Kavitha Ramchandran

All Publications

• End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration. Journal of the American Geriatrics Society Gidwani, R., Asch, S. M., Needleman, J., Faricy-Anderson, K., Boothroyd, D. B., Illarmo, S., Lorenz, K. A., Patel, M. I., Hsin, G., Ramchandran, K., Wagner, T. H. 2020

  Abstract

  BACKGROUND/OBJECTIVES: To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA).DESIGN: A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equation to evaluate monthly cost trajectories experienced by patients in their last year of live, with patients nested within hospital referral region.SETTING: Care received at VA facilities or by Medicare-reimbursed providers nationwide.PARTICIPANTS: A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare.MEASUREMENTS: We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life.RESULTS: All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care.CONCLUSION: Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.

  View details for DOI 10.1111/jgs.16941

  View details for PubMedID 33368171

• DEVELOPMENT, FEASIBILITY AND ACCEPTABILITY OF AN ONLINE COURSE TO TEACH PRIMARY PALLIATIVE CARE SKILLS TO HEPATOLOGY PROVIDERS. Verma, M., Denofrio, J., Ramchandran, K., Taddei, T. H., Volk, M., Navarro, V. J. WILEY. 2020: 1156?57

  View details for Web of Science ID 000574027004356

• The role of palliative care in the management of patients with lung cancer LUNG CANCER MANAGEMENT Tan, I., Ramchandran, K. 2020

  View details for DOI 10.2217/lmt-2020-0016

  View details for Web of Science ID 000553560300001

• KEAP1/NFE2L2 mutations to predict local recurrence after radiotherapy but not surgery in localized non-small cell lung cancer. Binkley, M. S., Jeon, Y., Nesselbush, M., Moding, E. J., Nabet, B., Almanza, D. S., Yoo, C., Kurtz, D., Owen, S., Backhus, L., Berry, M. F., Shrager, J. B., Ramchandran, K., Padda, S., Das, M., Neal, J. W., Wakelee, H. A., Alizadeh, A. A., Loo, B. W., Diehn, M. AMER SOC CLINICAL ONCOLOGY. 2020

  View details for Web of Science ID 000560368303348

• Distress screening through PROMIS at an academic cancer center and network site: Implementation of a hybrid model. Roy, M., Neal, J. W., Bugos, K., Sharp, C., Falconer, P., Rosenthal, E., Blayney, D. W., Modaressi, S., Robinson, A., Ramchandran, K. AMER SOC CLINICAL ONCOLOGY. 2020

  View details for Web of Science ID 000560368301136

• A mid-chemoradiation dynamic risk model integrating tumor features and ctDNA analysis for lung cancer outcome prediction. Moding, E. J., Esfahani, M., Nabet, B., Liu, Y., Chabon, J. J., He, J., Qiao, Y., Xu, T., Yao, L., Gandhi, S., Liao, Z. X., Das, M., Ramchandran, K., Padda, S., Neal, J. W., Wakelee, H. A., Loo, B. W., Lin, S. H., Alizadeh, A. A., Diehn, M. AMER SOC CLINICAL ONCOLOGY. 2020

  View details for Web of Science ID 000560368303378

• Noninvasive Early Identification of Therapeutic Benefit from Immune Checkpoint Inhibition. Cell Nabet, B. Y., Esfahani, M. S., Moding, E. J., Hamilton, E. G., Chabon, J. J., Rizvi, H., Steen, C. B., Chaudhuri, A. A., Liu, C. L., Hui, A. B., Almanza, D., Stehr, H., Gojenola, L., Bonilla, R. F., Jin, M. C., Jeon, Y. J., Tseng, D., Liu, C., Merghoub, T., Neal, J. W., Wakelee, H. A., Padda, S. K., Ramchandran, K. J., Das, M., Plodkowski, A. J., Yoo, C., Chen, E. L., Ko, R. B., Newman, A. M., Hellmann, M. D., Alizadeh, A. A., Diehn, M. 2020

  Abstract

  Although treatment of non-small cell lung cancer (NSCLC) with immune checkpoint inhibitors (ICIs) can produce remarkably durable responses, most patients develop early disease progression. Furthermore, initial response assessment by conventional imaging is often unable to identify which patients will achieve durable clinical benefit (DCB). Here, we demonstrate that pre-treatment circulating tumor DNA (ctDNA) and peripheral CD8 T cell levels are independently associated with DCB. We further show that ctDNA dynamics after a single infusion can aid in identification of patients who will achieve DCB. Integrating these determinants, we developed and validated an entirely noninvasive multiparameter assay (DIREct-On, Durable Immunotherapy Response Estimation by immune profiling and ctDNA-On-treatment) that robustly predicts which patients will achieve DCB with higher accuracy than any individual feature. Taken together, these results demonstrate that integrated ctDNA and circulating immune cell profiling can provide accurate, noninvasive, and early forecasting of ultimate outcomes for NSCLC patients receiving ICIs.

  View details for DOI 10.1016/j.cell.2020.09.001

  View details for PubMedID 33007267

• KEAP1/NFE2L2 mutations predict lung cancer radiation resistance that can be targeted by glutaminase inhibition. Cancer discovery Binkley, M. S., Jeon, Y. J., Nesselbush, M., Moding, E. J., Nabet, B. Y., Almanza, D., Kunder, C., Stehr, H., Yoo, C. H., Rhee, S., Xiang, M., Chabon, J. J., Hamilton, E., Kurtz, D. M., Gojenola, L., Owen, S. G., Ko, R. B., Shin, J. H., Maxim, P. G., Lui, N. S., Backhus, L. M., Berry, M. F., Shrager, J. B., Ramchandran, K. J., Padda, S. K., Das, M., Neal, J. W., Wakelee, H. A., Alizadeh, A. A., Loo, B. W., Diehn, M. 2020

  Abstract

  Tumor genotyping is not routinely performed in localized non-small cell lung cancer (NSCLC) due to lack of associations of mutations with outcome. Here, we analyze 232 consecutive patients with localized NSCLC and demonstrate that KEAP1 and NFE2L2 mutations are predictive of high rates of local recurrence (LR) after radiotherapy but not surgery. Half of LRs occurred in KEAP1/NFE2L2 mutation tumors, indicating they are major molecular drivers of clinical radioresistance. Next, we functionally evaluate KEAP1/NFE2L2 mutations in our radiotherapy cohort and demonstrate that only pathogenic mutations are associated with radioresistance. Furthermore, expression of NFE2L2 target genes does not predict LR, underscoring the utility of tumor genotyping. Finally, we show that glutaminase inhibition preferentially radiosensitizes KEAP1 mutant cells via depletion of glutathione and increased radiation-induced DNA damage. Our findings suggest that genotyping for KEAP1/NFE2L2 mutations could facilitate treatment personalization and provide a potential strategy for overcoming radioresistance conferred by these mutations.

  View details for DOI 10.1158/2159-8290.CD-20-0282

  View details for PubMedID 33071215

• Symptom relief and palliative care in gynecologic oncology. Current opinion in obstetrics & gynecology Roy, M., Ramchandran, K. 2019

  Abstract

  PURPOSE OF REVIEW: Patients with gynecologic malignancies experience varied and often difficult-to-manage symptoms through their disease course, along with decisions surrounding preferences for advance care planning. This review focuses on evidence-based symptom management for these patients and offers a framework for conversations regarding goals of therapy.RECENT FINDINGS: There is increasing literature on palliative care specifically in gynecologic oncology, including barriers and possible solutions for early palliative care use, along with updated guidelines on postoperative pain management and tools for communication.SUMMARY: Integration of early palliative care and focus on symptom management is an important and multidisciplinary approach to help patients with gynecologic malignancies.

  View details for DOI 10.1097/GCO.0000000000000601

  View details for PubMedID 31851044

• Palliative care clinicians and online education in India: a survey BMJ SUPPORTIVE & PALLIATIVE CARE Kiss-Lane, T., Spruijt, O., Day, T., Lam, V., Ramchandran, K. J., Chan, S., Hsin, G., Vallath, N., Bhatnagar, S., Rajagopal, M. R., Lorenz, K. A. 2019; 9 (4)

  View details for DOI 10.1136/bmjspcare-2018-001546

  View details for Web of Science ID 000505622500010

• Feasibility and design of a cloud-based digital platform in patients with advanced cancer. Roy, M., Hall, E., Velazquez, B., Shah, S., Fardeen, T., Cunanan, K., San Pedro-Salcedo, M., Wakelee, H. A., Neal, J. W., Padda, S., Das, M., Fan, A. C., Srinivas, S., Fisher, G. A., Haraldsdottir, S., Johnson, T., Chu, G., McMillan, A., Ramchandran, K. AMER SOC CLINICAL ONCOLOGY. 2019

  View details for DOI 10.1200/JCO.2019.37.27_suppl.211

  View details for Web of Science ID 000518223100208

• Introducing Palliative Care within the Treatment of End-Stage Liver Disease: The Study Protocol of a Cluster Randomized Controlled Trial. Journal of palliative medicine Verma, M., Kosinski, A. S., Volk, M. L., Taddei, T., Ramchandran, K., Bakitas, M., Green, K., Green, L., Navarro, V. 2019; 22 (S1): 34?43

  Abstract

  Introduction: Patients with end-stage liver disease (ESLD) suffer from myriad symptoms due to the systemic effects of the disease and unpredictable acute episodes, which contribute to progressive deterioration in quality of life (QOL). Despite clear evidence that palliative care (PC) improves QOL in other serious illnesses, PC is underutilized and delayed for ESLD patients. Through a comparative effectiveness trial of specialist led consultative PC (Model 1) versus trained hepatologist led PC (Model 2), we aim to build evidence on introducing PC into the routine outpatient care of ESLD patients. Objective: We hypothesize that trained hepatologist led PC model will have a better improvement in QOL compared to consultative PC model. Methods: This two-arm, multicenter cluster-randomized trial assesses the effectiveness of two PC models for patients with ESLD. Fourteen clinical centers will recruit 1260 patient-caregiver dyads. Each center is the unit of randomization. Hepatologists at sites randomized to the Model 2 have undergone web-based training in the principles of PC as pertained to ESLD. PC intervention is delivered over four visits (initial, one, two, and three months). Follow-up assessments occur at 6, 9, and 12 months. Eligible patients are those with new onset or ongoing complications of ESLD with a caregiver willing to participate. Outcomes: The primary outcome is change in patients' QOL from baseline to three months. Secondary outcomes include symptom burden, depression, distress, satisfaction with care, caregiver burden and QOL, goal concordant care, and health care utilization. Challenges and Contributions Engagement: A research advisory board has been developed with representatives from the participating centers, who have provided active feedback on the protocol, outcomes, study methods, and training program. Intervention Fidelity: Intervention fidelity will be maintained by adherence to a visit agenda and providers in both models completing a PC checklist after each study visit.

  View details for DOI 10.1089/jpm.2019.0121

  View details for PubMedID 31486722

• Automated Survival Prediction in Metastatic Cancer Patients Using High-Dimensional Electronic Medical Record Data JNCI-JOURNAL OF THE NATIONAL CANCER INSTITUTE Gensheimer, M. F., Henry, A., Wood, D. J., Hastie, T. J., Aggarwal, S., Dudley, S. A., Pradhan, P., Banerjee, I., Cho, E., Ramchandran, K., Pollom, E., Koong, A. C., Rubin, D. L., Chang, D. T. 2019; 111 (6): 568?74

  View details for DOI 10.1093/jnci/djy178

  View details for Web of Science ID 000474267400007

• ctDNA analysis for personalization of consolidation immunotherapy in localized non-small cell lung cancer. Moding, E. J., Liu, Y., Nabet, B., Chabon, J. J., Chaudhuri, A., Hui, A. B., He, J., Qiao, Y., Heymach, J., Tsao, A. S., Liao, Z. X., Gomez, D., Ramchandran, K., Neal, J. W., Wakelee, H. A., Loo, B. W., Lin, S. H., Alizadeh, A. A., Diehn, M. AMER SOC CLINICAL ONCOLOGY. 2019

  View details for DOI 10.1200/JCO.2019.37.15_suppl.2547

  View details for Web of Science ID 000487345804497

• Randomized phase II study of adjuvant afatinib for three months versus two years in patients with resected stage I-III EGFR mutant NSCLC. Chaft, J. E., Costa, D., Muzikansky, A., Shrager, J. B., Lanuti, M., Huang, J., Ramchandran, K., Rangachari, D., Huberman, M., Piotrowska, Z., Kris, M. G., Azzoli, C. G., Sequist, L. V., Neal, J. W. AMER SOC CLINICAL ONCOLOGY. 2019

  View details for Web of Science ID 000487345806385

• Impact of KEAP1/NFE2L2/CUL3 mutations on duration of response to EGFR tyrosine kinase inhibitors in EGFR mutated non-small cell lung cancer. Lung cancer (Amsterdam, Netherlands) Hellyer, J. A., Stehr, H., Das, M., Padda, S. K., Ramchandran, K., Neal, J. W., Diehn, M., Wakelee, H. A. 2019; 134: 42?45

  Abstract

  For patients with Epidermal Growth Factor Receptor (EGFR)-mutated non-small cell lung cancer (NSCLC), frontline EGFR-tyrosine kinase inhibitor (TKI) therapy compared to chemotherapy improves outcomes. However, resistance to these agents uniformly develops. Recently, mutations in the KEAP1-NFE2L2 pathway have been implicated as a potential mechanism of acquired EGFR TKI resistance.We examined all patients with metastatic NSCLC with mutations in both EGFR and KEAP1/NFE2L2/CUL3 identified on next generation sequencing from 2015 - 2018. These patients were compared to a NSCLC control cohort with mutations in EGFR and wild type in KEAP1/NFE2L2/CUL3 matched on the basis of sex, smoking status, age and race. Time to treatment failure on EGFR TKI therapy and overall survival were examined.Among 228 EGFR mutant NSCLCs, 17 (7%) also carried mutations in KEAP1, NFE2L2, or CUL3. The most common co-mutation in both the KEAP1/NFE2L2/CUL3 mutant and wild-type cohort was TP53. Patients with KEAP1/NFE2L2/CUL3 mutations had a shorter median time to treatment failure on EGFR TKI (4.7 months) compared with the wild-type matched cohort (13.0 months), p= 0.0014. There was no difference in overall survival.For NSCLC patients with mutations in EGFR, co-mutations in KEAP1/NFE2L2/CUL3 are associated with significantly decreased time to treatment failure. Our results suggest that these mutations represent a mechanism of intrinsic resistance to TKI treatment.

  View details for DOI 10.1016/j.lungcan.2019.05.002

  View details for PubMedID 31319993

• Health System and Beneficiary Costs Associated With Intensive End-of-Life Medical Services. JAMA network open Gidwani-Marszowski, R., Asch, S. M., Mor, V., Wagner, T. H., Faricy-Anderson, K., Illarmo, S., Hsin, G., Patel, M. I., Ramchandran, K., Lorenz, K. A., Needleman, J. 2019; 2 (9): e1912161

  Abstract

  Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services.To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life.This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48?937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019.American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days.Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region.Of 48?937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23?612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15?952 (95% CI, $15?676-$16?206; P?

  View details for DOI 10.1001/jamanetworkopen.2019.12161

  View details for PubMedID 31560384

• Phase II trial of single agent amrubicin in patients with previously treated advanced thymic malignancies. Lung cancer (Amsterdam, Netherlands) Hellyer, J. A., Gubens, M. A., Cunanan, K. M., Padda, S. K., Burns, M., Spittler, A. J., Riess, J. W., San Pedro-Salcedo, M., Ramchandran, K. J., Neal, J. W., Wakelee, H. A., Loehrer, P. J. 2019; 137: 71?75

  Abstract

  There are limited treatment options for patients with thymic malignancies. Here we present data supporting treatment with single agent amrubicin, a third generation anthracycline and topoisomerase II inhibitor.This was a phase 2 open-label, single arm trial of amrubicin in patients with thymoma (T) or thymic carcinoma (TC), conducted at two academic institutions. Patients were included if they had received at least one prior chemotherapy regimen. The first 18 patients received amrubicin at 40?mg/m2 IV days 1-3 repeated every 3-weeks. Due to the high incidence of febrile neutropenia, dosing was subsequently amended to 35?mg/m2 for the final 15 patients.A total of 33 patients (14?T/19?TC) were enrolled from 2011 to 2014. Median number of prior therapies was 2. Best response included 6 partial responses, 21 stable disease, and 6 progressive disease (all TC). Objective response rate was 18% (90% exact binomial CI 8.2%-32.8%; T?=?4/14 (29%), TC?=?2/19 (11%)). Median progression-free survival was 7.7 months (T: 8.3 months; TC: 7.3) and median overall survival was 29.7 months (T: 54.1 months; TC: 18 months). There was a high rate of febrile neutropenia (7 patients) that occurred despite a reduction in amrubicin dose and one related death. Five patients had reduction in LVEF below 50% during the course of treatment resulting in treatment discontinuation in one patient.Amrubicin shows promise as a single agent in heavily pre-treated patients with thymic malignancies. Notable side effects include febrile neutropenia and the use of growth factor support is essential. Further investigation of this agent is warranted.

  View details for DOI 10.1016/j.lungcan.2019.09.015

  View details for PubMedID 31557562

• Role of KEAP1/NFE2L2 mutations in the chemotherapeutic response of non-small cell lung cancer patients. Clinical cancer research : an official journal of the American Association for Cancer Research Jeong, Y., Hellyer, J. A., Stehr, H., Hoang, N. T., Niu, X., Das, M., Padda, S. K., Ramchandran, K., Neal, J. W., Wakelee, H. A., Diehn, M. 2019

  Abstract

  Activation of NFE2L2 has been linked to chemoresistance in cell line models. Recently, somatic mutations which activate NFE2L2, including mutations in NFE2L2,KEAP1, or CUL3,have been found to be associated with poor outcomes in patients with non-small cell lung cancer (NSCLC). However, the impact of these mutations on chemoresistance remains incompletely explored.We investigated the effect of Keap1 deletion on chemoresistance in cell lines from Trp53-based mouse models of lung squamous cell carcinoma (LSCC) and lung adenocarcinoma (LUAD). Separately, we identified 51 stage IV NSCLC patients with KEAP1, NFE2L2, or CUL3mutations and a matched cohort of 52 wildtype patients. Time to treatment failure after front line platinum doublet chemotherapy and overall survival was compared between the two groups.Deletion of Keap1 in Trp53-null murine LUAD and LSCC resulted in increased clonogenic survival upon treatment with diverse cytotoxic chemotherapies. In NSCLC patients, median time to treatment failure (TTF) after first line chemotherapy for the KEAP1/NFE2L2/CUL3-mutant cohort was 2.8 months compared to 8.3 months in the control group (p < 0.0001) Median overall survival (OS) was 11.2 months in the KEAP1/NFE2L2/CUL3-mutant group and 36.8 months in the control group (p = 0.006). Conclusions: Keap1 deletion confers chemoresistance in murine lung cancer cells. Patients with metastatic NSCLC with mutations in KEAP1, NFE2L2, or CUL3 have shorter time to treatment failure and overall survival after first line platinum doublet chemotherapy compared with matched controls. Novel approaches for improving outcomes in this subset of NSCLC patients are therefore needed.

  View details for DOI 10.1158/1078-0432.CCR-19-1237

  View details for PubMedID 31548347

• Feasibility of a massive online open course to teach skills in primary palliative care for a global audience. Kerkar, A., DeNofrio, J., Tribett, E., Ramchandran, K. AMER SOC CLINICAL ONCOLOGY. 2018

  View details for DOI 10.1200/JCO.2018.36.34_suppl.111

  View details for Web of Science ID 000464876100107

• Automated Survival Prediction in Metastatic Cancer Patients Using High-Dimensional Electronic Medical Record Data. Journal of the National Cancer Institute Gensheimer, M. F., Henry, A. S., Wood, D. J., Hastie, T. J., Aggarwal, S., Dudley, S. A., Pradhan, P., Banerjee, I., Cho, E., Ramchandran, K., Pollom, E., Koong, A. C., Rubin, D. L., Chang, D. T. 2018

  Abstract

  Background: Oncologists use patients' life expectancy to guide decisions and may benefit from a tool that accurately predicts prognosis. Existing prognostic models generally use only a few predictor variables. We used an electronic medical record dataset to train a prognostic model for patients with metastatic cancer.Methods: The model was trained and tested using 12588 patients treated for metastatic cancer in the Stanford Health Care system from 2008 to 2017. Data sources included provider note text, labs, vital signs, procedures, medication orders, and diagnosis codes. Patients were divided randomly into a training set used to fit the model coefficients and a test set used to evaluate model performance (80%/20% split). A regularized Cox model with 4126 predictor variables was used. A landmarking approach was used due to the multiple observations per patient, with t0 set to the time of metastatic cancer diagnosis. Performance was also evaluated using 399 palliative radiation courses in test set patients.Results: The C-index for overall survival was 0.786 in the test set (averaged across landmark times). For palliative radiation courses, the C-index was 0.745 (95% confidence interval [CI] = 0.715 to 0.775) compared with 0.635 (95% CI = 0.601 to 0.669) for a published model using performance status, primary tumor site, and treated site (two-sided P<.001). Our model's predictions were well-calibrated.Conclusions: The model showed high predictive performance, which will need to be validated using external data. Because it is fully automated, the model can be used to examine providers' practice patterns and could be deployed in a decision support tool to help improve quality of care.

  View details for PubMedID 30346554

• Palliative care clinicians and online education in India: a survey. BMJ supportive & palliative care Kiss-Lane, T., Spruijt, O., Day, T., Lam, V., Ramchandran, K. J., Chan, S., Hsin, G., Vallath, N., Bhatnagar, S., Rajagopal, M. R., Lorenz, K. A. 2018

  Abstract

  BACKGROUND: Whether online resources can facilitate spread of palliative care knowledge and skills in India is an urgent question given few providers and a large, ageing population.OBJECTIVES: We surveyed needs and feasibility regarding e-learning.METHODS: Indian, Australian and North American palliative care experts developed an electronic survey using Qualtrics, emailed to all registrants of the 2017 Indian Association of Palliative Care (IAPC) conference and distributed during the conference.RESULTS: Of 60 respondents (66% men, 60% doctors), most worked in hospitals and had oncology backgrounds, and 35% were from Kerala and Tamil Nadu. Most (90.9%) received palliative care training in India or overseas with 41% trained in a Trivandrum Institute of Palliative Sciences residential course (4-6 weeks). 17% completed the IAPC essential certificate and 22% had undertaken various distance learning courses. Interest in online training was substantial for most aspects of palliative care.CONCLUSION: There was a high level of interest and reported feasibility in taking a case-based online course. This pilot survey provides support for online case-based education in India, particularly among physicians.

  View details for PubMedID 30301753

• Oncologists' Views on Using Value to Guide Cancer Treatment Decisions VALUE IN HEALTH Gidwani-Marszowski, R., Nevedal, A. L., Blayney, D. W., Patel, M., Kelly, P., Timko, C., Ramchandran, K., Murrell, S. S., Asch, S. M. 2018; 21 (8): 931?37

  Abstract

  Cancer costs have increased substantially in the past decades, prompting specialty societies to urge oncologists to consider value in clinical decision making. Despite oncologists' crucial role in guiding cancer care, current literature is sparse with respect to the oncologists' views on value. Here, we evaluated oncologists perceptions of the use and measurement of value in cancer care.We conducted in-depth, open-ended interviews with 31 US oncologists practicing nationwide in various environments. Oncologists discussed the definition, measurement, and implementation of value. Transcripts were analyzed using matrix and thematic analysis.Oncologists' definitions of value varied greatly. Some described versions of the standard health economic definition of value, that is, cost relative to health outcomes. Many others did not include cost in their definition of value. Oncologists considered patient goals and quality of life as important components of value that they perceived were missing from current value measurement. Oncologists prioritized a patient-centric view of value over societal or other perspectives. Oncologists were inclined to consider the value of a treatment only if they perceived treatment would pose a financial burden to patients. Oncologists had differing opinions regarding who should be responsible for determining whether care is low value but generally felt this should remain within the purview of the oncology community.Oncologists agreed that cost was an important issue, but disagreed about whether cost was involved in value as well as the role of value in guiding treatment. Better clarity and alignment on the definition of and appropriate way to measure value is critical to the success of efforts to improve value in cancer care.

  View details for PubMedID 30098670

• Quality Of End-Of-Life Care Is Higher In The VA Compared To Care Paid For By Traditional Medicare HEALTH AFFAIRS Gidwani-Marszowski, R., Needleman, J., Mor, V., Faricy-Anderson, K., Boothroyd, D. B., Hsin, G., Wagner, T. H., Lorenz, K. A., Patel, M. I., Joyce, V. R., Murrell, S. S., Ramchandran, K., Asch, S. M. 2018; 37 (1): 95?103

  Abstract

  Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA's directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010-14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA's integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purchasing programs should develop coordination and quality monitoring programs to guard against overly intensive end-of-life care.

  View details for PubMedID 29309227

• The Appropriate Provision of Primary versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives JOURNAL OF PALLIATIVE MEDICINE Gidwani, R., Nevedal, A., Patel, M., Blayney, D. W., Timko, C., Ramchandran, K., Kelly, P. A., Asch, S. M. 2017; 20 (4): 395-403

  Abstract

  Many cancer patients do not receive recommended palliative care (PC). Oncologists' perspectives about PC have not been adequately described qualitatively and may explain some of the gaps in the delivery of PC.To characterize U.S. oncologists' perceptions of: primary and specialist PC; experiences interacting with PC specialists; and the optimal interface of PC and oncology in providing PC.In-depth interviews with practicing oncologists.Oncologists working in: the general community, academic medical centers (AMC), and Veterans Health Administration.Semistructured telephone interviews with 31 oncologists analyzed using matrix and thematic approaches.Seven major themes emerged: PC was perceived as appropriate throughout the disease trajectory but due to resource constraints was largely provided at end of life; oncologists had three schools of thought on primary versus specialist PC; there was an under-availability of outpatient PC; poor communication about prognosis and care plans created tension between providers; PC was perceived as a "team of outsiders"; PC had too narrow a focus of care; and AMC-based PC evidence did not generalize to community practices. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of nonphysician palliative team members.Oncologists in our sample were supportive of PC, but they reported obstacles related to care coordination and inpatient PC. Inpatient PC posed some unique challenges with respect to conflicting prognoses and care practices that would be mitigated through the increased availability and use of outpatient PC.

  View details for DOI 10.1089/jpm.2016.0399

  View details for Web of Science ID 000398452000016

• The Appropriate Provision of Primary Versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives. Journal of palliative medicine Gidwani, R., Nevedal, A., Patel, M., Blayney, D. W., Timko, C., Ramchandran, K., Kelly, P. A., Asch, S. M. 2016

  Abstract

  Many cancer patients do not receive recommended palliative care (PC). Oncologists' perspectives about PC have not been adequately described qualitatively and may explain some of the gaps in the delivery of PC.To characterize U.S. oncologists' perceptions of: primary and specialist PC; experiences interacting with PC specialists; and the optimal interface of PC and oncology in providing PC.In-depth interviews with practicing oncologists.Oncologists working in: the general community, academic medical centers (AMC), and Veterans Health Administration.Semistructured telephone interviews with 31 oncologists analyzed using matrix and thematic approaches.Seven major themes emerged: PC was perceived as appropriate throughout the disease trajectory but due to resource constraints was largely provided at end of life; oncologists had three schools of thought on primary versus specialist PC; there was an under-availability of outpatient PC; poor communication about prognosis and care plans created tension between providers; PC was perceived as a "team of outsiders"; PC had too narrow a focus of care; and AMC-based PC evidence did not generalize to community practices. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of nonphysician palliative team members.Oncologists in our sample were supportive of PC, but they reported obstacles related to care coordination and inpatient PC. Inpatient PC posed some unique challenges with respect to conflicting prognoses and care practices that would be mitigated through the increased availability and use of outpatient PC.

  View details for DOI 10.1089/jpm.2016.0399

  View details for PubMedID 27997278

• The Current State of Palliative Care for Patients Cared for at Leading US Cancer Centers: The 2015 NCCN Palliative Care Survey. Journal of the National Comprehensive Cancer Network Calton, B. A., Alvarez-Perez, A., Portman, D. G., Ramchandran, K. J., Sugalski, J., Rabow, M. W. 2016; 14 (7): 859-866

  Abstract

  ASCO and IOM recommend palliative care (PC) across health care settings for patients with serious illnesses, including cancer. This study provides an overview of the current availability, structure, and basic quality of PC services within NCCN Member Institutions.A PC survey was developed by NCCN staff and a working group of PC experts from 11 NCCN Member Institutions under the auspices of the NCCN Best Practices Committee. The survey was piloted and refined by 3 working group members and sent electronically to all 26 NCCN Member Institutions. NCCN staff and working group leaders analyzed the survey data.A total of 22 of 26 institutions responded (85%). All respondents (100%) reported an inpatient PC consult service (staffed by an average of 6.8 full-time equivalents [FTEs], seeing 1,031 consults/year with an average length of stay [LOS] of 10 days). A total of 91% of respondents had clinic-based PC (with an average of 469 consults/year, staffed by an average of 6.8 FTEs, and a 17-day wait time). For clinics, a comanagement care delivery model was more common than strict consultation. Home-based PC (23%) and inpatient PC units (32%) were less prevalent. Notably, 80% of institutions reported insufficient PC capacity compared with demand. Across PC settings, referrals for patients with solid tumors were more common than for hematologic malignancies. Automatic or "triggered" referrals were rare. The most common services provided were symptom management (100%) and advance care planning (96%). Most programs were funded through fee-for-service billing and institutional support. Partnerships with accountable care organizations and bundled payment arrangements were infrequent. PC program data collection and institutional funding for PC research were variable across institutions.Despite the prevalence of PC inpatient and clinic services among participating NCCN Member Institutions, PC demand still exceeds capacity. Opportunities exist for expansion of home-based PC and inpatient PC units, optimizing referrals, research, and payer collaborations.

  View details for PubMedID 27407126

• Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer. Current treatment options in oncology Chandrasekar, D., Tribett, E., Ramchandran, K. 2016; 17 (5): 23-?

  Abstract

  Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

  View details for DOI 10.1007/s11864-016-0397-1

  View details for PubMedID 27032645

  View details for PubMedCentralID PMC4819778

• Integrating Palliative Care Into Oncology: A Way Forward CANCER CONTROL Ramchandran, K., Tribett, E., Dietrich, B., Von Roenn, J. 2015; 22 (4): 386-395

  View details for Web of Science ID 000368051500003

• Implementation of supportive care and best supportive care interventions in clinical trials enrolling patients with cancer?. Annals of oncology Lee, R. T., Ramchandran, K., Sanft, T., Von Roenn, J. 2015; 26 (9): 1838-1845

  Abstract

  With the growing and evolving role of palliative care in oncology, we examined how supportive care (SC) and best supportive care (BSC) are implemented in clinical trials when used as a comparison treatment arm.We conducted a systematic review of the literature for clinical trials published between 1980 and 2012 in which systemic anticancer therapy was compared with an SC-only arm and compared SC implementation with World Health Organization (WHO) published guidelines.Our search identified 189 articles, 73 of which met our inclusion criteria with the following cancer types: 29 lung, 7 colorectal, 6 pancreatic, 5 gastric and 26 others. Fifty-five studies (75%) provided some definition of SC, and 48 studies (66%) used the term BSC. Twenty-one of the 55 studies that provided a definition described the use of palliative therapies as being 'at the discretion of the treating physician' without standardization. Only two studies provided SC that incorporated routine physical, psychological and social assessments including rapid referral to SC specialists. SC interventions most commonly included analgesics (47%) and radiotherapy (44%). Trials using the term BSC versus SC were more likely to include blood transfusions (P = 0.002) and antibiotics (P = 0.033), but less likely to include steroids (P = 0.05) and palliative specialists (P = 0.047).The implementation of SC in clinical trials in this systematic review is highly variable. The vast majority of the studies did not meet the WHO guidelines on SC because palliative care therapies were not recommended or integrated into care. Future clinical trials utilizing a SC intervention arm should define these interventions in a standardized approach that meets current guidelines such as the WHO recommendations.

  View details for DOI 10.1093/annonc/mdv207

  View details for PubMedID 25922064

• Prolonged survival of patients with non-small-cell lung cancer with leptomeningeal carcinomatosis in the modern treatment era. Clinical lung cancer Riess, J. W., Nagpal, S., Iv, M., Zeineh, M., Gubens, M. A., Ramchandran, K., Neal, J. W., Wakelee, H. A. 2014; 15 (3): 202-206

  Abstract

  Leptomeningeal carcinomatosis (LM) is a severe complication of non-small-cell lung cancer (NSCLC) historically associated with poor prognosis. New chemotherapeutic and targeted treatments could potentially affect the natural history of LM.Patients with a pathologic diagnosis of NSCLC with LM treated at Stanford between 2003 and 2011 were identified via institutional databases and medical records. LM was defined by cerebrospinal fluid (CSF) that was positive for malignant cells or by LM enhancement on magnetic resonance imaging with gadolinium contrast. Retrospective, landmark analyses were performed to estimate survival. Statistical analyses were performed using SAS Enterprise Guide, version 4.3.LM was identified in 30 patients. All cases were adenocarcinoma; 60% of patients had a known or suspected driver mutation. The mean age was 58 years. Of the 30 patients, 67% were women; 70% were nonsmokers; 27% initially presented with LM; 84% received systemic treatment at or after development of LM; and 53% of these patients received modern systemic therapy for their LM, defined as a regimen containing pemetrexed, bevacizumab, or a tyrosine kinase inhibitor. Mean overall survival after LM diagnosis was 6 months (95% CI, 3-12). Patients who received modern systemic therapy for LM had decreased hazard of death (hazard ratio [HR], 0.24; P = .007).In this retrospective, single-institution analysis, median survival with LM was higher compared with historical experience. Patients who received modern systemic therapy for their LM had particularly good outcomes. These data provide evidence for improving survival outcomes in the modern treatment era for this difficult-to-treat complication.

  View details for DOI 10.1016/j.cllc.2013.12.009

  View details for PubMedID 24524822

• A predictive model to identify hospitalized cancer patients at risk for 30-day mortality based on admission criteria via the electronic medical record. Cancer Ramchandran, K. J., Shega, J. W., von Roenn, J., Schumacher, M., Szmuilowicz, E., Rademaker, A., Weitner, B. B., Loftus, P. D., Chu, I. M., Weitzman, S. 2013; 119 (11): 2074-2080

  Abstract

  This study sought to develop a predictive model for 30-day mortality in hospitalized cancer patients, by using admission information available through the electronic medical record.Observational cohort study of 3062 patients admitted to the oncology service from August 1, 2008, to July 31, 2009. Matched numbers of patients were in the derivation and validation cohorts (1531 patients). Data were obtained on day 1 of admission and included demographic information, vital signs, and laboratory data. Survival data were obtained from the Social Security Death Index.The 30-day mortality rate of the derivation and validation samples were 9.5% and 9.7% respectively. Significant predictive variables in the multivariate analysis included age (P < .0001), assistance with activities of daily living (ADLs; P = .022), admission type (elective/emergency) (P = .059), oxygen use (P < .0001), and vital signs abnormalities including pulse oximetry (P = .0004), temperature (P = .017), and heart rate (P = .0002). A logistic regression model was developed to predict death within 30 days: Score = 18.2897 + 0.6013*(admit type) + 0.4518*(ADL) + 0.0325*(admit age) - 0.1458*(temperature) + 0.019*(heart rate) - 0.0983*(pulse oximetry) - 0.0123 (systolic blood pressure) + 0.8615*(O2 use). The largest sum of sensitivity (63%) and specificity (78%) was at -2.09 (area under the curve = -0.789). A total of 25.32% (100 of 395) of patients with a score above -2.09 died, whereas 4.31% (49 of 1136) of patients below -2.09 died. Sensitivity and positive predictive value in the derivation and validation samples compared favorably.Clinical factors available via the electronic medical record within 24 hours of hospital admission can be used to identify cancer patients at risk for 30-day mortality. These patients would benefit from discussion of preferences for care at the end of life. Cancer 2013;119:2074-2080. © 2013 American Cancer Society.

  View details for DOI 10.1002/cncr.27974

  View details for PubMedID 23504709

• Palliative Care Always ONCOLOGY-NEW YORK Ramchandran, K., Von Roenn, J. H. 2013; 27 (1): 13-?

  Abstract

  Palliative cancer care is the integration into oncologic care of therapies that address the issues that cause physical and psychosocial suffering for the patient and family. Effective provision of palliative cancer care requires an interdisciplinary team that can provide care in all settings (home, inpatient, and outpatient). There is clear evidence for improved outcomes in multiple domains-symptoms, quality of end-of-life care, provider satisfaction, cost of care-with the integration of palliative care into cancer care. As a result, there are now guideline-based recommendations for incorporating palliative care into cancer care. Unfortunately there continue to be barriers to effective integration; these include gaps in education and research, and a cultural stigma that equates palliative care with end-of-life care. These barriers will need to be addressed in order to achieve seamless palliative care integration across the continuum of cancer care for all patients and their families.

  View details for Web of Science ID 000314141000002

  View details for PubMedID 23461040

• Emerging Concepts in the Pathology and Molecular Biology of Advanced Non-Small Cell Lung Cancer AMERICAN JOURNAL OF CLINICAL PATHOLOGY Kulesza, P., Ramchandran, K., Patel, J. D. 2011; 136 (2): 228-238

  Abstract

  Non-small cell lung cancer (NSCLC) is traditionally classified histologically, but until recently, the histologic subtype has had little impact on the selection of therapy. Drugs such as pemetrexed and bevacizumab are indicated for specific NSCLC subtypes, and this type of stratification represents the first step toward individualizing therapy in NSCLC. Beyond histologic features, the status of molecular targets, such as the epidermal growth factor receptor (EGFR) gene, has been shown to correlate with response to treatment with EGFR tyrosine kinase inhibitors in patients with relapsed or refractory disease and in the first-line therapy setting. New therapies targeting the EGFR and other molecular aberrations are under way to help define specific subsets of patients responsive to certain molecularly targeted treatments. The role of pathologists in guiding treatment decisions will increase because molecular profiling, together with pathologic and histologic analysis, represents the future of personalizing medicine for patients with NSCLC.

  View details for DOI 10.1309/AJCPO66OIRULFNLZ

  View details for Web of Science ID 000292905000006

  View details for PubMedID 21757595

• Phantom Limb Pain #212 JOURNAL OF PALLIATIVE MEDICINE Ramchandran, K., Hauser, J. 2010; 13 (10): 1285-1286

  View details for DOI 10.1089/jpm.2010.9775

  View details for Web of Science ID 000282953900020

  View details for PubMedID 20942763

• Sex Differences in Susceptibility to Carcinogens SEMINARS IN ONCOLOGY Ramchandran, K., Patel, J. D. 2009; 36 (6): 516-523

  Abstract

  Lung cancer has reached epidemic proportions in women, and is now the most common cause of cancer death among both men and women in the United States. While smoking rates have declined marginally in women, the rising impact of lung cancer in women may imply that women are at higher risk from carcinogens secondary to underlying factors related to sex. These factors include differences in female physiology such as bronchial responsiveness and airway size, sex-based differences in nicotine metabolism via the cytochrome p450 system driven by hormones, and differences in DNA repair capacity, as well as the evolution of cigarettes. These hypotheses will be explored in depth in this article.

  View details for DOI 10.1053/j.seminoncol.2009.09.005

  View details for Web of Science ID 000278079100006

  View details for PubMedID 19995643

• My Friend, My Patient JOURNAL OF PALLIATIVE MEDICINE Ramchandran, K. 2009; 12 (1): 95-96

  View details for DOI 10.1089/jpm.2009.9688

  View details for Web of Science ID 000262827900026

  View details for PubMedID 19284274