Spirituality, Patients' Worry, and Follow-Up Health-Care Utilization among Cancer Survivors

Cancer worry is associated with increased use of supportive health care-results from the multinational InCHARGE study

PURPOSE

To assess use of health care following a diagnosis of endometrial, cervical, and ovarian cancer in the Netherlands, Norway, and Denmark. Furthermore, to analyze the association between cancer worry and use of supportive care.

METHODS

An international multicenter cross-sectional questionnaire study was undertaken among female cancer survivors with endometrial, cervical, or ovarian cancer 1-7 years post diagnosis. We investigated different aspects of cancer survivorship and follow-up care. Health care use included information on the use of supportive health care, general practitioner (GP), and follow-up visits to the department of gynecology. Cancer worry was assessed with the Impact of Cancer (IoCv2) questionnaire.

RESULTS

A total of 1433 women completed the questionnaire. Health care use decreased from time of diagnosis and was higher among cervical and ovarian cancer survivors than endometrial cancer survivors. Twenty-five percent of the women with ovarian cancer reported severe cancer worry, in contrast to 10 and 15% of women diagnosed with endometrial and cervical cancer, respectively. Women with severe worry had significantly higher use of supportive care activities. In a multivariable regression analysis, cancer worry remained a significant correlate for use of supportive health care services irrespective of disease severity or prognosis. The strongest association was found for use of a psychologist (OR 2.1 [1.71-2.58]).

CONCLUSION

Cancer worry is associated with increased use of supportive care.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted, timely, and accessible psychological support aimed at severe cancer worry may improve survivorship care and ensure optimal referral of patients in need of additional care.

Interplay between spirituality and religiosity on the physical and mental well-being of cancer survivors

PURPOSE

This study explored the relationship of spirituality and religiosity as it affects the physical and mental quality of life (pQOL, mQOL) of cancer survivors.

METHODS

This is a prospective observational study that included adults ≥ 19 years who received treatment for various types of cancer. Patients' QOL was obtained at baseline, 6, and 12 months. Cohorts were categorized according to spirituality/religiosity levels: low spirituality-low religiosity (LSLR), low spirituality-high religiosity (LSHR), high spirituality-low religiosity (HSLR), and high spirituality-high religiosity (HSHR).

RESULTS

Of the 551 eligible, 248 (45%) had HSHR, 196 (36%) had LSHR, 75 (14%) had LSLR, and 32 (6%) had HSLR. The pQOL of LSLR were significantly lower than those with HSHR (p = 0.02). The differences in pQOL between LS and HS were observed among those who have HR (p < 0.0001). Among patients with LR, pQOL did not differ. The mQOL of patients with LSLR was significantly lower than those with HSHR (p < 0.0001). The mQOL of those with HS was significantly higher than those with LS in both cohorts having LR (p < 0.0001) or HR (p < 0.0001). pQOL decreased while mQOL increased over time regardless of spirituality or religiosity levels.

CONCLUSION

Spirituality is important in the improvement of both pQOL and mQOL of cancer survivors, while religiosity may have some impact on pQOL. Clinicians' incorporation of spirituality into cancer treatment facilitates well-rounded care, which offers measurable improvements for patients with an illness, of which the treatment is often arduous, and uncertain.

Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines

•This ESMO Clinical Practice Guideline provides key recommendations for end-of-life care for patients with advanced cancer. •It details care that is focused on comfort, quality of life and approaching death of patients with advanced cancer. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the authors’ collective expert opinion.

Physician management of thyroid cancer patients' worry

PURPOSE

The purpose of this study is to understand physician management of thyroid cancer-related worry.

METHODS

Endocrinologists, general surgeons, and otolaryngologists identified by Surveillance, Epidemiology, and End Results (SEER) patients were surveyed 2018-2019 (response rate 69% (448/654)) and asked to rate in general their patients' worry at diagnosis and actions they take for worried patients. Multivariable-weighted logistic regressions were conducted to determine physician characteristics associated with reporting thyroid cancer as "good cancer" and with encouraging patients to seek help managing worry outside the physician-patient relationship.

RESULTS

Physicians reported their patients as quite/very worried (65%), somewhat worried (27%), and a little/not worried (8%) at diagnosis. Half of the physicians tell patients their thyroid cancer is a "good cancer." Otolaryngology (odds ratio (OR) 1.87, 95% confidence interval (CI) 1.08-3.21, versus endocrinology), private practice (OR 2.48, 95% CI 1.32-4.68, versus academic setting), and Los Angeles (OR 2.24, 95% CI 1.45-3.46, versus Georgia) were associated with using "good cancer." If patients are worried, 97% of physicians make themselves available for discussion, 44% refer to educational websites, 18% encourage communication with family/friends, 13% refer to support groups, and 7% refer to counselors. Physicians who perceived patients being quite/very worried were less likely to use "good cancer" (OR 0.54, 95% CI 0.35-0.84) and more likely to encourage patients to seek help outside the physician-patient relationship (OR 1.82, 95% CI 1.17-2.82).

IMPLICATIONS FOR CANCER SURVIVORS

Physicians perceive patient worry as common and address it with various approaches, with some approaches of unclear benefit. Efforts are needed to develop tailored interventions targeting survivors' psychosocial needs.

Spirituality in cancer patients on phase 1 clinical trials

OBJECTIVES

Patients with cancer who are at a transition to Phase I investigational treatments have been identified as an underserved population with regard to palliative care. This disease transition is often accompanied by spiritual and existential concerns. The study objective was to conduct a secondary analysis of data from a larger study testing a palliative care intervention. This paper reports the findings of this secondary focus on the spiritual needs of this population.

METHODS

Patients (n = 479) were accrued to this study prior to initiating a Phase I clinical trial with data collected at baseline, and 4, 12, and 24 week follow-up.

RESULTS

Qualitative data revealed that the transition to Phase 1 trial participation is a time of balancing hope for extended life with the reality of advancing disease. Quantitative results demonstrated increased spirituality over time in both religious- and non-religious-affiliated patients.

CONCLUSIONS

Patients entering Phase I trials have important spiritual needs as they face treatment decisions, advancing disease, and often mortality. Spiritual care should be provided to seriously ill patients as a component of quality care.

Improving implementation of psychological interventions to older adult patients with cancer: Convening older adults, caregivers, providers, researchers

INTRODUCTION

Older adults with cancer (OACs) are a large and growing population. Psychological distress is prevalent in this population yet few OACs receive evidence-based psychological care. The purpose of this project was to identify barriers and strategies for the implementation of psychological interventions to OACs from the perspective of OACs, OAC caregivers, researchers, clinicians, and advocacy organization members.

METHODS

The Cornell Research-to-Practice (RTP) Consensus Workshop Model was used to organize and convene a consensus conference. The one-day conference consisted of small and large group discussions regarding barriers, facilitators, and strategies for the implementation of psychological interventions targeting OACs. A half-day roundtable meeting was subsequently conducted to organize data generated at the conference. De-identified transcriptions of the small group discussions were uploaded into NVivo 11 software and qualitatively analyzed using standard methods.

RESULTS

Thirty-five participants attended the consensus conference from across stakeholder groups. Three themes related to implementation barriers were identified: lack of knowledge about psychological interventions in patients and providers; personal and social factors associated with being an OAC; and institutional-level factors. Themes related to implementation strategies focused on increasing awareness, tailoring interventions for older adults, and modifying institutional-level factors.

DISCUSSION

Effective implementation of psychological interventions to OACs is complex and barriers exist across multiple levels of care. However, this project indicates that implementation can be improved in various ways that include all members of the healthcare system. Further clarification of implementation strategies and rigorous evaluation of their effectiveness is vital to improving care and care outcomes of OACs.

Fear of cancer recurrence in lymphoma survivors: A descriptive study

Objectives: Fear of cancer recurrence (FCR) is a common experience among cancer survivors and often persists after the termination of cancer treatments. The purpose of this paper was to evaluate FCR in survivors of Hodgkin's and diffuse large B-cell lymphomas, given a high rate of survivorship in this patient population.Research Approach: The parent study was a multi-site, cluster-randomized trial to assess a communication skills intervention: survivorship planning consultation (versus a time-attention control - wellness rehabilitation intervention) to promote transition to survivorship.Participants & Methodological Approach: 199 patients enrolled in the study and completed a survivorship (or control) consultation one-month after receiving the news of their survivorship status; 141 of those patients (n = 92 experimental arm, n = 49 control arm) completed an interview at their 6-month follow-up consultation. In the interview, participants described frequency of FCR, causes of FCR, coping mechanisms, and specific things oncologists said to reduce FCR. Both qualitative and quantitative methods were utilized for analyzing participant responses.Findings: The majority (88%) of participants reported experiencing FCR, with a higher number of participants in the experimental arm significantly more likely to endorse FCR compared to the control group participants. The main causes of FCR were having medical appointments and concerns about potential relapse and secondary cancers. Participants endorsed utilizing self-sufficient coping mechanisms. As well, participants reported that oncologists most frequently cited specific cure rates of lymphoma to reduce patients' FCR.Interpretation & Implications for Psychosocial Providers: Communication skills training programs should emphasize FCR in survivorship consultations.

Spiritual Considerations

Spiritual issues play a prominent role for patients with cancer. Studies have demonstrated a positive connection between a patient's spirituality and health outcomes, including quality of life, depression and anxiety, hopefulness, and the ability to cope with illness. Spiritual or existential distress is prominent in patients with cancer. Models are described that identify ways for clinicians to identify or diagnose spiritual or existential distress, and to attend to that distress. It is critical that all clinicians assess for spiritual distress as part of a routine distress assessment, identify appropriate treatment strategies, and work closely with trained spiritual care professionals.

Assessing the relationship between fear of cancer recurrence and health care utilization in early-stage breast cancer survivors

PURPOSE

The purpose of this study was to determine whether fear of cancer recurrence (FCR) is associated with greater health care utilization (HCU) in early-stage breast cancer survivors.

METHODS

Three hundred early-stage breast cancer survivors diagnosed within the past 7 years reported on FCR as well as calls and visits to oncology providers and primary care providers during the preceding 3 months. Participants also reported on use of mental health services and psychotropic medications since diagnosis. Structural equation modeling was used to create a latent FCR factor and evaluate this factor as a predictor of various HCU outcomes controlling for age at diagnosis, years since diagnosis, generalized anxiety, objective risk of recurrence, and number of comorbidities.

RESULTS

FCR predicted more visits to both oncology providers (RR = 1.53, p = .002) and primary care providers (RR = 1.31, p = .013), as well as more phone calls to oncology providers (RR = 2.08, p = .007). FCR was not a significant predictor of phone calls to primary care providers (RR = 1.39, p = .054), utilization of mental health treatment (OR = 1.27, p = .362), or use of psychotropic medications (OR = 1.37, p = .178).

CONCLUSIONS

FCR was associated with increases in some types of HCU, which may reflect excessive medical reassurance-seeking and lead to unnecessary medical costs.

IMPLICATIONS FOR CANCER SURVIVORS

FCR is a serious concern that warrants greater attention to reduce distress-related health care utilization. Utilization of mental health services to address FCR may represent higher-value health care.

Prevalence and correlates of high fear of cancer recurrence in late adolescents and young adults consulting a specialist adolescent and young adult (AYA) cancer service

OBJECTIVE

High fear of cancer recurrence (FCR) is a frequently reported problem among cancer patients. Previous research has shown that younger age is associated with higher levels of FCR. However, little attention has been given to date about how FCR manifests itself among adolescent and young adult (AYA) cancer patients. This study explores the prevalence, correlates of high FCR, and its association with HRQoL in cancer patients in their late adolescence or young adulthood.

METHODS

Seventy-three AYA cancer patients, aged 18-35 years at diagnosis, consulted the AYA team of the Radboud University Medical Center completed questionnaires including the Cancer Worry Scale (CWS), Quality of Life-Cancer Survivors (QOL-CS), and Hospital Anxiety and Depression Scale (HADS). Sociodemographic and medical data was collected by self-reported questionnaire.

RESULTS

Forty-five participants experienced high FCR (62%), which was higher than the 31-52% reported in previous studies among mixed adult cancer patient samples. Sociodemographic and medical variables were not associated with levels of FCR. High FCR was significantly associated with lower levels of social and psychological functioning and overall HRQoL and higher levels of anxiety and psychological distress.

CONCLUSION

Results illustrate that FCR is a significant problem among AYA cancer patients consulting an AYA team, with participants reporting higher levels of FCR than cancer patients of mixed ages. Health care providers should pay specific attention to this problem by screening and the provision of appropriate psychosocial care when needed.

Perceived and Actual Change in Religion/Spirituality in Cancer Survivors: Longitudinal Relationships With Distress and Perceived Growth

This observational cohort study examined the relationships between actual and perceived R/S change at 12 months post cancer diagnosis with depression, anxiety, and perceived growth 6 months later. Older adult military veteran cancer survivors (n = 111) completed self-report surveys at 6, 12, and 18 months post cancer diagnosis. Perceived R/S change was assessed at 12 months postdiagnosis with "Have your religious or spiritual beliefs changed as a result of your cancer" (more R/S, less R/S, other). Actual R/S change was assessed at 6 and 12 months postdiagnosis on a single item, "I have faith in God or a Higher Power" (no, somewhat, yes). A notable minority reported perceived (18.9%) and actual (14.4%) change. Greater perceived R/S change predicted more severe symptoms of depression and anxiety and greater perceived growth at 18 months postdiagnosis; perceived growth was positively associated with anxiety. Cancer survivors who report R/S changes may benefit from spiritual and/or psychological support.

Palliative care and spiritual well-being in lung cancer patients and family caregivers

BACKGROUND

Spiritual well-being is an important dimension of quality of life (QOL) and is a core component of quality oncology and palliative care. In this analysis, we aimed to describe spiritual well-being outcomes in a National Cancer Institute (NCI)-supported Program Project that tested the effectiveness of an interdisciplinary palliative care intervention in lung cancer patients and their family caregivers (FCGs).

METHODS

Patients undergoing treatments for NSCLC and their FCGs were enrolled in a prospective, quasi-experimental study. Patients and FCGs in the intervention group were presented at interdisciplinary care meetings and received four educational sessions that included one session focused on spiritual well-being. Spiritual well-being for patients was measured using the FACIT-Sp-12, and FCG spiritual well-being was measured using the COH-QOL-FCG spiritual well-being subscale. Multivariate analysis of covariance was undertaken for subscale and item scores at 12 weeks, controlling for baseline, by religious affiliations (yes or no) and group assignment.

RESULTS

Religiously affiliated patients reported better scores in the Faith subscale and items on finding strength and comfort in faith and spiritual beliefs compared to non-affiliated patients. Non-affiliated patients had better scores for feeling a sense of harmony within oneself. By group, patients who received the intervention had significantly better scores for the Meaning/Peace subscale.

CONCLUSIONS

Our findings support the multidimensionality of spiritual well-being that includes constructs such as meaning and faith for lung cancer patients and FCGs with or without religious affiliations. Palliative care interventions should include content that targets the spiritual needs of both patients and FCGs. Copyright © 2015 John Wiley & Sons, Ltd.

Improving Spiritual Well-Being in Patients with Lung Cancers

Patients with lung cancer report more disease burden and lower spiritual well-being (SWB) compared with other cancer patients. Understanding variables that lessen disease burden and improve SWB is essential. The aim of this study was to explore the relationship between motivational level for physical activity and SWB in patients with lung cancer. Linear regression showed increased SWB as stage of change for physical activity increased (p < 0.0001), even after adjusting for multiple demographic variables.

Fear of cancer recurrence in colorectal cancer survivors

Purpose

Although long-term colorectal cancer (CRC) survivors generally report a good quality of life, fear of cancer recurrence (FCR) remains an important issue. This study investigated whether the Cancer Worry Scale (CWS) can detect high FCR, the prevalence, and characteristics of FCR in CRC survivors.

Methods

Two hundred and eleven patients who had undergone successful CRC surgery in the period 2003–2010 in the Radboud University Medical Center in the Netherlands were asked to participate. All patients were sent an information letter plus questionnaires for collecting information on demographic and medical variables, FCR, distress, and quality of life.

Results

Seventy-six patients (36 %; median age of 67.7 years range 41–88 years) completed the questionnaires a median of 5.1 years after surgery. A cut-off score of 14 or higher on the CWS was optimal to detect high FCR. Twenty-nine patients (38 %) experienced high levels of FCR, characterized by higher levels of distress, post-traumatic stress symptoms, and lower quality of life. These individuals particularly reacted to disease-related triggers, felt helpless, were worried, and experienced limitations in daily functioning. High FCR was not associated with demographic or medical variables.

Conclusion

Long after successful CRC surgery, FCR is a serious problem that impairs the quality of life for a substantial proportion of patients. With the CWS, it is possible to detect high FCR and thereby assist survivors in receiving appropriate care.

Cancer-related worry in Canadian thyroid cancer survivors

CONTEXT

Little is known about cancer-related worry in thyroid cancer survivors.

OBJECTIVES

We quantified cancer-related worry in Canadian thyroid cancer survivors and explored associated factors.

DESIGN, SETTING, AND PARTICIPANTS

We performed a cross-sectional, self-administered, written survey of thyroid cancer survivor members of the Thyroid Cancer Canada support group. Independent factors associated with cancer-related worry were identified using a multivariable linear regression analysis.

MAIN OUTCOME MEASURE

We used the Assessment of Survivor Concerns (ASC) questionnaire, which includes questions on worry about diagnostic tests, second primary malignancy, recurrence, dying, health, and children's health.

RESULTS

The response rate for eligible members was 60.1% (941 of 1567). Most respondents were women (89.0%; 837 of 940), and the age was < 50 years in 54.0% of participants (508 of 941). Thyroid cancer was diagnosed within ≤ 5 years in 66.1% of participants (622 of 940). The mean overall ASC score was 15.34 (SD, 4.7) (on a scale from 6 [least worry] to 24 [most worry]). Factors associated with increased ASC score included: younger age (P < .001), current suspected or proven recurrent/persistent disease (ie, current proven active disease or abnormal diagnostic tests) (P < .001), partnered marital status (P = .021), having children (P = .029), and ≤5 years since thyroid cancer diagnosis (P = .017).

CONCLUSIONS

In a population of Canadian thyroid cancer survivors, cancer-related worry was greatest in younger survivors and those with either confirmed or suspected disease activity. Family status and time since thyroid cancer diagnosis were also associated with increased worry. More research is needed to confirm these findings and to develop effective preventative and supportive strategies for those at risk.

Mindfulness based stress reduction (MBSR(BC)) in breast cancer: evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT)

To investigate the mechanism(s) of action of mindfulness based stress reduction (MBSR(BC)) including reductions in fear of recurrence and other potential mediators. Eighty-two post-treatment breast cancer survivors (stages 0-III) were randomly assigned to a 6-week MBSR(BC) program (n = 40) or to usual care group (UC) (n = 42). Psychological and physical variables were assessed as potential mediators at baseline and at 6 weeks. MBSR(BC) compared to UC experienced favorable changes for five potential mediators: (1) change in fear of recurrence problems mediated the effect of MBSR(BC) on 6-week change in perceived stress (z = 2.12, p = 0.03) and state anxiety (z = 2.03, p = 0.04); and (2) change in physical functioning mediated the effect of MBSR(BC) on 6-week change in perceived stress (z = 2.27, p = 0.02) and trait anxiety (z = 1.98, p = 0.05). MBSR(BC) reduces fear of recurrence and improves physical functioning which reduces perceived stress and anxiety. Findings support the beneficial effects of MBSR(BC) and provide insight into the possible cognitive mechanism of action.

Spirituality in the cancer trajectory

Spirituality is an essential element of person-centered care and a critical factor in the way patients with cancer cope with their illness from diagnosis through treatment, survival, recurrence and dying. Studies have indicated a significant relationship between spirituality and quality of life. Spirituality, in its broadest sense speaks to the meaning patients find in their lives especially during times of stress, illness and dying. Illness can trigger deep existential issues that could trigger profound suffering and distress. A model is presented that describes the role of each member of the healthcare team in addressing patients' spirituality. Spiritual distress, as a diagnosis, requires attention and treatment just as any other clinical symptom. Spiritual resources of strength need to be identifies and recognized as positive factors in patients' coping. Finally a treatment plan needs to include the spiritual as well as the physical and psychosocial issues of patients. Chaplains and other spiritual care professionals need to be recognized as the experts in spiritual care and should be integral members of the healthcare team. Integrating spirituality as an essential domain of care will result in better health outcomes, particularly quality of life for patients across the trajectory of cancer care.

The role of chaplains within oncology interdisciplinary teams

PURPOSE OF REVIEW

The role of chaplains/spiritual care professionals and the importance of addressing spiritual needs within interdisciplinary oncology teams are in need of systematic review and critical appraisal. This review focuses on four key areas: basic concepts of spirituality within the healthcare domain; the relevance of spirituality within cancer care; the role of spiritual care within interdisciplinary cancer teams; and the current status of spiritual care professionals in interdisciplinary cancer teams.

RECENT FINDINGS

Addressing cancer patient's spiritual issues is recognized as a component of comprehensive cancer care. Spirituality has a positive effect on subjective and emotional aspects of cancer patient's health, including quality of life, wellbeing and distress. Failing to address cancer patients spiritual needs impacts patient wellbeing, satisfaction with care, perceived quality of care and is associated with higher healthcare costs. Although a variety of disciplines address spiritual issues, spiritual care professionals are recognized by patients, clinicians, researchers and within best practice guidelines of national health councils as specialists within this domain.

SUMMARY

Spiritual care professionals are increasingly recognized as integral members of interdisciplinary oncology teams. However, the full integration of spiritual care professionals within the standard practice of oncology interdisciplinary teams is lacking, as spiritual care services continue to be treated as ancillary services within cancer care organizations.