The implementation and impact of Holistic Needs Assessments for people affected by cancer: A systematic review and thematic synthesis of the literature

The symptom burden and the assessment of palliative symptoms in patients with metastatic upper gastrointestinal cancer: A qualitative interview study

OBJECTIVES

Patients with metastatic upper gastrointestinal (GI) cancer may experience a large physical symptom burden. However, less is known about existential, social, and psychological symptoms. To provide the patient with palliative care, quality-of-life questionnaires are used for structured needs assessment. These are sporadically implemented, and there seems to be uncertainty to the efficiency of current practice. The aim of study was to explore the experienced assessment-process and treatment of palliative symptoms, as well as the experienced symptom burden, in patients with metastatic upper GI cancer.

METHODS

Qualitative, semi-structured interviews were conducted in 10 patients with metastatic upper GI cancer. Data were analyzed using content analysis.

RESULTS

The patients did not expect treatment for all physical symptoms. Existential symptoms revolved around death and dying, social issues were mainly related to family, and psychological issues were based in the continuous dealing with serious illness. Existential, social, and psychological symptoms were mostly not considered part of the expected care when admitted to hospital. Patients had only vague recollections of their experiences with structured needs assessment, and the process had been inconsequential in the treatment of symptoms.

SIGNIFICANCE OF RESULTS

Patients with upper GI cancer experience symptoms related to all 4 areas of palliative care being physical, existential, social, and psychological, but these are differentiated in the way patients perceive their origins and treatability. Structured needs assessment was not routinely carried out, and in cases where this had been done, no follow-up was effectuated. This calls for increased focus and proper implementation for the process to be relevant in the treatment of palliative symptoms.

What is the evidence behind cancer care reviews, a primary care cancer support tool? A scoping review

PURPOSE

A "cancer care review" (CCR) is a conversation between a patient recently diagnosed with cancer and primary care practitioner soon after a diagnosis of cancer in the UK. This scoping review aimed to identify: methodology and validated outcome measures used to evaluate CCRs, the impact of CCRs on quality of life or symptoms, and the views of patients, their carers and healthcare professionals on CCRs.

METHODS

A scoping review was performed and five databases (MEDLINE, Embase, PsychINFO, Scopus, Web of Science, Google Scholar) were searched systematically from January 2000 to March 2022.

RESULTS

Of 4133 articles, ten met the inclusion criteria. These included surveys, qualitative research on stakeholders' views and a small study evaluating group consultation CCRs. There were no studies on methodology to evaluate CCRs or the impact of CCRs on patient quality of life or symptoms. Some primary care professionals felt CCRs were a tick-box exercise, and that they had inadequate time to deliver care, compounded by inadequate primary-secondary care coordination and lack of expertise which was echoed by patients. Interviews with patients found few recalled CCRs and those that recalled CCRs did, did not find them particularly helpful. Partners of patients would welcome CCRs to raise personal health concerns and remain updated on patient care.

CONCLUSIONS

Further studies should identify the role that stakeholders believe they should have in CCRs, improve care coordination between primary care and secondary care and how to support caregivers.

IMPLICATIONS FOR CANCER SURVIVORS

There is currently insufficient evidence to support the use of CCRs in general practice.

Improving personalised care and support planning for people living with treatable-but-not-curable cancer

People living with treatable-but-not-curable (TbnC) cancer encounter cancer-related needs. While the NHS long-term plan commits to offering a Holistic Needs Assessment (HNA) and care plan to all people diagnosed with cancer, the content, delivery and timing of this intervention differs across practice. Understanding how people make sense of their cancer experience can support personalised care. A conceptual framework based on personal narratives of living with and beyond cancer (across different cancer types and all stages of the disease trajectory), identified three interlinked themes: Adversity, Restoration and Compatibility, resulting in the ARC framework.Our aim was to use the ARC framework to underpin the HNA to improve the experience of personalised care and support planning for people living with TbnC cancer. We used clinical work experience to operationalise the ARC framework and develop the intervention, called the ARC HNA, and service-level structure, called the ARC clinic. We sought expert input on the proposed content and structure from patients and clinicians through involvement and engagement activities. Delivered alongside standard care, the ARC HNA was piloted with patients on the TbnC cancer (myeloma and metastatic breast, prostate or lung) pathway, who were 6-24 months into their treatment. Iterations were made to the content, delivery and timing of the intervention based on user feedback.Fifty-one patients received the intervention. An average of 12 new concerns were identified per patient, and 96% of patients achieved at least one of their goals. Patients valued the space for reflection and follow-up, and clinicians valued the collaborative approach to meeting patients' supportive care needs. Compared with routine initial HNA and care plan completion rates of 13%, ARC clinic achieved 90% with all care plans shared with general practitioners. The ARC clinic adopts a novel and proactive approach to delivering HNAs and care plans in a meaningful and personalised way.

Holistic needs assessment in outpatient cancer care: a randomised controlled trial

DESIGN

Analyst blinded, parallel, multi-centre, randomised controlled trial (RCT).

PARTICIPANTS

People with confirmed diagnoses of cancer (head and neck, skin or colorectal) attending follow-up consultation 3 months post-treatment between 2015 and 2020.

INTERVENTION

Holistic needs assessment (HNA) or care as usual during consultation.

OBJECTIVE

To establish whether incorporating HNA into consultations would increase patient participation, shared decision making and postconsultation self-efficacy.

OUTCOME MEASURES

Patient participation in the consultations examined was measured using (a) dialogue ratio (DR) and (b) the proportion of consultation initiated by patient. Shared decision making was measured with CollaboRATE and self-efficacy with Lorig Scale. Consultations were audio recorded and timed.

RANDOMISATION

Block randomisation.

BLINDING

Audio recording analyst was blinded to study group.

RESULTS

147 patients were randomised: 74 control versus 73 intervention.

OUTCOME

No statistically significant differences were found between groups for DR, patient initiative, self-efficacy or shared decision making. Consultations were on average 1 min 46 s longer in the HNA group (respectively, 17 m 25 s vs 15 min 39 s).

CONCLUSION

HNA did not change the amount of conversation initiated by the patient or the level of dialogue within the consultation. HNA did not change patient sense of collaboration or feelings of self-efficacy afterwards. HNA group raised more concerns and proportionally more emotional concerns, although their consultations took longer than treatment as usual.

IMPLICATIONS FOR PRACTICE

This is the first RCT to test HNA in medically led outpatient settings. Results showed no difference in the way the consultations were structured or received. There is wider evidence to support the roll out of HNA as part of a proactive, multidisciplinary process, but this study did not support medical colleagues facilitating it.

TRIAL REGISTRATION NUMBER

NCT02274701.

A NEw MOdel of individualized and patient-centered follow-up for women with gynecological cancer (the NEMO study)-protocol and rationale of a randomized clinical trial

BACKGROUND

Follow-up programs for gynecological cancer patients are currently under revision. There is limited evidence that traditional follow-up and clinical examinations improve survival in an early-stage gynecological setting. Further, traditional follow-up programs fail to accommodate the patient's need for psychosocial and sexual supportive care and to actively involve patients and their relatives in the follow-up process. Individualized programs may replace traditional routine follow-up with fixed intervals and length. Focusing on alarm-symptoms and self-reporting may ensure detection of recurrence while allowing a continuous attention to the patient's well-being and return to daily life. In this study, a nurse-led, individualized, and need-based intervention with a specific focus on patient empowerment is tested against a standard physician-led model primarily focusing on the detection of recurrence.

METHODS

The study is designed as a clinical, randomized trial conducted in one of four national onco-gynecological centers in Denmark. Patients with early-stage cervical or endometrial cancer are eligible for inclusion. The intervention group undergoes individualized, nurse-led follow-up supporting patient empowerment including repeated use of electronic patient-reported outcome measures (ePROMs) before each contact as a dialogue support tool. The follow-up contacts are mainly conducted by telephone. All project nurses attended a special training program before project start and are all well-educated and dedicated onco-gynecological nurses. The control group receives standard, physician-led, follow-up without use of ePROMs or specific focus on empowerment. The effect of the intervention is evaluated by questionnaires completed by patients at baseline (3 months after surgery) and 12, 18, and 36 months after surgery. Outcomes include empowerment using the Skill and technique subscale of the HEI-Q questionnaire as the primary outcome while fear of cancer recurrence and health-related quality of life as well as the remaining subscales of the HEI-Q represent secondary outcomes. Data is collected by use of the REDCap technology, which also provides a customized visual support function for the dialogue tool.

DISCUSSION

This study will provide new information about follow-up in early-stage gynecological cancer settings and thereby contribute to improvement of future follow-up programs. Importantly, the study will provide knowledge about the impact of specific focus on patient empowerment in follow-up programs and, further, how to facilitate empowerment among patients.

TRIAL REGISTRATION

The study is registered at clinicaltrials.gov: ID no. NCT03838861. Registered on 6 February 2019. Protocol version 2, issue date 21 November 2022.

Are older patients less likely to be treated for pancreatic cancer? A systematic review and meta-analysis

Pancreatic cancer is the seventh commonest cause of cancer-related death worldwide. Although prognosis is poor, both surgery and adjuvant chemotherapy improve survival. However, it has been suggested that not all pancreatic cancer patients who may benefit from treatment receive it. This systematic review and meta-analysis investigated the existence of age-related inequalities in receipt of first-line pancreatic cancer treatment. Medline, Embase, Cochrane Library and grey literature were searched for population-based studies investigating treatment receipt, reported by age, for patients with primary pancreatic cancer from inception until 4th June 2020, and updated 5th August 2021. Studies from countries with universal healthcare were included, to minimise influence of health system-related economic factors. A modified version of the Newcastle-Ottawa Scale was used to assess risk of bias. Random-effects meta-analysis was undertaken comparing likelihood of treatment receipt in older versus younger patients. Sensitivity and subgroup analyses were conducted. Eighteen papers were included; 12 independent populations were eligible for meta-analysis. In most studies, < 10% of older patients were treated. Older age (generally ≥65) was significantly associated with reduced receipt of any treatment (OR=0.14, 95% CI 0.10-0.21, n = 12 studies), surgery (OR=0.15, 95% CI 0.09-0.24, n = 9 studies) and chemotherapy as a primary treatment (OR=0.13, 95% CI 0.07-0.24, n = 5 studies). The effect of age was independent of methodological quality, patient population or time-period of patient diagnosis and remained in studies with confounder adjustment. The mean quality score of included studies was 6/8. Inequalities in receipt of healthcare interventions across social groups is a recognised concern internationally. This review shows that older age is significantly, and consistently, associated with non-receipt of treatment in pancreatic cancer. However, there are risks and side-effects associated with pancreatic cancer treatment. Further research on what influences patient and professional treatment decision-making is required to better understand these apparent inequalities.

Breast Cancer Survivorship Programme: Follow-Up, Rehabilitation, Psychosocial Oncology Care. 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

Follow-up includes ongoing contact with and health education of the patient, surveillance and control of the adverse effects of surgery, oncological therapies or radiotherapy, screening of metachronous cancers, and comprehensive (physical, psychological and social) patient rehabilitation, which may be enhanced by a healthy lifestyle. Primary attention should be paid to early detection and, when needed, curative treatment of local/regional tumour recurrences. Similarly, with the hope of curative solution, it is important to recognize the entity of a low-mass and relatively indolent recurrence or metastasis (oligometastasis); however, there is still no need to investigate distant metastases by routine diagnostic imaging or assess tumour markers. Below there is a list of possible sources of support, with respect to adjuvant hormone therapy continued during long-term care, social support resources, pivotal points and professional opportunities for physical and mental rehabilitation. Individual solutions for specific issues (breast cancer risk/genetic mutation, pregnancy) are provided by constantly widening options. Ideally, a complex breast cancer survivorship programme is practised by a specially trained expert supported by a cooperative team of oncologists, surgeons, breast radiologists, social workers, physiotherapists, psycho-oncologists and psychiatrists. The approach of follow-up should be comprehensive and holistic.

Concurrent Validity and Prognostic Utility of the Needs Assessment Tool: Progressive Disease Heart Failure

CONTEXT

People with advanced heart failure have supportive and palliative needs requiring systematic assessment.

OBJECTIVES

We aimed to assess the validity of the Needs Assessment Tool: Progressive Disease - Heart Failure (NAT:PD-HF).

METHODS

Secondary analysis of routinely collected patient data from a specialist palliative care-heart disease service improvement project. NAT:PD-HF, the Integrated Palliative care Outcome Scale (IPOS), and patient and/or carer-report data were collected. Concurrent validity between NAT:PD-HF items and comparison measures (Kendall's tau; kappa); construct validity via known-group comparisons; predictive utility of NAT:PD-HF for survival (multivariable Cox hazard regression model).

RESULTS

Data from 88 patients (50% men; mean age 85; median survival 205 days; 64% left ventricular systolic dysfunction) were analyzed. Prevalence- and bias-adjusted kappa values indicated moderate agreement for physical symptom needs (k: 0.33 for patients, 0.42 for carers). Substantial agreement was observed for patient and/or carer psychological symptoms, and information needs (k ≥ 0.6). NAT:PD-HF distinguished between patients with different survival, comorbidities, functional scores, and palliative Phase of Illness with moderate to high effect sizes. NAT did not predict survival when adjusted for mortality risk score and functional status (2+ needs HR: 1.52, 95% CI: 1.01-1.74).

CONCLUSION

The NAT:PD-HF is a valid tool for clinician assessment of physical, psychosocial, and information patient and/or carer needs.

Holistic Needs Assessment of Cancer Survivors-Supporting the Process Through Digital Monitoring of Circadian Physiology

The year 2022 could represent a significant juncture in the incorporation of mHealth solutions in routine cancer care. With the recent global COVID-19 pandemic leading a surge in both observation- and intervention-based studies predominantly aimed at remote monitoring there has been huge intellectual investment in developing platforms able to provide real time analytics that are readily usable. Another fallout from the pandemic has seen record waiting times and delayed access to cancer therapies leading to exhausting pressures on global healthcare providers. It seems an opportune time to utilize this boom in platforms to offer more efficient “at home” clinical assessments and less “in department” time for patients. Here, we will focus specifically on the role of digital tools around cancer survivorship, a relevant aspect of the cancer journey, particularly benefiting from integrative approaches. Within that context a further concept will be introduced and that is of the likely upsurge in circadian-based interpretation of continuous monitoring and the engendered therapeutic modifications. Chronobiology across the 24-hour span has long been understood to control key bodily aspects and circadian dysregulation plays a significant role in the risk of cancer and also the response to therapy and therefore progressive outcome. The rapid improvement in minimally invasive monitoring devices is, in the opinion of the authors, likely to advance introducing chronobiological amendments to routine clinical practices with positive impact on cancer survivors.

Meeting psychosocial needs to improve health: a prospective cohort study

Background

Cancer impacts on patients and their families across a range of different domains. For that reason, optimal cancer care has moved away from a disease-centric focus to a more holistic approach in order to proactively support people with their individual needs and concerns. While international policy clearly advocates this agenda, implementation into routine care is limited. Therefore, relevant interventions that measurably improve patient outcomes are essential to understand if this ideal is to become routine multidisciplinary practice. The aim of this study was to analyse the impact of a proactive, holistic, community-based intervention on health-related quality of life in a cohort of people diagnosed with cancer. Secondary aim was to explore the relationship between changes in health status and: cancer type, cancer stage, number of concerns expressed and change in severity of concerns pre and post intervention.

Method

Prospective observational cohort study. A convenience sample of 437 individuals were referred to the service ‘Improving the Cancer Journey (ICJ) in the UK. Each completed the Euroqol EQ-5D-3 L and visual analogue scale (VAS) and a Holistic Needs Assessment (HNA) during initial visit to the service and again at follow-up review, median 84 days later. Change between scores was tested with paired t-tests and relationships between variables with multiple regression models with heteroscedasticity-consistent standard errors.

Results

Participants were White British with median age between 50 and 64 years. Cancer type and stage were varied. EQ-5D utility scores improved at follow-up by 0.121 [0.0891–0.153], p < .001, and VAS scores improved by 7.81 [5.88–9.74], p < .001. The strongest predictor of change was a decrease in severity of concerns. Cancer stage ‘palliative care’ contributed to a reduction in health status.

Conclusion

This study is the first to show that a holistic community intervention dedicated to supporting the individual concerns of participants had both a statistically significant and clinically meaningful impact on participants’ health-related quality of life. The mean change in EQ-5D scores was more than the ‘minimally important clinical difference’ described in the literature. This is important because while quality of life has multiple determinants, this study has shown for the first time that it is possible to capture a clinically meaningful improvement as a function of reducing someone’s personally identified concerns.

Current status and future perspectives in the endocrine treatment of postmenopausal, hormone receptor-positive metastatic breast cancer

INTRODUCTION

Endocrine therapy is a fundamental component of the therapeutic repertoire for treatment of metastatic, hormone receptor-positive breast cancer. Inevitably, however, tumors develop resistance to these compounds, and overcoming this phenomenon is a key motivator of research in this field.

AREAS COVERED

This review summarizes the current status of endocrine therapy for the treatment of metastatic disease, with a main focus on postmenopausal patients. Furthermore, strategies that could potentially sustain endocrine resistance and future perspectives in this direction are also to be described. Relevant references were identified by PubMed searches and from the abstract books of the annual meetings of The European Society of Clinical Oncology (ESMO), The American Society of Clinical Oncology (ASCO) and from the San Antonio Breast Cancer Symposia.

EXPERT OPINION

Combinations of endocrine therapy with HER2 targeting agents, as well as with compounds that can interfere with PI3K/Akt/mTOR signaling, are two promising strategies for delaying or overcoming endocrine resistance, mediated by these relevant biological pathways. Due to increased costs and the burden of toxicity associated with these combination therapies, compared to endocrine therapy alone, it is imperative to concentrate efforts on establishing biomarkers that can predict efficacy.