[Psycho-oncological aspects of malignant melanoma. A systematic review from 1990-2008]

Experiences of In-Patients with Skin Cancer in a German University Hospital Setting: A Cross-Sectional Survey

PURPOSE

An important measure of hospital quality is the satisfaction of the patients receiving in-patient care. This cross-sectional study aimed to assess skin cancer patients' experiences in a university hospital setting as a measure of quality of cancer care.

PATIENTS AND METHODS

Questionnaires were mailed to patients with skin cancer after receiving in-patient overnight treatment in the dermatological unit of the university hospital Erlangen (Germany) from 1 September to 30 November 2017. Patients were asked to evaluate their overall experience of this episode of care and to complete the Picker Inpatient Survey questionnaire on specific aspects of their care, such as patient satisfaction regarding contact with staff, need for information, recommendation of the hospital as well as tumor-specific questions. The results were re-coded as problems and reported as frequencies and their percentage.

RESULTS

A total of 103 of 159 questionnaires were returned (64.8%). All patients rated the treatment and care they had received to be good or very good. Additionally, all patients would recommend our in-patient clinic to their families or friends. The patients most commonly criticized inconsistency of care delivered by the same physician (29.7%, 30/101) and feeling of insufficient involvement in the decision-making processes (21.1%, 20/95). Besides this, 19.0% (11/58) and 34.6% (18/52) of patients were not satisfied with physicians and nurses, respectively, appropriately addressing their fears or anxieties. In the cancer-specific questionnaire, the majority of patients were dissatisfied with further support regarding professional and social rehabilitation possibilities (85.7%, 30/35) and psycho-oncology (56.3%, 18/32).

CONCLUSION

Overall, the majority of patients were satisfied with the in-patient skin cancer treatment. However, physicians and nurses can enhance patient satisfaction by addressing patients' fears and anxieties regarding their disease and treatment. Besides, our results highlight the importance of psycho-oncological support.

Psychosocial stress of dermatology inpatients and their relatives - Comparison of patients with and without cancer

BACKGROUND

In the clinical treatment pathways of certified oncological centers, psychotherapeutic services are mandatory. Although patients with somatic, non-oncological illnesses show an equally high prevalence of psychosocial stress, these guidelines do not exist for the general hospital sector. Are these patients really less burdened and is psychological support only needed in individual cases? The example of dermatological patients will be used to show whether the need for psychosocial care and the desire for support vary between individuals with and without malignant disease.

PATIENTS AND METHODS

Using the Hornheider screening instrument and distress thermometer, 216 dermatological inpatients assessed their psychosocial stress and that of a close relative. In addition, they were asked about their desire for support and preferred support provider.

RESULTS

i) Patients without skin cancer were more frequently and more severely distressed than cancer patients. ii) Patients of both groups assessed their relatives to be approximately equally distressed. Compared with their own distress, cancer patients assessed their relatives as more frequently and on average more severely distressed. More than 50 % of all patients regarded their own disease as the cause of their relatives' distress. iii) The desire for support in both groups was about 18 %. iv) Doctors and psychologists were usually named as potential contact persons.

CONCLUSIONS

The expansion of psychosocial support services for non-tumor patients and their relatives seems necessary. The establishment of appropriate screening methods should be considered. Further studies in other clinical areas are required.

[Supportive therapy and management of side effects in dermato-oncology]

In the context of supportive therapy, possible complaints which may be caused by the cancer itself, by the antitumoral therapy or by psychosocial concerns are considered. Due to the introduction of new anticancer drugs in dermato-oncology, clinicians are confronted with a novel spectrum of adverse events. There are a number of inflammatory, immune-mediated side effects caused by immunotherapies, which can affect virtually any organ. Targeted therapies also have specific side effects. Basically, the management of adverse events depends on their severity. Besides treatment breaks and dosage modifications, immunotherapy-related adverse events are treated with systemic immunosuppressants. Supportive symptomatic therapy is offered. The additional consideration of psychosocial problems can improve quality of life of cancer patients.

Psycho-oncological care of melanoma patients in certified skin cancer centers

BACKGROUND

The establishment und certification of skin cancer centers (SCCs) in compliance with requirements issued by the German Cancer Society play a key role for quality-assured treatment of skin cancer patients. These requirements also call for the implementation of a qualified psycho-oncology program. When planning the present study, we assumed site-specific differences in the way such programs were implemented at various SCCs.

METHODS

In 2014, we conducted a cross-sectional survey of all SCCs certified at the time (n = 43), in which these institutions were asked to provide information on the structural and process quality of their psycho-oncology programs.

RESULTS

Overall, 81.4 % of certified SCCs (n = 35) participated in the survey. Thirty-seven percent of SCCs directly employed personnel trained in psycho-oncology. Nearly all facilities offered information/counseling, crisis intervention, one-on-one discussions, and palliative/end-of-life care as part of their psycho-oncology program. Standardized screening tools were commonly used to evaluate patients' need for psycho-oncological support. Eighty-three percent of psycho-oncology programs primarily focused on inpatients. On average, 25.2 % of melanoma patients received psycho-oncological support. Ninety-seven percent of SCCs stated that the certification requirements had actually improved the psycho-oncological care of their patients. Seventy-one percent of SCCs reported to be satisfied with the implementation of the requirements.

CONCLUSIONS

The certification of institutions as SCCs has led to the implementation of personnel, structural, and content requirements relating to psycho-oncological care. The majority of SCCs surveyed reported to be satisfied with the quality of care thus achieved.

Psychosocial distress and desire for support among inpatients with skin cancer

BACKGROUND

Regular assessment of psychosocial distress is an important component of adequate psycho-oncological and social support in cancer patients. To date, relevant studies on skin cancer patients have primarily included individuals with melanoma.

OBJECTIVES

(1) Does the need for psychosocial support vary with the type of skin cancer? (2) Do mentally distressed patients desire support? (3) From the various individuals in the treatment team, whom do patients choose as potential contact person?

PATIENTS UND METHODS

Inpatients with skin cancer were asked to self-assess their psychosocial situation using the Hornheide questionnaire. In addition, they were asked about their desire for psychosocial support and the preferred potential contact person.

RESULTS

The need for support among the 116 patients surveyed varied significantly depending on the diagnosis (p = 0.007). However, the direct comparison between patients with melanoma (n = 38; 32.8 %) and squamous cell carcinoma (n = 9; 7.8 %) (p = 0.724) or other types of skin cancer (n = 20; 17.2 %) (p = 0.366) revealed no such difference. The prevalence of psychosocial distress (n = 49; 42.2 %) and the desire for support (n = 20; 17.4 %) showed considerable differences. Patients primarily chose a physician (n = 14/35) or a psychologist (n = 13/35) as potential "go-to" person for their mental distress.

CONCLUSIONS

Apart from psychosocial distress, the desire for support should be assessed, and patients should be provided access to additional psychosocial care options. With respect to the need for psychosocial support, it does not seem to be justified to preferentially - or even exclusively - consider melanoma patients in clinical practice and research.

Determinants of illness-specific social support and its relation to distress in long-term melanoma survivors

Background

Social support is considered to be one of the most important resources for coping with cancer. However, social interactions may also be detrimental, e. g. disappointing or discouraging. The present study explored: 1. the extent of illness-specific positive aspects of social support and detrimental interactions in melanoma survivors, 2. their relationships to mental health characteristics (e. g. distress, quality of life, fatigue, coping processes, and dispositional optimism) and 3. Combinations of positive social support and detrimental interactions in relation to depression and anxiety.

Methods

Based on the cancer registry of Rhineland-Palatinate, Germany, melanoma patients diagnosed at least 5 years before the survey were contacted by their physicians. N = 689 melanoma patients filled out the Illness-specific Social Support Scale ISSS (German version) and standardised instruments measuring potential psychosocial determinants of social support.

Results

Using principal component analysis, the two factor structure of the ISSS could be reproduced with acceptable reliability; subscales were “Positive Support” (PS) and “Detrimental Interactions” (DI); Cronbach’s α = .95/.72. PS was rated higher than DI. Multivariable linear regressions identified different associations with psychosocial determinants. Survivors living in a partnership and those actively seeking out support had a higher probability of receiving PS, but not DI. PS and DI interacted regarding their association with distress: Survivors reporting high DI but low PS were the most depressed and anxious. High DI was partly buffered by PS. When DI was low, high or low PS made no difference regarding distress.

Conclusion

Psycho-oncologic interventions should take into account both positive and negative aspects of support in order to promote coping with the disease.

Psychosocial Care Needs of Melanoma Survivors: Are They Being Met?

Patients who have survived malignant melanoma for more than five years may lack the opportunity to talk about their burden. As a consequence their psychosocial care needs remain undetected and available supportive interventions may not be utilised. Therefore, the psychosocial burden of this patient group needs to be assessed using specific screening instruments. The aim of this study was to investigate the psychosocial burden of long-term melanoma survivors, their psychosocial care needs and the determinants of these needs. We wanted to find out if the use of professional support corresponds to the care needs defined by experts. Using the cancer registry of Rhineland-Palatinate, melanoma patients diagnosed at least 5 years before the survey were contacted by physicians. N = 689 former patients completed the Hornheide Questionnaire (short form HQ-S) to identify psychosocial support need (scale cut off ≥ 16 or item-based cut-off score) and the potential psychosocial determinants of these needs. Additionally, they were asked about their utilisation of the professional support system. More than one third (36%) of them was in need for professional psychosocial support. The highest burden scores concerned worry about tumour progression. Younger age (< 50), higher general fatigue, higher symptom burden, lower general health, negative social interactions and unfulfilled information needs were significant predictors of the need for psychosocial intervention. Related to the percentage of survivors identified as 'in need', the professional support system was underused. Further studies should investigate whether using the HQ-S to routinely identify burdened melanoma patients could lead to better fulfilment of their intervention needs, ultimately enhancing health-related quality of life.

[Psycho-oncological care for melanoma patients: conception and implementation]

Offering psycho-oncological care is an essential, guideline-based component of comprehensive care in skin cancer centers. This paper describes the development, implementation and utilization of a specific psycho-oncologic care concept for melanoma patients in the University Dermatology Clinic Freiburg. Based on the stepped-care principle, the concept is composed of interdisciplinary group sessions for patients and their relatives offered every 4-6 weeks addressing medical and psycho-oncological topics related to treatment of malignant melanoma and then individual psycho-oncological sessions modified for the patient's treatment needs. Between April 2010 and July 2012, 67 % of the melanoma patients treated in the Freiburg Skin Cancer Center were reached by the program. A stepped-care concept with a routinely initiated first contact and low-threshold patient education group sessions is a reliable approach to reach patients and inform them about further psycho-oncological care. The advantages justify the allocation of resources and the approach proved successful for routine clinical practice.

Screening for distress in routine oncological care-a survey in 520 melanoma patients

Introduction

Despite the increasing incidence of melanoma little is known about patients' emotional distress associated with this disease. Supplemented by the problem list (PL), the distress thermometer (DT) is a recommended screening instrument to measure psychosocial distress in cancer patients. Our objective was to explore the acceptance and the feasibility of the DT and PL as a concise screening tool in an ambulatory setting for routine care and to elucidate determinants of distress in melanoma patients with regard to sociodemographic and clinical variables.

Methods

Consecutive melanoma outpatients were asked to complete the DT with the PL prior to their scheduled consultation. Demographic and clinical data were obtained from the patients' charts. Clinical data included melanoma stage, time since diagnosis, previous treatment, current treatment, and other cancer disease.

Results

Out of 734 patients recruited into the study, 520 patients (71%) completed both the DT and the PL. Forty-seven percent met the ≥5 cut-off score for distress. Younger and employed patients reported higher distress than older and retired patients. A cut-off score of ≥5 was closely associated with self-reported emotional sources of distress, with practical problems, especially at work, family problems (dealing with the partner), and physical problems like pain, appearance, getting around, and nausea. Apart from higher distress under current systemic treatment, no associations were found between distress and clinical data.

Conclusion

The DT together with the PL seems to be an economically reasonable screening tool to measure psychosocial distress in melanoma patients. In particular, younger melanoma patients who are currently employed are prone to experience distress at some point after diagnosis, but there appears to be almost no association between clinical data and the extent of distress. To characterize the impact of distress on disease outcome and quality of life in melanoma patients, further research is needed.

Self-efficacy for coping with cancer in melanoma patients: its association with physical fatigue and depression

OBJECTIVE

The purpose of this study was to explore the impact of self-efficacy for coping with cancer (SECC) on physical fatigue and depressive symptoms in melanoma patients, in comparison with objective factors, such as treatment with interferon-alpha (IFN-α) and medical and sociodemographic variables. Current literature shows that psychological distress in melanoma patients is generally moderate, that they experience high quality of life, and that symptoms of depression and fatigue have been mostly associated with adjuvant IFN-α treatment

METHODS

A total of 175 melanoma patients, stages Ib-IIIc with and without low-dose IFN-α therapy, completed surveys on SECC, depression, and fatigue. Two hierarchical regression analyses were conducted to explore the predictive role of objective factors (first step: tumor stage, time since diagnosis, and current IFN-α treatment; second step: age and gender) in conjunction with the subjective factor of SECC (third step) on physical fatigue and depression.

RESULTS

Regression analysis revealed no significant effect of IFN-α treatment upon depression. Current IFN-α treatment was predictive of higher fatigue scores, however. The highest predictive effect by far was obtained for SECC, indicating higher fatigue and depression in patients with lower SECC.

CONCLUSIONS

The findings suggest that the treatment with IFN-α is mainly accompanied by physical fatigue in melanoma patients rather than by mood changes. Most notably, the potential influence of increased SECC on reducing both physical fatigue and depression is suggested by the data, indicating the importance of self-efficacy enhancing interventions in the psycho-oncological support of melanoma patients.

Gesundheitsverhalten von Hautkrebspatienten während der Melanomnachsorge

Zusammenfassung. Das maligne Melanom ist die häufigste Krebserkrankung im mittleren Erwachsenenalter. Es zeichnet sich durch besonders hohe Heilungschancen in frühen Krankheitsstadien und Therapieresistenz metastasierter Melanome aus. Zudem ist das Melanom einer der wenigen soliden Tumore, die sich – beobachtbar für den Fachmann aber auch für den medizinischen Laien – an der Hautoberfläche entwickeln. Die Überlebenswahrscheinlichkeit wird primär durch das Melanomstadium zum Zeitpunkt der Diagnose bestimmt. Die frühzeitige Behandlung von Krankheitsprogression ist von entscheidender Bedeutung für die Dauer und Qualität der verbleibenden Lebenszeit. Dementsprechend fokussieren Interventionen zur Senkung melanombedingter Morbidität und Mortalität auf die frühestmögliche Entdeckung der Melanome und der Krankheitsprogression. Regelmäßige Hautselbstuntersuchungen als sekundäre und tertiäre Präventionsmaßnahme stellen ein hocheffektives Komplement zu ärztlicher Vor- und Nachsorge dar, da die Mehrzahl der Melanome sowie die Krankheitsprogression von Patienten, deren Familie und Freunden selbst entdeckt werden. Eine wichtige Fragestellung stellt daher das auf die Melanomerkrankung bezogene Selbstuntersuchungsverhalten und Möglichkeiten seiner Optimierung dar. Psychoonkologische Forschung hat bisher darauf fokussiert, Handlungsergebniserwartung und Selbstwirksamkeitserwartung durch dermatologische Patientenschulung zu erhöhen. Die vorliegende Studie untersucht psychosoziales Belastungserleben und Krankheitsbewältigung in ihrer Bedeutung für das Selbstuntersuchungsverhalten in einer Stichprobe von 164 Patienten in der Melanomnachsorge. Mehr als 70% der Patienten gaben an, nicht von ihrem Arzt zur Selbstuntersuchung angeleitet worden zu sein. Angeleitete Patienten maßen der Selbstuntersuchung höhere Bedeutung bei und praktizierten diese häufiger, obwohl sie sich dadurch unangenehm an die Krebserkrankung erinnert fühlten. Nichtinstruierte Patienten zeigen ein weniger funktionales Verhaltensmuster: Die Selbstuntersuchungshäufigkeit wurde u.a. durch erlebte Selbstunsicherheit, mangelnde ärztliche Unterstützung und berufliche/finanzielle Probleme bestimmt, während das objektive Rückfallrisiko keine Rolle spielte. Auf Basis dieser sowie weiterer psychoonkologischer Befunde und gesundheitspsychologischer Paradigmen wird ein integratives Modell für die dringend notwendige Forschung und evidenzbasierte Praxis der individuellen Gesundheitsfürsorge bei Personen mit erhöhtem Melanomrisiko vorgeschlagen.

Outpatient Follow-up and Secondary Prevention for Melanoma Patients

Health care providers and their patients jointly participate in melanoma prevention, surveillance, diagnosis, and treatment. This paper reviews screening and follow-up strategies for patients who have been diagnosed with melanoma, based on current available evidence, and focuses on methods to assess disease recurrence and second primary occurrence. Secondary prevention, including the roles of behavioral modification and chemoprevention are also reviewed. The role of follow-up dermatologist consultation, with focused physical examinations complemented by dermatoscopy, reflectance confocal microscopy, and/or full-body mapping is discussed. Furthermore, we address the inclusion of routine imaging and laboratory assessment as components of follow-up and monitoring of advanced stage melanoma. The role of physicians in addressing the psychosocial stresses associated with a diagnosis of melanoma is reviewed.