IMPORTANCE:Symptom monitoring interventions are increasingly becoming the standard of care in oncology, but studies assessing these interventions in the hospital setting are lacking.OBJECTIVE:To evaluate the effect of a symptom monitoring intervention on symptom burden and health care use among hospitalized patients with advanced cancer.DESIGN, SETTING, AND PARTICIPANTS:This nonblinded randomized clinical trial conducted from February 12, 2018, to October 30, 2019, assessed 321 hospitalized adult patients with advanced cancer and admitted to the inpatient oncology services of an academic hospital. Data obtained through November 13, 2020, were included in analyses, and all analyses assessed the intent-to-treat population.INTERVENTIONS:Patients in both the intervention and usual care groups reported their symptoms using the Edmonton Symptom Assessment System (ESAS) and the 4-item Patient Health Questionnaire-4 (PHQ-4) daily via tablet computers. Patients assigned to the intervention had their symptom reports displayed during daily oncology rounds, with alerts for moderate, severe, or worsening symptoms. Patients assigned to usual care did not have their symptom reports displayed to their clinical teams.MAIN OUTCOMES AND MEASURES:The primary outcome was the proportion of days with improved symptoms, and the secondary outcomes were hospital length of stay and readmission rates. Linear regression was used to evaluate differences in hospital length of stay. Competing-risk regression (with death treated as a competing event) was used to compare differences in time to first unplanned readmission within 30 days.RESULTS:From February 12, 2018, to October 30, 2019, 390 patients (76.2% enrollment rate) were randomized. Study analyses to assess change in symptom burden included 321 of 390 patients (82.3%) who had 2 or more days of symptom reports completed (usual care, 161 of 193; intervention, 160 of 197). Participants had a mean (SD) age of 63.6 (12.8) years and were mostly male (180; 56.1%), self-reported as White (291; 90.7%), and married (230; 71.7%). The most common cancer type was gastrointestinal (118 patients; 36.8%), followed by lung (60 patients; 18.7%), genitourinary (39 patients; 12.1%), and breast (29 patients; 9.0%). No significant differences were detected between the intervention and usual care for the proportion of days with improved ESAS-physical (unstandardized coefficient [B] = -0.02; 95% CI, -0.10 to 0.05; P = .56), ESAS-total (B = -0.05; 95% CI, -0.12 to 0.02; P = .17), PHQ-4-depression (B = -0.02; 95% CI, -0.08 to 0.04; P = .55), and PHQ-4-anxiety (B = -0.04; 95% CI, -0.10 to 0.03; P = .29) symptoms. Intervention patients also did not differ significantly from patients receiving usual care for the secondary end points of hospital length of stay (7.59 vs 7.47 days; B = 0.13; 95% CI, -1.04 to 1.29; P = .83) and 30-day readmission rates (26.5% vs 33.8%; hazard ratio, 0.73; 95% CI, 0.48-1.09; P = .12).CONCLUSIONS AND RELEVANCE:This randomized clinical trial found that for hospitalized patients with advanced cancer, the assessed symptom monitoring intervention did not have a significant effect on patients' symptom burden or health care use. These findings do not support the routine integration of this type of symptom monitoring intervention for hospitalized patients with advanced cancer.TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT03396510.

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.

Background: Patient-reported medical status and treatment goal are measures of prognostic understanding with demonstrated relationships to important clinical and patient-reported outcomes in the general cancer population. Among older adults, relationships between these measures and other patient-reported (quality of life [QOL], symptoms, functional impairment) and dinical (hospitalization risk, survival) outcomes remains unclear. Methods: We enrolled patients >= 70 with advanced gastrointestinal cancers, collecting patient-reported medical status ( terminally ill vs not), treatment goal (curative vs non-curative), QOL (EORTC-Elderly Cancer Patients), symptoms (Edmonton Symptom Assessment System [ESAS]), and functional impairment (activities of daily living [ADIs]). We also obtained information about hospitalizations and survival. To explore relationships between patient-reported medical status, treatment goal, QOL, symptoms, functional impairment, hospitalizations, and survival, we used regression models adjusted for age, sex, and education. Results: Of 103 patients, 49.5% reported terminally ill status and 64.0% a non-curative treatment goal. Terminally ill status was associated with worse QOL (EORTC illness burden: 53.59 vs 35.26, p = 0.001), higher symptom burden (ESAS: 28.15 vs 16.79, p = 0.002), more functional impairment (ADLs: 3.63 vs 5.24, p - 0.006), greater hospitalization risk (HR- 2.41, p = 0.020), and worse survival (HR 1.93, p = 0.010). We did not find associations between patient-reported treatment goal and these outcomes. Conclusions: In older adults with advanced cancer, report of terminally ill status was associated with other important patient-reported and clinical outcomes, suggesting disease severity may inform illness perceptions. We did not find similar associations for patient-reported treatment goal, indicating that questions related to medical status and treatment goal measure different constructs and more nuanced measures are needed. Published by Elsevier Ltd.

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.

23 Background: Patients with cancer receiving chemotherapy often present to the ED and require hospitalization to manage acute issues. However, little work has sought to understand characteristics associated with hospitalizations for patients with cancer receiving chemotherapy who present to the ED. Methods: As part of a quality improvement initiative, we reviewed ED visits within 30-days of patients receiving intravenous chemotherapy at Massachusetts General Hospital from October 2017-January 2018. We used descriptive statistics to compare sociodemographic and clinical factors for hospitalized and non-hospitalized patients. We used logistic regression to explore variables independently associated with being hospitalized. We also compared death rates within 6 months between groups. Results: We identified 500 ED visits during our study period, which resulted in 350 (70.0%) hospitalizations. Hospitalized and non-hospitalized patients did not differ by age (mean 64.1 vs 63.4, P = 0.61), sex (48.9% vs 51.3% female, P = 0.61), or presence of metastatic disease (71.1% vs 68.7%, P = 0.59). Hospitalized patients were more likely to have gastrointestinal (25.7% vs 20.7%) and lung (14.0% vs 11.3%) cancer; less likely to have breast cancer (7.4% vs 16.7%, P < 0.01). Hospitalized patients were more likely to come to the ED on a Thursday (15.7% vs 6.7%); less likely to come on a Wednesday (10.3% vs 19.3%, P < 0.01). On logistic regression, factors associated with higher likelihood of being hospitalized included white race (OR = 1.84, P = 0.03), and presenting with fever/cold symptoms (OR = 2.64, P < 0.01), fatigue (OR = 2.15, P = 0.04), or dyspnea (OR = 2.29, P = 0.04). Death rates within 6 months were higher for the hospitalized patients (50.0% vs 18.7%, P < 0.01). Conclusions: Patients with cancer who visited the ED within 30-days of receiving intravenous chemotherapy often require hospitalization. We identified factors associated with higher likelihood of hospitalization, including patient characteristics, presenting symptoms, and the day of the week. Our findings should inform future efforts to enhance care delivery and outcomes for patients with cancer receiving chemotherapy.

e23016 Background: Perceptions of medical status and treatment goal are often used to assess prognostic awareness, but whether these items fully capture patients’ understanding of their prognosis remains unclear. We sought to better understand these measures by investigating their relationship with quality of life (QOL), symptom burden, functional impairment, hospitalizations, and overall survival (OS). Methods: We enrolled patients age ≥70 years within 8 weeks of a diagnosis of incurable gastrointestinal cancer. We surveyed patients to assess perceptions of medical status [terminally ill vs not], treatment goal [curative vs non-curative], QOL (EORTC - Elderly Cancer Patients), symptom burden (Edmonton Symptom Assessment System [ESAS]), and functional impairment (activities of daily living [ADLs]). We used regression models adjusted for age, sex, and education to explore relationships between these items and patients’ QOL, symptom burden, functional impairment, risk of hospitalizations, and OS. Results: Of 132 patients approached, 103 (78.0%) enrolled (mean age 77.62 years, 47.6% female). Half (49.5%) reported a terminally ill medical status and nearly two-thirds (64.0%) reported a non-curative treatment goal, with 42.0% reporting discordant responses to these items. Patient report of a terminally ill status was associated with worse QOL (EORTC illness burden: 53.59 vs 35.26, p = .001), higher symptom burden (ESAS score: 28.15 vs 16.79, p = .002), more functional impairment (number of ADLs: 3.63 vs 5.24, p = .006), greater risk of hospitalizations (HR = 2.41, p = .020), and worse OS (HR = 1.93, p = .010). We found no associations between these outcomes and patient-reported treatment goal. Conclusions: In older adults with advanced cancer, half reported a terminally ill medical status and nearly two-thirds reported a non-curative treatment goal. Patient report of a terminally ill status was associated with worse QOL, symptom burden, functional impairment, risk of hospitalizations, and OS. We did not find associations between these outcomes and patient report of their treatment goal. Our findings suggest that these questions measure different constructs and more nuanced tools for assessing prognostic awareness are needed.

22 Background: ED utilization among patients with cancer is often cited as a potential metric to improve the quality of oncology care. However, efforts to understand emergency department (ED) utilization among patients with cancer receiving IV chemotherapy are lacking. We sought to describe sociodemographic and clinical factors associated with ED utilization and explore predictors of ED arrival time. Methods: We conducted a quality improvement assessment of patients who visited the ED within 30-days of receiving IV chemotherapy at Massachusetts General Hospital from October 2017 to January 2018. We used descriptive statistics to describe the sociodemographic and clinical factors associated with ED visits. We used multivariable regression models to explore predictors of the following outcomes: (1) ED visit occurring during normal clinic hours; and (2) ED visit occurring during the weekend. Results: Of the approximately 2,600 patients receiving IV chemotherapy during the assessment period, we identified 500 ED visits (~19.2%). For these ED visits, median patient age was 65 years (range: 22-93), and 49.6% were female. The majority were white race (84.8%), married (63.6%), diagnosed with metastatic disease (70.4%), and 8+ days since receiving most recent chemotherapy (71.4%). The most common cancer types were gastrointestinal (24.2%), lung (13.2%), and lymphomas (11.0%). The most common reason for ED visits included pain (20.4%), fever/cold symptoms (18.0%), and fatigue (11.0%). Over half (50.4%) of ED visits occurred during normal clinic hours and over one-fourth (28.2%) occurred during the weekend. We found that ED visits were less likely to occur during normal clinic hours for patients with lymphomas (OR = 0.44, P = 0.013) compared with other cancer types. ED visits were less likely to occur during the weekend for patients of older age (OR = 0.98, P = 0.020). Conclusions: We identified a substantial number of ED visits among patients with cancer within 30-days of receiving IV chemotherapy, often occurring during normal clinic hours and most commonly for pain, fever/cold symptoms, and fatigue. These findings highlight issues to address when seeking to reduce ED utilization and enhance cancer care quality.