Restoring a sense of wellness following colorectal cancer: a grounded theory

Quality of Life After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC): Cancer Survivors' Perspective Through In-Depth Interviews

BACKGROUND

CRS/HIPEC patients face unique quality of life (QoL) challenges due to advanced disease (peritoneal carcinomatosis), the extent of procedure, and risk for long-term complications. Standard QoL questionnaires are generic, focusing on tumor type and standard treatments, and likely do not capture this select population's full experience, suggesting the need for tailored instruments. We aimed to characterize the QoL challenges faced by CRS/HIPEC cancer survivors and determine whether these were captured by a standard QoL questionnaire.

PATIENTS AND METHODS

An anonymous, semi-structured individual interview was conducted with CRS/HIPEC patients addressing their experience at diagnosis, challenges related to CRS/HIPEC, and access to CRS/HIPEC information. Verbatim transcripts were interpreted using thematic analysis. Code and theme identification was inductive. Questions addressing common themes that were not encompassed by a standard QoL questionnaire were developed.

RESULTS

We interviewed eight patients. Median age was 55 (range 30-71) years and 75% (n = 6) were women. Primary tumor sites included appendix (n = 4), ovarian (n = 3), and peritoneal mesothelioma (n = 1). Median time from CRS/HIPEC was 40.1 (range 3.1-216.3) months. Overall, 133 codes were identified and categorized into 9 themes. The most recurring were physical symptoms after CRS/HIPEC (specifically gastrointestinal symptoms), adjusting to survivorship, mental health, expectations from CRS/HIPEC, and access to care. A total of 22 questions that did not overlap with a standardized QoL questionnaire were developed.

CONCLUSIONS

There is an unmet need to understand the unique QoL challenges CRS/HIPEC patients encounter. Patient-centered QoL questionnaires based on CRS/HIPEC patient experiences can capture these unique challenges and help guide future studies and care.

Exploring How Values of Colorectal Cancer Patients and their Caregivers Influence Treatment Decision-Making

BACKGROUND

As we adopt value models to inform drug reimbursement, coverage, clinical trials, and treatment choices, aligning these models to reflect patient values and preferences becomes increasingly relevant. In this study, we focus on colorectal cancer (CRC), which is highly prevalent and a leading cause of death in Canada, and new drug treatment options are costly.

OBJECTIVE

The aim of this study was to understand how the values and experiences of people with CRC and their caregivers inform their perspectives about new and emerging colorectal cancer drug treatments.

METHODS

We applied qualitative methods to identify key personal, social, and system factors about how the values of people with CRC and their caregivers' values influence their treatment decision-making in a more holistic manner. Canadian adults (>18 years) living with non-metastatic or metastatic CRC and caregivers were recruited from oncology clinics and Colorectal Cancer Canada (CCC) using purposive sampling. Participants engaged in structured interviews by telephone. Interviews were transcribed verbatim and analyzed thematically guided by a qualitative phenomenological approach and Sherwin's ethical theory of relational autonomy using NVivo software.

RESULTS

We conducted structured interviews with 12 people with CRC and six of their caregivers, and elicited patient and caregiver values and their influence on treatment decision-making context of key personal, social, and system factors. Thematic analysis of transcripts led to the development of four overarching and intersecting themes that were identified as influencing people with CRC and their caregivers' treatment decision-making: treatment outcomes and effectiveness, intrapersonal and interpersonal factors, quality of life, and survivorship and prognosis.

DISCUSSION

Our findings suggest intersecting influences of patient-, community-, and social network-, and systemic-level factors that influence patients' decisions on treatment. Perceived clinical benefit, requirements of treatment, available information, the impact of treatment on social relationships and daily life, and the impact of social support were key factors described by participants. To our knowledge, this is the first study to utilize the theory of relational autonomy to understand patient and caregiver values in the context of treatment decisions in CRC. Using these findings, a continued exploration of people with CRC's values in treatment decision-making and how much patients value or weight the different aspects of treatment would help further advance patient care and guide healthcare system decision-making.

'The last bridge'- How patients experience the CAR T-cell therapy. A qualitative study

PURPOSE

CAR T-cell therapy gives patients new hope, who are diagnosed with relapsed or refractory B-cell lymphoma or B-cell leukaemia. To date, there is no scientific knowledge about the experiences of patients with CAR T-cell therapy, their process of treatment decision making or how they handle potential side effects. The study aims at deepening the understanding of the patient's experiences, indicating how to improve nursing care for this patient population.

METHOD

A qualitative study was carried out. Episodic guideline-based interviews were conducted with 14 patients who had received CAR T-cell therapy. The data analysis was performed according to the Grounded Theory. The study took place at a German university hospital.

RESULTS

Data analysis showed five sequential phases including the following concepts: 'living with cancer recurrence', 'deciding on CAR T-cell therapy', 'waiting for the reinfusion of the CAR T-cells', 'experiencing CAR T-cell therapy' and 'recovering and staying healthy'. The decision for CAR T-cell therapy was characterised by the lack of alternatives and uncertainty about the outcome and side effects.

CONCLUSIONS

Before, during and after CAR T-cell therapy, patients are faced with major challenges for which they need nursing support and guidance. These include preparation for CAR T-cell therapy, handling of side effects and preparation for discharge home.

Qualitative Research and Applications in Colorectal Surgery

Traditionally employed in medical anthropologic and sociologic literature, qualitative methods are emerging as an essential component of clinical research as surgeons and researchers strive to optimize care informed by patient perspectives. Qualitative methods in health care-related research may be used to understand subjective experiences, beliefs, and concepts that are not captured using quantitative analyses and to gain in-depth knowledge of a specific context or culture. A qualitative approach may also be employed to explore under-researched problems and generate new ideas. Here, we provide an overview of aspects to consider when designing and conducting a qualitative research study.

Development and Testing of the Smart Healthcare Prototype System through COVID-19 Patient Innovation

Since the outbreak of the novel coronavirus disease 2019 (COVID-19), the epidemic has gradually slowed down in various countries and people’s lives have gradually returned to normal. To monitor the spread of the epidemic, studies discussing the design of related healthcare information systems have been increasing recently. However, these studies might not consider the aspect of user-centric design when developing healthcare information systems. This study examined these innovative technology applications and rapidly built prototype systems for smart healthcare through a systematic literature review and a study of patient innovation. The design guidelines for the Smart Healthcare System (SHS) were then compiled through an expert review process. This will provide a reference for future research and similar healthcare information system development.

Coping with cystic fibrosis: An analysis from the sibling's point of view

BACKGROUND

Cystic fibrosis (CF) is a chronic, life-threatening condition that results in life-long morbidity and premature mortality. CF has a significant impact on healthy siblings' adaptation and well-being. Siblings of patients with a chronic disease may experience psychological difficulties, such as anxiety, depression symptoms and troubles in adaptation. This study aimed to explore the participants' experiences of growing up with a CF patient diagnosed at a paediatric age and their adaptation strategies.

METHODS

We enrolled eight CF siblings (adolescents and young adults) in a 6-month focus group sessions programme. Each session had two phases (psychoeducational and experiential). Transcripts were analysed and grouped through grounded theory analysis to elaborate on data-driven theory.

RESULTS

We identified 14 subthemes by which the raw data could be organized. All the subthemes were gathered together according to the axial coding process into six themes (illness, changes, communication, avoidance, normalization, and protection and care). We then grouped the six themes into two main themes ('Growing up with a CF brother or sister' and 'Finding the right distance') and conceptualized the grounded theory 'Keeping the right distance'. The participants described the evolving process of maintaining a balance between the illness of their brother or sister, family organization and their own needs.

CONCLUSIONS

Knowing siblings' experiences and their common strategies to deal with the experience of having a brother or sister with a chronic health condition may be useful to ensure more tailored and specific interventions.

Patient-reported recovery in upper abdominal cancer surgery care: A prospective study

The study aimed to describe and analyse patient-reported recovery in patients after upper abdominal cancer surgery. This study had a quantitative design and patients were consecutively included in a university hospital in southern Sweden. Twenty-four patients answered the Postoperative Recovery Profile (PRP) questionnaire at three measurement points. All five dimensions were affected. In the physical symptoms dimension, the majority of patients reported a lack of energy upon discharge. High levels of anxiety were reported. Over 50% of patients reported some degree of depressed mood at all three measurement points. In the social dimension, the majority of patients reported some degree of being dependent on help from others in everyday life at 4 weeks after discharge. Few patients are fully recovered at 4 weeks after discharge. Individual patient-reported recovery estimates may be valuable in identifying and planning interventions tailored to each patient's needs throughout the care process.

Colorectal cancer survivorship: A systematic review and thematic synthesis of qualitative research

INTRODUCTION

With rapid changes in treatments for colorectal cancer (CRC), qualitative research into CRC survivorship requires greater synthesis. This paper aims to fill this gap through a systematic review (PROSPERO CRD42019131576) and thematic synthesis of the qualitative literature on survivorship experiences across early-stage and advanced CRC survivors.

METHODS

CINAHL, Embase, MEDLINE, PsycINFO and PubMed were searched for qualitative CRC survivorship papers. Titles, abstracts and full texts were screened. Included articles (n = 81) underwent data extraction, CASP qualitative bias ratings and thematic synthesis.

RESULTS

Bowel dysfunction caused functional limitations and negative quality of life (QoL), while stomas posed threats to body image and confidence. Physical symptoms hindered return to work, increasing financial burdens. Survivors' unmet needs included information regarding symptom expectations and management, and ongoing support throughout recovery. Advanced and early-stage survivors shared similar experiences. Advanced survivors struggled with fear of cancer recurrence/progression and feelings of powerlessness. Functional limitations, financial impacts and sexuality in advanced survivors were underexplored areas.

CONCLUSION

CRC and its treatments impact survivors' QoL in all areas. A coordinated supportive care response is required to address survivors' unmet needs. Future qualitative studies should explore advanced CRC subpopulations, treatment-specific impacts on QoL and long-term (>5 years) impacts on CRC survivors.

State of Recovery 6 Months After Rectal Cancer Surgery: Postoperative Symptoms and Differences With Regard to Surgical Procedure

Rectal cancer surgery has developed to be highly technological and precise. Nevertheless, postoperative symptoms can affect patients for a long time after surgery and might also be persistent. The purpose of this study was to describe the level of postoperative symptoms 6 months after rectal cancer surgery as well as differences in symptoms with regard to surgical procedure. Data from 117 patients recovering from rectal cancer surgery were collected 6 months after surgery using the Postoperative Recovery Profile (PRP) questionnaire measuring self-reported postoperative symptoms. Results showed that the majority of patients had no or mild problems with the 19 symptoms recorded in the questionnaire. There was a significant difference between surgical procedures: patients after anterior resection experienced mild problems in gastrointestinal function (physical domain) and interest in their surroundings (social domain), whereas most patients after abdominoperineal resection and abdominoperineal resection with myocutaneous flap showed no problems. In all groups, a considerably high proportion of patients reported severe problems in sexual activity (physical domain). Findings in this study emphasize that healthcare professionals should pay attention to patients recovering from anterior resection especially regarding problems in the gastrointestinal function. Moreover, there is a need to acknowledge eventual sexual dysfunctions in all rectal cancer patients.

Experiences of patients with colorectal cancer from diagnosis until completion of treatment: A meta-ethnography approach

OBJECTIVE

The purpose of this meta-synthesis was to explore the experience of living with symptoms caused by colorectal cancer (CRC) and its treatment from the perspectives of those affected.

METHODS

In a systematic search of qualitative studies published up to September 2017, 21 relevant papers were identified. The meta-ethnography followed the approach developed by Noblit and Hare. To relate key themes from one paper to similar themes of different papers, a "reciprocal translation" was carried out.

RESULTS

Through synthesis, a new model was developed during treatment ("lines-of-argument synthesis"). Two constructs of experiences took place before the illness. Six third-order constructs were developed to capture patients' experiences during treatment, including "disruption in life through CRC" as well as the complex and circular experiences summarized as "experiences of symptoms and challenges by CRC". In contrast, experiences in dealing with changes that CRC and the treatment imply were "making sense of the experience", "sharing the experience", "experiences with controlling ones' body", and "experiences with reforming life".

CONCLUSIONS

This meta-ethnography clarifies fundamental aspects of patients' experience in very different settings or starting points by specifying a more complete and holistic spectrum of experiences with CRC and its treatment.

Living and dying with metastatic bowel cancer: Serial in-depth interviews with patients

Colorectal cancer is the second highest cause of cancer deaths. There are significant physical and psycho‐social effects on quality of life with advanced disease. Despite this, there are few accounts of the patient experience from advanced illness through to dying. We elicited the longitudinal experiences of living and dying with incurable metastatic colorectal cancer by conducting serial interviews with patients for 12 months or until they died. The interviews were analysed, using a narrative approach, longitudinally as case studies and then together. Thirty‐six interviews with 16 patients were conducted. Patients experience metastatic colorectal cancer in three phases; (1) Diagnosis and initial treatment; (2) Deterioration and social isolation and (3) Death and dying. Many patients initially said they hoped to survive, but, as “private” and in‐depth accounts of the experience emerged in further interviews, so did the understanding that this hope co‐existed with the knowledge that death was near. Palliative chemotherapy and the challenge of accessing private accounts of patient experience can inhibit care planning and prevent patients benefitting from an active holistic palliative care approach earlier in the disease trajectory. This study has immediate clinical relevance for health care professionals in oncology, palliative care and primary care.

The cost of survival: an exploration of colorectal cancer survivors' experiences of pain

BACKGROUND

The Institute of Medicine report 'From Cancer Patient to Cancer Survivor' has drawn widespread attention to the experiences of cancer survivors. Research examining the symptom experiences of survivors are proliferative within the literature but limited by samples which include multiple tumor groups and varying inclusion criteria. This cross-sectional quantitative study seeks to examine pain and quality of life (QoL) in the context of colorectal cancer (CRC) survivorship, as defined by the Institute of Medicine.

MATERIAL AND METHODS

A purposive sample of CRC survivors (n = 252) attending hospitals and cancer support centers in the Republic of Ireland were recruited between September 2014 and January 2016. Self-rated health (SRH), QoL and pain were assessed in the sample using the EuroQOL questionnaire, the Functional Assessment of Therapy-Colorectal (FACT-C) questionnaire, and symptom experience items.

RESULTS

One hundred participants (40%) indicated they had pain on the day of the survey or in the past week. Of those with pain, many also experienced a lack of energy (95%), bowel dysfunction (74%), sleep disturbance (76%) or interference with their ability to enjoy life (75%). Pain was associated with younger age, female gender, current chemotherapy treatment, and previous radiotherapy treatment. Although participants reported positive QoL scores, statistical analysis revealed pain was linked to significantly poorer SRH and overall QoL, and poorer physical, emotional, functional, social/family and CRC-specific wellbeing, compared to those who did not indicate pain.

DISCUSSION

Pain was experienced by almost two fifths of CRC survivors up to five years after treatment and was associated with poorer SRH and QoL. In light of these findings, healthcare professionals must endeavor to manage cancer survivors' needs in a manner which is cognizant of the burden of pain and in the context of other symptoms and morbidities experienced by long-term cancer survivors.

General health and state anxiety in patients recovering from colorectal cancer surgery

AIM

To describe and compare general health and state anxiety before surgery and up to 6 months after surgery in patients with colorectal cancer undergoing elective rectal resection, abdominoperineal resection or colonic resection in an enhanced recovery context.

BACKGROUND

Little is known about patient-reported health and anxiety after colorectal cancer surgery in an enhanced recovery context.

DESIGN

A prospective cohort study.

METHODS

Data were collected from October 2011-February 2013. The questionnaires - EuroQol 5-Dimensions 3-Levels and State-Trait Anxiety Inventory - were answered before surgery, at discharge and 1 and 6 months after surgery. Data were analysed using inferential statistics to describe differences between groups of patients (Kruskal-Wallis test) and between assessments within groups (Friedman's anova).

RESULTS

Patients (N = 105), divided into three groups based on surgical procedure, showed a high health index and a low state anxiety in all assessments without differences between the groups. Patients considered for abdominoperineal resection rated their pre-operative health as significantly higher than patients after rectal and colonic resections did. Within groups, patients recovering from abdominoperineal resection and rectal resection deteriorated significantly in health index 1 month after surgery. However, after 6 months they had improved again. After colonic resection, patients improved significantly in self-rated health and anxiety 1 month after surgery with no further discernible improvement after 6 months.

CONCLUSION

The study showed that patients generally had a high level of health and a low level of anxiety throughout the study period. Only a few differences occurred between assessments within groups.

Self-Reorientation Following Colorectal Cancer Treatment - A Grounded Theory Study

After colorectal cancer (CRC) treatment, people reorganize life in ways that are consistent with their understanding of the illness and their expectations for recovery. Incapacities and abilities that have been lost can initiate a need to reorient the self. To the best of our knowledge, no studies have explicitly focused on the concept of self-reorientation after CRC treatment. The aim of the present study was therefore to explore self-reorientation in the early recovery phase after CRC surgery. Grounded theory analysis was undertaken, using the method presented by Charmaz. The present results explained self-reorientation as the individual attempting to achieve congruence in self-perception. A congruent self-perception meant bringing together the perceived self and the self that was mirrored in the near environs. The results showed that societal beliefs and personal explanations are essential elements of self-reorientation, and that it is therefore important to make them visible.

Ethical considerations on the value of patient knowledge in long-term care: a qualitative study of patients suffering from Korsakoff 's syndrome

AIM

This study explores experiences of patients suffering from Korsakoff's syndrome. It contributes to improved reflection on the value of patient knowledge.

BACKGROUND

An ethics of care perspective states the importance of moving to patients in their vulnerable state of being, and to figure out patients' individual needs necessary to provide good care. The information given by patients suffering from Korsakoff's syndrome might be mistaken, invented and even not true. The value of these patients' experiences and knowledge had not been researched to date.

METHOD

Data from six in-depth interviews were analysed concurrently through the constant comparative method.

ETHICAL CONSIDERATIONS

The principles of voluntariness, confidentiality and anonymity were respected during the research process.

FINDINGS

Four important themes within patients' knowledge emerged: health condition, involuntary admission into the nursing home, the daily routine and interpretation of the caring abilities of healthcare professionals. The findings show that our respondents were able to provide a window into their inner perspective.

CONCLUSION

This study deepens our understanding of the value of patient knowledge in situations where patients see the world in a different manner as do healthcare professionals. The conversations revealed personal subjective knowledge which our respondents create and live by. Healthcare professionals are encouraged to discover and affirm the understandings of these patients, and not be prepossessed due to the diagnosis or general nursing home rules. Understanding patients' unique knowledge through appreciation of the complexity and richness of different views on the situation can assist to give a more humane response to individual needs and pain. Health staff in healthcare institutions are encouraged to evaluate the - unintended - effect of rigidly applied nursing home rules, and the government is challenged to rethink its policy about care, and provide more resources permitting relational care that nurtures the dignity of patients suffering from Korsakoff's syndrome.

Addressing patients’ colorectal cancer needs in preoperative education

Purpose

– The purpose of this paper is to understand and develop ways to enhance patients’ experiences of preoperative education received prior to surgery for colorectal cancer.

Design/methodology/approach

– Based in the UK, three-action research cycles were undertaken to evaluate preoperative education, identify changes seen by patients and staff as likely to improve the service and to re-evaluate such changes following implementation. Data in each cycle were collected from: observations of clinic interactions; patient questionnaires; individual semi-structured interviews with multidisciplinary colorectal unit staff; longitudinal semi-structured interviews with patients and carers pre-surgery, two weeks post-surgery and 12 weeks post-surgery; patient and carer focus groups post-surgery; and existing educational material.

Findings

– In total, 138 participants shared their experiences of either giving or receiving preoperative education. Findings were themed into why patients want preoperative education, and patients’ views of the educational processes.

Practical implications

– Patients emphasised the need for educational provision to be fully understandable, comprehensive and client-centred using a range of communication processes. Patients emphasised the need for educational provision to be more fully understandable, comprehensive and client-centred and that important messages should be reinforced using a range of media. At a time of many uncertainties for patients’ lives, such education needed to encompass the experiences patients could expect, delivered by confident healthcare professionals.

Originality/value

– Contextualising understanding and facilitating their own actions, enabled patients to regain control in circumstances particularly disruptive of bodily and other life routines. Establishing a sense of control is confirmed as important for patient's wellbeing in preparing for surgery and postoperative rehabilitation.