A Shared Symptom Burden Presents Opportunities for Collaboration between Outpatient Palliative Care and Psycho-Oncology Providers NICOLE BATES, MD, PGY-IV PSYCHIATRY RESIDENT WESTERN PSYCHIATRIC INSTITUTE AND CLINIC APRIL 21, 2018
Learning Objectives By the completion of this session, participants should be able to: Identify symptoms shared by cancer patients presenting for psycho-oncology and palliative care outpatient services. Discuss correlations between physical and mental health symptoms reported in patients presenting for outpatient psycho-oncology services at an academic medical center. Describe a rationale for greater collaboration between psycho-oncology and palliative care outpatient clinics in addressing physical and mental health symptoms.
Common Ground: Oncology, Psychiatry, and Palliative Care Palliative Care Psychiatry Physical Symptoms Depression Anxiety Cognition Care of Cancer Patients
Our Clinical Experience Significant Symptoms Referrals from Palliative Care Suspected Referral Gap to PC Need to Collaborate
Study Objectives Patient Symptoms Characterize depressive, anxious, physical, and functional symptoms in psycho-oncology patients Palliative Care Determine receipt of proximal outpatient palliative care services Correlations Explore associations between depressive, anxious, and physical symptoms and receipt of palliative care services.
Methods Subjects UPMC Center for Counseling and Cancer Support Cancer patients completing intake surveys Feb Dec, 2016 Captured patient demographics and cancer status Survey Depression: Patient Health Questionnaire-9 item (PHQ-9) Anxiety: Generalized Anxiety Disorder-7 (GAD-7) Physical/functional symptoms: Hybrid ESAS & MDAS Palliative Care Receipt of palliative care via EMR review Study timeframe limited to 6 months before and after survey completion Analysis Descriptive reporting of patient baseline characteristics and symptoms Pearson correlation for association between symptoms Two-sample t-tests and one-way ANOVA comparisons
Patient Characteristics Characteristic Number (%), n = 134 Mean age, years (range) 56 (20-80) Cancer Type Female 82 (61.2%) Race Caucasian African American Asian Other or not reported Cancer Stage Stage 0, in situ Stage 1, local Stage 2/3 (A/B), regional Stage 4, distant Not staged Do not know 119 (88.8%) 12 (9.0%) 1 (0.7%) 2 (1.5%) 7 (5.2%) 15 (11.2%) 38 (28.4%) 38 (28.4%) 15 (11.2%) 21 (15.6%) Characteristic Breast Hematologic Gastrointestinal Lung Colorectal Melanoma/skin Head/neck Brain/CNS Prostate Gynecologic Other Referral Source Oncology/Hematology Palliative care Mental health Other medical provider Self Other Unknown Number (%), n = 134 31 (23.1%) 16 (11.9%) 15 (11.2%) 14(10.4%) 13 (9.7%) 11 (8.2%) 11 (8.2%) 10 (7.5%) 3 (2.2%) 3 (2.2%) 7 (5.2%) 94 (70.1%) 15 (11.2%) 6 (4.5%) 3 (2.2%) 9 (6.7%) 1 (0.7%) 6 (4.5%)
Presenting Psychiatric Symptoms Measure Mean Score (SD) Moderate to Severe Pearson Correlations Physical Sx p- value* PHQ-9 10.0 (6.3) 58 (43.3%).618 <.001 GAD-7 9.7 (6.3) 62 (46.3%).314 <.001 Physical Symptoms 26.3 (16.3) See Figure 1 1 -
Presenting Physical Symptoms FATIGUE 74.6% SLEEP 51.5% PAIN MEMORY APPETITE 37.3% 36.6% 43.3% NUMBNESS NAUSEA CONSTIPATION DIARRHEA 23.1% 22.4% 16.4% 15.7% VOMITING 8.2% 0 20 40 60 80 100 120 Number of Patients Reporting Moderate to Severe Symptoms (n = 134)
Receipt of Palliative Care 22.4% Number of Patients (n=134) 14.2% 5.2% 1.5% 1.5% ANY, ±6 MONTHS FROM SURVEY DATE 3-6 MONTHS BEFORE <3 MONTHS BEFORE <3 MONTHS AFTER 3-6 MONTHS AFTER Palliative Care Involvement Relative to Psycho-oncology Intake Survey
Symptom Burden by Palliative Care Status Measure Mean Score (SD) Any PC (n = 30) No PC (n= 104) t Equality of Means p- value PHQ-9 13.0 (7.15) 9.1 (5.82) 2.683 0.011 GAD-7 11.1 (6.18) 9.3 (6.35) 1.370 0.173 Physical 39.3 Symptoms (15.95) 22.6 (14.42) 5.470 <0.001 Mean Diff (SE) 3.822 (1.425) 1.792 (1.309) 16.747 (3.062)
Do Symptoms Differ Across Palliative Care Status? No palliative care Palliative care within 6 months before Palliative care within 6 months after 41.36 33.75 Mean Score 22.59 13.36 11.88 9.14 9.31 11.18 10.88 PHQ-9 GAD-7 PHYSICAL SYMPTOMS
Do Symptoms Differ Across Palliative Care Status? p = 0.041 No palliative care Palliative care within 6 months before Palliative care within 6 months after p < 0.001 41.36 p = NS 33.75 Mean Score p = 0.004 22.59 13.36 11.88 9.14 9.31 11.18 10.88 PHQ-9 GAD-7 PHYSICAL SYMPTOMS
Conclusions Patients Both depressive and physical symptomatology appear more severe in oncology patients receiving concurrent outpatient palliative and psycho-oncology services Successes Outpatient psycho-oncology patients engaged with palliative care appear appropriately referred Weaknesses Palliative care appears under-utilized in our population Limited timeframe and referral tracking to palliative care Opportunities Our findings underscore the need for care collaboration between outpatient psycho-oncology and palliative care
References 1. Teunissen, S.C.C.M. et al., 2007. Are anxiety and depressed mood related to physical symptom burden? A study in hospitalized advanced cancer patients. Palliative Medicine, 21(4):341 346. 2. Patterson, K.R. et al., 2014. Current state of psychiatric involvement on palliative care consult services: results of a national survey. Journal of Pain and Symptom Management, 47(6) :1019 1027. 3. Ogawa A, et al., 2012. Availability of psychiatric consultation-liaison services as an integral component of palliative care programs at Japanese cancer hospitals. Japanese Journal of Clinical Oncology, 42(1):47-52. 4. Hannon B, et al., 2015. Modified Edmonton Symptom Assessment System including constipation and sleep: validation in outpatients with cancer. Journal of Pain and Symptom Management, 49(5):945-952. 5. Cleeland C.S. et al., 2000. Assessing symptom distress in cancer patients. Cancer, 89:1634-1646
Thanks and Questions Carissa Low, PhD Andrea Croom, PhD Linda King, MD Kaleena Chilcote, MD Ms. Tiffiany Dotson Dionysios Kavalieratos, PhD Heidi Patterson, MLIS WPIC Consultation-Liaison Psychiatry