The diagnosis and treatment decisions of cancer patients in rural Western Australia

Cancer Survivors Living in Rural Settings: A Qualitative Exploration of Concerns, Positive Experiences and Suggestions for Improvements in Survivorship Care

In Canada, the number of cancer survivors continues to increase. It is important to understand what continues to present difficulties after the completion of treatment from their perspectives. Various factors may present barriers to accessing help for the challenges they experience following treatment. Living rurally may be one such factor. This study was undertaken to explore the major challenges, positive experiences and suggestions for improvement in survivorship care from rural-dwelling Canadian cancer survivors one to three years following treatment. A qualitative descriptive analysis was conducted on written responses to open-ended questions from a national cross-sectional survey. A total of 4646 individuals living in rural areas responded to the survey. Fifty percent (2327) were male, and 2296 (49.4%) were female; 69 respondents were 18 to 29 years (1.5%); 1638 (35.3%) were 30 to 64 years; and 2926 (63.0%) were 65 years or older. The most frequently identified major challenges (n = 5448) were reduced physical capacity and the effects of treatment. Positive experiences included family and friend support and positive self-care practices. The suggestions for improvements focused on the need for better communication and information about self-care, side effect management, and programs and services, with more programs available locally for practical and emotional support.

Medical treatment decision-making in rural cancer patients: A qualitative systematic review and meta-synthesis

OBJECTIVE

Rural cancer patients have unique care needs which may impact upon treatment decision-making. Our aim was to conduct a qualitative systematic review and meta-synthesis to understand their perspectives and experiences of making treatment decisions.

METHODS

A systematic search of MEDLINE, PsycINFO, CINAHL and RURAL was conducted for qualitative studies in rural cancer patients regarding treatment decision-making. Articles were screened for relevance, and data from the included articles were extracted and analysed using meta-thematic synthesis.

RESULTS

Twelve studies were included, with 4 themes and 9 subthemes identified. Many studies reported patients were not given a choice regarding their treatment. Choice, if given, was influenced by personal factors such as finances, proximity to social supports, convenience, and their personal values. Patients were also influenced by the opinions of others and cultural norms. Finally, it was reported that patients made choices in the context of seeking the best possible medical care and the patient-clinician relationship.

CONCLUSIONS

In the rural context, there are universal and unique factors that influence the treatment decisions of cancer patients.

PRACTICAL IMPLICATIONS

Our findings are an important consideration for clinicians when engaging in shared decision-making, as well as for policymakers, to understand and accommodate the unique rural perspective.

Comparing Pathways to Diagnosis and Treatment for Rural and Urban Patients With Colorectal or Breast Cancer: A Qualitative Study

PURPOSE

Colorectal cancer patients living in rural areas have poorer outcomes than urban counterparts, but such disparities are not found for breast cancer. Although time to care may contribute to rural-urban disparities, few studies examine patient experiences to understand how and why delays may occur. We compared rural and urban patient experiences of pathways to colorectal or breast cancer diagnosis and treatment in Victoria, Australia.

METHODS

Semistructured telephone interviews were conducted with 43 patients (49% colorectal; 60% rural, median 7 months postdiagnosis). A framework analysis was applied using the Model of Pathways to Treatment.

FINDINGS

Rural and urban patients expressed similar attitudes and reasons for prolonged symptom appraisal and help-seeking triggers. However, some rural patients reported long waiting times to see a Primary Care Practitioner (PCP) and perceived greater gatekeeping to diagnostic services. Patient perceptions of the urgency of PCP referral could impact behavior, such as waiting longer to book appointments. Colorectal cancer patients reported more variable types of symptoms, interpretation, and coping strategies, as well as diverse presentation routes and reduced sense of urgency, compared to breast cancer patients. Waiting time for colonoscopy could be long, particularly in the public health system, but mammograms were quickly arranged.

CONCLUSIONS

Pathway variation was more evident by cancer type than residential location. However, access to primary care and diagnostic services for rural patients with colorectal cancer may be important policy targets. Future research should investigate the impact of diagnostic service accessibility on PCP referral behavior to further understand rural-urban disparities.

Managing Cancer Experiences: An Interpretive Description Study of Internet Information Use

BACKGROUND

People with cancer increasingly use the Internet to find information about their illness. However, little is known regarding people's use of cancer-related Internet information (CRII) to manage their patient experience, defined as patients' cumulative perceptions of interactions with the healthcare system during their illness.

OBJECTIVE

The purpose of this study was to create an understanding of CRII use by people newly diagnosed with cancer and how it shapes their patient experience and informs their interactions with healthcare professionals and healthcare services.

METHODS

An embedded mixed design guided this study. Nineteen people with cancer were interviewed twice and completed a survey about CRII use. Qualitative data were analyzed using thematic analysis. Descriptive statistics summarized the quantitative findings.

RESULTS

Participants of all ages and educational levels reported using CRII as a pivotal resource, across the cancer trajectory. Cancer-related Internet information played a central role in how patients understood their illness and when they sought and used healthcare services. Two themes emerged based on patient interviews: (1) person in context and (2) management of information.

CONCLUSION

Cancer-related Internet information plays a crucial role in how people manage their illness and take control of their patient experience. Participants used CRII to learn about their illness, support their efforts to self-manage, and complement information from professionals.

IMPLICATIONS FOR PRACTICE

Individuals and institutions can promote and encourage tailored CRII use by engaging patients and suggesting websites based on their needs. Doing so may create efficiencies in service use and empower patients to be more involved in their own care.

Novel insights into the role of aptamers in the fight against cancer

PURPOSE

Aptamers are a class of single-stranded nucleic acid (DNA or RNA) oligonucleotides that are screened in vitro by a technique called systematic evolution of ligands by exponential enrichment (SELEX). They have stable three-dimensional structures that can bind to various targets with high affinity and specificity. Due to distinct properties such as easy synthesis, high stability, small size, low toxicity and immunogenicity, they have been largely studied as anticancer agents/tools. Consequently, aptamers are starting to play important roles in disease prevention, diagnosis and therapy. This review focuses on studies that evaluated the effect of aptamers on various aspects of cancer therapy. It also provides novel and unique insights into the role of aptamers on the fight against cancer.

METHODS

We reviewed literatures about the role of aptamers against cancer from PUBMED databases in this article.

RESULTS

Here, we summarized the role of aptamers on the fight against cancer in a unique point of view. Meanwhile, we presented novel ideas such as aptamer-pool-drug conjugates for the treatment of refractory cancers.

CONCLUSIONS

Aptamers and antibodies should form a "coalition" against cancers to maximize their advantages and minimize disadvantages.

How rural and urban patients in Australia with colorectal or breast cancer experience choice of treatment provider: A qualitative study

Modern healthcare systems promote patient choice of cancer treatment provider, but little is known about how place of residence influences decision-making. This research explored how rural and urban patients with breast or colorectal cancer experience choice of cancer treatment provider in Victoria, Australia. Realist thematic analysis of 43 semi-structured telephone interviews identified little active participation in decision-making regardless of area of residence or cancer diagnosis. Perceptions of choice were impacted by urgency for treatment, insurance status and access to providers, a key issue for rural patients. All patients wanted high quality care, but needed to trust health professional's recommendations. Rural patients experienced more complex decision-making, balancing a range of social factors with perceptions about quality of accessible care. Further research into variation in quality of care and complex cancer pathways for rural and urban cancer patients is warranted to inform choices and enhance patient-centred care.

Who provides care for people dying of cancer? A comparison of a rural and metropolitan cohort in a South Australian bereaved population study

OBJECTIVE

To examine and compare urban and rural palliative care service availability and patterns of care from randomised, population-based surveys of caregivers of people at the end of life.

DESIGN, SETTING & PARTICIPANTS

Survey responses on the death of 'someone close' from 23,588 interviews of South Australians conducted between 2001 and 2007 are analysed.

INTERVENTIONS

A randomised population survey.

MAIN OUTCOME MEASURES

Explored palliative care service availability, caregiving provided, and characteristics of the deceased and their caregivers.

RESULTS

There was no difference in reported rates of accessing specialist palliative care services between rural and urban respondents (in unadjusted and adjusted analyses) nor did the proportion of people for whom cancer was their life-limiting illness. There was greater reliance on friends than first degree relatives in hands-on care provided at the end of life in rural settings. The rates of reported need for more support did not differ between urban and rural respondents for caregivers of people at the end of life.

CONCLUSION

Use of palliative care services was similar for rural and urban caregivers for someone close at the end of life with similar levels of met and unmet needs.

Managing Matajoosh: determinants of first Nations' cancer care decisions

BACKGROUND

Accessing cancer treatment requires First Nation peoples living in rural and remote communities to either commute to care, or to relocate to an urban centre for the length or part of the treatment. While Canadians living in rural and remote communities must often make difficult decisions following a cancer diagnosis, such decisions are further complicated by the unique policy and socio-historical contexts affecting many First Nation peoples in Canada. These contexts often intersect with negative healthcare experiences which can be related to jurisdictional confusion encountered when seeking care. Given the rising incidence of cancer within First Nation populations, there is a growing potential for negative health outcomes.

METHODS

The analysis presented in this paper focuses on the experience of First Nation peoples' access to cancer care in the province of Manitoba. We analyzed policy documents and government websites; interviewed individuals who have experienced relocation (N = 5), family members (N = 8), healthcare providers and administrators (N = 15).

RESULTS

Although the healthcare providers (social workers, physicians, nurses, patient navigators, and administrators) we interviewed wanted to assist patients and their families, the focus of care remained informed by patients' clinical reality, without recognition of the context which impacts and constrains access to cancer care services. Contrasting and converging narratives identify barriers to early diagnosis, poor coordination of care across jurisdictions and logistic complexities that result in fatigue and undermine adherence. Providers and decision-makers who were aware of this broader context were not empowered to address system's limitations.

CONCLUSIONS

We argue that a whole system's approach is required in order to address these limitations.

A qualitative study of rural women's views for the treatment of early breast cancer

AIM

Identify what factors rural women perceived to influence their surgical choice for EBC.

BACKGROUND

Higher rates of mastectomy still remain for women with early breast cancer (EBC) in rural areas. While access to radiotherapy is a commonly identified barrier, there is growing debate around other factors which are also important influences on surgical choice.

METHODS

Qualitative study with 70 interviews with women diagnosed with EBC in rural Gippsland, Australia. Twenty-nine women had a mastectomy and 41 had breast conserving surgery (BCS).

RESULTS

Patient led psychosocial and surgeon led factors influenced surgical choice. Psychosocial factors were a greater influence for the mastectomy group. These included a high fear of cancer recurrence and radiotherapy, negative views of the body and breast, a family history of cancer, wanting to avoid the negative treatment experiences they had seen significant others go through, and not wanting to travel for treatment. Surgeon led factors were a greater influence for the BCS group, in particular, the direct recommendation made by the surgeon for BCS. For both groups, urgency to act was a shared psychosocial factor. Trust and confidence in the expertise and reputation of the surgeon and their consultation style were surgeon led factors shared by the groups.

CONCLUSIONS

To ensure women achieve the best treatment outcome, patients and clinicians need to work together to identify how important and influential the various factors are for the women and, if necessary, to seek support to ensure informed decisions are made.

Supporting patients treated for prostate cancer: a video vignette study with an email-based educational program in general practice

Background

Men who have been treated for prostate cancer in Australia can consult their general practitioner (GP) for advice about symptoms or side effects at any time following treatment. However, there is no evidence that such men are consistently advised by GPs and patients experience substantial unmet need for reassurance and advice.

Objective

The intent of the study was to evaluate a brief, email-based educational program for GPs to manage standardized patients presenting with symptoms or side effects months or years after prostate cancer treatment.

Methods

GPs viewed six pairs of video vignettes of actor-patients depicting men who had been treated for prostate cancer. The actor-patients presented problems that were attributable to the treatment of cancer. In Phase 1, GPs indicated their diagnosis and stated if they would prescribe, refer, or order tests based on that diagnosis. These responses were compared to the management decisions for those vignettes as recommended by a team of experts in prostate cancer. After Phase 1, all the GPs were invited to participate in an email-based education program (Spaced Education) focused on prostate cancer. Participants received feedback and could compare their progress and their performance with other participants in the study. In Phase 2, all GPs, regardless of whether they had completed the program, were invited to view another set of six video vignettes with men presenting similar problems to Phase 1. They again offered a diagnosis and stated if they would prescribe, refer, or order tests based on that diagnosis.

Results

In total, 64 general practitioners participated in the project, 57 GPs participated in Phase 1, and 45 in Phase 2. The Phase 1 education program was completed by 38 of the 57 (59%) participants. There were no significant differences in demographics between those who completed the program and those who did not. Factors determining whether management of cases was consistent with expert opinion were number of sessions worked per week (OR 0.78, 95% CI 0.67-0.90), site of clinical practice (remote practice, OR 2.25, 95% CI 1.01-5.03), number of patients seen per week (150 patients or more per week, OR 10.66, 95% CI 3.40-33.48), and type of case viewed. Completion of the Spaced Education did impact whether patient management was consistent with expert opinion (not completed, OR 0.88, 95% CI 0.5-1.56).

Conclusions

The management of standardized patients by GPs was particularly unlikely to be consistent with expert opinion in the management of impotence and bony metastasis. There was no evidence from this standardized patient study that Spaced Education had an impact on the management of patients in this context. However, the program was not completed by all participants. Practitioners with a greater clinical load were more likely to manage cases as per expert opinion.

Patients' experiences of referral for colorectal cancer

Background

Outcomes for colorectal cancer patients vary significantly. Compared to other countries, Australia has a good record with patient outcomes, yet there is little information available on the referral pathway. This paper explores the views of Australian patients and their experiences of referral for colorectal cancer treatment following diagnosis; the aim was to improve our understanding of the referral pathway and guide the development of future interventions.

Methods

A purposive sampling strategy was used, recruiting 29 patients representing urban and rural areas from 3 Australian states who participated in 4 focus groups. Seven patients provided individual interviews to supplement the data. Recordings were transcribed verbatim, data was coded with NVivo software and analysed thematically before deductive analysis.

Results

Four aspects of the referral process were identified by patients, namely detection/diagnosis, referral for initial treatment/specialist care, the roles of the GP/specialist, and the patient’s perceived involvement in the process. The referral process was characterised by a lack of patient involvement, with few examples of shared decision-making and few examples of limited choice. However, patients did not always feel they had the knowledge to make informed decisions. Information exchange was highly valued by patients when it occurred, and it increased their satisfaction with the process. Other factors mediating care included the use of the public versus private health system, the quality of information exchange (GP to specialist and GP to patient), continuity of care between GP and specialist, and the extent of information provision when patients moved between specialist and GP care.

Conclusions

Patients described poor GP continuity, ad hoc organisational systems and limited information exchange, at both interpersonal and inter-organisational levels, all leading to sub-optimal care. Implementation of a system of information feedback to GPs and engagement with them might improve information exchange for patients, enabling them to be more involved in improved referral outcomes.

Self-advocacy and cancer: a concept analysis

AIM

To report an analysis of the concept of self-advocacy among individuals with cancer to clarify its meaning, to differentiate this meaning with related concepts, and to unify understanding of the concept in cancer research and practice.

BACKGROUND

Cancer survivors are increasingly required to assume an active role in their health care. A thorough analysis of how survivors advocate for themselves is a crucial aspect in supporting survivors' ability to engage and manage their care throughout all stages of cancer survivorship.

DESIGN

Walker and Avant's eight-step process of conducting a concept analysis was used.

DATA SOURCES

PubMed, PsycINFO, and CINAHL databases were searched for articles, reviews, editorials, and grey literature directly addressing self-advocacy.

REVIEW METHODS

A broad inquiry into the literature from 1960 to 2012 that produces a definition of self-advocacy. Model and contrary cases of self-advocacy demonstrate the concept's application and intricacies.

RESULTS

Antecedents to self-advocacy include particular personal characteristics, learned skills, and attainable support. The essential element of self-advocacy and what differentiates it from related concepts, is the internalization of these antecedent resources into self-advocacy thoughts and actions while incorporating personal values and priorities in a way that upholds the survivors' goals and beliefs. A full realization of self-advocacy facilitates a cancer survivor attaining a strong self-concept, sense of control, and adaptation to a life with cancer.

CONCLUSIONS

Self-advocacy is a process of internalizing skills and resources to act in a way that supports survivors' needs and goals.