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The use of patient-reported outcomes (PROs) for routine cancer distress screening is endorsed globally as a quality-care standard. However, there is little research on the integration of PROs in “real-world” oncology practices using implementation science methods. The Improving Patient Experience and Health Outcome Collaborative (iPEHOC) intervention was established at multisite disease clinics to facilitate the use of PRO data by clinicians for precision symptom care. The aim of this study was to examine if patients exposed to the intervention differed in their healthcare utilization compared with contemporaneous controls in the same time frame. We used a PRE- and DURING-intervention population cohort comparison study design to estimate the effects of the iPEHOC intervention on the difference in difference (DID) for relative rates (RR) for emergency department (ED) visits, hospitalizations, psychosocial oncology (PSO), palliative care visits, and prescription rates for opioids and antidepressants compared with controls. A small significantly lower Difference in Difference (DID) (− 0.223) in the RR for ED visits was noted for the intervention compared with controls over time (0.947, CI 0.900–0.996); and a DID (− 0.0329) for patients meeting ESAS symptom thresholds (0.927, CI 0.869–0.990). A lower DID in palliative care visits (− 0.0097), psychosocial oncology visits (− 0.0248), antidepressant prescriptions (− 0.0260) and an increase in opioid prescriptions (0.0456) in the exposed population compared with controls was also noted. A similar pattern was shown for ESAS as a secondary exposure variable. Facilitating uptake of PROs data may impact healthcare utilization but requires examination in larger scale “real-world” trials.

Although robust evidence demonstrates that specialty palliative care integrated into oncology care improves patient and health system outcomes, few clinicians are familiar with the standards, guidelines, and quality measures related to integration. These types of guidance outline principles of best practice and provide a framework for assessing the fidelity of their implementation. Significant advances in the understanding of effective methods and procedures to guide integration of specialty palliative care into oncology have led to a proliferation of guidance documents around the world, with several areas of commonality but also some key differences. Commonalities originate from a shared vision for integration; differences arise from diverse roles of palliative care specialists within cancer care globally. In this review we discuss three of the most cited standards/guidelines, as well as quality measures related to integrated palliative and oncology care. We also recommend changes to the quality measurement framework for palliative care and a new way to match palliative care services to patients with advanced cancer on the basis of care complexity and patient needs, irrespective of prognosis.

Background: Routine early palliative care (EPC) improves quality of life (QoL) for patients with advanced cancer, but it may not be necessary for all patients. We assessed the feasibility of Symptom screening with Targeted Early Palliative care (STEP) in a phase II trial. Methods: Patients with advanced cancer were recruited from medical oncology clinics. Symptoms were screened at each visit using the Edmonton Symptom Assessment System-revised (ESAS-r); moderate to severe scores (screen-positive) triggered an email to a palliative care nurse, who called the patient and offered EPC. Patient-reported outcomes of QoL, depression, symptom control, and satisfaction with care were measured at baseline and at 2, 4, and 6 months. The primary aim was to determine feasibility, according to predefined criteria. Secondary aims were to assess whether STEP identified patients with worse patient-reported outcomes and whether screen-positive patients who accepted and received EPC had better outcomes over time than those who did not receive EPC. Results: In total, 116 patients were enrolled, of which 89 (77%) completed screening for ≥70% of visits. Of the 70 screen-positive patients, 39 (56%) received EPC during the 6-month study and 4 (6%) received EPC after the study end. Measure completion was 76% at 2 months, 68% at 4 months, and 63% at 6 months. Among screen-negative patients, QoL, depression, and symptom control were substantially better than for screen-positive patients at baseline (all PPConclusions: STEP is feasible in ambulatory patients with advanced cancer and distinguishes between patients who remain stable without EPC and those who benefit from targeted EPC. Acceptance of the triggered EPC visit should be encouraged. ClinicalTrials.gov identifier: NCT04044040.

Cancer-related dyspnea is a common, distressing, and difficult-to-manage symptom in cancer patients, resulting in diminished quality of life and poor prognosis. Buspirone, a non-benzodiazepine anxiolytic which does not suppress respiration and has proven efficacy in the treatment of generalized anxiety disorder, has been suggested to relieve the sensation of dyspnea in patients with COPD. The main objective of our study was to evaluate whether buspirone alleviates dyspnea in cancer patients. We report on a randomized, placebo-controlled trial of 432 patients (mean age 64, female 51 %, lung cancer 62 %) from 16 participating Community Clinical Oncology Program (CCOP) sites with grade 2 or higher dyspnea, as assessed by the Modified Medical Research Council Dyspnea Scale. Dyspnea was assessed by the Oxygen Cost Diagram (OCD; higher scores are better) and anxiety by the state subscale of the State‐Trait Anxiety Inventory (STAI-S; lower scores are better) at baseline and after the 4-week intervention (post-intervention). Mean scores from baseline to post-intervention for buspirone were OCD 8.7 to 9.0 and STAI-S 40.5 to 40.1 and for placebo were OCD 8.4 to 9.3 and STAI-S 40.9 to 38.6 with raw improvements over time on both measures being greater in the placebo group. Analysis of covariance (ANCOVA) controlling for baseline scores showed no statistically significant difference between groups for OCD (P = 0.052) or STAI-S (P = 0.062). Buspirone did not result in significant improvement in dyspnea or anxiety in cancer patients. Thus, buspirone should not be recommended as a pharmacological option for dyspnea in cancer patients.

Purpose: Previous work in Ontario demonstrated that 33% of patients with cancer with severe pain did not receive opioids at the time of their pain assessment. With efforts to increase symptom screening and management since then, the objective of this study was to examine temporal trends in opioid prescribing. Methods: The cohort was comprised of Ontario residents ≥ 65 years of age with a cancer history who were eligible for the government pharmacare program and had a pain assessment using the Edmonton Symptom Assessment System. Use of the Edmonton Symptom Assessment System is part of a provincial initiative to screen ambulatory patients with cancer for symptoms. Annually between 2007 and 2013, we used the date of an individual’s highest pain score as the index date to calculate annual opioid prescription rates for claims within 30 days before and up to 7 days after the index date. A logistic regression model evaluated the association between index year and odds of receiving an opioid prescription. Results: During the study period, the number of individuals undergoing symptom assessment annually increased more than eight-fold. Opioid prescription rates were directly related to pain scores, but there was an annual 5% relative decrease in the odds of receiving an opioid prescription during the era from 2009 to 2013. Conclusion: We are doing better at screening for pain, but this has not led to an increase in analgesic intervention for those identified. Additional work is required to determine what opioid prescribing rate is optimal to ensure we are not missing opportunities to improve patient comfort.

11604 Background: Routine early palliative care (EPC) by specialized teams improves quality of life for patients with advanced cancer, but may not be scalable. To plan for a larger randomized controlled trial, we conducted a phase 2 trial of STEP, a novel intervention of targeted EPC based on symptom screening. Methods: Participants with advanced cancer, ECOG 0-2, and clinical prognosis ≥6 months were recruited from lung, gastrointestinal, genitourinary, breast and gynecology outpatient clinics. Symptoms were screened at every outpatient visit using the Edmonton Symptom Assessment System-revised (ESAS-r). Moderate to severe symptom scores (≥4/10 for pain, nausea, dyspnea, depression, anxiety; ≥7/10 for fatigue, appetite, drowsiness, well-being) triggered an e-mail to a nurse, who called the patient, offering an EPC visit. Participants completed outcome measures at baseline, 2, 4 and 6 months (primary endpoint). Trial feasibility criteria were: i) ≥100 patients accrued in 12 months; ii) ≥70% complete screening for ≥70% of visits; iii) ≥60% of those for whom a call is triggered meet at least once with the EPC team; iv) ≥60% complete measures at each endpoint. Results: From 11/2016-1/2018, 116 patients were enrolled; 89/116 (77%) completed screening for ≥70% of visits and 59% (69/116) received a call triggered by symptoms. Of those receiving a call, 62% (43/69) received EPC; 3 further patients were referred by their oncologist. Measure completion was 79% (81/116) at 2, 61% (71/116) at 4, and 57% (66/116) at 6 months. By trial end (6 months), patients who received a call and accepted EPC involvement had better symptom control (ESAS-r-CS mean change in those receiving vs. deferring EPC: -0.07±16.9 vs 11.8±13.7, p = 0.02) and less deterioration in mood (PHQ-9: -0.4±3.4 vs 2.6±2.3, p = 0.003). There was no difference between those receiving versus deferring EPC in quality of life (FACIT-Sp: -4.7±13.6 vs -3.2±15.4, p = 0.75; QUAL-E: -2.6±8.4 vs -1.5±11.0, p = 0.62), or satisfaction with care (FAMCARE-P-16: -3.2±7.9 vs -3.5±6.1, p = 0.79). Conclusions: STEP is feasible in patients with advanced cancer. More than half of patients have moderate to severe symptoms, and acceptance of the triggered EPC visit should be encouraged.

Purpose of review Loss of skeletal muscle mass and cachexia are important manifestations of chronic obstructive pulmonary disease and have been associated with breathlessness, functional limitation and poor prognosis. A number of other life-limiting illnesses, including cancer and chronic heart failure as well as acute conditions seen in ICU such as sepsis, are characteristically associated with cachexia and sarcopenia. These conditions may have respiratory muscle atrophy of sufficient magnitude to contribute to the development of breathlessness and associated functional limitation. The purpose of this review is to summarize findings related to a direct role for severe respiratory muscle wasting in the etiology of breathlessness in advanced, life limiting illness. Recent findings Localized wasting of respiratory muscles appears to be part of systemic wasting of skeletal muscles, driven by deconditioning, nutritional insufficiencies and inflammation, and because of disease-specific factors (tumor factors and exacerbations), anabolic insufficiency, autonomic dysfunction, drugs (such as corticosteroids and chemotherapy agents), mechanical ventilation and comorbidities. Marked morphological and biochemical abnormalities have been noted in diaphragm muscle biopsies. Summary Older patients with multiple comorbidities associated with muscle loss and cachexia are likely to be at elevated risk of respiratory muscle atrophy and functional loss, because of the presence of multiple, interacting etiologic factors.

Purpose Ontario's cancer system is unique because it has implemented two standardized assessment tools population-wide to improve care: the Edmonton Symptom Assessment System (ESAS) measures severity of nine symptoms (scale 0 to 10; 10 indicates the worst) and the Palliative Performance Scale (PPS) measures performance status (scale 0 to 100; 0 indicates death). This article describes the trajectory of ESAS and PPS scores 6 months before death. Patients and Methods Observational cohort study of cancer decedents between 2007 and 2009. Decedents required ≥1 ESAS or PPS assessment in the 6 months before death for inclusion. Outcomes were the decedents' average ESAS and PPS scores per week before death. Results Ten thousand seven hundred fifty-two (ESAS) and 7,882 (PPS) decedents were included. The mean age was 65 years, half were female, and approximately 75% of assessments occurred in cancer clinics. Average PPS score declined slowly over the 6 months before death, starting at approximately 70 and ending at 40, declining more rapidly in the last month. For ESAS symptoms, average pain, nausea, anxiety, and depression scores remained relatively stable over the 6 months. Conversely, shortness of breath, drowsiness, well-being, lack of appetite, and tiredness increased in severity over time, particularly in the month before death. More than one third of the cohort reported moderate to severe scores (ie, 4 to 10) for most symptoms in the last month of life. Conclusion In this large outpatient cancer population, trajectories of mean ESAS scores followed two patterns: increasing versus generally flat. The latter was perhaps due to available treatment (eg, prescriptions) for those symptoms. Future research should prioritize addressing symptoms that worsen over time.

Objective: In late 2006, Cancer Care Ontario launched a quality improvement initiative to implement routine screening with the Edmonton Symptom Assessment System (ESAS) for cancer patients seen in fourteen Regional Cancer Centres throughout the province. Methods: A central team: created a provincial project plan and management and evaluation framework; developed common tools and provided expert coaching and guidance, provincial data analysis, progress reporting and program evaluation. Regional Steering Committees and Improvement teams were accountable for planning and coordination within each region and supported by a funded Regional Improvement Coordinator. A hybrid model for quality improvement facilitated process improvements and uptake of screening. Results: Challenges to implementation included: lack of consensus on the chosen screening tool, lack of guidance for assessment or management of high scores, concern of inadequate time or resources to address issues identified by the screening, data entry was labour intensive, resistance to change and challenges to the traditional care model. Essential components for success were: centralized project management, a person dedicated to implementation of the project locally, clinical champions, clearly identified aims, monthly regional data reporting and implementation of quality improvement methodologies with expectations for performance. To achieve screening aims many centres engaged all members of the team, examined the roles of the different members and reorganized workflow and responsibilities and changed booking times. In March 2010, approximately 25,000 ESAS's were completed in the regional cancer centres across Ontario, with 60% of lung cancer patients and almost 40% of all other cancer patients who visited the Regional Cancer Centres screened. Conclusion: Routine physical and psychological distress screening is possible within regional cancer centres. Although considerable effort and investment is required, it is worthwhile as it helps create a culture that is more patient-centered. Copyright © 2011 John Wiley & Sons, Ltd.

Background: Acute-care hospitals have a role in managing the needs of people with cancer when they are at the end-of-life; however, overutilization of hospital care at the end-of-life results in poorer quality of life and can worsen the patient's experience. Early integration of comprehensive palliative care can greatly reduce unplanned visits to the emergency department, reduce avoidable admissions to hospital, shorten hospital stays, and increase the number of home deaths as well as improve the quality of life of patients with advanced cancer. Aim: To describe the current landscape of acute-care hospital utilization near the end-of-life across Canada and indirectly examine access to palliative care in cancer patients who die in hospital. Methods: Data were obtained from the Canadian Institute for Health Information. The analysis was restricted to adults aged 18+ who died in an acute care hospital in 2014/15 and 2015/16 for nine provinces and three territories. The Discharge Abstract Database was used to extract acute-care cancer death abstracts. Data on intensive care unit (ICU) admissions includes only facilities that report ICU data. Results: Acute care utilization at end-of-life remains commonplace. In Canada (excluding Québec), 43% (48,987) of deaths from cancer occurred in acute-care hospitals, with 70% admitted through the emergency department (ED). In the last six months of life, cancer patients dying in hospital had a median cumulative length of stay ranging from 17 to 25 days, depending on the province. Between 18.1% and 32.8% of patients experienced two or more admissions to the hospital in the last month of life. The proportion of cancer patients admitted to the ICU in the last 14 days of life ranged from 6.4% to 15.1%. Patient demographics (age, sex, place of residence) and clinical factors (cancer type) were often predictors of hospital utilization at end-of-life and likely point to inequities in access to palliative and end-of-life care. Conclusion: Despite previous patient surveys indicating that patients would prefer to receive care and spend their finals days at home or in a hospice, there appears to be overuse of and overreliance on acute care hospital services near the end-of-life in Canada. The high rates of hospital deaths and admissions through the ED at the end-of-life for cancer patients may signal a lack of planning for impeding death and inadequate availability of or access to community- and home-based palliative and end-of-life care services. Acute care hospitals may have a role in managing the health care needs of people affected by cancer; however, end-of-life care should be an option in other settings that align with patient preferences. Standards or practice guidelines to identify, assess and refer patients to palliative care services earlier in their cancer journey should be developed and implemented to ensure optimal quality of life.

6520Background: Our research team previously found that the rate of opioid use in cancer patients surviving at least 5 years beyond diagnosis was 1.2 times higher compared with age-sex matched cont...

Purpose In 1998, the American Society of Clinical Oncology (ASCO) published a special article regarding palliative care and companion recommendations. Herein we summarize the major accomplishments of ASCO regarding palliative cancer and highlight current needs and make recommendations to realize the Society's vision of comprehensive cancer care by 2020. Methods ASCO convened a task force of palliative care experts to assess the state of palliative cancer care in the Society's programs. We reviewed accomplishments, assessed current needs, and developed a definition of palliative cancer. Senior ASCO members and the Board of Directors reviewed and endorsed this article for submission to Journal of Clinical Oncology. Results Palliative cancer care is the integration into cancer care of therapies that address the multiple issues that cause suffering for patients and their families and impact their life quality. Effective provision of palliative cancer care requires an interdisciplinary team that can provide care in all patient settings, including outpatient clinics, acute and long-term care facilities, and private homes. Changes in current policy, drug availability, and education are necessary for the integration of palliative care throughout the experience of cancer, for the achievement of quality improvement initiatives, and for effective palliative cancer care research. Conclusion The need for palliative cancer care is greater than ever notwithstanding the strides made over the last decade. Further efforts are needed to realize the integration of palliative care in the model and vision of comprehensive cancer care by 2020.

Tools to collect patient-reported outcome measures (PROMs) are frequently used in the healthcare setting to collect information that is most meaningful to patients. Due to discordance among how patients and healthcare providers rank symptoms that are considered most meaningful to the patient, engagement of patients in the development of PROMs is extremely important. This review aimed to identify studies that described how patients are involved in the item generation stage of cancer-specific PROM tools developed for cancer patients. A literature search was conducted using keywords relevant to PROMs, cancer, and patient engagement. A manual search of relevant reference lists was also conducted. Inclusion criteria stipulated that publications must describe patient engagement in the item generation stage of development of cancer-specific PROM tools. Results were excluded if they were duplicate findings or non-English. The initial search yielded 230 publications. After removal of duplicates and review of publications, 6 were deemed relevant. Fourteen additional publications were retrieved through a manual search of references from relevant publications. A total of 13 unique PROM tools that included patient input in item generation were identified. The most common method of patient engagement was through qualitative interviews or focus groups. Despite recommendations from international groups and the emphasized importance of incorporating patient feedback in all stages of development of PROMs, few unique tools have incorporated patient input in item generation of cancer-specific tools. Moving forward, a framework of best practices on how to best engage patients in developing PROMs is warranted to support high-quality patient-centered care.

In 2007, the provincial cancer agency in Ontario, Canada initiated a wide-scale program to screen for symptoms in the cancer population using the Edmonton Symptom Assessment Scale (ESAS). The purpose of this study is to evaluate the impact of screening with ESAS on emergency department (ED) visit rates in women with breast cancer receiving adjuvant chemotherapy. This retrospective cohort study used linked administrative health care data from across the province of Ontario, Canada. The cohort included all women aged ≥18 who were diagnosed with stage I–III breast cancer between January 2007 and December 2009 and received adjuvant chemotherapy within 6 months of diagnosis. Using an adjusted recurrent event model, we examined the association of screening with ESAS at a clinic visit on the ED visit rate. The relative rate of ED visits was 0.57 when prior ESAS screening occurred compared to when it did not. The relative rate of ED visits was 0.83 when the prior number of ESAS screens was modeled as a continuous variable. Alternatively stated, the rate of ED visits was 43 % lower among patients previously screened with ESAS compared to those not previously screened. For each additional prior ESAS assessment, there was a 17 % decreased rate of ED visits. Our results demonstrate that screening with ESAS is associated with decreased ED visits. To our knowledge, this is the first report on the effectiveness of routinely documenting a patient reported outcome on ED visits, in a real-world setting.

Objective: Practice guidelines indicate that patients who have months to weeks left to live should not be offered chemotherapy. We examined factors associated with clinician-reported poor performance status as determined by the Palliative Performance Scale (PPS) and subsequent initiation of intravenous (IV) chemotherapy in an ambulatory cancer population in Ontario, Canada. Methods: In this retrospective study, patients who had at least one PPS assessment indicating poor performance status (a PPS score of 50 or lower) comprised the study cohort. Using linked administrative databases, we observed the cohort for initiation of IV chemotherapy within 30 days of the first (index) poor PPS assessment. Results: We excluded patients for whom IV or oral chemotherapy was on going or recently completed or whose performance status improved following the index assessment. Of the remaining cohort, 9.3 percent (264/2,842) received IV chemotherapy within 30 days of the index PPS. Conclusion: A small number of cancer patients with poor performance status began IV chemotherapy in the month following assessment. Objectif: Les directives de pratiques cliniques recommandent que l'on ne propose pas de traitements de chimiothérapie aux patients présentant une espérance de survie de quelques semaines à quelques mois. Nous avons examiné, chez un groupe de patients atteints du cancer en Ontario, au Canada, les éléments associés au faible statut des malades selon les paramètres de l'Έchelle de performance pour soins palliatifs afin d'identifier les facteurs qui ont déterminé l'amorce de la chimiothérapie. Méthode: Cette étude rétrospective comprenait les patients chez qui lors du test d'évaluation de performance on avait noté au moins un élément négatif, soit un score de performance de 50 ou moins. En utilisant plusieurs banques de données administratives interreliées, nous avons étudié cette cohorte de patients devant être traités par chimiothérapie au cours de la période de 30 jours suivant leur évaluation. Résultats: Nous avons exclu les patients pour lesquels le traitement de chimiothérapie orale ou intraveineuse était déjà en cours ou récemment terminé ou ceux dont le statut s'était amélioré selon l'Έchelle de performance. De la partie restante de la cohorte, 9,3 pourcent (264/2 842) ont reçu le traitement par voie intraveineuse à l'intérieur des 30 jours suivant l'indice de l'Έchelle de performance. Conclusion: Un petit nombre de patients ayant un faible statut ont commencé la traitement de chimiothérapie au cours du mois suivant l'évaluation.

298 Background: Opioid prescribing has been increasingly scrutinized in the non-cancer patient population due to concerns with morbidity, mortality and diversion. Resulting regulatory changes have decreased prescribing. As an unintended consequence, we hypothesized that cancer patients might be similarly impacted. Methods: All Ontario residents ≥ 65 years are eligible for government paid pharmacare. For each year from 2004 to 2013, Ontarians ≥ 65 years were stratified into 3 groups: no cancer history, cancer diagnosis > 5 years ago and cancer diagnosis ≤ 5 years ago. We evaluated time trends in 2 outcomes: (1) opioid prescription rate = total number of pharmacare claims / total population of ≥ 65 year olds, and (2) mean daily opioid dose (in morphine equivalents) = sum of all patient’s mean daily opioid doses over their first 90 days of opioid therapy in each year / total patients with an opioid prescription in that year. Results: Ontario’s population of ≥ 65 year olds increased each year with 2.1 million residents in 2013 (5% recent cancer, 10% remote cancer). Demographics were similar by year for each group. Across all years, overall opioid prescription rates were highest for those with a recent cancer and lowest for those with no cancer history. Overall prescription rates increased over time by 23%, 14% and 10% in the non-cancer, remote cancer and recent cancer groups respectively, primarily due to increases in long acting opioids and immediate release single agents. Decreases were seen in long acting oxycodone and fentanyl prescriptions in all cancer groups. The mean daily opioid dose increased for patients receiving long acting oxycodone and fentanyl but was relatively stable for other drug classes. With the exception of immediate release single agents, the mean daily dose was similar between cancer groups regardless of drug class. Conclusions: Regulatory measures have succeeded in decreasing prescription rates in some but not all drug classes among Ontarians aged ≥ 65. Changes over time in both prescription rates and mean daily opioid dose were similar for all 3 groups, suggesting that factors influencing prescribing are affecting cancer and non-cancer patients similarly, possibly to the detriment of some cancer patients.

Background Cluster identification has emerged as a priority for symptom research. Variation in statistical approaches has hampered the identification of common clusters that should be targeted for intervention. The purpose of this study was to identify and validate common symptom clusters in a large population-based cohort of ambulatory cancer subjects. Methods This descriptive, factor analysis study used bootstrap methods to derive a stable factor structure to identify symptom clusters in a population-based sample of cancer patients. Subjects were identified from a provincial symptom database and linked to other provincial databases. Symptom clusters were validated using confirmatory factor analysis in a randomly selected portion of the sample and model fit examined using common goodness of fit criteria. Results The cluster cohort included 14,247 subjects. Three symptom clusters were identified: fatigue-sickness symptoms (tiredness, nausea, drowsiness and shortness of breath), emotional distress (depression and anxiety), and a poor sense of well-being (appetite and well-being). These clusters were stable across most sub-populations in the cohort. Conclusion The identification of common symptom clusters using robust statistical methods will help to yield targets to improve symptom management and identify populations at risk for worse disease outcomes.

Purpose The purpose of this study was to measure opioid prescription (OP) rates in elderly cancer outpatients around the time of assessment for pain and to evaluate factors associated with receiving OPs for those with severe pain. Patients and Methods The cross-sectional cohort includes all patients with cancer in Ontario older than age 65 years who completed a pain assessment as part of a provincial initiative of systematic symptom screening. Patients were assigned to mutually exclusive categories by pain score severity: 0, 1 to 3 (mild), 4 to 6 (moderate), and 7 to 10 (severe). We linked multiple provincial health databases to examine the proportion of patients with an OP within 7 days after or 30 days before the assessment date. We examined factors associated with OPs for patients with pain scores of 7 to 10. Results The proportion of patients with an OP increased as pain score severity increased: 10% of those with no pain, 24% of those with mild pain, 45% of those with moderate pain, and 67% of those with severe pain. More specifically, for those with severe pain, 41% filled an OP within 7 days of assessment for pain, and 26% had an OP from the 30 days before assessment for pain, leaving 33% without an OP. In multivariable analysis, factors associated with OPs are younger age, male sex, comorbid illness, cancer type, and assessment at home. Conclusion Despite a generous time window for capturing OPs, the proportion of patients without an OP seems high. Further knowledge translation is required to maximize the impact of the symptom screening initiative in Ontario and to optimize management of cancer-related pain.

BACKGROUND. For ambulatory cancer patients, Ontario has standardized symptom and performance status assessment population-wide, using the Edmonton Symptom Assessment System (ESAS) and Palliative Performance Scale (PPS). In a broad cross-section of cancer outpatients, the authors describe the ESAS and PPS scores and their relation to patient characteristics. METHODS. This is a descriptive study using administrative healthcare data. RESULTS. The cohort included 45,118 and 23,802 patients’ first ESAS and PPS, respectively. Fatigue was most prevalent (75%), and nausea least prevalent (25%) in the cohort. More than half of patients reported pain or shortness of breath; about half of those reported moderate to severe scores. Seventy-eight percent had stable performance status scores. On multivariate analysis, worse ESAS outcomes were consistently seen for women, those with comorbidity, and those with shorter survivals from assessment. Lung cancer patients had the worst burden of symptoms. CONCLUSIONS. This is the first study to report ESAS and PPS scores in a large, geographically based cohort with a full scope of cancer diagnoses, including patients seen earlier in the cancer trajectory (ie, treated for cure). In this ambulatory cancer population, the high prevalence of numerous symptoms parallels those reported in palliative populations and represents a target for improved clinical care. Differences in outcomes for subgroups require further investigation. This research sets the groundwork for future research on patient and provider outcomes using linked administrative healthcare data. Cancer 2010;116:5767–76. V C 2010 American Cancer Society.

Purpose To construct empirically a conversion table to convert performance status scores among the Eastern Cooperative Oncology Group (ECOG), Karnofsky Performance Status (KPS) and Palliative Performance Scale (PPS) measures, using a large sample of patients with advanced cancer. Methods Seven physicians completed assessments on 1385 consecutive patients attending an oncology palliative care clinic, or admitted to an acute cancer palliative care unit. The three measures were distributed as a questionnaire package; the order in which they were presented was randomly assigned for each week. Scales were compared using the hit rate and the weighted kappa coefficient ( κ w ). The KPS and PPS were compared directly; for comparisons of either scale with the ECOG, all 70 possible categorisations of KPS and PPS were computed. An ‘ideal’ categorisation was selected based on maximisation of both statistical methods. Results The KPS and PPS matched in 1209 out of 1385 assessments (hit rate 87%; κ w 0.97). For both the KPS and the PPS, the categorisation of 100 (ECOG 0), 80–90 (1), 60–70 (2), 40–50 (3), 10–30 (4) had the highest hit rate (75%), and the second highest κ w (0.84, p κ w (0.85 for both KPS and PPS), but a lower hit rate (73% for KPS, 72% for PPS). Conclusions We have derived empirically a conversion scale among the ECOG, KPS and PPS scales. The proposed scale provides a means of translating amongst these measures, which may improve accuracy of communication about performance status amongst oncology clinicians and researchers.

Typical inferential statistical procedures, such as the t-test and analysis of variance, compare differences in mean values of variables. This approach can sometimes obscure rather than illuminate research data. Here we present and discuss alternative data analytic techniques. Potential advantages of box plots over conventional t-tests for understanding data are shown by comparing the area under high and low frequencies from spectral curves of autonomic changes following chemotherapy treatment. Typical t-tests provide information regarding statistical significance in terms of the differences in group means; box plots and related exploratory techniques provide information regarding the characteristics of the distributions within the groups as well as examination of potential outliers. Multivariate analysis of variance (MANOVA) and other multivariate techniques are commonly used to deal with potentially complex data sets with multiple outcome measures. The potential advantages of visual clustering techniques such as star plots, Chernoff faces, and Andrew's Function Plots are demonstrated by examining changes in facial pallor caused by chemotherapy-induced nausea and vomiting. Typical MANOVA approaches can identify potential differences in mean values between groups; visual clustering approaches do this by graphically presenting complex interrelationships for individual cases. This approach enhances the visual interpretation of potential interactions that would be obscured by simply focusing on overall mean values. Preliminary data from a meta-analysis on the effect of metoclopramide on chemotherapy-induced vomiting demonstrates the potential uses and advantages of this summary technique over simple tabular summaries. We found significant relationships between the effect size of the drug and variables such as the year of study publication and whether the publication was an article or an abstract. While none of these techniques are meant to replace traditional inferential statistics, they offer advantages in terms of data exploration and understanding relationships within data sets that are not clearly addressed by other methods. They are potentially valuable alternatives worthy of exploration. Finally, we discuss issues of interim analyses and multiple endpoint assessment for clinical trials.

Dyspnea, like pain, is a subjective experience that incorporates physical elements and affective components. Management of breathlessness in patients with cancer requires expertise that includes an understanding and assessment of the multidimensional components of the symptom, knowledge of the pathophysiologic mechanisms and clinical syndromes that are common in cancer, and familiarity with the indications and limitations of the available therapeutic approaches. Relief of breathlessness should be the goal of treatment at all stages of cancer. Good control of dyspnea will improve the patient's quality of life.

159 Background: The goal of the collaborative is to improve the quality and consistency of physical and emotional symptom management across the cancer journey. Objectives are to promote the adoption of electronic symptom assessment using a standardized tool and to increase the clinical use of evidence based guidelines to effectively manage patient identified symptoms. Methods: The actions taken for this initiative are (a) manage cancer symptoms through a patient reported measurement tool; (b) improve the quality of symptom management through the uptake of symptom management guides and algorithms for care; and (c) drive improvement through the adoption of an electronic symptom assessment platform. The following aims were established for this work: (1) aim for symptom screening and assessment (70% of ambulatory cancer clinic patients are screened for symptom severity using ESAS at least once/month); (2) aim for symptom management (evidence from chart audits show intervention as per evidence based guidelines for patients reported symptom scores); (3) aim for patient satisfaction (90% of target population indicates that their health care team took their scores into consideration when developing a care plan); and (4)aim for evidence of use (90% of patients state that their doctor or nurse spoke with them about their symptom screen). Results: 60% of cancer patients are screened each month representing over 28,000 people. Six of fourteen cancer regions are above the provincial target of 70%, with some close to 90%. 92% of patients felt ESAS was important to complete to help health care providers know how they are feeling. Conclusions: Cancer Care Ontario has been able to drive improvements in symptom management through the implementation of system wide electronic symptom assessment. For other jurisdictions interested in adopting this approach, the following areas are critical for success: a) leadership at all levels of the system; b) clinical tools at the point of care; c) engagement of patients in the design of care; d) communications support to spread information to all stakeholders; and e) using to data to drive performance improvement and accountability.

56 Background: The goal of the collaborative is to improve the quality and consistency of physical and emotional symptom management across the cancer journey. Objectives are: (a) promote the adoption of electronic symptom assessment using a standardized tool and (b) increase the clinical use of evidence based guidelines to effectively manage patient identified symptoms. Methods: The actions taken for this initiative are to manage cancer symptoms through a patient reported measurement tool; improve the quality of symptom management through the uptake of symptom management guides and algorithms for care; and drive improvement through the adoption of an electronic symptom assessment platform The following aims were established for this work: (1) Aim for symptom screening and assessment (70% of ambulatory cancer clinic patients are screened for symptom severity using ESAS at least once/month) (2) aim for symptom management (evidence from chart audits show intervention as per evidence based guidelines for patients reported symptom scores) (3) aim for patient satisfaction (90% of target population indicates that their health care team took their scores into consideration when developing a care plan) and (4) aim for evidence of use (90% of patients state that their doctor or nurse spoke with them about their symptom screen). Results: 60% of cancer patients are screened each month representing over 28,000 people. Six of fourteen cancer regions are above the provincial target of 70%, with some close to 90%. 92% of patients felt ESAS was important to complete to help health care providers know how they are feeling. Conclusions: Cancer Care Ontario has been able to drive improvements in symptom management through the implementation of system wide electronic symptom assessment. For other jurisdictions interested in adopting this approach, the following areas are critical for success. (a.) Leadership at all levels of the system; (b.) clinical tools at the point of care; (c) engagement of patients in the design of care; (d) communications support to spread information to all stakeholders; and (e) using to data to drive performance improvement and accountability.

6514 Background: In 2007 the provincial cancer agency in Ontario, Canada initiated a wide scale program to screen for symptoms in the cancer population using the Edmonton Symptom Assessment Scale (...

The understanding and treatment of dyspnea in the cancer patient are where the science of pain management was 15 or 20 years ago. Very few studies have examined the pathophysiologic mechanisms that cause dyspnea in cancer patients, and few investigators have evaluated therapeutic strategies to control dyspnea in this patient group. The optimal therapy for dyspnea is treatment of the underlying cause. When this is not possible, opioids and phenothiazines provide effective symptomatic relief in most cases, but many unanswered questions remain. Are these the optimal drugs, and what are their optimal doses? What are the effects of chronic dosing? Which is the best route of administration? How serious are the risks of respiratory depression? A clear consensus supports the aggressive treatment of pain in terminally ill cancer patients, even if death is hastened as an unintended consequence. No such position has yet been reached in the management of dyspnea in the same population. As a result, dyspnea is addressed only very late in the course of the disease, perhaps reducing the patient's quality of life and function at earlier stages and resulting in a very small "therapeutic window" in the terminal phase. Clearly, a need exists for more research to determine the most effective management of this common and very distressing symptom.

9023 Background: Dyspnea is a commonly reported symptom in patients with cancer, not just at end-of-life, but at presentation and during treatment, and it is not limited to patients with lung cance...

6084 Background: Since 2007 in Ontario, Canada, the Edmonton Symptom Assessment System (ESAS) has been routinely used to assess symptoms, including pain, in cancer patients in both ambulatory and h...

9621 Background: The morbidity of patients with cancer would be significantly reduced if they received optimal symptom management. This requires early identification of the symptoms, comprehensive ...

6039 Background: Since 2007 in Ontario, Canada, the Edmonton Symptom Assessment System (ESAS) has been routinely used to assess symptoms in cancer patients in both ambulatory and home-care settings. The purpose of this study was to determine the relationship between individual patient symptoms, and their severity, with the likelihood of an emergency department (ED) visit. Methods: The cohort includes all cancer patients in Ontario who completed an ESAS assessment between January 2007 and March 2009. We linked multiple provincial health databases to describe the cohort and determine if an ED visit occurred within 7 days of the patient’s first ESAS. Multivariate logistic regression was used to determine the association between symptom scores (absent: score 0; mild: 1-3; moderate: 4-7; severe: 8-10) and the likelihood of an ED visit. Results: The cohort included 45,118 unique patients whose first assessment contributes to the study. 3.8% (n=1732) had an ED visit. The patients with ED visits were more likely to be men, to have lung or gastro-intestinal cancer, to have had recent radio or chemotherapy, and to have a shorter survival. The proportion of patients with ED visits increased from 2% to 10-12% as individual symptom scores increased from 0 to 10. Anxiety and depression were not associated with ED visits in the model, regardless of severity. Pain, nausea, drowsiness, appetite and shortness of breath with moderate or severe scores were associated with ED visits. Tiredness and wellbeing were the only symptoms to show a significant association for mild, moderate and severe scores. A well being score of 7-10 (reference score=0) had the highest odds ratio of 1.8 (95% CI 1.4-2.3). Conclusions: Worsening symptoms clearly contribute to ED visits. While specific symptoms like pain are obvious targets for management in the outpatient setting, constitutional symptoms like wellbeing or fatigue are associated with even higher odds. Though difficult to manage, such symptoms also warrant detailed assessment in order to optimize patient outcomes.