BACKGROUND:Peripheral edema is a common but under-researched complication in advanced cancer, significantly impacting patients' quality of life. It can result from various causes beyond lymphatic dysfunction, necessitating a mechanism-based management approach. AIM:This study aims to address knowledge gaps by characterizing the causes, treatments, and outcomes of peripheral edema in patients with advanced cancer. DESIGN:A predefined protocol was registered on the Open Science Framework, using a five-step scoping review methodology. Eligible studies included adult patients with peripheral edema related to advanced cancer, its treatments, or comorbidities. Searches were conducted in MEDLINE, Embase, and the Cochrane Library from 2010 to June 30, 2023. Two independent reviewers screened titles, abstracts, and full texts; extracted data, and assessed the quality of observational studies using the Effective Public Health Practice Project's tool. RESULTS:Of 426 publications, 31 studies met inclusion criteria: 10 observational studies (2,128 patients), 5 case series (79 patients), and 16 case reports (16 patients). Most studies involved patients with limited prognoses. The 10 observational studies had moderate (6/10) or weak (4/10) quality ratings. Among these studies, the reported causes included overhydration, malignant inferior vena cava obstruction, and multiple risk factors. Seven observational studies addressed treatments, often using mechanism-guided (and sometimes multimodal) strategies, encompassing stenting, parenteral fluid and medication management including diuretics, and decongestive physical therapy interventions. CONCLUSIONS:Peripheral edema in patients with advanced cancer arises from diverse and often overlapping mechanisms, and the available limited evidence from this scoping review suggests that mechanism-based interventions can yield meaningful short-term improvements in symptom burden. Targeted management, such as hydration or medication management, decongestive therapy, or inferior vena cava stenting, produced measurable benefits. These findings underscore the need for standardized assessment and more prospective studies to strengthen the evidence base for individualized, mechanism-driven care for peripheral edema in the advanced cancer population.

BACKGROUND:Hypovitaminosis D is associated with adverse health outcomes, including increased mortality in patients with cancer. Although vitamin D insufficiency (23%-72%) and deficiency (20%-71%) are common among patients admitted to inpatient rehabilitation, their prevalence and predictors in cancer-specific inpatient rehabilitation populations remain uncharacterized. OBJECTIVE:To determine the prevalence of hypovitaminosis D in adults with cancer admitted to acute inpatient rehabilitation and to identify demographic, clinical, laboratory, and functional predictors. DESIGN:Retrospective observational cohort study. SETTING:An inpatient rehabilitation service within a tertiary cancer hospital. PATIENTS:Consecutive adults with a cancer diagnosis admitted for acute inpatient rehabilitation between December 1, 2023, and May 24, 2024. INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURE(S):The primary outcome was the prevalence of hypovitaminosis D (25-hydroxyvitamin D ≤ 29 ng/mL). Secondary outcomes included predictors of hypovitaminosis D and evaluation of the timing and frequency of vitamin D supplementation upon index hospital admission, upon admission to inpatient rehabilitation, and at 3 and 6 months post discharge. RESULTS:Of 126 patients, 78 (62%) had hypovitaminosis D. Significant predictors included relatively younger age (median 66.0 vs 71.5 years; effect size, 5.5 with 95% confidence interval [CI], 1.60-9.40, p = .006) and presence of neurogenic bladder or bowel (16.7% vs 2.4%; odds ratio, 0.12 with 95% CI, 0.003-0.924, p = .019). At hospital admission, 29% (n = 36) were receiving supplementation, and 40% (n = 51) initiated supplementation during inpatient rehabilitation. At 3 and 6 months post discharge, 48% (n = 61) and 39% (n = 49), respectively, had records of continued supplementation. Vitamin D supplementation was generally well tolerated during inpatient rehabilitation, with only minor side effects that were managed in three patients. CONCLUSIONS:Hypovitaminosis D was highly prevalent among adult patients with cancer undergoing inpatient rehabilitation. Identified predictors, including relatively younger age and neurogenic bladder or bowel, may help guide targeted screening.

The Anorexia-Cachexia Syndrome (ACS) is characterized by loss of appetite and unintentional weight loss.[1] Important clinical outcomes are associated with ACS including increased risk of chemotherapy side effects, decreased survival and quality of life (QOL). Because ACS is driven by complex metabolic derangements and a chronic pro-inflammatory response, weight loss cannot be easily reversed by conventional nutritional supplementation alone. Insufficient intake of calories and protein exacerbate weight loss experienced by patients with ACS, while physical inactivity accelerates muscle wasting. In addition, uncontrolled symptoms such as pain, xerostomia, nausea, early satiety, and depression aggravate poor nutritional intake and are known as nutrition impact symptoms (NIS). [2] Addressing these potentially reversible contributors to ACS requires an interdisciplinary team (IDT) effort including oncologists, palliative medicine and rehabilitation clinicians, dietitians, and psychologists. The composition and leadership of the team depend on institutional support and the patient population being treated, advanced cancer versus peri-operative rehabilitation. Because frail patients may be burdened by frequent visits to multiple healthcare providers and a special skill set is required of the IDT to address ACS.[3] Specialized nutritional rehabilitation clinics are ideally needed to address ACS. The role of the oncologist is to direct cancer treatment and minimize systemic toxicities. The dietitian provides malnutrition screening, measuring calories and protein intake, and offers nutritional counseling. A rehabilitation physician assesses body composition and functional status as well as encourages compliance with exercise. The palliative care provider optimizes symptom management and coordinates care. A psychologist assesses for mood disorders, body image distress, and provides psycho-social support. As more effective anti-cachexia agents are being developed, the IDT could effortlessly incorporate novel interventions [4] into multimodal management. The proposed talk will highlight the management of NIS and the role of an IDT in treating anorexia-cachexia syndrome.

OBJECTIVES:No studies examining clinical outcomes for patients transferred to an acute palliative care unit (APCU) from an intensive care unit (ICU) versus a non-ICU exist. The objectives were to determine the proportions and outcomes of patients being discharged alive from an APCU after being transferred from an ICU versus a non-ICU. METHODS:All patients transferred to our APCU from an ICU from 1 September 2021 to 31 August 2023 and an equally sized random sample of patients transferred from a non-ICU during the same period were identified. Demographics, clinical characteristics and outcomes were compared between the two groups. RESULTS:400 patients (214 ICU and 186 non-ICU) were included (mean age, 62 years (SD, 14.3); 51.3% women; 63.8% in a relationship; 67.8% white). Non-ICU patients were more likely to be discharged alive than were ICU patients (32.8% (95% CI 26.5 to 39.8%) vs 22.4% (95% CI 17.4 to 28.5%); p=0.02). Of the 109 patients discharged from our APCU, most went either to hospice care at home (54.1%, n=59) or to inpatient hospice care (40.4%, n=44), and there was no difference in discharge location between the ICU and the non-ICU groups (p=0.93). On multivariable analysis, APCU mortality was more likely in the group overall among patients who were receiving oxygen via a high-flow nasal cannula (HFNC) (OR, 2.47 (1.25 to 4.90); p=0.01). CONCLUSIONS:Despite the APCU mortality in this cohort being high, 22.4% of patients transferring from the ICU were successfully discharged to the community. HFNC use at the time of APCU transfer was independently associated with increased odds of APCU mortality.

Purpose:We investigated the associations between smoking, pain expression, opioid use, substance use behaviors, coping strategies, and risk of chemical coping in Korean patients with advanced cancer. Materials and Methods:In this prospective study, 240 patients were enrolled. Demographic and clinical information were obtained from medical records. Smoking status, symptom burden by the Edmonton Symptom Assessment System (ESAS), the Cut down/Annoyed/Guilty/Eye-opener (CAGE) alcoholism questionnaire results, morphine equivalent daily dose (MEDD), tranquilizers and coffee use, coping strategies, and physician-assessed risk of chemical coping and somatization were assessed using questionnaires and interviews. Results:Of the 240 patients, 49 (20.4%) were current smokers, 104 (43.3%) were former smokers, and 87 (36.3%) were never-smokers. 161 were male (67.1%); 89.4% (144/161) of these men were current or former smokers, while 88.6% (70/79) of women were never-smokers (p<0.001). ESAS pain scores did not differ by smoking status (3.0 vs. 2.9 vs. 2.7, p=0.480), but current smokers had higher MEDD (63.5 mg/day vs. 25.1 mg/day vs. 22.3 mg/day, p=0.015). Current smokers were more often CAGE-positive (32.7% vs. 16.3% vs. 2.3%, p<0.001), heavy coffee drinkers (24.5% vs. 12.5% vs. 0%, p<0.001) and showed a greater physician-assessed risk of chemical coping (26.5% vs. 8.7% vs. 13.8%, p=0.015). Conclusion:Among Korean patients with advanced cancer, current smokers were more likely to use higher doses of opioids, have positive CAGE results, and drink more coffee. Close monitoring and appropriate management for the possibility of chemical coping or non-medical opioid use will be important in these patients.

BACKGROUND:Patients with cancer often experience weight loss, which contributes to a decreased quality of life and signals a poor prognosis. The objective of this retrospective study is to investigate whether the self-reported race/ethnicity of patients undergoing palliative care is associated with weight loss. METHODS:The charts of 1,253 patients with advanced lung cancer who had a Palliative Medicine consultation, during 2022, were identified and random sample of 94 Asian, 94 Black, 87 Hispanic and 91 non-Hispanic-White patients were selected for evaluation. Patient demographics, the Eastern Cooperative Oncology Group (ECOG) performance status, body mass index (BMI), weight history, symptom burden measured by the Edmonton Symptom Assessment System (ESAS), cancer treatments provided (chemotherapy, radiation, surgery, or immunotherapy), prescription of appetite stimulants [megestrol acetate, steroids, olanzapine, cannabinoids, metoclopramide, or mirtazapine), and nutritional laboratory markers (albumin, protein level, neutrophile-to-lymphocyte ratio (NLR)] were collected. Univariate and multivariable regression linear analysis were performed to explore whether a patient's self-identified race/ethnicity was an independent predictor of weight loss. RESULTS:Among the different self-identified racial/ethnic groups of patients, no significant differences in age, gender, appetite stimulants received, and NLR were noted. The Asian and Hispanic cohort had significantly lower weight and BMI at first encounter, Palliative Medicine consultation, and final recorded visit compared to all other groups (P<0.01). The median time from the first encounter to the last recorded weight was 6.7 months for the whole cohort. Asian patients had significantly less total weight loss (8.2 kg) compared to Black (13.4 kg), Hispanic (9.1 kg), and non-Hispanic White (10.2 kg) patients (P=0.04); but all four groups experienced similar proportion of weight loss (%) (12.8 vs. 14.9 vs. 12.2 vs. 12.9; P=0.79), respectively. Asian patients had a higher median household income (P<0.001), less likely to live alone (P=0.02), and more likely to be married or have a significant other (P<0.001). In a multivariate analysis, the weight at first encounter but not race/ethnicity was the only independent predictor of percentage weight loss. CONCLUSIONS:In patients with advanced lung cancer, BMI and total weight loss but not percentage change in weight was significantly associated with self-identified race/ethnicity at the time of Palliative Medicine consultation. On multivariate analysis, the percentage loss in weight was significantly influenced by the weight at first encounter but not race/ethnicity. Racial/ethnic variations in BMI but not percentage weight loss should be accounted for when diagnosing cancer cachexia and more research is needed.

BACKGROUND Acute palliative care units (APCUs) provide evidence-based end-of-life care [1]. No studies exist looking at outcomes among patients transferred from an intensive care unit (ICU) versus non-ICU to an APCU. OBJECTIVES To determine the proportion of adult patients discharged alive from our APCU after transfer from an ICU compared to a non-ICU and identification of predictors of being discharged alive. METHODS All patients with cancer transferred from an ICU to our APCU during a two-year period and an equal random sample of patients transferred from a non-ICU were reviewed for eligibility. Patients were excluded if they had a COVID-19 infection or received ICU care (in the non-ICU cohort) during their admission. RESULTS 400 patients were included in the analysis (214 ICU, 186 non-ICU), with mean age of 62 years (SD 14.3). Most were female (51%), married (62%), white (68%) and non-Hispanic (82%). The alive discharge rate of the ICU cohort was 23% [17.8-29.0%] and 33% [26.5-39.8%] from the non-ICU cohort (p=0.033). On univariable analysis, likelihood of inpatient mortality was increased in the ICU cohort among patients who ever received cancer-directed treatment (OR 1.9 (95% CI 1.2-2.9), p=0.03) or were single (3.2 (1.5-6.7), p< 0.01) and in both cohorts combined in patients receiving high-flow oxygen (HFNC) (2.5 (1.5-4.1), p< 0.001), those with hematological malignancies (2.8, (1.4-5.6), p< 0.01) and those who had not received surgical cancer treatment (1.7 (1.1-2.6, p=0.03). On multivariable analysis, only HFNC use remained significant among cohorts combined (2.5 (1.5-4.3), p=0.001). CONCLUSION While the overall rate of being discharged alive was low, especially for patients on HFNC, our team was able to discharge 23% of patients transferred to our APCU from an ICU in a two-year period. This will provide critical discharge planning information for caregivers and quality metrics for APCU in tertiary cancer centers.

The anorexia-cachexia syndrome (ACS) is characterized by loss of appetite and unintentional weight loss. Important clinical outcomes are associated with ACS including increased risk of chemotherapy side effects, decreased survival, and quality of life. Because ACS is driven by complex metabolic mechanisms and a chronic pro-inflammatory response, the weight loss and muscle wasting cannot be reversed by conventional nutritional supplementation alone. However, insufficient intake of calories and protein exacerbate weight loss experienced by patients with ACS, while physical inactivity accelerate muscle wasting. In addition, uncontrolled symptoms, such as pain, mucositis, nausea, early satiety, and depression aggravate poor nutritional intake and are known as nutrition impact symptoms. Addressing these potentially reversible contributors to ACS requires an interdisciplinary team (IDT) effort including oncologists, palliative medicine, rehabilitation clinicians, dietitians, and psychologists. The composition and leadership of the team depends on institutional support and the patient population being treated (eg, advanced cancer vs peri-operative rehabilitation vs geriatric). Because patients may be burdened by frequent visits to multiple healthcare providers and a special skill set is required of the IDT to address ACS-measuring caloric and protein intake, assessing body composition, optimal symptom management, and providing psycho-social support-a specialized clinic would be ideal. As more effective anti-cachexia agents are being developed, nutritional rehabilitation programs and cachexia clinics could facilitate incorporation of novel treatments into multimodal management of ACS. The narrative review highlights the management of nutrition impact symptoms and the potential benefits and challenges of specialized nutrition rehabilitation programs and cachexia clinics.

Neuroleptic and benzodiazepine medications are often considered for patients with persistent agitated delirium in the last days of life; however, the risk-to-benefit ratio of these medications is ill-defined and benzodiazepine medications have not been compared to placebo. To compare the effect of scheduled haloperidol, lorazepam, haloperidol plus lorazepam, and placebo on patients with advanced cancer and delirium and experiencing restlessness and/or agitation in the palliative care setting. This multicenter randomized clinical trial was conducted at 3 acute palliative care units in Taiwan and the US with patients with advanced cancer experiencing persistent restlessness and/or agitation despite nonpharmacologic therapies and standard-dose haloperidol. Among 245 eligible patients, 111 were enrolled, and 75 received blinded treatments. Participants were randomized in a 1:1:1:1 ratio (stratified by site and Richmond Agitation-Sedation Scale [RASS] score). The study period was from July 16, 2019, to June 8, 2023, with a 30-day follow-up after medication administration. Data analysis was performed from October 10, 2023, to April 11, 2025. Scheduled intravenous haloperidol, lorazepam, haloperidol plus lorazepam, or placebo every 4 hours until discharge, death, or withdrawal from study. Medications in all 4 groups had identical volume and appearance. Change in RASS scores during the first 24 hours. Secondary outcomes included the use of rescue neuroleptics or benzodiazepines for breakthrough restlessness or agitation during the first 24 hours, delirium severity, perceived patient comfort, and adverse events. The primary outcome was assessed in 72 patients (mean [SD] age, 64 [12] years, 42 male [58%]) with a median (IQR) MDAS score of 24 (18-29). The lorazepam group had significantly lower RASS scores than the haloperidol group (mean difference, −2.1; 95% CI, −3.4 to −0.9; P < .001) and the combination group had significantly lower RASS scores than the haloperidol group (−2.0; 95% CI, −3.2 to −0.8; P = .002); however, there was no difference observed between haloperidol and placebo groups (−0.5; 95% CI, −1.7 to 0.7; P = .42) nor between the combination and lorazepam groups (0.2; 95% CI, −1.1 to 1.4; P = .79). The combination and lorazepam groups required fewer rescue medications for breakthrough restlessness or agitation compared to the haloperidol and placebo groups (32%, 37%, 56%, 83%, respectively; P = .006). Adverse events or survival did not differ between groups. The results of this randomized clinical trial indicate that proactive use of scheduled sedatives, particularly lorazepam-based regimens, may reduce persistent restlessness and/or agitation in patients with advanced cancer and delirium in the palliative care setting. Clinicaltrials.gov Identifier: NCT03743649

Importance:Neuroleptic and benzodiazepine medications are often considered for patients with persistent agitated delirium in the last days of life; however, the risk-to-benefit ratio of these medications is ill-defined and benzodiazepine medications have not been compared to placebo. Objective:To compare the effect of scheduled haloperidol, lorazepam, haloperidol plus lorazepam, and placebo on patients with advanced cancer and delirium and experiencing restlessness and/or agitation in the palliative care setting. Design, Settings, and Participants:This multicenter randomized clinical trial was conducted at 3 acute palliative care units in Taiwan and the US with patients with advanced cancer experiencing persistent restlessness and/or agitation despite nonpharmacologic therapies and standard-dose haloperidol. Among 245 eligible patients, 111 were enrolled, and 75 received blinded treatments. Participants were randomized in a 1:1:1:1 ratio (stratified by site and Richmond Agitation-Sedation Scale [RASS] score). The study period was from July 16, 2019, to June 8, 2023, with a 30-day follow-up after medication administration. Data analysis was performed from October 10, 2023, to April 11, 2025. Interventions:Scheduled intravenous haloperidol, lorazepam, haloperidol plus lorazepam, or placebo every 4 hours until discharge, death, or withdrawal from study. Medications in all 4 groups had identical volume and appearance. Main Outcomes and Measures:Change in RASS scores during the first 24 hours. Secondary outcomes included the use of rescue neuroleptics or benzodiazepines for breakthrough restlessness or agitation during the first 24 hours, delirium severity, perceived patient comfort, and adverse events. Results:The primary outcome was assessed in 72 patients (mean [SD] age, 64 [12] years, 42 male [58%]) with a median (IQR) MDAS score of 24 (18-29). The lorazepam group had significantly lower RASS scores than the haloperidol group (mean difference, -2.1; 95% CI, -3.4 to -0.9; P < .001) and the combination group had significantly lower RASS scores than the haloperidol group (-2.0; 95% CI, -3.2 to -0.8; P = .002); however, there was no difference observed between haloperidol and placebo groups (-0.5; 95% CI, -1.7 to 0.7; P = .42) nor between the combination and lorazepam groups (0.2; 95% CI, -1.1 to 1.4; P = .79). The combination and lorazepam groups required fewer rescue medications for breakthrough restlessness or agitation compared to the haloperidol and placebo groups (32%, 37%, 56%, 83%, respectively; P = .006). Adverse events or survival did not differ between groups. Conclusions and Relevance:The results of this randomized clinical trial indicate that proactive use of scheduled sedatives, particularly lorazepam-based regimens, may reduce persistent restlessness and/or agitation in patients with advanced cancer and delirium in the palliative care setting. Trial Registration:Clinicaltrials.gov Identifier: NCT03743649.

ABSTRACT Background Patients with advanced cancer are at risk for malnutrition and anorexia‐cachexia syndrome. The study objective was to determine the frequency of these conditions in patients evaluated in an outpatient supportive care clinic (SCC). Methods One hundred patients with cancer were prospectively enrolled to complete a cross‐sectional one‐time survey. We collected patient demographics, cancer diagnosis, weight history and height and Zubrod performance status from electronic health records. Patients completed the Functional Assessment of Anorexia Therapy–Anorexia/Cachexia Subscale (FAACT‐A/CS) questionnaire, the Edmonton Symptom Assessment Scale (ESAS), the Patient‐Generated Subjective Global Assessment–Short Form (PG‐SGA‐SF), the Hospital Anxiety and Depression Scale (HADS) and a Body Image Scale (BIS). A PG‐SGA‐SF cut‐off of ≥ 6 indicated malnutrition risk, and loss of appetite was defined as either ESAS ≥ 3 or FAACT‐ACS ≤ 37. Results Of the 165 patients approached, 100 (61%) completed the survey. The average (SD) age was 61.6 years old (11.5). The majority were female (52%), White (75%) and married (80%). The most common cancers were gastrointestinal (22%) and genitourinary (21%). Sixty‐one per cent (61%) screened positive for risk of malnutrition (PG‐SGA‐SF ≥ 6), anorexia was noted in 60% (ESAS ≥ 3) and 53% (FAACT‐A/CS ≤ 37) of patients, 10% of patients were noted to have a body mass index < 18.5, and 28% had body image dissatisfaction (BIS ≥ 10). Documented > 5% weight loss over the past 6 months was noted in 49%; 61% noted > 10% lifetime weight loss, relative to usual adult body weight or at time of diagnosis. Patients with anorexia (FAACT‐ACS ≤ 37) compared with no anorexia reported significantly higher HADS anxiety score (4.4 vs. 3.2, p = 0.04), depression (5.9 vs. 3.5, p = 0.001), body image distress (BIS 7.2 vs. 4.9, p = 0.03) and worse appetite (ESAS 1.4 vs. 0.6, p = 0.02). Symptoms including depression, anxiety and body image distress were not significantly different between patients with either a history of > 10% lifetime weight loss or > 5% weight loss over 6 months. Conclusions Malnutrition risk was noted in roughly 60% of patients with advanced cancer. Inclusion of patients' body mass index to malnutrition or cachexia criteria resulted in underdiagnosis. Subjective symptoms of anorexia, but not objective weight loss, was significantly associated with anxiety and depression. Routine malnutrition screening with the PG‐SGA‐SF should be incorporated into all outpatient SCC visits and, comparing current weight to documented pre‐illness baseline weight, should be obtained to determine the severity of cachexia.

Context Naloxone nasal spray is recommended for patients with risk factors for opioid overdose. However, cancer patients' perceptions and beliefs regarding naloxone prescriptions and their self-perceived risks for overdose are understudied. Objective To determine the proportion of cancer patients at risk for overdose who perceived naloxone as beneficial. Methods Between July 2020 and April 2022, we surveyed 150 adult patients from the supportive care ambulatory clinic at a tertiary cancer center in the United States who received a co-prescription of naloxone nasal spray. We measured patients' knowledge of overdose risk-factors, attitudes, beliefs, and education received on naloxone. Risk-factors between beneficial vs. non-beneficial groups were analyzed. The survey was administered on paper or via a telephone interview. Results Of the 150 patients, 55% were male, 70% were white, and 81% had advanced cancer. The majority of patients believed naloxone was beneficial (100/150, 67%). When compared to the non-beneficial group, more patients from the beneficial group agreed that the concurrent use of alcohol (100% vs. 90%;p=0.004) or sedating drugs (96% vs.85%;p=0.04) with opioids could result in overdoses and felt safe having naloxone at home (95% vs. 60%;p<0.0001). More patients from the non-beneficial group associated naloxone prescription with being suspected of misusing opioids (12/50 vs. 8/100;p=0.01), and fewer had confidence in their caregivers' ability to administer naloxone (69% vs. 95%;p<0.0001). Conclusion Most patients understood the benefits of naloxone and felt safe having one at home. More research is needed to identify knowledge gaps and develop educational strategies for those who find it non-beneficial.

A self-reported electronic questionnaire to advocate for a consensus definition of nutrition impact symptoms (NISs) was conducted in a diverse group of international healthcare providers. The questionnaire had 2 components: the definition of NISs and the relevance of each symptom as a NIS. Agreement on the tentative definition and 24 symptoms were evaluated using a seven-point Likert scale. For the factor validity and internal consistency of symptoms, an exploratory factor analysis was employed, and Cronbach's alpha coefficients (Cronbach's alpha) were calculated in each domain. A total of 66 healthcare providers responded. Regarding the tentative definition of NISs, the percentages of the number of participants with agree and strongly agree were 40.9% and 42.4%. Three conceptual groups were extracted as follows: 1) symptoms that interfere with patients' ability to ingest or digest nutrients, 2) symptoms that compromise patients' desire to eat and take nutrients, and 3) symptoms that indirectly compromise patients' food and nutrient intake. The values of Cronbach's alpha were 0.91, 0.92, and 0.87. We proposed a new definition - NISs are symptoms that compromise patients' desire or ability to eat, interfering with their nutritional needs and increasing the risk for malnutrition, loss of lean body mass, and impaired QOL.

BACKGROUND:Few studies examine how patients with advanced cancer cope with stress. The objective of our study was to evaluate coping strategies adopted by patients with cancer and their relationship with symptom burden. METHODS:A secondary data analysis of a prospective cross-sectional survey of patients with cancer and tobacco use was conducted, which examined demographics, symptom burden (Edmonton Symptom Assessment System), and coping strategies (the Brief COPE Questionnaire). Demographic characteristics were summarized by standard summary statistics; we also examined associations between patient characteristics and coping strategies using t-test, rank-sum test, chi-squared test, or Fisher's exact test depending on the distribution of data. RESULTS:Among 399 patients, the majority were female (60%), Caucasian (70%), the mean age was 56.5 (±12.0) years, and the most common malignancies were gastrointestinal (21%) and breast (19%). Patients with cancer adopted multiple adaptive coping strategies, most frequently acceptance (86.7%) and emotional support (79.9%), with humor (18.5%) being the least. Common maladaptive strategies included venting (14.5%) and self-distraction (36.6%), while substance use (1.0%) was infrequently reported. Of the adaptive strategies, female gender was significantly associated with higher engagement with emotional and instrumental support, positive reframing, religious coping, and acceptance (P < .05 for all). College educated patients reported significantly higher implementation of humor, planning, and acceptance. Maladaptive coping strategies such as denial were associated with increased pain and depression, while patients adopting emotional-focused strategies rated decreased emotional distress. CONCLUSIONS:The majority of patients with advanced cancer reported adopting multiple, adaptive coping strategies, and a minority utilized maladaptive or avoidant strategies, rarely substance use, and may need additional psychological support.

The following review will highlight the development of anamorelin to treat cancer anorexia-cachexia syndrome (CACS) including the potential benefits, limitations, and future directions. Ghrelin, a 28-amino acid peptide hormone, is secreted by the stomach mucosa and regulates appetite, promotes lipogenesis, increases body weight, improves gastric motility, reduces catabolic wasting and inflammation. Several randomized, double-blind, placebo-controlled clinical trials evaluating anamorelin, a ghrelin agonist, for the treatment of CACS have reported improvement in appetite and body composition including both lean body and fat mass; however, most studies noted no improvement in physical function as assessed by measuring non-dominant hand-grip strength. Common adverse effects of anamorelin include the development of diabetes mellitus, hyperglycemia, and less frequently, hepatic abnormalities and cardiovascular events including conduction abnormalities, hypertension, and ischemic cardiomyopathy. Anamorelin has the potential to stimulate appetite, improve gastric movement, and may have anti-inflammatory effects on patients with CACS. In patients with cancer, studies involving anamorelin combined with other multimodal treatments including nutrition counseling (branched chain amino acids, omega 3 fatty acids, and other nutrients), exercise, treatment of hormonal abnormalities including hypogonadism and hypovitaminosis D, and anti-inflammatory agents are needed. Compliance with multimodality treatment has been a barrier and future studies may need to incorporate motivational counseling to promote adherence.

Clinicians are often uncertain about their prognostic estimates, which may impede prognostic communication and clinical decision-making. We assessed the impact of a web-based prognostic calculator on physicians’ prognostic confidence. In this prospective study, palliative care physicians estimated the prognosis of patients with advanced cancer in an outpatient clinic using the temporal, surprise, and probabilistic approaches for 6 m, 3 m, 2 m, 1 m, 2 w, 1 w, and 3 d. They then reviewed information from www.predictsurvival.com , which calculated survival estimates from seven validated prognostic scores, including the Palliative Prognostic Score, Palliative Prognostic Index, and Palliative Performance Status, and again provided their prognostic estimates after calculator use. The primary outcome was prognostic confidence in temporal CPS (0–10 numeric rating scale, 0 = not confident, 10 = most confident). Twenty palliative care physicians estimated prognoses for 217 patients. The mean (standard deviation) prognostic confidence significantly increased from 5.59 (1.68) before to 6.94 (1.39) after calculator use (p < 0.001). A significantly greater proportion of physicians reported feeling confident enough in their prognosis to share it with patients (44

257 Background: Patients with cancer are at risk for malnutrition and the development of anorexia-cachexia syndrome, which is often under-treated. The objective of our study was to determine the frequency of these conditions in advanced cancer patients who were evaluated in an outpatient Supportive Care Clinic (SCC). Methods: Advanced cancer patients seen in SCC were prospectively enrolled to complete a cross-sectional one-time survey. We collected patient demographics, weight history and height, cancer history, the Functional Assessment of Anorexia Therapy – Anorexia/Cachexia Subscale (FAACT-A/CS) questionnaire, Edmonton Symptom Assessment Scale (ESAS), the Patient Generated Subjective Global Assessment – short form (PG-SGA SF), and a Body Image Scale (BIS) questionnaire. Malnutrition was indicated by a PG-SGA cut-off of ≥ 5, and loss of appetite, anorexia, was defined as either ESAS ≥ 3 or FAACT-ACS ≤ 37. Results: Of 165 cancer patients that were approached, 100 (61%) completed the prospective survey. The average (SD) age was 61.6 years old (11.5). The majority of patients were female gender (52%), Caucasian (75%), were married (80%), and the most common cancers were gastrointestinal (22%) and genitourinary (21%). At the time of the survey, 14% of patients were noted to have a BMI < 20, 60% of patients reported anorexia (ESAS ≥ 3), 53% patients screened positive for the FAACT-A/CS (≤ 37), 69% were malnourished (PGSGA ≥ 5), and 55% had body image dissatisfaction (BIS ≥ 4). Documented weight loss of >10% in the medical records was recorded in 59% of patients with an average (SD) of -12.8% (15.3). Patient self-reported weight loss of > 5% over 6 months and > 10% over a lifetime was noted in 56% and 62% of the patients, respectively. Conclusions: Advanced cancer patients seen in an outpatient SCC are at high risk of malnutrition and roughly 60% experience complications of anorexia-cachexia syndrome. Routine screening for malnutrition and weight loss should be incorporated into all Supportive Care encounters, and nutritional counseling and support should be offered to the majority of cancer patients.

BACKGROUND:Cancer patients often experience symptoms such as anorexia, anxiety and insomnia, which can impact their quality of life. Randomized placebo-controlled trials support prophylactic use of olanzapine for the prevention of nausea and vomiting due to moderate and high-emetic risk chemotherapy. In the setting of palliative care, olanzapine is increasingly utilized as an off-label treatment of symptoms including anorexia-cachexia, anxiety, and insomnia. The following case reports will highlight the potential benefits and risks of off-label olanzapine use for symptom management in cancer patients.CASE DESCRIPTION:Patient 1 is a female in her 70s with stage IV infiltrating ductal carcinoma of the right breast was having trouble tolerating treatment with letrozole, palbociclib, and denosumab due to uncontrolled nausea resulting in weight loss. Her nausea was refractory to multiple anti-emetics. Low dose olanzapine (2.5 mg) prevented nausea and allowed her to tolerate treatment. Patient 2 is a male in his 50s with renal cell carcinoma, who was receiving treatment with cabozantinib, presented with uncontrolled pain improved with opioid rotation from oxycodone to morphine. He was also experiencing uncontrolled anxiety despite treatment with alprazolam. Alprazolam was weaned and replaced with olanzapine resulting in improvement of his symptoms. Patient 3 is a male in his 60s with pancreatic adenocarcinoma who presented with muscle weakness and fatigue resulting in discontinuation of gemcitabine plus cisplatin. He also had symptoms of depression, poor appetite, and sleep problems. He was prescribed short course of dexamethasone 4 mg by mouth twice daily and olanzapine 5 mg by mouth nightly to improve symptoms. One week after, he presented with confusion and workup revealed hyperammonia which was treated with lactulose, which led to the return of baseline mentation.CONCLUSIONS:Olanzapine antagonizes multiple receptors and has potential to treat a host of symptoms including nausea, anorexia, anxiety, and insomnia, but healthcare providers should be mindful of potential risks and unclear benefits for off-label indications. More research and funding are needed evaluating off-label use of olanzapine for palliation of symptoms in cancer patients who are often frail and susceptible to adverse events.

294 Background: Immunotherapy (IO)-related fatigue is a common yet underrecognized adverse event (AE). The objective of this study was to determine the frequency of IO-related fatigue and non-IO-related fatigue, contributing factors, and the association between fatigue and treatment outcome in patients with advanced tumors, who received different types of IO-based treatments. Methods: We performed a retrospective chart review of patients treated on IO-based early phase clinical trials between September 2016 and May 2021. We collected data on baseline patient characteristics, AEs, fatigue at baseline and on-treatment, response to treatment, progression free survival (PFS), and overall survival (OS). AEs attribution to treatment were determined by the investigator. We determined IO-related based on the timing of the highest-grade fatigue with respect to treatment start date. Cox proportional hazards were used to assess association between fatigue and survival endpoints. Results: A total of 511 patients with 45 different cancer types were included in this analysis. The most common tumor types were colon (n=50), pancreatic, ovarian, sarcoma (n=35 each), cervical (n=29), and melanoma (n=26). The median age was 62 years, and 98% of patients were ECOG 1. Of the 136 patients (26.6 %) who reported fatigue, 21 (4.1%) had baseline fatigue and 115 (22.5%) developed fatigue after treatment initiation. A total of 69 (13.5%) patients had IO-related and 67 (13.1%) had non-IO related fatigue. The majority of the patients (87.8%) were treated on immune checkpoint-inhibitor-based regimens. Among 69 patients with IO-related fatigue, 58% of the patients reported fatigue only after treatment initiation and 29% had worsening grades of fatigue. In univariate analysis, patients with IO-related fatigue had a higher frequency of baseline depression than those with non-IO-related (14.5% vs. 3%, p=0.0391). Among the 81 patients with fatigue who were evaluated for response by irRECIST, objective response rate was 11.1% (5/45) in patients with IO-related versus 8.3% (3/36) in those with non-IO related fatigue. The median PFS was 4.08 mo in patients with IO related versus 3.68 in non-IO-related fatigue (p=0.27). The median OS was 15 mo in patients with IO related vs 10.6 mo (p=0.8) in non-IO related fatigue. The median OS for all the patients on the study was 14.7 mo in patients with IO-related vs 9.4 mo in non-IO related fatigue (p=0.32). Conclusions: In half of the patients reporting fatigue on IO-based clinical trials, fatigue was related to treatment. Patients with IO-related fatigue had higher response rates, improved PFS and OS, although not significant. Ongoing analysis with patient-reported outcome may provide more insight into prevalence of fatigue in this patient population. Further understanding of underlying biology may help to develop treatment strategies.