Purpose. Palliative care consultation services are now available in the majority of cancer centers, yet most referrals to palliative care occur late. We previously found that the term "palliative care" was perceived by oncology professionals as a barrier to early patient referral. We aimed to determine whether a service name change to supportive care was associated with earlier referrals.Patients and Methods. Records of 4,701 consecutive patients with a first palliative care consultation before (January 2006 to August 2007) and after (January 2008 to August 2009) the name change were analyzed, including demographics and dates of first registration to hospital, advanced cancer diagnosis, palliative care consultation, and death. One-sample proportions tests, median tests, 2 tests, and log-rank tests were used to identify group differences.Results. The median age was 59 years, 50% were male, and 90% had solid tumors. After the name change, we found: (a) a 41% greater number of palliative care consultations (1,950 versus 2,751 patients; p < .001), mainly as a result of a rise in inpatient referrals (733 versus 1,451 patients; p < .001), and (b) in the outpatient setting, a shorter duration from hospital registration to palliative care consultation (median, 9.2 months versus 13.2 months; hazard ratio [HR], 0.85; p < .001) and from advanced cancer diagnosis to palliative care consultation (5.2 months versus 6.9 months; HR, 0.82; p < .001), and a longer overall survival duration from palliative care consultation (median 6.2 months versus 4.7 months; HR, 1.21; p < .001).Conclusion. The name change to supportive care was associated with more inpatient referrals and earlier referrals in the outpatient setting. The outpatient setting facilitates earlier access to supportive/palliative care and should be established in more centers. The Oncologist 2011;16:105-111

BACKGROUND Cancer pain initiatives recommend using the personalized pain goal (PPG) to tailor pain management. This study was conducted to examine the feasibility and stability of PPG, and how it compares to the clinical pain response criteria. METHODS Records of 465 consecutive cancer patients seen in consultation at the Supportive Care Clinic were reviewed. Pain relief was assessed as clinical response (≥30% or ≥2 point pain reduction), and PPG-response (pain≤PPG). RESULTS 152 (34%), 95 (21%), and 163 (37%) patients presented with mild (1-4), moderate (5-6), and severe (7-10) pain, respectively. Median age (59 years), males(52%), advanced cancer status (84%) did not differ by pain category. Median PPG at initial clinic consult was 3 (interquartile range 2-3), similar across pain groups, and remained unchanged (p=0.57) at follow-up (median 14 days). Clinical response was higher among patients with severe pain (60%) as compared to moderate (40%) and mild pain (33%, p<0.001). PPG-response was higher among patients with mild pain (63%) as compared to moderate (44%) and severe pain (27%, p< 0.001). Using PPG-response as gold standard for pain relief, the sensitivity of clinical response was highest (98%) among patients with severe pain, but had low specificity (54%). In patients with mild pain, clinical response was most specific for pain relief (98%), but had low sensitivity (52%). CONCLUSION PPG is a simple patient reported outcome for pain goals. Majority of patients were capable of stating their desired level for pain-relief. The median PPG was 3, and it was highly stable at follow-up assessment.

Clinicians have limited accuracy in the prediction of patient survival. We assessed the accuracy of probabilistic clinician prediction of survival (CPS) and temporal CPS for advanced cancer patients admitted to our acute palliative care unit, and identified factors associated with CPS accuracy. Eight physicians and 20 nurses provided their estimation of survival on admission by (a) the temporal approach, "What is the approximate survival for this patient (in days)?" and (b) the probabilistic approach, "What is the approximate probability that this patient will be alive (0%-100%)?" for >24 hours, 48 hours, 1 week, 2 weeks, 1 month, 3 months, and 6 months. We also collected patient and clinician demographics. Among 151 patients, the median age was 58 years, 95 (63%) were female, and 138 (81%) had solid tumors. The median overall survival time was 12 days. The median temporal CPS was 14 days for physicians and 20 days for nurses. Physicians were more accurate than nurses. A higher accuracy of temporal physician CPS was associated with older patient age. Probabilistic CPS was significantly more accurate than temporal CPS for both physicians and nurses, although this analysis was limited by the different criteria for determining accuracy. With the probabilistic approach, nurses were significantly more accurate at predicting survival at 24 hours and 48 hours, whereas physicians were significantly more accurate at predicting survival at 6 months. The probabilistic approach was associated with high accuracy and has practical implications. The Oncologist 2011;16:1642-1648

Context Approximately 80% of patients with advanced cancer report pain and receive opioids. Information is limited about deviations from prescribed opioid doses and barriers to pain control, but poor opioid adherence has been reported in 49%–70% of patients. Objectives To evaluate the frequency and severity of self-reported opioid deviation and barriers to opioid pain management in outpatients with advanced cancer. Methods We surveyed 198 patients and collected pain scores (0–10), prescribed opioid dose, confidential patient-reported opioid prescription dose and intake (as long as there was no severe opioid deviation), barriers to pain management (Barriers Questionnaire-II [BQ-II]) scores, and adherence scores. Opioid deviation was defined as <70% or >130% of the prescribed dose. Results Median patient age was 55 years; 91 (46%) were female. Median pain intensity and morphine equivalent daily dose were 4 (interquartile range [IQR]=3–7) and 120 mg (IQR=45–270mg), respectively. Prescribed and patient-reported prescribed doses were highly correlated for regular (r=0.90, P<0.001) and regular plus breakthrough opioid intake (r=0.94, P<0.001). Nineteen (9.6%) patients deviated. Deviation was more frequent in males (P=0.039) and non-Whites (P=0.0270). Non-White patients had higher scores on the BQ-II than White patients (P=0.038). Low adherence scores were significantly associated with higher BQ-II scores (1.99±0.80) for lower motivation score vs. 1.61±0.77 for higher score, P=0.007; and 2.13±0.79 for lower knowledge score vs. 1.57±0.72 for higher score, P=0.001. Conclusion Very few patients reported dose deviations, which were mostly towards lower dose. More research is necessary to better characterize the frequency and predictors of opioid deviation in this population.

Background Phase I trials offer advanced cancer patients the opportunity to pursue life-prolonging cancer treatments. In this study, we compared the timing of referral and symptom burden between patients referred to palliative care by Phase I oncologists and those referred by non-Phase I oncologists. Methods All 57 patients with advanced solid tumors referred by Phase I to our palliative care outpatient clinic in 2007/2008 were included. The comparison cohort consisted of 114 non-Phase I patients stratified by age, sex and cancer diagnosis in a 1:2 ratio. We retrieved information regarding patient characteristics, Edmonton Symptom Assessment Scale (ESAS), timing of referral and survival. Results Both cohorts had the following matched characteristics: average age 57, female 44% and gastrointestinal cancers 47%. At the time of palliative care consultation, Phase I patients were more likely than non-Phase I patients to have a better performance status (ECOG 0-1, 61% vs. 36%, P=0.003). ESAS was not different except for better well-being in the Phase I cohort (mean 4.5 vs. 5.5, p=0.03). No difference was found for the duration between M.D. Anderson registration and palliative care consult (13 vs. 11 months, P=0.41) and overall survival from time of palliative care consult (5 vs. 4 months, P=0.69). Conclusions Phase I outpatients referred to palliative care had a better performance status but similar symptom burden as non-Phase I patients. Phase I involvement did not delay palliative care referral compared to non-Phase I. This supports the development of a simultaneous care model.