Lymphomas: long-term sequelae and survivorship issues

[Adherence to treatment of hematological malignancies patients with anxiety and depression]

AIM

To establish the features of the influence of anxiety and depressive disorders on treatment adherence, as well as to clarify the factors associated with it in hematologic malignancies patients.

MATERIALS AND METHODS

The study included 117 patients: 51 men and 66 women, aged 19 to 67 years, with Hodgkin's lymphoma - 88, acute lymphoblastic leukemia - 16 and aplastic anemia - 13 patients. Patients were examined by psychiatrist using the Brief Psychiatric Rating Scale, as well as some psychometric methods.

RESULTS

Anxiety-depressive spectrum disorders were detected in 36 (40.9%) patients with Hodgkin's lymphoma and 8 (50%) with acute lymphoblastic leukemia, in the aplastic anemia group there were three (23.1%) of such patients. It was found that the average adherence to treatment was in 2/3 of patients, low and high - in the remaining 1/3 of patients. With medium and low adherence to treatment, the risk of adverse events increases by an average of 1.7 times. The adherence to treatment it is significantly higher in patients older than 45 years. Signs of depression that negatively correlated with adherence to treatment were pessimism and disruption of social ties. Adherence to treatment significantly positively correlates with the following types of attitudes towards the disease: anosognosic, hypochondriac and egocentric, and significantly negatively correlates with the following types of attitudes towards the disease: anxious, melancholic and dysphoric.

CONCLUSION

Anxiety/depressive disorders contribute to reduced adherence of hematologic malignancies patients to treatment. Their correction and increased adherence should be carried out jointly by hematologists and mental health professionals.

Survivorship transitions in blood cancer: Identifying experiences and supportive care needs for caregivers

PURPOSE

Survivorship care often refers to continued healthcare after cancer treatment. Jacobsen and colleagues advocated to expand this to include patients on extended treatments and maintenance/prophylactic therapies, recognizing the care continuum as more complex. Transitions of care for individuals diagnosed with a blood cancer can be complicated. We sought to better understand blood cancer caregivers' experiences as their diagnosed family member encountered "survivorship transitions" across the continuum.

METHODS

We conducted semi-structured interviews with adults caring for a parent or a child with a blood cancer. Caregivers were segmented into survivorship groups based on two transitional contexts: (1) when patients transitioned to a new line of therapy (active treatment or maintenance therapy); (2) when patients ended treatment. We conducted a thematic analysis and triangulated findings to compare transitional experiences.

RESULTS

Caregivers in both groups reported experiencing a "new normal," which included personal, relational, and environmental adjustments. Caregivers in the treatment transitions group (n = 23) also described uncertainty challenges (e.g., losing their "safety net") and disrupted expectations (e.g., feeling "caught off guard" by challenges). Whereas caregivers in the end-of-treatment transitions group (n = 15) described relief coupled with worry (e.g., feeling hopeful yet worried).

CONCLUSIONS

Survivorship transitions for caregivers are riddled with challenges that include difficult readjustments, uncertainty/worry, and unmet expectations. While there seems to be a cohesive experience of "survivorship transitions," each transition group revealed nuanced distinctions.

IMPLICATIONS FOR CANCER SURVIVORS

Tailored supportive resources are needed for caregivers throughout survivorship transitions.

Efficacy of a survivorship-focused consultation versus a time-controlled rehabilitation consultation in patients with lymphoma: A cluster randomized controlled trial

BACKGROUND

Survivors of cancer often describe a sense of abandonment after treatment along with heightened uncertainty and limited knowledge of what lies ahead. This study examined the efficacy of a survivorship care plan (SCP) intervention to help physicians to address survivorship issues through communication skills training plus a new consultation focused on the use of an SCP for patients with Hodgkin lymphoma and diffuse large B-cell lymphoma.

METHODS

This 4-site cluster randomized trial examined the efficacy of a survivorship planning consultation (SPC) in patients who achieved complete remission after the completion of first-line therapy (for the SPC, physicians received communication skills training and, using an SCP, applied those skills in a survivorship-focused office visit) versus a control arm in which physicians were trained in and subsequently provided a time-controlled, manualized wellness rehabilitation consultation (WRC) focused only on discussion of healthy nutrition and exercise as rehabilitation after chemotherapy. The primary outcomes for patients were changes in knowledge about lymphoma and adherence to physicians' recommendations for vaccinations and cancer screenings.

RESULTS

Forty-two physicians and 198 patients participated across the 4 sites. Patients whose physicians were in the SPC arm had greater knowledge about their lymphoma (P = .01) and showed greater adherence to physician recommendations for influenza vaccinations (P = .02) and colonoscopy (P = .02) than patients whose physicians were in the WRC arm.

CONCLUSIONS

A dedicated consultation using an SCP and supported by communication skills training may enhance patients' knowledge and adherence to some health promotion recommendations.

Protocol for a cluster randomised trial of a communication skills intervention for physicians to facilitate survivorship transition in patients with lymphoma

INTRODUCTION

Survivors of cancer often describe a sense of abandonment post-treatment, with heightened worry, uncertainty, fear of recurrence and limited understanding of what lies ahead. This study examines the efficacy of a communication skills training (CST) intervention to help physicians address survivorship issues and introduce a new consultation focused on the use of a survivorship care plan for patients with Hodgkin's lymphoma and diffuse large B-cell lymphoma.

METHODS AND ANALYSIS

Specifically, this randomised, 4-site trial will test the efficacy of a survivorship planning consultation (physicians receive CST and apply these skills in a new survivorship-focused office visit using a survivorship plan) with patients who have achieved complete remission after completion of first-line therapy versus a control arm in which physicians are trained to subsequently provide a time-controlled, manualised wellness rehabilitation consultation focused only on discussion of healthy nutrition and exercise as rehabilitation postchemotherapy. The primary outcome for physicians will be uptake and usage of communication skills and maintenance of these skills over time. The primary outcome for patients is changes in knowledge about lymphoma and adherence to physicians' recommendations (eg, pneumococcus and influenza vaccinations); secondary outcomes will include perceptions of the doctor-patient relationship, decreased levels of cancer worry and depression, quality of life changes, satisfaction with care and usage of healthcare. This study will also examine the moderators and mediators of change within our theoretical model derived from Leventhal's Common-Sense Model of health beliefs.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Boards at Memorial Sloan Kettering Cancer Centers and all other participating sites. This work is funded by the National Cancer Institute (R01 CA 151899 awarded to DWK and SH as coprincipal investigators). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute (NCI) or the National Institutes of Health (NIH). The study findings will be disseminated to the research and medical communities through publication in peer-reviewed journals and through presentations at local, national and international conferences.

TRIAL REGISTRATION NUMBER

NCT01483664.

A preliminary study of a health related quality of life assessment of priority symptoms in advanced lymphoma: the National Comprehensive Cancer Network-Functional Assessment of Cancer Therapy - Lymphoma Symptom Index

Despite the recent advances in cancer therapeutics for lymphoma (Lym), a continuum of disease, treatment and psychological challenges, adversely impacting health-related quality of life, remain for the clinical management of the patient with Lym. In response, this study presents the development and validation of the National Comprehensive Cancer Network-Functional Assessment of Cancer Therapy (NCCN-FACT) Lymphoma Symptom Index-18 (FLymSI-18). Patients with advanced Lym (n = 50) rated the significance of 40 symptoms, and hematologist-oncologists (n = 10) rated these symptoms according to importance and disease-related or treatment-related origin. Patient symptom priorities were unified with clinician priorities for symptom measurement in Lym for instrument development. Reliability estimates indicate that FLymSI-18 has acceptable internal consistency (α = 0.87), content validity and concurrent validity as indicated by moderate to strong correlations with the FACIT (Functional Assessment of Chronic Illness Therapy). Overall, the FLymSI-18 provides evidence for its reliability and validity as a brief assessment of the most important symptoms associated with advanced Lym in the clinical trial research environment.

Physical activity and quality of life in adult survivors of non-Hodgkin's lymphoma

PURPOSE

To examine the prevalence and correlates of physical activity in adult survivors of aggressive non-Hodgkin's Lymphoma (NHL) and to explore the association between physical activity level and health-related quality of life (HRQOL).

PATIENTS AND METHODS

Physical activity and HRQOL data from 319 survivors of NHL (mean age, 59.8 years, standard deviation, +/-14.8) who were diagnosed in Los Angeles County approximately 2 to 5 years before the study was analyzed.

RESULTS

One quarter of survivors of NHL met public health guidelines of 150 minutes or more of moderate to vigorous exercise per week. More than half (53%) reported some activity but less than 150 minutes per week, whereas 20% reported no physical activity. Females, those with lower perceived health competence, and individuals with more comorbid limitations were at increased risk for inactivity. Individuals who met public health guidelines reported better HRQOL than those who were sedentary. Interestingly, our findings suggest a significant positive association between HRQOL and those who get at least some exercise.

CONCLUSION

The effort to promote physical activity among cancer survivors, who are at risk for poor quality of life as a result of treatment, is of great importance to the health of this growing population. As NHL, similar to other cancers, becomes a disease that people live with as opposed to one that people die as a result of, oncologists and primary care physicians will be increasingly challenged to provide evidence-based guidance for the long-term management of the patient's health. Consideration should be given to how clinicians frame exercise-promoting messages to cancer survivors, especially to those who are sedentary.

Population-based survivorship research using cancer registries: a study of non-Hodgkin's lymphoma survivors

INTRODUCTION

Several recent reports have recommended use of population-based cancer registries for evaluating the long-term health outcomes of cancer survivors. Drawing upon experiences from a study of survivors of non-Hodgkin's Lymphoma (NHL), we discuss conceptual and methodological challenges to and opportunities for conducting population-based survivorship research using cancer registries.

MATERIALS AND METHODS

Survivors of aggressive NHL diagnosed between June 1998 and August 2001, 2-5 years prior to the study, were sampled from the Los Angeles Surveillance Epidemiology and End Results (SEER) registry. A conceptual framework was developed to systematically evaluate the association of sociodemographic, clinical, social, psychological, and behavioral factors with survivors' health-related quality of life. Data were collected primarily by a mailed questionnaire; medical records were also abstracted.

RESULTS

Of 744 eligible survivors identified from the registry, 181 (24.3%) were lost to follow-up; 408 responded to the questionnaire (54.8%); 155 (20.8%) refused. Those lost to follow-up included a significantly higher proportion of younger, male, and Hispanic survivors compared to the other two groups (P <or= 0.01). There were no sociodemographic or clinical differences among the questionnaire respondents and survivors who refused study participation. Medical records were abstracted for 59.8% of the respondents. A high percentage of agreement was seen between survivors' self-report and medical record documentation of key treatments and disease status (>or=95% for survivors with complete records).

CONCLUSIONS

The cancer registry served as a valuable resource for recruiting one of the largest population-based samples of NHL survivors. The methodology and example of a conceptual framework utilized in this study provide a model for future population-based cancer survivorship research.

Quality of life of long-term survivors of breast cancer and lymphoma treated with standard-dose chemotherapy or local therapy

PURPOSE

This study compared the quality of life (QOL) of long-term survivors of breast cancer and lymphoma who had been treated with standard-dose systemic chemotherapy or local therapy only.

PATIENTS AND METHODS

Long-term survivors (mean, 10.0 +/- 5.3 years after treatment) of breast cancer or lymphoma who had been treated with systemic chemotherapy (breast, n = 141, age = 57.0 +/- 10.1 years; lymphoma, n = 66, age = 55.8 +/- 13.5 years) or local therapy only (breast, n = 294, age = 65.8 +/- 9.1 years; lymphoma, n = 37, age = 50.4 +/- 12.8 years) were interviewed by phone using the Quality of Life-Cancer Survivors Tool.

RESULTS

Multivariate analysis of covariance, controlling for sex, age, education, stage of disease, and time since last treatment, revealed that survivors who had been treated with systemic chemotherapy scored significantly lower on overall QOL compared with survivors treated with local therapy only (P = .04). Analysis of covariance on the subscale scores revealed that, compared with survivors who received local therapy, survivors treated with chemotherapy scored significantly lower on the Social subscale (P < .0001), but no differences emerged on the Psychological or Spiritual subscales. There was a statistically significant interaction between treatment and diagnosis (P = .01), as measured by the Physical subscale, indicating that lymphoma survivors treated with chemotherapy scored worse than all other groups.

CONCLUSION

Important QOL differences emerged between the chemotherapy and local therapy groups, suggesting that long-term QOL may vary depending on the type of treatment and diagnosis.

Differences in physical performance between men and women with and without lymphoma

OBJECTIVES

To describe and compare physical performance profiles in men and women with lymphoma with age- and gender-matched controls and to examine relationships among fatigue severity and physical performance in men and women with lymphoma.

DESIGN

Case-control study.

SETTING

Outpatient lymphoma service in a major cancer teaching hospital.

PARTICIPANTS

Fifty-one patients with lymphoma (26 women, 25 men), age- and gender-matched to 51 subjects without lymphoma.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A physical performance test battery consisting of a 50-ft (15-m) walk, a 6-minute walk, forward reach, repeated sit-to-stand, repeated reach-up, timed belt tie, sock test, and coin test. Patients also completed the Brief Fatigue Inventory (BFI).

RESULTS

Multivariate analysis of variance was significant for main effects of group (F(8,89)=27.12, P<.05) and gender (F(8,89)=3.09, P<.05), and there was no significant interaction. Subsequent analyses found significant differences between groups and gender in the repeated reach-up task, forward reach, 50-ft walk, and distance walked in 6 minutes. Correlations among physical performance tasks and total BFI interference scores were moderate (r range,.27-.43; P<.05) for tasks involving upper extremity, and stronger (r range,.51 to -.73; P<.05) for tasks that involved whole-body movements.

CONCLUSION

There is a leveling effect of lymphoma across gender on most tasks. The significant relations between physical performance tasks and fatigue are suggestive of the pervasive influence of fatigue on physical function.

Chemotherapy-induced Secondary Malignancies

Changes in chemotherapy protocols have influenced the risk and rate of secondary malignancies in high-risk populations. The alkylating agents, topoisomerase inhibitors, and anthracycline agents pose the highest risk of initiating carcinogenesis. Normal cells that are especially sensitive to chemotherapy and most likely to begin carcinogenesis include those of the bone marrow, hair follicles, and the epithelial cells of the gastrointestinal tract. Thus, the development of secondary hematologic cancers such as leukemia and lymphoma pose the greatest risk to adult and childhood cancer survivors. Lifelong surveillance is recommended.

Survivorship resources for post-treatment cancer survivors

PURPOSE

The purpose of this project was to determine the scope of services and resources available to cancer survivors who have completed active treatment and their families at National Cancer Institute (NCI)-designated comprehensive cancer centers.

DESCRIPTION OF STUDY

Patient education program contacts from the 37 NCI-designated comprehensive cancer centers participated in a telephone interview. Program contacts were asked to identify the types of medical and psychosocial services that their respective cancer center offered.

RESULTS

Telephone interviews were completed by patient education program contacts from all NCI-designated comprehensive cancer centers for a total response rate of 100%. Services pertaining to lymphedema management were identified in 70% of cancer centers. Other common services identified specifically for post-treatment cancer survivors at cancer centers were professionally led support groups (49% of cancer centers), long-term medical care (38% of cancer centers), school re-entry programs (19% of cancer centers), nutrition counseling (14% of cancer centers), and counseling addressing fertility and sexual concerns (14% of cancer centers).

CLINICAL IMPLICATIONS

Results from this project outline the range of services and resources that are provided to post-treatment cancer survivors by NCI-designated comprehensive cancer centers, and can be used to develop standards of care for future cancer control programs.

Quality of life for long-term survivors of cancer: influencing variables

The study's purpose was to describe the relations among self-esteem, learned resourcefulness, and social support, and to show how they predict health-related quality of life (HRQL) for long-term survivors of cancer. With advances in oncology and increased survival, variables influencing the HRQL of long-term survivors of cancer must be explored. The design was descriptive and correlational. Five instruments were sent to 456 long-term survivors in southern California. Data were analyzed for 62 of 111 consenting individuals, most of whom were married, retired, white, college-educated, female survivors of breast cancer older than 60 years of age treated by radiation and surgery. Subjects with higher self-esteem reported higher HRQL (r = 0.69; p = 0.00). Learned resourcefulness had a significant negative relation with HRQL (r = -0.32; p = 0.01). Social support was operationalized as functional components, network properties, and recent loss. Only the loss component of social support had a significant negative relation with HRQL (r = -0.38; p = 0.00). Together, the three variables explained more than half of the variance (R2 = 0.53) of HRQL, with self-esteem being the strongest predictor. The HRQL of long-term survivors of cancer may increase with interventions such as both survivor- and nurse-led support groups aimed at supporting and improving self-esteem. In addition, education to anticipate social support losses may further enhance HRQL.