Publications

BACKGROUND: Clinicians place comfort measures only (CMO) orders for hospitalized patients at the end-of-life when a decision has been made to focus on patient comfort and allow the natural dying process to occur.

OBJECTIVES: Our primary aim was to assess the associations of specialty palliative consults (SPC) or documented goals of care conversations (GOCC) with in-hospital mortality among patients with CMO orders.

DESIGN: We completed a retrospective cross-sectional study of data from the electronic medical record.

SETTING/PARTICIPANTS: We assessed all adult patients with CMO orders admitted to four hospitals in the United States between 2022 and 2024.

MEASUREMENTS: We used descriptive statistics and multivariable logistic regression and linear regression models to identify the association of SPC and documented GOCC with patient outcomes.

RESULTS: Of 6789 hospitalized patients with CMO orders, 48% were female, and these patients had median age 71 years. Seventy-three percent died in-hospital, and 22% were discharged with hospice. SPC placed anytime during hospital admission were associated with lower in-hospital mortality (aOR 0.4, 95% CI 0.3-0.6, p < 0.0001) and higher discharge with hospice (aOR 2.4, 95% CI 1.8-3.2, p < 0.0001). In contrast, documented GOCC anytime during admission were associated with higher in-hospital mortality (aOR 1.8, 95% CI 1.3-2.4, p = 0.0004) and lower discharge with hospice (aOR 0.5, 95% CI 0.4-0.7, p = 0.0003).

CONCLUSIONS: For patients with CMO orders, SPC, rather than documented GOCC, were associated with lower in-hospital mortality and higher receipt of hospice. Future research should explore reasons why only SPC, and not documented GOCC, were associated with these findings.

OBJECTIVES: To understand the unmet needs of bladder cancer survivors in the acute recovery after cystectomy and how remote monitoring may improve their care. These results are part of user-centered design studies on a remote monitoring recovery aid.

METHODS: We invited bladder cancer survivors who underwent a radical cystectomy and their support persons from bladder cancer survivorship groups. We conducted semi-structured interviews regarding participants' experiences during recovery from cystectomy, their perspectives regarding unmet needs, and the resources they used during the perioperative period, emphasizing the 2 weeks following hospital discharge. Transcripts were coded using a deductive/inductive approach. Coded excerpts were summarized to develop themes and subthemes. Findings were refined as needed by consensus to accurately capture participants' experiences.

RESULTS: A total of 20 bladder cancer survivors and 5 primary support persons were included. Patient participants were on average 3 years from their cystectomy. Barriers to acute recovery were categorized into system- and patient-level challenges, including difficulty connecting with knowledgeable providers and with information, as well as mental/emotional and physical hurdles. Three key facilitators to patients' acute recovery following cystectomy included identifying indicators of physical progress, facilitating access to provider recommendations, and implementing the survivor perspective into recovery support.

CONCLUSIONS: This study classified barriers and facilitators to cystectomy recovery. The majority of participants expressed interest in remote monitoring programs. Opportunities exist for stakeholders to improve the acute recovery experience for cystectomy patients through mobile interventions delivered via smartphones and wearable devices.

PURPOSE: Navigation is an evidence-based model of cancer care designed to address barriers to quality care. Minimal work has been done to explore peer navigation models to improve patients' supportive care needs, including conceptually grounded training in how patients should self-advocate. This pilot study aimed to assess the feasibility and acceptability of training peer navigators to support underserved patients' ability to self-advocate, especially patients with advanced cancer.

METHODS: We designed training based on peer navigation and patient self-advocacy frameworks. We recruited adults with experience as a cancer patient interested in becoming a peer navigator for people with cancer through an ongoing clinical trial and a public research registry. Eligible participants who consented to this pilot trial completed navigation and patient self-advocacy training. We calculated feasibility metrics (e.g., approach-to-consent rates, consent-to-complete rates, and reasons for attrition) and conducted one-on-one interviews and self-reported measures to assess acceptability.

RESULTS: Between November 2024 and January 2025, we approached 13 individuals and 9 (69.2%) consented to participate in the training. One participant withdrew prior to receiving training due to hospice enrollment. The remaining 8 (88.9%) consented participants completed the self-advocacy training, and 6 (66.7%) completed the navigation training with noncompleters citing time constraints and technical difficulties. Participants expressed feeling confident in being able to provide peer navigation and gave feedback on ways to improve the training.

CONCLUSIONS: Individuals with cancer who are from disadvantaged backgrounds and living with advanced cancer can be trained to provide peer navigation and self-advocacy support to other patients with cancer.

BACKGROUND: Wearable devices are becoming more ubiquitous and are capable of capturing health-relevant information that patients may be interested in sharing with their providers. However, limited research has been conducted on oncology provider perspectives on how these data could be used to inform cancer care.

OBJECTIVE: The goal of this study was to understand oncology clinicians' preferences about which data would be most clinically valuable and in what clinical scenarios, the benefits and barriers to integrating wearable device data into cancer care, and perspectives on how wearable device data could impact decision-making using 3 clinical vignettes.

METHODS: A total of 13 oncology care clinicians completed an online questionnaire to assess the perceived value of different types of wearable device data in different clinical scenarios and participated in semistructured interviews to gather preferences around integrating these data into clinical workflows. During the interviews, providers were also presented with 3 clinical vignettes and asked for clinical recommendations both before and after seeing the patient's wearable device data. Descriptive statistics were calculated to summarize quantitative data from questionnaires and structured interview questions, and interviews were transcribed and coded using an iterative thematic analysis approach.

RESULTS: Survey responses indicated that providers were most interested in tracking vital sign metrics, followed by data related to falls and functioning, and then by data on sleep and activity. Clinicians thought that wearable device data might be especially useful for remotely monitoring patients at high-risk moments in their care trajectory, such as after an acute hospitalization or after starting a new outpatient treatment. Four main themes were discussed by providers in the interviews: (1) corroborating reports, (2) identifying new issues, (3) coordinating care, and (4) patient-provider communication. Although there were no statistically significant differences in clinical recommendations before and after viewing wearable device data for any vignette (all P>.25), all clinicians reported that the wearable device data impacted their decision-making confidence, and most rated the wearable device data as helpful.

CONCLUSIONS: Oncology providers highlighted the potential clinical value of vital sign and physical functioning data from wearable devices, particularly when outpatients might be at risk for readmissions or other acute deteriorations between clinic visits. Providers noted that the objective data captured by consumer wearable devices can be helpful complements to patient and caregiver subjective reports and that this information could improve patient-provider communication and care coordination. During the interviews, most providers found wearable device data to be helpful when making decisions. While there are challenges to address on how to integrate this information into the clinical workflow and communicate alerts with patients, there is cautious enthusiasm among clinicians about how these data could inform and improve cancer care.

Eating disorders (ED), particularly anorexia nervosa (AN), represent high-morbidity, high-mortality psychiatric illnesses with multisystem medical complications, frequent relapse, and substantial caregiver burden. As palliative care (PC) clinicians increasingly encounter patients with severe and enduring ED, they may be asked to help manage complex symptom distress, navigate treatment refusals, support families, and participate in values-based goals of care discussions amid prognostic uncertainty. At the same time, the emerging and contested discourse around "terminal anorexia nervosa" underscores the need for careful clinical reasoning, nuanced capacity assessment, and ethically rigorous, interdisciplinary deliberation. In this article, an interdisciplinary group of PC, psychiatry, psychology, and eating-disorder specialist clinicians presents a practical "Top Ten Tips" framework to support real-world care. Tips emphasize early recognition of countertransference and moral distress, medical severity assessment and refeeding risk, trauma-informed and harm-reduction approaches, task-specific decision-making capacity evaluations, communication strategies that prioritize values and meaning over labels, and collaboration with eating-disorder specialty teams, ethics consultation, and community resources. We aim to provide actionable guidance that strengthens PC clinicians' confidence and consistency when caring for patients with severe EDs.

BACKGROUND: Cancer care increasingly emphasizes holistic, patient-centered support across the disease trajectory; however, many health systems lack sufficient resources to address patients' physical, psychosocial, and logistical care needs, particularly in under-resourced settings. Patient navigation, delivered by trained non-clinician, peer, or community-based navigators, has demonstrated effectiveness in improving cancer screening and treatment initiation, yet its role in addressing the ongoing health and related care needs of people living with cancer remains less well characterized.

METHODS: This scoping review aimed to synthesize peer-reviewed and gray literature evaluating patient navigation interventions focused on the care needs of people living with cancer to summarize program characteristics, facilitators, and barriers. A search of Ovid MEDLINE (1990-June 2024) identified 4300 records.

RESULTS: Following rigorous screening and data extraction, 17 studies met the inclusion criteria. Most studies were conducted in the United States (88%), and over half employed randomized or cohort designs. Navigation programs varied widely in patient populations, cancer types, intervention duration, delivery modality, and navigator training and roles. Nearly half of the studies targeted under-resourced or marginalized populations. Interventions commonly addressed unmet needs, symptom management, care coordination, survivorship, palliative and end-of-life care, insurance, or psychosocial support. Across heterogeneous outcomes, most studies reported statistically significant improvements in patient-reported outcomes (e.g., quality of life, self-efficacy, psychosocial well-being), navigation process outcomes (e.g., satisfaction, feasibility, navigator-patient relationships), and, less frequently, health-related outcomes such as health care access and utilization. Key facilitators included strong institutional infrastructure, integration within oncology teams, flexible and accessible delivery, cultural responsiveness, and robust navigator training and supervision. Barriers included limited perceived need among lower-acuity patients, role ambiguity, technological challenges, insufficient follow-up, reimbursement constraints, and mismatches between program intensity and patient or caregiver needs.

CONCLUSIONS: Findings highlight the importance of flexible, relationship-centered, and well-integrated patient navigation models and underscore the need for standardized training, sustainable reimbursement, and patient-driven programs designed to optimize impact and equity.

Oncology Advanced Practice Providers (APPs) including Advanced Practice Registered Nurses, Physician Assistants, and Clinical Pharmacists (CPs), play a vital role in delivering high-quality, patient-centered cancer care across the United States. Despite their widespread presence in oncology practices, APPs remain underutilized in cancer clinical research, representing a missed opportunity to expand trial access and improve patient outcomes. Clinical trials are essential to advancing oncology care, yet participation remains critically low among adult patients. Given Oncology APPs' and CPs' central role in cancer care delivery, their meaningful engagement in oncology clinical trial research is imperative as the standard of oncology care. This position paper, with contributions from five professional societies, presents solutions and resources to barriers limiting APPs' and CPs' involvement in cancer clinical research, including gaps in education, role expectations, limited protected time, restrictive policies, insufficient financial support, and under-recognition of contributions. Integrating APPs and CPs more fully into the clinical research enterprise is essential to improving trial access, patient outcomes, closing equity gaps, and accelerating innovation in oncology care.

BACKGROUND: Breast cancer survivors (BCS) experience persistent physical and psychological effects after treatment, with racially diverse groups demonstrating lower adherence to cancer-specific resistance exercise guidelines. Online resistance exercise interventions show promise for enhancing accessibility and health outcomes among BCS. However, evidence regarding their feasibility of implementation remains limited. Yet, such information is critical for assessing scalability and implementation in non-laboratory settings.

PURPOSE: Using the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework, this study evaluated the reach, efficacy, adoption, and implementation of a 12-week, supervised, online resistance exercise intervention for racially diverse BCS.

METHODS: A mixed methods approach with a pre-post-study design was used. Quantitative outcomes included sociodemographic representativeness (reach), physical function (efficacy), and session fidelity (implementation). Qualitative interviews examined participant experiences, barriers, and facilitators (adoption).

RESULTS: The intervention enrolled a racially diverse BCS sample (N = 47; 57.4% White, 23.4% Black, 14.8% Asian) that was mostly representative of the host institution catchment area, though participants had higher education levels. The intervention group demonstrated statistically significant improvements in upper- (P = .009) and lower-body physical function (P = .003) versus control, only. Adoption facilitators included program convenience, accessibility of online delivery, and trainer support, while barriers were equipment challenges, competing priorities, and cancer-related side effects. Program implementation fidelity was high for core components.

CONCLUSIONS: Key factors contributed to the feasibility of implementation of the intervention. Future remote exercise interventions should address equipment needs, individualized support, and tailored recruitment to enhance adoption and facilitate scalability in non-laboratory settings.

CLINICAL TRIAL INFORMATION: The Clinical Trials Registration #NCT04562233.

BACKGROUND: To investigate the cumulative impact of individual- and neighborhood-level social determinants of health (SDoH) on patient-reported outcome measures (PROMs) among head and neck cancer (HNC) survivors.

METHODS: Among 93 survivors who underwent radiotherapy, associations between SDoH (independently and in a composite score) and validated PROMs were analyzed using univariable and multivariable regression models.

RESULTS: For every 1-point increase in the composite SDoH score, indicating an increase in the number of adverse individual- and neighborhood-level factors, physical QoL decreased by 2.92 points (p = 0.010) and depression severity increased by 0.62 points (p = 0.018). Higher neighborhood deprivation and Medicaid/no insurance were associated with worse physical and social-emotional QoL, depression severity, and anxiety severity. Higher neighborhood deprivation was also associated with worse neck disability.

CONCLUSION: Accumulating adverse individual- and neighborhood-level SDoH collectively increase the risk of poorer PROMs. Multilevel SDoH interventions are needed to improve health outcomes and promote equitable care in HNC.

All-payer claims databases (APCDs) comprise claims from multiple payers that can be traced to a single patient. To correctly estimate cost-sharing for an individual patient, we developed an algorithm to reconcile payments from secondary and tertiary payers to claims that are not fully covered by primary insurance. In a Colorado APCD cancer cohort (n = 70,100), reconciliation of claims across multiple payers markedly lowered estimated cost-sharing for patients with more than one source of coverage ($5,544 (no reconciliation); $5,013 (primary payer only) to $1,580). The largest reductions in cost-sharing after reconciliation were for individuals with Traditional Medicare with Medigap ($6,449→$1,123; Δ = -$5,326), dual Medicare-Medicaid ($4,439→$2,340; Δ = -$2,099), and Medicaid-commercial ($2,708→$2,009; Δ = -$699). Excluding secondary payments from estimates of cost-sharing systematically inflates cost-sharing estimates. A transparent reconciliation algorithm is necessary to correctly estimate cost-sharing and is recommended for researchers and policymakers who use the APCD for estimating costs across payers and to the patient.