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Ozdemir S, Chaudhry I, Malhotra C, Teo I, Finkelstein EA. Goals of Care Among Patients With Advanced Cancer and Their Family Caregivers in the Last Years of Life. JAMA Netw Open 2024; 7:e245866. [PMID: 38602677 PMCID: PMC11009823 DOI: 10.1001/jamanetworkopen.2024.5866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/13/2024] [Indexed: 04/12/2024] Open
Abstract
Importance Understanding goals of care for terminally ill patients at the end of life is crucial to ensure that patients receive care consistent with their preferences. Objectives To investigate the patterns of goals of care among patient-caregiver dyads over the last years of the patient's life and the associations of the goals of care with patient-caregiver characteristics. Design, Setting, and Participants This prospective cohort study of 210 patient-caregiver dyads involved surveys every 3 months from July 8, 2016, until the patient's death or February 28, 2022. Data from the last 2 years of the patients' lives were analyzed. Dyads, which comprised patients with stage IV solid cancer and their caregivers, were recruited from outpatient clinics at 2 major cancer centers in Singapore. Main Outcomes and Measures Goals of care were examined via the tradeoffs between life extension and symptom management and between life extension and cost containment. The actor-partner interdependence framework was implemented using mixed-effects linear regressions. Results This study included 210 dyads (patients: mean [SD] age, 62.6 [10.5] years; 108 men [51.4%]; caregivers: mean [SD] age, 49.4 [14.6] years; 132 women [62.9%]). On average, 34% of patients (264 of 780 observations; range, 23%-42%) and 29% of caregivers (225 of 780 observations; range, 20%-43%) prioritized symptom management over life extension, whereas 24% of patients (190 of 780 observations; range, 18%-32%) and 19% of caregivers (148 of 780 observations; range, 8%-26%) prioritized life extension. Between cost containment and life extension, on average, 28% of patients (220 of 777 observations; range, 22%-38%) and 17% of caregivers (137 of 780 observations; range, 10%-25%) prioritized cost containment, whereas 26% of patients (199 of 777 observations; range, 18%-34%) and 35% of caregivers (271 of 780 observations; range, 25%-45%) prioritized life extension. Goals of care did not change as patients approached death. Patients prioritized symptom management if they experienced higher symptom burden (average marginal effect [SE], 0.04 [0.01]), worse spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and accurate (vs inaccurate) prognostic awareness (average marginal effect [SE], 0.40 [0.18]) and if their caregivers reported accurate prognostic awareness (average marginal effect [SE], 0.53 [0.18]), lower impact of caregiving on finances (average marginal effect [SE], -0.28 [0.08]), and poorer caregiving self-esteem (average marginal effect [SE], -0.48 [0.16]). Compared with patients, caregivers expressed lower preferences for cost containment (average marginal effect [SE], -0.63 [0.09]). Patients prioritized cost containment if they were older (average marginal effect [SE], 0.03 [0.01]), had higher symptom burden (average marginal effect [SE], 0.04 [0.01]), had poorer spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and their caregivers reported poorer caregiving self-esteem (average marginal effect [SE], -0.51 [0.16]) and more family support (average marginal effect [SE], -0.30 [0.14]). Conclusions and Relevance In this cohort study of patient-caregiver dyads, findings suggested the importance of interventions aimed at reducing discordance in goals of care between patients and caregivers and helping them develop realistic expectations to avoid costly, futile treatments.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
- Department of Population Health Sciences, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Isha Chaudhry
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Irene Teo
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
- Department of Psychosocial Oncology, National Cancer Centre, Singapore
| | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
- Department of Population Health Sciences, Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Brookes G, Baker P. Cancer services patient experience in England: quantitative and qualitative analyses of the National Cancer Patient Experience Survey. BMJ Support Palliat Care 2024; 13:e1149-e1155. [PMID: 35768203 PMCID: PMC10850824 DOI: 10.1136/spcare-2022-003543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine patients' responses to the English National Cancer Patient Experience Survey to understand what proportions of patients give positive and negative feedback, and to identify themes in responses which drive evaluations. METHODS Data comprise 214 340 survey responses (quantitative ratings and free-text comments) dated 2015-2018. The proportions of patients giving each quantitative rating (0-10) are compared and free-text comments are analysed using computer-assisted linguistic methods in order to ascertain frequent thematic drivers of positive and negative feedback. RESULTS Patients were most likely to give a most positive score of 10 (38.25%), while the overwhelming majority (87.12%) gave a score between 8 and 10. Analysis of 1000 positive comments found that most respondents (54%) praised staff's interpersonal skills. Other frequent themes of positive feedback included treatment standards, staff's communication skills, speed of diagnosis and treatment, and staff members' technical competence. The most prominent themes in the negative comments were communication skills, treatment standards and waiting times for appointments and test/scan results, and delays and cancellations to appointments and operations. CONCLUSION Standards of treatment and staff's communication skills are prominent themes of positive and negative feedback. Staff's interpersonal skills are more likely to be praised than criticised, while negative feedback is more likely to focus on issues around time (ie, delays and long waits). Clarity and honesty in communication about the lengths and causes of waits and delays are likely to increase patient satisfaction.
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Affiliation(s)
- Gavin Brookes
- Linguistics and English Language, Lancaster University, Lancaster, UK
| | - Paul Baker
- Linguistics and English Language, Lancaster University, Lancaster, UK
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3
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Dias LM, Frutig MDA, Bezerra MR, Barra WF, Castro L, Rego F. Advance Care Planning and Goals of Care Discussion: Barriers from the Perspective of Medical Residents. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3239. [PMID: 36833934 PMCID: PMC9961136 DOI: 10.3390/ijerph20043239] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/08/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Advance care planning (ACP) and goals of care discussion involve the exploration of what is most important to a person to prepare for health-care decision making. Despite their well-established benefits, they are still not frequently performed in clinical oncology practice. This study aims to describe the barriers to discussion goals of care with oncology patients from the perspective of medical residents. METHODS This cross-sectional and qualitative study applied the "Decide-Oncology" questionnaire, adapted to Portuguese language, to assess barriers to goals of care discussion among medical residents from three university hospitals in Brazil. Residents were asked to rank the importance of various barriers to discuss goals of care (ranging from 1-extremely unimportant to 7-extremely important). RESULTS Twenty-nine residents answered the questionnaire (30.9%). The most reported barriers were related to patients and their families' difficulty in understanding and accepting the diagnosis and the prognosis as well as patients' desire to receive full active treatment. Furthermore, the physician and external factors such as lack of training and lack of time to have these conversations were also very important barriers. The identification of the key barriers that limit the discussion of ACP and early palliative care referrals can certainly help to prioritize the next steps for future studies aimed at improving ACP and goals of care discussions.
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Affiliation(s)
- Laiane Moraes Dias
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- João de Barros Barreto University Hospital, Federal University of Pará, Belém 66075-110, PA, Brazil
| | | | - Mirella Rebello Bezerra
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- IMIP, Instituto de Medicina Integral Professor Fernando Figueira, Recife 50070-902, PE, Brazil
| | - Williams Fernandes Barra
- João de Barros Barreto University Hospital, Federal University of Pará, Belém 66075-110, PA, Brazil
| | - Luísa Castro
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - Francisca Rego
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
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4
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van der Velden NCA, Smets EMA, Hagedoorn M, Applebaum AJ, Onwuteaka-Philipsen BD, van Laarhoven HWM, Henselmans I. Patient-Caregiver Dyads' Prognostic Information Preferences and Perceptions in Advanced Cancer. J Pain Symptom Manage 2023; 65:442-455.e2. [PMID: 36731806 DOI: 10.1016/j.jpainsymman.2023.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/04/2023]
Abstract
CONTEXT Prognostic information is considered important for advanced cancer patients and primary informal caregivers to prepare for the end of life. Little is known about discordance in patients' and caregivers' prognostic information preferences and prognostic perceptions, while such discordance complicates adaptive dyadic coping, clinical interactions and care plans. OBJECTIVES To investigate the extent of patient-caregiver discordance in prognostic information preferences and perceptions, and the factors associated with discordant prognostic perceptions. METHODS We conducted secondary analyses of a cross-sectional study (PROSPECT, 2019-2021). Advanced cancer patients (median overall survival ≤12 months) from seven Dutch hospitals and caregivers completed structured surveys (n = 412 dyads). RESULTS Seven percent of patient-caregiver dyads had discordant information preferences regarding the likelihood of cure; 24%-25% had discordant information preferences regarding mortality risk (5/2/1 year). Seventeen percent of dyads had discordant perceptions of the likelihood of cure; 12%-25% had discordant perceptions of mortality risk (5/2/1 year). Dyads with discordant prognostic information preferences (P < 0.05) and dyads in which patients reported better physical functioning (P < 0.01) were significantly more likely to perceive the one-year mortality risk discordantly. CONCLUSION Physicians should be sensitive to discordant prognostic information preferences and prognostic perceptions among patient-caregiver dyads in advanced cancer care.
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Affiliation(s)
- Naomi C A van der Velden
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam (N.C.A.V., E.M.A.S, I.H.), Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands.
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam (N.C.A.V., E.M.A.S, I.H.), Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands
| | - Mariët Hagedoorn
- Department of Health Psychology, University Medical Center Groningen, University of Groningen (M.H), The Netherlands
| | - Allison J Applebaum
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center (A.J.A), New York, New York, USA
| | - Bregje D Onwuteaka-Philipsen
- Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC location Vrije Universiteit Amsterdam (B.D.O-P, I.H.), Amsterdam, The Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands; Department of Medical Oncology, Amsterdam UMC location University of Amsterdam (H.W.M.L), Amsterdam, The Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam (N.C.A.V., E.M.A.S, I.H.), Amsterdam, The Netherlands; Quality of Care, Amsterdam Public Health (N.C.A.V, E.M.A.S, B.D.O-P, I.H.), Amsterdam, The Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam (N.C.A.V., E.M.A.S, H.W.M.L, I.H.), Amsterdam, The Netherlands
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Wright AA, Thompson E, Nguyen MV, Wescott P, Barry MJ, Lathan CS, Keating NL. The SHARE Study: Pilot Study of a Communication Intervention Designed to Elicit Advanced-Stage Cancer Patients' Preferences and Goals. J Palliat Med 2022; 25:1646-1654. [PMID: 35736783 PMCID: PMC9836691 DOI: 10.1089/jpm.2021.0655] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 01/22/2023] Open
Abstract
Background: Helping seriously ill cancer patients identify and communicate their care preferences improves outcomes. Objective: The aim of this study was to pilot test the feasibility and acceptability of an intervention designed to elicit patients' preferences and goals of care and share them with their oncology teams. Design: A single-arm pilot study of a 2.5-minute video, 3-page brief questionnaire, and a wallet card with question prompts was conducted. Primary outcomes were feasibility (≥60% approach-to-consent ratio, ≥60% participants rated the intervention positively) and acceptability (≥60% recommended the intervention). Secondary outcomes, measured pre- and post-intervention, included patient anxiety and distress, hope, quality of life, and therapeutic alliance. Setting/subjects: The study subjects were advanced-stage cancer patients and their clinicians at a U.S. academic and community oncology practice. Results: Among 59 potentially eligible patients, 53 agreed to participate (90% approach-to-consent ratio); 4 were nonevaluable due to death. Overall, 45 of 49 patients (92%) rated their experience as excellent, very good, or good. Participants (mean age = 63 years, range 40-86) agreed or strongly agreed that they would recommend the video (83%), brief questionnaire (88%), and wallet card (63%). However, only 34% of participants reported reviewing the questionnaire with their oncologist. There were no increases in patient anxiety or distress associated with the intervention or reductions in hope or therapeutic alliances with oncologists (all p > 0.05); quality of life was better post-intervention (p = 0.02). Conclusions: This communication intervention that combined a video, questionnaire, and wallet card was both feasible and acceptable for helping advanced cancer patients identify their care preferences and goals and should be tested in a future randomized clinical trial. Clinical Trial Registration: ClinicalTrials.gov NCT03392090.
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Affiliation(s)
- Alexi A. Wright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Embree Thompson
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mimi V. Nguyen
- University of California San Diego Medical School, San Diego, California, USA
| | - Pam Wescott
- Healthwise/Informed Medical Decisions Foundation, Boston, Massachusetts, USA
| | - Michael J. Barry
- Health Decisions Sciences Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Chris S. Lathan
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Park ER, Skurla SE, Caballero GYJ, Friedman ER, Ponzani C, Wallace R, Malin J, Keating NL. Long-term follow-up of smokers following lung and colorectal cancer diagnosis. Support Care Cancer 2022; 30:7801-7809. [PMID: 35552828 DOI: 10.1007/s00520-022-07111-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/02/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Continued smoking after a cancer diagnosis limits the effectiveness of treatment, increases the risk of cancer recurrence or secondary malignancies, and is associated with poorer quality of life and survival. A cancer diagnosis may provide a meaningful timepoint for quitting, but the prevalence and characteristics of continued smoking through survivorship are poorly understood. METHODS In the multi-regional Cancer Care Outcomes Research and Surveillance (CanCORS) cohort, we examined smoking rates and factors associated with continued smoking at long-term follow-up among lung and colorectal cancer patients. This paper builds upon previous CanCORS participant data addressing quit rates and associated characteristics at baseline and 5 months post-diagnosis. RESULTS At long-term follow-up (median 7.3 years post-diagnosis [IQR = 5.9-8.7]), 16.7% of lung cancer and 11.6% of colorectal cancer survivors continued to smoke combustible cigarettes. Factors independently associated with continued smoking at long-term follow-up included being male, younger, not married or partnered, having Medicare, Medicaid/other public or no insurance, more depression symptoms, smoking more cigarettes per day, and having a history of lung disease (p < .05). Continued smoking did not vary by lung vs. colorectal cancer diagnosis. CONCLUSION Of active smokers at the time of diagnosis, an important minority of lung and colorectal cancer survivors continued to smoke well into survivorship. Understanding characteristics associated with continued smoking after a cancer diagnosis may help inform the development of tobacco treatment programs for cancer patients and survivors. IMPLICATIONS FOR SURVIVORS While addressing smoking cessation at the time of diagnosis is critical to ensure better long-term treatment outcomes and quality of life, it is essential to continue smoking cessation discussions and efforts throughout care and survivorship.
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Affiliation(s)
- Elyse R Park
- Health Policy Research Center at the Mongan Institute, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA.
- Health Promotion and Resiliency Intervention Research Program, Massachusetts General Hospital, Boston, MB, USA.
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
| | - Sarah E Skurla
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, USA
| | | | - Emily R Friedman
- Health Policy Research Center at the Mongan Institute, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Colin Ponzani
- Health Policy Research Center at the Mongan Institute, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Robert Wallace
- Department of Epidemiology, The University of Iowa, Iowa City, IA, USA
| | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Division of General Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Zhu Z, Xing W, Wen H, Sun Y, So WKW, Lizarondo L, Peng J, Hu Y. Psychometric properties of self-reported financial toxicity measures in cancer survivors: a systematic review. BMJ Open 2022; 12:e057215. [PMID: 35750459 PMCID: PMC9234804 DOI: 10.1136/bmjopen-2021-057215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The aim of this systematic review was to summarise the psychometric properties of patient-reported outcome measures (PROMs) measuring financial toxicity (FT) in cancer survivors. DESIGN This systematic review was conducted according to the guidance of the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology. DATA SOURCES Comprehensive searches were performed in PubMed, MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, ProQuest and Cochrane Library from database inception to February 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included studies that reported any PROMs for measuring FT in cancer survivors who were ≥18 years old. FT was defined as perceived subjective financial distress resulting from objective financial burden. Studies that were not validation studies and that used a PROM only as an outcome measurement were excluded. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data from the included papers. We used the COSMIN criteria to summarise and evaluate the psychometric properties of each study regarding structural validity, internal consistency, reliability, measurement error, hypothesis testing for construct validity, cross-cultural validity/measurement invariance, criterion validity and responsiveness. RESULTS A total of 23 articles (21 PROMs) were eligible for inclusion in this study. The findings highlighted that the Comprehensive Score for Financial Toxicity (COST) had an adequate development process and showed better psychometric properties than other PROMs, especially in internal consistency (Cronbach's α=0.92), reliability (intraclass correlation coefficient=0.80) and hypothesis testing (r=0.42-0.20). CONCLUSIONS From a psychometric property perspective, the COST could be recommended as the most suitable worldwide available measure for use in research and clinical practice across different contexts. We suggest that PROMs should be selected only after careful consideration of the local socioeconomic context. Future studies are warranted to develop various FT PROMs based on different social and cultural backgrounds and to clarify the theoretical grounds for assessing FT.
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Affiliation(s)
- Zheng Zhu
- School of Nursing, Fudan University, Shanghai, China
- Fudan University Centre for Evidence-based Nursing: A Joanna Briggs Institute Centre of Excellence, Fudan University, Shanghai, China
| | - Weijie Xing
- School of Nursing, Fudan University, Shanghai, China
- Fudan University Centre for Evidence-based Nursing: A Joanna Briggs Institute Centre of Excellence, Fudan University, Shanghai, China
| | - Huan Wen
- School of Public Health, Fudan University, Shanghai, China
| | - Yanling Sun
- School of Public Health, Fudan University, Shanghai, China
| | - Winnie K W So
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China
| | - Lucylynn Lizarondo
- The Joanna Briggs Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Jian Peng
- School of Nursing, Fudan University, Shanghai, China
| | - Yan Hu
- School of Nursing, Fudan University, Shanghai, China
- Fudan University Centre for Evidence-based Nursing: A Joanna Briggs Institute Centre of Excellence, Fudan University, Shanghai, China
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Dar MA, Chauhan R, Murti K, Trivedi V, Dhingra S. Development and Validation of Subjective Financial Distress Questionnaire (SFDQ): A Patient Reported Outcome Measure for Assessment of Financial Toxicity Among Radiation Oncology Patients. Front Oncol 2022; 11:819313. [PMID: 35186720 PMCID: PMC8847677 DOI: 10.3389/fonc.2021.819313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/29/2021] [Indexed: 11/24/2022] Open
Abstract
Background Financial toxicity is a consequence of subjective financial distress experienced by cancer patients as a result of treatment expenditures. Financial toxicity has been associated with poor quality of life, early mortality, and non-adherence. It is evident from the literature that the currently available instruments for the assessment of financial toxicity do not measure coping and support seeking domains. The aim of this study was to develop an instrument for the assessment of financial toxicity among radiation oncology patients that captures and integrates all the relevant domains of subjective financial distress. Materials and Methods The study was conducted among Head & Neck cancer (HNC) patients (age ≥18 years) who have completed the radiotherapy either as stand-alone or part of a multimodal treatment. Literature review, expert opinion, and patient interviews were used for scale item generation. The validity and underlying factor structure were evaluated by Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). The reliability and internal consistency of the final scale was assessed using Cronbach’s alpha coefficient. Results A total of 17 items were identified for scale development. The preliminary 17-item instrument was administered to 142 HNC patients. Among 142 participants, 85.9% were male and 98.6% were from rural areas. EFA was performed on 17 items and three items were removed (factor loadings <0.5). The remaining 14 items loaded onto three factors (eigenvalue >1) explaining 62.0% of the total variance. The Chi-square goodness of fit test in CFA and the values of other model fit indices, namely, RMSEA = 0.045, SRMR = 0.014, GFI = 0.92, CFI = 0.98, and TLI=0.97 indicate a good model fit suggesting the three-factor model adequately fits the data. The Cronbach’s α for the final 14-item scale was 0.87 indicating excellent reliability and the Cronbach’s α coefficient of all the individual 14 items was ≥0.85 (range 0.85–0.88). Conclusion The SFDQ showed excellent validity and reliability. SFDQ captures and integrates all the relevant domains of financial toxicity. However, the provisional SFDQ instrument warrants further larger sample studies for validation and psychometric evaluation in different primary cancer subsites and treatment modalities from multiple cancer centers to improve the generalizability of this instrument.
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Affiliation(s)
- Mukhtar Ahmad Dar
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, India
| | - Richa Chauhan
- Department of Radiotherapy, Mahavir Cancer Sansthan and Research Centre (MCSRC), Phulwarisharif, India
| | - Krishna Murti
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, India
| | - Vinita Trivedi
- Department of Radiotherapy, Mahavir Cancer Sansthan and Research Centre (MCSRC), Phulwarisharif, India
| | - Sameer Dhingra
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, India
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9
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Ozdemir S, Malhotra C, Teo I, Tan SNG, Wong WHM, Joad ASK, Hapuarachchi T, Palat G, Tuong PN, Bhatnagar S, Rahman R, Mariam L, Ning X, Finkelstein EA. Patient-Reported Roles in Decision-Making Among Asian Patients With Advanced Cancer: A Multicountry Study. MDM Policy Pract 2021; 6:23814683211061398. [PMID: 34820528 PMCID: PMC8606935 DOI: 10.1177/23814683211061398] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose. We investigated 1) perceived roles in decision-making among advanced cancer patients in 5 Asian countries 2) associations of patient characteristics with these roles, and 3) the association of perceived roles with quality of life and perceived quality of care. Methods. We surveyed 1585 patients with stage IV solid cancer. Multinomial logistic regressions were used to analyze associations of patient characteristics with decision-making roles. Multivariate regressions were used to analyze associations of decision-making roles with quality of life and care. Results. The most common perceived-role was no patient involvement. Most patients (73%) reported roles consistent with their preferences. Being male, nonminority, higher educated, aware of advanced cancer diagnosis, and knowledge of cancer diagnosis for ≥1 year were associated with higher levels of patient involvement in decision-making. Compared to no patient involvement, joint decision-making (together with physicians/family) was associated with higher social (β = 2.49, P < 0.01) and spiritual (β = 2.64, P < 0.01) well-being, and better quality of physician communication (β = 9.73, P < 0.01) and care coordination (β = 13.96, P < 0.01) while making decisions alone was associated with lower emotional (β = -1.43, P < 0.01), social (β = -2.39, P < 0.01), and spiritual (β = -2.98, P < 0.01) well-being. Conclusions. Findings suggest that a substantial number of advanced cancer patients were not (and preferred not to be) involved in decision-making. Despite this finding, joint decision-making together with physicians/family was associated with better quality of life and care. Implications. Physicians should explain the benefits of shared decision making to patients and encourage participation in decision-making, while ensuring that patients feel supported and do not find decision-making overwhelming.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Irene Teo
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | | | | | - Anjum S Khan Joad
- Department of Palliative Care, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | | | - Gayatri Palat
- Department of Pain and Palliative Medicine, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, India
| | | | - Sushma Bhatnagar
- Palliative Access Program, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, India
| | - Rubayat Rahman
- Centre for Palliative Care, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Lubna Mariam
- Radiation Oncology, National Institute of Cancer Research and Hospital, Dhaka, Bangladesh
| | - Xiaohong Ning
- Department of Geriatrics, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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10
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Roydhouse JK, Wilson IB, Gutman R, Wallace RB, Berman T, Keating NL. Association of Patient-Reported Physician Awareness of Complementary Medicine, Medical Care Experience and Care Quality. J Patient Exp 2021; 8:23743735211049665. [PMID: 34722868 PMCID: PMC8554556 DOI: 10.1177/23743735211049665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim was to examine the association of patient-reported physician awareness of biological CAM use and patient perceptions of care experience and quality with a population-based study of patients with incident lung and colorectal cancer. This was a secondary data analysis using regression models. Outcomes of interest were patient reports of medical care experience and quality ratings. Among 716 patients who reported biological CAM use, 69% reported their physicians were aware of this. Patients who reported physician awareness of biological CAM use had higher adjusted scores for medical care experience ( + 5.4, 95%CI:2.3,8.6) and care quality ( + 3.6, 95%CI:−0.3, + 7.5). These associations suggest that physicians should be encouraged to inquire about biological CAM use.
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Affiliation(s)
- Jessica K Roydhouse
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Ira B Wilson
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Robert B Wallace
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Tara Berman
- Division of Oncology Products, US Food and Drug Administration, Silver Spring, MD, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston MA, USA
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11
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Ozdemir S, Ng S, Malhotra C, Teo I, Finkelstein EA. Patient-Caregiver Treatment Preference Discordance and Its Association With Caregiving Burden and Esteem. Innov Aging 2021; 5:igab020. [PMID: 34316519 PMCID: PMC8306724 DOI: 10.1093/geroni/igab020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Indexed: 11/14/2022] Open
Abstract
Background and Objectives Many patient–caregiver dyads report conflicting treatment decisions regarding preferences for life extension treatments and symptom management. It is possible that this discordance will lead to negative psychological outcomes including lowered caregiving esteem and increased caregiver burden. However, the relationships between treatment discordance among dyads and caregiver psychological outcomes are not well studied among advanced cancer patients—a gap this study aims to fill. Research Design and Methods Outcome variables included caregiver burden and caregiving esteem, measured via a modified 4-domain Caregiver Reaction Assessment Scale. The main independent variable was patient–caregiver treatment preference discordance, examined using questions adapted from an existing protocol. Analyses were conducted using multivariable regressions. Results A convenience sample of 285 patient–caregiver dyads were recruited from outpatient clinics at 2 tertiary hospitals in Singapore. The majority (60%) of patient–caregiver dyads reported discordant treatment preferences. Discordance in this study arose because caregivers wanted a balance between life extension and symptom management while patients preferred life-extending treatment. In multivariable analyses, discordance predicted caregiver burden arising from impact on caregiver schedule and health (β = 0.16, p = .07) and lack of family support (β = 0.13, p = .04). Discussion and Implications Theoretically, this study provided a more nuanced understanding of how dyad discordance may worsen the burdens felt by caregivers, and which aspects of their lives (i.e., burden due to impact of caregiver schedule and health and lack of family support) are most affected. Our findings can aid in establishing therapeutic interventions targeted toward improving communication skills and encouraging end-of-life discussions among patients, caregivers, and their health care providers. The importance of establishing and improving therapy programs specifically targeted toward caregivers was also underlined.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Sean Ng
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Irene Teo
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,National Cancer Centre Singapore, Singapore
| | - Eric A Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
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12
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Ozdemir S, Teo I, Bundoc FG, Malhotra C, Yeo KK, David Sim KL, Finkelstein EA. Role in decision making among congestive heart failure patients and its association with patient outcomes: a baseline analysis of the SCOPAH study. PATIENT EDUCATION AND COUNSELING 2021; 104:496-504. [PMID: 32928597 DOI: 10.1016/j.pec.2020.08.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/24/2020] [Accepted: 08/21/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE We investigated the predictors of patient-experienced and preferred roles for decision making, and the association between patient-experienced role in decision making and patient outcomes among congestive heart failure (HF) patients in a multi-ethnic Asian population. METHODS We surveyed 246 HF patients classified as New York Heart Association class 3/4. Multivariable regressions were used to analyse the associations between patient-experienced roles and patient outcomes. RESULTS Patients who were male, attained higher education, and had a higher cognitive score were more likely to experience and prefer active roles in decision making. Younger patients and patients with lower symptom burden were more likely, while married patients were less likely to prefer leading decision making. Patients with collaborative (family and/or physician) decision making reported higher emotional well-being and sense of meaning/peace. Collaborative and patient-led decision making were associated with higher perceived control over illness. Those who were led by others or made decisions alone reported lower quality of physician communication. CONCLUSION Collaborative decision making was associated with higher emotional well-being, sense of meaning/peace, and higher perceived control over illness among HF patients. PRACTICE IMPLICATIONS Physicians should explain the benefits of shared decision making and encourage patients to participate in treatment decisions.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, 169857, Singapore; Health Services and System Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore.
| | - Irene Teo
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, 169857, Singapore; Health Services and System Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore.
| | - Filipinas Gines Bundoc
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, 169857, Singapore; Health Services and System Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore.
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, 169857, Singapore; Health Services and System Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore.
| | - Khung Keong Yeo
- National Heart Centre Singapore, 5 Hospital Drive, 169609, Singapore.
| | | | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, 169857, Singapore; Health Services and System Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore; Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA.
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13
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Discordance Between Advanced Cancer Patients' Perceived and Preferred Roles in Decision Making and its Association with Psychological Distress and Perceived Quality of Care. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 14:581-589. [PMID: 33569723 DOI: 10.1007/s40271-020-00480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We investigated patient-reported roles of families, physicians, and patients themselves in treatment decision making and whether discordance between perceived and preferred roles is associated with psychological distress and perceived quality of care among patients with cancer. METHODS We analyzed cross-sectional survey data from 599 adults with stage IV solid malignancy in Singapore. Stuart-Maxwell tests were used to compare patients' perceived and preferred roles in decision making. Types of discordance were categorized as follows: involvement at a lesser level than preferred, involvement at a greater level than preferred, and no change in patient involvement. Ordinary least squares regressions examined the associations between types of discordance and patient outcomes, controlling for patient characteristics. RESULTS Discordance between perceived and preferred roles was observed in 16% of patients. Amongst patients with discordance, 33% reported being involved at a lesser level than they preferred, 47% reported being involved at a greater level than they preferred, and 19% reported discordance where level of patient involvement did not change. Multivariable analyses showed that lesser involvement than preferred and discordance with no change in patient involvement were associated with poorer quality of physician communication (β = - 9.478 [95% confidence interval {CI} - 16.303 to - 2.653] and β = - 9.184 [95% CI - 18.066 to - 0.301]) and poorer care coordination (β = - 11.658 [95% CI - 17.718 to - 5.597] and β = - 8.856 [95% CI - 16.744 to - 0.968]) compared with concordance. CONCLUSIONS Most patients reported participating at their desired level. Despite this finding, our results suggest that involving patients at a lesser level than they prefer can lead to poorer perceived quality of physician communication and care coordination and that encouraging patient participation is a safe approach to minimizing poor outcomes.
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14
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Roydhouse JK, Gutman R, Wilson IB, Kehl KL, Keating NL. Patient and proxy reports regarding the experience of treatment decision-making in cancer care. Psychooncology 2020; 29:1943-1950. [PMID: 32840909 DOI: 10.1002/pon.5528] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Shared decision-making, including the elicitation of patient preferences regarding treatment decisions, is considered part of high-quality cancer care. However, patients may not be able to self-report due to illness, and therefore proxy reports may be used. We sought to determine the difference between proxy and patient reports about patient decisions and preferences among patients who received or were scheduled for chemotherapy using data from a large, population-based survey of patients with incident lung or colorectal cancer. METHODS Of 3573 patients who received or were scheduled for chemotherapy, 3108 self-reported and 465 had proxies reporting on their behalf about preferred and actual decision roles regarding this treatment. Preferred and actual decision roles were assessed using the Control Preferences Scale, and categorized as shared, patient-controlled, or doctor-controlled. Multivariable logistic regression models were used to assess the association between patient and proxy responses and whether preferences were met. The models adjusted for sociodemographic and clinical variables and patient/proxy-reported health status. RESULTS Sixty-three percent of all respondents reported actual roles in decisions that matched their preferred roles (role attainment). Proxies and patients were similarly likely to report role attainment (65% vs 63%). In adjusted analyses, proxies were more likely report role attainment (OR = 1.27, 95%CI = 1.02-1.59), but this difference was smaller if health variables were excluded from the model (OR = 1.14, 95%CI = 0.92-1.41). CONCLUSION Most patients' preferences for treatment participation were met. Surveys from proxies appear to yield small differences on the reports of attainment of preferred treatment decision-making roles in cancer care vs surveys from patients.
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Affiliation(s)
- Jessica K Roydhouse
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ira B Wilson
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kenneth L Kehl
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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15
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Wynn Mon S, Myint Zu WW, Myint Maw M, Win H, Zin Thant K, Yang G, Malhotra C, Teo I, Finkelstein E, Ozdemir S. Awareness of and preference for disease prognosis and participation in treatment decisions among advanced cancer patients in Myanmar: Results from the APPROACH study. Asia Pac J Clin Oncol 2020; 17:149-158. [PMID: 32921003 DOI: 10.1111/ajco.13430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 06/20/2020] [Indexed: 11/25/2022]
Abstract
AIM To investigate prognostic awareness, preference for prognostic information, and perceived and preferred roles in decision making among patients with advanced cancer in Myanmar. METHODS A cross-sectional survey was administered at the Yangon General Hospital to stage 4 cancer patients who were at least 21 years old and aware of their cancer diagnosis. Patients were asked questions about their prognosis, participation in treatment decisions, sociodemographic and clinical information. Data from 131 patients were analyzed using descriptive statistics and logistic regressions. RESULTS Only 15% of patients surveyed were aware that their cancer was advanced and only a quarter (26%) of patients knew that treatment intent was noncurative. The likelihood of treatment-intent awareness was higher among patients who were male, high income, and aware that they had advanced cancer. Roughly 60% of patients reported playing an active or collaborative role in treatment decisions, with a strong preference (59%) for the latter. For the majority of patients (69%), perceived and preferred roles in decision making were the same. Sociodemographic characteristics did not predict perceived and preferred roles in decision making. CONCLUSIONS This is the first effort to analyze prognostic awareness and decision-making practices among advanced cancer patients in Myanmar. Patients had inadequate knowledge on their disease progression and intent of treatment. Yet, the majority of them were keen to be involved in treatment decisions.
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Affiliation(s)
- Ssu Wynn Mon
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Wah Wah Myint Zu
- Department of Radiotherapy, Yangon General Hospital, Yangon, Myanmar
| | - Myo Myint Maw
- Department of Medical Oncology, Yangon General Hospital, Yangon, Myanmar
| | - Han Win
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Kyaw Zin Thant
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Grace Yang
- Division of Palliative Medicine, National Cancer Centre, Singapore, Singapore.,Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Irene Teo
- Division of Palliative Medicine, National Cancer Centre, Singapore, Singapore.,Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Eric Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
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16
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Assessing Cancer Patient Experience of Care in Outpatient Oncology Practices in the United States. Med Care 2020; 58:744-748. [PMID: 32692141 DOI: 10.1097/mlr.0000000000001339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Cancer patients' experience of care is an important component of quality that has not previously been used for comparing performance. We administered a new patient experience survey to cancer patients receiving outpatient chemotherapy treatment. We examined its measures for sensitivity to adjustment for case-mix and response tendency (level of general optimism/pessimism) and reliability for making performance comparisons between practices. METHODS We surveyed 2304 cancer patients who received chemotherapy at 23 medical oncology practices in Southeastern Pennsylvania, receiving 715 responses (response rate 31%; 14 practices had 10 or more responses). We aggregated patient responses to calculate practice-level scores on 5 predefined composites: Affective Communication, Shared Decision-Making, Patient Self-Management, Exchanging Information, and Access. We then ranked the practices on each composite before and after adjustment for standard case-mix variables and supplemental adjustment for response tendency (measured via the Life Orientation Test-Revised). We calculated the reliability of practice scores on each composite using hierarchical linear models and calculated minimum sample sizes necessary to achieve reliabilities exceeding 0.7. RESULTS After adjusting responses for case-mix and converting to a 0-100 scale, composite scores ranged from 77 for the Patient Self-Management composite to 92 for the Access composite. Adjustment for response tendency had an impact on practice rankings only for the Shared Decision-Making composite. The number of responses necessary to create reliable practice-level measurements ranged from 17 (Access composite) to 96 (Affective Communication composite). CONCLUSIONS Patient experiences at oncology practices can be measured reliably using reasonable sample sizes. Standard case-mix adjustment is adequate for making comparisons on most composites.
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17
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Perceived quality of care and its associated factors among Chinese patients with advanced cancer: findings from the APPROACH study in Beijing. Support Care Cancer 2020; 29:1395-1401. [PMID: 32671564 DOI: 10.1007/s00520-020-05559-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/28/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Patient-perceived quality of care has become an increasingly important index within the healthcare setting. We examined patient-reported overall quality of care and patient experiences in three specific domains of care (physician communication, nursing care, and care coordination) in a sample of Chinese patients with advanced cancer. METHODS A cross-sectional study was conducted with stage IV cancer patients (N = 202) who were recruited from a public, tertiary hospital in Beijing. Study participants completed surveys administered by a research assistant. Multivariable regression analysis was conducted to examine the extent to which patient demographic factors (age, gender, socioeconomic status), disease/treatment factors, and domain-specific care were associated with overall quality of care. RESULTS A majority of patients reported overall quality of care scores that we were either excellent (23%) or very good (41%). Patients reported highest ratings in the domain of nursing care (M = 87.57, SD = 31.05), followed by physician communication (M = 68.93, SD = 32.30), and care coordination (M = 66.79, SD = 25.17). Better perceived physician communication (b = 0.17, p < 0.01), care coordination (b = 0.26, p < 0.01), and higher socioeconomic status (b = 11.30, p < 0.05) were associated with higher overall quality of care. CONCLUSIONS A majority of patients with advanced cancer in this Chinese hospital reported positive overall quality of care. Physician communication and care coordination are potential areas to focus on to improve patient-reported overall quality of care. Understanding perceptions of care quality will allow opportunities to improve delivery of healthcare.
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18
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Hueniken K, Douglas CM, Jethwa AR, Mirshams M, Eng L, Hope A, Chepeha DB, Goldstein DP, Ringash J, Hansen A, Martino R, Li M, Liu G, Xu W, de Almeida JR. Measuring financial toxicity incurred after treatment of head and neck cancer: Development and validation of the Financial Index of Toxicity questionnaire. Cancer 2020; 126:4042-4050. [PMID: 32603521 DOI: 10.1002/cncr.33032] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/14/2020] [Accepted: 05/09/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND The treatment of head and neck cancer (HNC) may cause significant financial toxicity to patients. Herein, the authors have presented the development and validation of the Financial Index of Toxicity (FIT) instrument. METHODS Items were generated using literature review and were based on expert opinion. In item reduction, items with factor loadings of a magnitude <0.3 in exploratory factor analysis and inverse correlations (r < 0) in test-retest analysis were eliminated. Retained items constituted the FIT. Reliability tests included internal consistency (Cronbach α) and test-retest reliability (intraclass correlation). Validity was tested using the Spearman rho by comparing FIT scores with baseline income, posttreatment lost income, and the Financial Concerns subscale of the Social Difficulties Inventory. Responsiveness analysis compared change in income and change in FIT between 12 and 24 months. RESULTS A total of 14 items were generated and subsequently reduced to 9 items comprising 3 domains identified on exploratory factor analysis: financial stress, financial strain, and lost productivity. The FIT was administered to 430 patients with HNC at 12 to 24 months after treatment. Internal consistency was good (α = .77). Test-retest reliability was satisfactory (intraclass correlation, 0.70). Concurrent validation demonstrated mild to strong correlations between the FIT and Social Difficulties Inventory Money Matters subscale (Spearman rho, 0.26-0.61; P < .05). FIT scores were found to be inversely correlated with baseline household income (Spearman rho, -0.34; P < .001) and positively correlated with lost income (Spearman rho, 0.24; P < .001). Change in income was negatively correlated with change in FIT over time (Spearman rho, -0.25; P = .04). CONCLUSIONS The 9-item FIT demonstrated internal and test-retest reliability as well as concurrent and construct validity. Prospective testing in patients with HNC who were treated at other facilities is needed to further establish its responsiveness and generalizability.
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Affiliation(s)
- Katrina Hueniken
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Catriona M Douglas
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ashok R Jethwa
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Maryam Mirshams
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Lawson Eng
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Andrew Hope
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas B Chepeha
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Hansen
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Rosemary Martino
- Department of Speech-Language Pathology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Madeline Li
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Geoffrey Liu
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Epidemiology, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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19
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Haggstrom DA, Kahn KL, Klabunde CN, Gray SW, Keating NL. Oncologists' perceptions of the usefulness of cancer survivorship care plan components. Support Care Cancer 2020; 29:945-954. [PMID: 32537684 DOI: 10.1007/s00520-020-05531-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/14/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The Institute of Medicine recommends that cancer patients receive survivorship care plans (SCP) summarizing information important to the individual's long-term care. The various components of SCPs have varying levels of evidence supporting their impact. We surveyed medical oncologists to better understand how they perceived the relative value of different SCP components. METHODS Medical oncologists caring for patients in diverse US practice settings were surveyed (357 respondents; participation rate 52.9%) about their perceptions of the usefulness of various components of SCPs to both patients and primary care physicians (PCPs). RESULTS Oncologists perceived treatment summaries as "very useful" for PCPs but were less likely to perceive them as "very useful" for patients (55% vs. 40%, p < 0.001). Information about the psychological effects of cancer (41% vs. 29%; p < 0.001) and healthy behaviors (67% vs. 41%; p < 0.001) were considered more useful to patients than to PCPs. From 3 to 20% of oncologists believed that any given component of the SCP was not useful to either PCPs or patients. Oncologists who perceived SCPs to be more useful tended to be female or to practice in settings with a fully implemented electronic health record. CONCLUSIONS Oncologists do not perceive all components of SCPs to be equally useful to both patients and PCPs. To be successfully implemented, the SCP should be efficiently tailored to the unique needs and knowledge of patients and their PCPs. A minority of oncologists appear to be late adopters, suggesting that some resistance to the adoption of SCPs remains.
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Affiliation(s)
- David A Haggstrom
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. .,Regenstrief Institute, Inc., Center for Health Services Research, 1101 West Tenth Street, Indianapolis, IN, 46202, USA. .,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, IN, USA.
| | - Katherine L Kahn
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA
| | - Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | - Stacy W Gray
- City of Hope Comprehensive Cancer Center, Beckman Research Institute, Duarte, CA, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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20
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Zhu Z, Xing W, Lizarondo L, Peng J, Hu Y, So WK. Psychometric properties of self-reported financial toxicity measures in cancer survivors: a systematic review protocol using COSMIN methodology. BMJ Open 2020; 10:e036365. [PMID: 32423939 PMCID: PMC7239540 DOI: 10.1136/bmjopen-2019-036365] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/17/2020] [Accepted: 04/16/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Due to the higher costs associated with advancements in cancer treatment and longer duration of cancer survivorship, increasing financial toxicity has become a great threat to survivors, caregivers and public healthcare systems. Since accurate and reproducible measures are prerequisites for robust results, choosing an acceptable measure with strong psychometric properties to assess financial toxicity is essential. However, a description of the psychometric properties of existing measures is still lacking. The aim of this study is to apply COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology to systematically review the content and structural validity of patient-reported outcome measures (PROMs) of financial toxicity for cancer survivors. METHODS AND ANALYSIS PubMed/Medline, Medline (Ovid), Embase (Ovid), CINAHL (EBSCO), Web of Science, ProQuest Dissertations and Theses, and Cochrane Library (Wiley) will be comprehensively searched from database inception to 15 November 2019. Studies that report the measurement properties of PROMs assessing financial toxicity for cancer survivors will be included. The evaluation of measurement properties, data extraction and data synthesis will be conducted according to the COSMIN methodology. ETHICS AND DISSEMINATION No individual data are involved in this systematic review. The results will be disseminated to a clinical audience and policy-makers though peer-reviewed journals and conferences and will support researchers in choosing the best measure to evaluate the financial toxicity of cancer survivors.
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Affiliation(s)
- Zheng Zhu
- School of Nursing, Fudan University, Shanghai, China
- Fudan University Centre for Evidence-based Nursing, A Joanna Briggs Institute Centre of Excellence, Shanghai, China
| | - Weijie Xing
- School of Nursing, Fudan University, Shanghai, China
- Fudan University Centre for Evidence-based Nursing, A Joanna Briggs Institute Centre of Excellence, Shanghai, China
| | - Lucylynn Lizarondo
- The Joanna Briggs Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Jian Peng
- School of Nursing, Fudan University, Shanghai, China
- Fudan University Centre for Evidence-based Nursing, A Joanna Briggs Institute Centre of Excellence, Shanghai, China
| | - Yan Hu
- School of Nursing, Fudan University, Shanghai, China
- Fudan University Centre for Evidence-based Nursing, A Joanna Briggs Institute Centre of Excellence, Shanghai, China
| | - Winnie Kw So
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China
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21
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Japuntich SJ, Kumar P, Pendergast JF, Juarez Caballero GY, Malin JL, Wallace RB, Chrischilles EA, Keating NL, Park ER. Smoking Status and Survival Among a National Cohort of Lung and Colorectal Cancer Patients. Nicotine Tob Res 2020; 21:497-504. [PMID: 29351659 DOI: 10.1093/ntr/nty012] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/16/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The purpose of this study was to explore the association of smoking status and clinically relevant duration of smoking cessation with long-term survival after lung cancer (LC) or colorectal cancer (CRC) diagnosis. We compared survival of patients with LC and CRC who were never-smokers, long-term, medium-term, and short-term quitters, and current smokers around diagnosis. METHODS We studied 5575 patients in Cancer Care Outcomes Research and Surveillance (CanCORS), a national, prospective observational cohort study, who provided smoking status information approximately 5 months after LC or CRC diagnosis. Smoking status was categorized as: never-smoker, quit >5 years prior to diagnosis, quit between 1-5 years prior to diagnosis, quit less than 1 year before diagnosis, and current smoker. We examined the relationship between smoking status around diagnosis with mortality using Cox regression models. RESULTS Among participants with LC, never-smokers had lower mortality risk compared with current smokers (HR 0.71, 95% CI 0.57 to 0.89). Among participants with CRC, never-smokers had a lower mortality risk as compared to current smokers (HR 0.79, 95% CI 0.64 to 0.99). CONCLUSIONS Among both LC and CRC patients, current smokers at diagnosis have higher mortality than never-smokers. This effect should be further studied in the context of tumor biology. However, smoking cessation around the time of diagnosis did not affect survival in this sample. IMPLICATIONS The results from our analysis of patients in the CanCORS consortium, a large, geographically diverse cohort, show that both LC and CRC patients who were actively smoking at diagnosis have worse survival as compared to never-smokers. While current smoking is detrimental to survival, cessation upon diagnosis may not mitigate this risk.
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Affiliation(s)
- Sandra J Japuntich
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital and Department of Psychiatry and Human Behavior, The Alpert Medical School of Brown University, Providence, RI
| | - Pallavi Kumar
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jane F Pendergast
- Department of Biostatistics, Duke University School of Medicine, Durham, NC
| | | | - Jennifer L Malin
- David Geffen School of Medicine at University of California Los Angeles, California and Veterans Affairs Medical Center, Greater Los Angeles, CA
| | - Robert B Wallace
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Elyse R Park
- Tobacco Research and Treatment Center, and the Mongan Institute for Health Policy Center, Massachusetts General Hospital, Boston, MA.,Department of Psychiatry, Harvard Medical School, Boston, MA
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22
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Roydhouse JK, Gutman R, Keating NL, Mor V, Wilson IB. Propensity scores for proxy reports of care experience and quality: are they useful? HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2019. [DOI: 10.1007/s10742-019-00205-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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23
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Patient-clinician interactions and disparities in breast cancer care: the equality in breast cancer care study. J Cancer Surviv 2019; 13:968-980. [PMID: 31646462 PMCID: PMC10187984 DOI: 10.1007/s11764-019-00820-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/09/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE To examine whether interpersonal aspects of patient-clinician interactions, such as patient-perceived medical discrimination, clinician mistrust, and treatment decision-making contribute to racial/ethnic/educational disparities in breast cancer care. METHODS A telephone interview was administered to 542 Asian/Pacific Islander (API), Black, Hispanic, and White women identified through the Greater Bay Area Cancer Registry, ages 20 and older diagnosed with a first primary invasive breast cancer. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated from logistic regression models that assessed associations between race/ethnicity/education, medical discrimination, clinician mistrust, and treatment decision-making with concordance to breast cancer treatment guidelines (guideline-concordant treatment) and perceived quality of care (pQoC). RESULTS Approximately three-quarters of women received treatment that was guideline-concordant (76.6%) and reported that their breast cancer care was excellent (72.1%). Non-college-educated Black women had lower odds of guideline-concordant care (aOR (CI) = 0.29 (0.12-0.67)) vs. college-educated White women. Odds of excellent pQoC were lower among the following: college-educated Hispanic women (aOR (CI) = 0.09 (0.02-0.47)) and API women regardless of education (aORs ≤ 0.50) vs. college-educated White women, women reporting low and moderate levels of discrimination (aORs ≤ 0.44) vs. none, and women reporting any clinician mistrust (aOR (CI) = 0.50 (0.29-0.88)) vs. none. Disparities in guideline-concordant care and pQoC persisted after controlling for medical discrimination, clinician mistrust, and decision-making. CONCLUSIONS Interpersonal aspects of the patient-clinician interaction had an impact on pQoC but not receipt of guideline-concordant treatment and did not explain disparities in either outcome. IMPLICATIONS FOR CANCER SURVIVORS Although breast cancer survivors' interpersonal interactions with clinicians did not influence receipt of appropriate treatment, intervention strategies to improve patient-clinician relations may help attenuate disparities in survivors' pQoC.
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Sisk BA, Kang TI, Mack JW. Racial and Ethnic Differences in Parental Decision-Making Roles in Pediatric Oncology. J Palliat Med 2019; 23:192-197. [PMID: 31408409 DOI: 10.1089/jpm.2019.0178] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Prior work in adult oncology suggests minority patients are less involved in decision making than preferred. However, few studies have explored decision-making experiences of minority parents in pediatric oncology. Objective: To determine whether parental decision-making preferences and experiences vary by race/ethnicity. Design: Questionnaire-based cohort study. Setting/Subjects: Three hundred sixty five parents of children with cancer and their oncologists at two academic centers. Measurements: Parents reported on preferred and actual decision-making roles. Associations between race/ethnicity and decision-making outcomes determined by chi-squared test. Results: Most parents preferred shared decision making (235/368, 64%), whereas 23% (84/368) preferred parent-led decision making and 13% (49/368) preferred oncologist-led decision making. Parental decision-making preferences did not differ by race/ethnicity (p = 0.38, chi-squared test). However, the actual role parents played in decision making differed by parental race/ethnicity, with 25% (71/290) of white parents reporting parent-led decision making, versus 37% (9/24) of black parents, 48% (13/27) of Hispanic parents, and 56% (15/27) of Asian/other parents (p = 0.005, chi-squared test). Oncologists accurately predicted parental preferences for decision making 49% of the time (n = 165/338), but accuracy also differed by race and ethnicity. Oncologists accurately predicted parental preferences for 53% of white parents (140/266), 23% of black parents (5/22), 37% of Hispanic parents (10/27), and 43% of Asian/other race parents (10/23) (p = 0.026, chi-squared test). Conclusions: Minority parents held more active roles than white parents, and oncologists had more difficulty predicting decisional preferences for minority parents relative to white parents. These findings suggest that minority parents are at risk of inferior decision-making experiences.
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Affiliation(s)
- Bryan A Sisk
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Tammy I Kang
- Section of Pediatric Palliative Care, Texas Children's Hospital, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jennifer W Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
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Smith TG, Troeschel AN, Castro KM, Arora NK, Stein K, Lipscomb J, Brawley OW, McCabe RM, Clauser SB, Ward E. Perceptions of Patients With Breast and Colon Cancer of the Management of Cancer-Related Pain, Fatigue, and Emotional Distress in Community Oncology. J Clin Oncol 2019; 37:1666-1676. [PMID: 31100037 PMCID: PMC6804889 DOI: 10.1200/jco.18.01579] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Pain, fatigue, and distress are common among patients with cancer but are often underassessed and undertreated. We examine the prevalence of pain, fatigue, and emotional distress among patients with cancer, as well as patient perceptions of the symptom care they received. PATIENTS AND METHODS Seventeen Commission on Cancer-accredited cancer centers across the United States sampled patients with local/regional breast (82%) or colon (18%) cancer. We received 2,487 completed surveys (61% response rate). RESULTS Of patients, 76%, 78%, and 59% reported talking to a clinician about pain, fatigue, and distress, respectively, and 70%, 61%, and 54% reported receiving advice. Sixty-one percent of patients experienced pain, 74% fatigue, and 46% distress. Among those patients experiencing each symptom, 58% reported getting the help they wanted for pain, 40% for fatigue, and 45% for distress. Multilevel logistic regression models revealed that patients experiencing symptoms were significantly more likely to have talked about and received advice on coping with these symptoms. In addition, patients who were receiving or recently completed curative treatment reported more symptoms and better symptom care than did those who were further in time from curative treatment. CONCLUSION In our sample, 30% to 50% of patients with cancer in community cancer centers did not report discussing, getting advice, or receiving desired help for pain, fatigue, or emotional distress. This finding suggests that there is room for improvement in the management of these three common cancer-related symptoms. Higher proportions of talk and advice among those experiencing symptoms imply that many discussions may be patient initiated. Lower rates of talk and advice among those who are further in time from treatment suggest the need for more assessment among longer-term survivors, many of whom continue to experience these symptoms. These findings seem to be especially important given the high prevalence of these symptoms in our sample.
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Affiliation(s)
| | | | | | - Neeraj K. Arora
- Patient‐Centered Outcomes Research Institute, Washington, DC
| | - Kevin Stein
- Emory University, Atlanta, GA
- Cancer Support Community, Washington, DC
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26
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Witte J, Mehlis K, Surmann B, Lingnau R, Damm O, Greiner W, Winkler EC. Methods for measuring financial toxicity after cancer diagnosis and treatment: a systematic review and its implications. Ann Oncol 2019; 30:1061-1070. [PMID: 31046080 PMCID: PMC6637374 DOI: 10.1093/annonc/mdz140] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Patients experiencing financial distress as a side-effect of cancer are not only reported in the United States, but also in third-party payer healthcare systems in Europe. Since validated survey instruments are a prerequisite for robust and comparable results, we aimed to compile and classify available instruments to enable both a better understanding of the underlying construct of financial toxicity and to facilitate further studies that are adjustable to various healthcare systems. We did a systematic literature search on studies that provide data on perceived cancer-related financial distress experienced by adult patients using PubMed, CINAHL and Web of Science databases up to 2018. We analyzed all detected instruments, items domains and questions with regard to their wording, scales and the domains of financial distress covered. Among 3298 records screened, 41 publications based on 40 studies matched our inclusion criteria. Based on the analysis of 352 different questions we identified 6 relevant subdomains that represent perceptions of and reactions to experienced financial distress: (i) active financial spending, (ii) use of passive financial resources, (iii) psychosocial responses, (iv) support seeking, (v) coping with care or (vi) coping with ones' lifestyle. We found an inconsistent coverage and use of these domains that makes it difficult to compare and quantify the prevalence of financial distress. Moreover, some existing instruments do not reflect relevant domains for patients in third-party payer systems. There is neither a consistent understanding of the construct of financial burden nor do available instruments cover all relevant aspects of a patients' distress perception. We encourage using the identified six domains to further develop survey instruments and adjust them to different health systems.
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Affiliation(s)
- J Witte
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - K Mehlis
- Department of Medical Oncology, Programme for Ethics and Patient Oriented Care, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
| | - B Surmann
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - R Lingnau
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - O Damm
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - W Greiner
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - E C Winkler
- Department of Medical Oncology, Programme for Ethics and Patient Oriented Care, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany.
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Sisk BA, Kang TI, Mack JW. The evolution of regret: decision-making for parents of children with cancer. Support Care Cancer 2019; 28:1215-1222. [PMID: 31297592 DOI: 10.1007/s00520-019-04933-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/07/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE Parents of children with cancer make treatment decisions in highly emotional states while feeling overwhelmed with information. In previous work, 1 in 6 parents demonstrated heightened decisional regret regarding treatment at diagnosis. However, it is unclear how regret evolves over time. We aimed to determine whether parents of children with cancer experience decisional regret over time and to identify parental characteristics and clinician behaviors associated with longitudinal regret. METHODS Prospective, questionnaire-based cohort study of parents of children with cancer at two academic pediatric hospitals. Parents reported decisional regret at diagnosis, 4 months, and 12 months. RESULTS At baseline, 13% of parents (21/158) reported heightened regret, 11% (17/158) at 4 months (p = 0.43, McNemar's test relative to baseline), and 11% (16/158) at 12 months (p = 0.35 relative to baseline and p = 0.84 relative to 4 months). In multivariable analysis using generalized estimating equations adjusted for the time point of survey completion, heightened regret was associated with non-white race/ethnicity (OR 11.57, 95% CI 3.53 to 41.05, p < .0001) and high anxiety (OR 2.01, 95% CI 1.04 to 3.90, p = .04). Parents with high peace of mind (OR 0.24, 95% CI 0.09 to 0.62, p = .003) and those reporting high-quality information (OR 0.22, 95% CI 0.07 to 0.69, p = 0.01) had lower odds of heightened regret. We found no association between heightened regret and the time point of survey administration. CONCLUSIONS A small, significant proportion of parents experience heightened regret throughout the first year of their child's cancer treatment; non-white parents are at higher risk. Effective communication may protect against regret.
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Affiliation(s)
- Bryan A Sisk
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8005, St. Louis, MO, 63110, USA.
| | - Tammy I Kang
- Section of Pediatric Palliative Care, Texas Children's Hospital, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer W Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA
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28
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Mack JW, Fasciano KM, Block SD. Adolescent and Young Adult Cancer Patients' Experiences With Treatment Decision-making. Pediatrics 2019; 143:peds.2018-2800. [PMID: 31000684 DOI: 10.1542/peds.2018-2800] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Adolescents and young adults (AYAs) with cancer generally want to engage in decision-making but are not always able to do so. We evaluated cancer treatment decision-making among AYAs, including decisional engagement and regret. METHODS We surveyed 203 AYA patients with cancer aged 15 to 29 (response rate 74%) treated at a large academic center and their oncologists. Patients were approached within 6 weeks of diagnosis and asked to report decision-making preferences and experiences (Decisional Roles Scale) and the extent to which they regretted their initial treatment decision (Decisional Regret Scale) assessed at baseline and 4 and 12 months later. RESULTS A majority of AYAs (58%) wanted to share responsibility for decision-making with oncologists; half (51%) preferred limited involvement from parents. Although most AYAs held roles they preferred, those who did not reported holding more passive roles relative to oncologists (P < .0001) and parents (P = .002) than they desired. Nearly one-quarter of patients (24%; 47 of 195) experienced regret about initial cancer treatment decisions at baseline, with similar rates at 4 (23%) and 12 (19%) months. In a multivariable model adjusted for age, decisional roles were not associated with regret; instead, regret was less likely among patients who trusted oncologists completely (odds ratio 0.17 [95% confidence interval 0.06-0.46]; P < .001) and who reported that oncologists understood what was important to them when treatment started (odds ratio 0.13 [95% confidence interval 0.04-0.42]; P < .001). CONCLUSIONS Nearly one-fourth of AYA patients expressed regret about initial treatment decisions. Although some AYAs have unmet needs for decisional engagement, attributes of the patient-oncologist relationship, including trust and mutual understanding, may be most protective against regret.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Department of Pediatric Oncology, McGraw/Patterson Center for Outcomes and Policy Research and .,Division of Hematology and Oncology, Boston Children's Hospital, Boston, Massachusetts; and
| | - Karen M Fasciano
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Departments of Psychiatry and
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Departments of Psychiatry and.,Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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29
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Doria-Rose VP, Greenlee RT, Buist DSM, Miglioretti DL, Corley DA, Brown JS, Clancy HA, Tuzzio L, Moy LM, Hornbrook MC, Brown ML, Ritzwoller DP, Kushi LH, Greene SM. Collaborating on Data, Science, and Infrastructure: The 20-Year Journey of the Cancer Research Network. EGEMS (WASHINGTON, DC) 2019; 7:7. [PMID: 30972356 PMCID: PMC6450242 DOI: 10.5334/egems.273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/16/2018] [Indexed: 12/13/2022]
Abstract
The Cancer Research Network (CRN) is a consortium of 12 research groups, each affiliated with a nonprofit integrated health care delivery system, that was first funded in 1998. The overall goal of the CRN is to support and facilitate collaborative cancer research within its component delivery systems. This paper describes the CRN's 20-year experience and evolution. The network combined its members' scientific capabilities and data resources to create an infrastructure that has ultimately supported over 275 projects. Insights about the strengths and limitations of electronic health data for research, approaches to optimizing multidisciplinary collaboration, and the role of a health services research infrastructure to complement traditional clinical trials and large observational datasets are described, along with recommendations for other research consortia.
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Affiliation(s)
- V. Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, US
| | | | - Diana S. M. Buist
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, US
| | - Diana L. Miglioretti
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, US
- University of California Davis School of Medicine, Davis, CA, US
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, US
| | - Jeffrey S. Brown
- Department of Population Medicine, Harvard Medical School, Boston, MA, US
- Harvard Pilgrim Health Care Institute, Boston, MA, US
| | - Heather A. Clancy
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, US
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, US
| | - Lisa M. Moy
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, US
| | - Mark C. Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, US
- Retired
| | - Martin L. Brown
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, US
- Retired
| | | | - Lawrence H. Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, US
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Sisk BA, Kang TI, Goldstein R, DuBois JM, Mack JW. Decisional burden among parents of children with cancer. Cancer 2019; 125:1365-1372. [DOI: 10.1002/cncr.31939] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/19/2018] [Accepted: 11/26/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Bryan A. Sisk
- Division of Hematology/Oncology, Department of Pediatrics Washington University School of Medicine St. Louis Missour
| | - Tammy I. Kang
- Section of Pediatric Palliative Care Texas Children’s Hospital Houston Texas
- Department of Pediatrics Baylor College of Medicine Houston Texas
| | - Richard Goldstein
- Division of General Pediatrics, Department of Medicine Boston Children’s Hospital Boston Massachusetts
| | - James M. DuBois
- Department of Medicine Washington University School of Medicine St. Louis Missouri
| | - Jennifer W. Mack
- Pediatric Oncology, Dana‐Farber Cancer Institute Boston Massachusetts
- Division of Population Sciences Dana‐Farber Cancer Institute Boston Massachusetts
- Division of Pediatric Hematology/Oncology Boston Children’s Hospital Boston Massachusetts
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Roydhouse JK, Gutman R, Keating NL, Mor V, Wilson IB. The Association of Proxy Care Engagement with Proxy Reports of Patient Experience and Quality of Life. Health Serv Res 2018; 53:3809-3824. [PMID: 29806212 PMCID: PMC6153170 DOI: 10.1111/1475-6773.12980] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To assess the association of proxy-specific covariates with proxy-reported patient cancer care experience, quality rating, and quality of life. DATA SOURCES/STUDY SETTING Secondary analysis of data from the Cancer Care Outcomes Research and Surveillance (CanCORS) study. STUDY DESIGN Cross-sectional observational study. The respondents were proxies for patients with incident colorectal or lung cancer. DATA COLLECTION/EXTRACTION METHODS Analyses used linear regression models and adjusted for patient sociodemographic and clinical characteristics. Outcomes included patients' experiences with medical care, nursing care, and care coordination, overall quality ratings, and physical and mental health, all scored on 0-100 scales (0 = worst, 100 = best). Independent variables included the proxy's relationship with the patient and engagement in patient care. PRINCIPAL FINDINGS Of 1,011 proxies, most were the patient's spouse (50 percent) or child (36 percent). Although most proxies (66 percent) always attended medical visits, 3 percent reported never attending. After adjustment, on average children reported worse experiences and poorer quality care than spouses (4-9 points lower across outcomes). Proxies who never attended medical visits reported significantly worse medical care (-11 points, 95 percent CI = -18 to -3) and care coordination (-13 points, 95 percent CI = -20 to -6). CONCLUSIONS Collecting data on proxy engagement in care is warranted if proxy responses are used.
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Affiliation(s)
- Jessica K. Roydhouse
- Department of Health Services, Policy and PracticeBrown University School of Public HealthProvidenceRI
| | - Roee Gutman
- Department of BiostatisticsBrown University School of Public HealthProvidenceRI
| | | | - Vincent Mor
- Department of Health Services, Policy and PracticeBrown University School of Public HealthProvidenceRI
| | - Ira B. Wilson
- Department of Health Services, Policy and PracticeBrown University School of Public HealthProvidenceRI
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Agarwal R, Epstein AS. Advance Care Planning and End-of-Life Decision Making for Patients with Cancer. Semin Oncol Nurs 2018; 34:316-326. [PMID: 30100366 DOI: 10.1016/j.soncn.2018.06.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To highlight the importance, challenges, and evolution of advance care planning for patients with cancer. DATA SOURCES Peer-reviewed journal articles and clinical guidelines. CONCLUSION Advance care planning is fundamental to support the personhood of patients with advanced cancer. Patients must be encouraged by physicians and nurses to articulate what matters and provides meaning to them as they live, cope, and receive treatment for their cancer. IMPLICATIONS FOR NURSING PRACTICE Nurses can facilitate advance care planning and primary palliative care, to support patients and families to make informed and value-concordant decisions regarding cancer and end-of-life treatments.
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Litzelman K, Kent E, Rowland JH. Interrelationships Between Health Behaviors and Coping Strategies Among Informal Caregivers of Cancer Survivors. HEALTH EDUCATION & BEHAVIOR 2018; 45:90-100. [PMID: 28443370 PMCID: PMC5623644 DOI: 10.1177/1090198117705164] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Recent research among cancer survivors suggests that health behaviors and coping are intertwined, with important implications for positive behavior change and health. Informal caregivers may have poor health behaviors, and caregivers' health behaviors have been linked to those of survivors. AIMS This hypothesis generating study assessed the correlations among health behaviors and coping strategies in a population of lung and colorectal cancer caregivers. METHOD This cross-sectional study used data from the Cancer Care Outcomes Research & Surveillance Consortium. Caregivers ( n = 1,482) reported their health behaviors, coping, and sociodemographic and caregiving characteristics. Descriptive statistics assessed the distribution of caregivers' health and coping behaviors, and multivariable linear regressions assessed the associations between health behaviors and coping styles. RESULTS Many informal caregivers reported regular exercise (47%) and adequate sleep (37%); few reported smoking (19%) or binge drinking (7%). Problem-focused coping was associated with greater physical activity and less adequate sleep (effect sizes [ESs] up to 0.21, p < .05). Those with some physical activity scored higher on emotion-focused coping, while binge drinkers scored lower (ES = 0.16 and 0.27, p < .05). Caregivers who reported moderate daily activity, current smoking, binge drinking, and feeling less well rested scored higher on dysfunctional coping (ES up to 0.49, p < .05). DISCUSSION Health behaviors and coping strategies were interrelated among informal cancer caregivers. The relationships suggest avenues for future research, including whether targeting both factors concurrently may be particularly efficacious at improving informal caregiver self-care. CONCLUSION Understanding the link between health behaviors and coping strategies may inform health behavior research and practice.
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Affiliation(s)
- Kristin Litzelman
- University of Wisconsin-Madison, Department of Human Development and Family Studies, 4115 Nancy Nicholas Hall, 1300 Linden Dr., Madison, WI 53706
- University of Wisconsin-Extension, Family Living Programs
| | - Erin Kent
- National Cancer Institute, BG 9609 MSC 9760, 9609 Medical Center Drive, Bethesda, MD 20892
| | - Julia H. Rowland
- National Cancer Institute, BG 9609 MSC 9760, 9609 Medical Center Drive, Bethesda, MD 20892
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Busch EL, Don PK, Chu H, Richardson DB, Keku TO, Eberhard DA, Avery CL, Sandler RS. Diagnostic accuracy and prediction increment of markers of epithelial-mesenchymal transition to assess cancer cell detachment from primary tumors. BMC Cancer 2018; 18:82. [PMID: 29338703 PMCID: PMC5769498 DOI: 10.1186/s12885-017-3964-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 12/21/2017] [Indexed: 12/20/2022] Open
Abstract
Background Metastases play a role in about 90% of cancer deaths. Markers of epithelial-mesenchymal transition (EMT) measured in primary tumor cancer cells might provide diagnostic information about the likelihood that cancer cells have detached from the primary tumor. Used together with established diagnostic tests of detachment—lymph node evaluation and radiologic imaging—EMT marker measurements might improve the ability of clinicians to assess the patient’s risk of metastatic disease. Translation of EMT markers to clinical use has been hampered by a lack of valid analyses of clinically-informative parameters. Here, we demonstrate a rigorous approach to estimating the sensitivity, specificity, and prediction increment of an EMT marker to assess cancer cell detachment from primary tumors. Methods We illustrate the approach using immunohistochemical measurements of the EMT marker E-cadherin in a set of colorectal primary tumors from a population-based prospective cohort in North Carolina. Bayesian latent class analysis was used to estimate sensitivity and specificity in a setting of multiple imperfect diagnostic tests and no gold standard. Risk reclassification analysis was used to assess the extent to which addition of the marker to the panel of established diagnostic tests would improve mortality prediction. We explored how changing the latent class conditional dependence assumptions and definition of marker positivity would impact the results. Results All diagnostic accuracy and prediction increment statistics varied with the choice of cut point to define marker positivity. When comparing different definitions of marker positivity to each other, numerous trade-offs were observed in terms of sensitivity, specificity, predictive discrimination, and prediction model calibration. We then discussed several implementation considerations and the plausibility of analytic assumptions. Conclusions The approaches presented here can be extended to any EMT marker, to most forms of cancer, and to different kinds of EMT marker measurements, such as RNA or gene methylation data. These methods provide valid, clinically-informative assessment of whether and how to use a given EMT marker to refine tumor staging and consequent treatment decisions. Electronic supplementary material The online version of this article (10.1186/s12885-017-3964-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Evan L Busch
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, 3rd Floor, Boston, MA, 02115, USA. .,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA. .,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Prabhani Kuruppumullage Don
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Computer Science and Statistics, University of Rhode Island, Kingston, RI, USA
| | - Haitao Chu
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - David B Richardson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Temitope O Keku
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - David A Eberhard
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Christy L Avery
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Robert S Sandler
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Roydhouse JK, Gutman R, Keating NL, Mor V, Wilson IB. Proxy and patient reports of health-related quality of life in a national cancer survey. Health Qual Life Outcomes 2018; 16:6. [PMID: 29304818 PMCID: PMC5756370 DOI: 10.1186/s12955-017-0823-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 12/08/2017] [Indexed: 12/03/2022] Open
Abstract
Background Proxy respondents are frequently used in surveys, including those assessing health-related quality of life (HRQOL). In cancer, most research involving proxies has been undertaken with paired proxy-patient populations, where proxy responses are compared to patient responses for the same individual. In these populations, proxy-patient differences are small and suggest proxy underestimation of patient HRQOL. In practice, however, proxy responses will only be used when patient responses are not available. The difference between proxy and patient reports of patient HRQOL where patients are not able to report for themselves in cancer is not known. The objective of this study was to evaluate the difference between patient and proxy reports of patient HRQOL in a large national cancer survey, and determine if this difference could be mitigated by adjusting for clinical and sociodemographic information about patients. Methods Data were from the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Patients or their proxies were recruited within 3–6 months of diagnosis with lung or colorectal cancer. HRQOL was measured using the SF-12 mental and physical composite scales. Differences of ½ SD (=5 points) were considered clinically significant. The primary independent variable was proxy status. Linear regression models were used to adjust for patient sociodemographic and clinical covariates, including cancer stage, patient age and education, and patient co-morbidities. Results Of 6471 respondents, 1011 (16%) were proxies. Before adjustment, average proxy-reported scores were lower for both physical (−6.7 points, 95% CI -7.4 to −5.9) and mental (−6 points, 95% CI -6.7 to −5.2) health. Proxy-reported scores remained lower after adjustment (physical: −5.8 points, −6.6 to −5; mental: −5.8 points, −6.6 to 5). Proxy-patient score differences remained clinically and statistically significant, even after adjustment for sociodemographic and clinical variables. Conclusions Proxy-reported outcome scores for both physical and mental health were clinically and significantly lower than patient-reported scores for these outcomes. The size of the proxy-patient score differences was not affected by the health domain, and adjustment for sociodemographic and clinical variables had minimal impact.
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Affiliation(s)
- Jessica K Roydhouse
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S. Main Street, Providence, RI, 02912, USA.
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, 121 S. Main Street, Providence, RI, 02912, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA, 02115, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S. Main Street, Providence, RI, 02912, USA
| | - Ira B Wilson
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S. Main Street, Providence, RI, 02912, USA
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Abstract
Palliative care is a powerful adjunct to oncology that adds distinct value to the physical, mental, and psychosocial well-being of patients living with cancer. Its expanding role and integration with standard oncologic care has proven clinical benefit, as the practice of palliative care can help alleviate symptom burden, enhance illness and prognostic understanding, and improve both the quality of life and overall survival for patients. The primary aim of this review article is to highlight the significant interplay between palliative care and oncology and, in doing so, shed light on the areas for improvement and modern challenges that exist to meet the complex palliative care needs of patients with cancer.
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Affiliation(s)
- Rajiv Agarwal
- Department of Medicine, Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew S Epstein
- Division of Solid Tumor Oncology, Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Palliative Medicine Service, Memorial Sloan Kettering Cancer Center, New York, New York
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Mollica MA, Litzelman K, Rowland JH, Kent EE. The role of medical/nursing skills training in caregiver confidence and burden: A CanCORS study. Cancer 2017; 123:4481-4487. [PMID: 28727147 PMCID: PMC5673528 DOI: 10.1002/cncr.30875] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/30/2017] [Accepted: 05/30/2017] [Indexed: 11/05/2022]
Abstract
BACKGROUND Informal cancer caregivers provide essential support to cancer patients, including performing direct medical/nursing tasks, assisting with activities of daily living, and offering social support. This study examined associations between the receipt of medical/nursing skills training and the caregiver burden as well as the mediation of caregiving confidence on this relationship in a sample of caregivers of lung and colorectal cancer patients. METHODS Caregivers who had been identified by cancer patients in the Cancer Care Outcomes Research and Surveillance consortium completed a questionnaire assessing the care provided, the type of medical/nursing skills training received, the burden (measured with the modified short-form Zarit Burden Interview), and the confidence in caring for their patient's physical needs. Regression models that had been adjusted for sociodemographic, caregiver, and care recipient characteristics assessed the relationship between training received and burden, and a mediation analysis assessed the role of confidence in this relationship. RESULTS Six hundred forty-one caregivers performed some type of medical/nursing task, with 59% (n = 377) reporting that they did not receive training for all the care provided. Caregivers reported moderate levels of burden (mean summary score, 32.07; standard deviation, 12.66; possible range, 14-70), and a lack of receipt of training was associated with greater levels of burden (b = 2.60; standard error, 0.98; P = .01). Confidence partially mediated the relation between training and burden (Sobel's t = 1.90; P = 0.03). CONCLUSIONS As the number of cancer patients and caregivers increases, understanding how best to reduce the caregiver burden is necessary. Skills training is a potential area for interventions, but research on how best to provide training for caregivers (ie, the content, mode of delivery, and timing) is needed. Cancer 2017;123:4481-7. © 2017 American Cancer Society.
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Affiliation(s)
- Michelle A Mollica
- Outcomes Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Kristin Litzelman
- School of Human Ecology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Julia H Rowland
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Erin E Kent
- Outcomes Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
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Pisu M, Kenzik KM, Rim SH, Funkhouser EM, Bevis KS, Alvarez RD, Cantuaria G, Rocconi RP, Martin MY. Values and worries of ovarian cancer patients. Gynecol Oncol 2017; 147:433-438. [PMID: 28888542 PMCID: PMC5835401 DOI: 10.1016/j.ygyno.2017.08.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 08/24/2017] [Accepted: 08/27/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Older women with ovarian cancer (OC) are less likely to receive guideline concordant treatment. Differences in values and worries about treatment may explain why. METHODS Women with OC in 2013-2015 were surveyed about values and worries at the time of initial treatment. Existing values (11 item, e.g., maintaining quality of life) and worries (12 items, e.g., treatment side effects) scales were adapted based on OC literature. Responses were very/somewhat/a little/not at all important or worried. Principal Component Analyses (PCA) identified groups of values and worries that best explained scales' variation. We examined proportions reporting very/somewhat important/worried on ≥1 item in each component by age (older ≥65years, younger <65years). RESULTS Of 170 respondents, 42.3% were older. PCA components for values were: functional well-being (3 survey items, proportion of variance explained [PoVE] 26.3%), length of life and sexual functioning (3 items, PoVE 20.1%), attitudes (3 items, PoVE 14.2%), and not becoming a burden (2 items, PoVE 13.7%). PCA components for worries were: economic (4 items, PoVE 27.2%), uncertainty (6 items, PoVE 26.0%), and family impact (2 items, PoVE 16.3%). Older women were less likely to indicate very/somewhat worried to ≥1 item in the economic (51.4% vs 72.4%, p=0.006), uncertainty (80.6% vs. 98.0%, p=0.001), and family impact component (55.6% vs. 70.4%, p=0.03). No other age differences were found. CONCLUSIONS While worry during OC treatment decision-making may differ across age groups, values do not. Research should assess how differences in worry might affect OC medical decision-making for older and younger women.
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Affiliation(s)
- Maria Pisu
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Kelly M Kenzik
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States; Institute for Cancer Outcomes and Survivorship and Division of Hematology Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Sun Hee Rim
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Ellen M Funkhouser
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kerri S Bevis
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ronald D Alvarez
- Department of Obstetrics and Gynecology, School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Guilherme Cantuaria
- Division of Gynecologic Oncology, Northside Hospital, Atlanta, GA, United States
| | - Rodney P Rocconi
- Division of Gynecologic Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, United States
| | - Michelle Y Martin
- Center for Innovation in Health Equity Research (CIHER), Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
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Ilowite MF, Cronin AM, Kang TI, Mack JW. Disparities in prognosis communication among parents of children with cancer: The impact of race and ethnicity. Cancer 2017; 123:3995-4003. [PMID: 28873224 DOI: 10.1002/cncr.30960] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/19/2017] [Accepted: 06/27/2017] [Indexed: 07/13/2024]
Abstract
BACKGROUND Most parents of children with cancer say they want detailed information about their child's prognosis. However, prior work has been conducted in populations of limited diversity. The authors sought to evaluate the impact of parental race/ethnicity on prognosis communication experiences among parents of children with cancer. METHODS In total, 357 parents of children with cancer and the children's physicians were surveyed at Dana-Farber Cancer Institute/Boston Children's Hospital and Children's Hospital of Philadelphia. Outcome measures were parental preferences for prognostic information, physician beliefs about parental preferences, prognosis communication processes, and communication outcomes. Associations were assessed by logistic regression with generalized estimating equations to correct for physician clustering. RESULTS Two hundred eighty-one parents (79%) were white, 23 (6%) were black, 29 (8%) were Hispanic, and 24 (7%) were Asian/other. Eighty-seven percent of parents wanted as much detail as possible about their child's prognosis, with no significant differences by race/ethnicity (P = .75). However, physician beliefs about parental preferences for prognosis communication varied based on parent race/ethnicity, with physicians considering black and Hispanic parents less interested in details about prognosis than whites (P = .003). Accurate understanding of a less favorable prognosis was greater among white (49%) versus nonwhite parents (range, 20%-29%), although this difference was not statistically significant (P = .14). CONCLUSIONS Most parents, regardless of racial and ethnic background, want detailed prognostic information about their child's cancer. However, physicians underestimate the information needs of black and Hispanic parents. To meet parents' information needs, physicians should ask about parents' information preferences before prognosis discussions. Cancer 2017;123:3995-4003. © 2017 American Cancer Society.
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Affiliation(s)
- Maya F Ilowite
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Angel M Cronin
- Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tammy I Kang
- Section of Palliative Care, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
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Cunningham M, Wells M. Qualitative analysis of 6961 free-text comments from the first National Cancer Patient Experience Survey in Scotland. BMJ Open 2017; 7:e015726. [PMID: 28619780 PMCID: PMC5734250 DOI: 10.1136/bmjopen-2016-015726] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/27/2017] [Accepted: 03/20/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To analyse free-text responses from the first Scottish Cancer Patient Experience Survey (SCPES) to understand patients' experiences of care, identify valued aspects and areas for improvement. DESIGN Inductive thematic analysis of seven free-text comment boxes covering all stages of the cancer experience, from a national cohort survey. SETTING AND PARTICIPANTS Adult cancer patients diagnosed across all Health Boards in Scotland between July 2013 and March 2014, and who had an inpatient stay or hospital visit between January and September 2014. 2663 respondents (of n=4835 survey respondents) provided 6961 free-text comments. MAIN OUTCOME MEASURES Positive and negative themes of patients' experiences. Differences in the proportion of positive to negative comments by demographics. METHODS Data were analysed as follows: (1) comments were initially categorised at a high level (eg, positive, negative, miscellaneous, etc); (2) inductive codes were derived and applied to all relevant comments; (3) codes sharing similar meaning were amalgamated into subthemes, and code frequencies were measured; (4) subthemes were mapped into overarching themes; (5) difference in the proportion of positive to negative comments by demographics were analysed using χ2 tests. RESULTS Participants made more positive than negative comments (1:0.78). Analysis highlighted the importance to patients of Feeling that Individual Needs Are Met and Feeling Confident Within the System. Comments also provided insight into how Processes and Structures within the system of care can negatively impact on patients' experience. Particular issues were identified with care experiences in the lead-up to diagnosis. CONCLUSIONS This analysis provides a detailed understanding of patients' cancer care experiences, therefore indicating what aspects matter in those experiences. Although the majority of comments were positive, there were a significant number of negative comments, especially about the lead-up to diagnosis. Comments suggest patients would value greater integration of care from services involved in their treatment for cancer.
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Affiliation(s)
| | - Mary Wells
- NMAHP Research Unit, University of Stirling, Stirling, UK
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41
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Agarwal R, Epstein AS. Palliative care and advance care planning for pancreas and other cancers. Chin Clin Oncol 2017; 6:32. [PMID: 28705009 PMCID: PMC6119222 DOI: 10.21037/cco.2017.06.16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 05/27/2017] [Indexed: 12/25/2022]
Abstract
The principles of palliative care are fundamental to support and treat the physical, mental, and psychosocial health of patients living with pancreatic cancer. In addition to its proven advantages to help manage disease-related symptoms, improve accurate illness understanding, and enhance the quality of life and survival outcomes for patients with advanced disease, the inclusion of palliative care principles (whether by a specialist or by the primary oncology team) with standard oncologic care strengthens timely and quality advance care planning (ACP). The primary objective of this review article is to underscore the significant value of palliative care integration and ACP in oncology, including but not limited to care at the end of life, with a particular focus on its relevance to patients with advanced pancreatic cancer.
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Affiliation(s)
- Rajiv Agarwal
- Department of Medicine, Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Andrew S Epstein
- Gastrointestinal Oncology Service, Palliative Medicine Service, Memorial Sloan Kettering Cancer Center, New York, USA.
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Tamirisa NP, Goodwin JS, Kandalam A, Linder SK, Weller S, Turrubiate S, Silva C, Riall TS. Patient and physician views of shared decision making in cancer. Health Expect 2017; 20:1248-1253. [PMID: 28464430 PMCID: PMC5689235 DOI: 10.1111/hex.12564] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2017] [Indexed: 12/14/2022] Open
Abstract
CONTEXT Engaging patients in shared decision making involves patient knowledge of treatment options and physician elicitation of patient preferences. OBJECTIVE Our aim was to explore patient and physician perceptions of shared decision making in clinical encounters for cancer care. DESIGN Patients and physicians were asked open-ended questions regarding their perceptions of shared decision making throughout their cancer care. Transcripts of interviews were coded and analysed for shared decision-making themes. SETTING AND PARTICIPANTS At an academic medical centre, 20 cancer patients with a range of cancer diagnoses, stages of cancer and time from diagnosis, and eight physicians involved in cancer care were individually interviewed. DISCUSSION AND CONCLUSIONS Most physicians reported providing patients with written information. However, most patients reported that written information was too detailed and felt that the physicians did not assess the level of information they wished to receive. Most patients wanted to play an active role in the treatment decision, but also wanted the physician's recommendation, such as what their physician would choose for him/herself or a family member in a similar situation. While physicians stated that they incorporated patient autonomy in decision making, most provided data without making treatment recommendations in the format preferred by most patients. We identified several communication gaps in cancer care. While patients want to be involved in the decision-making process, they also want physicians to provide evidence-based recommendations in the context of their individual preferences. However, physicians often are reluctant to provide a recommendation that will bias the patient.
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Affiliation(s)
- Nina P Tamirisa
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA.,The University of California, San Francisco-East Bay, Oakland, CA, USA
| | - James S Goodwin
- Sealy Center on Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Arti Kandalam
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - Suzanne K Linder
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - Susan Weller
- Department of Family Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Stella Turrubiate
- Department of Oncology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Colleen Silva
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - Taylor S Riall
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
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Roydhouse JK, Gutman R, Keating NL, Mor V, Wilson IB. Differences between Proxy and Patient Assessments of Cancer Care Experiences and Quality Ratings. Health Serv Res 2017; 53:919-943. [PMID: 28255988 DOI: 10.1111/1475-6773.12672] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the impact of proxy survey responses on cancer care experience reports and quality ratings. DATA SOURCES/STUDY SETTING Secondary analysis of data from Cancer Care Outcomes Research and Surveillance (CanCORS). Recruitment occurred from 2003 to 2005. STUDY DESIGN The study was a cross-sectional observational study. The respondents were patients with incident colorectal or lung cancer or their proxies. DATA COLLECTION/EXTRACTION METHODS Analyses used linear regression models with an independent variable for proxy versus patient responses as well as study site and clinical covariates. The outcomes were experiences with medical care, nursing care, care coordination, and care quality rating. Multiple imputation was used for missing data. PRINCIPAL FINDINGS Among 6,471 respondents, 1,011 (16 percent) were proxies. The proportion of proxy respondents varied from 6 percent to 28 percent across study sites. Adjusted proxy scores were modestly higher for medical care experiences (+1.28 points [95 percent CI:+ 0.05 to +2.51]), but lower for nursing care (-2.81 [95 percent CI: -4.11 to -1.50]) and care coordination experiences (-2.98 [95 percent CI: -4.15 to -1.81]). There were no significant differences between adjusted patient and proxy ratings of quality. CONCLUSIONS Proxy responses have small but statistically significant differences from patient responses. However, if ratings of care are used for financial incentives, such differences could be exaggerated across practices or areas if proxy use varies.
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Affiliation(s)
- Jessica K Roydhouse
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, 02912
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, RI
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, 02912
| | - Ira B Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, 02912
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Ren NSX, Ji M, Tokar EJ, Busch EL, Xu X, Lewis D, Li X, Jin A, Zhang Y, Wu WKK, Huang W, Li L, Fargo DC, Keku TO, Sandler RS, Li X. Haploinsufficiency of SIRT1 Enhances Glutamine Metabolism and Promotes Cancer Development. Curr Biol 2017; 27:483-494. [PMID: 28162896 DOI: 10.1016/j.cub.2016.12.047] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 10/31/2016] [Accepted: 12/20/2016] [Indexed: 01/05/2023]
Abstract
SIRT1, the most conserved mammalian NAD+-dependent protein deacetylase, plays a vital role in the regulation of metabolism, stress responses, and genome stability. However, the role of SIRT1 in the multi-step process leading to transformation and/or tumorigenesis, as either a tumor suppressor or tumor promoter, is complex and may be dependent upon the context in which SIRT1 activity is altered, and the role of SIRT1 in tumor metabolism is unknown. Here, we demonstrate that SIRT1 dose-dependently regulates cellular glutamine metabolism and apoptosis, which in turn differentially impact cell proliferation and cancer development. Heterozygous deletion of Sirt1 induces c-Myc expression, enhancing glutamine metabolism and subsequent proliferation, autophagy, stress resistance, and cancer formation. In contrast, homozygous deletion of Sirt1 triggers cellular apoptotic pathways, increases cell death, diminishes autophagy, and reduces cancer formation. Consistent with the observed dose dependence in cells, intestine-specific Sirt1 heterozygous mice have enhanced intestinal tumor formation, whereas intestine-specific Sirt1 homozygous knockout mice have reduced development of colon cancer. Furthermore, SIRT1 reduction, but not deletion, is associated with human colorectal tumors, and colorectal cancer patients with low protein expression of SIRT1 have a poor prognosis. Taken together, our findings indicate that the dose-dependent regulation of tumor metabolism and possibly apoptosis by SIRT1 mechanistically contribute to the observed dual roles of SIRT1 in tumorigenesis. Our study highlights the importance of maintenance of a suitable SIRT1 dosage for metabolic and tissue homeostasis, which will have important implications in SIRT1-small-molecule-activator/inhibitor-based therapeutic strategies for cancers.
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Affiliation(s)
- Natalie S X Ren
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
| | - Ming Ji
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
| | - Erik J Tokar
- Stem Cell Toxicology Group, National Toxicology Program, Research Triangle Park, NC 27709, USA
| | - Evan L Busch
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Xiaojiang Xu
- Integrative Bioinformatics Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
| | - DeAsia Lewis
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
| | - Xiangchun Li
- Department of Anaesthesia and Intensive Care, Institute of Digestive Disease and State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Aiwen Jin
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Yanping Zhang
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - William K K Wu
- Department of Anaesthesia and Intensive Care, Institute of Digestive Disease and State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Weichun Huang
- Biostatistics and Computational Biology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
| | - Leping Li
- Biostatistics and Computational Biology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
| | - David C Fargo
- Integrative Bioinformatics Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
| | - Temitope O Keku
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Robert S Sandler
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Xiaoling Li
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA.
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Sullivan DR, Forsberg CW, Ganzini L, Au DH, Gould MK, Provenzale D, Slatore CG. Longitudinal Changes in Depression Symptoms and Survival Among Patients With Lung Cancer: A National Cohort Assessment. J Clin Oncol 2016; 34:3984-3991. [PMID: 27996350 PMCID: PMC5477833 DOI: 10.1200/jco.2016.66.8459] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose Depression symptoms are common among patients with lung cancer; however, longitudinal changes and their impact on survival are understudied. Methods This was a prospective, observational study from the Cancer Care Outcomes Research and Surveillance Consortium from five US geographically defined regions from September 2003 through December 2005. Patients enrolled within 3 months of their lung cancer diagnosis were eligible. The eight-item Center for Epidemiologic Studies Depression scale was administered at diagnosis and 12 months' follow-up. The main outcome was survival, which was evaluated using Kaplan-Meyer curves and adjusted Cox proportional hazards modeling. Results Among 1,790 participants, 681 (38%) had depression symptoms at baseline and an additional 105 (14%) developed new-onset depression symptoms during treatment. At baseline, depression symptoms were associated with increased mortality (hazard ratio [HR], 1.17; 95% CI, 1.03 to 1.32; P = .01). Participants were classified into the following four groups based on longitudinal changes in depression symptoms from baseline to follow-up: never depression symptoms (n = 640), new-onset depression symptoms (n = 105), depression symptom remission (n = 156), and persistent depression symptoms (n = 254) and HRs were calculated. Using the never-depression symptoms group as a reference group, HRs were as follows: new-onset depression symptoms, 1.50 (95% CI, 1.12 to 2.01; P = .006); depression symptom remission, 1.02 (95% CI, 0.79 to 1.31; P = .89), and persistent depression symptoms, 1.42 (95% CI, 1.15 to 1.75; P = .001). At baseline, depression symptoms were associated with increased mortality among participants with early-stage disease (stages I and II; HR, 1.61; 95% CI, 1.26 to 2.04), but not late-stage disease (stages III and IV; HR, 1.05; 95% CI, 0.91 to 1.22). At follow-up, depression symptoms were associated with increased mortality among participants with early-stage disease (HR, 1.71; 95% CI, 1.27 to 2.31) and those with late-stage disease (HR, 1.32; 95% CI, 1.04 to 1.69). Conclusion Among patients with lung cancer, longitudinal changes in depression symptoms are associated with differences in mortality, particularly among patients with early-stage disease. Symptom remission is associated with a similar mortality rate as never having had depression.
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Affiliation(s)
- Donald R. Sullivan
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Christopher W. Forsberg
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Linda Ganzini
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - David H. Au
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Michael K. Gould
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Dawn Provenzale
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
| | - Christopher G. Slatore
- Donald R. Sullivan, Christopher G. Slatore, and Linda Ganzini, Oregon Health & Science University; Donald R. Sullivan, Christopher W. Forsberg, Linda Ganzini, and Christopher G. Slatore, Veterans Affairs Portland Health Care System, Portland, OR; David H. Au, Veterans Affairs Puget Sound Health Care System David H. Au, University of Washington, Seattle, WA; Michael K. Gould, Kaiser Permanente Southern California, Pasadena; Michael K. Gould, University of Southern California, Los Angeles, CA; Dawn Provenzale, Durham VA Medical Center; and Dawn Provenzale, Duke University, Durham, NC
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Litzelman K, Kent EE, Mollica M, Rowland JH. How Does Caregiver Well-Being Relate to Perceived Quality of Care in Patients With Cancer? Exploring Associations and Pathways. J Clin Oncol 2016; 34:3554-3561. [PMID: 27573657 PMCID: PMC5074348 DOI: 10.1200/jco.2016.67.3434] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Perceived quality of care (QOC) is an increasingly important metric of care quality and can be affected by such factors among patients with cancer as quality of life and physician trust. This study sought to evaluate whether informal caregiver well-being was also associated with perceived QOC among patients with cancer and assessed potential pathways that link these factors. Methods This study used data from the Cancer Care Outcomes Research and Surveillance (CanCORS) consortium. Patients with lung and colorectal cancer enrolled in CanCORS (N = 689) nominated an informal caregiver to participate in a caregiving survey. Both groups self-reported sociodemographic, psychosocial, and caregiving characteristics; cancer characteristics were obtained from the CanCORS core data set. Multivariable logistic regression was used to assess the association between caregiver psychosocial factors and subsequent patient-perceived QOC, controlling for earlier patient-perceived QOC and covariates. Secondary analysis examined potential pathways that link these factors. Results Patients whose informal caregiver had higher levels of depressive symptoms were significantly more likely to report fair or poor QOC (odds ratio, 1.06; 95% CI, 1.01 to 1.13). When caregivers reported fair or poor self-rated health, patients were more than three times more likely to report fair or poor perceived QOC (odds ratio, 3.76; 95% CI, 1.76 to 9.55). Controlling for patient psychosocial factors and physician communication and coordination of medical care reduced the effect size and/or statistical significance of these relationships. Conclusion Informal caregivers are an important part of the care team and their well-being is associated with patient-perceived QOC. Engaging informal cancer caregivers as part of the care team and conducting ongoing risk stratification screening and intervention to optimize their health may improve patient-reported outcomes and QOC.
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Affiliation(s)
- Kristin Litzelman
- Kristin Litzelman, University of Wisconsin-Madison and University of Wisconsin-Extension, Madison, WI; Erin E. Kent, Michelle Mollica, and Julia H. Rowland, National Cancer Institute, Bethesda, MD
| | - Erin E. Kent
- Kristin Litzelman, University of Wisconsin-Madison and University of Wisconsin-Extension, Madison, WI; Erin E. Kent, Michelle Mollica, and Julia H. Rowland, National Cancer Institute, Bethesda, MD
| | - Michelle Mollica
- Kristin Litzelman, University of Wisconsin-Madison and University of Wisconsin-Extension, Madison, WI; Erin E. Kent, Michelle Mollica, and Julia H. Rowland, National Cancer Institute, Bethesda, MD
| | - Julia H. Rowland
- Kristin Litzelman, University of Wisconsin-Madison and University of Wisconsin-Extension, Madison, WI; Erin E. Kent, Michelle Mollica, and Julia H. Rowland, National Cancer Institute, Bethesda, MD
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Sullivan DR, Forsberg CW, Ganzini L, Au DH, Gould MK, Provenzale D, Lyons KS, Slatore CG. Depression symptom trends and health domains among lung cancer patients in the CanCORS study. Lung Cancer 2016; 100:102-109. [PMID: 27597288 PMCID: PMC5015687 DOI: 10.1016/j.lungcan.2016.08.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 08/09/2016] [Accepted: 08/14/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Among lung cancer patients depression symptoms are common and impact outcomes. The aims of this study were to determine risk factors that contribute to persistent or new onset depression symptoms during lung cancer treatment, and examine interactions between depression symptoms and health domains that influence mortality. MATERIALS AND METHODS Prospective observational study in five healthcare systems and 15 Veterans Affairs medical centers. Patients in the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium with lung cancer were eligible. The 8-item Center for Epidemiologic Studies Depression (CES-D) scale was administered at baseline and follow-up. Scores ≥4 indicated elevated depressive symptoms. Health domains were measured using validated instruments. We applied logistic regression and Cox proportional hazards modeling to explore the association between depression symptoms, health domains, and mortality. RESULTS Of 1790 participants, 38% had depression symptoms at baseline and among those still alive, 31% at follow-up. Risk factors for depression symptoms at follow-up included younger age (OR=2.81), female sex (OR=1.59), low income (OR=1.45), not being married (OR=1.74) and current smoking status (OR=1.80); high school education was associated with reduced odds of depression symptoms at follow-up, compared with lesser educational attainment (OR=0.74) (all p values <0.05). Patients with depression symptoms had worse health-related quality of life, vitality, cancer-specific symptoms, and social support than patients without depression symptoms (all p<0.001). The association between depression symptoms and increased mortality is greater among patients with more lung cancer symptoms (p=0.008) or less social support (p=0.04). CONCLUSIONS Patient risk factors for depression symptoms at follow-up were identified and these subgroups should be targeted for enhanced surveillance. Patients with depression symptoms suffer across all health domains; however, only more lung cancer symptoms or less social support are associated with worse mortality among these patients. These potentially modifiable health domains suggest targets for possible intervention in future studies.
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Affiliation(s)
- D R Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, United States; Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, United States.
| | - C W Forsberg
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, United States
| | - L Ganzini
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, United States; Division of Geriatric Psychiatry, Department of Psychiatry, Oregon Health and Science University, Portland, OR, United States
| | - D H Au
- Health Services Research and Development Service, Veterans Affairs Puget Sound Health Care System, and Department of Medicine, University of Washington, Seattle, WA, United States
| | - M K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - D Provenzale
- VA Cooperative Studies Program Epidemiology Center-Durham, Durham VA Medical Center, and Duke University, Durham, NC, United States
| | - K S Lyons
- School of Nursing, Oregon Health and Science University, Portland, OR, United States
| | - C G Slatore
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, United States; Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, OR, United States; Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, OR, United States
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Patient-Reported Roles, Preferences, and Expectations Regarding Treatment of Stage I Rectal Cancer in the Cancer Care Outcomes Research and Surveillance Consortium. Dis Colon Rectum 2016; 59:907-15. [PMID: 27602921 PMCID: PMC5015654 DOI: 10.1097/dcr.0000000000000662] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Historically, stage I rectal cancer was treated with total mesorectal excision. However, there has been growing use of local excision, with and without adjuvant therapy, to treat these early rectal cancers. Little is known about how patients and providers choose among the various treatment approaches. OBJECTIVE The purpose of this study was to identify patient roles, preferences, and expectations as they relate to treatment decision making for patients with stage I rectal cancer. DESIGN This is a population-based study. SETTINGS The study included a geographically diverse population and health-system-based cohort. PATIENTS A total of 154 adults with newly diagnosed and surgically treated stage I rectal cancer between 2003 and 2005 were included. MAIN OUTCOME MEASURES We compared patients by surgical treatment groups, including total mesorectal excision and local excision. Clinical, sociodemographic, and health-system factors were assessed for association with patient decision-making preferences and expectations. RESULTS A total of 80% of patients who underwent total mesorectal excision versus 63% of patients who underwent local excision expected that surgery would be curative (p = 0.04). The total mesorectal excision group was less likely to report that radiation would cure their cancer compared with the local excision group (27% vs 63%; p = 0.004). When asked about their preferred role in decision making, 28% of patients who underwent total mesorectal excision preferred patient-controlled decision making compared with 48% of patients who underwent local excision (p = 0.046). However, with regard to the treatment actually received, 38% of the total mesorectal excision group reported making their own surgical decision compared with 25% of the local excision group (p = 0.18). LIMITATIONS The study was limited by its sample size. CONCLUSIONS The preferred decision-making role for patients did not match the actual decision-making process. Future efforts should focus on bridging the gap between the decision-making process and patient preferences regarding various treatment approaches. This will be particularly important as newer innovative procedures play a more prominent role in the rectal cancer treatment paradigm.
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Mack JW, Cronin AM, Kang TI. Decisional Regret Among Parents of Children With Cancer. J Clin Oncol 2016; 34:4023-4029. [PMID: 27621402 DOI: 10.1200/jco.2016.69.1634] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Decision making is one of the ways in which parents serve as stewards of their children with cancer, but barriers to informed decision making among parents of children with cancer have been identified. We sought to evaluate the extent to which parents feel satisfied with, or regretful of, decisions made for their child's cancer treatment and to identify factors associated with heightened regret. Methods We surveyed 346 parents of children with cancer within 12 weeks of their initial cancer treatment decision and the children's physicians at Dana-Farber Cancer Institute/Boston Children's Hospital and the Children's Hospital of Philadelphia. Our main outcome measure was heightened regret as measured by the Decisional Regret Scale. Results Sixteen percent of parents (N = 54) met our definition of heightened decisional regret. In a multivariable logistic regression model, race/ethnicity was associated with regret, with black (odds ratio [OR], 6.55; 95% CI, 2.30 to 18.7), Hispanic (OR, 2.15; 95% CI, .69 to 6.65), and other race parents (OR, 4.68; 95% CI, 1.58 to 13.8) at increased risk for regret relative to whites ( P = .001 across all categories). In contrast, parents who reported receiving high-quality information (OR, .45; 95% CI, .23 to .91; P = .03) and detailed prognostic information (OR, .48; 95% CI, .24 to .96; P = .04), who trusted the oncologist completely (OR, .32; 95% CI, .17 to .63; P = .001), and who held their ideal role in decision making (OR, .49; 95% CI, .25 to .95; P = .04) were less likely to experience regret. Conclusion Although many parents are satisfied with decisions made for their children with cancer, racial and ethnic minority parents are at heightened risk for regret. Clinicians may be able to reduce this risk by providing high-quality information, including prognostic information, involving parents in decision making in the ways they wish, and serving as trusted providers.
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Affiliation(s)
- Jennifer W Mack
- Jennifer W. Mack and Angel M. Cronin, Dana-Farber Cancer Institute; Jennifer W. Mack, Boston Children's Hospital, Boston, MA; and Tammy I. Kang, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Angel M Cronin
- Jennifer W. Mack and Angel M. Cronin, Dana-Farber Cancer Institute; Jennifer W. Mack, Boston Children's Hospital, Boston, MA; and Tammy I. Kang, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tammy I Kang
- Jennifer W. Mack and Angel M. Cronin, Dana-Farber Cancer Institute; Jennifer W. Mack, Boston Children's Hospital, Boston, MA; and Tammy I. Kang, Children's Hospital of Philadelphia, Philadelphia, PA
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Mack JW, Cronin A, Fasciano K, Block SD, Keating NL. Cancer treatment decision-making among young adults with lung and colorectal cancer: a comparison with adults in middle age. Psychooncology 2016; 25:1085-91. [PMID: 26335435 PMCID: PMC4775442 DOI: 10.1002/pon.3949] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 06/10/2015] [Accepted: 08/05/2015] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Our aim is to understand experiences with treatment decision-making among young adults with cancer. METHODS We studied patients with lung cancer or colorectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium, a prospective cohort study. We identified 148 young adult patients aged 21-40 years who completed baseline interview questions about cancer treatment decision-making; each was propensity score matched to three middle adult patients aged 41-60 years, for a cohort of 592 patients. Patients were asked about decision-making preferences, family involvement in decision-making, and worries about treatment. An ordinal logistic regression model evaluated factors associated with more treatment worries. RESULTS Young and middle-aged adults reported similar decision-making preferences (p = 0.80) and roles relative to physicians (p = 0.36). Although family involvement was similar in the age groups (p = 0.21), young adults were more likely to have dependent children in the home (60% younger versus 28% middle-aged adults, p < 0.001). Young adults reported more worries about time away from family (p = 0.002), and, in unadjusted analyses, more cancer treatment-related worries (mean number of responses of 'somewhat' or 'very' worried 2.5 for younger versus 2.2 for middle-aged adults, p = 0.02.) However, in adjusted analyses, worries were associated with the presence of dependent children in the home (odds ratio [OR] 1.55, 95% CI = 1.07-2.24, p = 0.02), rather than age. CONCLUSIONS Young adults involve doctors and family members in decisions at rates similar to middle-aged adults but experience more worries about time away from family. Patients with dependent children are especially likely to experience worries. Treatment decision-making strategies should be based on individual preferences and needs rather than age alone. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Angel Cronin
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Karen Fasciano
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
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