A Case Study On Anticipated End-of-Life Caregiving Among The Millennial American Born Chinese

Millennial American Born Chinese (ABCs) are in a double jeopardy position with end-of-life (EOL) care for their immigrant parents, because of both cultural and generational clashes. There is no existing empirical study about the millennial ABCs’ attitudes or behaviors towards EOL caregiving. Our study is the first one to explore the millennial ABCs’ anticipated EOL caregiving behaviors, support and resources needed, attitudes towards terminal illness disclosure and advance care planning (ACP) discussion with their parents, and how acculturation influences. A qualitative in-depth phone interview using a case study approach, with a scenario of caring for parents with Parkinson’s disease and stage IV lung cancer, was adopted. Participants were recruited via convenience sampling, and a total of 27 (18 females and 9 males with an average age of 25) passed the screening and completed the interviews. Using the directed content analysis, researchers identified two themes: EOL caregiving and EOL decision making, which included five sub-themes: caregiving behaviors, needed supports and resources, care arrangement decision, terminal illness disclosure, and ACP. Both traditional Chinese culture of familism and filial piety, and western culture of autonomy and patients’ rights to know were exhibited in every theme. Most participants did not fully understand ACP concept, but they were willing to initiate ACP conversation after comprehending ACP concept. This study constitutes an essential step towards understanding the millennial ABC EOL caregivers’ financial, physical, and emotional needs from family, community and government, better establishing corresponding policies, and promoting public education in ACP to benefit this minority group.

Improving palliative care integration for patients with stage IV lung cancer at UConn Health by initiating a best practice advisory (BPA) in the electronic medical record (EMR).

331 Background: The American Society of Clinical Oncology (ASCO) practice updates on the integration of palliative care into standard oncology practice provides a key recommendation that patients with advanced cancer should receive palliative care services. Specifically, ASCO recommends that all patients with stage IV cancer receive a referral to an interdisciplinary palliative care team early in their course of disease and within 8 weeks of diagnosis. At UConn Health, it has been previously documented that only 28% of patients with stage IV cancer receive a referral to the palliative care team. To improve the quality of cancer care, a BPA with standardized criteria for palliative care referral was developed and implemented for patients with stage IV lung cancer. In this pilot study, the goal was to get 80-90% of patients a referral to palliative care team within 8 weeks of stage IV lung cancer diagnosis. Methods: The Model for Improvement using Plan-Do-Study-Act Cycles was completed: 1) created an EMR report to identify patients with stage IV lung cancer; 2) completed a retrospective review of patients with stage IV lung cancer referred to palliative care 6 months prior to BPA implementation; 3) created and implemented BPA; 4) educated providers about palliative care referral and BPA; 5) retrospectively reviewed referrals 6 months following BPA implementation; and 6) evaluated potential barriers. The palliative care EMR BPA was developed in collaboration with information technology specialists. The BPA alert populates the EMR when the provider opens a patient chart or visit encounter for all patients with 1) diagnosis of lung cancer; 2) stage IV disease; and 3) does not have a current order for palliative care referral. Results: Prior to BPA implementation (January 1, 2020- July 31, 2020), 8 of 28 patients (32%) with stage IV lung cancer were referred to palliative care service. The BPA became active on 9/15/2020. Within the six months following BPA implementation, 16 patients were newly diagnosed with stage IV lung cancer. Of these 16 patients, 81% of them had a referral to palliative care made within 8 weeks of clinical staging. Several barriers were identified with current process, including lack of staging tool use by all providers; lack of documentation of all data required for staging tool to automatically calculate stage, and inability to track patients who declined palliative care appointment. Conclusions: Incorporating a BPA reminding providers to consider a palliative care referral improved referrals of patients with newly diagnosed stage IV lung cancer to the palliative care clinic within 8 weeks of diagnosis, improving compliance with ASCO’s practice guidance on integration of palliative care. Next steps are to address barriers and expand the use of palliative care referral BPA to all patients with stage IV cancer.

Torque Teno Virus load in lung cancer patients correlates with age but not with tumor stage

Background Torque teno virus (TTV) is a ubiquitous non-pathogenic virus, which is suppressed in immunological healthy individuals but replicates in immune compromised patients. Thus, TTV load is a suitable biomarker for monitoring the immunosuppression also in lung transplant recipients. Since little is known about the changes of TTV load in lung cancer patients, we analyzed TTV plasma DNA levels in lung cancer patients and its perioperative changes after lung cancer surgery. Material and methods Patients with lung cancer and non-malignant nodules as control group were included prospectively. TTV DNA levels were measured by quantiative PCR using DNA isolated from patients plasma and correlated with routine circulating biomarkers and clinicopathological variables. Results 47 patients (early stage lung cancer n = 30, stage IV lung cancer n = 10, non-malignant nodules n = 7) were included. TTV DNA levels were not detected in seven patients (15%). There was no significant difference between the stage IV cases and the preoperative TTV plasma DNA levels in patients with early stage lung cancer or non-malignant nodules (p = 0.627). While gender, tumor stage and tumor histology showed no correlation with TTV load patients below 65 years of age had a significantly lower TTV load then older patients (p = 0.022). Regarding routine blood based biomarkers, LDH activity was significantly higher in patients with stage IV lung cancer (p = 0.043), however, TTV load showed no correlation with LDH activity, albumin, hemoglobin, CRP or WBC. Comparing the preoperative, postoperative and discharge day TTV load, no unequivocal pattern in the kinetics were. Conclusion Our study suggest that lung cancer has no stage dependent impact on TTV plasma DNA levels and confirms that elderly patients have a significantly higher TTV load. Furthermore, we found no uniform perioperative changes during early stage lung cancer resection on plasma TTV DNA levels.

Correlation Analysis of Mood State and Symptom Clusters in Patients With Stage-Ⅳ Lung Cancer During Immunotherapy

Purpose: To investigate the status of symptom clusters and mood states and analyze the correlation between them in patients with stage-IV lung cancer undergoing immunotherapy.Methods: Using a convenience sampling method, we selected 259 patients for analysis with stage-IV lung cancer who were admitted to the oncology department of a hospital for immunotherapy from February to December 2020. Three instruments were used: a general situation questionnaire, the Chinese version of the M. D. Anderson Symptom Inventory, and the Brief Profile of Mood State Short Form.Results: An exploratory factor analysis identified three main symptom clusters: the disturbance influence, general, and pain–fatigue related symptom clusters. The total score for mood state was (25.71 SD: ±8.32). The score of the depression dimension was the highest (3.30 ±1.85) in the negative mood state; the total score of mood state and the score of negative mood state at different latitudes were significantly positively correlated with the total score of symptom clusters (r = 0.420–0.529, p < 0.01).Conclusion: There are many symptom clusters in patients with lung cancer undergoing immunotherapy. The negative mood state is significant and changes along with changes in symptom clusters; moreover, there is high correlation between them. There should be more focus on the evaluation and management of symptom clusters of patients in nursing to improve the patients’ quality of life.

A case with hepatic immune-related adverse events caused by nivolumab exhibiting impaired accumulation of regulatory T cells

Systemic administration of anti-programmed cell death 1 (PD-1) antibody (Ab) has achieved remarkable success in metastatic cancers. The blockade of PD-1-mediated signaling pathways sometimes cause immune-related adverse events (irAEs) due to restored anti-cancer as well as anti-self immunity. Although the liver is a preferential organ for irAEs, the immuno-pathogenesis underlying hepatic irAEs has been poorly understood. We describe a 57-year-old man with Stage IV lung cancer who underwent the first-line regimen composed of carboplatin and paclitaxel. Nivolumab treatment (3.2 mg/kg, every 3 weeks) was initiated when the disease progressed after the first chemotherapy. Sequential occurrence of irAEs involving the multiorgan systems was observed. He developed hepatic irAEs (Grade 3) after endocrine, lung, and cutaneous irAEs. Lobular hepatitis characterized by predominant infiltration of CD8+ T cells was seen in the liver biopsy specimens. Interestingly, defective accumulation of regulatory T cells (Tregs) expressing forkhead box protein P3 (FOXP3) was evident in this case with hepatic irAEs as compared with typical cases with autoimmune hepatitis. This case suggests that hepatic irAEs are characterized not only by lobular infiltration of CD8+ T cells but also by defective accumulation of FOXP3+ Tregs.