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García Santos JM, Plasencia Martínez JM. Scanxiety: potential lessons for personalized radiology. Eur Radiol 2024:10.1007/s00330-024-10726-3. [PMID: 38627291 DOI: 10.1007/s00330-024-10726-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/01/2024] [Accepted: 03/09/2024] [Indexed: 04/20/2024]
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Affiliation(s)
- Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Evelien J M Kuip
- Department of Medical Oncology and Department of Anesthesiology, Pain and Palliative Care, Radboudumc, Nijmegen, The Netherlands
| | | | - Diana Lees
- Department of Respiratory Medicine, Liverpool University Foundation Teaching Hospital, United Kingdom
| | - Eduardo Bruera
- Department of Palliative Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, USA
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van de Wal D, den Hollander D, Desar IM, Gelderblom H, Oosten AW, Reyners AK, Steeghs N, Husson O, van der Graaf WT. Fear, anxiety and depression in gastrointestinal stromal tumor (GIST) patients in the Netherlands: Data from a cross-sectional multicenter study. Int J Clin Health Psychol 2024; 24:100434. [PMID: 38226006 PMCID: PMC10788803 DOI: 10.1016/j.ijchp.2023.100434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/28/2023] [Indexed: 01/17/2024] Open
Abstract
Background This study aims to (1) investigate the prevalence of anxiety, depression and severe fear of cancer recurrence or progression in gastrointestinal stromal tumor (GIST) patients treated in a curative or palliative setting, (2) compare their prevalence with a norm population, (3) identify factors associated with anxiety, depression and severe fear, and (4) study the impact of these psychological symptoms on health-related quality of life (HRQoL). Methods In a cross-sectional study, GIST patients completed the Hospital Anxiety and Depression Scale, Cancer Worry Scale, and EORTC QLQ-C30. Results Of the 328 patients, 15% reported anxiety, 13% depression, and 43% had severe fear. Anxiety and depression levels were comparable between the norm population and patients in the curative setting, but significantly higher for patients in the palliative setting. Having other psychological symptoms was associated with anxiety, while current TKI treatment and anxiety were associated with depression. Severe fear was associated with age, female sex, palliative treatment setting, anxiety, and GIST-related concerns. Conclusion GIST patients treated in a palliative setting are more prone to experience psychological symptoms, which can significantly impair their HRQoL. These symptoms deserve more attention in clinical practice, in which regular screening can be helpful, and appropriate interventions should be offered.
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Affiliation(s)
- Deborah van de Wal
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Dide den Hollander
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ingrid M.E. Desar
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Astrid W. Oosten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anna K.L. Reyners
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Olga Husson
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, the Netherlands
| | - Winette T.A. van der Graaf
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
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Berndsen M, Renberg S, Hølmebakk T, Hancke E, Puls F, Karlsson F, Stoldt S, Bjerkehagen B, Haglund de Flon F, Muth A, Papakonstantinou A, Boye K, Lindskog S. Long-term outcome after surgical resection of non-high-risk gastrointestinal stromal tumours without adjuvant therapy. Br J Surg 2023; 110:1857-1862. [PMID: 37758514 PMCID: PMC10638541 DOI: 10.1093/bjs/znad309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/04/2023] [Accepted: 09/08/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Gastrointestinal stromal tumour (GIST) is the most common intra-abdominal sarcoma. Risk classification systems, commonly the modified National Institutes of Health consensus criteria, identify tumour properties relating to patient outcomes. However, owing to limited long-term evidence, most guidelines recommend up to 10-year follow-up for all risk groups except very low-risk GIST. METHODS This retrospective multicentre study included patients who had complete resection of primary, non-metastatic GIST from three Scandinavian sarcoma centres: Gothenburg (2004-2020), Stockholm (2000-2019), and Oslo (2000-2017). Medical records were reviewed for clinical details regarding diagnosis, treatment, and follow-up, and recurrence-free and disease-specific survival evaluated. RESULTS The total cohort consisted of 1213 patients with GIST. High-risk patients and those treated with tyrosine kinase inhibitors were excluded. The remaining 649 patients were included in the present analysis: 118 with very low-, 381 with low-, and 150 with intermediate-risk GISTs. Five-year recurrence-free survival rates were 100, 98.5, and 100 per cent for the intermediate-, low-, and very low-risk groups respectively (P = 0.246). Disease-specific survival rates 10 years after surgery were 100, 98.4, and 100 per cent for the intermediate-, low-, and very low-risk groups respectively (P = 0.262). CONCLUSION Patients with completely resected non-high-risk GISTs have an excellent long-term outcome, irrespective of risk group. Follow-up programmes to detect disease recurrences in these patients are probably not indicated.
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Affiliation(s)
- Marta Berndsen
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Section of Endocrine and Sarcoma Surgery, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sara Renberg
- Department of Head, Neck, Lung and Skin Tumours, Karolinska University Hospital, Stockholm, Sweden
| | - Toto Hølmebakk
- Department of Abdominal and Paediatric Surgery, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway
| | - Emma Hancke
- Section of Endocrine and Sarcoma Surgery, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Florian Puls
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fredrik Karlsson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Breast Cancer, Endocrine Tumours and Sarcoma, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Stephan Stoldt
- Department of Abdominal and Paediatric Surgery, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway
| | - Bodil Bjerkehagen
- Department of Pathology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Felix Haglund de Flon
- Department of Oncology–Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Pathology and Cancer diagnostics, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Muth
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Section of Endocrine and Sarcoma Surgery, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andri Papakonstantinou
- Department of Breast Cancer, Endocrine Tumours and Sarcoma, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology–Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Kjetil Boye
- Department of Oncology, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway
| | - Stefan Lindskog
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Section of Endocrine and Sarcoma Surgery, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Halland Hospital, Varberg, Sweden
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Hussain M, Chau S, Turner M, Paterson C. Scan-Associated Distress in People Affected by Cancer: A Qualitative Systematic Review. Semin Oncol Nurs 2023; 39:151502. [PMID: 37735038 DOI: 10.1016/j.soncn.2023.151502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/26/2023] [Accepted: 08/23/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE The term "scanxiety" has been coined to describe the anxiety commonly associated with individuals undergoing cancer-related imaging. Despite the prevalence and severity of scanxiety across various clinical and demographic populations, there remains a significant lack of qualitative insights from existing studies that effectively capture patients' experiences of scanxiety in their own words. Therefore, this review addresses the following research question: What are the experiences of scanxiety distress among people affected by cancer across the cancer care continuum? DATA SOURCES Following the PRISMA methodology, a meta-aggregation of qualitative studies was performed, encompassing patients of all age groups who had been diagnosed with cancer or were indicated for a cancer-related scan. Of the 556 articles screened, 15 were deemed eligible for inclusion in the analysis. CONCLUSION The three overarching themes of 1) experience of "scan-itis," 2) experience of "patient-clinician support," and 3) development of self-management strategies reveal the complex and interconnected factors that influence scanxiety in individuals undergoing cancer-related imaging. These findings emphasized distress experienced by patients during the waiting period for scan results, the act of viewing the results, and even the delivery of "bad" news. Consequently, patients expressed a strong desire for increased information, communication, and empathy from attending healthcare providers. Patients also report a myriad of self-coping strategies to manage their scanxiety well before, during, and after their scan appointment. IMPLICATIONS FOR NURSING PRACTICE The study highlights the need for targeted interventions for those undergoing cancer-related scans, including increased awareness and education for health professionals regarding scanxiety.
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Affiliation(s)
- M Hussain
- Faculty of Health, University of Canberra, Bruce ACT, Australia
| | - S Chau
- Caring Futures Institute, Flinders University, Australia
| | - M Turner
- Faculty of Health, University of Canberra, Bruce ACT, Australia
| | - C Paterson
- Faculty of Health, University of Canberra, Bruce ACT, Australia; Caring Futures Institute, Flinders University, Australia; Central Adelaide Local Health Network, Adelaide; Robert Gordon University, Aberdeen, Scotland, UK; Flinders Medical Centre, Adelaide, Australia.
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Xu W, Liu Y. Association between acute adverse reactions to iodinated contrast media and anxiety in patients undergoing contrast-enhanced CT examination. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:1225-1233. [PMID: 37875363 PMCID: PMC10930856 DOI: 10.11817/j.issn.1672-7347.2023.220537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 10/26/2023]
Abstract
OBJECTIVES As the use of iodinated contrast media has become more widely with advances in imaging, several guidelines have suggested that anxiety increases the risk of acute adverse reactions associated with iodinated contrast media. This study aims to evaluate the impact of anxiety on the occurrence of acute adverse reactions (AAR) to iodinated contrast media in patients undergoing contrast-enhanced CT examinations. METHODS Inpatients who underwent contrast-enhanced CT examinations at the Third Xiangya Hospital between February and October 2021 were prospectively recruited. Prior to the imaging examinations, all patients completed the Generalized Anxiety Disorder Scale-7 (GAD-7) assessment before the imaging examinations to determine the severity of anxiety, which was categorized as mild, moderate, or severe. Based on the occurrence of AAR, patients were classified into an AAR group and a non-AAR group. The difference in anxiety was compared between the 2 groups. Multivariate logistic regression analysis was used to identify independent risk factors associated with AAR. To ensure comparability between the 2 groups, propensity score matching (PSM) was utilized to align the clinical characteristics. Subsequently, the difference in anxiety within the matched groups was analyzed. RESULTS The study comprised 880 patients, with 80 patients in the AAR group and 800 patients in the non-AAR group. There was a significant difference in proportion of patients with mild-severe anxiety between the 2 groups (75% in the AAR group and 36% in the non-AAR group, P<0.001). Additionally, differences were also observed in occupation, income, underlying diseases, and allergy history (all P<0.001). The results of multivariate logistic regression analysis revealed that patients' income, allergy history, and anxiety were independent risk factors for AAR to iodinated contrast media (all P<0.05). Following PSM, each matched group included 66 cases, and no significant differences in clinical characteristics were observed between the 2 groups (all P>0.05). However, the proportion of patients with mild-severe anxiety remained significantly higher in the AAR group compared to the non-AAR group (75% in the AAR group and 31% in the non-AAR group, P<0.001). CONCLUSIONS Anxiety is associated with an increased risk of AAR to iodinated contrast media in patients undergoing contrast-enhanced CT examinations, suggesting the clinical importance of screening for anxiety before imaging examinations.
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Affiliation(s)
- Wei Xu
- Department of Radiology, Third Xiangya Hospital, Central South University, Changsha 410013, China.
| | - Yan Liu
- Department of Radiology, Third Xiangya Hospital, Central South University, Changsha 410013, China.
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Dretzke J, Lorenc A, Adriano A, Herd C, Mehanna H, Nankivell P, Moore DJ. Systematic review of patients' and healthcare professionals' views on patient-initiated follow-up in treated cancer patients. Cancer Med 2023; 12:16531-16547. [PMID: 38771977 PMCID: PMC10469665 DOI: 10.1002/cam4.6243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 04/26/2023] [Accepted: 06/03/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Current follow-up models in cancer are seen to be unsustainable and inflexible, and there is growing interest in alternative models, such as patient-initiated follow-up (PIFU). It is therefore important to understand whether PIFU is acceptable to patients and healthcare professionals (HCPs). METHODS Standard systematic review methodology aimed at limiting bias was used for study identification (to January 2022), selection and data extraction. Thematic synthesis was undertaken for qualitative data, and survey findings were tabulated and described. RESULTS Nine qualitative studies and 22 surveys were included, mainly in breast and endometrial cancer. Women treated for breast or endometrial cancer and HCPs were mostly supportive of PIFU. Facilitators for PIFU included convenience, control over own health and avoidance of anxiety-inducing clinic appointments. Barriers included loss of reassurance from scheduled visits and lack of confidence in self-management. HCPs were supportive of PIFU but concerned about resistance to change, unsuitability of PIFU for some patients and costs. CONCLUSION PIFU is viewed mostly positively by women treated for breast or endometrial cancer, and by HCPs, but further evidence is needed from a wider range of cancers, men, and more representative samples. A protocol was registered with PROSPERO (CRD42020181412).
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Affiliation(s)
- Janine Dretzke
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
| | - Ava Lorenc
- Bristol Medical School: Population Health Sciences, University of BristolBristolUK
| | - Ada Adriano
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
| | - Clare Herd
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
| | - Hisham Mehanna
- Institute of Head and Neck Studies and EducationUniversity of BirminghamBirminghamUK
| | - Paul Nankivell
- Institute of Head and Neck Studies and EducationUniversity of BirminghamBirminghamUK
| | - David J. Moore
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
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Ahmed L, Constantinidou A, Chatzittofis A. Patients' perspectives related to ethical issues and risks in precision medicine: a systematic review. Front Med (Lausanne) 2023; 10:1215663. [PMID: 37396896 PMCID: PMC10310545 DOI: 10.3389/fmed.2023.1215663] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Background Precision medicine is growing due to technological advancements including next generation sequencing techniques and artificial intelligence. However, with the application of precision medicine many ethical and potential risks may emerge. Although, its benefits and potential harms are relevantly known to professional societies and practitioners, patients' attitudes toward these potential ethical risks are not well-known. The aim of this systematic review was to focus on patients' perspective on ethics and risks that may rise with the application of precision medicine. Methods A systematic search was conducted on 4/1/2023 in the database of PubMed, for the period 1/1/2012 to 4/1/2023 identifying 914 articles. After initial screening, only 50 articles were found to be relevant. From these 50 articles, 24 articles were included in this systematic review, 2 articles were excluded as not in English language, 1 was a review, and 23 articles did not include enough relevant qualitative data regarding our research question to be included. All full texts were evaluated following PRISMA guidelines for reporting systematic reviews following the Joanna Briggs Institute criteria. Results There were eight main themes emerging from the point of view of the patients regarding ethical concerns and risks of precision medicine: privacy and security of patient data, economic impact on the patients, possible harms of precision medicine including psychosocial harms, risk for discrimination of certain groups, risks in the process of acquiring informed consent, mistrust in the provider and in medical research, issues with the diagnostic accuracy of precision medicine and changes in the doctor-patient relationship. Conclusion Ethical issues and potential risks are important for patients in relation to the applications of precision medicine and need to be addressed with patient education, dedicated research and official policies. Further research is needed for validation of the results and awareness of these findings can guide clinicians to understand and address patients concerns in clinical praxis.
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Affiliation(s)
- Lawko Ahmed
- Medical School, University of Cyprus, Nicosia, Cyprus
| | | | - Andreas Chatzittofis
- Medical School, University of Cyprus, Nicosia, Cyprus
- Department of Clinical Sciences and Psychiatry, Umeå University, Umeå, Sweden
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Cederberg KB, Iyer RS, Chaturvedi A, McCarville MB, McDaniel JD, Sandberg JK, Shammas A, Sharp SE, Nadel HR. Imaging of pediatric bone tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper. Pediatr Blood Cancer 2023; 70 Suppl 4:e30000. [PMID: 36250990 PMCID: PMC10661611 DOI: 10.1002/pbc.30000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/08/2022]
Abstract
Malignant primary bone tumors are uncommon in the pediatric population, accounting for 3%-5% of all pediatric malignancies. Osteosarcoma and Ewing sarcoma comprise 90% of malignant primary bone tumors in children and adolescents. This paper provides consensus-based recommendations for imaging in children with osteosarcoma and Ewing sarcoma at diagnosis, during therapy, and after therapy.
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Affiliation(s)
- Kevin B. Cederberg
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ramesh S. Iyer
- Department of Radiology, Seattle Children’s Hospital, Seattle, WA
| | - Apeksha Chaturvedi
- Division of Pediatric Radiology, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY
| | - MB McCarville
- Department of Diagnostic Imaging, St Jude Children’s Research Hospital, Memphis, TN
| | - Janice D. McDaniel
- Department of Pediatric Interventional Radiology, Akron Children’s Hospital, Akron, OH and Department of Radiology, Northeast Ohio Medical University, Rootstown, OH
| | - Jesse K. Sandberg
- Department of Pediatric Radiology, Lucile Packard Children’s Hospital, Stanford University, Stanford, CA
| | - Amer Shammas
- Division of Nuclear Medicine, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, OH, Canada
| | - Susan E. Sharp
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Helen R. Nadel
- Department of Pediatric Radiology, Lucile Packard Children’s Hospital, Stanford University, Stanford, CA
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van de Wal D, Fauske L, Bruland ØS, Jones RL, Kasper B, Wilson R, van der Graaf WTA, Husson O. Psychological and social challenges of patients with locally advanced and metastatic gastrointestinal stromal tumours (GIST) on long-term treatment with tyrosine kinase inhibitors: a qualitative study with patients and medical oncologists. Support Care Cancer 2023; 31:352. [PMID: 37233829 DOI: 10.1007/s00520-023-07810-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/11/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE Tyrosine kinase inhibitors (TKIs) have revolutionized the treatment of locally advanced and metastatic gastrointestinal stromal tumours (GISTs). Patients are experiencing prolonged survival but often at the expense of their health-related quality of life. It is not only the physical side effects that impact GIST patients' daily lives but also the psychological and social challenges they have to deal with. This qualitative study aimed to explore the psychological and social life challenges of GIST patients with locally advanced and metastatic disease on ≥ 5 years TKI treatment. METHODS Semi-structured interviews with 15 locally advanced and/or metastatic GIST patients and 10 medical oncologists with experience of delivering care to this specific patient group were conducted. Thematic analysis was used to interpret the data. RESULTS Psychological challenges expressed by participants concerned fears, scanxiety, negative change in emotion and mood, doubts about their treatment and follow-up, living with uncertainty, lack of understanding from others or healthcare professionals, and constantly being reminded of their illness. Challenges regarding social health included financial difficulties, challenges in relationships, concerns about fertility and parenting, work, and impact on social activities. CONCLUSION The reported psychological and social challenges can significantly hamper the overall quality of life of GIST patients. Some challenges were clearly underreported and hardly recognized by medical oncologist, as they may tend to focus on the physical side effects and clinical outcomes of treatment. Therefore, it is essential to take the patient's perspective into account in research and clinical practice to ensure optimal care for this patient group.
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Affiliation(s)
- Deborah van de Wal
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Lena Fauske
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Øyvind S Bruland
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Robin L Jones
- Sarcoma Unit, The Royal Marsden NHS Foundation Trust, London, UK
- Division of Clinical Studies, The Institute of Cancer Research, London, UK
| | - Bernd Kasper
- Sarcoma Unit, Mannheim University Medical Center, University of Heidelberg, Mannheim, Germany
| | - Roger Wilson
- NCRI Consumer Forum, Sarcoma Patients Euronet, Shropshire, UK
| | - Winette T A van der Graaf
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Olga Husson
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Paalimäki-Paakki K, Virtanen M, Henner A, Vähänikkilä H, Nieminen MT, Schroderus-Salo T, Kääriäinen M. Effects of a 360° virtual counselling environment on patient anxiety and CCTA process time: A randomised controlled trial. Radiography (Lond) 2023; 29 Suppl 1:S13-S23. [PMID: 36280541 DOI: 10.1016/j.radi.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/27/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION This study investigated whether a 360° virtual counselling environment (360°VCE) was more effective at decreasing patients' anxiety than routine standard of care counselling for patients undergoing coronary computed tomography angiography (CCTA), and if there was any difference in the process times for both of these groups. METHODS A total of 86 patients underwent CCTA in this randomised controlled trial. Patients were randomly assigned to intervention and control groups. The 360°VCE was developed using spherical panoramic images and non-immersive 360° technology. The primary outcome, anxiety, was measured using the State-Trait Anxiety Inventory (STAI). The secondary outcome, CCTA process time, was measured from the time of arrival in the department until end of examination. RESULTS Pre-scan anxiety was lower among patients in the 360°VCE group immediately before CCTA in comparison to patients in the control group (p = 0.015). Women demonstrated higher levels of anxiety than men in both groups. No between-group differences were discerned in CCTA process time. CONCLUSION Access to 360°VCE can reduce patients' pre-CCTA anxiety levels. IMPLICATIONS FOR PRACTICE The presented results can be used to improve patient counselling and care, reduce anxiety among patients undergoing CCTA, and optimise the CCTA examination procedure.
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Affiliation(s)
- Karoliina Paalimäki-Paakki
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland; Degree Programme of Radiography and Radiation Therapy, Oulu University of Applied Sciences, Oulu, Finland.
| | - Mari Virtanen
- School of Rehabilitation and Examination, Helsinki Metropolia University of Applied Sciences, Helsinki, Finland
| | - Anja Henner
- Degree Programme of Radiography and Radiation Therapy, Oulu University of Applied Sciences, Oulu, Finland
| | - Hannu Vähänikkilä
- Northern Finland Birth Cohorts, Arctic Biobank, Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Miika T Nieminen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland; Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Tanja Schroderus-Salo
- Degree Programme of Radiography and Radiation Therapy, Oulu University of Applied Sciences, Oulu, Finland
| | - Maria Kääriäinen
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Oulu University Hospital, Oulu, Finland
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Bui KT, Li Z, Dhillon HM, Kiely BE, Blinman P. Scanxiety Conversations on Twitter: Observational Study. JMIR Cancer 2023; 9:e43609. [PMID: 37074770 PMCID: PMC10157462 DOI: 10.2196/43609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Scan-associated anxiety (or "scanxiety") is commonly experienced by people having cancer-related scans. Social media platforms such as Twitter provide a novel source of data for observational research. OBJECTIVE We aimed to identify posts on Twitter (or "tweets") related to scanxiety, describe the volume and content of these tweets, and describe the demographics of users posting about scanxiety. METHODS We manually searched for "scanxiety" and associated keywords in cancer-related, publicly available, English-language tweets posted between January 2018 and December 2020. We defined "conversations" as a primary tweet (the first tweet about scanxiety) and subsequent tweets (interactions stemming from the primary tweet). User demographics and the volume of primary tweets were assessed. Conversations underwent inductive thematic and content analysis. RESULTS A total of 2031 unique Twitter users initiated a conversation about scanxiety from cancer-related scans. Most were patients (n=1306, 64%), female (n=1343, 66%), from North America (n=1130, 56%), and had breast cancer (449/1306, 34%). There were 3623 Twitter conversations, with a mean of 101 per month (range 40-180). Five themes were identified. The first theme was experiences of scanxiety, identified in 60% (2184/3623) of primary tweets, which captured the personal account of scanxiety by patients or their support person. Scanxiety was often described with negative adjectives or similes, despite being experienced differently by users. Scanxiety had psychological, physical, and functional impacts. Contributing factors to scanxiety included the presence and duration of uncertainty, which was exacerbated during the COVID-19 pandemic. The second theme (643/3623, 18%) was the acknowledgment of scanxiety, where users summarized or labeled an experience as scanxiety without providing emotive clarification, and advocacy of scanxiety, where users raised awareness of scanxiety without describing personal experiences. The third theme was messages of support (427/3623, 12%), where users expressed well wishes and encouraged positivity for people experiencing scanxiety. The fourth theme was strategies to reduce scanxiety (319/3623, 9%), which included general and specific strategies for patients and strategies that required improvements in clinical practice by clinicians or health care systems. The final theme was research about scanxiety (50/3623, 1%), which included tweets about the epidemiology, impact, and contributing factors of scanxiety as well as novel strategies to reduce scanxiety. CONCLUSIONS Scanxiety was often a negative experience described by patients having cancer-related scans. Social media platforms like Twitter enable individuals to share their experiences and offer support while providing researchers with unique data to improve their understanding of a problem. Acknowledging scanxiety as a term and increasing awareness of scanxiety is an important first step in reducing scanxiety. Research is needed to guide evidence-based approaches to reduce scanxiety, though some low-cost, low-resource practical strategies identified in this study could be rapidly introduced into clinical care.
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Affiliation(s)
- Kim Tam Bui
- Medical Oncology, Concord Cancer Centre, Concord, Australia
- Sydney Medical School, University of Sydney, Camperdown, Australia
| | - Zoe Li
- Medical Oncology, Concord Cancer Centre, Concord, Australia
| | - Haryana M Dhillon
- Psycho-Oncology Cooperative Research Group, School of Psychology, University of Sydney, Camperdown, Australia
- Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Camperdown, Australia
| | - Belinda E Kiely
- Medical Oncology, Concord Cancer Centre, Concord, Australia
- Sydney Medical School, University of Sydney, Camperdown, Australia
| | - Prunella Blinman
- Medical Oncology, Concord Cancer Centre, Concord, Australia
- Sydney Medical School, University of Sydney, Camperdown, Australia
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13
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Antoni MH, Moreno PI, Penedo FJ. Stress Management Interventions to Facilitate Psychological and Physiological Adaptation and Optimal Health Outcomes in Cancer Patients and Survivors. Annu Rev Psychol 2023; 74:423-455. [PMID: 35961041 PMCID: PMC10358426 DOI: 10.1146/annurev-psych-030122-124119] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Cancer diagnosis and treatment constitute profoundly stressful experiences involving unique and common challenges that generate uncertainty, fear, and emotional distress. Individuals with cancer must cope with multiple stressors, from the point of diagnosis through surgical and adjuvant treatments and into survivorship, that require substantial psychological and physiological adaptation. This can take a toll on quality of life and well-being and may also promote cellular and molecular changes that can exacerbate physical symptoms and facilitate tumor growth and metastasis, thereby contributing to negative long-term health outcomes. Since modifying responses tostressors might improve psychological and physiological adaptation, quality of life, and clinical health outcomes, several randomized controlled trials have tested interventions that aim to facilitate stress management. We review evidence for the effects of stress management interventions on psychological and physiological adaptation and health outcomes in cancer patients and survivors and summarize emerging research in the field to address unanswered questions.
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Affiliation(s)
- Michael H Antoni
- Department of Psychology, University of Miami, Coral Gables, Florida, USA;
- Cancer Control Research Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Patricia I Moreno
- Cancer Control Research Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Public Health Sciences, University of Miami School of Medicine, Miami, Florida, USA
| | - Frank J Penedo
- Department of Psychology, University of Miami, Coral Gables, Florida, USA;
- Cancer Control Research Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Medicine, University of Miami School of Medicine, Miami, Florida, USA
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14
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Gonzales BA, Diniz AL, Torres SM, Salvador de Castro Ribeiro H, Correia de Farias I, Luís de Godoy A, Coimbra FJF, Fonseca de Jesus VH. Patterns of disease relapse and posttreatment follow-up of patients with resected pancreatic adenocarcinoma: A single-center analysis. J Surg Oncol 2022; 126:708-717. [PMID: 35699399 DOI: 10.1002/jso.26985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/02/2022] [Accepted: 06/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES To describe the patterns of disease relapse and follow-up of patients with resected pancreatic adenocarcinoma. Additionally, we looked at patients' characteristics at relapse and survival. METHODS We included patients with potentially resectable pancreatic adenocarcinoma diagnosed from 2008 to 2018 who were submitted to resection with clear macroscopic margins and started posttreatment surveillance. RESULTS The study population consists of 73 patients. The median interval between imaging studies was 3.2 months during the first 2 years of follow-up and 5.1 months thereafter. Forty-eight patients (65.8%) experienced disease relapse. The most frequent single site of relapse was locoregional (N = 21; 43.8%). At relapse, 31 patients (64.6%) were symptomatic and forty-two patients (87.6%) had Eastern Cooperative Oncology Group performance status 0 or 1. Most patients were able to undergo additional anticancer therapy (N = 41; 85.4%). Patients with asymptomatic relapses experienced longer median postrelapse survival (25.4 vs. 11.3 months; p = 0.015). CONCLUSIONS A follow-up protocol that included imaging studies every 3 months in the first 2 years and every 6 months thereafter is able to diagnose disease relapse when patients have adequate performance status and are still able to undergo additional anticancer treatment.
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Affiliation(s)
- Beatriz A Gonzales
- Department of Medical Oncology, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | - Alessandro L Diniz
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | - Silvio M Torres
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | | | - Igor Correia de Farias
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | - André Luís de Godoy
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | - Felipe J F Coimbra
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
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15
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Kolsteren EEM, Deuning-Smit E, Chu AK, van der Hoeven YCW, Prins JB, van der Graaf WTA, van Herpen CML, van Oort IM, Lebel S, Thewes B, Kwakkenbos L, Custers JAE. Psychosocial Aspects of Living Long Term with Advanced Cancer and Ongoing Systemic Treatment: A Scoping Review. Cancers (Basel) 2022; 14:cancers14163889. [PMID: 36010883 PMCID: PMC9405683 DOI: 10.3390/cancers14163889] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Studies examining the psychosocial impact of living long term on systemic treatment in advanced cancer patients are scarce. This scoping review aimed to answer the research question “What has been reported about psychosocial factors among patients living with advanced cancer receiving life-long systemic treatment?”, by synthesizing psychosocial data, and evaluating the terminology used to address these patients; (2) Methods: This scoping review was conducted following the five stages of the framework of Arksey and O’Malley (2005); (3) Results: 141 articles published between 2000 and 2021 (69% after 2015) were included. A large variety of terms referring to the patient group was observed. Synthesizing qualitative studies identified ongoing uncertainty, anxiety and fear of disease progression or death, hope in treatment results and new treatment options, loss in several aspects of life, and worries about the impact of disease on loved ones and changes in social life to be prominent psychosocial themes. Of 82 quantitative studies included in the review, 76% examined quality of life, 46% fear of disease progression or death, 26% distress or depression, and 4% hope, while few studies reported on adaptation or cognitive aspects. No quantitative studies focused on uncertainty, loss, or social impact; (4) Conclusion and clinical implications: Prominent psychosocial themes reported in qualitative studies were not included in quantitative research using specific validated questionnaires. More robust studies using quantitative research designs should be conducted to further understand these psychological constructs. Furthermore, the diversity of terminology found in the literature calls for a uniform definition to better address this specific patient group in research and in practice.
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Affiliation(s)
- Evie E. M. Kolsteren
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Psychology, 6525 Nijmegen, The Netherlands
- Correspondence:
| | - Esther Deuning-Smit
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Psychology, 6525 Nijmegen, The Netherlands
| | - Alanna K. Chu
- School of Psychology, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Yvonne C. W. van der Hoeven
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Psychology, 6525 Nijmegen, The Netherlands
| | - Judith B. Prins
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Psychology, 6525 Nijmegen, The Netherlands
| | - Winette T. A. van der Graaf
- Department of Medical Oncology, Netherlands Cancer Institute, 1066 Amsterdam, The Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus Medical Center, 3015 Rotterdam, The Netherlands
| | - Carla M. L. van Herpen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Oncology, 6525 Nijmegen, The Netherlands
| | - Inge M. van Oort
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Urology, 6525 Nijmegen, The Netherlands
| | - Sophie Lebel
- School of Psychology, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Belinda Thewes
- School of Psychology, Sydney University, Camperdown 2050, Australia
| | - Linda Kwakkenbos
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Psychology, 6525 Nijmegen, The Netherlands
- Clinical Psychology, Radboud University, 6525 Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 6525 Nijmegen, The Netherlands
- Radboud University Medical Center, Radboudumc Center for Mindfulness, Department of Psychiatry, 6525 Nijmegen, The Netherlands
| | - José A. E. Custers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Psychology, 6525 Nijmegen, The Netherlands
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16
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Mano MS, Morgan G. Telehealth, Social Media, Patient Empowerment, and Physician Burnout: Seeking Middle Ground. Am Soc Clin Oncol Educ Book 2022; 42:1-10. [PMID: 35561300 DOI: 10.1200/edbk_100030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The digital revolution is an ongoing process that has nevertheless profoundly affected century-old medical practice. Digitalization has many facets, ranging from telehealth to social media and even new instant communication devices, each of which affect both patients' and physicians' realities. Although the benefits of developments such as telehealth and novel applications of social media to medicine are more easily perceived by all stakeholders, they still have their own hurdles and risks, such as coldness and impersonal treatment in telehealth, and misinformation on social media. The widespread digitalization of health records has greatly facilitated patient access to health information, becoming a major patient empowerment tool; however, some forms of unrestricted access, such as to test results-in particular, prior to consultations-have unclear benefits to patients with cancer and have also become a hurdle for care teams. In addition, the advent of instant messaging, which is revolutionizing personal communication in many cultures, is gradually affecting patient-physician communication and, combined with unrestricted patient access to test results, is creating new challenges for physicians. How these transformations are affecting patients themselves and physicians' well-being and mental health are matters addressed in this text. Last, to address potential biases in an article written by two oncologists, and in line with this year's ASCO presidential theme of including a diversity of voices, we decided to give voice to patients with cancer by collecting the opinions of high-profile patient advocates about the controversial topics addressed in this text.
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Affiliation(s)
- Max S Mano
- Grupo Oncoclínicas, São Paulo, Brazil
- Academy of Leadership Sciences Switzerland, Zurich, Switzerland
| | - Gilberto Morgan
- Skåne University Hospital, Department of Clinical Oncology, Lund, Sweden
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Pantziarka P, Blagden S. Inhibiting the Priming for Cancer in Li-Fraumeni Syndrome. Cancers (Basel) 2022; 14:cancers14071621. [PMID: 35406393 PMCID: PMC8997074 DOI: 10.3390/cancers14071621] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/08/2022] [Accepted: 03/20/2022] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Li-Fraumeni Syndrome (LFS) is a rare cancer pre-disposition syndrome associated with a germline mutation in the TP53 tumour suppressor gene. People with LFS have a 90% chance of suffering one or more cancers in their lifetime. No treatments exist to reduce this cancer risk. This paper reviews the evidence for how cancers start in people with LFS and proposes that a series of commonly used non-cancer drugs, including metformin and aspirin, can help reduce that lifetime risk of cancer. Abstract The concept of the pre-cancerous niche applies the ‘seed and soil’ theory of metastasis to the initial process of carcinogenesis. TP53 is at the nexus of this process and, in the context of Li-Fraumeni Syndrome (LFS), is a key determinant of the conditions in which cancers are formed and progress. Important factors in the creation of the pre-cancerous niche include disrupted tissue homeostasis, cellular metabolism and chronic inflammation. While druggability of TP53 remains a challenge, there is evidence that drug re-purposing may be able to address aspects of pre-cancerous niche formation and thereby reduce the risk of cancer in individuals with LFS.
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Affiliation(s)
- Pan Pantziarka
- The George Pantziarka TP53 Trust, London KT1 2JP, UK
- The Anti-Cancer Fund, Brusselsesteenweg 11, 1860 Meise, Belgium
- Correspondence:
| | - Sarah Blagden
- Department of Oncology, University of Oxford, Oxford OX3 7DQ, UK;
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18
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Temel JS, Petrillo LA, Greer JA. Patient-Centered Palliative Care for Patients With Advanced Lung Cancer. J Clin Oncol 2022; 40:626-634. [PMID: 34985932 DOI: 10.1200/jco.21.01710] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The evidence base demonstrating the benefits of an early focus on palliative care for patients with serious cancers, including advanced lung cancer, is substantial. Early involvement of specialty-trained palliative care clinicians in the care of patients with advanced lung cancer improves patient-reported outcomes, such as quality of life, and health care delivery, including hospice utilization. Since the time that many of these palliative care trials were conducted, the paradigm of cancer care for many cancers, including lung cancer, has changed dramatically. The majority of patients with advanced lung cancer are now treated with immune checkpoint inhibitors or targeted therapies, both of which have had a significant impact on patient's experience and outcomes. With this changing landscape of lung cancer therapeutics, patients are facing new and different challenges, including dealing with novel side effect profiles and coping with greater uncertainty regarding their prognosis. Patients who are living longer with their advanced cancer also struggle with how to address survivorship issues, such as sexual health and exercise, and decision making about end-of-life care. Although palliative care clinicians remain well-suited to address these care needs, they may need to learn new skills to support patients treated with novel therapies. Additionally, as the experience of patients with advanced lung cancer is becoming more varied and individualized, palliative care research interventions and clinical programs should also be delivered in a patient-centered manner to best meet patient's needs and improve their outcomes. Tailored and technology-based palliative care interventions are promising strategies for delivering patient-centered palliative care.
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Affiliation(s)
- Jennifer S Temel
- Harvard Medical School, Boston, MA.,Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Laura A Petrillo
- Harvard Medical School, Boston, MA.,Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Joseph A Greer
- Harvard Medical School, Boston, MA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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