Lesperance, Mary

Abstract Background: Several randomized trials had shown the benefits of palliative care interventions in patients with metastatic cancer. However, there is a paucity of data evaluating the benefit of palliative care in racially diverse patient populations, and no systematic analysis of the effect of race/ethnicity on these interventions have been done. Recently, our group completed a randomized clinical trial showing that an Advanced Registered Nurse Practitioner (ARNP)-directed palliative care intervention for patients with metastatic cancer leads to improvement in the patients' emotional quality of life (EQoL) as determined by a validated quality of life tool, the FACT-G (PAL-1 study, Dyar et al: J Palliative Medicine 15: 890, 2012). The PAL-2 pilot study reported herein evaluated the feasibility of this program in underserved racially diverse patient populations. PAL-2 incorporated PAL-1 interventions of advanced directives discussions, hospice services education and assessment of QoL using the FACT-G tool. In addition, the PAL-2 program incorporated home visits and implementation of FACT-G driven palliative interventions. Aims: The primary endpoint was to assess the feasibility of an ARNP-directed palliative care intervention trial for racially diverse cancer patients. The ultimate goal was to use the data from this pilot study to plan for a subsequent larger randomized trial. Secondary end points included evaluation of the effects of the intervention on the patient's QoL and emotional well-being as determined by a change in FACT-G , EQoL scores, as well as measurement of knowledge about hospice as determined by changes in a hospice knowledge questionnaire (HKQ) scores. Methods: 25 adult patients with metastatic cancer were recruited. All patients completed a FACT-G and a HKQ at baseline, had an ARNP consultation, and a home visit whenever feasible, with a second ARNP consultation visit 4 weeks later. Results: Of 25 patients who participated (16 males, 9 females, mean age 57, age range 33-89, 16 Caucasians (C), 8 African Americans (AA), 1 Asian), 15 patients (8C, 7AA) completed their first and second ARNP consultation visits and 12 (5C, 7AA) completed all questionnaires and were available for secondary endpoint analysis. The main reason for failure to complete the study was disease progression. The most common interventions implemented were advanced directives discussions, assessment of family support, stress management education, assessment of psychological status, spirituality assessment, financial assistance programs, and pain and symptom management. Interventions offered but not selected by most patients included: use of computer based social networking tools, psychological interventions, occupational training and cancer support group participation. Home visits were completed in 11 patients and provided significant insight into the patients' needs and their available support. The palliative care intervention and the FACT-G tool were well accepted by patients. There was no significant change in the EQoL as a result of the intervention ( EQoL change, mean (SD)= -1.2 (13.52), median 3.7, p=0.6719). A trend was observed towards improvement in HKQ results (n=8, change from baseline score mean (SD)= 21.2 (29.58), median 15.4, p= 0.0938). Conclusions: The FACT-G tool was well received by the patients and providers, and its use can be incorporated into clinical care to direct palliative care interventions and assess their impact on patients' QoL. A nurse practitioner-directed palliative care intervention is well accepted by patients of diverse race. Significant attrition of participants due to disease progression (40%) will need to be considered in planning larger randomized trials. Randomized clinical trials evaluating the impact of race, ethnicity and socio-economic status on the benefits of different palliative care interventions in patients with metastatic cancer are feasible and needed. Citation Format: Gerardo Colon-Otero, Mary Lesperance, Fauzia Rana, Robert Shannon, Jeffrey Sloan. A nurse practitioner-directed palliative care intervention trial in racially diverse patients with metastatic cancer. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A42.

Palliative care services are not available in most outpatient oncology practices. A program training 11 mid-level providers from oncology practices on advanced directive discussions and supportive symptom assessment and management performed by palliative care specialists was completed. A follow-up session 9 months later identified barriers to implementation. Of the 11 mid-level providers, 8 participated in the follow-up session, and 9 of the 11 providers implemented advanced directive’s discussions and symptom assessment and management for patients with metastatic cancer. Main barriers included uncertainties about reimbursement, patients’ lack of knowledge about palliative care, and lack of access to supportive services. This program successfully promoted advanced directive discussions and supportive/palliative care symptom assessment and management to community oncology practices, which will hopefully translate into improved quality of life for patients with metastatic cancer.

Abstract Background: African Americans are underrepresented in cancer research trials. We propose that a collaborative effort with African American churches that brings cancer education events and a translational research project to the community with a mobile research unit will facilitate cancer awareness education and increase participation in translational research protocols among African Americans. Methods: From February 2010 through April 2010, Mayo Clinic partnered with predominantly African American Jacksonville churches, with the Volunteers in Medicine Clinic for the working uninsured, and with the local chapter of the Leukemia and Lymphoma Society, to provide 12 education programs focused on five behaviors that reduce cancer risk: proper nutrition, adequate fitness, tobacco cessation, breastfeeding, and limited alcohol consumption. Also offered during these programs was on site access to a translational cancer research pilot project evaluating the prevalence of t(14,18) and monoclonal proteins in African Americans and other racial/ethnic minorities. Translational research participation was facilitated by a mobile research unit (MRU), a converted RV that has sample collection, processing, and storage capabilities. Participants were surveyed on health knowledge and their willingness to participate in research. Results: A total of 236 of 318 participants (74%) returned written questionnaires provided during the education events. Forty-three percent resided in a health zone of Jacksonville that has worse health outcomes compared with any other sections of the city. Eighty-three percent responded that they had some type of health insurance and 88% had a primary care provider. Sixty-seven percent had never received any information on multiple myeloma, and 57% had never received information about clinical research studies. Sixty percent responded that they would participate in research studies and 61 % indicated that they would participate if the research focused on health issues that impacted African Americans. A total of 175 of 318 participants (55%) were enrolled in the translational research feasibility study. Seventy-two percent of the research study participants were female and 77% were African American, 19% Caucasians, and 4% Hispanic or of other racial/ethnic group. Ninety-three percent agreed to have their samples used for research of other health conditions and 85% agreed to have their samples shared with other research institutions. Conclusions: A high rate of participation in a blood collection translational research project was observed among this predominantly African American population. Most participants expressed a positive attitude towards research participation. Partnerships with African American churches in projects that provide community education and bring research to church venues with a mobile research unit are effective in improving health literacy related to a targeted topic, and in increasing translational research participation among African Americans. Funded by Mayo Clinic Comprehensive Cancer Center (NCI grant number P50-CA01508), Mayo Clinic CTSA (NCRR/NIH Grant Number 1 UL1 RR024150) and Active SPORE CA 90297052. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A38.