Employment implications of informal cancer caregiving

Health-Related Quality of Life in Danish Cancer Survivors Referred to a Late Effects Clinic: A Prospective Cohort Study

PURPOSE

The Region of Southern Denmark has recently established four late effects clinics to help cancer survivors suffering from complex and severe late effects. This study aimed to capture and analyze the full range of physical, mental, and psychosocial issues using patient-reported outcomes. Moreover, we aimed to describe demographic data and the type and severity of the late effects.

METHODS

A prospective cohort study was conducted among cancer survivors referred to a late effects clinic. Before their first appointment, patients completed the European Organization for Research and Treatment of Cancer Quality of Life cancer survivorship core questionnaire (EORTC QLQ-SURV100). We compared mean scores of the EORTC QLQ-SURV100 scales that were comparable to the scales/items from the EORTC QLQ-C30 questionnaire with norm data for the Danish population and EORTC reference values.

RESULTS

All patients referred to the clinic within its first 2 years were included (n = 247). The mean age was 57 [23-85] years and 74% were females. The most common cancer diagnoses was breast cancer (39%). The five most commonly reported late effects were fatigue (66%), pain (51%), cognitive impairment (53%), sleep problems (42%), and neuropathy (40%). A total of 236 of the patients entering the clinic completed QLQ-SURV100. They reported significantly worse mean scores on all scales compared to the Danish norm population and EORTC reference values for pretreatment cancer patients, p < 0.001. Effect sizes were moderate or large for all scales.

INTERPRETATION

In this study, we collected demographic data and described the late effects presented by the patents referred to the clinic. Moreover, we captured and analyzed the full range of physical, mental, and psychosocial issues using QLQ-SURV100. Patients referred to the Late Effects Clinic (LEC) had a number of late effects and reported a significantly lower health-related quality of life compared to the general Danish population and patients who have just been diagnosed with cancer, suggesting the aim of helping patients suffering from late effects gain a better quality of life is in dire need.

Caregiver costs and financial burden in caregivers of African American cancer survivors

PURPOSE

People with cancer commonly rely on loved ones as informal caregivers during and after treatment. Costs related to caregiving and their association with caregiver financial burden are not well understood.

METHODS

Results include data from 964 caregivers of African American cancer survivors in the Detroit Research on Cancer Survivors (ROCS) cohort. Caregiving costs include those related to medications, logistics (e.g., transportation), and medical bills. Financial burden measures included caregiver financial resources, strain, and difficulty paying caregiving costs. Prevalence ratios (PR) and 95% confidence intervals (CI) of associations between costs and high financial burden were calculated using modified Poisson models controlling for caregiver characteristics.

RESULTS

Caregivers included spouses (36%), non-married partners (8%), family members (48%), and friends (9%). Nearly two-thirds (64%) of caregivers reported costs related to caregiving. Logistical costs were the most common (58%), followed by medication costs (35%) and medical bills (17%). High financial hardship was reported by 38% of caregivers. Prevalence of high financial hardship was 52% (95% CI: 24%, 86%) higher among caregivers who reported any versus no caregiver costs. Associations between caregiver costs and high financial burden were evident for costs related to medications (PR: 1.33, 95% CI: 1.12, 1.58), logistics (PR: 1.57, 95% CI: 1.29, 1.92), and medical bills (PR: 1.57, 95% CI: 1.28, 1.92).

CONCLUSIONS

Most caregivers experienced costs related to caregiving, and these costs were associated with higher prevalence of high caregiver financial burden.

IMPLICATIONS FOR CANCER SURVIVORS

Informal caregivers experience financial hardship related to cancer along with cancer survivors.

A proactive financial navigation intervention in patients with newly diagnosed gastric and gastroesophageal junction adenocarcinoma

PURPOSE

Many cancer patients and caregivers experience financial hardship, leading to poor outcomes. Gastric and gastroesophageal junction (GEJ) cancer patients are particularly at risk for financial hardship given the intensity of treatment. This pilot randomized study among gastric/GEJ cancer patients and caregivers tested a proactive financial navigation (FN) intervention to obtain a signal of efficacy to inform a larger, more rigorous randomized study.

METHODS

We tested a 3-month proactive FN intervention among gastric/GEJ cancer patients and caregivers compared to usual care. Caregiver participation was optional. The primary endpoint was incidence of financial hardship, defined as follows: accrual of debt, income decline of ≥ 20%, or taking loans to pay for treatment. Data from participant surveys and documentation by partner organizations delivering the FN intervention was analyzed and outcomes were compared between study arms.

RESULTS

Nineteen patients and 12 caregivers consented. Primary FN resources provided included insurance navigation, budget planning, and help with out-of-pocket medical expenses. Usual care patients were more likely to experience financial hardship (50% vs 40%) and declines in quality of life (37.5% vs 0%) compared to intervention patients. Caregivers in both arms reported increased financial stress and poorer quality of life over the study period.

CONCLUSIONS

Proactive financial navigation has potentially positive impacts on financial hardship and quality of life for cancer patients and more large-scale randomized interventions should be conducted to rigorously explore the impact of similar interventions. Interventions that have the potential to lessen caregiver financial stress and burden need further exploration.

TRIAL REGISTRATION

TRN: NCT03986502, June 14, 2019.

Comprehensive needs, social support, and disease perception in lung cancer patients treated with immune checkpoint inhibitors: a cross-sectional study

PURPOSE

The aim of this study was to investigate the comprehensive needs of lung cancer patients treated with immune checkpoint inhibitors and to explore the relationships between comprehensive needs and social support and disease perception, moreover, to analyse associated factors of comprehensive needs.

METHODS

The study was conducted in a teaching hospital in Jiaxing Province, China. A total of 141 patients with lung cancer completed a battery of self-report questionnaires, including the Comprehensive Needs Assessment Tool in Cancer for Patients (CNAT), Social Supportive Rating Scale (SSRS), Brief Illness Perception Questionnaire (BIPQ), and demographic and clinical characteristics questionnaire.

RESULTS

The level of comprehensive needs was highest in the domain "medical demand" (42.17 ± 26.57), and the item with the highest level of comprehensive needs was "I need information about the financial support for my medical expenses" (2.00 ± 1.07). Statistically significant correlations were identified between the comprehensive needs score, social support, and disease perception. The multiple regression analysis showed that immunotherapy course, whether irAEs occur, social support, and disease perception were factors influencing patients' comprehensive needs.

CONCLUSIONS

The most prevalent needs in lung cancer patients were found in the "medical needs" domain. Additionally, immunotherapy course, whether irAEs occur, disease perception, and social support were associated with comprehensive needs among lung cancer patients. It is essential to combine the associated factors to accurately evaluate patient needs. We should pay more attention to proposing the comprehensive measures for these patients and providing more individualized supportive care during the lengthy treatment period.

Experiences of financial toxicity among caregivers of cancer patients: a meta-synthesis of qualitative studies

OBJECTIVES

The purpose of this study was to explore the experience of financial toxicity among caregivers of cancer patients and to provide recommendations for subsequent intervention strategies.

METHODS

Computer searches of PubMed, EmBase, The Cochrane Library, Web of Science, CINAHL (EBSCO), CNKI, Wanfang database, and SinoMed for qualitative studies experience of financial toxicity among caregivers cancer patients. The search time frame was from the establishment of the database to May 2023. The quality of included studies was assessed using the Qualitative Research Checklist from the Joanna Briggs Institute (JBI) Reviewer's Manual. The meta-synthesis was integrated following the meta-aggregation method proposed by the Joanna Briggs Institute (JBI) and reported following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines.

RESULTS

A total of nine studies were included, distilling 25 qualitative findings into nine new categories and synthesizing three synthesized findings: caregivers have strong negative experiences that affect their family relationships, daily work and life; caregivers use different strategies to cope with financial toxicity; needs and expectations of caregivers coping with financial toxicity.

CONCLUSIONS

Financial toxicity among caregivers of cancer patients affects their daily lives. Receiving timely recognition of this financial burden and providing assistance to enhance their coping skills are crucial in mitigating its impact. Healthcare professionals should focus on the financial toxicity experienced by caregivers of people with cancer, address their supportive needs, and develop a comprehensive support system to improve caregivers' coping abilities and quality of life.

Parental, caregiving, and family leave during clinical neuropsychology postdoctoral training: Recommendations and guidelines from the Women in Neuropsychology (WIN) committee and Education Advisory Committee (EAC) of the Society for Clinical Neuropsychology (SCN; APA division 40)

Objective: Parental and other caregiving leave is important to postdoctoral fellows, yet there is no field-wide recommendation for leave policies among clinical neuropsychology postdoctoral training programs, which is of particular relevance given the two-year requirement for eligibility for board certification. The aims of this manuscript are to (a) discuss general guidelines and recommendations for leave policies, both informed by prior empirical evidence as well as relevant existing policy guidelines from various academic and healthcare organizations, and (b) use vignettes to provide possible solutions for potential leave scenarios. Method: A critical review of literature on family leave from public policy and political science, industrial-organizational psychology, academic medicine, and psychology was conducted and findings were synthesized. Results and Conclusions: Fellowship training programs are encouraged to adopt a competency-based model that permits flexibility in leave during training without necessarily requiring an extended end date. Programs should adopt clear policies and make this information readily available to trainees and think flexibly about training options that best meet the training needs and goals of each individual. We also encourage neuropsychologists at all levels to engage in advocacy for broader systemic supports of trainees seeking equitable family leave.

Economic costs of family caregiving for persons with advanced stage cancer: a longitudinal cohort study

PURPOSE

To form a multifaceted picture of family caregiver economic costs in advanced cancer.

METHODS

A multi-site cohort study collected prospective longitudinal data from caregivers of patients with advanced solid tumor cancers. Caregiver survey and out-of-pocket (OOP) receipt data were collected biweekly in-person for up to 24 weeks. Economic cost measures attributed to caregiving were as follows: amount of OOP costs, debt accrual, perceived economic situation, and working for pay. Descriptive analysis illustrates economic outcomes over time. Generalized linear mixed effects models asses the association of objective burden and economic outcomes, controlling for subjective burden and other factors. Objective burden is number of activities and instrumental activities of daily living (ADL/IADL) tasks, all caregiving tasks, and amount of time spent caregiving over 24 h.

RESULTS

One hundred ninety-eight caregivers, 41% identifying as Black, were followed for a mean period of 16 weeks. Median 2-week out-of-pocket costs were $111. One-third of caregivers incurred debt to care for the patient and 24% reported being in an adverse economic situation. Whereas 49.5% reported working at study visit 1, 28.6% of caregivers at the last study visit reported working. In adjusted analysis, a higher number of caregiving tasks overall and ADL/IADL tasks specifically were associated with lower out-of-pocket expenses, a lower likelihood of working, and a higher likelihood of incurring debt and reporting an adverse economic situation.

CONCLUSIONS

Most caregivers of cancer patients with advanced stage disease experienced direct and indirect economic costs.

IMPLICATIONS FOR CANCER SURVIVORS

Results support the need to find solutions to lessen economic costs for caregivers of persons with advanced cancer.

Financial toxicity of oral therapies in advanced prostate cancer

The treatment landscape of advanced prostate cancer (CaP) has evolved significantly over the past 20 years. As the number of oral anticancer treatment options continues to increase, so do the costs of these drugs. Furthermore, payment responsibility for these treatments is increasingly shifted from insurers to patients. In this narrative review, we sought to summarize existing assessments of financial toxicity (FT) associated with oral advanced CaP treatments, describe efforts targeted at limiting FT from these agents, and identify areas in need of further investigation. FT is understudied in advanced CaP. Oral treatment options are associated with significantly higher direct costs to patients compared to standard androgen deprivation therapy or chemotherapy. Financial assistance programs, Medicare low-income subsidies, and recent health policy changes help offset these costs for some patients. Physicians are reluctant to discuss treatment costs with patients and further work is needed to better understand best practices for inclusion of FT discussions in shared decision-making. Oral therapies for advanced CaP are associated with significantly higher patient out-of-pocket costs which may contribute to FT. Currently, little is known regarding the extent and severity of these costs on patients' lives. While recent policy changes have helped reduce these costs for some patients, more work is needed to better characterize FT in this population to inform interventions that improve access to care and lessen the harms associated with the cost of novel treatments.

Assessment of financial screening and navigation capabilities at National Cancer Institute community oncology clinics

BACKGROUND

Cancer-related financial hardship is a side effect of cancer diagnosis and treatment, and affects both patients and caregivers. Although many oncology clinics have increased financial navigation services, few have resources to proactively provide financial counseling and assistance to families affected by cancer before financial hardship occurs. As part of an ongoing randomized study testing a proactive financial navigation intervention, S1912CD, among sites of the National Cancer Institute Community Oncology Research Program (NCORP), we conducted a baseline survey to learn more about existing financial resources available to patients and caregivers.

METHODS

The NCORP sites participating in the S1912CD study completed a required 10-question survey about their available financial resources and an optional 5-question survey that focused on financial screening and navigation workflow and challenges prior to starting recruitment. The proportion of NCORP sites offering financial navigation services was calculated and responses to the optional survey were reviewed to determine current screening and navigation practices and identify any challenges.

RESULTS

Most sites (96%) reported offering financial navigation for cancer patients. Sites primarily identified patients needing financial assistance through social work evaluations (78%) or distress screening tools (76%). Sites revealed challenges in addressing financial needs at the outset and through diagnosis, including lack of proactive screening and referral to financial navigation services as well as staffing challenges.

CONCLUSIONS

Although most participating NCORP sites offer some form of financial assistance, the survey data enabled identification of gaps and challenges in providing services. Utilizing community partners to deliver comprehensive financial navigation guidance to cancer patients and caregivers may help meet needs while reducing site burden.

Nature-Based Virtual Reality Feasibility and Acceptability Pilot for Caregiver Respite

Home-based informal caregivers (CGs), such as the family members and friends of cancer patients, often suffer averse emotional symptoms, such as anxiety and depression, due to the burden associated with providing care. The natural environment has been valued as a healing sanctuary for easing emotional pain, promoting calmness, relaxation, and restoration. The use of virtual reality (VR) nature experiences offers an alternative option to CGs to manage emotional symptoms and improve their quality of life. The aim of this mixed-method pilot was to evaluate the feasibility and acceptability of a nature-based VR experience for home-based CGs. Nine informal CGs participated in a 10 min nature-based VR session and completed feasibility, acceptability, and VR symptom measures in the laboratory. Semi-structured interviews with five of the CGs provided qualitative data regarding their experiences with VR. The CGs (mean age 64.78 years) were mostly female (n = 7). Our analysis showed high feasibility (15.11 ± 1.76; range 0-16) and acceptability (15.44 ± 1.33; range 0-16), as well as low VR Symptoms (1.56 ± 1.33; range 0-27). Participants primarily expressed positive perceptions regarding VR feasibility and acceptability during interviews. Our findings show promise for the use of VR nature experiences. In the next phase of the study, the intervention will be tested on home-based informal CGs of patients at end of life.

Parental Cancer History and Its Association With Minor Children's Unmet Food, Housing, and Transportation Economic Needs

Importance

A cancer diagnosis is associated with substantial economic burden for patients and their families. Young adult cancer survivors with dependent children may be particularly vulnerable to financial hardship.

Objective

To examine associations of parental cancer with their children's unmet economic needs.

Design, Setting, and Participants

This cross-sectional study used data from the nationally representative 2013 to 2018 US National Health Interview Survey. Children aged 5 to 17 years living in families with and without parental cancer history were queried about recent 1-year experiences. Statistical analyses were conducted from January 2022 to April 2023.

Exposure

Parental cancer history.

Main Outcomes and Measures

The main outcomes were children's unmet economic needs, including family-level food insecurity, parent's financial worry about paying for monthly bills and housing costs, and delayed child medical care owing to lack of transportation. Multivariable logistic regressions adjusted for (1) child's characteristics (ie, age group, sex, and race and ethnicity), (2) parent's characteristics (ie, age group, sex, health insurance coverage, comorbid conditions, and obesity status), and (3) family's characteristics (ie, family structure [married or cohabiting parents vs single parent families], highest educational attainment in the family, and family income). Additional analyses focused on children with a parental cancer history to identify potentially modifiable characteristics associated with unmet economic needs.

Results

In this cross-sectional study of 22 941 children with (812 children; weighted number, 860 488 children) and without (22 129 children; weighted number, 24 545 463 children) a parental cancer history, the majority of children were aged 5 to 11 years (12 022 children [52.4%]), male (11 920 children [52.0%]), and non-Hispanic White (11 863 children [51.7%]). In adjusted analyses, parental cancer history was associated with more severe family-level food insecurity, including worrying about food running out (odds ratio [OR], 1.97; 95% CI, 1.56-2.49; P < .001), food not lasting (OR, 2.01; 95% CI, 1.56-2.58; P < .001), and inability to afford balanced meals (OR, 1.38; 95% CI, 1.06-1.79; P = .02). Moreover, parental cancer history was associated with parent's worry about paying monthly bills (OR, 1.41; 95% CI, 1.15-1.74; P = .001) and housing-related costs (OR, 1.31; 95% CI, 1.07-1.60; P = .009) and delays in child medical care because of lack of transportation (OR, 2.31; 95% CI, 1.49-3.59; P < .001). Among children with parental cancer history, female children, non-Hispanic Black children, children whose parents had multiple comorbidities, and children living in low-income families were especially vulnerable to unmet economic needs.

Conclusions and Relevance

Parental cancer is associated with greater likelihood of food insecurity, unaffordability of housing and other necessities, and transportation barriers to medical care for minor children. Strategies to identify such children and address their needs are warranted.

Assessing impact, needs and quality-of-life among informal carers of people with pancreatic cancer, a prospective study: the PAN-CARER study protocol

INTRODUCTION

Approximately 10 300 people are diagnosed with pancreatic cancer each year in the UK. The cancer and its treatment inflict a significant physical, functional and emotional burden on patients. Research suggests that patients have many ongoing needs for support and care, but that these needs are not met by existing services. Family members often step in to fill this gap and provide support and care during and after treatment. Research in other cancers shows that this informal caregiving can place a very heavy burden on carers. However, there are few studies in the international literature that have focused on informal carers in pancreatic cancer; none have been conducted in the UK.

METHODS AND ANALYSIS

Two complementary research methods will be utilised. First, a longitudinal quantitative study of 300 carers investigating, using validated questionnaires to assess the impact of caregiving (Caregiver Reaction Assessment), the unmet needs of carers (Supportive Care Needs Survey) and the quality-of-life (Short Form 12-item health survey), will be conducted. Second, qualitative interviews will be conducted with up to 30 carers to explore their experiences in more depth. Mixed-effects regression models will be applied to survey results to determine how impact, needs and quality-of-life vary over time, compare outcomes between carers of patients with operable and inoperable disease and identify social factors which affect outcomes. Interview data will undergo reflexive thematic analysis.

ETHICS AND DISSEMINATION

The protocol has been approved by the Health Research Authority of the UK (Ethical approval IRAS ID 309503). Findings will be published in peer-reviewed journals and presented at national and international conferences.

Perceptions and Experiences of Informal Caregivers of Breast Cancer Patients in South India: A Qualitative Study

BACKGROUND

This study was conducted to explore the prevailing perceptions and experiences of caregiving burden among informal caregivers of women living with breast cancer in South India.

METHODS

In-depth interviews were conducted among breast cancer care-receivers (n=35) and their informal caregivers (n=39) and a thematic analysis was used to analyze the data. Informal caregiver in the context of this study was defined as one who takes up the responsibility of an informal caregiving role, and were either self-identified or acknowledged by the care-receivers.

RESULTS

Four main inductive themes in the domains of: emotional culpability, financial and workplace liability, psychosocial affliction, physical strain and health system demand were identified, that were associated with caregiver burden.

CONCLUSION

Informal caregivers form an integral part of the cancer care continuum in India. It is recommended to factor in the identified themes while developing a caregiver needs assessment model in the context of caring for breast cancer patients in the Indian setting.

A prospective study of psychological distress among patients with advanced cancer and their caregivers

BACKGROUND

Cancer can impact the psychological well-being of both patients and their informal caregivers. We investigated the joint trajectories of psychological distress among Singaporean advanced cancer patients-caregiver dyads. We also examined predictors of trajectory group membership.

METHODS

This study utilised data from 299 patients with advanced solid cancer and their caregivers over 33 months (12 times points). Group-based trajectory modelling was used to examine the joint trajectories of patient anxiety, patient depression, caregiver anxiety and caregiver depression scores using the Hospital Anxiety and Depression Scale.

RESULTS

Four joint trajectory groups were found: (1) Patient-caregiver low distress (27%), (2) patient-caregiver increasing distress (28.5%), (3) patient low- caregiver borderline distress (25%), (4) patient-caregiver high distress (19.5%). Dyads where the patient is below 50 years of age were more likely to be in Group 4. Dyads where caregiver-patient emotional closeness was low were more likely to be in Groups 2 or 4 where dyads reported increasing/high distress. Dyads that reported financial inadequacy were more likely to be in Groups 2, 3 and 4, while dyads with caregivers who were employed were more likely to be in group 3.

CONCLUSIONS

A substantial proportion of patients and caregivers reported anxiety and/or depression that lasted or increased throughout the study duration. We found significant heterogeneity in how dyads experienced psychological distress, suggesting that efforts should consider dyadic differences when providing psychological support. Particular focus should be placed on identifying dyads that are at risk and who require additional support.

The Burden of a Multiple Myeloma Diagnosis on Patients and Caregivers in the First Year: Western European Findings

Background

This research aimed to quantify the burden of illness (BoI) in transplant eligible (TE) and transplant non-eligible (TNE) newly diagnosed multiple myeloma (NDMM) patients and their caregivers, in the first year after diagnosis: at months 0, 3, and 12.

Methods

Prospective, cross-sectional, observational NDMM study of TE and TNE patients and their caregivers from France, Germany, Italy, and Spain was conducted between May 2019 and January 2021. A structured, online questionnaire measuring disease burden, direct and costs, out-of-pocket expenses, and health-related quality of life (HRQoL) was used. Descriptive statistics were performed.

Results

A total of 164, 160, and 190 NDMM patients [>65 years; self-described healthy; not working; living with caregiver] answered at months 0, 3, and 12. Patients lost independence to perform daily activities; mean pain intensity rose and opioid utilization increased, more significantly among TNE patients. Overall health status and HRQoL remained stable. Median 3-month direct medical costs peaked at month 3. Specialist consultations and hospital admissions were the greatest cost amongst TE and TNE patients. Home adaptations increased out-of-pocket expenditures amongst TNE patients. Patients describing themselves as working spent a median 0 hours in the office at all time points. A total of 131, 122, and 124 caregivers answered at months 0, 3, and 12. Mean self-rated burden score rose. By month 12, half of caregivers developed stress, anxiety or depression. Most employed caregivers continued working. Productivity was low at month 0 with a trend of recovering at month 12. Caregivers of TNE compared to TE patients reported greater time burden. Caregivers' HRQoL was stable over time.

Conclusion

NDMM is burdensome for patients and caregivers in the first year after diagnosis. TNE patients are more dependent on caregivers and incur higher care costs than TE patients. Despite the financial, physical, and emotional burden, HRQoL remains stable possibly indicating resilience and illness adjustment amongst patients and caregivers.

Productivity Loss and Indirect Costs for Patients Newly Diagnosed with Early- versus Late-Stage Cancer in the USA: A Large-Scale Observational Research Study

BACKGROUND

The total economic burden of cancer reflects direct and indirect costs, including productivity loss due to employment change, absenteeism, and presenteeism of patients and caregivers.

OBJECTIVE

This study estimated the magnitude of employment decrease, work absence (WA), short-term disability (STD), long-term disability (LTD), and associated indirect costs among employees newly diagnosed with metastatic versus non-metastatic cancer in the USA.

METHODS

IBM® MarketScan® Commercial Claims and Encounters and Health and Productivity Management databases were used to identify employees aged 18-64 years and newly diagnosed with any cancer from 2009 to 2019. Proportions of patients with employment decrease, WA, STD, and LTD claims, and number of days missing from work were summarized by metastatic status during the first 12 months after diagnosis and the entire follow-up period. Subgroup analyses were conducted by age (< 50 years, ≥ 50 years) and cancer type (breast, lung, colon, pancreatic, and liver cancer).

RESULTS

During the first year after diagnosis, compared to patients without metastases, significantly higher proportions of patients with metastases had employment decrease and STD or LTD claims (p < 0.001). The mean total number of days missing from work for patients with versus without metastases was 33.39 versus 14.91 (ratio = 2.40), 64.05 versus 27.15 (ratio = 2.36), and 105.93 versus 46.29 (ratio = 2.29) days within 3, 6, and 12 months after diagnosis, respectively. Estimates of indirect cost differences between the two groups ranged from $6,877 to $22,283 in the first year.

CONCLUSION

Earlier detection of cancer may reduce productivity loss of patients and indirect costs by initiating treatment before cancer progresses to late stage.

Navigating job and cancer demands during treatment: A qualitative study of ovarian cancer patients

OBJECTIVE

Our objective was to obtain perspectives from ovarian cancer patients on job demands, cancer demands, and workplace or cancer resources and strategies to manage the cancer-work interface using the cancer-work management conceptual framework.

METHODS

We recruited ovarian cancer patients receiving systemic therapy who screened positive for financial distress using Comprehensive Score for Financial Toxicity <26. Interviews were conducted with participants about their costs of care, including employment concerns. Interviews were recorded, transcribed verbatim, and analyzed by three researchers using an inductive thematic analysis.

RESULTS

Of 22 participants, the average age was 57 years old, 36% were Black, 68% had income <$40,000, 41% had public insurance, and 68% were being treated for recurrent disease. Job demands included decreased productivity, inability to return to work, and worry about losing a job or employer-based health insurance coverage. Cancer demands included physical and cognitive limitations due to cancer treatment and reliance on caregivers, especially for transportation. Workplace resources/strategies including having a supportive employer, modifying job responsibilities, and utilizing family medical leave. Cancer care resources/strategies included planning appointments ahead of time and utilizing resources, such as disability.

CONCLUSIONS

Cancer care teams should consider screening patients for employment concerns; streamline care to minimize the side effects, time, and transportation demands of treatment on patients and caregivers; maximize utilization of available resources; and proactively communicate with employers to accommodate patients and caregivers who want or need to work.

Use of scheduled and unscheduled health services by cancer survivors and their caregivers

PURPOSE

The purpose was to determine predictors of scheduled and unscheduled health services use by cancer survivors undergoing treatment and their informal caregivers.

METHODS

English- or Spanish-speaking adult cancer survivors undergoing chemotherapy or targeted therapy for a solid tumor cancer identified a caregiver (N = 380 dyads). Health services use over 2 months was self-reported by survivors and caregivers. Logistic regression models were used to relate the likelihood of service use (hospitalizations, emergency department [ED] or urgent care visits, primary care, specialty care) to social determinants of health (age, sex, ethnicity, level of education, availability of health insurance), and number of comorbid conditions. Co-habitation with the other member of the dyad and other member's health services use were considered as additional explanatory variables.

RESULTS

Number of comorbid conditions was predictive of the likelihood of scheduled health services use, both primary care and specialty care among caregivers, and primary care among survivors. Greater probability of specialty care use was associated with a higher level of education among survivors. Younger age and availability of health insurance were associated with greater unscheduled health services use (hospitalizations among survivors and urgent care or ED visits among caregivers). Unscheduled health services use of one member of the dyad was predictive of use by the other.

CONCLUSIONS

These findings inform efforts to optimize health care use by encouraging greater use of scheduled and less use of unscheduled health services. These educational efforts need to be directed especially at younger survivors and caregivers.

Balancing Work and Cancer Care: Challenges Faced by Employed Informal Caregivers

Simple Summary

Caregiving for a family member or close friend with cancer can be particularly demanding for employed individuals who are juggling work responsibilities while providing care. With an eye toward stimulating research to develop programs and resources to support this vulnerable subgroup of caregivers, this narrative review first describes the financial, work, and mental health impacts of cancer on employed caregivers. Next, critical knowledge gaps are identified and directions for future research are described. The article concludes by formulating an agenda for practice that includes a multipronged effort on behalf of employers, healthcare, and community-based organizations to support and empower employed cancer caregivers.

Abstract

Individuals with cancer commonly rely on their informal caregivers (e.g., spouse/partner, family member, close friend) to help them manage the demands of the disease and its treatment. Caregiving, including helping with patient care, performing household chores, and providing emotional and practical support, can be particularly demanding for employed caregivers, who must juggle their work responsibilities while providing care. Although a burgeoning literature describes the toll that balancing these oft-competing demands can exact, few resources exist to support employed cancer caregivers. To address this gap, we conducted a narrative review of the impacts of cancer on employed caregivers. We found that employed caregivers experience significant financial impacts in terms of lost time and income. They also experience a variety of work-related (e.g., reduced productivity, absenteeism) and mental health (e.g., stress, burden) impacts. Going forward, prospective studies are needed to characterize changes in caregiver support needs and preferences at different time points along the cancer care continuum (e.g., at diagnosis, during treatment, end-of-life) so that appropriate workplace accommodations can be provided. More population-based studies are also needed to develop models for identifying caregivers who are at increased risk for poor employment or mental health outcomes so that more targeted support programs can be developed. Ultimately, a multipronged effort on behalf of employers, healthcare, and community-based organizations may be needed to support and empower this vulnerable subgroup.

Cancer Survivorship and Supportive Care Economics Research: Current Challenges and Next Steps

BACKGROUND

Rapid growth in the number of cancer survivors raises numerous questions about health and economic outcomes among survivors along with their families, caregivers, and employers. Health economics theory and methods can contribute to many open questions to improve survivorship.

METHODS

In this paper, we review key areas where more research is needed and describe strategies for improving data infrastructure, research funding, and capacity building to strengthen survivorship health economics research.

CONCLUSIONS

Health economics has broadened an understanding of key supply- and demand-side factors that promote cancer survivorship. To ensure necessary research in survivorship health economics moving forward, we recommend dedicated funding, inclusion of health economics outcomes in primary data collection, and investments in secondary data sets.

The cost of caring: How advanced cancer patients affect Caregiver's employment in Singapore

BACKGROUND

With ageing populations and rising cancer incidence, more people are becoming informal caregivers. Informal caregivers are less likely to work than non-caregivers, yet little is known about how their employment changes over time. This study aimed to examine the association between decline in cancer patient's health (termed health shock) and caregiver's employment. A secondary aim was to assess characteristics of caregivers who stayed employed despite the health shock and the burden of caring for advanced stage cancer patients.

METHOD

This study used data from 270 dyads of advanced cancer patients and their caregivers who participated in the Cost of Medical Care of Patients with Advanced Serious Illness in Singapore study. The dyads were interviewed every 3 months for 2 years. Fixed-effects regression was used to analyse the association between patient health shock and two caregiver employment outcomes (i.e., employment status and work disruptions).

RESULTS

Ninety-seven% of caregivers whose patient experienced a health shock reported work disruptions. About 13% of caregivers whose patient experienced at least one health shock left employment, compared to 5% of those whose patient did not experience any health shock. Following a patient health shock, caregivers were significantly less likely to be employed (β: -0.03; 95% CI, -0.05 to -0.001) and more likely to experience work disruptions (β: 0.06; 95% confidence interval [CI], -0.01 to 0.12). Caregivers who were young, educated, unmarried, not spousal caregivers, and not living with their patients were more likely to stay employed despite patient health shock (p < 0.01 for all).

CONCLUSION

Findings show that caregivers' employment is affected by their patients' health through the caregiving trajectory. Continuous support for caregivers catered to specific vulnerable subgroups may be important to keeping caregivers in the workforce.

'Nobody can take the stress away from me': a qualitative study on experiences of partners of patients with cancer regarding their work and health

PURPOSE

To explore experienced health- and work-related problems of partners of patients with cancer, and their needs for support.

MATERIALS AND METHODS

Semi-structured interviews were conducted with Dutch partners of patients with cancer. Interviews were transcribed verbatim. Data were analysed thematically, following the six steps of Braun & Clarke.

RESULTS

Of 20 included partners (mean age: 50 years [31-63]), 60% was female. Five themes consistently emerged from the data: 1) overwhelming chaos calls for taking control; 2) impact of prolonged stress; 3) flexibility and support of the employer are crucial; 4) coping with family and friends is a delicate matter; and 5) support from healthcare professionals is needed, but not a given.

CONCLUSIONS

Findings from this study show that the burden on partners of patients with cancer is substantial and cannot be overlooked. The state of survival mode that partners get into during the diagnosis, treatment and follow-up of their loved ones can have various implications on their physical and mental health, and work situation. Given this high burden and as legislation for care leave from work and (health care) support for partners appear to be insufficiently in place in the Dutch context, there is a need for better-targeted support for partners of patients with cancer. Implications for RehabilitationThe survival mode that partners of patients with cancer get into during the diagnosis, treatment and follow-up of their loved ones can have various implications on their physical and mental health, and work situation.This study showed that the burden on partners of patients with cancer is substantial and cannot be overlooked.Given this high burden and because legislation for care leave from work and (health care) support for partners appears to be insufficiently in place in the Dutch context, there is a need for better-targeted support for partners of patients with cancer.

Cancer survivors' financial hardship and their caregivers' employment: results from a statewide survey

PURPOSE

Many caregivers take paid and/or unpaid time off work, change from full-time to part-time, or leave the workforce. We hypothesized that cancer survivor-reported material hardship (e.g., loans, bankruptcy), behavioral hardship (e.g., skipping care/medication due to cost), and job lock (i.e., staying at a job for fear of losing insurance) would be associated with caregiver employment changes.

METHODS

Adult cancer survivors (N = 627) were surveyed through the Utah Cancer Registry in 2018-2019, and reported whether their caregiver had changed employment because of their cancer (yes, no). Material hardship was measured by 9 items which we categorized by the number of instances reported (0, 1-2, and ≥ 3). Two items represented both behavioral hardship (not seeing doctor/did not take medication because of cost) and survivor/spouse job lock. Odds ratios (OR) were estimated using survey-weighted logistic regression to examine the association of caregiver employment changes with material and behavioral hardship and job lock, adjusting for cancer and sociodemographic factors.

RESULTS

There were 183 (29.2%) survivors reporting their caregiver had an employment change. Survivors with ≥ 3 material hardships (OR = 3.13, 95%CI 1.68-5.83), who skipped doctor appointments (OR = 2.88, 95%CI 1.42-5.83), and reported job lock (OR = 2.05, 95%CI 1.24-3.39) and spousal job lock (OR = 2.19, 95%CI 1.17-4.11) had higher odds of caregiver employment changes than those without these hardships.

CONCLUSIONS

Caregiver employment changes that occur because of a cancer diagnosis are indicative of financial hardship.

IMPLICATIONS FOR CANCER SURVIVORS

Engaging community and hospital support for maintenance of stable caregiver employment and insurance coverage during cancer may lessen survivors' financial hardship.

Employment outcomes in family supporters of patients with early stage breast cancer and their association with patients' health-related quality of life and financial burden

BACKGROUND

Little is known about how cancer impacts the employment status of patients' family supporters, or about associations between patients' health-related quality of life, perceived financial burden, and supporters' employment trajectory.

METHODS

We surveyed patients with early stage breast cancer reported to the Georgia and Los Angeles SEER registries in 2014-15, and their spouse/partner or other family supporters. Patients and supporters were asked about employment impacts of the patient's cancer, and descriptive analyses of supporters' employment trajectories were generated. We measured patients' health-related quality of life (HRQoL) using the PROMIS scale for global health. We measured patients' perceived financial burden attributed to cancer by asking them two questions regarding (i) their financial status since their breast cancer diagnosis and (ii) how much it was impacted by their breast cancer and treatment. Associations between patients' HRQoL, perceived financial burden, and supporters' employment status were assessed using linear mixed model regression analyses.

RESULTS

In total, 2502 patients (68% response rate) and 1203 supporters (70% response rate) responded; 1057 paired patient-supporter dyads were included. Similar proportions of spouse/partner and other family supporters reported missed work and lost employment due to patients' cancer. After adjustment, lower HRQoL and an increased odds of perceived financial burden among patients were associated with changes in other family supporters' employment (both p < 0.05), but not with changes in spouses'/partners' employment. Lower HRQoL was also associated with changes in patients' own employment among patients with both types of supporters (both p < 0.001). An increased odds of perceived financial burden among patients was associated with changes in patients' employment only in those supported by other family members (p < 0.001).

CONCLUSIONS

Both spouse/partner and other family supporters faced adverse employment outcomes due to patients' cancer. This contributes to worse HRQoL and greater perception of financial burden among patients, especially those whose supporter is not a spouse/partner.

Couple Communication in Cancer: Protocol for a Multi-Method Examination

Cancer and its treatment pose challenges that affect not only patients but also their significant others, including intimate partners. Accumulating evidence suggests that couples' ability to communicate effectively plays a major role in the psychological adjustment of both individuals and the quality of their relationship. Two key conceptual models have been proposed to account for how couple communication impacts psychological and relationship adjustment: the social-cognitive processing (SCP) model and the relationship intimacy (RI) model. These models posit different mechanisms and outcomes, and thus have different implications for intervention. The purpose of this project is to test and compare the utility of these models using comprehensive and methodologically rigorous methods. Aims are: (1) to examine the overall fit of the SCP and RI models in explaining patient and partner psychological and relationship adjustment as they occur on a day-to-day basis and over the course of 1 year; (2) to examine the fit of the models for different subgroups (males vs. females, and patients vs. partners); and (3) to examine the utility of various methods of assessing communication by examining the degree to which baseline indices from different measurement strategies predict self-reported adjustment at 1-year follow up. The study employs a longitudinal, multi-method approach to examining communication processes including: standard self-report questionnaires assessing process and outcome variables collected quarterly over the course of 1 year; smartphone-based ecological momentary assessments to sample participant reports in real time; and laboratory-based couple conversations from which we derive observational measures of communicative behavior and affective expression, as well as vocal indices of emotional arousal. Participants are patients with stage II-IV breast, colon, rectal, or lung cancer and their spouses/partners, recruited from two NCI-designated comprehensive cancer centers. Results will be published in scientific journals, presented at scientific conferences, and conveyed to a larger audience through infographics and social media outlets. Findings will inform theory, measurement, and the design and implementation of efficacious interventions aimed at optimizing both patient and partner well-being.

Financial toxicity and its impact on health outcomes and caregiver burden among adult cancer survivors in the USA

Aim: To examine the association between cancer-related financial toxicity on cancer survivors' physical and mental health outcomes and caregiver burden. Materials & methods: 2016-2017 Medical Expenditure Panel Survey data were used to identify adult cancer survivors with cancer-related financial toxicity. Multivariable regression analyses were employed to examine the association between cancer-related financial toxicity and cancer survivors' self-reported physical and mental health outcomes and caregiver burden. Results: A total of 53.7% of adult cancer survivors reported experiencing financial toxicity. Those who experienced financial toxicity reported 14% greater pain, and poorer physical and mental health outcomes as compared to those who did not experience financial toxicity, ranging from 38% greater odds for activity limitations to 427% greater odds for mental task limitation. Moreover, cancer survivors with financial toxicity reported 206% greater odds for caregiver burden. Conclusions: Intervention programs for reducing financial toxicity among adult cancer survivors and their caregivers should be developed.

A sequential explanatory study of the employment experiences of population-based breast, colorectal, and prostate cancer survivors

PURPOSE

Cancer treatment often leads to work disruptions including loss of income, resulting in long-term financial instability for cancer survivors and their informal caregivers.

METHODS

In this sequential explanatory study, we conducted a cross-sectional survey of employment experiences among ethnically diverse, working-age individuals diagnosed with breast, colorectal, or prostate cancer. Following the survey, we conducted semi-structured interviews with cancer survivors and informal caregivers to explore changes in employment status and coping techniques to manage these changes.

RESULTS

Among employed survivors (n = 333), cancer caused numerous work disruptions including issues with physical tasks (53.8%), mental tasks (46.5%) and productivity (76.0%) in the workplace. Prostate cancer survivors reported fewer work disruptions than female breast and male and female colorectal cancer survivors. Paid time off and flexible work schedules were work accommodations reported by 52.6% and 36.3% of survivors, respectively. In an adjusted regression analysis, household income was positively associated with having received a work accommodation. From the qualitative component of the study (survivors n = 17; caregivers n = 11), three key themes emerged: work disruptions, work accommodations, and coping mechanisms to address the disruptions. Survivors and caregivers shared concerns about lack of support at work and resources to navigate issues caused by changes in employment.

CONCLUSIONS

This study characterized employment changes among a diverse group of cancer survivors. Work accommodations were identified as a specific unmet need, particularly among low-income cancer survivors. Addressing changes in employment among specific groups of cancer survivors and caregivers is critical to mitigate potential long-term consequences of cancer.

Annual Report to the Nation on the Status of Cancer, Part 2: Patient Economic Burden Associated With Cancer Care

BACKGROUND

The American Cancer Society, National Cancer Institute, Centers for Disease Control and Prevention, and North American Association of Central Cancer Registries provide annual information about cancer occurrence and trends in the United States. Part 1 of this annual report focuses on national cancer statistics. This study is part 2, which quantifies patient economic burden associated with cancer care.

METHODS

We used complementary data sources, linked Surveillance, Epidemiology, and End Results-Medicare, and the Medical Expenditure Panel Survey to develop comprehensive estimates of patient economic burden, including out-of-pocket and patient time costs, associated with cancer care. The 2000-2013 Surveillance, Epidemiology, and End Results-Medicare data were used to estimate net patient out-of-pocket costs among adults aged 65 years and older for the initial, continuing, and end-of-life phases of care for all cancer sites combined and separately for the 21 most common cancer sites. The 2008-2017 Medical Expenditure Panel Survey data were used to calculate out-of-pocket costs and time costs associated with cancer among adults aged 18-64 years and 65 years and older.

RESULTS

Across all cancer sites, annualized net out-of-pocket costs for medical services and prescriptions drugs covered through a pharmacy benefit among adults aged 65 years and older were highest in the initial ($2200 and $243, respectively) and end-of-life phases ($3823 and $448, respectively) and lowest in the continuing phase ($466 and $127, respectively), with substantial variation by cancer site. Out-of-pocket costs were generally higher for patients diagnosed with later-stage disease. Net annual time costs associated with cancer were $304.3 (95% confidence interval = $257.9 to $350.9) and $279.1 (95% confidence interval = $215.1 to $343.3) for adults aged 18-64 years and ≥65 years, respectively, with higher time costs among more recently diagnosed survivors. National patient economic burden, including out-of-pocket and time costs, associated with cancer care was projected to be $21.1 billion in 2019.

CONCLUSIONS

This comprehensive study found that the patient economic burden associated with cancer care is substantial in the United States at the national and patient levels.

Cancer Caregiving While Employed: Caregiving Roles, Employment Adjustments, Employer Assistance, and Preferences for Support

Cancer patients commonly require assistance from a relative or friend, and many of these "family caregivers" are navigating employment while caring. The purpose of this analysis was to understand the experience of employment while providing care to someone with cancer, including these caregivers' roles and burden, adjustments made to employment, assistance provided by employers, and preferences for employment and financial support. To further highlight this group of cancer caregivers, we compare it with (1) cancer caregivers who were not employed while caring; (2) caregivers for patients with a primary condition other than cancer who were employed while caring; and (3) caregivers for patients with a primary condition other than cancer who were not employed while caring. This secondary analysis is drawn from the National Alliance for Caregiving's (NAC)/AARP Caregiving in the US dataset of unpaid adult (i.e., age 18 and older) caregivers. Half of the cancer caregivers were employed while providing care, and these employed caregivers were significantly more likely to be younger than those non-employed while caring. The employed cancer caregivers provided significantly fewer hours of care per week on average than those non-employed (23.4 vs. 42.5 h/week) but provided a nearly equivalent number of ADLs on average. Nearly half (48%) of the employed cancer caregivers reported coming in late to work, leaving early, or taking off work to accommodate caregiving, while 24% cut back on hours at work or went from full-time to part-time employment and 11% retired early or quit work entirely. The employed cancer caregivers (excluding self-employed) indicated having access to flexible working hours (57%) or paid sick leave (48%), and most (73%) reported that their supervisor was aware of their caregiving role, which was significantly higher than employed non-cancer caregivers (55%). These findings suggest that balancing work and cancer caregiving is especially prevalent among younger caregivers, and that work adjustments are needed but that the cancer caregiving role might be more commonly discussed or shared with supervisors. These findings suggest the need to develop workplace educational resources for employees caring for a cancer patient but also for supervisors to enhance their understanding of caregiver strain, workload, and work-based strategies to assist cancer caregivers.

Association between employment status change and depression and anxiety in allogeneic stem cell transplant caregivers

PURPOSE

Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is a demanding treatment that requires caregiver support during the first 100 days post-transplant. Little is known about the association between caregivers' employment changes and their well-being during this lengthy and challenging time when caregivers may be balancing work with caregiving responsibilities.

METHODS

We used data from employed caregivers of Allo-HSCT patients who participated in two randomized clinical trials (N = 187) of an intervention for caregivers. Caregiver depression and anxiety were assessed using the Center for Epidemiologic Studies Depression and the Spielberger State-Trait Anxiety Inventory. ANCOVA was used to measure the associations between reducing work with depression and anxiety. Caregiver's demographics and baseline employment status were controlled in the analysis along with the patient's transplant conditioning intensity.

RESULTS

Approximately 45% of caregivers reduced hours worked following the resumption of their caregiving duties. These caregivers, on average, had 3.49 points higher depression scores than caregivers who did not report a reduction in work (p < 0.01). Similarly, these caregivers also reported, on average, 3.56 higher anxiety scores (p < 0.10).

CONCLUSIONS

Caregivers who reduced hours worked while caregiving reported greater distress. The underlying cause of this distress deserves further investigation.

IMPLICATIONS FOR CANCER SURVIVORS

Caregivers of patients diagnosed with cancer may experience considerable stress related to work discontinuation and caregiving. Interventions are needed to support caregivers who are trying to balance work and caregiving responsibilities.

Effect of instrumental support on distress among family caregivers: Findings from a nationally representative study

BACKGROUND AND OBJECTIVE

A priority focus on palliative and supportive care is helping the 43.5 million caregivers who care for individuals with serious illness. Lacking support may lead to caregiver distress and poorer care delivery to patients with serious illness. We examined the potential of instrumental support (assistance with material and task performance) to mitigate distress among caregivers.

METHOD

We analyzed data from the nationally representative Health Information National Trends Survey (HINTS V2, 2018). Informal/family caregivers were identified in HINTS V2 if they indicated they were caring for or making healthcare decisions for another adult with a health problem. We used the PROMIS® instrumental support four-item short-form T-scores and the Patient Health Questionnaire (PHQ-4) for distress. We examined multivariable linear regression models for associations between distress and instrumental support, adjusted for sampling weights, socio-demographics, and caregiving variables (care recipient health condition(s), years caregiving (≥2), relationship to care recipient, and caregiver burden). We examined interactions between burden and instrumental support on caregiver distress level.

RESULTS

Our analyses included 311 caregivers (64.8% female, 64.9% non-Hispanic White). The unweighted mean instrumental support T-score was 50.4 (SD = 10.6, range = 29.3-63.3); weighted mean was 51.2 (SE = 1.00). Lower instrumental support (p < 0.01), younger caregiver age (p < 0.04), higher caregiving duration (p = 0.008), and caregiver unemployment (p = 0.006) were significantly associated with higher caregiver distress. Mean instrumental support scores by distress levels were 52.3 (within normal limits), 49.4 (mild), 48.9 (moderate), and 39.7 (severe). The association between instrumental support and distress did not differ by caregiver burden level.

CONCLUSIONS

Poor instrumental support is associated with high distress among caregivers, suggesting the need for palliative and supportive care interventions to help caregivers leverage instrumental support.

Employment of Young Adult Cancer Caregivers, Other Disease Caregivers, and Non-Caregiving Adults

Young adults are increasingly taking on caregiving roles in the United States, and cancer caregivers often experience a greater burden than other caregivers. An unexpected caregiving role may disrupt caregiver employment, leading to lost earning potential and workforce re-entry challenges. We examined caregiving employment among young adult caregivers (i.e., family or friends) using the 2015 Behavioral Risk Factor Surveillance System (BRFSS), which included caregiving, employment, and sociodemographic variables. Respondents’ ages varied between 18 and 39, and they were categorized as non-caregivers (n = 16,009), other caregivers (n = 3512), and cancer caregivers (n = 325). Current employment was compared using Poisson regressions to estimate adjusted incidence rate ratios (aIRR) and 95% confidence intervals (95% CI), including gender-stratified models. We estimated employment by cancer caregiving intensity (low, moderate, high). Cancer caregivers at all other income levels were more likely to be employed than those earning below USD 20,000 (aIRR ranged: 1.88–2.10, all p< 0.015). Female cancer caregivers who were 25–29 (aIRR = 0.71, 95% CI = 0.51–1.00) and single (aIRR = 0.70, 95% CI = 0.52–0.95) were less likely to be employed than their counterparts. College-educated males were 19% less likely to be employed than high school-educated caregivers (95% CI = 0.68–0.98). Evaluating caregiver employment goals and personal financial situations may help identify those at risk for employment detriments, especially among females, those with lower educational attainment, and those earning below USD 20,000 annually.

Behavioral Research in Cancer Prevention and Control: Emerging Challenges and Opportunities

It is estimated that behaviors such as poor diet, alcohol consumption, tobacco use, sedentary behavior, and excessive ultraviolet exposure account for nearly one-half of all cancer morbidity and mortality. Accordingly, the behavioral, social, and communication sciences have been important contributors to cancer prevention and control research, with methodological advances and implementation science helping to produce optimally effective interventions. To sustain these contributions, it is vital to adapt to the contemporary context. Efforts must consider ancillary effects of the 2019 coronavirus disease pandemic, profound changes in the information environment and public understanding of and trust in science, renewed attention to structural racism and social determinants of health, and the rapidly increasing population of cancer survivors. Within this context, it is essential to accelerate reductions in tobacco use across all population subgroups; consider new models of energy balance (diet, physical activity, sedentary behavior); increase awareness of alcohol as a risk factor for cancer; and identify better communication practices in the context of cancer-related decisions such as screening and genetic testing. Successful integration of behavioral research and cancer prevention depends on working globally and seamlessly across disciplines, taking a multilevel approach where possible. Methodological and analytic approaches should be emphasized in research training programs and should use new and underused data sources and technologies. As the leadership core of the National Cancer Institute’s Behavioral Research Program, we reflect on these challenges and opportunities and consider implications for the next phase of behavioral research in cancer prevention and control.

Differences in Caregiving Intensity Among Distinct Sociodemographic Subgroups of Informal Caregivers: Joint Effects of Race/Ethnicity, Gender, and Employment

More than 40 million informal caregivers in the United States provide essential care to older adults. Recent research has identified substantial differences in caregiving intensity by gender, race/ethnicity, and employment status. Using intersectionality theory, the current study extends the existing literature by exploring the relationship between caregiving intensity and the unique experiences of individuals with different intersections of gender, ethnicity, and employment. We used generalized linear models to estimate multivariate associations between caregiving intensity assessed by three different measures (hours of caregiving per month and number of activities of daily living and instrumental activities of daily living [IADLs] assisted with) and the three sociodemographic factors of interest (race/ethnicity, gender, and employment status). Unemployed White males provided, on average, 77 fewer hours per month of care (p < 0.001) and assisted with 1.9 fewer IADLs (p = 0.004) than unemployed Black males. Employed White females provided 42.6 fewer hours per month of care (p = 0.002) than employed Black females and 49.2 fewer hours per month (p = 0.036) than employed females of other races. Study findings suggest that examining racial/ethnic or gender differences in isolation does not provide a true picture of differences in caregiving intensity. There is a critical need to understand how the intersections of race/ethnicity, gender, employment, and other sociodemographic factors shape the experiences of caregiver subgroups. [Journal of Gerontological Nursing, 47(7), 23-32.].

Survivorship, Version 1.2021

The NCCN Guidelines for Survivorship are intended to help healthcare professionals working with cancer survivors to ensure that each survivor's complex and varied needs are addressed. The Guidelines provide screening, evaluation, and treatment recommendations for consequences of adult-onset cancer and its treatment; recommendations to help promote healthful lifestyle behaviors, weight management, and immunizations in survivors; and a framework for care coordination. This article summarizes the recommendations regarding employment and return to work for cancer survivors that were added in the 2021 version of the NCCN Guidelines.

Systematic review of financial burden assessment in cancer: Evaluation of measures and utility among adolescents and young adults and caregivers

The cost of cancer care is rising and represents a stressor that has significant and lasting effects on quality of life for many patients and caregivers. Adolescents and young adults (AYAs) with cancer are particularly vulnerable. Financial burden measures exist but have varying evidence for their validity and reliability. The goal of this systematic review is to summarize and evaluate measures of financial burden in cancer and describe their potential utility among AYAs and their caregivers. To this end, the authors searched PubMed, Embase, the Cochrane Library, CINAHL, and PsycINFO for concepts involving financial burden, cancer, and self-reported questionnaires and limited the results to the English language. They discarded meeting abstracts, editorials, letters, and case reports. The authors used standard screening and evaluation procedures for selecting and coding studies, including consensus-based standards for documenting measurement properties and study quality. In all, they screened 7250 abstracts and 720 full-text articles to identify relevant articles on financial burden. Eighty-six articles met the inclusion criteria. Data extraction revealed 64 unique measures for assessing financial burden across material, psychosocial, or behavioral domains. One measure was developed specifically for AYAs, and none were developed for their caregivers. The psychometric evidence and study qualities revealed mixed evidence of methodological rigor. In conclusion, several measures assess the financial burden of cancer. Measures were primarily designed and evaluated in adult patient populations with little focus on AYAs or caregivers despite their increased risk of financial burden. These findings highlight opportunities to adapt and test existing measures of financial burden for AYAs and their caregivers.

Understanding the characteristics of US cancer survivors with informal caregivers

BACKGROUND

Although informal caregivers such as family and friends provide people with cancer needed physical care and emotional support, little is known about which individuals have access to such caregivers. The purpose of this article is to provide a nationally representative description of the sociodemographic characteristics of cancer survivors who have or had an informal caregiver in the United States.

METHODS

Cross-sectional data were taken from the Experiences With Cancer Survivorship Supplement of the Medical Expenditure Panel Survey in 2011, 2016, and 2017. People were cancer survivors from diagnosis until the end of life. The study population consisted of adult survivors of cancer other than nonmelanoma skin cancer who were treated for cancer less than 3 years before the survey and were living in the community (n = 720). The main outcome measure was whether or not the cancer survivor reported having an informal caregiver.

RESULTS

In the United States, 55.2% of cancer survivors reported having an informal caregiver during or after their cancer treatment. The relationship of the caregiver to the survivor varied by sex: males were more likely to have a spouse as their caregiver, and females were more likely to have a child as their caregiver. In multivariate analyses, cancer survivors who were female, were married, were of a race/ethnicity other than White, or were in poor health were more likely to have an informal caregiver.

CONCLUSIONS

Future research can examine whether those without informal caregivers might need more formal support as they undergo cancer treatment and transition into cancer survivorship.

Developing and Sustaining an Effective and Resilient Oncology Careforce: Opportunities for Action

Advances in cancer care have led to improved survival, which, coupled with demographic trends, have contributed to rapid growth in the number of patients needing cancer care services. However, with increasing caseload, care complexity, and administrative burden, the current workforce is ill equipped to meet these burgeoning new demands. These trends have contributed to clinician burnout, compounding a widening workforce shortage. Moreover, family caregivers, who have unique knowledge of patient preferences, symptoms, and goals of care, are infrequently appreciated and supported as integral members of the oncology "careforce." A crisis is looming, which will hinder access to timely, high-quality cancer care if left unchecked. Stemming from the proceedings of a 2019 workshop convened by the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine, this commentary characterizes the factors contributing to an increasingly strained oncology careforce and presents multilevel strategies to improve its efficiency, effectiveness, and resilience. Together, these will enable today's oncology careforce to provide high-quality care to more patients while improving the patient, caregiver, and clinician experience.

Unmet Care Needs and Financial Hardship in Patients With Metastatic Non-Small-Cell Lung Cancer on Immunotherapy or Chemoimmunotherapy in Clinical Practice

PURPOSE

Immunotherapy or chemoimmunotherapy is now standard treatment for most patients with metastatic non-small-cell lung cancer (mNSCLC), yet patient supportive care needs (SCNs) on immunotherapy are not well defined. This study characterized the SCNs and financial hardship of patients with mNSCLC treated with immunotherapy or chemoimmunotherapy and examined the relationship between patient and caregiver cancer-related employment reductions and patient financial hardship.

METHODS

Patients with mNSCLC on immunotherapy or chemoimmunotherapy from a single academic medical center completed the SCNs Survey-34, items indexing material, psychological, and behavioral financial hardship, and the Comprehensive Score for Financial Toxicity. Univariate and bivariate analyses examined care needs, financial hardship, and impact of cancer-related employment reductions on patient financial hardship.

RESULTS

Sixty patients (40% male; 75% White, mean age = 62.5 years, 57% on immunotherapy alone) participated. Fifty-five percent reported unmet needs in physical or daily living and psychological domains. Financial hardship was common (33% material, 63% psychological, and 57% behavioral). Fifty-two percent reported hardship in at least two domains. Forty percent reported a caregiver cancer-related employment reduction. Caregiver employment reduction was related to patient financial hardship (68% of those reporting caregiver employment reduction reported at least two domains of hardship v 40% of those without reduction, P = .03) and patient financial distress (mean Comprehensive Score for Financial Toxicity = 19.6 among those with caregiver employment reduction v 26.8 without, P = .01).

CONCLUSION

Patients with mNSCLC treated with immunotherapy or chemoimmunotherapy report multiple unmet care needs and financial hardship. Psychological, functional, financial, and caregiver concerns merit assessment and intervention in this population.

Identification of Psychological and Social Problems in Caregivers of Individuals Diagnosed with Hematologic Malignancy

Objective:

Caring for patients with hematological malignancy could lead to many problems in different aspects regarding the lives of caregivers. However, there is limited data on the emotional and social problems of caregivers, who deal with patients of hematological malignancy. The aim of this study is to determine the emotional and social problems in caregivers of individuals diagnosed with hematological malignancy.

Methods:

The study was carried out descriptively to identify the emotional and social problems in the relatives of the patients diagnosed with hematological malignancy as their caregivers, as well as the factors affecting these problems. The data of the study were collected with the Introductory Information Form and Identification of Emotional and Social Problems Form that were administered to the relatives of the patients. The data were evaluated by using Spearman's Rho correlation analysis and the Logit analysis in Statistical Package for the Social Sciences software.

Results:

Among the caregivers, 59.8% were in the age group of 30–51 years, and 66.2% were female. Of the caregivers, 70.1% had difficulty in fulfilling their responsibilities. Spiritual distress had the highest score among the emotional problems, and experiencing caregiver strain had the highest score among the social problems. In the Logit model, the changes in the professional life was the variable that affects the emotional and social problems the most and significantly. In addition, emotional problems were affected by the financial problems at a statistically significant level.

Conclusions:

In this study, it is suggested that the caregivers should be provided with certain conveniences in their professional lives based on the fact that the problem, which affected emotional and social problems the most, is the change in the professional life; it is recommended that further studies should be carried out on the caregivers.

Employment changes among Chinese family caregivers of long-term cancer survivors

Background

Family caregivers (FCGs) play a key role in the plan of care provision for long-term cancer survivors, yet few studies have been conducted on the impact of long-term caregiving on FCGs and their employment patterns. This study aims to further our understanding of the effect that caregiving role has on FCGs by identifying what cancer-related characteristics influence reduction of employment hours among FCGs in the post-treatment phase in China.

Methods

A total of 1155 cancer survivors participated in this study. Patients reported changes in the employment patterns of their FCGs. Descriptive analysis looked at demographic and cancer-related characteristics of cancer survivors and types of FCGs’ employment changes in both primary- and post-treatment phases. Chi-square test was used to statistically test the association between survivors’ characteristics and changes in FCGs’ hours of labor force work in post-treatment phase. Separate multivariable logistic regression models were used to examine the relationship between cancer-related characteristics of participants and employment reduction patterns among FCGs in post-treatment phase while controlling for demographic factors.

Results

In the primary-treatment phase, 45.6% of all FCGs reduced their working hours and 17.4% stopped working altogether. In the post-treatment phase, 25.2% of FCGs worked fewer hours and 6.6% left the workforce completely. The results show that a higher probability of change in employment hours among FCGs is associated with the following patient characteristics: having comorbidities, receiving chemotherapy treatment, limited ability to perform physical tasks, limited ability to perform mental tasks, and diagnosis of stage II of cancer.

Conclusions

Care for cancer patients in both primary- and post- treatment phases may have substantial impacts on hours of formal employment of Chinese FCGs. Interventions helping FCGs balance caregiving duties with labor force work are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09922-9.

Transitions in Labour Force Participation over the Palliative Care Trajectory

BACKGROUND

Home-based palliative programs rely on family caregivers, who often miss time from employment. This article identified changes in caregivers' labour force participation over the palliative trajectory.

METHODS

Family caregivers (n = 262) were interviewed biweekly to measure transitions across four employment categories.

RESULTS

More than half of the caregivers had one employment transition and 29% had three or more. The highest proportion of transitions occurred for caregivers who were employed part-time.

INTERPRETATION

Understanding these transitions is critical to the development of strategies tailored to caregivers to contain labour force losses and to support caregivers during a time of high caregiving demands.

Breast Cancer Survivorship Experiences of Urban Hispanic Women

The purpose of this study was to explore determinates of health that impact survivorship of urban Hispanic breast cancer survivors who are at risk for experiencing poorer outcomes than others. Some challenges have been characterized, but gaps in our knowledge of the impact of some of the social determinates of health remain. Challenges likely exist prior to a diagnosis of cancer and may amplify in intensity during survivorship, potentially shortening survival and quality of life of these women. A narrative, focus group was conducted with a group of urban Hispanic breast cancer survivors. A series of linked vignettes describing survivorship challenges and late effects of breast cancer pathology and treatment were used to stimulate discussion. Three themes impacting survivorship were identified. The themes included communication (health literacy), isolation, and social support and financial cost. Communication issues resulted in delays in treatment denial of services. While these themes in cancer survivors are independent of residence (rural, suburban, or urban) and across ethnic groups, some unique issues were identified in urban Hispanic breast cancer survivors. Members of the healthcare team are in a unique position to enhance survivor's health literacy, advocate for programmatic efforts to enhance navigation roles in the hospital and communities, decrease delays in initiating care, and decrease the rate of patients lost.

A Pilot Study of a Comprehensive Financial Navigation Program in Patients With Cancer and Caregivers

Background: Few studies have engaged patients and caregivers in interventions to alleviate financial hardship. We collaborated with Consumer Education and Training Services (CENTS), Patient Advocate Foundation (PAF), and Family Reach (FR) to assess the feasibility of enrolling patient–caregiver dyads in a program that provides financial counseling, insurance navigation, and assistance with medical and cost of living expenses. Methods: Patients with solid tumors aged ≥18 years and their primary caregiver received a financial education video, monthly contact with a CENTS counselor and PAF case manager for 6 months, and referral to FR for help with unpaid cost of living bills (eg, transportation or housing). Patient financial hardship and caregiver burden were measured using the Comprehensive Score for Financial Toxicity–Patient-Reported Outcomes (COST-PRO) and Caregiver Strain Index (CSI) measures, respectively, at baseline and follow-up. Results: Thirty patients (median age, 59.5 years; 40% commercially insured) and 18 caregivers (67% spouses) consented (78% dyad participation rate). Many participants faced cancer-related financial hardships prior to enrollment, such as work change or loss (45% of patients; 39% of caregivers) and debt (64% of patients); 39% of caregivers reported high levels of financial burden at enrollment. Subjects received $11,000 in assistance (mean, $772 per household); 66% of subjects with income ≤$50,000 received cost-of-living assistance. COST-PRO and CSI scores did not change significantly. Conclusions: Patient–caregiver dyads were willing to participate in a financial navigation program that addresses various financial issues, particularly cost of living expenses in lower income participants. Future work should address financial concerns at diagnosis and determine whether doing so improves patient and caregiver outcomes.

Measuring the societal burden of cancer: a case of lost productivity in Nepal

OBJECTIVES

The global patterns of cancer incidences and mortality rates are slowly shifting towards low- and middle-income countries. Through our article, we highlight the societal cost associated with premature mortality and morbidity of cancer in Nepal. The monetary loss is indicative of the severity of the issue and it serves to motivate the policymakers realize the urgency in devising appropriate cancer control strategies.

STUDY DESIGN

The study design is a cross-sectional study using the GLOBOCAN 2012 data.

METHODS

Using the human capital approach, we measure the number of years of life lost (YLL) and the number of years of productive life lost (YPLL) due to cancer in Nepal.

RESULTS

We found that following diagnosis, a Nepali patient with cancer is likely to lose out on 19.64 years of their life; the average number of YLL is higher for females (22.2 years vs 16.8 years in males). After adjusting for labor force participation rate and predicted growth rate of the economy, we found that cancer led to a total productivity loss of $149 million (males) and $121 million (females) in 2012. The burden of the top five cancers accounted for almost half of the total productivity loss in both the genders. Cervical and lung cancer incur the maximum cost to society, respectively, for females and males.

CONCLUSIONS

The article highlighted the severity of the cancer issue and emphasized the urgency needed in devising cancer control policies in Nepal.

Design, data linkage, and implementation considerations in the first cooperative group led study assessing financial outcomes in cancer patients and their informal caregivers

BACKGROUND

Few studies have assessed the financial impact of cancer diagnosis on patients and caregivers in diverse clinical settings. S1417CD, led by the SWOG Cancer Research Network, is the first prospective longitudinal cohort study assessing financial outcomes conducted in the NCI Community Oncology Research Program (NCORP). We report our experience navigating design and implementation barriers.

METHODS

Patients age ≥ 18 within 120 days of metastatic colorectal cancer diagnosis were considered eligible and invited to identify a caregiver to participate in an optional substudy. Measures include 1) patient and caregiver surveys assessing financial status, caregiver burden, and quality of life and 2) patient credit reports obtained from the credit agency TransUnion through a linkage requiring social security numbers and secure data transfer processes. The primary endpoint is incidence of treatment-related financial hardship, defined as one or more of the following: debt accrual, selling or refinancing home, ≥20% income decline, or borrowing money. Accrual goal was n = 374 patients in 3 years.

RESULTS

S1417CD activated on Apr 1, 2016 and closed on Feb 1, 2019 after reaching its accrual goal sooner than anticipated. A total of 380 patients (median age 59.7 years) and 155 caregivers enrolled across 548 clinical sites. Credit data were not obtainable for 76 (20%) patients due to early death, lack of credit, or inability to match records.

CONCLUSIONS

Robust accrual to S1417CD demonstrates patients' and caregivers' willingness to improve understanding of financial toxicity despite perceived barriers such as embarrassment and fears that disclosing financial status could influence treatment recommendations.

Financial hardship in Chinese cancer survivors

BACKGROUND

The purpose of this study was to estimate the proportion of Chinese cancer survivors experiencing financial hardship and then examine the relationship between material and behavioral financial hardship.

METHODS

This study surveyed 964 cancer survivors who were 30 to 64 years old and 644 survivors who were 65 years old or older during 2015-2016 (1608 survivors in all). Material financial hardship was measured by whether they had borrowed money because of cancer, its treatment, or the lasting effects of treatment, and behavioral financial hardship was measured by whether they had forgone some cancer-related medical care because of cost. Multivariable logistic regression models were used to examine factors associated with material financial hardship by age group.

RESULTS

Approximately 44% of the cancer survivors who were 65 years old or older borrowed money or went into debt because of cancer, and 54% of younger patients (P < .01) reported cancer-related debts. Among these survivors with cancer care debt, survivors aged 65 years old or older had a lower proportion of borrowing more than 50,000 Chinese yuan (CNY; approximately US $7700) than survivors aged 30 to 64 years (14% vs 20%). In both age groups, approximately 10% of cancer survivors reported that they had experienced behavioral financial hardship. After adjustments for covariates, cancer survivors who reported material financial problems were more likely to report behavioral financial hardship (odds ratio [OR] for those aged 30-64 years, 3.72; 95% confidence interval [CI], 2.13-6.50; OR for those aged 65 years or older, 5.48; 95% CI, 2.69-11.15).

CONCLUSIONS

Older cancer survivors in China experience significant material financial hardship, but it is not as noticeable as younger patients' hardship. The results highlight the importance of identifying cancer survivors who are more likely to experience financial hardship and improving the affordability of cancer care in China.

Work Performance Among Informal Caregivers: A Review of the Literature

Objectives: To examine the association between informal caregiving and caregiver work performance. Method: A systematized review of the literature. Results: We found that caregiving has an adverse impact on work performance: caregivers experience substantial work disruptions and negative work performance outcomes, and these findings were consistent across measures. Our synthesis suggests that caregivers miss a significant amount of work and have reductions in productivity due to their caregiving responsibilities. However, significant methodological limitations with the reviewed studies make systematic interpretations and causal determinations challenging. Discussion: Examining the effect of caregiving on work performance is critical to better understand the full impact of caregiving, especially as demand for caregivers increases as the population ages. This comprehensive review suggests that caregiving has a significant negative impact on work performance, although methodological challenges remain in this area of science. These findings should inform both public policy development and workplace benefits design.