Susan Birk

CHICAGO - Nonpain symptoms, particularly fatigue, sleep disturbance, and drowsiness, were the most common moderate to severe symptoms among cancer patients undergoing treatment in a community ambulatory setting, according to new data from the Eastern Cooperative Oncology Group study of Symptom Outcomes and Practice Patterns.

The researchers had hypothesized that pain, fatigue, and emotional distress would surface as the most frequent problems in the sample of 3,123 patients (median age 61 years; 30% male) with solid breast (50%), colorectal (23%), lung (17%), and prostate tumors (10%).

The study also found that outpatients who were more ill and symptomatic at baseline were more likely to report benefiting from supportive oncology care at a 1-month follow-up visit, said Dr. Michael J. Fisch, director of the general medical oncology program at M.D. Anderson Cancer Center in Houston.

"It’s upside down of the way we think about treating cancer," Dr. Fisch said in a focus session on symptom management at the annual Chicago Supportive Oncology Conference. "The better off you are, the more likely you are to benefit from chemotherapy or aggressive therapy. But when it comes to symptom management, the sicker you are, the more likely you are to benefit. First of all, you have more room to improve ... but it probably also has something to do with the fact that the sicker you are, the more dedicated [physicians] are at making that problem better. We are not going to take aim at ... things that are more middle-of-the-road in severity."

The study was conducted at 7 academic and 32 community clinics to highlight the most prevalent and significant physical and psychological symptoms in the course of a visit and a follow-up visit in outpatient medical oncology practice, and to describe the pattern and magnitude of functional change in these symptoms.

"We weren’t just interested in patients who were highly symptomatic or patients who had advanced disease," he said. "We wanted to see how things really are as they flow through [the system]. We knew that solid tumor care dominates what really goes on in terms of the patterns and reflexes of care, so we restricted it to the four most common solid tumors. And we let people come as they were, whether they were there for their first visit, long-term follow-up, or third cycle chemotherapy."

Participants took the M.D. Anderson Symptom Inventory (MDASI), which asks patients to rate the severity of multiple symptoms over the previous 24 hours on a 0-10 scale. The inventory was administered again 1 month later. A 2-point change in numerical rating was used as the criterion for meaningful change in a symptom. Data were analyzed on 3,100 patients.

The most prevalent moderate to severe symptoms were fatigue (34%), disturbed sleep (27%) and drowsiness (22%). Other important symptoms in the moderate to severe range were pain, numbness/tingling, distress, dry mouth, and hair loss (19%), and anorexia/cachexia, depression, and cognitive disturbance (16-17%).

Less prevalent symptoms in the moderate to severe range were dyspnea (15%), constipation (13%), diarrhea (11%), coughing (10%), nausea (8%), rash/pruritis (6%), sore mouth (5%), and vomiting (3%).

"We’re always very interested in nausea and vomiting – it’s a big problem – but just in terms of the prevalence of moderate to severe nausea and vomiting in any given outpatient oncology day, it’s not as prevalent," said Dr. Fisch.

Overall, changes in the top symptoms at 1 month were not impressive. For example, fatigue improved in 20% of patients but worsened in 26% of patients after supportive care, and pain improved in 15% of patients but worsened in 18%.

These results are "a little bit humbling," said Dr. Fisch, "if you are comprehensively assessing people and then following up 4-5 weeks later" and are using patients’ ratings on the [MDASI] to plan care. "Overall, symptom burden remains substantial and difficult to resolve."

The largest improvements were seen in patients whose symptoms were moderate to severe. For example, vomiting improved in 78% of patients and worsened in only 2% of patients who reported moderate to severe problems with this symptom at baseline. Similarly, 52% of patients reported improvements in pain and 10% said their pain got worse.

"I had a sense that we would do better than that [with pain management] – that it might be more like 85%," Dr. Fisch said.

Colorectal cancer patients were the only group whose pain significantly improved. The improvement was significantly better than patients with lung cancer, even after adjustment for other variables. In addition, patients with poor performance status significantly improved their pain, and their improvement was significantly better than those with better performance status.

Dr. Fisch said he and his colleagues plan to make the data from this study available online so that clinicians can use it to plan care without having to wait for the results to be published.

Dr. Fisch reported having no disclosures.

CHICAGO - Nonpain symptoms, particularly fatigue, sleep disturbance, and drowsiness, were the most common moderate to severe symptoms among cancer patients undergoing treatment in a community ambulatory setting, according to new data from the Eastern Cooperative Oncology Group study of Symptom Outcomes and Practice Patterns.

The researchers had hypothesized that pain, fatigue, and emotional distress would surface as the most frequent problems in the sample of 3,123 patients (median age 61 years; 30% male) with solid breast (50%), colorectal (23%), lung (17%), and prostate tumors (10%).

The study also found that outpatients who were more ill and symptomatic at baseline were more likely to report benefiting from supportive oncology care at a 1-month follow-up visit, said Dr. Michael J. Fisch, director of the general medical oncology program at M.D. Anderson Cancer Center in Houston.

"It’s upside down of the way we think about treating cancer," Dr. Fisch said in a focus session on symptom management at the annual Chicago Supportive Oncology Conference. "The better off you are, the more likely you are to benefit from chemotherapy or aggressive therapy. But when it comes to symptom management, the sicker you are, the more likely you are to benefit. First of all, you have more room to improve ... but it probably also has something to do with the fact that the sicker you are, the more dedicated [physicians] are at making that problem better. We are not going to take aim at ... things that are more middle-of-the-road in severity."

The study was conducted at 7 academic and 32 community clinics to highlight the most prevalent and significant physical and psychological symptoms in the course of a visit and a follow-up visit in outpatient medical oncology practice, and to describe the pattern and magnitude of functional change in these symptoms.

"We weren’t just interested in patients who were highly symptomatic or patients who had advanced disease," he said. "We wanted to see how things really are as they flow through [the system]. We knew that solid tumor care dominates what really goes on in terms of the patterns and reflexes of care, so we restricted it to the four most common solid tumors. And we let people come as they were, whether they were there for their first visit, long-term follow-up, or third cycle chemotherapy."

Participants took the M.D. Anderson Symptom Inventory (MDASI), which asks patients to rate the severity of multiple symptoms over the previous 24 hours on a 0-10 scale. The inventory was administered again 1 month later. A 2-point change in numerical rating was used as the criterion for meaningful change in a symptom. Data were analyzed on 3,100 patients.

The most prevalent moderate to severe symptoms were fatigue (34%), disturbed sleep (27%) and drowsiness (22%). Other important symptoms in the moderate to severe range were pain, numbness/tingling, distress, dry mouth, and hair loss (19%), and anorexia/cachexia, depression, and cognitive disturbance (16-17%).

Less prevalent symptoms in the moderate to severe range were dyspnea (15%), constipation (13%), diarrhea (11%), coughing (10%), nausea (8%), rash/pruritis (6%), sore mouth (5%), and vomiting (3%).

"We’re always very interested in nausea and vomiting – it’s a big problem – but just in terms of the prevalence of moderate to severe nausea and vomiting in any given outpatient oncology day, it’s not as prevalent," said Dr. Fisch.

Overall, changes in the top symptoms at 1 month were not impressive. For example, fatigue improved in 20% of patients but worsened in 26% of patients after supportive care, and pain improved in 15% of patients but worsened in 18%.

These results are "a little bit humbling," said Dr. Fisch, "if you are comprehensively assessing people and then following up 4-5 weeks later" and are using patients’ ratings on the [MDASI] to plan care. "Overall, symptom burden remains substantial and difficult to resolve."

The largest improvements were seen in patients whose symptoms were moderate to severe. For example, vomiting improved in 78% of patients and worsened in only 2% of patients who reported moderate to severe problems with this symptom at baseline. Similarly, 52% of patients reported improvements in pain and 10% said their pain got worse.

"I had a sense that we would do better than that [with pain management] – that it might be more like 85%," Dr. Fisch said.

Colorectal cancer patients were the only group whose pain significantly improved. The improvement was significantly better than patients with lung cancer, even after adjustment for other variables. In addition, patients with poor performance status significantly improved their pain, and their improvement was significantly better than those with better performance status.

Dr. Fisch said he and his colleagues plan to make the data from this study available online so that clinicians can use it to plan care without having to wait for the results to be published.

Dr. Fisch reported having no disclosures.

CHICAGO - Nonpain symptoms, particularly fatigue, sleep disturbance, and drowsiness, were the most common moderate to severe symptoms among cancer patients undergoing treatment in a community ambulatory setting, according to new data from the Eastern Cooperative Oncology Group study of Symptom Outcomes and Practice Patterns.

The researchers had hypothesized that pain, fatigue, and emotional distress would surface as the most frequent problems in the sample of 3,123 patients (median age 61 years; 30% male) with solid breast (50%), colorectal (23%), lung (17%), and prostate tumors (10%).

The study also found that outpatients who were more ill and symptomatic at baseline were more likely to report benefiting from supportive oncology care at a 1-month follow-up visit, said Dr. Michael J. Fisch, director of the general medical oncology program at M.D. Anderson Cancer Center in Houston.

"It’s upside down of the way we think about treating cancer," Dr. Fisch said in a focus session on symptom management at the annual Chicago Supportive Oncology Conference. "The better off you are, the more likely you are to benefit from chemotherapy or aggressive therapy. But when it comes to symptom management, the sicker you are, the more likely you are to benefit. First of all, you have more room to improve ... but it probably also has something to do with the fact that the sicker you are, the more dedicated [physicians] are at making that problem better. We are not going to take aim at ... things that are more middle-of-the-road in severity."

The study was conducted at 7 academic and 32 community clinics to highlight the most prevalent and significant physical and psychological symptoms in the course of a visit and a follow-up visit in outpatient medical oncology practice, and to describe the pattern and magnitude of functional change in these symptoms.

"We weren’t just interested in patients who were highly symptomatic or patients who had advanced disease," he said. "We wanted to see how things really are as they flow through [the system]. We knew that solid tumor care dominates what really goes on in terms of the patterns and reflexes of care, so we restricted it to the four most common solid tumors. And we let people come as they were, whether they were there for their first visit, long-term follow-up, or third cycle chemotherapy."

Participants took the M.D. Anderson Symptom Inventory (MDASI), which asks patients to rate the severity of multiple symptoms over the previous 24 hours on a 0-10 scale. The inventory was administered again 1 month later. A 2-point change in numerical rating was used as the criterion for meaningful change in a symptom. Data were analyzed on 3,100 patients.

The most prevalent moderate to severe symptoms were fatigue (34%), disturbed sleep (27%) and drowsiness (22%). Other important symptoms in the moderate to severe range were pain, numbness/tingling, distress, dry mouth, and hair loss (19%), and anorexia/cachexia, depression, and cognitive disturbance (16-17%).

Less prevalent symptoms in the moderate to severe range were dyspnea (15%), constipation (13%), diarrhea (11%), coughing (10%), nausea (8%), rash/pruritis (6%), sore mouth (5%), and vomiting (3%).

"We’re always very interested in nausea and vomiting – it’s a big problem – but just in terms of the prevalence of moderate to severe nausea and vomiting in any given outpatient oncology day, it’s not as prevalent," said Dr. Fisch.

Overall, changes in the top symptoms at 1 month were not impressive. For example, fatigue improved in 20% of patients but worsened in 26% of patients after supportive care, and pain improved in 15% of patients but worsened in 18%.

These results are "a little bit humbling," said Dr. Fisch, "if you are comprehensively assessing people and then following up 4-5 weeks later" and are using patients’ ratings on the [MDASI] to plan care. "Overall, symptom burden remains substantial and difficult to resolve."

The largest improvements were seen in patients whose symptoms were moderate to severe. For example, vomiting improved in 78% of patients and worsened in only 2% of patients who reported moderate to severe problems with this symptom at baseline. Similarly, 52% of patients reported improvements in pain and 10% said their pain got worse.

"I had a sense that we would do better than that [with pain management] – that it might be more like 85%," Dr. Fisch said.

Colorectal cancer patients were the only group whose pain significantly improved. The improvement was significantly better than patients with lung cancer, even after adjustment for other variables. In addition, patients with poor performance status significantly improved their pain, and their improvement was significantly better than those with better performance status.

Dr. Fisch said he and his colleagues plan to make the data from this study available online so that clinicians can use it to plan care without having to wait for the results to be published.

Dr. Fisch reported having no disclosures.

CHICAGO - Nonpain symptoms, particularly fatigue, sleep disturbance, and drowsiness, were the most common moderate to severe symptoms among cancer patients undergoing treatment in a community ambulatory setting, according to new data from the Eastern Cooperative Oncology Group study of Symptom Outcomes and Practice Patterns.

The researchers had hypothesized that pain, fatigue, and emotional distress would surface as the most frequent problems in the sample of 3,123 patients (median age 61 years; 30% male) with solid breast (50%), colorectal (23%), lung (17%), and prostate tumors (10%).

The study also found that outpatients who were more ill and symptomatic at baseline were more likely to report benefiting from supportive oncology care at a 1-month follow-up visit, said Dr. Michael J. Fisch, director of the general medical oncology program at M.D. Anderson Cancer Center in Houston.

"It’s upside down of the way we think about treating cancer," Dr. Fisch said in a focus session on symptom management at the annual Chicago Supportive Oncology Conference. "The better off you are, the more likely you are to benefit from chemotherapy or aggressive therapy. But when it comes to symptom management, the sicker you are, the more likely you are to benefit. First of all, you have more room to improve ... but it probably also has something to do with the fact that the sicker you are, the more dedicated [physicians] are at making that problem better. We are not going to take aim at ... things that are more middle-of-the-road in severity."

The study was conducted at 7 academic and 32 community clinics to highlight the most prevalent and significant physical and psychological symptoms in the course of a visit and a follow-up visit in outpatient medical oncology practice, and to describe the pattern and magnitude of functional change in these symptoms.

"We weren’t just interested in patients who were highly symptomatic or patients who had advanced disease," he said. "We wanted to see how things really are as they flow through [the system]. We knew that solid tumor care dominates what really goes on in terms of the patterns and reflexes of care, so we restricted it to the four most common solid tumors. And we let people come as they were, whether they were there for their first visit, long-term follow-up, or third cycle chemotherapy."

Participants took the M.D. Anderson Symptom Inventory (MDASI), which asks patients to rate the severity of multiple symptoms over the previous 24 hours on a 0-10 scale. The inventory was administered again 1 month later. A 2-point change in numerical rating was used as the criterion for meaningful change in a symptom. Data were analyzed on 3,100 patients.

The most prevalent moderate to severe symptoms were fatigue (34%), disturbed sleep (27%) and drowsiness (22%). Other important symptoms in the moderate to severe range were pain, numbness/tingling, distress, dry mouth, and hair loss (19%), and anorexia/cachexia, depression, and cognitive disturbance (16-17%).

Less prevalent symptoms in the moderate to severe range were dyspnea (15%), constipation (13%), diarrhea (11%), coughing (10%), nausea (8%), rash/pruritis (6%), sore mouth (5%), and vomiting (3%).

"We’re always very interested in nausea and vomiting – it’s a big problem – but just in terms of the prevalence of moderate to severe nausea and vomiting in any given outpatient oncology day, it’s not as prevalent," said Dr. Fisch.

Overall, changes in the top symptoms at 1 month were not impressive. For example, fatigue improved in 20% of patients but worsened in 26% of patients after supportive care, and pain improved in 15% of patients but worsened in 18%.

These results are "a little bit humbling," said Dr. Fisch, "if you are comprehensively assessing people and then following up 4-5 weeks later" and are using patients’ ratings on the [MDASI] to plan care. "Overall, symptom burden remains substantial and difficult to resolve."

The largest improvements were seen in patients whose symptoms were moderate to severe. For example, vomiting improved in 78% of patients and worsened in only 2% of patients who reported moderate to severe problems with this symptom at baseline. Similarly, 52% of patients reported improvements in pain and 10% said their pain got worse.

"I had a sense that we would do better than that [with pain management] – that it might be more like 85%," Dr. Fisch said.

Colorectal cancer patients were the only group whose pain significantly improved. The improvement was significantly better than patients with lung cancer, even after adjustment for other variables. In addition, patients with poor performance status significantly improved their pain, and their improvement was significantly better than those with better performance status.

Dr. Fisch said he and his colleagues plan to make the data from this study available online so that clinicians can use it to plan care without having to wait for the results to be published.

Dr. Fisch reported having no disclosures.

CHICAGO - Nonpain symptoms, particularly fatigue, sleep disturbance, and drowsiness, were the most common moderate to severe symptoms among cancer patients undergoing treatment in a community ambulatory setting, according to new data from the Eastern Cooperative Oncology Group study of Symptom Outcomes and Practice Patterns.

The researchers had hypothesized that pain, fatigue, and emotional distress would surface as the most frequent problems in the sample of 3,123 patients (median age 61 years; 30% male) with solid breast (50%), colorectal (23%), lung (17%), and prostate tumors (10%).

The study also found that outpatients who were more ill and symptomatic at baseline were more likely to report benefiting from supportive oncology care at a 1-month follow-up visit, said Dr. Michael J. Fisch, director of the general medical oncology program at M.D. Anderson Cancer Center in Houston.

"It’s upside down of the way we think about treating cancer," Dr. Fisch said in a focus session on symptom management at the annual Chicago Supportive Oncology Conference. "The better off you are, the more likely you are to benefit from chemotherapy or aggressive therapy. But when it comes to symptom management, the sicker you are, the more likely you are to benefit. First of all, you have more room to improve ... but it probably also has something to do with the fact that the sicker you are, the more dedicated [physicians] are at making that problem better. We are not going to take aim at ... things that are more middle-of-the-road in severity."

The study was conducted at 7 academic and 32 community clinics to highlight the most prevalent and significant physical and psychological symptoms in the course of a visit and a follow-up visit in outpatient medical oncology practice, and to describe the pattern and magnitude of functional change in these symptoms.

"We weren’t just interested in patients who were highly symptomatic or patients who had advanced disease," he said. "We wanted to see how things really are as they flow through [the system]. We knew that solid tumor care dominates what really goes on in terms of the patterns and reflexes of care, so we restricted it to the four most common solid tumors. And we let people come as they were, whether they were there for their first visit, long-term follow-up, or third cycle chemotherapy."

Participants took the M.D. Anderson Symptom Inventory (MDASI), which asks patients to rate the severity of multiple symptoms over the previous 24 hours on a 0-10 scale. The inventory was administered again 1 month later. A 2-point change in numerical rating was used as the criterion for meaningful change in a symptom. Data were analyzed on 3,100 patients.

The most prevalent moderate to severe symptoms were fatigue (34%), disturbed sleep (27%) and drowsiness (22%). Other important symptoms in the moderate to severe range were pain, numbness/tingling, distress, dry mouth, and hair loss (19%), and anorexia/cachexia, depression, and cognitive disturbance (16-17%).

Less prevalent symptoms in the moderate to severe range were dyspnea (15%), constipation (13%), diarrhea (11%), coughing (10%), nausea (8%), rash/pruritis (6%), sore mouth (5%), and vomiting (3%).

"We’re always very interested in nausea and vomiting – it’s a big problem – but just in terms of the prevalence of moderate to severe nausea and vomiting in any given outpatient oncology day, it’s not as prevalent," said Dr. Fisch.

Overall, changes in the top symptoms at 1 month were not impressive. For example, fatigue improved in 20% of patients but worsened in 26% of patients after supportive care, and pain improved in 15% of patients but worsened in 18%.

These results are "a little bit humbling," said Dr. Fisch, "if you are comprehensively assessing people and then following up 4-5 weeks later" and are using patients’ ratings on the [MDASI] to plan care. "Overall, symptom burden remains substantial and difficult to resolve."

The largest improvements were seen in patients whose symptoms were moderate to severe. For example, vomiting improved in 78% of patients and worsened in only 2% of patients who reported moderate to severe problems with this symptom at baseline. Similarly, 52% of patients reported improvements in pain and 10% said their pain got worse.

"I had a sense that we would do better than that [with pain management] – that it might be more like 85%," Dr. Fisch said.

Colorectal cancer patients were the only group whose pain significantly improved. The improvement was significantly better than patients with lung cancer, even after adjustment for other variables. In addition, patients with poor performance status significantly improved their pain, and their improvement was significantly better than those with better performance status.

Dr. Fisch said he and his colleagues plan to make the data from this study available online so that clinicians can use it to plan care without having to wait for the results to be published.

Dr. Fisch reported having no disclosures.

CHICAGO - Nonpain symptoms, particularly fatigue, sleep disturbance, and drowsiness, were the most common moderate to severe symptoms among cancer patients undergoing treatment in a community ambulatory setting, according to new data from the Eastern Cooperative Oncology Group study of Symptom Outcomes and Practice Patterns.

The researchers had hypothesized that pain, fatigue, and emotional distress would surface as the most frequent problems in the sample of 3,123 patients (median age 61 years; 30% male) with solid breast (50%), colorectal (23%), lung (17%), and prostate tumors (10%).

The study also found that outpatients who were more ill and symptomatic at baseline were more likely to report benefiting from supportive oncology care at a 1-month follow-up visit, said Dr. Michael J. Fisch, director of the general medical oncology program at M.D. Anderson Cancer Center in Houston.

"It’s upside down of the way we think about treating cancer," Dr. Fisch said in a focus session on symptom management at the annual Chicago Supportive Oncology Conference. "The better off you are, the more likely you are to benefit from chemotherapy or aggressive therapy. But when it comes to symptom management, the sicker you are, the more likely you are to benefit. First of all, you have more room to improve ... but it probably also has something to do with the fact that the sicker you are, the more dedicated [physicians] are at making that problem better. We are not going to take aim at ... things that are more middle-of-the-road in severity."

The study was conducted at 7 academic and 32 community clinics to highlight the most prevalent and significant physical and psychological symptoms in the course of a visit and a follow-up visit in outpatient medical oncology practice, and to describe the pattern and magnitude of functional change in these symptoms.

"We weren’t just interested in patients who were highly symptomatic or patients who had advanced disease," he said. "We wanted to see how things really are as they flow through [the system]. We knew that solid tumor care dominates what really goes on in terms of the patterns and reflexes of care, so we restricted it to the four most common solid tumors. And we let people come as they were, whether they were there for their first visit, long-term follow-up, or third cycle chemotherapy."

Participants took the M.D. Anderson Symptom Inventory (MDASI), which asks patients to rate the severity of multiple symptoms over the previous 24 hours on a 0-10 scale. The inventory was administered again 1 month later. A 2-point change in numerical rating was used as the criterion for meaningful change in a symptom. Data were analyzed on 3,100 patients.

The most prevalent moderate to severe symptoms were fatigue (34%), disturbed sleep (27%) and drowsiness (22%). Other important symptoms in the moderate to severe range were pain, numbness/tingling, distress, dry mouth, and hair loss (19%), and anorexia/cachexia, depression, and cognitive disturbance (16-17%).

Less prevalent symptoms in the moderate to severe range were dyspnea (15%), constipation (13%), diarrhea (11%), coughing (10%), nausea (8%), rash/pruritis (6%), sore mouth (5%), and vomiting (3%).

"We’re always very interested in nausea and vomiting – it’s a big problem – but just in terms of the prevalence of moderate to severe nausea and vomiting in any given outpatient oncology day, it’s not as prevalent," said Dr. Fisch.

Overall, changes in the top symptoms at 1 month were not impressive. For example, fatigue improved in 20% of patients but worsened in 26% of patients after supportive care, and pain improved in 15% of patients but worsened in 18%.

These results are "a little bit humbling," said Dr. Fisch, "if you are comprehensively assessing people and then following up 4-5 weeks later" and are using patients’ ratings on the [MDASI] to plan care. "Overall, symptom burden remains substantial and difficult to resolve."

The largest improvements were seen in patients whose symptoms were moderate to severe. For example, vomiting improved in 78% of patients and worsened in only 2% of patients who reported moderate to severe problems with this symptom at baseline. Similarly, 52% of patients reported improvements in pain and 10% said their pain got worse.

"I had a sense that we would do better than that [with pain management] – that it might be more like 85%," Dr. Fisch said.

Colorectal cancer patients were the only group whose pain significantly improved. The improvement was significantly better than patients with lung cancer, even after adjustment for other variables. In addition, patients with poor performance status significantly improved their pain, and their improvement was significantly better than those with better performance status.

Dr. Fisch said he and his colleagues plan to make the data from this study available online so that clinicians can use it to plan care without having to wait for the results to be published.

Dr. Fisch reported having no disclosures.

CHICAGO – Oncologists and others who care for cancer patients can improve outcomes by integrating palliative care into standard treatment earlier – even as early as the time of diagnosis, Dr. Charles F. von Gunten said in a plenary session at the Chicago Supportive Oncology Conference.

Doing so would require clinicians to expand their definition of palliative care far beyond the traditional boundaries of hospice, which begins only toward the end of life when other therapies are no longer working, said Dr. von Gunten of the University of California, San Diego, and provost at the Institute for Palliative Medicine at San Diego.

He called on clinicians to rethink the traditional "either-or" approach to cancer treatment – in which care consists of either therapies aimed at reducing or curing the illness or care designed to ease suffering and improve the quality of life – and to adopt a "both-and" model instead that employs both standard therapies and palliative interventions simultaneously.

Dr. von Gunten noted the growing accumulation of data during the past 20 years demonstrating the effectiveness of palliative care.

One recent study, for example, found that early palliative care significantly improved quality of life and mood among patients with metastatic non–small cell lung cancer as compared with standard care (N. Engl. J. Med. 2010;363:733-42). Although significantly fewer patients in the early palliative care group than in the standard treatment group received aggressive end-of-life care (33% vs. 54%, P = .05), median survival was significantly longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P = .02).

"Palliative care delivered by hospice programs in the [United States] is better than standard of care at the end of life," Dr. von Gunten said. "That has been proven. It is the gold standard. We should get rid of this language of 'choice': 'Hospice is a choice if you want it; antibiotics are a choice if you want it; chemotherapy is a choice if you want it.' We’re past that. This is the standard of care, and it should be advocated that way by all of us."

But palliative care still has a way to go before it becomes an integral part of cancer treatment, although some progress has been made, he said. While 98% of NCI-designated cancer centers and 78% of community cancer centers report having palliative care programs, 92% and 74% of these centers, respectively, have at least one palliative care physician on staff (JAMA 2010;303:1054-61).

More sobering, he said, is a 1998 membership survey by the American Society of Clinical Oncologists in which 90% of oncologists reported "trial and error" as their primary source of information about palliative care. "How enthusiastic would you be about a doctor who was going to take out your anus, and you said, 'Doctor, how did you learn about this?' and he said, 'Oh, trial and error,'?" Dr. von Gunten said.

Of those surveyed, 73% said they learned from colleagues and role models. "That's great, except where did colleagues and role models learn? Trial and error," he said. And 38% of oncologists said the most significant source of their information about palliative care was a traumatic experience. The underlying message is that no one is teaching palliative care to oncologists, he said. "We have no sense of some sort of systematic dissemination of information.

"Let us have no more talk of choice – no more 'either-or,'?" he said. "The key is how do we make sure [palliative care] is available for patients as part of comprehensive cancer care."

Dr. von Gunten had no disclosures.

CHICAGO – Oncologists and others who care for cancer patients can improve outcomes by integrating palliative care into standard treatment earlier – even as early as the time of diagnosis, Dr. Charles F. von Gunten said in a plenary session at the Chicago Supportive Oncology Conference.

Doing so would require clinicians to expand their definition of palliative care far beyond the traditional boundaries of hospice, which begins only toward the end of life when other therapies are no longer working, said Dr. von Gunten of the University of California, San Diego, and provost at the Institute for Palliative Medicine at San Diego.

He called on clinicians to rethink the traditional "either-or" approach to cancer treatment – in which care consists of either therapies aimed at reducing or curing the illness or care designed to ease suffering and improve the quality of life – and to adopt a "both-and" model instead that employs both standard therapies and palliative interventions simultaneously.

Dr. von Gunten noted the growing accumulation of data during the past 20 years demonstrating the effectiveness of palliative care.

One recent study, for example, found that early palliative care significantly improved quality of life and mood among patients with metastatic non–small cell lung cancer as compared with standard care (N. Engl. J. Med. 2010;363:733-42). Although significantly fewer patients in the early palliative care group than in the standard treatment group received aggressive end-of-life care (33% vs. 54%, P = .05), median survival was significantly longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P = .02).

"Palliative care delivered by hospice programs in the [United States] is better than standard of care at the end of life," Dr. von Gunten said. "That has been proven. It is the gold standard. We should get rid of this language of 'choice': 'Hospice is a choice if you want it; antibiotics are a choice if you want it; chemotherapy is a choice if you want it.' We’re past that. This is the standard of care, and it should be advocated that way by all of us."

But palliative care still has a way to go before it becomes an integral part of cancer treatment, although some progress has been made, he said. While 98% of NCI-designated cancer centers and 78% of community cancer centers report having palliative care programs, 92% and 74% of these centers, respectively, have at least one palliative care physician on staff (JAMA 2010;303:1054-61).

More sobering, he said, is a 1998 membership survey by the American Society of Clinical Oncologists in which 90% of oncologists reported "trial and error" as their primary source of information about palliative care. "How enthusiastic would you be about a doctor who was going to take out your anus, and you said, 'Doctor, how did you learn about this?' and he said, 'Oh, trial and error,'?" Dr. von Gunten said.

Of those surveyed, 73% said they learned from colleagues and role models. "That's great, except where did colleagues and role models learn? Trial and error," he said. And 38% of oncologists said the most significant source of their information about palliative care was a traumatic experience. The underlying message is that no one is teaching palliative care to oncologists, he said. "We have no sense of some sort of systematic dissemination of information.

"Let us have no more talk of choice – no more 'either-or,'?" he said. "The key is how do we make sure [palliative care] is available for patients as part of comprehensive cancer care."

Dr. von Gunten had no disclosures.

CHICAGO – Oncologists and others who care for cancer patients can improve outcomes by integrating palliative care into standard treatment earlier – even as early as the time of diagnosis, Dr. Charles F. von Gunten said in a plenary session at the Chicago Supportive Oncology Conference.

Doing so would require clinicians to expand their definition of palliative care far beyond the traditional boundaries of hospice, which begins only toward the end of life when other therapies are no longer working, said Dr. von Gunten of the University of California, San Diego, and provost at the Institute for Palliative Medicine at San Diego.

He called on clinicians to rethink the traditional "either-or" approach to cancer treatment – in which care consists of either therapies aimed at reducing or curing the illness or care designed to ease suffering and improve the quality of life – and to adopt a "both-and" model instead that employs both standard therapies and palliative interventions simultaneously.

Dr. von Gunten noted the growing accumulation of data during the past 20 years demonstrating the effectiveness of palliative care.

One recent study, for example, found that early palliative care significantly improved quality of life and mood among patients with metastatic non–small cell lung cancer as compared with standard care (N. Engl. J. Med. 2010;363:733-42). Although significantly fewer patients in the early palliative care group than in the standard treatment group received aggressive end-of-life care (33% vs. 54%, P = .05), median survival was significantly longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P = .02).

"Palliative care delivered by hospice programs in the [United States] is better than standard of care at the end of life," Dr. von Gunten said. "That has been proven. It is the gold standard. We should get rid of this language of 'choice': 'Hospice is a choice if you want it; antibiotics are a choice if you want it; chemotherapy is a choice if you want it.' We’re past that. This is the standard of care, and it should be advocated that way by all of us."

But palliative care still has a way to go before it becomes an integral part of cancer treatment, although some progress has been made, he said. While 98% of NCI-designated cancer centers and 78% of community cancer centers report having palliative care programs, 92% and 74% of these centers, respectively, have at least one palliative care physician on staff (JAMA 2010;303:1054-61).

More sobering, he said, is a 1998 membership survey by the American Society of Clinical Oncologists in which 90% of oncologists reported "trial and error" as their primary source of information about palliative care. "How enthusiastic would you be about a doctor who was going to take out your anus, and you said, 'Doctor, how did you learn about this?' and he said, 'Oh, trial and error,'?" Dr. von Gunten said.

Of those surveyed, 73% said they learned from colleagues and role models. "That's great, except where did colleagues and role models learn? Trial and error," he said. And 38% of oncologists said the most significant source of their information about palliative care was a traumatic experience. The underlying message is that no one is teaching palliative care to oncologists, he said. "We have no sense of some sort of systematic dissemination of information.

"Let us have no more talk of choice – no more 'either-or,'?" he said. "The key is how do we make sure [palliative care] is available for patients as part of comprehensive cancer care."

Dr. von Gunten had no disclosures.

CHICAGO - The anti-inflammatory properties of ginseng show promise for cancer-related fatigue that merits further attention, according to accumulating studies.

Inflammation is posited to be one of the physiological mechanisms underlying cancer-related fatigue, said Debra Barton, Ph.D., of the department of oncology at Mayo Clinic Cancer Center in Rochester, Minn.

"Inflammation causes an increase in cortisol, which then causes anti-inflammatory cytokines to be secreted to act as a feedback loop to get us back to homeostasis. The hypothesis is that this whole system may not be functioning optimally in patients with [cancer-related] fatigue," she explained at the annual Chicago Supportive Oncology Conference.

A study of fatigued breast cancer survivors revealed significantly higher serum levels of several markers associated with proinflammatory cytokine activity and significantly lower serum levels of cortisol than were present in nonfatigued patients (Psychosom. Med. 2002;64:604-11).

In metastatic cell lines, ginseng inhibits the up-regulation of MAP (mitogen-activated protein) kinase, so there might be some direct impact on inflammation, she said.

In a randomized, double-blind, dose-finding study by Dr. Barton and her colleagues, approximately two to three times as many patients taking 1,000 or 2,000 mg daily of American ginseng reported satisfaction with treatment and improvements in fatigue, compared with those patients who took placebo (Support. Care Cancer. 2010;18:179-87).

Photo Credit: (c) Orchidpoet/iStockphoto

In all, 282 cancer patients with advanced or early disease who were either on or off treatment received 750 mg, 1,000 mg, or 2,000 mg of ginseng daily or placebo twice daily over 8 weeks. "We were just trying to get an idea of [whether there is] a signal, what dose should we use, and in what population," she said. In all, 25% of patients on 1,000 mg and 27% of patients on 2,000 mg said they felt "moderately better" or "much better," compared with only 10% of patients in both the 750-mg and placebo groups.

As a follow-up to that pilot study, Dr. Barton and her colleagues are finishing a large, randomized trial of 2,000 mg of ginseng vs. placebo in breast cancer patients. In addition to looking at patient perceptions of benefit on the physical subscale of the multidimensional fatigue symptom inventory–short form, the study will measure cortisol and other markers in blood and saliva to look at relationships between these markers and fatigue at baseline and over time in the two arms.

Less promising were data on methylphenidate. Recent studies of the psychostimulant modafinil/armodafinil have not yielded stellar results, according to Dr. Barton, who is also a registered nurse. Although two very small studies indicated significant improvements in fatigue among patients on 200-mg modafinil vs. placebo (J. Palliat. Med. 2009;12:433-9; Palliat. Med. 2009;23:325-31), a much larger study of 867 patients found no significant differences over four cycles of chemotherapy and a trend toward improvement only among patients with the most severe fatigue (Cancer 2010;116:3513-20).

Dr. Barton disclosed that she has received study supplies from Ginseng Board of Wisconsin and Ortho-McNeil Janssen Pharmaceuticals Inc.

CHICAGO - The anti-inflammatory properties of ginseng show promise for cancer-related fatigue that merits further attention, according to accumulating studies.

Inflammation is posited to be one of the physiological mechanisms underlying cancer-related fatigue, said Debra Barton, Ph.D., of the department of oncology at Mayo Clinic Cancer Center in Rochester, Minn.

"Inflammation causes an increase in cortisol, which then causes anti-inflammatory cytokines to be secreted to act as a feedback loop to get us back to homeostasis. The hypothesis is that this whole system may not be functioning optimally in patients with [cancer-related] fatigue," she explained at the annual Chicago Supportive Oncology Conference.

A study of fatigued breast cancer survivors revealed significantly higher serum levels of several markers associated with proinflammatory cytokine activity and significantly lower serum levels of cortisol than were present in nonfatigued patients (Psychosom. Med. 2002;64:604-11).

In metastatic cell lines, ginseng inhibits the up-regulation of MAP (mitogen-activated protein) kinase, so there might be some direct impact on inflammation, she said.

In a randomized, double-blind, dose-finding study by Dr. Barton and her colleagues, approximately two to three times as many patients taking 1,000 or 2,000 mg daily of American ginseng reported satisfaction with treatment and improvements in fatigue, compared with those patients who took placebo (Support. Care Cancer. 2010;18:179-87).

Photo Credit: (c) Orchidpoet/iStockphoto

In all, 282 cancer patients with advanced or early disease who were either on or off treatment received 750 mg, 1,000 mg, or 2,000 mg of ginseng daily or placebo twice daily over 8 weeks. "We were just trying to get an idea of [whether there is] a signal, what dose should we use, and in what population," she said. In all, 25% of patients on 1,000 mg and 27% of patients on 2,000 mg said they felt "moderately better" or "much better," compared with only 10% of patients in both the 750-mg and placebo groups.

As a follow-up to that pilot study, Dr. Barton and her colleagues are finishing a large, randomized trial of 2,000 mg of ginseng vs. placebo in breast cancer patients. In addition to looking at patient perceptions of benefit on the physical subscale of the multidimensional fatigue symptom inventory–short form, the study will measure cortisol and other markers in blood and saliva to look at relationships between these markers and fatigue at baseline and over time in the two arms.

Less promising were data on methylphenidate. Recent studies of the psychostimulant modafinil/armodafinil have not yielded stellar results, according to Dr. Barton, who is also a registered nurse. Although two very small studies indicated significant improvements in fatigue among patients on 200-mg modafinil vs. placebo (J. Palliat. Med. 2009;12:433-9; Palliat. Med. 2009;23:325-31), a much larger study of 867 patients found no significant differences over four cycles of chemotherapy and a trend toward improvement only among patients with the most severe fatigue (Cancer 2010;116:3513-20).

Dr. Barton disclosed that she has received study supplies from Ginseng Board of Wisconsin and Ortho-McNeil Janssen Pharmaceuticals Inc.

CHICAGO - The anti-inflammatory properties of ginseng show promise for cancer-related fatigue that merits further attention, according to accumulating studies.

Inflammation is posited to be one of the physiological mechanisms underlying cancer-related fatigue, said Debra Barton, Ph.D., of the department of oncology at Mayo Clinic Cancer Center in Rochester, Minn.

"Inflammation causes an increase in cortisol, which then causes anti-inflammatory cytokines to be secreted to act as a feedback loop to get us back to homeostasis. The hypothesis is that this whole system may not be functioning optimally in patients with [cancer-related] fatigue," she explained at the annual Chicago Supportive Oncology Conference.

A study of fatigued breast cancer survivors revealed significantly higher serum levels of several markers associated with proinflammatory cytokine activity and significantly lower serum levels of cortisol than were present in nonfatigued patients (Psychosom. Med. 2002;64:604-11).

In metastatic cell lines, ginseng inhibits the up-regulation of MAP (mitogen-activated protein) kinase, so there might be some direct impact on inflammation, she said.

In a randomized, double-blind, dose-finding study by Dr. Barton and her colleagues, approximately two to three times as many patients taking 1,000 or 2,000 mg daily of American ginseng reported satisfaction with treatment and improvements in fatigue, compared with those patients who took placebo (Support. Care Cancer. 2010;18:179-87).

Photo Credit: (c) Orchidpoet/iStockphoto

In all, 282 cancer patients with advanced or early disease who were either on or off treatment received 750 mg, 1,000 mg, or 2,000 mg of ginseng daily or placebo twice daily over 8 weeks. "We were just trying to get an idea of [whether there is] a signal, what dose should we use, and in what population," she said. In all, 25% of patients on 1,000 mg and 27% of patients on 2,000 mg said they felt "moderately better" or "much better," compared with only 10% of patients in both the 750-mg and placebo groups.

As a follow-up to that pilot study, Dr. Barton and her colleagues are finishing a large, randomized trial of 2,000 mg of ginseng vs. placebo in breast cancer patients. In addition to looking at patient perceptions of benefit on the physical subscale of the multidimensional fatigue symptom inventory–short form, the study will measure cortisol and other markers in blood and saliva to look at relationships between these markers and fatigue at baseline and over time in the two arms.

Less promising were data on methylphenidate. Recent studies of the psychostimulant modafinil/armodafinil have not yielded stellar results, according to Dr. Barton, who is also a registered nurse. Although two very small studies indicated significant improvements in fatigue among patients on 200-mg modafinil vs. placebo (J. Palliat. Med. 2009;12:433-9; Palliat. Med. 2009;23:325-31), a much larger study of 867 patients found no significant differences over four cycles of chemotherapy and a trend toward improvement only among patients with the most severe fatigue (Cancer 2010;116:3513-20).

Dr. Barton disclosed that she has received study supplies from Ginseng Board of Wisconsin and Ortho-McNeil Janssen Pharmaceuticals Inc.

CHICAGO - Oncologists can navigate the sensitive and arduous communication of painful news to patients with greater honesty and compassion by expressing wishes in response to their patients’ sense of loss, futility, or unrealistic hope, Dr. Timothy E. Quill, told attendees at the annual Chicago Supportive Oncology Conference.

Communicating with statements such as "I wish there was more we could do for you," "I wish I had better news to give you," "I wish things had turned out better," or "I wish our palliative care was more effective" communicates empathy and caring without distorting the truth, fostering a false sense of hope, or emotionally bludgeoning the patient, said Dr. Quill, director of the center for ethics, humanities, and palliative care at the University of Rochester (N.Y.).

Wishes are effective because they acknowledge the emotional impact of the patient’s illness and allow the physician to respond as a human being to the patient’s emotional distress, while communicating with gentleness and compassion that the hoped-for outcome is unlikely, explained Dr. Quill, a professor of medicine, psychiatry, and medical humanities at the university. Simultaneously – and paradoxically – wishes enable the physician to identify with the patient’s hope while casting that hope in a realistic light.

Dr. Quill stressed, however, that wish statements should be used only as the beginning of an important dialogue. Wishes acknowledge that a desired result probably will not happen, and can elicit anger, hopelessness, terror, and despair. It is essential to talk with patients about their feelings and experiences, he said. The failure to do so could cause emotional harm.

Questions following wish statements – such as "What has been the hardest part for you?" "What are your biggest concerns?" and "How is your family managing this?" – can help to guide meaningful communication. Also critical are statements that validate the patient’s experience ("Anyone going through this would have such feelings") and express empathy ("I can imagine that must have been frightening"), as well as efforts to facilitate opportunities for growth and closure in addressing short-term medical decisions, financial and legal affairs, unfinished personal and family business, and, possibly, spiritual, religious, and existential issues.

He emphasized that this communication must be accompanied by the search for new treatment direction and hope through the appropriate use of standard treatment options, experimental treatment, palliative care, or hospice care.

In responding to an expression of loss, grief, and hopelessness ("I do not see how I can go on"), Dr. Quill noted that the clinician does not have to have all the answers. A statement such as "I wish I had a simple formula" allows the physician to take the same emotional stance as the patient, whereas expressions of empathy ("Tell me about the scariest part," "We can work on this together") can help patients deal with intense emotions, such as fear of abandonment.

In responding to a patient’s expression of unrealistic hope ("I want to live to see the birth of my grandchild"), Dr. Quill suggested that responding with a wish ("I wish I could promise that") and statements of empathy ("It must be hard to contemplate missing that; in case you cannot, perhaps you could ...") can provide support without creating unrealistic expectations.

Dr. Quill had no disclosures. The conference was sponsored by Elsevier Oncology, a company that is affiliated with this news organization.

CHICAGO - Oncologists can navigate the sensitive and arduous communication of painful news to patients with greater honesty and compassion by expressing wishes in response to their patients’ sense of loss, futility, or unrealistic hope, Dr. Timothy E. Quill, told attendees at the annual Chicago Supportive Oncology Conference.

Communicating with statements such as "I wish there was more we could do for you," "I wish I had better news to give you," "I wish things had turned out better," or "I wish our palliative care was more effective" communicates empathy and caring without distorting the truth, fostering a false sense of hope, or emotionally bludgeoning the patient, said Dr. Quill, director of the center for ethics, humanities, and palliative care at the University of Rochester (N.Y.).

Wishes are effective because they acknowledge the emotional impact of the patient’s illness and allow the physician to respond as a human being to the patient’s emotional distress, while communicating with gentleness and compassion that the hoped-for outcome is unlikely, explained Dr. Quill, a professor of medicine, psychiatry, and medical humanities at the university. Simultaneously – and paradoxically – wishes enable the physician to identify with the patient’s hope while casting that hope in a realistic light.

Dr. Quill stressed, however, that wish statements should be used only as the beginning of an important dialogue. Wishes acknowledge that a desired result probably will not happen, and can elicit anger, hopelessness, terror, and despair. It is essential to talk with patients about their feelings and experiences, he said. The failure to do so could cause emotional harm.

Questions following wish statements – such as "What has been the hardest part for you?" "What are your biggest concerns?" and "How is your family managing this?" – can help to guide meaningful communication. Also critical are statements that validate the patient’s experience ("Anyone going through this would have such feelings") and express empathy ("I can imagine that must have been frightening"), as well as efforts to facilitate opportunities for growth and closure in addressing short-term medical decisions, financial and legal affairs, unfinished personal and family business, and, possibly, spiritual, religious, and existential issues.

He emphasized that this communication must be accompanied by the search for new treatment direction and hope through the appropriate use of standard treatment options, experimental treatment, palliative care, or hospice care.

In responding to an expression of loss, grief, and hopelessness ("I do not see how I can go on"), Dr. Quill noted that the clinician does not have to have all the answers. A statement such as "I wish I had a simple formula" allows the physician to take the same emotional stance as the patient, whereas expressions of empathy ("Tell me about the scariest part," "We can work on this together") can help patients deal with intense emotions, such as fear of abandonment.

In responding to a patient’s expression of unrealistic hope ("I want to live to see the birth of my grandchild"), Dr. Quill suggested that responding with a wish ("I wish I could promise that") and statements of empathy ("It must be hard to contemplate missing that; in case you cannot, perhaps you could ...") can provide support without creating unrealistic expectations.

Dr. Quill had no disclosures. The conference was sponsored by Elsevier Oncology, a company that is affiliated with this news organization.

CHICAGO - Oncologists can navigate the sensitive and arduous communication of painful news to patients with greater honesty and compassion by expressing wishes in response to their patients’ sense of loss, futility, or unrealistic hope, Dr. Timothy E. Quill, told attendees at the annual Chicago Supportive Oncology Conference.

Communicating with statements such as "I wish there was more we could do for you," "I wish I had better news to give you," "I wish things had turned out better," or "I wish our palliative care was more effective" communicates empathy and caring without distorting the truth, fostering a false sense of hope, or emotionally bludgeoning the patient, said Dr. Quill, director of the center for ethics, humanities, and palliative care at the University of Rochester (N.Y.).

Wishes are effective because they acknowledge the emotional impact of the patient’s illness and allow the physician to respond as a human being to the patient’s emotional distress, while communicating with gentleness and compassion that the hoped-for outcome is unlikely, explained Dr. Quill, a professor of medicine, psychiatry, and medical humanities at the university. Simultaneously – and paradoxically – wishes enable the physician to identify with the patient’s hope while casting that hope in a realistic light.

Dr. Quill stressed, however, that wish statements should be used only as the beginning of an important dialogue. Wishes acknowledge that a desired result probably will not happen, and can elicit anger, hopelessness, terror, and despair. It is essential to talk with patients about their feelings and experiences, he said. The failure to do so could cause emotional harm.

Questions following wish statements – such as "What has been the hardest part for you?" "What are your biggest concerns?" and "How is your family managing this?" – can help to guide meaningful communication. Also critical are statements that validate the patient’s experience ("Anyone going through this would have such feelings") and express empathy ("I can imagine that must have been frightening"), as well as efforts to facilitate opportunities for growth and closure in addressing short-term medical decisions, financial and legal affairs, unfinished personal and family business, and, possibly, spiritual, religious, and existential issues.

He emphasized that this communication must be accompanied by the search for new treatment direction and hope through the appropriate use of standard treatment options, experimental treatment, palliative care, or hospice care.

In responding to an expression of loss, grief, and hopelessness ("I do not see how I can go on"), Dr. Quill noted that the clinician does not have to have all the answers. A statement such as "I wish I had a simple formula" allows the physician to take the same emotional stance as the patient, whereas expressions of empathy ("Tell me about the scariest part," "We can work on this together") can help patients deal with intense emotions, such as fear of abandonment.

In responding to a patient’s expression of unrealistic hope ("I want to live to see the birth of my grandchild"), Dr. Quill suggested that responding with a wish ("I wish I could promise that") and statements of empathy ("It must be hard to contemplate missing that; in case you cannot, perhaps you could ...") can provide support without creating unrealistic expectations.

Dr. Quill had no disclosures. The conference was sponsored by Elsevier Oncology, a company that is affiliated with this news organization.

CHICAGO - Oncologists can navigate the sensitive and arduous communication of painful news to patients with greater honesty and compassion by expressing wishes in response to their patients’ sense of loss, futility, or unrealistic hope, Dr. Timothy E. Quill, told attendees at the annual Chicago Supportive Oncology Conference.

Communicating with statements such as "I wish there was more we could do for you," "I wish I had better news to give you," "I wish things had turned out better," or "I wish our palliative care was more effective" communicates empathy and caring without distorting the truth, fostering a false sense of hope, or emotionally bludgeoning the patient, said Dr. Quill, director of the center for ethics, humanities, and palliative care at the University of Rochester (N.Y.).

Wishes are effective because they acknowledge the emotional impact of the patient’s illness and allow the physician to respond as a human being to the patient’s emotional distress, while communicating with gentleness and compassion that the hoped-for outcome is unlikely, explained Dr. Quill, a professor of medicine, psychiatry, and medical humanities at the university. Simultaneously – and paradoxically – wishes enable the physician to identify with the patient’s hope while casting that hope in a realistic light.

Dr. Quill stressed, however, that wish statements should be used only as the beginning of an important dialogue. Wishes acknowledge that a desired result probably will not happen, and can elicit anger, hopelessness, terror, and despair. It is essential to talk with patients about their feelings and experiences, he said. The failure to do so could cause emotional harm.

Questions following wish statements – such as "What has been the hardest part for you?" "What are your biggest concerns?" and "How is your family managing this?" – can help to guide meaningful communication. Also critical are statements that validate the patient’s experience ("Anyone going through this would have such feelings") and express empathy ("I can imagine that must have been frightening"), as well as efforts to facilitate opportunities for growth and closure in addressing short-term medical decisions, financial and legal affairs, unfinished personal and family business, and, possibly, spiritual, religious, and existential issues.

He emphasized that this communication must be accompanied by the search for new treatment direction and hope through the appropriate use of standard treatment options, experimental treatment, palliative care, or hospice care.

In responding to an expression of loss, grief, and hopelessness ("I do not see how I can go on"), Dr. Quill noted that the clinician does not have to have all the answers. A statement such as "I wish I had a simple formula" allows the physician to take the same emotional stance as the patient, whereas expressions of empathy ("Tell me about the scariest part," "We can work on this together") can help patients deal with intense emotions, such as fear of abandonment.

In responding to a patient’s expression of unrealistic hope ("I want to live to see the birth of my grandchild"), Dr. Quill suggested that responding with a wish ("I wish I could promise that") and statements of empathy ("It must be hard to contemplate missing that; in case you cannot, perhaps you could ...") can provide support without creating unrealistic expectations.

Dr. Quill had no disclosures. The conference was sponsored by Elsevier Oncology, a company that is affiliated with this news organization.

CHICAGO - Oncologists can navigate the sensitive and arduous communication of painful news to patients with greater honesty and compassion by expressing wishes in response to their patients’ sense of loss, futility, or unrealistic hope, Dr. Timothy E. Quill, told attendees at the annual Chicago Supportive Oncology Conference.

Communicating with statements such as "I wish there was more we could do for you," "I wish I had better news to give you," "I wish things had turned out better," or "I wish our palliative care was more effective" communicates empathy and caring without distorting the truth, fostering a false sense of hope, or emotionally bludgeoning the patient, said Dr. Quill, director of the center for ethics, humanities, and palliative care at the University of Rochester (N.Y.).

Wishes are effective because they acknowledge the emotional impact of the patient’s illness and allow the physician to respond as a human being to the patient’s emotional distress, while communicating with gentleness and compassion that the hoped-for outcome is unlikely, explained Dr. Quill, a professor of medicine, psychiatry, and medical humanities at the university. Simultaneously – and paradoxically – wishes enable the physician to identify with the patient’s hope while casting that hope in a realistic light.

Dr. Quill stressed, however, that wish statements should be used only as the beginning of an important dialogue. Wishes acknowledge that a desired result probably will not happen, and can elicit anger, hopelessness, terror, and despair. It is essential to talk with patients about their feelings and experiences, he said. The failure to do so could cause emotional harm.

Questions following wish statements – such as "What has been the hardest part for you?" "What are your biggest concerns?" and "How is your family managing this?" – can help to guide meaningful communication. Also critical are statements that validate the patient’s experience ("Anyone going through this would have such feelings") and express empathy ("I can imagine that must have been frightening"), as well as efforts to facilitate opportunities for growth and closure in addressing short-term medical decisions, financial and legal affairs, unfinished personal and family business, and, possibly, spiritual, religious, and existential issues.

He emphasized that this communication must be accompanied by the search for new treatment direction and hope through the appropriate use of standard treatment options, experimental treatment, palliative care, or hospice care.

In responding to an expression of loss, grief, and hopelessness ("I do not see how I can go on"), Dr. Quill noted that the clinician does not have to have all the answers. A statement such as "I wish I had a simple formula" allows the physician to take the same emotional stance as the patient, whereas expressions of empathy ("Tell me about the scariest part," "We can work on this together") can help patients deal with intense emotions, such as fear of abandonment.

In responding to a patient’s expression of unrealistic hope ("I want to live to see the birth of my grandchild"), Dr. Quill suggested that responding with a wish ("I wish I could promise that") and statements of empathy ("It must be hard to contemplate missing that; in case you cannot, perhaps you could ...") can provide support without creating unrealistic expectations.

Dr. Quill had no disclosures. The conference was sponsored by Elsevier Oncology, a company that is affiliated with this news organization.

CHICAGO - Oncologists can navigate the sensitive and arduous communication of painful news to patients with greater honesty and compassion by expressing wishes in response to their patients’ sense of loss, futility, or unrealistic hope, Dr. Timothy E. Quill, told attendees at the annual Chicago Supportive Oncology Conference.

Communicating with statements such as "I wish there was more we could do for you," "I wish I had better news to give you," "I wish things had turned out better," or "I wish our palliative care was more effective" communicates empathy and caring without distorting the truth, fostering a false sense of hope, or emotionally bludgeoning the patient, said Dr. Quill, director of the center for ethics, humanities, and palliative care at the University of Rochester (N.Y.).

Wishes are effective because they acknowledge the emotional impact of the patient’s illness and allow the physician to respond as a human being to the patient’s emotional distress, while communicating with gentleness and compassion that the hoped-for outcome is unlikely, explained Dr. Quill, a professor of medicine, psychiatry, and medical humanities at the university. Simultaneously – and paradoxically – wishes enable the physician to identify with the patient’s hope while casting that hope in a realistic light.

Dr. Quill stressed, however, that wish statements should be used only as the beginning of an important dialogue. Wishes acknowledge that a desired result probably will not happen, and can elicit anger, hopelessness, terror, and despair. It is essential to talk with patients about their feelings and experiences, he said. The failure to do so could cause emotional harm.

Questions following wish statements – such as "What has been the hardest part for you?" "What are your biggest concerns?" and "How is your family managing this?" – can help to guide meaningful communication. Also critical are statements that validate the patient’s experience ("Anyone going through this would have such feelings") and express empathy ("I can imagine that must have been frightening"), as well as efforts to facilitate opportunities for growth and closure in addressing short-term medical decisions, financial and legal affairs, unfinished personal and family business, and, possibly, spiritual, religious, and existential issues.

He emphasized that this communication must be accompanied by the search for new treatment direction and hope through the appropriate use of standard treatment options, experimental treatment, palliative care, or hospice care.

In responding to an expression of loss, grief, and hopelessness ("I do not see how I can go on"), Dr. Quill noted that the clinician does not have to have all the answers. A statement such as "I wish I had a simple formula" allows the physician to take the same emotional stance as the patient, whereas expressions of empathy ("Tell me about the scariest part," "We can work on this together") can help patients deal with intense emotions, such as fear of abandonment.

In responding to a patient’s expression of unrealistic hope ("I want to live to see the birth of my grandchild"), Dr. Quill suggested that responding with a wish ("I wish I could promise that") and statements of empathy ("It must be hard to contemplate missing that; in case you cannot, perhaps you could ...") can provide support without creating unrealistic expectations.

Dr. Quill had no disclosures. The conference was sponsored by Elsevier Oncology, a company that is affiliated with this news organization.

CHICAGO – Research on the psychology of loneliness is helping a large nonprofit organization better address the needs of socially isolated elders living in the community and, indirectly, reduce stress and burnout among the staff and volunteers who serve them.

Anna M. Walters, R.N., program director for the Chicago chapter of Little Brothers–Friends of the Elderly, explained that just over a year ago, Dr. John T. Cacioppo spoke to the organization about his work in the emerging field of social neuroscience. Ms. Walters reviewed the impact of that talk on her organization in a session she led with Dr. Cacioppo.

Dr. Cacioppo asserted that the feeling of loneliness is a “pain signal” that tells an individual that he or she is becoming disconnected from others. Biologically, the signal has helped the human species survive by motivating people to maintain contact.

People who fail to respond to the loneliness signal by finding meaningful connections risk a host of psychological and physical consequences, said Dr. Cacioppo, who is the director of the center for cognitive and social neuroscience at the University of Chicago. His and other studies have shown loneliness to be a major risk factor for morbidity and mortality, he added.

Ms. Walters said that Dr. Cacioppo's work led her to understand why some elders seem to be impervious to the support, friendship, and social opportunities offered to them through Little Brothers, whose mission is to relieve isolation and loneliness in adults older than age 70. “I had assumed we were making an impact with all our elders who met our criteria,” she said.

But she described “high need” elders as “intrinsically lonely” people who tend to maximize the negative and minimize the positive aspects of their lives. Their behavior can include lying, rudeness, and manipulation.

“Regardless of their level of isolation, regardless of how much we do for them, we can never do enough,” she said.

These individuals are on high alert for the danger of social rejection, and that state of fear becomes a self-fulfilling prophecy, Ms. Walters said. Some of these individuals also may be suffering from depression or bipolar disorder.

She contrasted these individuals with the “extrinsically lonely” whose loneliness is primarily situational; for example, those for whom transportation is a problem or those who have outlived all of their friends. When friendship is offered to them, such extrinisically lonely individuals typically blossom.

“I began to think … that when we cannot do enough [for high-need elders], one of the most important things I can do is to acknowledge and validate the staff and the volunteers,” Ms. Walters said. Knowing that dealing with these elders can be emotionally draining, Ms. Walters now makes a point of telling the caregivers that their difficulty in connecting is not their own failing. Realizing that, the caregivers develop more realistic expectations.

Ms. Walters also has begun to provide training programs on issues such as depression, hoarding, cultural and generational differences, and undeveloped relationship skills. Monthly support groups help staff and volunteers cope with stress, anxiety, and grief.

The program also offers guidance on maintaining healthy boundaries with elders who persistently focus on the negative and make unreasonable demands.

Ms. Walters counsels her staff to communicate compassionately but clearly with these high-need individuals about reasonable expectations. The overall message she tries to give to staff and volunteers is that “you are doing everything you can do. There are some issues we cannot fix, and that's okay,” she said.

The Chicago chapter of Little Brothers–Friends of the Elderly served 1,100 elders in 2009 (mean age, 83 years).

More information about LBFE is available at www.littlebrotherschicago.org

Staff at the Chicago chapter of LBFE are taught to communicate compassionately but clearly with elders.

Source Courtesy Little Brothers Friends of the Elderly Chicago Chapter

CHICAGO – Research on the psychology of loneliness is helping a large nonprofit organization better address the needs of socially isolated elders living in the community and, indirectly, reduce stress and burnout among the staff and volunteers who serve them.

Anna M. Walters, R.N., program director for the Chicago chapter of Little Brothers–Friends of the Elderly, explained that just over a year ago, Dr. John T. Cacioppo spoke to the organization about his work in the emerging field of social neuroscience. Ms. Walters reviewed the impact of that talk on her organization in a session she led with Dr. Cacioppo.

Dr. Cacioppo asserted that the feeling of loneliness is a “pain signal” that tells an individual that he or she is becoming disconnected from others. Biologically, the signal has helped the human species survive by motivating people to maintain contact.

People who fail to respond to the loneliness signal by finding meaningful connections risk a host of psychological and physical consequences, said Dr. Cacioppo, who is the director of the center for cognitive and social neuroscience at the University of Chicago. His and other studies have shown loneliness to be a major risk factor for morbidity and mortality, he added.

Ms. Walters said that Dr. Cacioppo's work led her to understand why some elders seem to be impervious to the support, friendship, and social opportunities offered to them through Little Brothers, whose mission is to relieve isolation and loneliness in adults older than age 70. “I had assumed we were making an impact with all our elders who met our criteria,” she said.

But she described “high need” elders as “intrinsically lonely” people who tend to maximize the negative and minimize the positive aspects of their lives. Their behavior can include lying, rudeness, and manipulation.

“Regardless of their level of isolation, regardless of how much we do for them, we can never do enough,” she said.

These individuals are on high alert for the danger of social rejection, and that state of fear becomes a self-fulfilling prophecy, Ms. Walters said. Some of these individuals also may be suffering from depression or bipolar disorder.

She contrasted these individuals with the “extrinsically lonely” whose loneliness is primarily situational; for example, those for whom transportation is a problem or those who have outlived all of their friends. When friendship is offered to them, such extrinisically lonely individuals typically blossom.

“I began to think … that when we cannot do enough [for high-need elders], one of the most important things I can do is to acknowledge and validate the staff and the volunteers,” Ms. Walters said. Knowing that dealing with these elders can be emotionally draining, Ms. Walters now makes a point of telling the caregivers that their difficulty in connecting is not their own failing. Realizing that, the caregivers develop more realistic expectations.

Ms. Walters also has begun to provide training programs on issues such as depression, hoarding, cultural and generational differences, and undeveloped relationship skills. Monthly support groups help staff and volunteers cope with stress, anxiety, and grief.

The program also offers guidance on maintaining healthy boundaries with elders who persistently focus on the negative and make unreasonable demands.

Ms. Walters counsels her staff to communicate compassionately but clearly with these high-need individuals about reasonable expectations. The overall message she tries to give to staff and volunteers is that “you are doing everything you can do. There are some issues we cannot fix, and that's okay,” she said.

The Chicago chapter of Little Brothers–Friends of the Elderly served 1,100 elders in 2009 (mean age, 83 years).

More information about LBFE is available at www.littlebrotherschicago.org

Staff at the Chicago chapter of LBFE are taught to communicate compassionately but clearly with elders.

Source Courtesy Little Brothers Friends of the Elderly Chicago Chapter

CHICAGO – Research on the psychology of loneliness is helping a large nonprofit organization better address the needs of socially isolated elders living in the community and, indirectly, reduce stress and burnout among the staff and volunteers who serve them.

Anna M. Walters, R.N., program director for the Chicago chapter of Little Brothers–Friends of the Elderly, explained that just over a year ago, Dr. John T. Cacioppo spoke to the organization about his work in the emerging field of social neuroscience. Ms. Walters reviewed the impact of that talk on her organization in a session she led with Dr. Cacioppo.

Dr. Cacioppo asserted that the feeling of loneliness is a “pain signal” that tells an individual that he or she is becoming disconnected from others. Biologically, the signal has helped the human species survive by motivating people to maintain contact.

People who fail to respond to the loneliness signal by finding meaningful connections risk a host of psychological and physical consequences, said Dr. Cacioppo, who is the director of the center for cognitive and social neuroscience at the University of Chicago. His and other studies have shown loneliness to be a major risk factor for morbidity and mortality, he added.

Ms. Walters said that Dr. Cacioppo's work led her to understand why some elders seem to be impervious to the support, friendship, and social opportunities offered to them through Little Brothers, whose mission is to relieve isolation and loneliness in adults older than age 70. “I had assumed we were making an impact with all our elders who met our criteria,” she said.

But she described “high need” elders as “intrinsically lonely” people who tend to maximize the negative and minimize the positive aspects of their lives. Their behavior can include lying, rudeness, and manipulation.

“Regardless of their level of isolation, regardless of how much we do for them, we can never do enough,” she said.

These individuals are on high alert for the danger of social rejection, and that state of fear becomes a self-fulfilling prophecy, Ms. Walters said. Some of these individuals also may be suffering from depression or bipolar disorder.

She contrasted these individuals with the “extrinsically lonely” whose loneliness is primarily situational; for example, those for whom transportation is a problem or those who have outlived all of their friends. When friendship is offered to them, such extrinisically lonely individuals typically blossom.

“I began to think … that when we cannot do enough [for high-need elders], one of the most important things I can do is to acknowledge and validate the staff and the volunteers,” Ms. Walters said. Knowing that dealing with these elders can be emotionally draining, Ms. Walters now makes a point of telling the caregivers that their difficulty in connecting is not their own failing. Realizing that, the caregivers develop more realistic expectations.

Ms. Walters also has begun to provide training programs on issues such as depression, hoarding, cultural and generational differences, and undeveloped relationship skills. Monthly support groups help staff and volunteers cope with stress, anxiety, and grief.

The program also offers guidance on maintaining healthy boundaries with elders who persistently focus on the negative and make unreasonable demands.

Ms. Walters counsels her staff to communicate compassionately but clearly with these high-need individuals about reasonable expectations. The overall message she tries to give to staff and volunteers is that “you are doing everything you can do. There are some issues we cannot fix, and that's okay,” she said.

The Chicago chapter of Little Brothers–Friends of the Elderly served 1,100 elders in 2009 (mean age, 83 years).

More information about LBFE is available at www.littlebrotherschicago.org

Staff at the Chicago chapter of LBFE are taught to communicate compassionately but clearly with elders.

Source Courtesy Little Brothers Friends of the Elderly Chicago Chapter

CHICAGO – A study of 119 cancer patients with solid tumors suggests that the complexity of some oral chemotherapeutic regimens can interfere with adherence to treatment.

Only one-third to one-half of patients on various intermittent regimens was fully compliant with their dosing schedules, reported Barbara A. Given, Ph.D., at the annual Chicago Supportive Oncology Conference.

Patients on simple regimens were much less likely to miss doses of oral drugs or to take doses on off days, according to Dr. Given, a registered nurse and associate dean of research in the college of nursing at Michigan State University in East Lansing.

The study assessed the feasibility of using an automated voice response (AVR) system to remind patients about their dosing schedules, to monitor adherence and medication side effects, and to identify patients in need of additional nursing support.

Investigators randomized patients with solid tumors (primarily of the breast and lung) who were treated with nonhormonal oral biologics to the following three groups:

• Weekly AVR calls during weeks 1-8 for evaluation of adherence and 15 symptoms.

• Weekly AVR calls for adherence and symptom evaluation, as well as nurse follow-up calls during weeks 5-8 if any symptom was above threshold or adherence was 80% or less.

• Weekly AVR calls for adherence evaluation only, with nurse assistance during weeks 5-8 for 80% or less adherence.

Patients were primarily women (82%) with a mean age of 61 years. All participants received a tool kit containing frequently asked questions and symptom self-management strategies. They were interviewed at baseline and at 10 weeks regarding symptom severity, depression, beliefs about oral agents, and cost of therapy.

Initially, 119 patients were enrolled in the study. Through attrition, the number of participants fell to 91 at 10 weeks. Investigators interviewed these patients about their satisfaction with AVR.

Adherence did not differ significantly among patients in any of the three arms, and neither symptom severity nor depression at intake was related to adherence. Symptom severity decreased in all three arms at 10 weeks, although symptom severity among lung cancer patients did not improve. At 8 weeks, 33% of patients had experienced adherence problems, with regimen complexity the major contributor.

"We would like to know what would happen at 12, 15, and 20 weeks, since some of [these patients] are on drugs for a long time," Dr. Given said.

Based on 100 patients assessed, the percentage who missed three or more doses was 12% among those on a consistent regimen (28 days on medication), but was 60%, 67%, and 38% among those on an intermittent regimen (14 days on, 7 days off; 7 days on, 7 days off; and other regimens, respectively).

Only 2% of patients on a consistent regimen overadhered to treatment (that is, took medication on an off day); however, 48%, 67%, and 13% of patients on the respective intermittent cycles overadhered. "Patients who overadhered by the end of the study really had worse symptoms, which then gave us another set of problems to deal with," Dr. Given said, reporting that patients who overadhered had an average score of 19 on the Symptom Experience Inventory, whereas those who did not overadhere scored 13.

Patients with breast tumors had a mean SEI score of 18.9 on intake and 12.8 at 10 weeks, whereas lung cancer patients scored a mean of 18.1 on intake and 18.4 at 10 weeks. Patients with other tumors had a mean score of 19.1 on intake and 12.4 at 10 weeks.

Full adherence was found in 88% of patients on the consistent cycle, but in only 36%, 33%, and 50% of patients on the respective intermittent cycles.

More than half of participants reported that AVR helped them manage their symptoms. A Web-based AVR system to help patients with adherence and symptom management "adds value" for patients, practitioners, and payers, and it can improve outcomes by allowing patients to be followed over time, Dr. Given said.

Specialty pharmacies also could help to educate patients, she added.

The Oncology Nursing Society funded the study. Dr. Given had no conflicts of interest.

CHICAGO – A study of 119 cancer patients with solid tumors suggests that the complexity of some oral chemotherapeutic regimens can interfere with adherence to treatment.

Only one-third to one-half of patients on various intermittent regimens was fully compliant with their dosing schedules, reported Barbara A. Given, Ph.D., at the annual Chicago Supportive Oncology Conference.

Patients on simple regimens were much less likely to miss doses of oral drugs or to take doses on off days, according to Dr. Given, a registered nurse and associate dean of research in the college of nursing at Michigan State University in East Lansing.

The study assessed the feasibility of using an automated voice response (AVR) system to remind patients about their dosing schedules, to monitor adherence and medication side effects, and to identify patients in need of additional nursing support.

Investigators randomized patients with solid tumors (primarily of the breast and lung) who were treated with nonhormonal oral biologics to the following three groups:

• Weekly AVR calls during weeks 1-8 for evaluation of adherence and 15 symptoms.

• Weekly AVR calls for adherence and symptom evaluation, as well as nurse follow-up calls during weeks 5-8 if any symptom was above threshold or adherence was 80% or less.

• Weekly AVR calls for adherence evaluation only, with nurse assistance during weeks 5-8 for 80% or less adherence.

Patients were primarily women (82%) with a mean age of 61 years. All participants received a tool kit containing frequently asked questions and symptom self-management strategies. They were interviewed at baseline and at 10 weeks regarding symptom severity, depression, beliefs about oral agents, and cost of therapy.

Initially, 119 patients were enrolled in the study. Through attrition, the number of participants fell to 91 at 10 weeks. Investigators interviewed these patients about their satisfaction with AVR.

Adherence did not differ significantly among patients in any of the three arms, and neither symptom severity nor depression at intake was related to adherence. Symptom severity decreased in all three arms at 10 weeks, although symptom severity among lung cancer patients did not improve. At 8 weeks, 33% of patients had experienced adherence problems, with regimen complexity the major contributor.

"We would like to know what would happen at 12, 15, and 20 weeks, since some of [these patients] are on drugs for a long time," Dr. Given said.

Based on 100 patients assessed, the percentage who missed three or more doses was 12% among those on a consistent regimen (28 days on medication), but was 60%, 67%, and 38% among those on an intermittent regimen (14 days on, 7 days off; 7 days on, 7 days off; and other regimens, respectively).

Only 2% of patients on a consistent regimen overadhered to treatment (that is, took medication on an off day); however, 48%, 67%, and 13% of patients on the respective intermittent cycles overadhered. "Patients who overadhered by the end of the study really had worse symptoms, which then gave us another set of problems to deal with," Dr. Given said, reporting that patients who overadhered had an average score of 19 on the Symptom Experience Inventory, whereas those who did not overadhere scored 13.

Patients with breast tumors had a mean SEI score of 18.9 on intake and 12.8 at 10 weeks, whereas lung cancer patients scored a mean of 18.1 on intake and 18.4 at 10 weeks. Patients with other tumors had a mean score of 19.1 on intake and 12.4 at 10 weeks.

Full adherence was found in 88% of patients on the consistent cycle, but in only 36%, 33%, and 50% of patients on the respective intermittent cycles.

More than half of participants reported that AVR helped them manage their symptoms. A Web-based AVR system to help patients with adherence and symptom management "adds value" for patients, practitioners, and payers, and it can improve outcomes by allowing patients to be followed over time, Dr. Given said.

Specialty pharmacies also could help to educate patients, she added.

The Oncology Nursing Society funded the study. Dr. Given had no conflicts of interest.

CHICAGO – A study of 119 cancer patients with solid tumors suggests that the complexity of some oral chemotherapeutic regimens can interfere with adherence to treatment.

Only one-third to one-half of patients on various intermittent regimens was fully compliant with their dosing schedules, reported Barbara A. Given, Ph.D., at the annual Chicago Supportive Oncology Conference.

Patients on simple regimens were much less likely to miss doses of oral drugs or to take doses on off days, according to Dr. Given, a registered nurse and associate dean of research in the college of nursing at Michigan State University in East Lansing.

The study assessed the feasibility of using an automated voice response (AVR) system to remind patients about their dosing schedules, to monitor adherence and medication side effects, and to identify patients in need of additional nursing support.

Investigators randomized patients with solid tumors (primarily of the breast and lung) who were treated with nonhormonal oral biologics to the following three groups:

• Weekly AVR calls during weeks 1-8 for evaluation of adherence and 15 symptoms.

• Weekly AVR calls for adherence and symptom evaluation, as well as nurse follow-up calls during weeks 5-8 if any symptom was above threshold or adherence was 80% or less.

• Weekly AVR calls for adherence evaluation only, with nurse assistance during weeks 5-8 for 80% or less adherence.

Patients were primarily women (82%) with a mean age of 61 years. All participants received a tool kit containing frequently asked questions and symptom self-management strategies. They were interviewed at baseline and at 10 weeks regarding symptom severity, depression, beliefs about oral agents, and cost of therapy.

Initially, 119 patients were enrolled in the study. Through attrition, the number of participants fell to 91 at 10 weeks. Investigators interviewed these patients about their satisfaction with AVR.

Adherence did not differ significantly among patients in any of the three arms, and neither symptom severity nor depression at intake was related to adherence. Symptom severity decreased in all three arms at 10 weeks, although symptom severity among lung cancer patients did not improve. At 8 weeks, 33% of patients had experienced adherence problems, with regimen complexity the major contributor.

"We would like to know what would happen at 12, 15, and 20 weeks, since some of [these patients] are on drugs for a long time," Dr. Given said.

Based on 100 patients assessed, the percentage who missed three or more doses was 12% among those on a consistent regimen (28 days on medication), but was 60%, 67%, and 38% among those on an intermittent regimen (14 days on, 7 days off; 7 days on, 7 days off; and other regimens, respectively).

Only 2% of patients on a consistent regimen overadhered to treatment (that is, took medication on an off day); however, 48%, 67%, and 13% of patients on the respective intermittent cycles overadhered. "Patients who overadhered by the end of the study really had worse symptoms, which then gave us another set of problems to deal with," Dr. Given said, reporting that patients who overadhered had an average score of 19 on the Symptom Experience Inventory, whereas those who did not overadhere scored 13.

Patients with breast tumors had a mean SEI score of 18.9 on intake and 12.8 at 10 weeks, whereas lung cancer patients scored a mean of 18.1 on intake and 18.4 at 10 weeks. Patients with other tumors had a mean score of 19.1 on intake and 12.4 at 10 weeks.

Full adherence was found in 88% of patients on the consistent cycle, but in only 36%, 33%, and 50% of patients on the respective intermittent cycles.

More than half of participants reported that AVR helped them manage their symptoms. A Web-based AVR system to help patients with adherence and symptom management "adds value" for patients, practitioners, and payers, and it can improve outcomes by allowing patients to be followed over time, Dr. Given said.

Specialty pharmacies also could help to educate patients, she added.

The Oncology Nursing Society funded the study. Dr. Given had no conflicts of interest.

CHICAGO — Twenty percent of health insurance claims are processed inaccurately, according to the American Medical Association's third annual National Health Insurer Report Card, which rates the nation's largest commercial insurers on timeliness and accuracy of claims processing.

Eliminating discrepancies in expected payment amounts would save doctors and insurers $15.5 billion annually, according to the report, which is based on a random sample of 2 million claims for 3.5 million services filed electronically February-March 2010 by 200 practices in 43 states.

Each year, claims processing costs as much as $210 billion and takes up 10%-14% of physicians' gross revenue and the equivalent for each physician of 5 work weeks, Dr. Nancy H. Nielsen, then immediate past president of the AMA, said in an educational session.

To remedy the problem, the AMA urges the creation of a single, transparent insurance industry standard “so that everybody knows in a seamless way how those claims are to be submitted and processed,” Dr. Nielsen said, adding that such a standard would reduce errors and free physicians to focus more on patients and less on administrative red tape.

Insurers made gains in some areas, including accuracy in the reporting of contract fees to physicians. They correctly reported contract fees 78%-94% of the time in 2010 versus 62%-87% of the time in 2008, Dr. Nielson said.

They also increased the transparency and accessibility of their fee schedules, according to Mark Rieger, chief executive officer of National Healthcare Exchange Services, Inc. of Sacramento, which conducted the research.

Physicians' electronic access to complete fee schedules plays a major role in processing accuracy, he said. “Where the payer makes the fee schedule available we have higher match rates.”

“There's still a need for better transparency. But we're optimistic that if payers continue to demonstrate some of the improvements that they've shown” additional efficiencies can be gained, he said.

Coventry Health Care, Inc. had the highest overall accuracy (88%), while Anthem Blue Cross Blue Shield had the lowest (74%). Other insurers addressed by the report were Aetna, CIGNA, Health Care Services Corporation, Humana, and UnitedHealth Group.

Mr. Rieger said that every 1% increase in the match rate for claims would generate a conservatively estimated $777.6 million for physicians and payers. A 100% match rate would yield an annual savings of $15.5 billion.

The AMA asked physicians to do their part to improve the claims process by working to submit claims correctly the first time and implementing practice efficiencies such as an effective electronic practice management system, said Tammy Banks, AMA director of practice management and payment advocacy. “There's a lot going on in the next five to 10 years. Make sure that your vendor is willing to notify you of changes and upgrades” in federal and state mandates and transaction codes, she emphasized.

Administrative portals for claims processing are not a long-term replacement for a direct relationship with payers through an effective electronic practice management system, she said.

The National Health Insurer Report Card is available at http://www.ama-assn.org/ama1/pub/upload/mm/368/2010-nhirc-results.pdf

CHICAGO — Twenty percent of health insurance claims are processed inaccurately, according to the American Medical Association's third annual National Health Insurer Report Card, which rates the nation's largest commercial insurers on timeliness and accuracy of claims processing.

Eliminating discrepancies in expected payment amounts would save doctors and insurers $15.5 billion annually, according to the report, which is based on a random sample of 2 million claims for 3.5 million services filed electronically February-March 2010 by 200 practices in 43 states.

Each year, claims processing costs as much as $210 billion and takes up 10%-14% of physicians' gross revenue and the equivalent for each physician of 5 work weeks, Dr. Nancy H. Nielsen, then immediate past president of the AMA, said in an educational session.

To remedy the problem, the AMA urges the creation of a single, transparent insurance industry standard “so that everybody knows in a seamless way how those claims are to be submitted and processed,” Dr. Nielsen said, adding that such a standard would reduce errors and free physicians to focus more on patients and less on administrative red tape.

Insurers made gains in some areas, including accuracy in the reporting of contract fees to physicians. They correctly reported contract fees 78%-94% of the time in 2010 versus 62%-87% of the time in 2008, Dr. Nielson said.

They also increased the transparency and accessibility of their fee schedules, according to Mark Rieger, chief executive officer of National Healthcare Exchange Services, Inc. of Sacramento, which conducted the research.

Physicians' electronic access to complete fee schedules plays a major role in processing accuracy, he said. “Where the payer makes the fee schedule available we have higher match rates.”

“There's still a need for better transparency. But we're optimistic that if payers continue to demonstrate some of the improvements that they've shown” additional efficiencies can be gained, he said.

Coventry Health Care, Inc. had the highest overall accuracy (88%), while Anthem Blue Cross Blue Shield had the lowest (74%). Other insurers addressed by the report were Aetna, CIGNA, Health Care Services Corporation, Humana, and UnitedHealth Group.

Mr. Rieger said that every 1% increase in the match rate for claims would generate a conservatively estimated $777.6 million for physicians and payers. A 100% match rate would yield an annual savings of $15.5 billion.

The AMA asked physicians to do their part to improve the claims process by working to submit claims correctly the first time and implementing practice efficiencies such as an effective electronic practice management system, said Tammy Banks, AMA director of practice management and payment advocacy. “There's a lot going on in the next five to 10 years. Make sure that your vendor is willing to notify you of changes and upgrades” in federal and state mandates and transaction codes, she emphasized.

Administrative portals for claims processing are not a long-term replacement for a direct relationship with payers through an effective electronic practice management system, she said.

The National Health Insurer Report Card is available at http://www.ama-assn.org/ama1/pub/upload/mm/368/2010-nhirc-results.pdf

CHICAGO — Twenty percent of health insurance claims are processed inaccurately, according to the American Medical Association's third annual National Health Insurer Report Card, which rates the nation's largest commercial insurers on timeliness and accuracy of claims processing.

Eliminating discrepancies in expected payment amounts would save doctors and insurers $15.5 billion annually, according to the report, which is based on a random sample of 2 million claims for 3.5 million services filed electronically February-March 2010 by 200 practices in 43 states.

Each year, claims processing costs as much as $210 billion and takes up 10%-14% of physicians' gross revenue and the equivalent for each physician of 5 work weeks, Dr. Nancy H. Nielsen, then immediate past president of the AMA, said in an educational session.

To remedy the problem, the AMA urges the creation of a single, transparent insurance industry standard “so that everybody knows in a seamless way how those claims are to be submitted and processed,” Dr. Nielsen said, adding that such a standard would reduce errors and free physicians to focus more on patients and less on administrative red tape.

Insurers made gains in some areas, including accuracy in the reporting of contract fees to physicians. They correctly reported contract fees 78%-94% of the time in 2010 versus 62%-87% of the time in 2008, Dr. Nielson said.

They also increased the transparency and accessibility of their fee schedules, according to Mark Rieger, chief executive officer of National Healthcare Exchange Services, Inc. of Sacramento, which conducted the research.

Physicians' electronic access to complete fee schedules plays a major role in processing accuracy, he said. “Where the payer makes the fee schedule available we have higher match rates.”

“There's still a need for better transparency. But we're optimistic that if payers continue to demonstrate some of the improvements that they've shown” additional efficiencies can be gained, he said.

Coventry Health Care, Inc. had the highest overall accuracy (88%), while Anthem Blue Cross Blue Shield had the lowest (74%). Other insurers addressed by the report were Aetna, CIGNA, Health Care Services Corporation, Humana, and UnitedHealth Group.

Mr. Rieger said that every 1% increase in the match rate for claims would generate a conservatively estimated $777.6 million for physicians and payers. A 100% match rate would yield an annual savings of $15.5 billion.

The AMA asked physicians to do their part to improve the claims process by working to submit claims correctly the first time and implementing practice efficiencies such as an effective electronic practice management system, said Tammy Banks, AMA director of practice management and payment advocacy. “There's a lot going on in the next five to 10 years. Make sure that your vendor is willing to notify you of changes and upgrades” in federal and state mandates and transaction codes, she emphasized.

Administrative portals for claims processing are not a long-term replacement for a direct relationship with payers through an effective electronic practice management system, she said.

The National Health Insurer Report Card is available at http://www.ama-assn.org/ama1/pub/upload/mm/368/2010-nhirc-results.pdf

CHICAGO — Frustration and concern about the lack of a permanent replacement for the Medicare Sustainable Growth Rate formula held center stage at the meeting.

Delegates passed a resolution calling for the AMA to “immediately formulate legislation for an additional payment option in Medicare fee for service that allows patients and physicians to freely contract, without penalty to either party, for a fee that differs from the Medicare payment schedule.”

Such a fee-for-service option would allow physicians to “balance bill”—they could bill patients for the difference between the Medicare fee schedule and their regular fee schedules.

In addition to helping physicians keep pace with inflation, the option would “give patients control of their Medicare benefit” by allowing them to use the 80% of the fee schedule that they receive from the government plan with physicians outside of “the very strict confines of a participating Medicare physician provider,” Dr. David O. Barbe, a member of the AMA board of trustees, said in an interview.

According to the resolution, the AMA must present the legislative language to its members by Sept. 30.

Introduced as an amendment from the floor during voting, the resolution provided teeth and proactive fervor to another proposed resolution from the AMA's legislative reference committee calling for the organization to study alternative payment options. The resolution that was passed eliminates this step.

Patients “want the conversation about health care to come from their doctors,” Dr. Marcy Zwelling-Aamot, president of the American Academy of Private Physicians, said in support of the substitute resolution, which passed by a large margin.

“I don't want Congress writing the bill about how I'm going to take care of my patients. We should write the bill. We don't need a study, we need action,” she added.

At a “Write Coat Rally” prior to the start of the house proceedings, delegates expressed opposition to the current Medicare payment system.

“Physicians want to care for seniors, but multiple short-term delays have created instability for physician practices nationwide, and this cut is basically the last straw,” Dr. J. James Rohack, then president of the AMA, said during a press conference at the meeting.

He cited a recent AMA survey of 9,000 physicians indicating that one in five physicians overall and nearly one in three primary care physicians currently restrict the number of Medicare patients they see because they feel Medicare payment rates are too low or that the likelihood of additional cuts makes Medicare an unreliable payer.

At the rally, delegates wrote on white lab coats about the urgent need for a workable alternative to the Sustainable Growth Rate (SGR) formula. The lab coats were delivered to Congress after the meeting.

Support for the resolution during the voting session was strong but not unanimous. AMA Past President Richard F. Corlin said that a bill from the AMA asking that physicians be allowed to contract for a fee that differs from Medicare payment and that does not forfeit benefits “is completely unachievable and will cause us to not be taken seriously by other people who would like to be our allies.”

He recommended focusing instead on changing the 2-year drop-out rule that prohibits physicians who opt out of Medicare from submitting claims to Medicare for any of their patients for 2 years.

“Let me abide by the Medicare limits for the patient who can't afford any more, and let me go my own way and bill what I want for the patient who can,” he argued.

Other delegates felt the resolution was too narrowly focused on physicians' financial interests and could ultimately do physicians more harm than good.

“We cannot keep going and asking for more and more money based on what we want to get without cutting the costs down,” said Dr. Lynn Parry, a Denver neurologist who received applause for her comments.

“None of this discussion has talked about our responsibilities; it's just talked about what we want. It's going to make us look stupid; it's going to make us look greedy; it's going to come back and haunt us.”

According to Dr. Jeff Terry of the Alabama delegation, “We're not asking for more. … We're asking for continued access for our patients to care. This is not greedy to say the least.”

Dr. Jeffrey W. Cozzens of the American Association of Neurological Surgeons added, “By having legislation that we wrote, we'll show the world that we have solutions to this problem.”

Dr. Barbe added, “If [the federal government is] not able to provide access for patients by providing appropriate reimbursement to physicians … then take off the [price] caps. Pay whatever you can pay … and then let the market take care of the rest. Let the patient and the doctor decide what that service is worth.”

Although the SGR formula and physician pay dominated action at the House of Delegates meeting, other topics were deliberated. Among them were:

▸ Skin cancer awareness. Delegates voted for the AMA to work with public health agencies and specialty societies, such as the American Academy of Dermatology, to promote screening for skin cancer as well as education about sun-protective behavior among people of color.

Five-year survival rates for melanoma are significantly lower among African Americans than whites (58.8% vs. 84.8%), and melanoma incidence among Hispanics now approaches that of whites, according to a statement from the AMA.

Noting that African Americans and Hispanics are much less likely to practice sun-protective behaviors, AMA board of trustees member Peter W. Carmel said, “All patients regardless of race or ethnicity should use the same sun-protection measures including sunscreen of at least SPF 15, avoid the sun during peak hours, and [get] regular exams.”

▸ Support for new antibiotics. Delegates adopted a policy to educate the public, physicians, the Obama administration, and Congress regarding the looming problem of antimicrobial resistance and the shortage of new antibiotic drugs in the development pipeline.

Specifically, the policy endorses the “10 20” initiative sponsored by the Infectious Diseases Society of America. This initiative urges global action by political, scientific, medical, industry, and policy leaders to drive the development of at least 10 effective new antibiotics by 2020.

▸ Smoke-free housing. Delegates passed a resolution to encourage federal, state, and local housing authorities to adopt policies prohibiting smoking in multiunit housing.

The word “public” was removed from language recommended by the public health reference committee to broaden support for efforts to include private multiunit housing as well. Mention was made on the floor of evidence pointing to the health hazards of third-hand smoke, the residue that remains on walls, carpeting, and other surfaces for extended periods.

▸ E-cigarette regulation. Delegates voted in favor of a report from the AMA Council on Science and Public Health recommending that e-cigarettes be classified as drug delivery devices and be subject to regulation by the Food and Drug Administration with standards for identity, strength, purity, packaging, and labeling, and with instructions and contraindications for use.

The new policy also asks state legislatures to prohibit the sale of non–FDA-approved e-cigarettes and recommends that the devices be covered by smoke-free laws but be classified separately from tobacco products.

▸ Education about the Gulf oil spill. Delegates approved a policy advocating that the AMA work to educate health professionals and the public about the potential health risks of oil spills and to encourage research on the Gulf oil spill's impact on air and water quality.

CHICAGO — Frustration and concern about the lack of a permanent replacement for the Medicare Sustainable Growth Rate formula held center stage at the meeting.

Delegates passed a resolution calling for the AMA to “immediately formulate legislation for an additional payment option in Medicare fee for service that allows patients and physicians to freely contract, without penalty to either party, for a fee that differs from the Medicare payment schedule.”

Such a fee-for-service option would allow physicians to “balance bill”—they could bill patients for the difference between the Medicare fee schedule and their regular fee schedules.

In addition to helping physicians keep pace with inflation, the option would “give patients control of their Medicare benefit” by allowing them to use the 80% of the fee schedule that they receive from the government plan with physicians outside of “the very strict confines of a participating Medicare physician provider,” Dr. David O. Barbe, a member of the AMA board of trustees, said in an interview.

According to the resolution, the AMA must present the legislative language to its members by Sept. 30.

Introduced as an amendment from the floor during voting, the resolution provided teeth and proactive fervor to another proposed resolution from the AMA's legislative reference committee calling for the organization to study alternative payment options. The resolution that was passed eliminates this step.

Patients “want the conversation about health care to come from their doctors,” Dr. Marcy Zwelling-Aamot, president of the American Academy of Private Physicians, said in support of the substitute resolution, which passed by a large margin.

“I don't want Congress writing the bill about how I'm going to take care of my patients. We should write the bill. We don't need a study, we need action,” she added.

At a “Write Coat Rally” prior to the start of the house proceedings, delegates expressed opposition to the current Medicare payment system.

“Physicians want to care for seniors, but multiple short-term delays have created instability for physician practices nationwide, and this cut is basically the last straw,” Dr. J. James Rohack, then president of the AMA, said during a press conference at the meeting.

He cited a recent AMA survey of 9,000 physicians indicating that one in five physicians overall and nearly one in three primary care physicians currently restrict the number of Medicare patients they see because they feel Medicare payment rates are too low or that the likelihood of additional cuts makes Medicare an unreliable payer.

At the rally, delegates wrote on white lab coats about the urgent need for a workable alternative to the Sustainable Growth Rate (SGR) formula. The lab coats were delivered to Congress after the meeting.

Support for the resolution during the voting session was strong but not unanimous. AMA Past President Richard F. Corlin said that a bill from the AMA asking that physicians be allowed to contract for a fee that differs from Medicare payment and that does not forfeit benefits “is completely unachievable and will cause us to not be taken seriously by other people who would like to be our allies.”

He recommended focusing instead on changing the 2-year drop-out rule that prohibits physicians who opt out of Medicare from submitting claims to Medicare for any of their patients for 2 years.

“Let me abide by the Medicare limits for the patient who can't afford any more, and let me go my own way and bill what I want for the patient who can,” he argued.

Other delegates felt the resolution was too narrowly focused on physicians' financial interests and could ultimately do physicians more harm than good.

“We cannot keep going and asking for more and more money based on what we want to get without cutting the costs down,” said Dr. Lynn Parry, a Denver neurologist who received applause for her comments.

“None of this discussion has talked about our responsibilities; it's just talked about what we want. It's going to make us look stupid; it's going to make us look greedy; it's going to come back and haunt us.”

According to Dr. Jeff Terry of the Alabama delegation, “We're not asking for more. … We're asking for continued access for our patients to care. This is not greedy to say the least.”

Dr. Jeffrey W. Cozzens of the American Association of Neurological Surgeons added, “By having legislation that we wrote, we'll show the world that we have solutions to this problem.”

Dr. Barbe added, “If [the federal government is] not able to provide access for patients by providing appropriate reimbursement to physicians … then take off the [price] caps. Pay whatever you can pay … and then let the market take care of the rest. Let the patient and the doctor decide what that service is worth.”

Although the SGR formula and physician pay dominated action at the House of Delegates meeting, other topics were deliberated. Among them were:

▸ Skin cancer awareness. Delegates voted for the AMA to work with public health agencies and specialty societies, such as the American Academy of Dermatology, to promote screening for skin cancer as well as education about sun-protective behavior among people of color.

Five-year survival rates for melanoma are significantly lower among African Americans than whites (58.8% vs. 84.8%), and melanoma incidence among Hispanics now approaches that of whites, according to a statement from the AMA.

Noting that African Americans and Hispanics are much less likely to practice sun-protective behaviors, AMA board of trustees member Peter W. Carmel said, “All patients regardless of race or ethnicity should use the same sun-protection measures including sunscreen of at least SPF 15, avoid the sun during peak hours, and [get] regular exams.”

▸ Support for new antibiotics. Delegates adopted a policy to educate the public, physicians, the Obama administration, and Congress regarding the looming problem of antimicrobial resistance and the shortage of new antibiotic drugs in the development pipeline.

Specifically, the policy endorses the “10 20” initiative sponsored by the Infectious Diseases Society of America. This initiative urges global action by political, scientific, medical, industry, and policy leaders to drive the development of at least 10 effective new antibiotics by 2020.

▸ Smoke-free housing. Delegates passed a resolution to encourage federal, state, and local housing authorities to adopt policies prohibiting smoking in multiunit housing.

The word “public” was removed from language recommended by the public health reference committee to broaden support for efforts to include private multiunit housing as well. Mention was made on the floor of evidence pointing to the health hazards of third-hand smoke, the residue that remains on walls, carpeting, and other surfaces for extended periods.

▸ E-cigarette regulation. Delegates voted in favor of a report from the AMA Council on Science and Public Health recommending that e-cigarettes be classified as drug delivery devices and be subject to regulation by the Food and Drug Administration with standards for identity, strength, purity, packaging, and labeling, and with instructions and contraindications for use.

The new policy also asks state legislatures to prohibit the sale of non–FDA-approved e-cigarettes and recommends that the devices be covered by smoke-free laws but be classified separately from tobacco products.

▸ Education about the Gulf oil spill. Delegates approved a policy advocating that the AMA work to educate health professionals and the public about the potential health risks of oil spills and to encourage research on the Gulf oil spill's impact on air and water quality.

CHICAGO — Frustration and concern about the lack of a permanent replacement for the Medicare Sustainable Growth Rate formula held center stage at the meeting.

Delegates passed a resolution calling for the AMA to “immediately formulate legislation for an additional payment option in Medicare fee for service that allows patients and physicians to freely contract, without penalty to either party, for a fee that differs from the Medicare payment schedule.”

Such a fee-for-service option would allow physicians to “balance bill”—they could bill patients for the difference between the Medicare fee schedule and their regular fee schedules.

In addition to helping physicians keep pace with inflation, the option would “give patients control of their Medicare benefit” by allowing them to use the 80% of the fee schedule that they receive from the government plan with physicians outside of “the very strict confines of a participating Medicare physician provider,” Dr. David O. Barbe, a member of the AMA board of trustees, said in an interview.

According to the resolution, the AMA must present the legislative language to its members by Sept. 30.

Introduced as an amendment from the floor during voting, the resolution provided teeth and proactive fervor to another proposed resolution from the AMA's legislative reference committee calling for the organization to study alternative payment options. The resolution that was passed eliminates this step.

Patients “want the conversation about health care to come from their doctors,” Dr. Marcy Zwelling-Aamot, president of the American Academy of Private Physicians, said in support of the substitute resolution, which passed by a large margin.

“I don't want Congress writing the bill about how I'm going to take care of my patients. We should write the bill. We don't need a study, we need action,” she added.

At a “Write Coat Rally” prior to the start of the house proceedings, delegates expressed opposition to the current Medicare payment system.

“Physicians want to care for seniors, but multiple short-term delays have created instability for physician practices nationwide, and this cut is basically the last straw,” Dr. J. James Rohack, then president of the AMA, said during a press conference at the meeting.

He cited a recent AMA survey of 9,000 physicians indicating that one in five physicians overall and nearly one in three primary care physicians currently restrict the number of Medicare patients they see because they feel Medicare payment rates are too low or that the likelihood of additional cuts makes Medicare an unreliable payer.

At the rally, delegates wrote on white lab coats about the urgent need for a workable alternative to the Sustainable Growth Rate (SGR) formula. The lab coats were delivered to Congress after the meeting.

Support for the resolution during the voting session was strong but not unanimous. AMA Past President Richard F. Corlin said that a bill from the AMA asking that physicians be allowed to contract for a fee that differs from Medicare payment and that does not forfeit benefits “is completely unachievable and will cause us to not be taken seriously by other people who would like to be our allies.”

He recommended focusing instead on changing the 2-year drop-out rule that prohibits physicians who opt out of Medicare from submitting claims to Medicare for any of their patients for 2 years.

“Let me abide by the Medicare limits for the patient who can't afford any more, and let me go my own way and bill what I want for the patient who can,” he argued.

Other delegates felt the resolution was too narrowly focused on physicians' financial interests and could ultimately do physicians more harm than good.

“We cannot keep going and asking for more and more money based on what we want to get without cutting the costs down,” said Dr. Lynn Parry, a Denver neurologist who received applause for her comments.

“None of this discussion has talked about our responsibilities; it's just talked about what we want. It's going to make us look stupid; it's going to make us look greedy; it's going to come back and haunt us.”

According to Dr. Jeff Terry of the Alabama delegation, “We're not asking for more. … We're asking for continued access for our patients to care. This is not greedy to say the least.”

Dr. Jeffrey W. Cozzens of the American Association of Neurological Surgeons added, “By having legislation that we wrote, we'll show the world that we have solutions to this problem.”

Dr. Barbe added, “If [the federal government is] not able to provide access for patients by providing appropriate reimbursement to physicians … then take off the [price] caps. Pay whatever you can pay … and then let the market take care of the rest. Let the patient and the doctor decide what that service is worth.”

Although the SGR formula and physician pay dominated action at the House of Delegates meeting, other topics were deliberated. Among them were:

▸ Skin cancer awareness. Delegates voted for the AMA to work with public health agencies and specialty societies, such as the American Academy of Dermatology, to promote screening for skin cancer as well as education about sun-protective behavior among people of color.

Five-year survival rates for melanoma are significantly lower among African Americans than whites (58.8% vs. 84.8%), and melanoma incidence among Hispanics now approaches that of whites, according to a statement from the AMA.

Noting that African Americans and Hispanics are much less likely to practice sun-protective behaviors, AMA board of trustees member Peter W. Carmel said, “All patients regardless of race or ethnicity should use the same sun-protection measures including sunscreen of at least SPF 15, avoid the sun during peak hours, and [get] regular exams.”

▸ Support for new antibiotics. Delegates adopted a policy to educate the public, physicians, the Obama administration, and Congress regarding the looming problem of antimicrobial resistance and the shortage of new antibiotic drugs in the development pipeline.

Specifically, the policy endorses the “10 20” initiative sponsored by the Infectious Diseases Society of America. This initiative urges global action by political, scientific, medical, industry, and policy leaders to drive the development of at least 10 effective new antibiotics by 2020.

▸ Smoke-free housing. Delegates passed a resolution to encourage federal, state, and local housing authorities to adopt policies prohibiting smoking in multiunit housing.

The word “public” was removed from language recommended by the public health reference committee to broaden support for efforts to include private multiunit housing as well. Mention was made on the floor of evidence pointing to the health hazards of third-hand smoke, the residue that remains on walls, carpeting, and other surfaces for extended periods.

▸ E-cigarette regulation. Delegates voted in favor of a report from the AMA Council on Science and Public Health recommending that e-cigarettes be classified as drug delivery devices and be subject to regulation by the Food and Drug Administration with standards for identity, strength, purity, packaging, and labeling, and with instructions and contraindications for use.

The new policy also asks state legislatures to prohibit the sale of non–FDA-approved e-cigarettes and recommends that the devices be covered by smoke-free laws but be classified separately from tobacco products.

▸ Education about the Gulf oil spill. Delegates approved a policy advocating that the AMA work to educate health professionals and the public about the potential health risks of oil spills and to encourage research on the Gulf oil spill's impact on air and water quality.