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Colmar Figueroa-Moseley, Pascal Jean-Pierre, Joseph A. Roscoe, Julie L. Ryan, Sadhna Kohli, Oxana G. Palesh, Elizabeth P. Ryan, Jennifer Carroll, and Gary R. Morrow

Anticipatory nausea and vomiting (ANV) is associated with a significant reduction in the quality of life for many chemotherapy patients. The use of 5-hydroxytryptamine type 3 receptor antagonists provides some relief for chemotherapy-induced nausea and vomiting, but does not seem to control ANV. Nonpharmacologic approaches, which include behavioral interventions, may provide the greatest promise in relieving symptoms. Little evidence supports the use of complementary and alternative methods, such as acupuncture and acupressure, in relieving ANV. Behavioral interventions, especially progressive muscle relaxation training and systematic desensitization, should be considered important methods for preventing and treating ANV.

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Ronald Chow, Daniel E. Lage, Grant R. Williams, Mina S. Sedrak, Joseph A. Greer, Jennifer S. Temel, and Ryan D. Nipp

Background: Older adults account for 70% of cancer-related deaths, but previous studies have shown that they are underrepresented in cancer clinical trials. We sought to analyze the representation and outcomes of older adults in trials conducted in the era of novel targeted therapy and immunotherapy. Methods: We searched the 2020 NCCN Clinical Practice Guidelines in Oncology and retrieved trials from the past 10 years leading to category 1 recommendations in the first-line metastatic setting for the 5 most common causes of cancer death. We categorized trials by cancer type, single-agent versus multiagent approach, and therapeutic class. We described the percentage of older adults (according to each trial’s definition) and used a Mantel-Haenszel random-effects meta-analysis model to compare overall and progression-free survival by age. Results: We identified 30 trials consisting of 24,416 patients. Across all trials, 44% of enrolled patients were older adults. Representation of older adults by cancer type within trials was 49% prostate cancer, 38% pancreatic cancer, 37% breast cancer, and 34% non–small cell lung cancer. Representation of older adults also varied by therapeutic class: 20% received immunotherapy, 44% received cytotoxic chemotherapy, 54% received targeted/hormonal therapy, and 34% received combination therapy (P<.001 for all comparisons). For each year since 2010, the percentage of older adults enrolled in trials increased by 1.9%, although this difference was not significant. We observed no difference in overall or progression-free survival between older and younger adults. In our analysis of practice-changing clinical trials, we found that 44% of clinical trial participants were older adults. Trials that included immunotherapy or a combination of therapeutic classes had a lower representation of older adults (<40%). Conclusions: We found that >40% of patients in practice-changing trials are older adults. Although they remain underrepresented in clinical trials compared with the general population, older adults in practice-changing trials seem to be better represented than in previously reported analyses of cooperative group trials.

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Subha Perni, Danielle Bitterman, Jennifer Ryan, Julie K. Silver, Eileen Mitchell, Sarah Christensen, Megan Daniels, Mara Bloom, Ephraim Hochberg, David Ryan, Daphne Haas-Kogan, Jay S. Loeffler, Nancy J. Tarbell, Aparna R. Parikh, and Jennifer Wo

Background: Philanthropic donations are important funding sources in academic oncology but may be vulnerable to implicit or explicit biases toward women. However, the influence of gender on donations has not been assessed quantitatively. Methods: We queried a large academic cancer center’s development database for donations over 10 years to the sundry funds of medical and radiation oncologists. Types of donations and total amounts for medical oncologists and radiation oncologists hired prior to April 1, 2018 (allowing ≥2 years on faculty prior to query), were obtained. We also obtained publicly available data on physician/academic rank, gender, specialty, disease site, and Hirsch-index (h-index), a metric of productivity. Results: We identified 127 physicians: 64% men and 36% women. Median h-index was higher for men (31; range, 1–100) than women (17; range, 3–77; P=.003). Men were also more likely to have spent more time at the institution (median, 15 years; range, 2–43 years) than women (median, 12.5 years; range, 3–22 years; P=.025). Those receiving donations were significantly more likely to be men (70% vs 30%; P=.034). Men received significantly higher median amounts ($259,474; range, $0–$29,507,784) versus women ($37,485; range, $0–$7,483,726; P=.019). On multivariable analysis, only h-index and senior academic rank were associated with donation receipt, and only h-index with donation amount. Conclusions: We found significant gender disparities in receipt of philanthropic donations on unadjusted analyses. However, on multivariable analyses, only productivity and rank were significantly associated with donations, suggesting gender disparities in productivity and promotions may contribute to these differences.

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Daniel E. Lage, Areej El-Jawahri, Charn-Xin Fuh, Richard A. Newcomb, Vicki A. Jackson, David P. Ryan, Joseph A. Greer, Jennifer S. Temel, and Ryan D. Nipp

Background: National guidelines recommend regular measurement of functional status among patients with cancer, particularly those who are elderly or high-risk, but little is known about how functional status relates to clinical outcomes among hospitalized patients with advanced cancer. The goal of this study was to investigate how functional impairment is associated with symptom burden and healthcare utilization and clinical outcomes. Patients and Methods: We conducted a prospective observational study of patients with advanced cancer with unplanned hospitalizations at Massachusetts General Hospital from September 2014 through March 2016. Upon admission, nurses assessed patients’ activities of daily living (ADLs; mobility, feeding, bathing, dressing, and grooming). Patients with any ADL impairment on admission were classified as having functional impairment. We used the revised Edmonton Symptom Assessment System (ESAS-r) and Patient Health Questionnaire-4 to assess physical and psychological symptoms, respectively. Multivariable regression models were used to assess the relationships between functional impairment, hospital length of stay, and survival. Results: Among 971 patients, 390 (40.2%) had functional impairment. Those with functional impairment were older (mean age, 67.18 vs 60.81 years; P<.001) and had a higher physical symptom burden (mean ESAS physical score, 35.29 vs 30.85; P<.001) compared with those with no functional impairment. They were also more likely to report moderate-to-severe pain (74.9% vs 63.1%; P<.001) and symptoms of depression (38.3% vs 23.6%; P<.001) and anxiety (35.9% vs 22.4%; P<.001). Functional impairment was associated with longer hospital length of stay (β = 1.29; P<.001) and worse survival (hazard ratio, 1.73; P<.001). Conclusions: Hospitalized patients with advanced cancer who had functional impairment experienced a significantly higher symptom burden and worse clinical outcomes compared with those without functional impairment. These findings provide evidence supporting the routine assessment of functional status on hospital admission and using this to inform discharge planning, discussions about prognosis, and the development of interventions addressing patients’ symptoms and physical function.

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Hanyu Chen, Jie Liu, Xiaoyu Zong, Ai Zhang, Jennifer Tappenden, Thomas Walsh, Deyali Chatterjee, Ryan Courtney Fields, Graham Andrew Colditz, and Yin Cao

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Areej El-Jawahri, Deborah Forst, Alyssa Fenech, Keri O. Brenner, Amanda L. Jankowski, Lauren Waldman, Isabella Sereno, Ryan Nipp, Joseph A. Greer, Lara Traeger, Vicki Jackson, and Jennifer Temel

Background: Studies have shown gaps in prognostic understanding among patients with cancer. However, few studies have explored patients’ perceptions of their treatment goals versus how they perceive their oncologist’s goals, and the association of these views with their psychological distress. Methods: We conducted a cross-sectional study of 559 patients with incurable lung, gastrointestinal, breast, and brain cancers. The Prognosis and Treatment Perception Questionnaire was used to assess patients’ reports of their treatment goal and their oncologist’s treatment goal, and the Hospital Anxiety and Depression Scale was used to assess patients’ psychological symptoms. Results: We found that 61.7% of patients reported that both their treatment goal and their oncologist’s treatment goal were noncurative, whereas 19.3% reported that both their goal and their oncologist’s goal were to cure their cancer, 13.9% reported that their goal was to cure their cancer whereas their oncologist’s goal was noncurative, and 5% reported that their goal was noncurative whereas their oncologist’s goal was curative. Patients who reported both their goal and their oncologist’s goal as noncurative had higher levels of depression (B=0.99; P=.021) and anxiety symptoms (B=1.01; P=.015) compared with those who reported that both their goal and their oncologist’s goal was curative. Patients with discordant perceptions of their goal and their oncologist’s goal reported higher anxiety symptoms (B=1.47; P=.004) compared with those who reported that both their goal and their oncologist’s goal were curative. Conclusions: One-fifth of patients with incurable cancer reported that both their treatment goal and their oncologist’s goal were to cure their cancer. Patients who acknowledged the noncurative intent of their treatment and those who perceived that their treatment goal was discordant from that of their oncologist reported greater psychological distress.

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Emily van Seventer, J. Peter Marquardt, Amelie S. Troschel, Till D. Best, Nora Horick, Chinenye Azoba, Richard Newcomb, Eric J. Roeland, Michael Rosenthal, Christopher P. Bridge, Joseph A. Greer, Areej El-Jawahri, Jennifer Temel, Florian J. Fintelmann, and Ryan D. Nipp

Background: Low muscle mass (quantity) is common in patients with advanced cancer, but little is known about muscle radiodensity (quality). We sought to describe the associations of muscle mass and radiodensity with symptom burden, healthcare use, and survival in hospitalized patients with advanced cancer. Methods: We prospectively enrolled hospitalized patients with advanced cancer from September 2014 through May 2016. Upon admission, patients reported their physical (Edmonton Symptom Assessment System [ESAS]) and psychological (Patient Health Questionnaire-4 [PHQ-4]) symptoms. We used CT scans performed per routine care within 45 days before enrollment to evaluate muscle mass and radiodensity. We used regression models to examine associations of muscle mass and radiodensity with patients’ symptom burden, healthcare use (hospital length of stay and readmissions), and survival. Results: Of 1,121 patients enrolled, 677 had evaluable muscle data on CT (mean age, 62.86 ± 12.95 years; 51.1% female). Older age and female sex were associated with lower muscle mass (age: B, –0.16; P<.001; female: B, –6.89; P<.001) and radiodensity (age: B, –0.33; P<.001; female: B, –1.66; P=.014), and higher BMI was associated with higher muscle mass (B, 0.58; P<.001) and lower radiodensity (B, –0.61; P<.001). Higher muscle mass was significantly associated with improved survival (hazard ratio, 0.97; P<.001). Notably, higher muscle radiodensity was significantly associated with lower ESAS-Physical (B, –0.17; P=.016), ESAS-Total (B, –0.29; P=.002), PHQ-4-Depression (B, –0.03; P=.006), and PHQ-4-Anxiety (B, –0.03; P=.008) symptoms, as well as decreased hospital length of stay (B, –0.07; P=.005), risk of readmission or death in 90 days (odds ratio, 0.97; P<.001), and improved survival (hazard ratio, 0.97; P<.001). Conclusions: Although muscle mass (quantity) only correlated with survival, we found that muscle radiodensity (quality) was associated with patients’ symptoms, healthcare use, and survival. These findings underscore the added importance of assessing muscle quality when seeking to address adverse muscle changes in oncology.

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Ryan D. Nipp, Leah L. Thompson, Brandon Temel, Charn-Xin Fuh, Christine Server, Paul S. Kay, Sophia Landay, Daniel E. Lage, Lara Traeger, Erin Scott, Vicki A. Jackson, Nora K. Horick, Joseph A. Greer, Areej El-Jawahri, and Jennifer S. Temel

Background: Oncologists often struggle with managing the complex issues unique to older adults with cancer, and research is needed to identify patients at risk for poor outcomes. Methods: This study enrolled patients aged ≥70 years within 8 weeks of a diagnosis of incurable gastrointestinal cancer. Patient-reported surveys were used to assess vulnerability (Vulnerable Elders Survey [scores ≥3 indicate a positive screen for vulnerability]), quality of life (QoL; EORTC Quality of Life of Cancer Patients questionnaire [higher scores indicate better QoL]), and symptoms (Edmonton Symptom Assessment System [ESAS; higher scores indicate greater symptom burden] and Geriatric Depression Scale [higher scores indicate greater depression symptoms]). Unplanned hospital visits within 90 days of enrollment and overall survival were evaluated. We used regression models to examine associations among vulnerability, QoL, symptom burden, hospitalizations, and overall survival. Results: Of 132 patients approached, 102 (77.3%) were enrolled (mean [M] ± SD age, 77.25 ± 5.75 years). Nearly half (45.1%) screened positive for vulnerability, and these patients were older (M, 79.45 vs 75.44 years; P=.001) and had more comorbid conditions (M, 2.13 vs 1.34; P=.017) compared with nonvulnerable patients. Vulnerable patients reported worse QoL across all domains (global QoL: M, 53.26 vs 66.82; P=.041; physical QoL: M, 58.95 vs 88.24; P<.001; role QoL: M, 53.99 vs 82.12; P=.001; emotional QoL: M, 73.19 vs 85.76; P=.007; cognitive QoL: M, 79.35 vs 92.73; P=.011; social QoL: M, 59.42 vs 82.42; P<.001), higher symptom burden (ESAS total: M, 31.05 vs 15.00; P<.001), and worse depression score (M, 4.74 vs 2.25; P<.001). Vulnerable patients had a higher risk of unplanned hospitalizations (hazard ratio, 2.38; 95% CI, 1.08–5.27; P=.032) and worse overall survival (hazard ratio, 2.26; 95% CI, 1.14–4.48; P=.020). Conclusions: Older adults with cancer who screen positive as vulnerable experience a higher symptom burden, greater healthcare use, and worse survival. Screening tools to identify vulnerable patients should be integrated into practice to guide clinical care.

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Ryan D. Nipp, Brandon Temel, Charn-Xin Fuh, Paul Kay, Sophia Landay, Daniel Lage, Esteban Franco-Garcia, Erin Scott, Erin Stevens, Terrence O’Malley, Supriya Mohile, William Dale, Lara Traeger, Ardeshir Z. Hashmi, Vicki Jackson, Joseph A. Greer, Areej El-Jawahri, and Jennifer S. Temel

Background: Oncologists often struggle with managing the unique care needs of older adults with cancer. This study sought to determine the feasibility of delivering a transdisciplinary intervention targeting the geriatric-specific (physical function and comorbidity) and palliative care (symptoms and prognostic understanding) needs of older adults with advanced cancer. Methods: Patients aged ≥65 years with incurable gastrointestinal or lung cancer were randomly assigned to a transdisciplinary intervention or usual care. Those in the intervention arm received 2 visits with a geriatrician, who addressed patients’ palliative care needs and conducted a geriatric assessment. We predefined the intervention as feasible if >70% of eligible patients enrolled in the study and >75% of eligible patients completed study visits and surveys. At baseline and week 12, we assessed patients’ quality of life (QoL), symptoms, and communication confidence. We calculated mean change scores in outcomes and estimated intervention effect sizes (ES; Cohen’s d) for changes from baseline to week 12, with 0.2 indicating a small effect, 0.5 a medium effect, and 0.8 a large effect. Results: From February 2017 through June 2018, we randomized 62 patients (55.9% enrollment rate [most common reason for refusal was feeling too ill]; median age, 72.3 years; cancer types: 56.5% gastrointestinal, 43.5% lung). Among intervention patients, 82.1% attended the first visit and 79.6% attended both. Overall, 89.7% completed all study surveys. Compared with usual care, intervention patients had less QoL decrement (–0.77 vs –3.84; ES = 0.21), reduced number of moderate/severe symptoms (–0.69 vs +1.04; ES = 0.58), and improved communication confidence (+1.06 vs –0.80; ES = 0.38). Conclusions: In this pilot trial, enrollment exceeded 55%, and >75% of enrollees completed all study visits and surveys. The transdisciplinary intervention targeting older patients’ unique care needs showed encouraging ES estimates for enhancing patients’ QoL, symptom burden, and communication confidence.

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Dominik J. Ose, Richard Viskochil, Andreana N. Holowatyj, Mikaela Larson, Dalton Wilson, William A. Dunson Jr, Vikrant G. Deshmukh, J. Ryan Butcher, Belinda R. Taylor, Kim Svoboda, Jennifer Leiser, Benjamin Tingey, Benjamin Haaland, David W. Wetter, Simon J. Fisher, Mia Hashibe, and Cornelia M. Ulrich

Background: This study aimed to understand the prevalence of prediabetes (preDM) and diabetes mellitus (DM) in patients with cancer overall and by tumor site, cancer treatment, and time point in the cancer continuum. Methods: This cohort study was conducted at Huntsman Cancer Institute at the University of Utah. Patients with a first primary invasive cancer enrolled in the Total Cancer Care protocol between July 2016 and July 2018 were eligible. Prevalence of preDM and DM was based on ICD code, laboratory tests for hemoglobin A1c, fasting plasma glucose, nonfasting blood glucose, or insulin prescription. Results: The final cohort comprised 3,512 patients with cancer, with a mean age of 57.8 years at cancer diagnosis. Of all patients, 49.1% (n=1,724) were female. At cancer diagnosis, the prevalence of preDM and DM was 6.0% (95% CI, 5.3%–6.8%) and 12.2% (95% CI, 11.2%–13.3%), respectively. One year after diagnosis the prevalence was 16.6% (95% CI, 15.4%–17.9%) and 25.0% (95% CI, 23.6%–26.4%), respectively. At the end of the observation period, the prevalence of preDM and DM was 21.2% (95% CI, 19.9%–22.6%) and 32.6% (95% CI, 31.1%–34.2%), respectively. Patients with myeloma (39.2%; 95% CI, 32.6%–46.2%) had the highest prevalence of preDM, and those with pancreatic cancer had the highest prevalence of DM (65.1%; 95% CI, 57.0%–72.3%). Patients who underwent chemotherapy, radiotherapy, or immunotherapy had a higher prevalence of preDM and DM compared with those who did not undergo these therapies. Conclusions: Every second patient with cancer experiences preDM or DM. It is essential to foster interprofessional collaboration and to develop evidence-based practice guidelines. A better understanding of the impact of cancer treatment on the development of preDM and DM remains critical.