Publications

BACKGROUND: Medical cannabis consumption is rising, but limited evidence informs the safety and efficacy of cannabis use in cancer patients. A national survey of oncology trainees found that most fellows felt insufficiently informed to make clinical recommendations about cannabis.

AIM: In this secondary analysis, we aimed to measure how frequently trainees recommend in favor of cannabis and determine factors influencing this clinical practice.

METHODS: In this cross-sectional survey study for fellows enrolled in oncology training programs across the United States, an online survey assessing trainee practices regarding medical cannabis was sent to 155 oncology fellowship program directors from January - March 2021; who were asked to distribute it to their fellows. The primary outcome was the frequency with which oncology fellows recommended cannabis in the prior year.

RESULTS: Nationally, 40 programs from 25 states participated, with 189 of 462 trainees across these programs responding (40.9% response rate). 22% (95% CI: 16.3-29.0%) of participants reported recommending medical cannabis to > 5 patients in the past year. 24% (95% CI: 18.4-30.5%) of participants had prior training in medical cannabis. Regarding participant characteristics, only prior training in medical cannabis was significantly associated with recommending cannabis to > 5 patients (RR: 2.4; 95% CI: 1.4-4.2).

CONCLUSIONS: With increasing cannabis use among patients with cancer and given that a substantial number of oncology fellows recommend its use, it is crucial that fellowship training incorporate evidence-based curricula regarding medical cannabis use to guide informed decision-making between patients and their fellow providers.

OBJECTIVE: Messaging about breast cancer screening cessation may reduce over-screening by raising awareness of the harms of screening, but in a background of strongly positive beliefs about screening among the public, such messaging may be perceived negatively. We aimed to assess whether older women perceived it to be ethically appropriate for clinicians to share a message that encourages breast cancer screening cessation.

METHODS: As part of a large national online survey experiment with women 65+ years, we presented a message (hereafter referred to as primary message) describing the rationales for stopping breast cancer screening (e.g., guideline recommendation, harms of screening) and assessed how ethical women thought it would be for doctors to share this information with patients. We assessed open-ended reactions. We also tested two variations of the primary message with different wordings of the recommendation to consider stopping screening.

RESULTS: Of 683 participants, 75.9 % agreed that the primary message is ethically appropriate for doctors to share with patients., 13.2 % neither agree or disagree, and 10.9 % disagreed. Themes in open-ended responses suggested that the difference in participant response was partly attributed to whether participants perceived the message as informative or persuasive. Comparing across message variations, messages with stronger recommendations to stop screening were perceived to be less ethically appropriate than the primary message.

CONCLUSIONS: Most older women perceived that it was ethically appropriate for doctors to share messages aimed at reducing breast cancer over-screening with patients.

PRACTICE IMPLICATIONS: Interventions should be developed to deliver messages to reduce over-screening among older women in practice settings, with evaluations to monitor their response.

BACKGROUND: Treatment burden refers to the patient-perceived effort of managing health and health care, which impacts quality of life and engagement in care. International studies of treatment burden have found high rates of treatment burden among adults with chronic conditions. However, the scope of treatment burden among US older adults is unknown. We described the prevalence of and characteristics associated with treatment burden among US adults age ≥ 50 years.

METHODS: We performed a cross-sectional study of 1795 adult respondents to the 2022 Health and Retirement Study (HRS) Treatment Burden Questionnaire (TBQ), a random sub-sample from a nationally-representative panel study of community-dwelling US adults age ≥ 50 years. The primary outcome was total treatment burden score (15 items each scored 0-10, total 0-150; threshold ≥ 59 for high burden). We used multivariable linear regression to examine the association between log-transformed total treatment burden score and sociodemographic, health, and functional status characteristics.

RESULTS: The mean age of 1795 respondents was 68.5 (SD 8.5) years, 56% were female, and the median TBQ score was 12 (IQR 5-25). Overall, 87% (n = 1550) reported treatment burden (TBQ score ≥ 1); 5% reported high burden. The most common sources of treatment burden were reminders of health problems (61%) and administrative (53%) and financial burdens (46%). Adults age ≥ 65 years were both less likely to report treatment burden and reported lower burden than adults age 50-64 years. Factors associated with greater burden included a higher number of chronic conditions, vision or hearing impairment, ADL/IADL difficulty, and mobility difficulty.

CONCLUSIONS: Most US adults age ≥ 50 years report treatment burden, though there is wide variation in the degree of burden reported. Reducing treatment burden within the US may require reducing administrative and financial burdens of care and addressing factors that impair patient capacity to manage health and health care.

BACKGROUND: Oncology providers often lack the confidence to make clinical recommendations about medical cannabis (MC). This study aimed to develop and evaluate the feasibility of implementing an educational curriculum on the use of MC in patient care for oncology trainees.

METHODS: A multidisciplinary team designed an educational curriculum for MC use in oncology. The curriculum was piloted as a 1-hour interactive webinar across 8 United States-based hematology/oncology fellowship programs between 2022 and 2023. Incentivized surveys measuring feasibility outcomes, including cultural attitudes/norms, acceptability, compatibility, and self-efficacy (a composite index of self-confidence in discussing MC efficacy, risks, modes of use, and role in symptom management), were distributed before, immediately after, and 12 weeks post-webinar.

RESULTS: Of 103 trainees, 75 (72.8%) completed the pretraining survey and 66 (64.1%) completed the posttraining survey. Most respondents believed discussions about the role of MC in symptom management were valuable (n=56; 74.7%), though few (14.7%) believed trainees were expected to engage in such discussions. Most participants rated the curriculum as helpful (92.4%), beneficial for oncology trainees (84.8%), and likely to be recommended to colleagues (87.9%). Post-webinar, 78.8% of participants reported an increased likelihood of initiating discussions with patients regarding MC. There were significant improvements in the composite self-confidence index from pre- to post-webinar (2.7% vs 65.2%; P<.001), which persisted in the follow-up surveys (n=36; response rate, 34.9%).

CONCLUSIONS: This multisite study demonstrates the feasibility of implementing a novel curriculum focused on MC for oncology trainees. These findings can guide the design of a prospective, multi-institutional study to evaluate knowledge expansion, retention, and behavioral changes resulting from the intervention.

BackgroundAdvance care planning (ACP) helps older adults make end-of-life medical decisions. While ACP discussions are associated with improved patient outcomes, overall engagement remains low in the emergency department (ED).ObjectivesThis study assessed ACP engagement in older ED patients.MethodsWe conducted a questionnaire study among adults ≥65 in a Boston ED (July-Oct 2023). Our primary outcome was ACP Engagement as measured by a validated 9-item instrument with three ACP self- efficacy and six ACP readiness questions. Secondary outcomes included participants' preferences for learning about five ACP topics in the ED-medical decision makers, what matters most, leeway and flexibility for decision makers, sharing wishes, and asking questions)-as well as their favored learning formats (eg, pamphlets, videos, clinician conversations). Each was rated on a 5-point Likert scale. We examined the relationship between ACP engagement and existing electronic health record (EHR) documentation.ResultsNinety-nine older adults participated (mean age 75.5; 53.5% women). On the 9-item ACP Engagement Survey, participants reported high overall scores with a mean of 4.1 (95% CI: 4.0-4.2). Among ACP readiness topics, 80 (81.6%) named a decision-maker; 37 (40.2%) discussed end-of-life wishes with doctors. Participants preferred ED team conversations. Among the 51 participants who reported having signed paperwork regarding end-of-life wishes, only 7 (13.7%) had forms documented in the EHR.ConclusionsAmong older adults in a large Boston-based ED, ACP engagement was high, but few patients had documentation of end-of-life wishes available in the EHR. Findings highlight the need for better ACP documentation in EDs.