Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access

Limited knowledge and access to palliative care among women with cervical cancer: an opportunity for integrating oncology and palliative care in Zimbabwe

BACKGROUND

Cervical cancer is mostly diagnosed at advanced stages among the majority of women in low-income settings, with palliative care being the only feasible form of care. This study was aimed at investigating palliative care knowledge and access among women with cervical cancer in Harare, Zimbabwe.

METHODS

Sequential mixed methods design was used, consisting of two surveys and a qualitative inquiry. A census of 134 women diagnosed with cervical cancer who visited two cancer treating health facilities and one palliative care provider in Harare between January and April, 2018 were enrolled in the study. Seventy-eight health workers were also enrolled in a census in the respective facilities for a survey. Validated structured questionnaires in electronic format were used for both surveys. Descriptive statistics were generated from the surveys after conducting univariate analysis using STATA. Qualitative study used interview/discussion guides for data collection. Thematic analysis was conducted for qualitative data.

RESULTS

Mean ages of patients and health workers in the surveys were 52 years (SD = 12) and 37 years (SD = 10,respectively. Thirty-two percent of women with cervical cancer reported knowledge of where to seek palliative care. Sixty-eight percent of women with cervical cancer had received treatment, yet only 13% reported receiving palliative care. Few women with cervical cancer associated treatment with pain (13%) and side effects (32%). More women associated cervical cancer with bad smells (81%) and death (84%). Only one of the health workers reported referring patients for palliative care. Seventy-six percent of health workers reported that the majority of patients with cervical cancer sourced their own analgesics from private pharmacies. Qualitative findings revealed a limited or lack of cervical cancer knowledge among nurses especially in primary health care, the existence of stigma among women with cervical cancer and limited implementation of palliative policy.

CONCLUSIONS

This study revealed limited knowledge and access to palliative care in a low-income setting due to multi-faceted barriers. These challenges are not unique to the developing world and they present an opportunity for low-income countries to start considering and strategizing the integration of oncology and palliative care models in line with international recommendations.

Development and Validation of the Palliative Care Attitudes Scale (PCAS-9): A Measure of Patient Attitudes Toward Palliative Care

CONTEXT

Palliative Care is underutilized, and research has neglected patient-level factors including attitudes that could contribute to avoidance or acceptance of Palliative Care referrals. This may be due in part to a lack of existing measures for this purpose.

OBJECTIVES

The objective of this study was to develop and validate a nine-item scale measuring patient attitudes toward Palliative Care, comprised of three subscales spanning emotional, cognitive, and behavioral factors.

METHODS

Data were collected online in three separate waves, targeting individuals with cancer (Sample 1: N = 633; Sample 2: N = 462) or noncancer serious illnesses (Sample 3: N = 225). Participants were recruited using ResearchMatch.org and postings on the web sites, social media pages, and listservs of international health organizations.

RESULTS

Internal consistency was acceptable for the total scale (α = 0.84) and subscales: emotional (α = 0.84), cognitive (αs = 0.70), and behavioral (α = 0.90). The PCAS-9 was significantly associated with a separate measure of Palliative Care attitudes (ps < 0.001) and a measure of Palliative Care knowledge (ps < 0.004), supporting its construct validity in samples of cancer and noncancer serious illnesses. The scale's psychometric properties, including internal consistency and factor structure, generalized across patient subgroups based on diagnosis, other health characteristics, and demographics.

CONCLUSION

Findings support the overall reliability, validity, and generalizability of the PCAS-9 in serious illness samples and have implications for increasing Palliative Care utilization via clinical care and future research efforts.

Barriers to palliative and hospice care utilization in older adults with cancer: A systematic review

The number of older adults with cancer and the need for palliative care among this population is increasing in the United States. The objective of this systematic review was to synthesize the evidence on the barriers to palliative and hospice care utilization in older adults with cancer. A systematic literature search was conducted using PubMed, CINAHL, PsycINFO, Embase, and Cochrane Library databases (from inception to 2018) in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Research articles that examined palliative or hospice care utilization in older adults with cancer were included in this review. Fineout-Overholt's Level of Evidence was used for quality appraisal. A total of 19 studies were synthesized in this review. Barriers to palliative and hospice care utilization were categorized into socio-demographic barriers, provider-related barriers, and health insurance-related barriers. Findings revealed that male, racial minority, unmarried individuals, individuals with low socio-economic status or residing in rural areas, and fee-for-service enrollees were less likely to use palliative or hospice care. Lack of communication with care providers is also a barrier of using palliative or hospice care. The factors identified in this review provide guidance on identification of high-risk population and intervention development to facilitate the use of palliative and hospice care in older adults with cancer. Larger prospective studies on this topic are needed to address this critical issue.

Patient-reported outcomes from a workplace intervention program for cancer survivors highlight ongoing needs to support continuation of work

Purpose

The aim of this study was to investigate the perceptions of cancer survivors who continue to work and provide information to evaluate and develop a supportive workplace program (Ensemble) based on the principles of navigation.

Methods

A mixed-methods design using surveys and open-ended questions was used to study the perceptions of two groups of cancer survivors in the same workplace: those who chose to use a workplace navigational program (Ensemble program users) and those who declined (non-users). Key outcomes were communication and attitudinal self-efficacy, measured by the Communication and Attitudinal Self-Efficacy scale for cancer (CASE-cancer); emotional and informational social support, measured by the Patient-Reported Outcomes Measurement Information System Social Support domain (PROMIS-Social Support); and satisfaction with the navigator relationship, measured using the Patient Satisfaction with Interpersonal Relationship with Navigator (PSN-I).

Results

The study included 7 program users and 17 non-users. There were no significant differences in attitudinal self-efficacy, emotional support, or informational support between the groups. The relationship with the Nurse Navigator was rated highly by program users. The most frequent themes to the open-ended responses included work demands, privacy, integration of life and work, and program improvement.

Conclusions

Successful reintegration into/continuation of work remains a key need for cancer survivors. The navigation program design for cancer survivors should be further improved and applied across work settings.

Electronic supplementary material

The online version of this article (10.1007/s00520-019-04964-1) contains supplementary material, which is available to authorized users.

Barriers and facilitators to community-based psycho-oncology services: A qualitative study of health professionals' attitudes to the feasibility and acceptability of a shared care model

OBJECTIVE

Psychological therapies combined with medication are effective treatments for depression and anxiety in patients with cancer. However, the psycho-oncology workforce is insufficient to meet patient need and is hard to access outside of the major cities. To bridge this gap, innovative models of care are required. Implementation of a new model of care requires attention to the facilitators and barriers. The aim of this study was to explore stakeholders' attitudes to the feasibility and acceptability of a community-based, shared care model for the treatment of depression and anxiety.

METHODS

Semi-structured interviews were conducted with community-based clinical psychologists (n = 10), general practitioners (n = 6), and hospital-based psychologists working in psycho-oncology (n = 9). Framework analysis was conducted to identify key themes.

RESULTS

All stakeholders perceived the model as feasible and acceptable. Potential barriers/facilitators to implementation were summarised under six key themes: (a) initiative, ownership, and autonomy; (b) resources; (c) pathway establishment; (d) support; (e) skill acquisition; and (f) patient engagement. Facilitators included quality communication between health professionals across primary and tertiary care and appropriate education and support for community-based clinicians.

CONCLUSIONS

This in-depth exploration of Australian health professionals' perceptions of the feasibility and acceptability of a community-based model of psycho-oncology care revealed that most clinicians were willing to adopt the proposed changes into practice. An RCT of a shared care intervention for depressed patients with cancer is needed.

Knowledge of Palliative Care Among American Adults: 2018 Health Information National Trends Survey

CONTEXT

Palliative care will play an important role to alleviate disease suffering and improve quality of life for cancer patients and their family caregivers.

OBJECTIVE

We examined the knowledge penetration of palliative care in a nationally representative sample of U.S. adults.

METHODS

We used the 2018 National Cancer Institute's Health Information National Trends Survey to determine the proportion of respondents who had knowledge of palliative care as well as the depth and sources of their knowledge. We used the Pearson chi-square test and a multivariable logistic regression model to assess the association of respondents' basic demographic characteristics as well as health status and having knowledge of palliative care.

RESULTS

We identified 3194 respondents (weighted sample size: 229,591,005) who met the inclusion criteria. About 71% (2097) of all respondents had no knowledge of palliative care and 84.5% of Hispanic respondents had no knowledge of palliative care. Multivariable analyses indicated the middle-aged (50-64 years old, odds ratio, 1.58; 95% CI, 1.15-2.19, P = 0.006) and elder population (65 years or older, odds ratio, 1.70, 95% CI, 1.30-2.22, P < 0.001) have a significantly better knowledge of palliative care than those under age 50. Common misconceptions existed in respondents, even those who had self-reported adequate knowledge of palliative care.

CONCLUSION

The proportion of adults who have knowledge of palliative care is low in the U.S. Greater efforts are needed to promote palliative care and reduce the misconceptions of palliative care in the general population.

Symptom Assessment and Early Access to Supportive and Palliative Care for Patients With Advanced Solid Tumors in Mexico

BACKGROUND

Early specialized palliative care improves quality of life of patients with advanced cancer, and guidelines encourage its integration into standard oncology care. However, many patients fail to obtain timely palliative/supportive care evaluations, particularly in limited-resource settings. We aimed to determine the proportion of patients with advanced cancer who received an assessment of symptoms and were referred to supportive and palliative care services during the first year after diagnosis in a Mexican hospital.

METHODS

Individuals with newly diagnosed advanced solid tumors and 1 year of follow-up at the oncology clinics in the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran in Mexico City from October 2015 to April 2016 were included in this retrospective study.

RESULTS

Seventy-seven patients were included. Forty-two (54.5%) were referred to the various supportive care services during the first year after diagnosis, and 23 (29.8%) were referred to the palliative care clinic. The most commonly assessed symptoms by oncologists were pain (77.9%), anorexia (74.0%), fatigue (68.8%), and nausea (55.8%), while depression/anxiety were evaluated in 10 (12.9%) patients. The oncologist offered to clarify treatment goals in 39 (50.6%) cases and evaluated the understanding of diagnosis/illness and prognosis in 22 (28.5%).

CONCLUSION

Palliative and supportive care services were widely underutilized, which may be related to a lack of standardized symptom assessments and poor end-of-life communication. Novel strategies are needed to improve the implementation of tools for systematic symptom assessment and to optimize the integration of supportive care interventions into oncology care in developing countries.

Palliative care use amongst patients with bladder cancer

OBJECTIVES

To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.

PATIENTS AND METHODS

Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients diagnosed with muscle-invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis.

RESULTS

Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N⁺ , or M⁺ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder-sparing approach. The adjusted probability of receiving palliative care did not significantly change over time.

CONCLUSIONS

Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease-specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician-, patient-, and system-level barriers to this care.

Predictors for use of psychosocial services in patients with metastatic colorectal cancer receiving first line systemic treatment

BACKGROUND

Patients with advanced disease experience high levels of psychological distress, yet there is low uptake of psychosocial services offered to patients who screened positive for distress. In this study we aimed to identify predictors for use of psychosocial services in patients with metastatic colorectal cancer (mCRC) receiving first line chemotherapy enrolled in a prospective cluster randomized trial (CRT).

METHODS

Patients completed measures on psychological distress, physical distress, and quality of life at baseline. Demographics, clinical characteristics at baseline and clinical events during treatment (e.g. severe adverse events, clinical benefit) were extracted from patient records. Patients reported psychosocial service utilization in- and outside the hospital after 10, 24 and 48 weeks of treatment. Multivariable logistic regression models were used to identify predictors for the use of psychosocial services.

RESULTS

Out of 349 patients, seventy patients (20.0%) used psychosocial support services during the follow-up period. Use of psychosocial services was associated with younger age, a higher educational level, presence of more pain (at baseline), and the expressed need to talk to a professional (at baseline). In addition, patients without progressive disease within the first ten weeks of treatment were more likely to use psychosocial services .

CONCLUSIONS

One in five patients with mCRC receiving first line palliative treatment used psychosocial services during this prospective longitudinal CRT. Sociodemographic factors (age, education), clinical factors (pain and no progressive disease) and the expressed need to talk to a professional predicted use of psychosocial services. Identification of these predictors may contribute to the understanding of factors that determine the need for psychosocial services.

TRIAL REGISTRATION

Netherlands Trial Register NTR4034 .

Statewide Differences in Personality Associated with Geographic Disparities in Access to Palliative Care: Findings on Openness

Background: Geographic disparities in access to palliative care cause unnecessary suffering near the end-of-life in low-access U.S. states. The psychological mechanisms accounting for state-level variation are poorly understood. Objective: To examine whether statewide differences in personality account for variation in palliative care access. Design: We combined 5 state-level datasets that included the 50 states and national capital. Palliative care access was measured by the Center to Advance Palliative Care 2015 state-by-state report card. State-level personality differences in openness, conscientiousness, agreeableness, neuroticism, and extraversion were identified in a report on 619,387 adults. The Census and Gallup provided covariate data. Regression analyses examined whether state-level personality predicted state-level palliative care access, controlling for population size, age, gender, race/ethnicity, socioeconomic status, and political views. Sensitivity analyses controlled for rurality, nonprofit status, and hospital size. Results: Palliative care access was higher in states that were older, less racially diverse, higher in socioeconomic status, more liberal, and, as hypothesized, higher in openness. In regression analyses accounting for all predictors and covariates, higher openness continued to account for better state-level access to palliative care (β = 0.428, p = 0.008). Agreeableness also emerged as predicting better access. In sensitivity analyses, personality findings persisted, and less rural states and those with more nonprofits had better access. Conclusions: Palliative care access is worse in states lower in openness, meaning where residents are more skeptical, traditional, and concrete. Personality theory offers recommendations for palliative care advocates communicating with administrators, legislators, philanthropists, and patients to expand access in low-openness states.

Experiences of Dutch general practitioners and district nurses with involving care services and facilities in palliative care: a mixed methods study

Background

Generals practitioners (GPs) and district nurses (DNs) play a leading role in providing palliative care at home. Many services and facilities are available to support them in providing this complex care. This study aimed to examine the extent to which GPs and DNs involve these services, what their experiences are, and how involvement of these services and facilities can be improved.

Methods

Sequential mixed methods consisting of an online questionnaire with structured and open questions completed by 108 GPs and 258 DNs, followed by three homogenous online focus groups with 8 GPs and 19 DNs, analyzed through open coding.

Results

Most GPs reported that they sometimes or often involved palliative home care teams (99%), hospices (94%), and palliative care consultation services (93%). Most DNs reported sometimes or often involving volunteers (90%), hospices (88%), and spiritual caregivers (80%). The least involved services and facilities were psychologists and psychiatrists (51% and 50%) and social welfare (44% and 57%). Main reason for not involving services and facilities was ‘not needing’ them. If they had used them, most GPs and DNs (68–93%) reported solely positive experiences. Hardly anyone (0–3%) reported solely negative experiences with any of the services and the facilities. GPs and DNs suggested improvements in three areas: (1) establishment of local centers giving information on available services and facilities, (2) presentation of services and facilities in local multidisciplinary meetings, and (3) support organizations to proactively offer their facilities and services.

Conclusion

Psychological, social, and spiritual services are involved less often, suggesting that the classic care model, which focuses strongly on somatic issues, is still well entrenched. More familiarity with services that can provide additional care in these areas, regarding their availability and their added value, could improve the quality of life for patients and relatives at the end of life.

Barriers and Facilitators to Effective Inpatient Palliative Care Consultations: A Qualitative Analysis of Interviews With Palliative Care and Nonpalliative Care Providers

OBJECTIVE

To identify factors that hinder or facilitate the palliative care consultation team's (PCCT) successful collaboration with other providers from the perspectives of both PCCT and nonpalliative specialists.

METHODS

Qualitative study, including semistructured interviews with PCCT and nonpalliative care providers from various specialties at 4 Midwestern hospitals. Interviews were audio-recorded and transcribed into written text documents for thematic analysis. Palliative care consultation team (n = 19) and nonpalliative care providers (n = 29) were interviewed at their respective hospital sites or via telephone. Palliative care consultation team providers included physicians, nurse practitioners, registered nurses, social workers, and one chaplain. Specialists included critical care physicians, surgeons, hospitalists, nephrologists, oncologists, and cardiologists.

RESULTS

Six themes emerged reflecting barriers to and facilitators of successful collaboration between the PCCT and other providers. Primary barriers included attitudes about palliative care, lack of knowledge about the role of the PCCT, and patient and family resistance. Facilitators included marketing of the palliative care service and education about the expertise of the PCCT.

CONCLUSION

In order to engage in more effective collaboration with other specialty providers, the PCCT may consider strategies including structured educational interventions, increased visibility in the hospital, and active marketing of the utility of palliative care across disciplines.

Multilevel Opportunities to Address Lung Cancer Stigma across the Cancer Control Continuum

The public health imperative to reduce the burden of lung cancer has seen unprecedented progress in recent years. Fully realizing the advances in lung cancer treatment and control requires attention to potential barriers in their momentum and implementation. In this analysis, we present and evaluate the argument that stigma is a highly significant barrier to fulfilling the clinical promise of advanced care and reduced lung cancer burden. This evaluation of the stigma of lung cancer is based on a multilevel perspective that incorporates the individual, persons in the individual's immediate environment, the health care system, and the larger societal structure that shapes perceptions and decisions. We also consider current interventions and interventional needs within and across aspects of the lung cancer continuum, including prevention, screening, diagnosis, treatment, and survivorship. Current evidence suggests that stigma detrimentally affects psychosocial, communication, and behavioral outcomes over the entire lung cancer control continuum and across multiple levels. Interventional efforts to alleviate stigma in the context of lung cancer show promise, yet more work is needed to evaluate their impact. Understanding and addressing the multilevel role of stigma is a crucial area for future study to realize the full benefits offered by lung cancer prevention, control, and treatment. Coordinated, interdisciplinary, and well-conceptualized efforts have the potential to reduce the barrier of stigma in the context of lung cancer and facilitate demonstrable improvements in clinical care and quality of life.

Impact of an Inpatient Palliative Care Consultation in Terminally Ill Cancer Patients

Abstract: Limited data are available to guide the timing of palliative care involvement in the treatment of cancer. We describe the referral patterns of inpatient palliative care consultations(IPCC) in advanced cancer patients in a tertiary care center.

Methods: A retrospective review was performed of IPCC for cancer patients from January 1, 2014, to December 31, 2014. Descriptive statistics are reported.

Results: IPCCs were requested for 245 cancer inpatients, of which 130 were male (53.1%) and 115 (46.9%) were female; 128 (52.2%) were Caucasian, 114 (46.5%) were African American, and 3 (1.2%) were another race. Of the 245 patients, 79 (32.2%) were newly diagnosed during the current admission, and the remaining 146 (67.8%) had been diagnosed previously. Fifty-seven (23.3%) patients were admitted to the intensive care unit (ICU) during hospitalization. Of the 39 patients (15.9%) who died during their hospital stay, 34 (87.0%) had an ICU stay during the hospitalization or died in the ICU. The most common malignancies were lung (71; 29.0%), pancreatic-biliary (33; 13.4%), lymphoma and leukemia (22; 8.9%), hepatocellular (18; 7.3%), head and neck (16; 6.5%), and upper gastrointestinal tract(GI) (16; 6.5%).

Conclusions: Our data show that 15.9% of terminally ill cancer patients with IPCC died in the hospital, the majority of whom died in the ICU. This was likely due to delays in the initiation of outpatient palliative care consultation, leading to an increased strain on tertiary referral centers. Our study highlights a racial disparity in the rate of IPCC in African Americans, compared to historical data.

Help-seeking behaviour in newly diagnosed lung cancer patients: Assessing the role of perceived stigma

Objective

This study explored help‐seeking behaviours, group identification, and perceived legitimacy of discrimination, and its potential relationship with perceived lung cancer stigma.

Methods

Consecutive consenting adults (n = 274) with a primary diagnosis of lung cancer within the previous 4 months were recruited at 31 outpatient clinics in Australia. A self‐report survey assessed help‐seeking, group identification, perceived legitimacy of discrimination, and perceived lung cancer stigma.

Results

Services providing assistance from health professionals (69.5%) and informational support (68.5%) were more frequently used than emotional‐based support. Only a small proportion (2.6%) of participants were unlikely to seek help from anyone, with the most popular sources of help being the general practitioner (91.0%), and oncologist/treating clinician (81.3%). One‐fifth (21.1%) indicated they identified with being a lung cancer patient, and most did not perceive discrimination against lung cancer patients. Higher perceived lung cancer stigma was significantly associated with greater perceived legitimacy of discrimination (P < 0.001), but not help‐seeking behaviours or group identification.

Conclusions

The relationship between lung cancer stigma and perceived legitimacy of discrimination may guide initiatives to reduce stigma for patients. It is encouraging that perceived stigma did not appear to inhibit help‐seeking behaviours. However, further research in this emerging field is needed to investigate patterns of perceived stigma and help‐seeking over time to identify how and when to offer support services most appropriate to the needs of lung cancer patients.

The Underutilization of Rehabilitation to Treat Physical Impairments in Breast Cancer Survivors

Breast cancer survivors can experience multiple neuromuscular, musculoskeletal, pain, and functional disorders as a result of their cancer and its treatment. Common disorders include shoulder dysfunction, postmastectomy syndrome, chemotherapy-induced peripheral neuropathy, axillary cording, lymphedema, and a host of others. Cancer rehabilitation is a process that helps breast cancer and other survivors to obtain and maintain the highest possible physical, social, psychological, and vocational functioning within the limits created by cancer and its treatments. There are good data supporting the safety and efficacy of cancer rehabilitation in the treatment of many breast cancer-related impairments, including shoulder dysfunction and lymphedema, among others. Despite the goals and efficacy of cancer rehabilitation, there is a marked underuse of services. The reasons for this phenomenon are many, but broadly result from a lack of knowledge about cancer rehabilitation on the part of patients and referring clinicians, limited access to services, and suboptimal adherence. This article explores underutilization of cancer rehabilitation in breast cancer survivors and provides an opportunity to consider ways to improve this gap in care.

Palliative Care Use Among Patients With Solid Cancer Tumors: A National Cancer Data Base Study

BACKGROUND

Palliative care has been increasingly recognized as an important part of cancer care but remains underutilized in patients with solid cancers. There is a current gap in knowledge regarding why palliative care is underutilized nationwide.

OBJECTIVE

To identify the factors associated with palliative care use among deceased patients with solid cancer tumors.

METHODS

Using the 2016 National Cancer Data Base, we identified deceased patients (2004-2013) with breast, colon, lung, melanoma, and prostate cancer. Data were described as percentages. Associations between palliative care use and patient, facility, and geographic characteristics were evaluated through multivariate logistic regression.

RESULTS

A total of 1 840 111 patients were analyzed; 9.6% received palliative care. Palliative care use was higher in the following patient groups: survival >24 months (17% vs 2%), male (54% vs 46%), higher Charlson-Deyo comorbidity score (16% vs 8%), treatment at designated cancer programs (74% vs 71%), lung cancer (76% vs 28%), higher grade cancer (53% vs 24%), and stage IV cancer (59% vs 13%). Patients who lived in communities with a greater percentage of high school degrees had higher odds of receiving palliative care; Central and Pacific regions of the United States had lower odds of palliative care use than the East Coast. Patients with colon, melanoma, or prostate cancer had lower odds of palliative care than patients with breast cancer, whereas those with lung cancer had higher odds.

CONCLUSIONS

Palliative care use in solid cancer tumors is variable, with a preference for patients with lung cancer, younger age, known insurance status, and higher educational level.

The Determinants of Palliative Care Use in Patients With Colorectal Cancer: A National Study

BACKGROUND

Palliative care is associated with improved survival and quality of life, but its use among patients with colorectal cancer varies nationwide and the determinants of those variations are not clear.

OBJECTIVE

To determine the factors associated with palliative care use among patients who died of colorectal cancer.

METHODS

Deceased patients treated for colorectal cancer (2004-2013) were identified within the National Cancer Database. Multivariable logistic regression was used to evaluate patient and institutional characteristics associated with palliative care use. Patients were classified based on their length of survival (<6 months, 6-24 months, and 24+ months) to provide timing context.

RESULTS

A total of 287 923 patients were analyzed. Overall, 4.3% of the patients received palliative care. Patients who received palliative care were more likely to be younger, recently diagnosed, treated at academic hospitals, and have stage IV disease. Patients living in Mountain and Pacific regions had higher odds of palliative care receipt than those in the East Coast. Patients without insurance had higher odds of palliative care if they survived <24 months. Insurance coverage through Medicaid was associated with increased palliative care use among patients who survived 6 to 24 months. Patients who survived <6 months and lived >9 miles from the institution received more palliative care.

CONCLUSION

Palliative care use among patients with colorectal cancer is associated with a younger age, a more recent year of diagnosis, insurance status, academic hospitals, and living in Mountain and Pacific regions.

The use of psychosocial support services among Japanese breast cancer survivors

Background

This study aimed to investigate the use of psychosocial support services, the intention to use these services, and to elucidate the characteristics of survivors most likely to use support services among Japanese breast cancer survivors.

Methods

We invited breast cancer survivors to complete an online questionnaire via an email sent to subscribers of a non-profit organization mailing list. We asked participants questions related to demographics, opinions on the state of psychosocial support services, and their interest in using these services. Participants were also asked to complete the Hospital Anxiety and Depression Scale and the Brief Cancer Worry Inventory (BCWI).

Results

We analyzed the data of 171 participants. Those who used some form of psychosocial support service constituted 50.9% of the participant population. Participants used cancer consulting and support center services (13.5%), hospital and non-hospital support groups (12.9%, respectively), psychiatry (11.1%), hospital and non-hospital cancer salons (8.8%, respectively), psychosomatic medicine (8.2%), therapist counseling (6.4%) and psycho-oncology department services (4.1%). Non-users who suffered from adjustment disorders or major depression (52.1%) reported higher total BCWI and the subscale scores had no concrete plans to use psychosocial support services.

Conclusions

The usage levels of psychiatry, psychosomatic medicine and psycho-oncology services in our study were higher than those reported in any previous Japanese study within the psycho-oncology field. Participants joining a breast cancer survivors' mailing list, or their being female, may have led to a higher use of such services. A high degree of distress does not necessarily lead cancer survivors to seek psychosocial support services.

Practice Patterns, Attitudes, and Barriers to Palliative Care Consultation by Gynecologic Oncologists

PURPOSE

We sought to describe practice patterns, attitudes, and barriers to the integration of palliative care services by gynecologic oncologists.

METHODS

Members of the Society of Gynecologic Oncology were electronically surveyed regarding their practice of incorporating palliative care services and to identify barriers for consultation. Descriptive statistics were used, and two-sample z-tests of proportions were performed to compare responses to related questions.

RESULTS

Of the 145 respondents, 71% were attending physicians and 58% worked at an academic medical center. The vast majority (92%) had palliative care services available for consultation at their hospital; 48% thought that palliative care services were appropriately used, 51% thought they were underused, and 1% thought they were overused. Thirty percent of respondents thought that palliative care services should be incorporated at first recurrence, whereas 42% thought palliative care should be incorporated when prognosis for life expectancy is ≤ 6 months. Most participants (75%) responded that palliative care consultation is reasonable for symptom control at any stage of disease. Respondents were most likely to consult palliative care services for pain control (53%) and other symptoms (63%). Eighty-three percent of respondents thought that communicating prognosis is the primary team's responsibility, whereas the responsibilities for pain and symptom control, resuscitation status, and goals of care discussions were split between the primary team only and both teams. The main barrier for consulting palliative care services was the concern that patients and families would feel abandoned by the primary oncologist (73%). Ninety-seven percent of respondents answered that palliative care services are useful to improve patient care.

CONCLUSION

The majority of gynecologic oncologists perceived palliative care as a useful collaboration that is underused. Fear of perceived abandonment by the patient and family members was identified as a significant barrier to palliative care consult.

Does educating patients about the Early Palliative Care Study increase preferences for outpatient palliative cancer care? Findings from Project EMPOWER

OBJECTIVES

Randomized controlled trials, especially the Early Palliative Care Study (Temel et al., 2010), have shown that early outpatient palliative cancer care can improve quality of life for patients with advanced cancer or serious symptoms. However, fear and misconceptions drive avoidance of palliative care. Drawing from an empowerment perspective, we examined whether educating patients about evidence from the Early Palliative Care Study would increase preferences for palliative care.

METHOD

A sample of 598 patients with prostate, breast, lung, colon/rectal, skin, and other cancer diagnoses completed an Internet-mediated experiment using a between-group prepost design. Intervention participants received a summary of the Early Palliative Care Study; controls received no intervention. Participants completed baseline and posttest assessments of preferences of palliative care. Analyses controlled for age, gender, education, cancer type, presence of metastases, time since diagnosis, and baseline preferences.

RESULTS

As hypothesized, the intervention had a favorable impact on participants' preferences for outpatient palliative cancer care relative to controls (d = 1.01, p < .001), while controlling for covariates. Intervention participants came to view palliative care as more efficacious (d = 0.79, p < .001) and less scary (d = 0.60, p < .001) and exhibited stronger behavioral intentions to utilize outpatient palliative care if referred (d = 0.60, p < .001). Findings were comparable in patients with metastatic disease, those with less education, and those experiencing financial strain.

CONCLUSIONS

Educating patients about the Early Palliative Care Study increases preferences for early outpatient palliative care. This research has implications for future studies aimed at improving quality of life in cancer by increasing palliative care utilization. (PsycINFO Database Record

Integrating Oncology Massage Into Chemoinfusion Suites: A Program Evaluation

OBJECTIVE

This article reports on the development, implementation, and evaluation of an integrative clinical oncology massage program for patients undergoing chemotherapy for breast cancer in a large academic medical center.

MATERIALS AND METHODS

We describe the development and implementation of an oncology massage program embedded into chemoinfusion suites. We used deidentified program evaluation data to identify specific reasons individuals refuse massage and to evaluate the immediate impact of massage treatments on patient-reported outcomes using a modified version of the Distress Thermometer delivered via iPad. We analyzed premassage and postmassage data from the Distress Thermometer using paired t test and derived qualitative data from participants who provided written feedback on their massage experiences.

RESULTS

Of the 1,090 massages offered, 692 (63%) were accepted. We observed a significant decrease in self-reported anxiety (from 3.9 to 1.7), nausea (from 2.5 to 1.2), pain (from 3.3 to 1.9), and fatigue (from 4.8 to 3.0) premassage and postmassage, respectively (all P < .001). We found that 642 survey participants (93%) were satisfied with their massage, and 649 (94%) would recommend it to another patient undergoing treatment. Spontaneous patient responses overwhelmingly endorsed the massage as relaxing. No adverse events were reported. Among the 398 patients (36%) who declined a massage, top reasons were time concerns and lack of interest.

CONCLUSION

A clinical oncology massage program can be safely and effectively integrated into chemoinfusion units to provide symptom control for patients with breast cancer. This integrative approach overcomes patient-level barriers of cost, time, and travel, and addresses the institutional-level barrier of space.

Exercise therapy in oncology rehabilitation in Australia: A mixed-methods study

AIM

Oncology rehabilitation improves outcomes for cancer survivors but little is known about program availability in Australia. The aims of this study were: to describe oncology rehabilitation programs in Australia: determine whether the exercise component of programs is consistent with guidelines: and to explore barriers and facilitators to program implementation.

METHODS

A sequential, explanatory mixed-methods study was completed in two phases: (1) a survey of Australian oncology rehabilitation programs; and (2) purposively sampled follow-up semistructured interviews with senior clinicians working in oncology rehabilitation who were involved with exercise prescription.

RESULTS

Hospitals and/or cancer centers from 42 public hospital health networks (representing 163 hospitals) and 39 private hospitals were contacted to identify 31 oncology rehabilitation programs. All 31 surveys were returned (100% response rate). Programs were typically multidisciplinary, ran twice weekly, provided education and exercise and included self-management strategies. Exercise prescription and progression was patient centered and included a combination of resistance and aerobic training supplemented by balance, pelvic floor, and core stability exercises. Challenges to implementation included a lack of awareness of programs in the community and organizational barriers such as funding. Strong links with oncologists facilitated program referrals.

CONCLUSION

Despite evidence to support oncology rehabilitation, there are few programs in Australia and there are challenges that limit it becoming part of standard practice. Programs that exist are multidisciplinary with a focus on exercise with the majority of programs following a cardiac rehabilitation model of care.

The prevalence and nature of supportive care needs in lung cancer patients

PURPOSE

In the present work, we set out to comprehensively describe the unmet supportive care and information needs of lung cancer patients.

METHODS

This cross-sectional study used the Supportive Care Needs Survey Short Form 34 (34 items) and an informational needs survey (8 items). Patients with primary lung cancer in any phase of survivorship were included. Demographic data and treatment details were collected from the medical charts of participants. The unmet needs were determined overall and by domain. Univariable and multivariable regression analyses were performed to determine factors associated with greater unmet needs.

RESULTS

From August 2013 to February 2014, 89 patients [44 (49%) men; median age: 71 years (range: 44-89 years)] were recruited. The mean number of unmet needs was 8 (range: 0-34), and 69 patients (78%) reported at least 1 unmet need. The need proportions by domain were 52% health system and information, 66% psychological, 58% physical, 24% patient care, and 20% sexuality. The top 2 unmet needs were "fears of the cancer spreading" [n = 44 of 84 (52%)] and "lack of energy/tiredness" [n = 42 of 88 (48%)]. On multivariable analysis, more advanced disease and higher MD Anderson Symptom Inventory scores were associated with increased unmet needs. Patients reported that the most desired information needs were those for information on managing symptoms such as fatigue (78%), shortness of breath (77%), and cough (63%).

CONCLUSIONS

Unmet supportive care needs are common in lung cancer patients, with some patients experiencing a very high number of unmet needs. Further work is needed to develop resources to address those needs.

Toward a Broader Role for Occupational Therapy in Supportive Oncology Care

Supportive care in oncology helps people cope with cancer and its psychological, physical, and emotional side effects. However, cancer survivors report dissatisfaction with supportive care and a need for more psychosocial and self-management services. Occupational therapy practitioners represent an integral part of the supportive care team because their scope of practice emphasizes function. Through a focus on function, practitioners address the full spectrum of physical and psychosocial care. Currently, conceptualizations of occupational therapy for cancer survivors often focus solely on physical interventions and, therefore, do not represent the unique involvement of the profession in supportive oncology care. We advocate for a focused framework for occupational therapy practitioners in oncology as experts in function and providers of both physical and psychosocial treatments. Barriers to a focus on function are identified, and strategies are suggested for expanding involvement for the profession in supportive oncology care.

ReCAP: Attitudes, Beliefs, and Awareness of Graduate Medical Education Trainees Regarding Palliative Care at a Comprehensive Cancer Center

PURPOSE

Palliative care (PC) training and integration with oncology care remain suboptimal. Current attitudes and beliefs of the oncology trainees regarding PC are not fully known. This study was undertaken in an attempt to address this issue.

PARTICIPANTS AND METHODS

We conducted a survey to determine awareness of PC among graduate medical trainees at a comprehensive cancer center with an established PC program. One hundred seventy oncology trainees who completed$9 months of training in medical, surgical, gynecologic, and radiation oncology fellowships and residency programs during the 2013 academic year completed an online questionnaire. Descriptive, univariable, and multivariable analyses were performed.

RESULTS

The response rate was 78% (132 of 170 trainees); 10 trainees without hands-on patient care were excluded. Medical (53 of 60 [88%]), gynecologic (six of six [100%]), and radiation oncology (20 of 20 [100%]) trainees reported more awareness of PC compared with surgical oncology (22 of 36 [61%]) trainees (P = .001). One hundred twelve of 122 (92%) perceived PC as beneficial to patients and families. One hundred eight of 122 (89%) perceived that PC can reduce health care costs, 78 (64%) believed that PC can increase survival, and 90 (74%) would consult PC for a patient with newly diagnosed cancer with symptoms. Eighty-two trainees (67%) believed a mandatory PC rotation is important. Trainees with previous exposure to PC rotations were more aware of the role of PC services than were trainees without PC rotation (96% [46 of 48] v 74% [55 of 74]; P = .005, respectively).

CONCLUSION

Surgical trainees and trainees without previous PC rotation had significantly less awareness of PC. Overall, trainees perceived PC as beneficial to patients and capable of reducing costs while increasing survival; they also supported early PC referrals and endorsed a mandatory PC rotation.

The Association Between Home Palliative Care Services and Quality of End-of-Life Care Indicators in the Province of Québec

CONTEXT

In Canada, governments have increased spending on home care to promote better end-of-life care. In the province of Québec, Canada, home palliative care (PC) services (HPCS) are provided by Public Local Community-Based Health Care Service providers (Centres Locaux de Services Communautaires [CLSC]) with universal coverage. Accordingly, there should be no regional variations of these services and their effect on quality of end-of-life PC (QEoLPC) indicators.

OBJECTIVES

To test if all the CLSCs provided the same level of HPCS to cancer patients in the province of Québec, Canada, and the association between level of HPCS and QEoLPC indicators.

METHODS

Characteristics of 52,316 decedents with cancer were extracted from administrative databases between 2003 and 2006. Two gender-specific "adjusted performance of CLSCs in delivering HPCS" models were created using gender-specific hierarchical regression adjusted for patient and CLSC neighborhood characteristics. Using the same approach, the strength of the association between the adjusted performance of CLSCs in delivering HPCS and the QEoLPC indicators was estimated.

RESULTS

Overall, 27,255 (52.1%) decedents had at least one HPCS. Significant variations in the adjusted performance of CLSC in delivering HPCS were found. Higher performance led to a lower proportion of men having more than one emergency room visit during the last month of life (risk ratio [RR] 0.924; 95% CI 0.867-0.985), and for women, a higher proportion dying at home (RR 2.255; 95% CI 1.703-2.984) and spending less time in hospital (RR 0.765; 95% CI 0.692-0.845).

CONCLUSION

Provision of HPCS remained limited in Québec, but when present, they were associated with improved QEoLPC indicators.

Use of inpatient palliative care services in patients with metastatic incurable head and neck cancer

BACKGROUND

Substantial health care resources are used on aggressive end-of-life care, despite an increasing recognition that palliative care improves quality of life and reduces health care costs. We examined the incidence of palliative care encounters in in-patients with incurable head and neck cancer and associations with in-hospital mortality, length of hospitalization, and costs.

METHODS

Data from the Nationwide Inpatient Sample (NIS) for 80,514 head and neck cancer patients with distant metastatic disease in 2001 to 2010 was analyzed using cross-tabulations and multivariate regressions.

RESULTS

Palliative care encounters occurred in 4029 cases (5%) and were significantly associated with age ≥80 years, female sex, self-pay payor status, and prior radiation. Palliative care was significantly associated with increased in-hospital mortality and reduced hospital-related costs.

CONCLUSION

Inpatient palliative care consultation in terminal head and neck cancer is associated with reduced hospital-related costs, but appears to be underutilized and restricted to the elderly, uninsured, and patients with an increased risk of mortality.

A systematic review of barriers to optimal outpatient specialist services for individuals with prevalent chronic diseases: what are the unique and common barriers experienced by patients in high income countries?

Health utilization and need assessment data suggest there is considerable variation in access to outpatient specialist care. However, it is unclear if the types of barriers experienced are specific to chronic disease groups or experienced universally. This systematic review provides a detailed summary of common and unique barriers experienced by chronic disease groups when accessing and receiving care, and a synthesized list of possible health service initiatives to improve equitable delivery of optimal care in high-income countries. Quantitative articles describing barriers to specialist outpatient services were retrieved from CINAHL, MEDLINE, Embase, and PyscINFO. To be eligible for review, studies: were published from 2002 to May 2014; included samples with cancer, diabetes mellitus, osteoporosis, arthritis, ischaemic heart disease, stroke, asthma, chronic pulmonary disorder (COPD) or depression; and, were conducted in high-income countries. Using a previously validated model of access (Penchansky and Thomas' model of fit), barriers were grouped according to five overarching domains and defined in more detail using 33 medical subject headings. Results from reviewed articles, including the scope and frequency of reported barriers, are conceptualized using thematic analysis and framed as possible health service initiatives. A total of 3181 unique records were screened for eligibility, of which 74 studies were included in final analysis. The largest proportion of studies reported acceptability barriers (75.7 %), of which demographic disparities (44.6 %) were reported across all diseases. Other frequently reported barriers included inadequate need assessment (25.7 %), information provision (32.4 %), or health communication (20 %). Unique barriers were identified for oncology, mental health, and COPD samples. Based on the scope, frequency and measurement of reported barriers, eight key themes with associated implications for health services are presented. Examples include: common accommodation and accessibility barriers caused on service organization or physical structure, such as parking and appointment scheduling; common barriers created by poor coordination of care within the healthcare team; and unique barriers resulting from inadequate need assessment and referral practices. Consideration of barriers, across and within chronic diseases, suggests a number of specific initiatives are likely to improve the delivery of patient-centered care and increase equity in access to high-quality health services.

Evaluating Stakeholder-Identified Barriers in Accessing Palliative Care at an NCI-Designated Cancer Center with a Rural Catchment Area

BACKGROUND

The new Commission on Cancer (CoC) accreditation standards encompass palliative care (PC) and a patient-centered approach, including specific quality measurements and outcomes. However, cancer centers differ in their interpretation of the CoC standards for PC in level of integration in the care trajectory and services provided.

OBJECTIVE

The aim of this study was to identify existing barriers in accessing PC services for cancer patients at a National Cancer Institute (NCI)-designated academic cancer center with a rural catchment area, using the CoC guidelines as a point of reference.

METHODS

This study utilized a cross-sectional qualitative design and conventional content analysis. Subjects were faculty/staff from the cancer center or from community affiliates located outside the main campus. Measurement was by semistructured qualitative interviews. Forty-two interviews were included in the final sample: clinicians, administrative support staff, and service support personnel.

RESULTS

Four themes were developed from the analysis focusing on barriers to PC integration: (1) fragmentation of services, (2) unclear pathways and triggers for referral, (3) demand exceeds available practitioners, and (4) insufficient or inadequate education for patients and oncology providers.

CONCLUSIONS

This study highlights aspects of integration of PC that can be enhanced from a process, education, and systems perspective with a particular focus on the care coordination of a rural cancer population.

Supportive care needs and preferences of lung cancer patients: a semi-structured qualitative interview study

PURPOSE

Lung cancer patients report both high levels of unmet supportive care need and underutilisation of support services, but the existing literature offers limited understanding of their specific needs and preferences for help. This study aimed to address this research gap through qualitative exploration of the supportive care needs and preferences of lung cancer patients.

METHODS

Semi-structured interviews were conducted with ten lung cancer patients recruited from the Chest Clinic, Royal Adelaide Hospital (South Australia). Interviews particularly focussed on four key supportive care domains: medical information, physical symptoms, activities of daily living and emotional needs.

RESULTS

Participants reported low use of supportive care services and resources in all four domains. Verbal information from doctors was preferred over printed or online information, and upfront and honest communication was highly valued. Attitude was viewed as important for coping with physical symptoms. Participants demonstrated strong determination to manage activities of daily living independently and, when this was not possible, preferred to seek help from family over external organisations. Support groups and helplines were not utilised for a variety of reasons, although several benefits of connecting with fellow cancer patients were identified.

CONCLUSIONS

The reasons behind underutilisation of supportive care services by lung cancer patients are more complex than simple lack of awareness or availability of services. Information about patients' needs and preferences reveals opportunities for service improvement and alternative models of supportive care.

A qualitative analysis of patient and family perspectives of palliative care

BACKGROUND

To provide truly patient-centered palliative care services, there is a need to better understand the perspectives and experiences of patients and families. Increased understanding will provide insight into the development of health care team competencies and organizational changes necessary to improve patient care.

OBJECTIVE

Our aim was to explore patient and family perceptions of palliative care services at the end of life or during serious illness and to identify facilitators and barriers to receipt of palliative care services.

METHODS

In-depth, semi-structured patient and family interviews were conducted, transcribed, and independently reviewed using grounded theory methodology and preliminary interpretations. A combined deductive and inductive iterative qualitative approach was used to identify recurring themes. The study was conducted in a physician-led, not-for-profit, multispecialty integrated health system serving three large, western, rural states. A purposive sample of 14 individuals who received palliative care services were interviewed alone or with their families for a total of 12 interviews.

RESULTS

Presence, Reassurance, and Honoring Choices emerged as central themes linked to satisfaction with palliative care services. Themes were defined as including health care professional attributes of respect, approachability, genuineness, empathy, connectedness, compassion, sensitivity, an ability to listen, good communication, provision of information, empowerment, and timeliness. Honoring Choices included those pertaining to treatment, spirituality, and family needs.

CONCLUSIONS

At end of life or during times of serious illness, patients and families identified behaviors of Presence, Reassurance, and Honoring Choices as important. According to patients/families, health care providers must be compassionate and empathetic and possess skills in listening, connecting, and interacting with patients and families.

Patients' Perspectives on Integrating Acupuncture into the Radiation Oncology Setting

INTRODUCTION

Acupuncture has potential as a supportive care service for cancer symptom management. However, little is known about patients' willingness to use acupuncture in the context of conventional cancer care.

METHODOLOGY

We conducted a cross-sectional survey study among patients with cancer during their last week of fractionated/external beam radiotherapy (RT). The main outcome variable was self-reported likelihood of using acupuncture during RT. Knowledge about acupuncture and pain severity was measured along with socio-demographic and clinical variables. Multivariate logistic regression was performed to identify factors associated with willingness to use acupuncture.

RESULTS

Among the 305 participants, 79 (26.4%) were likely to use acupuncture during RT if such services were offered at a reasonable price, 143 (46.9%) had no knowledge of acupuncture, and 206 (67.6%) reported having pain. In multivariate analyses, non-Whites (adjusted odds ratio [AOR] 1.94, 95% Confidence Interval [CI] 1.06-3.56), and those with pain (AOR 2.52, CI 1.25-5.10) were more interested in using acupuncture. In addition, patients with preexisting knowledge about acupuncture were also more likely to use acupuncture than those without this knowledge (AOR 2.23, CI 1.28-3.88).

CONCLUSIONS

Patients of non-White race, those with pain or those with prior knowledge about acupuncture were more willing to utilize acupuncture during RT. Since half of the patients had no knowledge about acupuncture, interventions to improve patients' knowledge are needed to facilitate the successful integration of acupuncture into cancer care.

Integrating palliative care: when and how?

PURPOSE OF REVIEW

Lung cancer is the leading cause of cancer mortality in men and women. Most patients present with advanced disease and face significant morbidity, with many reporting distressing symptoms throughout the course of their illness. The purpose of this review is to highlight the recent studies that support the integration of early palliative care into the standard oncology care of patients with advanced lung cancer.

RECENT FINDINGS

Historically, palliative care was provided predominantly as a hospital-based consultation service; however, recent data support an outpatient delivery model of early palliative care alongside standard oncology care. In two randomized controlled trials, patients with advanced cancer who were assigned to early palliative care reported improved quality of life and mood. Numerous organizations have published guidelines to support the integration of palliative care into the routine care of patients with lung cancer.

SUMMARY

Palliative care is appropriate for patients at any point in a serious illness. Unlike hospice, palliative care is not limited by prognosis and may be provided at the same time as disease-directed therapies. There is strong evidence underscoring the importance of integrating palliative care across the trajectory of lung cancer. The primary oncology team should routinely assess for pain and other symptoms, and regularly inquire about a patient's understanding of his disease and his goals of care. Specialty palliative care can provide an extra layer of support for patients with lung cancer and their families by helping with more challenging symptom management, psychosocial support, complex decision-making, advance care planning, and transitions in care.

Patient and health professional's perceived barriers to the delivery of psychosocial care to adults with cancer: a systematic review

OBJECTIVE

To explore the barriers experienced and perceived by health professionals and patients in the delivery of psychosocial care to adults with cancer.

METHODS

Systematic searches were undertaken using the PsychInfo, Medline and CINAHL electronic databases, up to October 2013. Research reporting health professional or patient experiences and perceptions of barriers to psychosocial care are included in the review. The systematic review includes studies that have non-experimental, exploratory and observational designs, as is appropriate to answer the review question. Included studies were critically appraised. The results of individual quantitative studies were aggregated. Qualitative content analysis was used to analyse the qualitative results.

RESULTS

Twenty-five papers met the pre-specified inclusion criteria for the final review. The most commonly perceived barrier for patients relates to receiving adequate support from elsewhere and a lack of perceived need for psychosocial care. Health professionals report barriers at an organisational level most frequently followed by cultural and then individual clinician-related barriers.

CONCLUSIONS

Barriers exist on a variety of levels. People with cancer need clear appropriate information and communication about psychosocial services, including information about the role of psychosocial care in addition to existing supports. Interventions that target the complex interplay of individual, organisational and cultural factors need to be developed. Strategies that improve health professional communication skills, identify clear referral pathways, improve acceptability of interventions and clearly identify the need for services could address many of the barriers identified in this review.

Barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients

OBJECTIVE

This study examined barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients (N=165) at two medical centers in the Midwestern United States.

METHODS

Lung cancer patients completed an assessment of anxiety and depressive symptoms, mental health service use, barriers to using these services, and preferences for addressing emotional concerns.

RESULTS

Only 45% of distressed patients received mental health care since their lung cancer diagnosis. The most prevalent patient-reported barriers to mental health service use among non-users of these services (n=110) included the desire to independently manage emotional concerns (58%) and inadequate knowledge of services (19%). In addition, 57% of distressed patients who did not access mental health services did not perceive the need for help. Seventy-five percent of respondents (123/164) preferred to talk to a primary care physician if they were to have an emotional concern. Preferences for counseling, psychiatric medication, peer support, spiritual care, or independently managing emotional concerns also were endorsed by many patients (range=40-50%). Older age was associated with a lower likelihood of preferring to see a counselor.

CONCLUSIONS

Findings suggest that many distressed lung cancer patients underuse mental health services and do not perceive the need for such services. Efforts to increase appropriate use of services should address patients' desire for autonomy and lack of awareness of services.

Early palliative care for patients with advanced cancer: how to make it work?

PURPOSE OF REVIEW

As the benefit of early palliative care for the quality of life of patients with advanced cancer is currently receiving widespread recognition, cancer specialists increasingly inquire about the practical implications of this concept. This publication presents the available information about how to provide early palliative care for patients with advanced cancer.

RECENT FINDINGS

Oncologists and other cancer specialists provide general palliative care from the time of diagnosis of incurable cancer together with the patients' family doctors. This includes basic assessment of symptoms and distress, their initial management as well as sensitive communication with the patient, including advance care planning and end-of-life issues and hope. The additional integration of a specialized palliative care team early in the care trajectory has been found to be beneficial for quality of life and survival. This concept is known as 'early palliative care' or 'early integration' and has become recommended by institutions such as the American Society of Clinical Oncology.

SUMMARY

Palliative care is warranted from the time of diagnosis of incurable cancer. From this early stage, palliative care consists of general palliative care provided by cancer specialists and family doctors and additional support of a specialized palliative care program. Guidance from different guidelines is presented alongside practical recommendations derived from our experience with an early palliative care program for comprehensive cancer care over the last 7 years.

Validation of QuickDASH outcome measure in breast cancer survivors for upper extremity disability

OBJECTIVE

To validate the QuickDASH as a patient-reported outcome measure for assessing upper extremity disability in breast cancer survivors.

DESIGN

Large cross-sectional survey.

SETTING

Ambulatory care center at a university hospital.

PARTICIPANTS

Postmenopausal women (N=150) with stage I to III hormone receptor-positive breast cancer currently taking a third-generation aromatase inhibitor.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

QuickDASH, an 11-item self-administered questionnaire, assesses global arm function over the past 7 days.

RESULTS

Of 150 surveys, 148 (99%) were scorable. The factor analysis demonstrated 1 factor with an eigenvalue of 6.7, which explains 61% of variance. The score was reliable with a Cronbach alpha of .93. The test-retest reliability was .78 over 2 weeks. The mean QuickDASH score ± SD for all patients was 19±19. Those with upper extremity arthralgias reported higher QuickDASH scores than controls without pain (26 vs 12, P=.001). Those with frozen shoulder pain also reported higher QuickDASH scores than controls without pain (37 vs 15, P=.001).

CONCLUSIONS

The QuickDASH instrument is a convenient, reliable, and valid patient-reported outcome measure to assess upper extremity disability in patients with breast cancer.

Support service use and interest in support services among lung cancer patients

OBJECTIVES

This study examined support service use and interest in support services among lung cancer patients (N = 165) at two comprehensive medical centers in the midwestern United States.

MATERIALS AND METHODS

Patients completed an assessment of support service use (i.e., receipt of mental health services, complementary and alternative medicine [CAM], and help from a spiritual leader), interest in support services, and physical and psychological symptoms.

RESULTS

Only 40% of patients with significant anxiety and depressive symptoms and 28% of the entire sample reported current mental health service use. However, nearly half (47%) of all patients were receiving support from a spiritual leader. Having late-stage lung cancer and a religious affiliation predicted receipt of spiritual support. Few patients who were not receiving mental health services or spiritual support were interested in these services (range = 4-18%). Conversely, although interest in CAM was expressed by a substantial minority of patients (27%) who were not using these services, rates of CAM use were relatively low (22%).

CONCLUSIONS

Findings suggest that distressed lung cancer patients underuse mental health services, but many patients receive help from spiritual leaders. Given the lack of interest in mental health services among patients who are not receiving them, efforts are needed to enhance palatability of services and identify and reduce barriers to evidence-based service use.

Cost-effectiveness of early palliative care intervention in recurrent platinum-resistant ovarian cancer

OBJECTIVE

To determine if early palliative care intervention in patients with recurrent, platinum-resistant ovarian cancer is potentially cost saving or cost-effective.

METHODS

A decision model with a 6 month time horizon evaluated routine care versus routine care plus early referral to a palliative medicine specialist (EPC) for recurrent platinum-resistant ovarian cancer. Model parameters included rates of inpatient admissions, emergency department (ED) visits, chemotherapy administration, and quality of life (QOL). From published ovarian cancer data, we assumed baseline rates over the final 6 months: hospitalization 70%, chemotherapy 60%, and ED visit 30%. Published data from a randomized trial evaluating EPC in metastatic lung cancer were used to model odds ratios (ORs) for potential reductions in hospitalization (OR 0.69), chemotherapy (OR 0.77), and emergency department care (OR 0.74) and improvement in QOL (OR 1.07). The costs of hospitalization, ED visit, chemotherapy, and EPC were based on published data. Ranges were used for sensitivity analysis. Effectiveness was quantified in quality adjusted life years (QALYs); survival was assumed equivalent between strategies.

RESULTS

EPC was associated with a cost savings of $1285 per patient over routine care. In sensitivity analysis incorporating QOL, EPC was either dominant or cost-effective, with an incremental cost-effectiveness ratio (ICER) <$50,000/QALY, unless the cost of outpatient EPC exceeded $2400. Assuming no clinical benefit other than QOL (no change in chemotherapy administration, hospitalizations or ED visits), EPC remained highly cost-effective with ICER $37,440/QALY.

CONCLUSION

Early palliative care intervention has the potential to reduce costs associated with end of life care in patients with ovarian cancer.

Training mid-level providers on palliative care: bringing advanced directives and symptom assessment and management to community oncology practices

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