Unmet information needs predict anxiety in early survivorship in young women with breast cancer

Needs of breast cancer survivors: a systematic review of quantitative data

This systematic review aimed to update the perceived needs of individuals with breast cancer (BC). Databases were searched for studies reporting quantitative data collected through validated assessment tools. Needs of adults with BC were reported by survivorship phase. The post-diagnosis and the post-surgery phases revealed the most needs; health system and information needs represented the greatest concern, with average Supportive Care Needs Survey-Short Form (SCNS-SF34) scores ranging from 62.0 to 75.8 post-diagnosis and from 45.0 to 67.8 post-surgery. Needs then seemed to decrease or remain stable up to within one year from diagnosis, when needs in all domains increased again; health system and information needs remained a priority. Younger age, side effects, type of treatment, and advanced stage were associated with the occurrence of unmet needs. The needs of BC survivors vary over the course of their cancer experience. This knowledge can assist the planning of appropriate assessments.

Supportive care needs after surgery in patients with breast cancer

PURPOSE

This study aimed to determine supportive care needs and related factors after surgery in patients with breast cancer.

METHODS

This cross-sectional study was conducted with 98 breast cancer patients in a Training and Research Hospital in Istanbul between September 2022 and November 2023. The Personal Information Form and the Supportive Care Needs Survey Short Form Turkish version were used to collect data. One-way variance analysis, post hoc (Tukey, LSD), and t-test were used to analyze the data.

RESULTS

The total scale mean score for women who underwent surgery for breast cancer in the study was 83.95 22.97. Statistically significantly higher total scale scores were observed in younger women and those who received chemotherapy and radiotherapy than in others. The mean physical and daily living subscale scores of those who received chemotherapy and radiotherapy were higher than those who did not (p < .05). The psychology subscale mean scores of those who were young and unemployed were higher than the others (p < .05). The mean sexuality scores of those who were young, those with high education levels, and those who received chemotherapy were higher than the other groups (p < .05). Age factor affects SCN scores in women with breast cancer.

CONCLUSION

Supportive care needs are higher among women with breast cancer who are younger and receive chemotherapy and radiotherapy. The physical needs of those who receive chemotherapy and radiotherapy, the psychological needs of those who are younger and unemployed, and the need for support regarding sexuality were greater among those who are younger and with higher education. Nurses should be aware of the specific needs of these disadvantaged groups and provide individualized holistic care.

Information Needs and Its Association With Depressive Symptoms in People With Type 2 Diabetes

PURPOSE

The purpose of this study was to describe the information needs and examine its association with depressive symptoms in people with type 2 diabetes (T2D).

METHODS

A descriptive, correlational design was used. People with T2D (N = 358) were recruited from 12 communities in Shanghai, China. Self-reported information needs and depressive symptoms were measured using the Information Needs in Diabetes Questionnaire and Patient Health Questionnaire-9 (PHQ-9), respectively. Multivariate linear regression analysis was performed.

RESULTS

The participants were 64.8 years on average, and 46.6% were men. One hundred fifty-one (42.2%) had depressive symptoms (PHQ-9 ≥ 5). Participants had the least knowledge about "diabetes research," "acute complications," and "lifestyle adjustment." The sample had the highest levels of information needs about topics including "mental strain," "treatment/therapy," and "diabetes in everyday life." Compared to those without depressive symptoms, those experiencing depressive symptoms were less informed and had higher levels of need for further information. Controlling for covariates, higher levels of need for further information were significantly associated with greater depressive symptoms (B = 0.368, 95% CI, 0.155-0.582, P = .001).

CONCLUSIONS

This study demonstrated areas that should be prioritized when meeting patients' information needs. It also showed the potential negative effect of unmet information needs on depression. These findings may help develop a more tailored intervention for people with T2D.

Characterizing informational needs and information seeking behavior of patients with breast cancer

BACKGROUND

Appropriate information may facilitate adjustment to cancer diagnoses. Our study aims to characterize informational satisfaction in breast cancer patients and assess resources used by patients to gain information.

METHODS

Newly diagnosed Stage 0-III breast cancer patients seen at an academic medical center between May and September 2020 received questionnaires assessing information satisfaction. Patients indicated resources used to obtain information along with satisfaction with information received in various topics. A subset of questionnaire respondents completed semi-structured interviews.

RESULTS

Fifty-two (35 ​%) patients completed the questionnaire. Patients received information from physicians (96 ​%), the internet (81 ​%), nurses (79 ​%), and fellow breast cancer patients (54 ​%). Interview participants preferred receiving information from providers when making medical decisions but found patient forums and social media to be important adjuncts for receiving information.

CONCLUSION

Patients are satisfied with information received about diagnosis and treatment, but finances, sexual health, and fertility are less frequently discussed.

Changes in unmet care needs, social support and distress from initial diagnosis to post-surgery in patients with gynecological cancer: A longitudinal study

PURPOSE

This study aimed to explore the changes in unmet care needs, perceived social support, and levels of distress experienced by newly diagnosed Greek patients with gynecological cancer during the phase after diagnosis and before surgical treatment (T0), and 4 months after surgical treatment at the first postoperative follow-up visit (T1).

METHODS

This was a prospective, longitudinal, descriptive study based on the framework of stress and coping theory. The Needs Evaluation Questionnaire, Depression, Anxiety and Stress Scale (DASS-21), Multidimensional Scale of Perceived Social Support (MSPSS), and a demographic and clinical data questionnaire were distributed to a convenience sample of 86 patients.

RESULTS

A convenience sample of 86 patients newly diagnoised with gynecological cancer participated in the study. The mean age of the participants was 60.7 years (SD = 10.9 years) while 57.6% of them were married. Overall, patients' needs and social support had significantly decreased at T1 compared to T0 (p = 0.005 and p = 0.029, respectively). DASS-21 subscale scores did not change significantly at T1, whereas anxiety levels were significantly lower at follow-up (p = 0.048). Changes in anxiety levels were associated with changes in needs related to family (p < 0.001), need for assistance/care (p = 0.013) and support (p = 0.004), and total needs (p = 0.004).

CONCLUSION

The phase following cancer diagnosis and awaiting surgery is a high-risk period for the mental health of women with gynecological cancer, and one that requires special attention from healthcare professionals. By identifying unmet needs, addressing anxiety and providing appropriate social support, healthcare professional can contribute significantly to improving patients' quality of life throughout their cancer journey.

Active Treatment to Survivorship Care: A Mixed-Methods Study Exploring Resource Needs and Preferences of Young Adult Cancer Survivors in Transition

Purpose: The purpose of this study was to identify resource needs and preferences of young adult cancer survivors (YAs) during the transition from active treatment to survivorship care to inform tailored care tools to support YAs during this period. Methods: A mixed methods study following a sequential explanatory approach was conducted among YAs between the ages of 15 and 39. Online surveys were distributed to assess participant information and resource needs, and responses were further explored during virtual focus group and interview discussions. Frequencies and proportions were calculated to identify quantitative resource needs, and a descriptive qualitative approach was used to gather and analyze qualitative data. Results: Thirty-one participants completed the online surveys, and 27 participated in qualitative data collection. The top resource needs identified in the surveys and discussed in focus groups and interviews were (1) fear of recurrence, (2) sleep and fatigue, (3) anxiety, (4) nutrition, (5) physical activity, and (6) finances. Emergent themes identified during transcript analyses included the need for (1) tailored, customizable resources, (2) connection with other survivors, (3) tools to guide conversations about cancer, (4) clarity in what to expect during treatment and survivorship, and (5) consistent and equitable care in YA oncology. Conclusions: Participants identified six important information needs in addition to an overarching need for tailored support and equitable distribution of resources while transitioning into early survivorship. Thus, tailored interventions are needed to enhance the distribution of YA-centered resources, improve equity in YA cancer care, and connect YAs with peer survivors.

Consumers' longitudinal health information needs and seeking: a scoping review

Needing and seeking health information often is a longitudinal everyday life information behavior that involves the use of technology. However, no reviews of consumers' longitudinal health information needs (HIN) and health information-seeking (HIS) behavior have been conducted. We performed a scoping review to address this gap. Specifically, we surveyed the characteristics, timeline construction and research findings of studies investigating consumers' longitudinal HIN and HIS. Initial searches were conducted in November 2019 and updated in July 2022. A total of 128 papers were identified, reviewed and analyzed using content and thematic analyses. Results showed that most papers were quantitative, conducted in the USA, related to cancer, conducted during the diagnosis and treatment phases, and followed preset time intervals. Findings concerning the development patterns of consumers' HIN degrees and HIS effort were mixed (i.e. increasing, decreasing or being consistent over time). They seemed to be shaped by factors such as health conditions, data collection methods and the length of data collection. Consumers' use of sources changes depending on health status and source accessibility; their medical terminologies seem to expand over time. HIS has a strong emotional dimension which may lead to adaptive or maladaptive information behaviors (e.g. information avoidance). Overall, the results revealed a lack of understanding of HIN and HIS from a longitudinal perspective, particularly along health condition progression and coping trajectories. There is also a lack of understanding of the role of technologies in the longitudinal HIS process.

Unmet supportive care needs of breast cancer survivors: a systematic scoping review

BACKGROUND

Breast cancer is the most common type of cancer in women worldwide. Though improved treatments and prolonged overall survival, breast cancer survivors (BCSs) persistently suffer from various unmet supportive care needs (USCNs) throughout the disease. This scoping review aims to synthesize current literature regarding USCNs among BCSs.

METHODS

This study followed a scoping review framework. Articles were retrieved from Cochrane Library, PubMed, Embase, Web of Science, and Medline from inception through June 2023, as well as reference lists of relevant literature. Peer-reviewed journal articles were included if USCNs among BCSs were reported. Inclusion/exclusion criteria were adopted to screen articles' titles and abstracts as well as to entirely assess any potentially pertinent records by two independent researchers. Methodological quality was independently appraised following Joanna Briggs Institute (JBI) critical appraisal tools. Content analytic approach and meta-analysis were performed for qualitative and quantitative studies respectively. Results were reported according to the PRISMA extension for scoping reviews.

RESULTS

A total of 10,574 records were retrieved and 77 studies were included finally. The overall risk of bias was low to moderate. The self-made questionnaire was the most used instrument, followed by The Short-form Supportive Care Needs Survey questionnaire (SCNS-SF34). A total of 16 domains of USCNs were finally identified. Social support (74%), daily activity (54%), sexual/intimacy (52%), fear of cancer recurrence/ spreading (50%), and information support (45%) were the top unmet supportive care needs. Information needs and psychological/emotional needs appeared most frequently. The USCNs was found to be significantly associated with demographic factors, disease factors, and psychological factors.

CONCLUSION

BCSs are experiencing a large number of USCNs in fearing of cancer recurrence, daily activity, sexual/intimacy, psychology and information, with proportions ranging from 45% to 74%. Substantial heterogeneity in study populations and assessment tools was observed. There is a need for further research to identify a standard evaluation tool targeted to USCNs on BCSs. Effective interventions based on guidelines should be formulated and conducted to decrease USCNs among BCSs in the future.

A mixed methods evaluation of the unmet needs of early-onset colorectal cancer survivors

PURPOSE

The incidence of colorectal cancer (CRC) is rising in people under age 50 (early-onset). Early-onset survivors face CRC during a critical point in their lives; many are establishing their families and careers. We sought to identify the unmet needs in a sample of early-onset CRC survivors and the resources they desired to address those needs.

METHODS

We conducted a mixed methods study where participants completed the Cancer Survivors Unmet Needs (CaSUN) survey and a subsequent qualitative interview to expand on their unmet needs and desired resources.

RESULTS

A total of 12 CRC survivors participated and 83% identified at least one unmet need, with an average of 13 unmet needs reported. Unmet needs were identified across every domain of the CaSUN measure, most commonly in the existential survivorship domain. Qualitative results demonstrated that survivors need more resources tailored for people their age and additional support for their families, including young children.

CONCLUSION

Early-onset CRC survivors' needs are framed by the stage of their lives in which they are diagnosed, and the demand for interventions to support these survivors will continue to rise. The results of this study can inform future, tailored interventions for early-onset CRC survivors with substantial needs.

Relationship between supportive care needs with coronavirus anxiety and death anxiety of women with gynecologic cancer during the COVID-19 pandemic

AIM

The study aimed to determine the relationship between supportive care needs with coronavirus anxiety and death anxiety of women with gynecologic cancer during COVID-19.

METHODS

The population of the study was women with gynecologic cancer who received chemotherapy in a university hospital. The study sample was calculated using G*Power 3.1.9.4 analysis program and completed with 64 patients who agreed to participate and met the research criteria. The personal information form, supportive care needs survey-short form (SCNS-SF29^Tr ), coronavirus anxiety scale (CAS), and death anxiety scale (DAS) were used for data collection.

RESULTS

The participants' SCNS-SF29^Tr mean score was 105.7 ± 17.26, CAS mean score was 11.19 ± 3.96, and DAS mean score was 40.13 ± 15.5. There was a positive, very high-level correlation between the health system and information and psychological needs subscales of SCNS-SF29^Tr and CAS (r = 0.809, r = 0.878, respectively; p < 0.05). In addition, a high-level relationship was found between the daily life subscale of SCNS-SF29^Tr and CAS (r = 0.674; p < 0.001). A positive low-level relationship was determined between the health system and information, daily life, and psychological needs (except for the sexuality) subscales of SCNS-SF29^Tr and DAS (r = 0.357, r = 0.252, r = 0.353 respectively; p < 0.05).

CONCLUSION

Gynecologic cancer participants had unmet supportive care needs in all subscales except for the sexuality. The participants had higher supportive care needs, high-level coronavirus anxiety, and medium-level death anxiety. In addition, the participants' all supportive care needs have increased as their coronavirus anxiety levels have increased. The participants' supportive care needs have increased, except for sexuality, as their death anxiety levels have increased.

Fear of cancer recurrence at 2.5 years after a cancer diagnosis: a cross-sectional study in Denmark

PURPOSE

The aim was to investigate the characteristics of cancer survivors with high levels of fear of cancer recurrence, and how such fear is associated with their needs for care.

METHODS

This cross-sectional study was based on survey data from Danish cancer survivors at 2.5 years after a cancer diagnosis. These data were linked to nationwide register data. We used the 7-item Fear of Cancer Recurrence Inventory (FCR7) to measure fear of cancer recurrence, focussing on emotional, cognitive and behavioural reactions to such fear. The FCR7 score was dichotomised at the 75th percentile. A logistic regression model was used to analyse the associations between a high level of fear of cancer recurrence and (1) characteristics of patient and primary cancer and (2) cancer survivors' statements concerning follow-up for cancer.

RESULTS

We included 1538 cancer survivors in the study. The median FCR7 score was 18 (interquartile interval: 13-21), and 366 (23.8%) respondents had an FCR7 score of > 21, defined as a high level of fear. In the adjusted analyses, a high level of fear was associated with female sex, younger age, comorbidity, advanced tumour stage and negative statements concerning follow-up, including feeling less safe in the follow-up programme. Fear was not related to the professional background of care providers involved in cancer follow-up.

CONCLUSION

Fear of cancer recurrence was associated with female sex, younger age, comorbidity, advanced tumour stage and discontent with cancer follow-up.

Integrated, cross-sectoral psycho-oncology (isPO): a new form of care for newly diagnosed cancer patients in Germany

Background

The annual incidence of new cancer cases has been increasing worldwide for many years, and is likely to continue to rise. In Germany, the number of new cancer cases is expected to increase by 20% until 2030. Half of all cancer patients experience significant emotional and psychosocial distress along the continuum of their disease, treatment, and aftercare, and also as long-term survivors. Consequently, in many countries, psycho-oncological programs have been developed to address this added burden at both the individual and population level. These programs promote the active engagement of patients in their cancer therapy, aftercare and survivorship planning and aim to improve the patients' quality of life.

In Germany, the “new form of care isPO” (“nFC-isPO”; integrated, cross-sectoral psycho-oncology/integrierte, sektorenübergreifende Psycho-Onkologie) is currently being developed, implemented and evaluated. This approach strives to accomplish the goals devised in the National Cancer Plan by providing psycho-oncological care to all cancer patients according to their individual healthcare needs. The term “new form of care" is defined by the Innovation Fund (IF) of Germany's Federal Joint Committee as “a structured and legally binding cooperation between different professional groups and/or institutions in medical and non-medical care”.

The nFC-isPO is part of the isPO project funded by the IF. It is implemented in four local cancer centres and is currently undergoing a continuous quality improvement process. As part of the isPO project the nFC-isPO is being evaluated by an independent institution: the Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Germany.

The four-year isPO project was selected by the IF to be eligible for funding because it meets the requirements of the federal government's National Cancer Plan (NCP), in particular, the “further development of the oncological care structures and quality assurance" in the psycho-oncological domain. An independent evaluation is required by the IF to verify if the new form of care leads to an improvement in cross-sectoral care and to explore its potential for permanent integration into the German health care system.

Methods

The nFC-isPO consists of six components: a concept of care (C1), care pathways (C2), a psycho-oncological care network (C3), a care process organization plan (C4), an IT-supported documentation and assistance system (C5) and a quality management system (C6). The two components concept of care (C1) and care pathways (C2) represent the isPO clinical care program, according to which the individual cancer patients are offered psycho-oncological services within a period of 12 months after program enrolment following the diagnosis of cancer. The remaining components (C3-C6) represent the formal-administrative aspects of the nFC-isPO that are intended to meet the legally binding requirements of patient care in the German health care system. With the aim of systematic development of the nFC-isPO while at the same time enabling the external evaluators to examine its quality, effectiveness and efficiency under conditions of routine care, the project partners took into consideration approaches from translational psycho-oncology, practice-based health care research and program theory. In order to develop a structured, population-based isPO care program, reference was made to a specific program theory, to the stepped-care approach, and also to evidence-based guideline recommendations.

Results

The basic version, nFC-isPO, was created over the first year after the start of the isPO project in October 2017, and has since been subject to a continuous quality improvement process. In 2019, the nFC-isPO was implemented at four local psycho-oncological care networks in the federal state North Rhine-Westphalia, in Germany. The legal basis of the implementation is a contract for "special care" with the German statutory health insurance funds according to state law (§ 140a SCB V; Social Code Book V for the statutory health insurance funds). Besides the accompanying external evaluation by the IMVR, the nFC-isPO is subjected to quarterly internal and cross-network quality assurance and improvement measures (internal evaluation) in order to ensure continuous quality improvement process. These quality management measures are developed and tested in the isPO project and are to be retained in order to ensure the sustainability of the quality of nFC-isPO for later dissemination into the German health care system.

Discussion

Demands on quality, effectiveness and cost-effectiveness of in the German health care system are increasing, whereas financial resources are declining, especially for psychosocial services. At the same time, knowledge about evidence-based screening, assessment and intervention in cancer patients and about the provision of psychosocial oncological services is growing continuously. Due to the legal framework of the statutory health insurance in Germany, it has taken years to put sound psycho-oncological findings from research into practice. Ensuring the adequate and sustainable financing of a needs-oriented, psycho-oncological care approach for all newly diagnosed cancer patients, as required by the NCP, may still require many additional years. The aim of the isPO project is to develop a new form of psycho-oncological care for the individual and the population suffering from cancer, and to provide those responsible for German health policy with a sound basis for decision-making on the timely dissemination of psycho-oncological services in the German health care system.

Trial registration

The study was pre-registered at the German Clinical Trials Register (https://www.drks.de/DRKS00015326) under the following trial registration number: DRKS00015326; Date of registration: October 30, 2018.

Unmet needs of 1210 Chinese breast cancer survivors and associated factors: a multicentre cross-sectional study

Background

Breast cancer survivors (BCSs) often have potential unmet needs. Identification of the specific needs of BCSs is very significant for medical service provision. This study aimed to (1) investigate the unmet needs and quality of life (QoL) of BCSs in China, (2) explore the diverse factors associated with their unmet needs, and (3) assess the association between their unmet needs and QoL.

Methods

A multicentre, cross-sectional survey was administered to 1210 Chinese BCSs. The Cancer Survivor Profile-Breast Cancer and the Functional Assessment of Cancer Therapy-Breast scale were administered to survivors who gave informed consent to participate. Data were analysed using t-test, ANOVA, multiple regression analysis, and Pearson correlations.

Results

The 1192 participants completed questionnaires (response rate 98.51%). Our study reveals that the most prevalent unmet needs were in the ‘symptom burden domain’. The unmet needs of BCSs depend on eleven factors; age, time since diagnosis, education level, occupation, payment, family income status, stage of cancer, treatment, family history of cancer, pain, and physical activities. To ensure the provision of high-quality survivorship care and a high satisfaction level, more attention should be paid to actively identifying and addressing the unmet needs of BCSs. The problem areas identified in the Cancer Survivor Profile for breast cancer were negatively associated with all subscales of QoL except the health behaviour domain, with the correlation coefficient ranging from − 0.815 to − 0.011.

Conclusion

Chinese BCSs exhibit a high demand for unmet needs in this study, and the most prevalent unmet needs were in the ‘symptom burden domain’. There was a significant association between patients’ unmet needs (as defined in the Cancer Survivor Profile for breast cancer) and QoL. Future research should focus on enhancements to survivorship or follow-up care to address unmet needs and further improve QoL.

Expanding access to cancer peer support: development of a website to deliver written peer support that meets patients' individual emotional and informational needs while reducing potential harms

Cancer patients often want information from "peers" with the same diagnosis or treatment. To increase access to this valuable resource, we developed a website to deliver written peer support to cancer patients undergoing stem cell transplant. Because little evidence describes how to optimize benefits or reduce potential harms of written peer support, we gathered multiple forms of stakeholder feedback to inform the website's ethical approach, personalization, design, function, and content: a Community Advisory Board; a longitudinal study of patients' written peer support needs and motivations; focus groups; semi-structured interviews; and usability testing. Findings provide a rich foundation for website development.

Emotional, informational and instrumental support needs in patients with breast cancer who have undergone surgery: a cross-sectional study

OBJECTIVES

This study evaluated emotional, informational and instrumental support needs in patients with breast cancer who had undergone surgery, then identified the variables associated with those needs.

DESIGN

This was a cross-sectional survey study.

SETTING

Questionnaires were distributed in tertiary hospitals in China between January 2018 and July 2020.

PARTICIPANTS

We recruited 477 eligible patients with breast cancer via convenience sampling. Due to exclusions for response errors, the final analysed sample included 461 participants (mean age of 50.9 years). Each completed a questionnaire consisting of a sociodemographic information component and three short forms from the Patient-Reported Outcome Measurement Information System (social relationships short forms, anxiety short form and depression short form). Subsequent analyses included the χ² test, Pearson correlation and multivariate regression.

RESULTS

The T scores for informational support were lower than those for the reference group (general population), while those for emotional and informational support were average. Marital status, childbearing history, lifestyle, employment status, anxiety and depression levels were related to the scores for emotional, informational and instrumental support in this population. The regression analysis revealed that emotional support levels, instrumental support levels, marital status, employment status, anxiety and depression outcomes were predictors for informational support levels.

CONCLUSIONS

Informational support should be specifically assessed and promoted among patients with breast cancer in general, while marital status, childbearing history, lifestyle, employment status, anxiety and depression levels should be evaluated when conducting interventions to promote emotional, informational and instrumental support for those who have undergone surgery. Early and regular screenings for high-risk patients will help nurses identify those who are likely to benefit from targeted preventive interventions aimed at emotional, informational and instrumental support issues.

TRIAL REGISTRATION NUMBER

ChiCTR2000035439; ClinicalTrials.gov registry.

Improving access to cancer information and supportive care services: A systematic review of mechanisms applied to link people with cancer to psychosocial supportive care services

OBJECTIVE

Previous research has described the low uptake of psychosocial support services in people living with cancer. While characteristics of individuals using services have been examined, mechanisms applied to link individuals to support services are less frequently considered. This review aims to identify the mechanisms used to link people with cancer to support services and assess their impact.

METHODS

Systematic searches of Pubmed, CINAHL, EMBASE and PsycINFO were conducted up to May 2020. Studies reporting service use associated with mechanisms to link adults with cancer to support services targeting emotional, informational, practical or social support needs were eligible. Eligible study designs included controlled trials, pre-post designs and observational studies. Study quality was assessed and a narrative synthesis of findings undertaken.

RESULTS

A total of 10 papers (from 8,037 unique titles) were eligible. Testing the feasibility of the linkage mechanism was the primary aim in five (50%) studies. Three linkage mechanisms were identified: (a) outreach from the support service; (b) clinician recommendation/referral; (c) mailed invitation. Outreach was the most successful in connecting people with cancer to services (52%-90% use); clinician recommendation/referral was least successful (3%-28%). The impact of different linkage mechanisms for different demographic groups was not assessed.

CONCLUSIONS

Outreach from services shows the most potential for increasing access to support services. However, the limited number of studies and limitations in the types of support services people with cancer were linked to, demonstrated the need for further work in this area. Identifying mechanisms that are effective for underserved, high-needs patient groups is also needed.