine the frequency and factors predicting a risk for aberrant opioid and drug use behaviors (ADB) among patients who received an outpatient supportive care consultation at a comprehensive cancer center. In addition, the screening performance of the Cut Down-Annoyed-Guilty-Eye Opener (CAGE) questionnaire adapted to include drug use (CAGE-AID) was compared with that of the 14-item Screener and Opioid Assessment for Patients With Pain (SOAPP-14) tool as instruments for identifying patients at risk for ADB.In total, 751 consecutive patients with cancer who were referred to a supportive care clinic were reviewed. Patients were eligible if they had diagnosis of cancer and had received opioids for pain for at least 1 week. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), the SOAPP-14, and the CAGE-AID. SOAPP scores ≥7 (SOAPP-positive) were used to identify patients who were at risk of ADB.Among the 729 of 751 (97%) evaluable consults, 143 (19.6%) were SOAPP-positive, and 73 (10.5%) were CAGE-AID-positive. Multivariate analysis revealed that the odds ratio of a positive SOAPP score was 2.3 for patients who had positive CAGE-AID scores (P.0001), 2.08 for men (P = .0013), 1.10 per point for ESAS pain (P = .014), 1.13 per point for ESAS anxiety (P = .0015), and 1.09 per point for ESAS financial distress (P = .012). A CAGE-AID cutoff score of 1 in 4 had 43.3% sensitivity and 90.93% specificity for screening patients with a high risk of ADB.The current results indicate a high frequency of an elevated risk of ADB among patients with cancer. Men and patients who have anxiety, financial distress, and a prior history of alcoholism/illicit drug use are at increased risk of ADB.

14 Background: Opioid pharmacotherapy is used to manage moderate and severe pain in palliative care (PC). Pain affects 80% pancreatic cancer patients older than 65 years. We assessed the opioid utilization patterns in Medicare patients with pancreatic cancer whom did not use PC (NPC), used community-based PC (CBPC) or used hospital-based PC (HBPC). Methods: We assessed opioid use, types, dispensed days, opioid uptake rates, doses (measured by morphine equivalent doses (MEDs)), and related adverse events (AEs) after pancreatic cancer diagnosis in Medicare beneficiaries selected from the SEER-Medicare database between 2007 and 2013 using the log-binomial, generalized linear mixed, and Cox proportional hazards modeling. Results: 16,106 patients were identified (median age: 78 years; female: 55.2%), of whom 8.3% used CBPC and 19.6% used HBPC. PC users were more likely to use opioids (CBPC: 72.2% vs. HBPC: 63.4% vs. NPC: 56.3%, P

9 Background: Increasing total opioid dose is the standard approach for managing uncontrolled cancer pain. Other than simply increasing the opioid dose, palliative care interventions are multidimensional and may improve pain control in the absence of opioid dose increase. The purpose of this study was to determine the proportion of patients referred to our inpatient palliative care (IPC) team who achieved clinically improved pain (CIP) without opioid dose increase. Methods: We reviewed consecutive patients referred to our IPC team. Eligibility criteria included: 1) taking opioid medication; 2) having ≥ 2 consecutive visits with the IPC team; 3) Edmonton Symptom Assessment Scale (ESAS) pain score ≥ 4 at consultation. We assessed patient demographics and clinical variables, including cancer type, opioid prescription data (type, route, oral morphine equivalent daily dose [MEDD]), presence of opioid rotation, psychological consultation, changes in adjuvant medications (e.g., corticosteroids, benzodiazepines, and neuroleptics), and achievement of CIP. Results: Of the 300 patients enrolled, CIP was achieved in 196 (65%) patients. Of CIP patients, 85 (43%) achieved CIP without an increase in MEDD. CIP without MEDD increase was associated with more adjuvant medication changes (P = 0.003), less opioid rotation (P = 0.005), and lower symptom distress scale of ESAS (P = 0.04). Conclusions: Nearly half of patients achieved CIP without MEDD increase, suggesting that multidimensional palliative care intervention is effective in improving pain control in many opioid-tolerant patients without the need to increase the opioid dose.

110 Background: Cancer-related-fatigue (CRF) is the most debilitating symptom in patients with advanced cancer. Physical activity (PA) improves CRF with lower adherence in advanced cancer. Dexamethasone (Dex) improves CRF but has long-term side effects. The purpose of the study was to determine whether a brief course of Dex improves adherence to PA for CRF management. Methods: Advanced cancer patients with CRF ≥ 4/10 on Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomized to either 4mg of Dex (LoDex) or 8mg of Dex (HiDex) orally BID for 7 days Plus standardized aerobic and resistance exercise for 4 weeks. Change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) fatigue subscale from baseline to Day 8 (primary outcome) and Day 29 were assessed. Secondary outcomes included changes in fatigue (ESAS, PROMIS, MFSI), Sleep Quality (PSQI), fasting blood glucose, and myopathy. Results: Total evaluable patients were 60 (31 LoDex and 29 HiDex arms). The study was feasible (N = 60/67 were evaluable); 84% and 65% LoDex, and 96% and 68% Hi Dex were adherent to aerobic and resistance exercise, respectively [All Patients were adherent to study medication]. There was no significant difference in grade 3+ AE’s between the two arms (P = 0. 92). The FACIT fatigue subscale Cohen’s d in Lo Dex was 0.90 (P < 0.001) and 0.94(P < 0.001); and Hi Dex was 0.86(P < 0.001); and 1.05(P < 0.001) at Day 8 and Day 29, respectively. Similar improvement was found for ESAS Fatigue (P < 0.001), MFSI total (P = 0.005), and PROMIS –fatigue total (P = 0.005). Mixed model analysis showed significant improvement in FACIT-F fatigue scores at Day 8 (P = 0.0006), Day 15 (P = 0.0002), and D (P = 0.0018). There was no significant difference between the two arms at Day 8 and Day 29 in fatigue scores, myopathy, fasting blood glucose levels, symptom distress, and sleep quality scores. Conclusions: Short course of dexamethasone Plus physical activity resulted in sustained and robust improvement in CRF outcomes for upto 3 weeks after discontinuation of steroids suggesting possible priming effects of steroids helped to sustain physical activity. Further larger studies are justified. Clinical trial information: NCT02491632.

11602 Background: Non-Medical opioid use is a growing crisis. Cancer patients at risk of harmful use of prescribed opioids are frequently underdiagnosed. The aim was to develop a nomogram to predict the probability of occurrence of Inappropriate opioid use that is, presence of SOAPP ≥ 7) among patients receiving outpatient supportive care consultation at a comprehensive cancer center. Methods: 3588 consecutive cancer patients referred to a supportive care clinic from March 1, 2016 to July 15, 2018 were reviewed. Patients were eligible if they had diagnosis of cancer, and were on opioids for pain for at least a week. All patients were assessed using Edmonton Symptom Assessment Scale with spiritual pain and financial distress (ESAS-FS), MEDD (morphine equivalent daily dose), SOAPP-14 (validated questionnaire for assessment of risk of inappropriate opioid use, and CAGE-AID (screening questionnaire for alcoholism/substance use disorder). Patients at with SOAPP+ were defined by SOAPP score ≥7. A nomogram was devised based on the risk factors determined in the multivariate logistic regression model and it can be used to estimate the probability of inappropriate opioid use. Results: Median age was 62yrs. Median ESAS pain item score on consultation was 5, Median ECOG was 2.20.4% were SOAPP+ and 10.1% were CAGE-AID+. SOAPP+ was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD and CAGE score. The C-index is 0.8(CI 0.78, 0.82). A nomogram was developed. For example, for a male Hispanic patient, who is married, never smoked, with the following ESAS scores: (depression = 3, anxiety = 3, financial distress = 8), CAGE score of 0, and MEDD of 20, the total score is 9+9+0+0+6+10+26+0+1 = 61. In the nomogram a score of 58 indicates the probability of inappropriate opioid use being 0.1 and a score of 88 indicates the probability of 0.2. Based on the patient’s total score of 61, the probability of his aberrant behavior is between 10% to 20% (close to 10%). Conclusions: A nomogram can predict the risk of inappropriate opioid use in cancer patients.

221 Background: Although urine drug testing (UDT) is an effective risk monitoring tool for patients on chronic opioid therapy, there is currently no evidence to guide physicians in identifying who should have UDT, or when and how often it should be ordered. The main objective of our study was to describe the characteristics of patients who underwent random UDT and a similar cohort who underwent targeted UDT. Methods: Demographic and clinical information of 212 patients who underwent random UDT was retrospectively reviewed and compared with 88 patients who underwent targeted UDT. Targeted UDT was ordered based on the physician’s estimation of patient risk for nonmedical opioid use. All patients were eligible for random UDT regardless of their risk potential for nonmedical opioid use. Results: 212/231 (92%) eligible patients underwent random UDT. Of these 59 (28%) had abnormal results. Among 64 abnormalities detected, 14 (20%) were prescribed opioids that were absent from the urine, 19 (30%) were unprescribed opioids that were present, and 32 (50%) were illicit drugs (91% marijuana). 38/88(43%) of targeted patients had abnormal results. Among 49 abnormalities detected, 13 (27%) were prescribed opioids that were absent from the urine, 15 (31%) were unprescribed opioids that were absent, and 21 (43%) were illicit drugs (71% marijuana). UDT abnormalities were significantly higher in the targeted group than the random group (43.2% vs. 27.8%, p=0.01). There were no significant differences in demographic and clinical characteristics between random and targeted patients with abnormal UDT findings. UDT abnormality was independently associated with age (OR= 0.97 per year, 95% CI: 0.95-0.99, p=0.012), female gender (OR=0.47, 95% CI: 0.28-0.81, p=0.006), anxiety (OR=1.11per point, 95% CI: 1.01-1.22, p=0.039), and appetite (OR= 1.14 per point, 95% CI: 1.04-1.26, p=0.006). Conclusions: More than 1 in 4 cancer patients who underwent random UDT had abnormal results. UDT abnormality in randomly selected patients were no different from targeted patients. Further studies are needed to guide clinical practice regarding standardization of UDT ordering among patients with cancer.

70 Background: No population-based studies have evaluated the impact of community-based palliative care (CBPC) on aggressive end-of-life (EOL) care use and Medicare charges for elderly pancreatic cancer patients. We analyzed the impact of CBPC on aggressive EOL care use in the last 30 days of life and on emergency department (ED) and intensive care unit (ICU) Medicare charges using the SEER-Medicare data. Methods: 12399 elderly pancreatic cancer patients survived for at least 1 month after diagnosis from 2007 to 2013 were identified. CBPC and hospital-based palliative care (HBPC) users were identified by diagnosis codes and place of services and matched by the coarsened exact matching [786:786; age, sex, residence urbanization level, comorbidities, illness duration, palliative care (PC) exposure]. Zero-inflated Poisson and multivariable logistic/linear regression models examined the variations of aggressive EOL care use in the matched patients. Generalized linear regression with a gamma distribution determined how CBPC impacted ED and ICU Medicare charges. Results: 22.1% eligible patients (median age: 76 years) used PC in the 6 years, including 7.7% who used CBPC and 14.5% who used HBPC. The median duration from cancer diagnosis to death of CBPC, HBPC and Non-PC users was 11 months, 6 months and 8 months (P < .001). Matched CBPC users were less likely than HBPC users to be admitted to ICU (risk ratio [RR], 0.64; 95% CI, 0.50-0.81), ED (RR, 0.63; 95% CI, 0.53-0.73), and hospital (RR, 0.50; 95% CI, 0.35-0.72). Compared to matched HBPC users, CBPC users utilized less life-extending care (OR, 0.59; 95% CI, 0.43-0.80) and had shorter hospital (Coef., −0.42; 95% CI, −0.65- −0.18) and ICU stays (Coef., −0.35; 95% CI, −0.59 - −0.10). They tended to die at home (OR, 1.46; 95% CI, 1.19-1.78) and not in ED/ICU/hospital settings (OR, 0.62; 95% CI, 0.45-0.83). CBPC users’ adjusted mean ED and ICU Medicare charges were 0.2% (P = .80) and 1.1% (P < .001) lower than those of Non-PC users and 4.5% (P = .43) and 21.0% (P = .08) lower than those of matched HBPC users. Conclusions: CBPC users utilized less aggressive EOL care than HBPC users, implying CBPC's potential to reduce aggressive EOL care use. Their ICU Medicare charge was lower than that of Non-PC users.

201 Background: Recent parenteral opioid shortage (POS) has the potential to impact cancer pain management in hospitalized patients. This study aims to compare changes in the opioid prescriptions by the inpatient palliative care (PC) team before and after the institution first reported the POS. Methods: We reviewed and compared the electronic health records of 386 consecutive eligible consultations seen by the inpatient PC team equally in one month before and after the announcement of POS on February 8, 2018. The eligibility criteria include (1) cancer diagnosis, (2) ≥18 years of age, (3) taking opioid medication at the time of consultation, and (4) having at least two consecutive visits with the PC team. Patient demographics, cancer type, opioid type, route, and dose defined as the morphine equivalent daily dose were assessed. Results: POS was associated with less use of parenteral opioids (patient controlled analgesia, and intravenous breakthrough) and more use of non-parenteral opioids (extended release, transdermal, and oral breakthrough) by the referring oncology teams, and PC team (P≤.001) (Table 1). At first PC follow-up, significantly less proportion of patients achieved better pain control after POS [119/193 (62%) versus 144/193 (75%) (P=.006)] However, at second PC follow-up, the proportion of pain improvement was similar in both cohorts. Conclusions: There is a significant change in opioid routes associated with POS. POS was associated with worse analgesia. More research is needed to better understand the impact of POS on cancer pain management.[Table: see text]

226 Background: Opioid misuse is a growing crisis. Cancer patients at risk of aberrant drug behaviors are frequently underdiagnosed. Primary aim was to determine the association between current tobacco smoking, daily opioid use, pain response, and risk for aberrant opioid use behaviors (AOB) among patients receiving outpatient supportive care consultation at a comprehensive cancer center. Methods: 1,501 consecutive cancer patients referred to a supportive care clinic from March 1, 2016 to June 6, 2018 were reviewed. Patients were eligible if they had diagnosis of cancer, and were on opioids for pain for at least a week. All patients were assessed using Edmonton Symptom Assessment Scale (ESAS), SOAPP-14 (validated questionnaire for assessment of risk for aberrant opioid use behaviors), and CAGE-AID. Patients with AOB (SOAPP+) were defined by SOAPP score ≥7. Results: Median age was 61yrs. Median ESAS pain item score on consultation was 5. Median ECOG was 2. Never smokers, previous smokers, and current smokers were 54%, 40%, and 6.6% respectively. 16.8% were AOB+ and 10.1% were CAGE-AID+. There was no significant difference in ESAS pain response at first follow-up between AOB+ versus AOB negative. Morphine Equivalent Daily Dose (MEDD) in AOB+ never smokers versus previous smokers versus current smokers was 45 mg versus 60 mg versus 75mg respectively (P=0.03). Table 1 shows that male pts and those with current or previous smoking history, anxiety, and prior alcoholism/illicit drug use are at increased risk of AOB. Conclusions: Male patients and those with history of current or previous smoking history, anxiety, and prior alcoholism/illicit drug use are at increased risk of AOB. [Table: see text]

185 Background: Poor sleep quality is frequent in patients with advanced cancer (62%), and is associated with a severe symptom distress and mortality. There are limited evidence based treatment options in advanced cancer patients.To obtain feasibility, preliminary estimates of the effects of various treatments [light therapy, melatonin, Methylphenidate] and combinations of treatments in multimodal therapy (MMT) to improve sleep quality, as measured by change in Pittsburg Sleep Quality Index (PSQI) scores from baseline to Day 15. We also examined MMT effects on FACT-G, insomnia - Insomnia severity index (ISI), actigraphy. Methods: Cancer patients with moderate sleep disturbance were eligible. Using a double-blind (patient, investigators) randomized factorial study design, eligible Pts were randomized into 1 of the 8 arms of the study which included all possible combinations of the interventions (light therapy, melatonin, and methylphenidate) and/or their corresponding placebo treatments for a duration of 2 weeks. All patients received 3 sessions of standardized CBT. Linear regression analysis was used to assess treatment effects. Results: 84% (54/ 64) randomized Pts were evaluable. At baseline, median (IQR) total PSQI was 13 (12, 15); and ISI was 18 (14, 21). There were no differences in the demographics and baseline sleep quality between groups. The adherence rates for light therapy, melatonin, and methylphenidate were 93%, 100%, and 100% respectively. Light therapy had moderate effects on sleep quality (effect size .43, P=0.017). No significant differences in ISI, FACT-G scores, and objective sleep variables between groups. There were no significant difference in adverse events by groups (P=.97). Conclusions: MMT interventions to treat sleep disturbance were feasible. Light therapy provided the best signal for improvement in sleep quality, and should proceed to large randomized control trials. Clinical trial information: NCT0168029. [Table: see text]