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Murnaghan S, Scruton S, Urquhart R. Psychosocial interventions that target adult cancer survivors' reintegration into daily life after active cancer treatment: a scoping review. JBI Evid Synth 2024; 22:607-656. [PMID: 38015073 PMCID: PMC10986786 DOI: 10.11124/jbies-23-00044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
OBJECTIVE This review explored psychosocial interventions targeting adult cancer survivors' reintegration following active cancer treatment. This included the types of interventions tested and the tools used to measure reintegration. INTRODUCTION Cancer survivors face lingering health issues following the completion of cancer treatment. Many cancer survivors still experience unmet psychosocial care needs despite receiving follow-up care. Further, many survivorship interventions do not specifically address outcomes important to survivors. A number of primary studies have identified reintegration as an outcome important to cancer survivors. Reintegration is a concept that focuses on returning to normal activities, routines, and social roles after cancer treatment; however, it is emerging and abstract. INCLUSION CRITERIA Studies involving adult cancer survivors (18 years or older at diagnosis) of any cancer type or stage were included in this review. Studies with psychosocial interventions targeted at reintegrating the person into daily life after cancer treatment were included. Interventions addressing clinical depression or anxiety, and interventions treating solely physical needs that were largely medically focused were excluded. METHODS A literature search was conducted in MEDLINE (Ovid), CINAHL (EBSCOhost), and Embase. Gray literature was searched using ProQuest Dissertations and Theses (ProQuest). Reference lists of included studies were searched. Studies were screened at the title/abstract and full-text levels, and 2 independent reviewers extracted data. Manuscripts in languages other than English were excluded due to feasibility (eg, cost, time of translations). Findings were summarized narratively and reported in tabular and diagrammatic format. RESULTS The 3-step search strategy yielded 5617 citations. After duplicates were removed, the remaining 4378 citations were screened at the title and abstract level, then the remaining 306 citations were evaluated at the full-text level by 2 independent reviewers. Forty studies were included that evaluated psychosocial interventions among adult cancer survivors trying to reintegrate after active cancer treatment (qualitative n=23, mixed methods n=8, quantitative n=8, systematic review n=1). Included articles spanned 10 different countries/regions. Over half of all included articles (n=25) focused primarily on breast cancer survivors. Many studies (n=17) were conducted in primary care or community-based settings. The most common types of interventions were peer-support groups (n=14), follow-up education and support (n=14), exercise programs (n=6), and multidisciplinary/multicomponent programs (n=6). While the majority of included studies characterized the outcome qualitatively, 9 quantitative tools were also employed. CONCLUSIONS This review identified 6 types of interventions to reintegrate survivors back into their daily lives following cancer treatment. An important thread across intervention types was a focus on personalization in the form of problem/goal identification. Given the number of qualitative studies, future research could include a qualitative systematic review and meta-aggregation. Quantitative tools may not be as effective for evaluating reintegration. More primary studies, including mixed methods studies, utilizing consistent measurement tools are required. Furthermore, this work provides a basis for future research to continue examining the complexity of implementing such interventions to successfully achieve reintegration. To do so, primary studies evaluating interventions from an implementation science and complex systems perspective would be useful. REVIEW REGISTRATION Open Science Framework https://osf.io/r6bmx.
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Affiliation(s)
- Sarah Murnaghan
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sarah Scruton
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Surgery, Nova Scotia Health, Halifax, NS, Canada
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Einarsson S, Bokström A, Laurell G, Tiblom Ehrsson Y. Mapping the impact of malnutrition as defined by the Global Leadership Initiative on Malnutrition and nutrition impact symptoms on the possibility of returning to work after treatment for head and neck cancer. Support Care Cancer 2023; 32:55. [PMID: 38133825 PMCID: PMC10746764 DOI: 10.1007/s00520-023-08252-x] [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: 06/02/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE This study aimed to investigate whether malnutrition or nutrition impact symptoms (NIS) affect the possibility of returning to work after treatment for head and neck cancer. METHODS Patients of working age with head and neck cancer were followed up from treatment initiation to 3 months (n = 238), 1 year (n = 182), and 2 years (n = 130) after treatment completion. The observed decrease in the number of patients over time was due to retirement, lack of follow-up, or death. Returning to work was dichotomised as yes or no. Malnutrition was diagnosed 7 weeks after treatment initiation using the Global Leadership Initiative on Malnutrition (GLIM) criteria. This time-point corresponds to the end of chemoradiotherapy or radiotherapy (with or without prior surgery), except for patients who underwent exclusive surgery. NIS were scored on a Likert scale (1-5) at each follow-up using the Head and Neck Patient Symptom Checklist© (HNSC©). Nonparametric tests were used to analyse the ability of patients with/without malnutrition and high/low NIS scores to return to work. RESULTS At 3 months, 1 year, and 2 years after treatment completion, 135/238 (56.7%), 49/182 (26.9%), and 23/130 (17.7%) patients had not returned to work. Patients with malnutrition at 7 weeks after treatment initiation were more likely to not return to work at 3 months than those without malnutrition, 70.5% compared to 47.1% (p < 0.001). At all three follow-up time-points, patients reporting high scores for a number of NIS had more often not returned to work, with this pattern being most distinct at 2 years. CONCLUSION Malnutrition according to the GLIM criteria at 7 weeks after treatment initiation and NIS assessed by the HNSC© at subsequent follow-ups were predictors of the return-to-work process after treatment for up to 2 years. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT03343236 (date of registration 17/11/2017).
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Affiliation(s)
- Sandra Einarsson
- Department of Food, Nutrition and Culinary Science, Umeå University, Umeå, Sweden.
| | - Anna Bokström
- Unit for Celiac Disease and Diabetes, Lund University, Department of Pediatrics, Skåne University Hospital, Malmö, Sweden
| | - Göran Laurell
- Department of Surgical Sciences, Section of Otorhinolaryngology and Head & Neck Surgery, Uppsala University, Uppsala, Sweden
| | - Ylva Tiblom Ehrsson
- Department of Surgical Sciences, Section of Otorhinolaryngology and Head & Neck Surgery, Uppsala University, Uppsala, Sweden
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Kristensen MB. Managing eating problems after cancer. Maturitas 2023; 178:107843. [PMID: 37659131 DOI: 10.1016/j.maturitas.2023.107843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/04/2023]
Abstract
Cancer treatment can cause food-limiting eating problems that persist or arise months or years after treatment, with negative consequences for the survivor's nutritional status, physical and social function, and quality of life. Hence, post-treatment follow-up and cancer rehabilitation services should aim to support the survivor in managing treatment-related eating problems. This narrative review summarizes the evidence on and provides an overview of interventions to manage eating problems after cancer. Interventions are grouped into four: 1) food-based interventions, including alternating food/fluids and experimenting through the trial-and-error strategy to find tolerated foods; 2) eating behavioral interventions, including instructions on swallowing techniques, posture, and utensils; 3) psychosocial support interventions, including group-based interventions and interventions including relatives; and 4) physical interventions, including exercises to improve dysphagia or trismus. While physical interventions are supported by evidence from several intervention studies, few studies evaluating the effect of other types of interventions in survivors were identified. Instead, qualitative and observational data providing insights on experiences of and coping strategies applied by survivors with eating problems underpin the need for the other types of interventions. Since existing research primarily focuses on survivors of head and neck cancer, future studies on the organization and effects of interventions aimed at managing eating problems among different groups of survivors are relevant.
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Bernstein RT, Garner-Purkis A, Gallagher JE, Newland-Pedley, Scambler S. A systematic review of social impacts of treatment and rehabilitation of head and neck cancer patients. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2023. [DOI: 10.1016/j.adoms.2023.100409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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“Song of Life”: A Comprehensive Evaluation of Biographical Music Therapy in Palliative Care by the EMW-TOPSIS Method. Processes (Basel) 2022. [DOI: 10.3390/pr10101962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The “Song of Life (SOL)” is a kind of music therapy in palliative care for addressing emotional and existential needs in terminally ill patients nearing the end of life. Few previous studies focus on objective data analysis methods to validate the effectiveness of psychotherapy therapy for patients’ overall state. This article combines the entropy weighting method (EWM) and the technique for order preference by similarity to the ideal solution (TOPSIS) method to evaluate the effectiveness of SOL music therapy and the treatment satisfaction of the patients and family members. Firstly, the collaborative filtering algorithm (CFA) machine learning algorithm is used to predict the missing ratings a patient might have given to a variable. Secondly, the EWM determines the weights of quality of life, spiritual well-being, ego-integrity, overall quality of life, and momentary distress. Thirdly, the EWM method is applied for the TOPSIS evaluation model to evaluate the patient’s state pre- and post-intervention. Finally, we obtain the state change in patients and recognition based on the feedback questionnaire. The multiple criteria decision making (MCDM) comprehensive evaluation method objectively validated the overall effectiveness of SOL music therapy. Based on MCDM method, we provide a new approach for judging the overall effect of psychological intervention and accurately recommend psychotherapy that fits the symptoms of psychological disorders.
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Hatton RA, Crane J, Rogers SN, Patterson J. Head and neck cancer peer-to-peer support and quality of life: systematic scoping review. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S30-S36. [PMID: 35271361 DOI: 10.12968/bjon.2022.31.5.s30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND/AIM The aim of this scoping review was to summarise the current evidence for peer-to-peer support and its impact on quality of life (QoL) in head and neck cancer (HNC). METHODS Five search engines were used-PubMed, CINAHL, APA PyscInfo, Web of Science and HaNDLE-on-QoL-to look for publications between 1981 and 2020. Adapted PICO (population, intervention, comparator and outcome) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) methodology was used. RESULTS Of the 1408 papers identified, 10 met the inclusion criteria: five qualitative, two cross-sectional, one case-control, one cohort and one quasi-experimental design. There were four common themes: patient experience of peer-to-peer support, delivery of peer-to-peer support, engagement with peer-to-peer support and impact on QoL. CONCLUSION This review highlights the paucity of evidence with regard to QoL and peer-to-peer support in HNC. It provides a summary of the literature and identifies considerations for clinical practice and future research.
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Affiliation(s)
- Rebecca A Hatton
- Medical Student, School of Health Sciences, Institute of Population Health/Liverpool Head and Neck Centre, University of Liverpool
| | - Julie Crane
- Senior Lecturer, Nursing, School of Health Sciences, University of Liverpool, formerly Centre Manager, North West Cancer Research Centre, University of Liverpool
| | - Simon N Rogers
- Professor and Consultant Maxillofacial Surgeon, Faculty of Health, Social Care and Medicine, Edge Hill University and Liverpool Head and Neck Centre, Liverpool University Hospital Aintree, ORCID iD: 0000-0002-5989-6142
| | - Jo Patterson
- Professor of Speech and Language Therapy, School of Health Sciences, Institute of Population Health/Liverpool Head and Neck Centre, University of Liverpool
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Dornan M, Semple C, Moorhead A. Experiences and perceptions of social eating for patients living with and beyond head and neck cancer: a qualitative study. Support Care Cancer 2022; 30:4129-4137. [PMID: 35072791 PMCID: PMC8785386 DOI: 10.1007/s00520-022-06853-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/19/2022] [Indexed: 01/27/2023]
Abstract
Purpose Patients with head and neck cancer (HNC) describe eating as more than a physical activity for nutrition and calories. After treatment for HNC, patients report a changed social experience around food, with eating and drinking in front of family and friends depicted as a challenge. However, there is limited research exploring how patients with HNC adapt and cope with social eating difficulties. This study aims to explore patients’ experiences and perceptions of social eating and drinking following treatment for HNC. Methods A qualitative research design using semi-structured interviews was employed to understand the experiences of social eating of patients living with and beyond HNC. Reflexive thematic analysis was used to inductively develop key themes from the data. Results Fourteen interviews were conducted with patients, and two key themes were identified: (1) “Social eating became a conscious process” and (2) “Strategies to maximise social eating participation”. To maximise social eating enjoyment, patients attempted to minimise the attention on their eating function and the fuss created around food. Patients with HNC established psychological and cognitive adaptations to manage expectations and promote positive participation in social eating. Conclusion This paper identifies key barriers limiting or diminishing social eating for patients with HNC; including being self-conscious, lack of understanding from others and functional issues with eating and drinking. This research highlights the need to raise awareness of social eating challenges and for the social dimensions of eating to be addressed through family-centred, supportive holistic interventions implemented early in the patient’s cancer journey.
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Affiliation(s)
- Mark Dornan
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK.
| | - Cherith Semple
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK.,Cancer Services, South Eastern Health and Social Care Trust, Belfast, UK
| | - Anne Moorhead
- School of Communication and Media, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
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Weaver R, O'Connor M, Golding RM, Gibson C, White R, Jackson M, Langbecker D, Bosco AM, Tan M, Halkett GKB. "My life's not my own": A qualitative study into the expectations of head and neck cancer carers. Support Care Cancer 2022; 30:4073-4080. [PMID: 35066666 DOI: 10.1007/s00520-021-06761-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/14/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Cancers that originate from the upper aerodigestive tract are collectively known as head and neck cancer. The most common are squamous cell carcinomas of the oropharynx, larynx, and oral cavity. Head and neck cancer patients experience significant physical and psychological changes because of the disease and treatment. There is a substantial strain on family carers who have extensive responsibilities over most aspects of the patient's life. The aim of the study was to understand the perspectives of being an HNC carer and their perceived expectations of the role. METHODS The study adopted a qualitative research design with a social constructionist epistemology. Interviews were conducted with 20 carers who were currently caring for someone diagnosed with head and neck cancer. RESULTS Three overarching themes were identified: taking responsibility for the patient's nutrition, navigating a new and different relationship, and "my life's not my own." Participants felt responsible for ensuring the patient was eating and became increasingly frustrated when the patient was unable to intake food. Carers prioritised the patients' needs at the expense of their own, and several came to resent the role. CONCLUSION Carers' expectations of their role informed how they approached giving care. Carers need to be supported from diagnosis and encouraged to prioritise their own wellbeing.
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Affiliation(s)
- Rhys Weaver
- Curtin School of Nursing, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia
| | - Moira O'Connor
- WA Cancer Prevention Research Unit, School of Population Health, Discipline of Psychology, Faculty of Health Sciences, Curtin University, Perth, WA, 6845, Australia
| | - Raelee M Golding
- Curtin School of Nursing, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia
| | - Chandrika Gibson
- Curtin School of Nursing, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia
| | - Rohen White
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Melanie Jackson
- GenesisCare Perth Radiation Oncology, Wembley, WA, Australia
| | - Danette Langbecker
- Centre for Online Health, The University of Queensland, St Lucia, Australia
| | - Anna Maria Bosco
- Curtin School of Nursing, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia
| | - Maureen Tan
- WA Cancer Prevention Research Unit, School of Population Health, Discipline of Psychology, Faculty of Health Sciences, Curtin University, Perth, WA, 6845, Australia
| | - Georgia K B Halkett
- Curtin School of Nursing, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.
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Cipriano-Crespo C, Conde-Caballero D, Rivero Jiménez B, Mariano-Juárez L. Eating experiences and quality of life in patients with larynx cancer in Spain. A qualitative study. Int J Qual Stud Health Well-being 2021; 16:1967262. [PMID: 34668841 PMCID: PMC8405063 DOI: 10.1080/17482631.2021.1967262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose This paper aims at describing the eating experience of people diagnosed with and treated for laryngeal cancer. Going beyond the mere conceptualization of “after-effect” or the quantification of the disease’s impact on the basis of standardized questionnaires, we present a qualitative analysis of the narratives of such experiences. Methods Ethnographic study. Data is obtained from conversations, semi-structured interviews, participant observation, and written documents. A discourse analysis of the narrative information was conducted, with process coding and using the constant comparative method, inductive content analysis, category analysis, units of meaning associated with each other, and triangulation. Results The impact of cancer on eating processes is not limited to nutrition, but also affects the social and cultural value of food, which is put into question. The symbolic and social values which accompany the traditional way of eating are modified, which is connected with impaired quality of life. Conclusions The impact on the eating process and its relationship with quality-of-life impairment are clear and connect with the importance of eating ways in culture and social organization. Greater attention should be paid to these contexts in clinical practice, which can affect even more than the impact on communicative processes.
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Affiliation(s)
- Carmen Cipriano-Crespo
- Faculty of Health Sciences, University of Castilla La Mancha, Talavera de la Reina, Spain
| | - David Conde-Caballero
- Faculty of Nursing and Occupational Therapy, University of Extremadura, Cáceres, Spain
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Jehn P, Spalthoff S, Lentge F, Zeller AN, Tavassol F, Neuhaus MT, Eckstein FM, Krüskemper G, Gellrich NC, Korn P. Postoperative quality of life and therapy-related impairments of oral cancer in relation to time-distance since treatment. J Cancer Surviv 2021; 16:1366-1378. [PMID: 34609700 DOI: 10.1007/s11764-021-01118-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/30/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Oral cancer resection can cause physical and psychological impairments that influence the quality of life (QoL). Depending on the postoperative time-distance, the occurrence and intensity of these impairments may change. We evaluated the sequelae and changes in therapy-related impairments during the postoperative course to detect associations between the time since surgery and the presence of disorders. METHODS Data from a questionnaire completed by 1359 patients who underwent surgical treatment of oral squamous cell carcinoma and were involved in a multicenter rehabilitation study of the German-Austrian-Swiss Cooperative Group on Tumors of the Maxillofacial Region (DÖSAK) that included 43 oral and maxillofacial clinics in Germany, Austria, and Switzerland were retrospectively analyzed. RESULTS Physical impairments, including those in appearance, mouth opening ability, ability to smell, gastric disorders, mandible mobility, breathing, and shoulder/arm mobility, were significantly associated with and increased with time-distance since surgery. Esthetic appearance most strongly correlated with the highest perception of worsening. Regarding psychological disorders, worry about tumor recurrence, depression, and worse prospects were significantly associated. Among the postoperative sequelae, fear of tumor recurrence decreased continuously; however, depression and worse prospects increased. The general QoL did not significantly differ overall during the postoperative course. CONCLUSIONS Therapy-related impairments change during the postoperative course based on the time-distance since surgery. The general QoL may not markedly vary; however, single impairments, to some extent, can increase or decrease. IMPLICATIONS FOR CANCER SURVIVORS Continuous adaptation of supportive cancer therapy is required during follow-up to sufficiently address individual treatment needs.
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Affiliation(s)
- Philipp Jehn
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Simon Spalthoff
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Fritjof Lentge
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Alexander-Nicolai Zeller
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Frank Tavassol
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Michael-Tobias Neuhaus
- Department of Oral, Craniomaxillofacial and Facial Plastic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Fabian Matthias Eckstein
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Gertrud Krüskemper
- Department of Medical Psychology, Ruhr University of Bochum, Bochum, Germany
| | - Nils-Claudius Gellrich
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Philippe Korn
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Hatton R, Crane J, Patterson J, Rogers S. A survey to ascertain peer support models available in Head and Neck cancer across the United Kingdom. Br J Oral Maxillofac Surg 2021; 60:488-492. [DOI: 10.1016/j.bjoms.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022]
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Crowder SL, Li Z, Sarma KP, Arthur AE. Chronic Nutrition Impact Symptoms Are Associated with Decreased Functional Status, Quality of Life, and Diet Quality in a Pilot Study of Long-Term Post-Radiation Head and Neck Cancer Survivors. Nutrients 2021; 13:nu13082886. [PMID: 34445046 PMCID: PMC8401587 DOI: 10.3390/nu13082886] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND As a result of tumor location and treatment that is aggressive, head and neck cancer (HNC) survivors experience an array of symptoms impacting the ability and desire to eat termed nutrition impact symptoms (NISs). Despite increasing cancer survival time, the majority of research studies examining the impact of NISs have been based on clinical samples of HNC patients during the acute phase of treatment. NISs are often chronic and persist beyond the completion of treatment or may develop as late side effects. Therefore, our research team examined chronic NIS complications on HNC survivors' functional status, quality of life, and diet quality. METHODS This was a cross-sectional study of 42 HNC survivors who were at least 6 months post-radiation. Self-reported data on demographics, NISs, quality of life, and usual diet over the past year were obtained. Objective measures of functional status included the short physical performance battery and InBody© 270 body composition testing. NISs were coded so a lower score indicated lower symptom burden, (range 4-17) and dichotomized as ≤10 vs. >10, the median in the dataset. Wilcoxon rank sum tests were performed between the dichotomized NIS summary score and continuous quality of life and functional status outcomes. Diet quality for HNC survivors was calculated using the Healthy Eating Index 2015 (HEI-2015). Wilcoxon rank sum tests examined the difference between the HNC HEI-2015 as compared to the National Health and Nutrition Examination Survey (NHANES) data calculated using the population ratio method. RESULTS A lower NIS score was statistically associated with higher posttreatment lean muscle mass (p = 0.002). A lower NIS score was associated with higher functional (p = 0.0006), physical (p = 0.0007), emotional (p = 0.007), and total (p < 0.0001) quality of life. Compared to NHANES controls, HNC survivors reported a significantly lower HEI-2015 diet quality score (p = 0.0001). CONCLUSIONS Lower NIS burden was associated with higher lean muscle mass and functional, physical, emotional, and total quality of life in post-radiation HNC survivors. HNC survivors reported a significantly lower total HEI-2015 as compared to healthy NHANES controls, providing support for the hypothesis that chronic NIS burden impacts the desire and ability to eat. The effects of this pilot study were strong enough to be detected by straight forward statistical approaches and warrant a larger longitudinal study. For survivors most impacted by NIS burden, multidisciplinary post-radiation exercise and nutrition-based interventions to manage NISs and improve functional status, quality of life, and diet quality in this survivor population are needed.
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Affiliation(s)
- Sylvia L. Crowder
- Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, 386 Bevier Hall 905 S Goodwin Ave, Urbana, IL 61801, USA;
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 4117 E Fowler Ave, Tampa, FL 33617, USA
- Correspondence: ; Tel.: +1-217-244-4090
| | - Zonggui Li
- Department of Psychology and Neuroscience, Boston College, 140 Commonwealth Ave, Chestnut Hill, MA 02467, USA;
| | - Kalika P. Sarma
- Carle Cancer Center, Carle Foundation Hospital, 602 W University Ave, Urbana, IL 61801, USA;
| | - Anna E. Arthur
- Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, 386 Bevier Hall 905 S Goodwin Ave, Urbana, IL 61801, USA;
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Nordentoft S, Dieperink KB, Johansson SD, Jarden M, Piil K. Evaluation of a multimodal rehabilitative palliative care programme for patients with high-grade glioma and their family caregivers. Scand J Caring Sci 2021; 36:815-829. [PMID: 34296773 DOI: 10.1111/scs.13019] [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: 02/10/2021] [Accepted: 07/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients diagnosed with high-grade glioma and their family caregivers often experience intense disease and treatment trajectories. Fluctuations in patient's symptoms lead to enormous burdens for caregivers and the risk of developing symptoms of stress, anxiety, and depression. AIM The study aim is to explore patient and caregiver experiences and evaluate the relevance of and satisfaction with a multimodal rehabilitative palliative care programme for patients diagnosed with a high-grade glioma and their family caregivers. METHODS In a longitudinal multi-methods study, adult patients with high-grade glioma (n = 17) and their family caregivers (n = 16) completed a 4-day residential programme and a 2-day follow-up programme 3 months later. Participants completed questionnaires after each programme, scoring relevance and satisfaction on a 5-point Likert scale. Qualitative data were collected during four evaluation group interviews with patients and caregivers. RESULTS The mean overall satisfaction score was 4.80 (standard deviation [SD], 0.55) for the initial 4-day programme and 4.28 (SD, 0.83) for the follow-up programme. Three themes emerged in the evaluation group interviews: (1) meeting peers strengthens social well-being, (2) the value of information and focusing on individual needs, and (3) accepting life as an unpredictable passage. CONCLUSION Participants found completing the REHPA-HGG programme feasible and rated all sessions highly for relevance and satisfaction. Qualitative findings confirm the value of individualised information, acceptance, and peer interactions. IMPLICATION FOR PRACTICE A multimodal rehabilitative palliative care programme addressed unmet patient and caregiver needs. Peer-to-peer interventions for family caregivers may address individual support needs. Similar programmes may maximise benefit by avoiding planned behaviour changes and enhancing palliative approaches.
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Affiliation(s)
- Sara Nordentoft
- Research Unit, Center for Cancer and Organ Disease, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Center for Cancer and Organ Diseases, Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karin B Dieperink
- Department of Oncology, Odense University Hospital, Odense, Denmark.,Danish Center for Rehabilitation and Palliative Care, REHPA, Nyborg, Denmark.,Family Focused Healthcare Center (FaCe), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Susan D Johansson
- Danish Center for Rehabilitation and Palliative Care, REHPA, Nyborg, Denmark
| | - Mary Jarden
- Department of Hematology, Center for Cancer and Organ Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Karin Piil
- Center for Cancer and Organ Diseases, Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark
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14
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Ehrsson YT, Fransson P, Einarsson S. Mapping Health-Related Quality of Life, Anxiety, and Depression in Patients with Head and Neck Cancer Diagnosed with Malnutrition Defined by GLIM. Nutrients 2021; 13:nu13041167. [PMID: 33916049 PMCID: PMC8066581 DOI: 10.3390/nu13041167] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/31/2022] Open
Abstract
Patients with cancer deal with problems related to physical, psychological, social, and emotional functions. The aim was to investigate malnutrition defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria in relation to health-related quality of life, anxiety, and depression in patients with head and neck cancer. This was a prospective observational research study with 273 patients followed at the start of treatment, seven weeks, and one year. Data collection included nutritional status and support, and the questionnaires: European Organization for Research and Treatment of Cancer Head and neck cancer module (EORTC QLQ-H&N35) and the Hospital Anxiety and Depression Scale (HADS). Malnutrition was defined using the GLIM criteria. The study showed that patients with malnutrition had significantly greater deterioration in their health-related quality of life at seven weeks. On a group level, health-related quality of life was most severe at this time point and some scores still implied problems at one year. Significantly, more patients reported anxiety at the start of treatment whereas significantly more patients reported depression at seven weeks. Over the trajectory of care, the need for support often varies. Psychosocial support is imperative and at the end of treatment extra focus should be put on nutritional interventions and managing treatment-related symptoms to improve nutritional status and health-related quality of life. In the long-term, head and neck cancer survivors need help to find strategies to cope with the remaining sequel.
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Affiliation(s)
- Ylva Tiblom Ehrsson
- Department of Surgical Sciences, Section of Otorhinolaryngology and Head & Neck Surgery, Uppsala University, SE-751 85 Uppsala, Sweden
- Correspondence:
| | - Per Fransson
- Department of Nursing, Umeå University, SE-901 87 Umeå, Sweden;
| | - Sandra Einarsson
- Department of Food, Nutrition and Culinary Science, Umeå University, SE-901 87 Umeå, Sweden;
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15
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Dornan M, Semple C, Moorhead A, McCaughan E. A qualitative systematic review of the social eating and drinking experiences of patients following treatment for head and neck cancer. Support Care Cancer 2021; 29:4899-4909. [PMID: 33646367 PMCID: PMC8295127 DOI: 10.1007/s00520-021-06062-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/07/2021] [Indexed: 01/02/2023]
Abstract
PURPOSE Patients living with and beyond head and neck cancer (HNC) often have long-term, functional challenges as a result of treatment. A key functional challenge relates to eating and drinking; often associated with physical, emotional, and social difficulties. Eating and drinking with family members and friends can become a struggle, increasing the risk of social isolation and loneliness. This systematic review aims to identify and synthesise the literature on the experiences of social eating and drinking for patients following treatment for HNC. METHODS Six electronic databases (Pubmed, Web of Science, CINAHL, EMBASE, PsychINFO, and Scopus) were systematically searched using subject headings and free-text word searches in February 2020. Citation chaining and Google Scholar were used to identify grey literature. PRISMA procedures were followed. RESULTS Of 6910 records identified, 24 studies met the inclusion criteria. Synthesis of the research findings results in two major themes: (1) the experience of loss associated with social eating and drinking, and (2) adjusting and support to promote social eating and drinking. CONCLUSION Losses associated with social eating affect a patient's psychological and emotional well-being and impact on close relationships. To promote positive participation in social eating, patients were more likely to seek and receive support from someone within their close social network, rather than a healthcare professional. Family and friends are an essential source of support and are integral in facilitating engagement with social eating following treatment for HNC. Future interventions should promote family orientated resources, incorporating self-management strategies.
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Affiliation(s)
- Mark Dornan
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK.
| | - Cherith Semple
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
- Cancer Services and Ulster Hospital, South Eastern Health and Social Care Trust, Belfast, UK
| | - Anne Moorhead
- School of Communication and Media, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Eilís McCaughan
- School of Nursing, Institute of Nursing and Health Research, Ulster University, Coleraine, UK
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16
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Kristensen MB, Wessel I, Beck AM, Dieperink KB, Mikkelsen TB, Møller JJK, Zwisler AD. Effects of a Multidisciplinary Residential Nutritional Rehabilitation Program in Head and Neck Cancer Survivors-Results from the NUTRI-HAB Randomized Controlled Trial. Nutrients 2020; 12:nu12072117. [PMID: 32708864 PMCID: PMC7400860 DOI: 10.3390/nu12072117] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/26/2020] [Accepted: 07/14/2020] [Indexed: 12/24/2022] Open
Abstract
Head and neck cancer survivors frequently experience nutritional challenges, and proper rehabilitation should be offered. The trial objective was to test the effect of a multidisciplinary residential nutritional rehabilitation programme addressing physical, psychological, and social aspects of eating problems after treatment. In a randomized controlled trial, 71 head and neck cancer survivors recruited through a nationwide survey were randomized to the program or a wait-list control group. Inclusion was based on self-reported interest in participation. The primary outcome was change in body weight. Secondary outcomes included physical function, quality of life, and symptoms of anxiety and depression. Differences between groups at the 3-month follow-up were tested. No significant differences were seen in body weight change, but there were overall trends towards greater improvements in physical function (hand grip strength: p = 0.042; maximal mouth opening: p = 0.072) and quality of life ("Role functioning": p = 0.041; "Speech problems": p = 0.040; "Pain": p = 0.048) in the intervention group. To conclude, a multidisciplinary residential nutritional rehabilitation program had no effect on body weight in head and neck cancer survivors with self-reported interest in participation, but it may have effect on physical function and quality of life. Further research on relevant outcomes, inclusion criteria, and the program's effect in different subgroups is needed.
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Affiliation(s)
- Marianne Boll Kristensen
- Department of Nursing and Nutrition, University College Copenhagen, Sigurdsgade 26, 2200 Copenhagen N, Denmark;
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, Vestergade 17, 5800 Nyborg, Denmark; (T.B.M.); (J.-J.K.M.); (A.-D.Z.)
- OPEN, Odense Patient data Explorative Network, Odense University Hospital, J.B. Winsløws Vej 9A, 5000 Odense C, Denmark
- Correspondence: ; Tel.: +45-2429-6329
| | - Irene Wessel
- Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark;
| | - Anne Marie Beck
- Department of Nursing and Nutrition, University College Copenhagen, Sigurdsgade 26, 2200 Copenhagen N, Denmark;
- Dietetics and Clinical Nutrition Research Unit, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 50, 4. 2730 Herlev, Denmark
| | - Karin B. Dieperink
- Research Unit of Oncology, Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark;
- Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19.3, DK-5000 Odense C, Denmark
| | - Tina Broby Mikkelsen
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, Vestergade 17, 5800 Nyborg, Denmark; (T.B.M.); (J.-J.K.M.); (A.-D.Z.)
| | - Jens-Jakob Kjer Møller
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, Vestergade 17, 5800 Nyborg, Denmark; (T.B.M.); (J.-J.K.M.); (A.-D.Z.)
| | - Ann-Dorthe Zwisler
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, Vestergade 17, 5800 Nyborg, Denmark; (T.B.M.); (J.-J.K.M.); (A.-D.Z.)
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17
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Head and Neck Cancer Survivors' Experiences with Chronic Nutrition Impact Symptom Burden after Radiation: A Qualitative Study. J Acad Nutr Diet 2020; 120:1643-1653. [PMID: 32646742 DOI: 10.1016/j.jand.2020.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/29/2020] [Accepted: 04/15/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Head and neck cancer (HNC) survivors may face an array of nutrition impact symptoms (NIS), including dysphagia, xerostomia, taste alterations, and difficulty chewing, which occur as a result of tumor location and treatment with radiation. Few qualitative studies have assessed the chronic impact of NIS on everyday life. OBJECTIVE The aim of this study was to obtain a comprehensive understanding of the lived experience of chronic NIS burden on HNC survivors. DESIGN AND PARTICIPANTS Semi-structured, face-to-face interviews were conducted with 31 HNC survivors to address the research aims and objectives. An interview guide was utilized to consider themes that had been generated through the review of literature and through the researchers' clinical experience within the field. There were probes within the interview for participants to raise unanticipated issues and flexibility to follow such leads. Interviews were conducted between March 2018 and May 2019. ANALYSIS A single researcher conducted the interviews to maintain consistency in data collection. Interviews lasted approximately 1 hour and were audio-recorded. All interview transcripts were professionally transcribed verbatim and checked for accuracy to ensure a complete account of participants' responses. Two researchers applied qualitative thematic content analysis to identify major themes. RESULTS The following 4 major thematic categories emerged from the interview data: symptom presence, dietary preferences, eating adjustments, and addressing symptoms. The most common symptoms were dysphagia, xerostomia, taste alterations, and bothered chewing. As a result of dietary preferences, survivors avoided citrus fruits, dry foods, raw vegetables, sweets, and meats. Survivors preferred soft and moist foods, spices or seasonings, and sauces or gravies. Eating adjustments were described as increased time to consume meals, cutting food into smaller pieces, consuming less food, and consuming more fluid. As a result of food preference changes and eating adjustments, survivors reported dietary pattern changes from pre to post treatment. All survivors experienced 1 or more chronic NIS, yet nearly 40% were unaware before treatment that NIS had the potential to persist chronically. CONCLUSIONS The results of this study provide unique qualitative insight into the lived experience of chronic NIS burden on HNC survivors. By recognizing the daily challenges, health care team members can better support HNC survivors in the transition from active treatment to follow-up care.
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18
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Kristensen MB, Wessel I, Beck AM, Dieperink KB, Mikkelsen TB, Møller JJK, Zwisler AD. Rationale and design of a randomised controlled trial investigating the effect of multidisciplinary nutritional rehabilitation for patients treated for head and neck cancer (the NUTRI-HAB trial). Nutr J 2020; 19:21. [PMID: 32183835 PMCID: PMC7079410 DOI: 10.1186/s12937-020-00539-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/03/2020] [Indexed: 12/24/2022] Open
Abstract
Background Eating problems frequently affect quality of life and physical, psychological and social function in patients treated for head and neck cancer (HNC). Residential rehabilitation programmes may ameliorate these adverse effects but are not indicated for all individuals. Systematic assessment of rehabilitation needs may optimise the use of resources while ensuring referral to rehabilitation for those in need. Yet, evidence lacks on which nutrition screening and assessment tools to use. The trial objectives are: 1) To test the effect of a multidisciplinary residential nutritional rehabilitation programme compared to standard care on the primary outcome body weight and secondary outcomes health-related quality of life, physical function and symptoms of anxiety and depression in patients curatively treated for HNC and 2) To test for correlations between participants’ development in outcome scores during their participation in the programme and their baseline scores in Nutritional Risk Screening 2002 (NRS 2002), the Scored Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), and M. D. Anderson Dysphagia Inventory (MDADI) and to assess sensitivity, specificity and predictive values of the three tools in relation to a clinically relevant improvement in outcome scores. Methods In a randomised controlled trial, 72 patients treated for HNC recruited through a nationwide survey will be randomised to a multidisciplinary residential nutritional rehabilitation programme or to a wait-list control group. Data are collected at baseline, three and six months. Primary outcome is change in body weight, and secondary outcomes include changes in quality of life, physical function and symptoms of anxiety and depression. Potential correlations between intervention effect and baseline scores in NRS 2002, PG-SGA-SF and MDADI will be tested, and sensitivity, specificity and predictive values of the three tools in relation to a clinically relevant improvement in outcome scores will be assessed. Discussion This is the first randomised controlled trial to test the effect of a multidisciplinary residential nutritional rehabilitation programme in patients treated for HNC. Recruitment through a nationwide survey gives a unique possibility to describe the trial population and to identify potential selection bias. As the trial will explore the potential of different nutrition screening and assessment tools in the assessment of rehabilitation needs in patients treated for HNC, the trial will create knowledge about how selection and prioritisation of nutritional rehabilitation aimed at patients treated for HNC should be offered. The results may contribute to a better organisation and use of existing resources in benefit of patients treated for HNC. Trial registration The trial is registered by The Danish Data Protection Agency (registration 2012-58-0018, approval number 18/14847) and the Regional Committees on Health Research Ethics for Southern Denmark (journal number 20182000–165). ClinicalTrials.gov Identifier: NCT03909256. Registered April 9, 2019.
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Affiliation(s)
- Marianne Boll Kristensen
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Odense University Hospital, Vestergade 17, Nyborg, DK-5800, Denmark. .,Department of Nursing and Nutrition, University College Copenhagen, Sigurdsgade 26, DK-2200, Copenhagen N, Denmark. .,OPEN, Odense Patient data Explorative Network, Odense University Hospital, J.B. Winsløws Vej 9A, DK-5000, Odense C, Denmark.
| | - Irene Wessel
- Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Anne Marie Beck
- Department of Nursing and Nutrition, University College Copenhagen, Sigurdsgade 26, DK-2200, Copenhagen N, Denmark.,Dietetics and Clinical Nutrition Research Unit, Herlev and Gentofte Hospital, Borgmester Ib Juuls Vej 50, 4, DK- 2730, Herlev, Denmark
| | - Karin B Dieperink
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Odense University Hospital, Vestergade 17, Nyborg, DK-5800, Denmark.,Research Unit of Oncology, Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.,Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19.3, 5000, Odense C, Denmark
| | - Tina Broby Mikkelsen
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Odense University Hospital, Vestergade 17, Nyborg, DK-5800, Denmark
| | - Jens-Jakob Kjer Møller
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Odense University Hospital, Vestergade 17, Nyborg, DK-5800, Denmark
| | - Ann-Dorthe Zwisler
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Odense University Hospital, Vestergade 17, Nyborg, DK-5800, Denmark
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