1
|
Stevens JM, Montgomery K, Miller M, Saeidzadeh S, Kwekkeboom KL. Common patient-reported sources of cancer-related distress in adults with cancer: A systematic review. Cancer Med 2024; 13:e7450. [PMID: 38989923 PMCID: PMC11238242 DOI: 10.1002/cam4.7450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Cancer-related distress (CRD) is widely experienced by people with cancer and is associated with poor outcomes. CRD screening is a recommended practice; however, CRD remains under-treated due to limited resources targeting unique sources (problems) contributing to CRD. Understanding which sources of CRD are most commonly reported will allow allocation of resources including equipping healthcare providers for intervention. METHODS We conducted a systematic review to describe the frequency of patient-reported sources of CRD and to identify relationships with CRD severity, demographics, and clinical characteristics. We included empirical studies that screened adults with cancer using the NCCN or similar problem list. Most and least common sources of CRD were identified using weighted proportions computed across studies. Relationships between sources of CRD and CRD severity, demographics, and clinical characteristics were summarized narratively. RESULTS Forty-eight studies were included. The most frequent sources of CRD were worry (55%), fatigue (54%), fears (45%), sadness (44%), pain (41%), and sleep disturbance (40%). Having enough food (0%), substance abuse (3%), childbearing ability (5%), fevers (5%), and spiritual concerns (5%) were infrequently reported. Sources of CRD were related to CRD severity, sex, age, race, marital status, income, education, rurality, treatment type, cancer grade, performance status, and timing of screening. CONCLUSIONS Sources of CRD were most frequently emotional and physical, and resources should be targeted to these sources. Relationships between sources of CRD and demographic and clinical variables may suggest profiles of patient subgroups that share similar sources of CRD. Further investigation is necessary to direct intervention development and testing.
Collapse
Affiliation(s)
- Jennifer M Stevens
- School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Megan Miller
- School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | | |
Collapse
|
2
|
Sato T, Fujisawa D, Arai D, Nakachi I, Takeuchi M, Nukaga S, Kobayashi K, Ikemura S, Terai H, Yasuda H, Kawada I, Sato Y, Satomi R, Takahashi S, Hashiguchi MH, Nakamura M, Oyamada Y, Terashima T, Sayama K, Saito F, Sakamaki F, Inoue T, Naoki K, Fukunaga K, Soejima K. Trends of concerns from diagnosis in patients with advanced lung cancer and their family caregivers: A 2-year longitudinal study. Palliat Med 2021; 35:943-951. [PMID: 33761790 PMCID: PMC8114458 DOI: 10.1177/02692163211001721] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Both advanced cancer patients and their family caregivers experience distress and have a range of concerns after cancer diagnosis. However, longitudinal studies on this topic have been lacking. AIM To investigate concerns in both patients with advanced lung cancer and their family caregivers longitudinally from diagnosis. DESIGN A multi-center prospective questionnaire-based study. SETTING/PARTICIPANTS We recruited patients with newly diagnosed advanced lung cancer and their family caregivers at 16 hospitals in Japan. We prospectively assessed the prevalence of their concerns using the Concerns Checklist and investigated the associations between their concerns and mental status as well as quality of life until 24 months after diagnosis. RESULTS A total of 248 patients and their 232 family caregivers were enrolled. The prevalence of serious concerns was highest at diagnosis (patients: 68.3%, family caregivers: 65.3%). The most common serious concern was concern about the future in both groups at diagnosis (38.2% and 40.5%, respectively) and this remained high in prevalence over time, while the high prevalence of concern about lack of information improved 3 months after diagnosis in both groups. Approximately one-third of patient-family caregiver dyads had discrepant reports of serious concerns. The presence of serious concerns was significantly associated with anxiety and depression continuously in both groups. CONCLUSIONS The majority of advanced lung cancer patients and their family caregivers have serious concerns from diagnosis, which is associated with their psychological distress. The spectrum of concerns alters over the disease trajectory, warranting efficient tailored care and support for both groups immediately after diagnosis.
Collapse
Affiliation(s)
- Takashi Sato
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Medicine, Keiyu Hospital, Yokohama, Japan.,Department of Medicine, Sano-kosei General Hospital, Sano, Japan
| | - Daisuke Fujisawa
- Division of Patient Safety, Keio University School of Medicine, Tokyo, Japan.,Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Arai
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan.,Pulmonary division, Internal Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Ichiro Nakachi
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan.,Pulmonary division, Internal Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Mari Takeuchi
- Palliative Care Center, Keio University Hospital, Tokyo, Japan
| | - Shigenari Nukaga
- Respiratory Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Keigo Kobayashi
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Medicine, Sano-kosei General Hospital, Sano, Japan
| | - Shinnosuke Ikemura
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hideki Terai
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan.,Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan
| | - Hiroyuki Yasuda
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ichiro Kawada
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Ryosuke Satomi
- Department of Medicine, Sano-kosei General Hospital, Sano, Japan.,Respiratory Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Saeko Takahashi
- Department of Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Mizuha Haraguchi Hashiguchi
- Department of Medicine, Keiyu Hospital, Yokohama, Japan.,Department of Respiratory Medicine, Nippon Kokan Hospital, Kawasaki, Japan
| | - Morio Nakamura
- Department of Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Yoshitaka Oyamada
- Respiratory Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Takeshi Terashima
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
| | - Koichi Sayama
- Division of Pulmonary Medicine, Kawasaki Municipal Hospital, Kawasaki, Japan
| | - Fumitake Saito
- Department of Pulmonary Medicine, Eiju General Hospital, Tokyo, Japan
| | - Fumio Sakamaki
- Division of Pulmonary Medicine, Department of Medicine, Tokai University Hachioji Hospital, Hachioji, Tokyo, Japan
| | - Takashi Inoue
- Department of Medicine, Sano-kosei General Hospital, Sano, Japan
| | - Katsuhiko Naoki
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Respiratory Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kenzo Soejima
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan.,Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan
| |
Collapse
|
3
|
Cheng TC, Lee YH, Chang YP, Lee DC. Improved urinary melatonin level as the perspective indicator that leads to better sleeping quality in bladder cancer patients. Ther Adv Urol 2020; 12:1756287220940870. [PMID: 32782482 PMCID: PMC7385844 DOI: 10.1177/1756287220940870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/17/2020] [Indexed: 12/24/2022] Open
Abstract
Background: Individuals with higher-than-average melatonin concentrations are less likely to develop cancer. In cancer patients, psychosomatic coping patterns and treatment side effects are important indicators of cancer prevention and immune system deterioration. This study focused on changes in the urinary melatonin concentration, life resilience, and sleep quality in bladder cancer patients before, and 3 months after, treatment. Methods: A controlled before-and-after study was performed. The subjects were patients who were previously diagnosed with bladder cancer and had received treatment (transurethral resection of bladder tumor + intravesical chemotherapy). Data from 23 subjects were analyzed. Results: The results showed a significant difference in the melatonin concentration before and after treatment (Wilcoxon signed-rank test, Z = −2.220, p = 0.026). The melatonin concentration in 16 patients (70%) increased after treatment. The mean Pittsburgh Sleep Quality Index (PSQI) score before treatment was 7.348 (SD = 4.030), which was associated with poor sleep quality. The mean PSQI score after treatment was 6.435 (SD = 3.300; Z = −2.071; p = 0.038). These results represent the improved sleep quality in patients post-treatment. Conclusions: After treatment, the urinary melatonin concentration and sleep quality (PSQI) improved, both of which were statistically significant in bladder cancer patients. Consequently, bladder cancer treatment should be initiated as soon as possible. There was no significant difference in overall life resilience before and after treatment, possibly because elderly individuals have strong personality traits and emotional stability and are not easily affected by life events or stress.
Collapse
Affiliation(s)
- Tse-Chou Cheng
- Department of Urology, Chi Mei Medical Center, Tainan City
| | - Yi-Hua Lee
- Department of Administration, National Health Research Institutes, Zhunan, Miaoli County
| | - Yuan-Ping Chang
- Nursing Department, Fooyin University, 151 Jinxue Rd, Daliao District, Kaohsiung City 83102 Taiwan
| | - De-Chih Lee
- Department of Information Management, Da-Yeh University, Dacun, Changhua
| |
Collapse
|
4
|
Malhotra C, Rajasekaran T, Kanesvaran R, Yee A, Bundoc FG, Singh R, Tulsky JA, Pollak KI. Pilot Trial of a Combined Oncologist-Patient-Caregiver Communication Intervention in Singapore. JCO Oncol Pract 2019; 16:e190-e200. [PMID: 31880975 DOI: 10.1200/jop.19.00412] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE High-quality end-of-life cancer care requires oncologists to communicate effectively and patients/caregivers to be participatory. However, most communication interventions target either but not both. We aimed to pilot a potentially disseminable combined oncologist-patient/caregiver intervention to improve oncologist empathic responses, discussions of prognosis and goals of care, and patient/caregiver participation. We assessed its feasibility, acceptability, and preliminary efficacy. METHODS Between June 2018 and January 2019, we conducted a pilot 2-arm cluster trial in Singapore, randomly assigning 10 oncologists in a 1:1 ratio to receive the combined intervention or usual care. Intervention arm oncologists received online communication skills training, and their patients received a brief prompt sheet before consultations. We audio recorded consultations with 60 patients with stage IV solid malignancy and analyzed 30 in the postintervention phase. The study was not powered for statistical significance. RESULTS Participation rates for oncologists and patients were 100% and 63%, respectively. All oncologists completed the online training within an average of 4.5 weeks; 73% of the patients selected at least 1 question in the prompt sheet. Compared with the control arm, intervention arm oncologists had more empathic responses in total (relative risk [RR], 1.66) and for every patient/caregiver negative emotion (RR, 2.01). Their consultations were more likely to involve discussions of prognosis (RR, 3.00) and goals of care, and their patients were more likely to ask a prognosis-related question (RR, 2.00; P > .05 for all). CONCLUSION The combined oncologist-patient/caregiver intervention is feasible and acceptable and has the potential to improve communication within consultations.
Collapse
Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | | | | | - Alethea Yee
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | | | - Ratna Singh
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - James A Tulsky
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Singapore
| |
Collapse
|
5
|
Liu J, Peh CX, Simard S, Griva K, Mahendran R. Beyond the fear that lingers: The interaction between fear of cancer recurrence and rumination in relation to depression and anxiety symptoms. J Psychosom Res 2018; 111:120-126. [PMID: 29935744 DOI: 10.1016/j.jpsychores.2018.06.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/06/2018] [Accepted: 06/08/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The Fear of Cancer Recurrence (FCR) is reported to be a normal response to cancer, but little is known about the interaction between FCR and maladaptive cognitive processes, which may increase the risk for depression and anxiety disorders among cancer survivors. Previous studies have shown the influence of rumination on depression and anxiety in other populations. Thus, the present study aimed to examine how FCR and rumination may relate to depression and anxiety symptoms among cancer survivors. METHODS The present study included cancer survivors (N = 388) who had completed their active treatment at the National University Cancer Institute Singapore, and achieved complete remission from cancer. All participants completed self-report measures of FCR (Fear of Cancer Recurrence Inventory), rumination (Rumination Response Scale), depression, and anxiety symptoms (Hospital Anxiety and Depression Scale). RESULTS The present study observed that (1) FCR and rumination were associated with more severe depression and anxiety symptoms, and (2) the interaction between FCR and rumination was associated with more severe depressive symptoms (p = .01). Specifically, rumination was significantly associated with higher depressive symptoms in individuals with high FCR (p < .001), while rumination was not associated with depressive symptoms in individuals with low FCR (p > .05). CONCLUSION Habitual rumination may be a maladaptive cognitive style to cope with high FCR. Therefore, the present study's findings elucidate the moderating effect of rumination on FCR, and such findings may better inform psychological interventions to reduce the risk of depression and anxiety among cancer survivors who experience high FCR.
Collapse
Affiliation(s)
- Jianlin Liu
- Department of Psychological Medicine, National University of Singapore, Singapore; Institute of Mental Health, Singapore
| | - Chao-Xu Peh
- Department of Psychological Medicine, National University of Singapore, Singapore; Department of Psychology, National University of Singapore, Singapore
| | - Sébastien Simard
- Université du Québec à Chicoutimi (UQAC), Centre de recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec
| | | | - Rathi Mahendran
- Department of Psychological Medicine, National University of Singapore, Singapore; Department of Psychological Medicine, National University Hospital, Singapore; Duke-NUS Medical School, Singapore.
| |
Collapse
|
6
|
Chan EA, Wong F, Cheung MY, Lam W. Patients' perceptions of their experiences with nurse-patient communication in oncology settings: A focused ethnographic study. PLoS One 2018; 13:e0199183. [PMID: 29912967 PMCID: PMC6005521 DOI: 10.1371/journal.pone.0199183] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 06/01/2018] [Indexed: 11/19/2022] Open
Abstract
Background The nursing shortage and its impact on patient care are well-documented global issues. Patients living with cancer as a chronic illness have many psychosocial problems and often lack adequate support as a result of ineffective nurse-patient communication. A review of the literature on factors influencing the delivery of psychosocial care to cancer patients indicates that the delivery of psychosocial care in routine cancer nursing within a biomedical healthcare system has not been widely explored. Objective To explore patients’ perceptions of their experiences with nurse-patient communication in an oncological clinical environment. Method A focused ethnographic study was undertaken in two oncology wards of a hospital in Hong Kong. Data were collected through observations of the ward environment, the activities and instances of nurse-patient communication, semi-structured interviews with patients, and a review of nursing documents. Results Two main themes were identified: 1. Nurses’ workload and the environment and 2. Nurse-patient partnership and role expectations. Within these two themes were related subthemes on: Sympathy for the busy nurses; Prioritizing calls to the nurses; Partnership through relationship; Nurses’ role in psychosocial care; and Reduction of psychosocial concerns through physical care. Conclusions Many cancer patients do not expect to receive psychosocial care in the form of emotional talks or counseling from busy nurses, but appreciate the attention paid by nurses to their physiological and physical needs. Nurse-patient partnerships in cancer care may reduce the potential workload of nurses. The psychosocial needs of cancer patients could be optimized by providing good physical care through effective communication within a time-constrained oncology setting.
Collapse
Affiliation(s)
- Engle Angela Chan
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong
- * E-mail: (EA)
| | - Fiona Wong
- School of Optometry, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Man Yin Cheung
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Winsome Lam
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong
| |
Collapse
|
7
|
Mahendran R, Lim HA, Tan JY, Kua EH, Griva K. The prevalence and predictors of subsyndromal anxiety and depression in adult Asian cancer patients across the first year of diagnosis. Asia Pac J Clin Oncol 2016; 12:476-489. [PMID: 27461268 DOI: 10.1111/ajco.12562] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 03/14/2016] [Accepted: 04/17/2016] [Indexed: 11/28/2022]
Abstract
AIM There is an increased prevalence of anxiety and depression in Asian patients diagnosed with cancers; these are known to interfere with treatment, treatment adherence and mortality. This study sought to investigate the prevalence and predictors of subsyndromal anxiety and depression in first-year Asian cancer patients. METHODS A total of 206 patients newly diagnosed with cancer in Singapore completed the Hospital Anxiety and Depression Scale (HADS) at T1 (baseline; on average 2 months post-diagnosis), T2 (3 months post-baseline) and T3 (6 months post-baseline). Subsyndromal anxiety and depression were identified using locally validated cut-offs (HADS-A ≥5 and HADS-D ≥7). Adjusted odds ratios were calculated using baseline predictors. RESULTS Across the three time points, 68-69% of participants were identified as having subsyndromal anxiety and close to 27-38% participants were identified as having subsyndromal depression. Multivariate logistic regressions revealed a lack of predictors for T1 subsyndromal anxiety and depression. Participants with late/metastatic stages of cancer were almost four times as likely to suffer from subsyndromal anxiety at T2. Single participants had a 75% lowered odds, but those living in three to four room public housing were close to four times as likely to suffer from subsyndromal depression at T2. Older patients and those who had undergone surgery were found to significantly suffer from subsyndromal depression at T3. CONCLUSION The significant levels of depression and anxiety coupled with the lack of consistent predictors across the first year following cancer diagnosis further underscore the importance of careful assessment and clinician-vigilance in recognizing and identifying Asian patients who may express these emotional sequelae following the cancer diagnosis. A better understanding of patients' pathophysiological and psychological responses and individual strengths and coping skills are thus essential.
Collapse
Affiliation(s)
- Rathi Mahendran
- Department of Psychological Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore.,Department of Psychological Medicine, National University Hospital, Singapore
| | - Haikel A Lim
- Department of Psychological Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Joyce Ys Tan
- Department of Psychological Medicine, National University of Singapore, Singapore
| | - Ee Heok Kua
- Department of Psychological Medicine, National University of Singapore, Singapore.,Department of Psychological Medicine, National University Hospital, Singapore
| | - Konstadina Griva
- Department of Psychology, National University of Singapore, Singapore
| |
Collapse
|
8
|
Lim HA, Tan JY, Chua J, Yoong RK, Lim SE, Kua EH, Mahendran R. Quality of life of family caregivers of cancer patients in Singapore and globally. Singapore Med J 2016; 58:258-261. [PMID: 27090600 DOI: 10.11622/smedj.2016083] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Family caregivers of cancer patients often suffer from impaired quality of life (QOL) due to stress arising from the responsibility of caregiving. Most research on such QOL impairments was conducted in Western populations. Thus, this exploratory study sought to (a) examine the QOL levels of family caregivers of cancer patients in an Asian population in Singapore, in relation to caregivers from other countries within and outside of Asia; and (b) investigate the association between sociodemographic factors and QOL impairments in family caregivers in Singapore. METHODS A total of 258 family caregivers of cancer patients who were receiving outpatient treatment completed the Caregiver Quality of Life Index-Cancer (CQOLC) and a sociodemographic survey. We compared the published CQOLC total scores from Turkey, Iran, Taiwan, South Korea, the United Kingdom, the United States and Canada with the Singapore dataset and examined the demographic relationships. RESULTS Caregivers in Singapore and Asia had lower CQOLC total scores than their Western counterparts. Caregivers who were male, of Chinese ethnicity, had parental relationships with their care recipient, or cared for advanced-stage cancer patients were found to have impaired QOL. CONCLUSION The findings of this study highlight possible areas in which support can be provided for family caregivers of cancer patients, and underscore the need to reconcile cultural diversity, values, societal expectations and demographic characteristics in Singapore.
Collapse
Affiliation(s)
- Haikel A Lim
- Department of Psychological Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Joyce Ys Tan
- Department of Psychological Medicine, National University of Singapore, Singapore
| | - Joanne Chua
- Department of Psychological Medicine, National University Hospital, Singapore
| | - Russell Kl Yoong
- Department of Psychological Medicine, National University of Singapore, Singapore
| | - Siew Eng Lim
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Ee Heok Kua
- Department of Psychological Medicine, National University of Singapore, Singapore.,Department of Psychological Medicine, National University Hospital, Singapore
| | - Rathi Mahendran
- Department of Psychological Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore.,Department of Psychological Medicine, National University Hospital, Singapore
| |
Collapse
|