Coping with melanoma-related worry: a qualitative study of the experiences and support needs of patients with malignant melanoma

"One more chance to survive": the experiences of patients with advanced melanoma and their partners with tumor-infiltrating lymphocyte therapy-a qualitative study and recommendations for future care

PURPOSE

Patients with advanced melanoma refractory to first-line treatment have a need for effective second-line treatment options. A recent phase 3 trial showed promising results for adoptive cell therapy with tumor-infiltrating lymphocytes (TILs) as second-line therapy in patients with advanced melanoma. However, it remains unknown how patients and their partners experience TIL therapy, which is key to evaluate and improve the quality of care.

METHODS

Semi-structured interviews about the experience of TIL therapy were conducted with patients with advanced melanoma and their partners 2-4 weeks post-treatment (short term) and >6 months after treatment (long term).

RESULTS

In total, 25 interviews were conducted with advanced melanoma patients treated with TIL (n=13) and their partners (n=12), with the majority being short-term interviews (n=17). Overall, patients and partners experienced TIL therapy as intense (uncertainty of successful TIL culture, multiple treatment-related toxicities, and extensive hospitalization). Patients and partners with young children or other caregiving responsibilities encountered the most challenges during TIL therapy. All patients, however, reported a recovery of all treatment-related toxicities within 2-4 weeks (except fatigue).

CONCLUSION

Clinical data justify the role of TIL therapy in the treatment of advanced melanoma. With the distinct nature of TIL therapy compared to the current standard of care, we have provided patient-centered recommendations that will further enhance the quality of TIL therapy.

IMPLICATIONS FOR CANCER SURVIVORS

As more patients with advanced melanoma are expected to receive TIL therapy in the future, our findings could be incorporated into survivorship care plans for this novel group of advanced melanoma survivors treated with TIL.

User Experiences in a Digital Intervention to Support Total Skin Self-examination by Melanoma Survivors: Nested Qualitative Evaluation Embedded in a Randomized Controlled Trial

BACKGROUND

Melanoma is a relatively common cancer type with a high survival rate, but survivors risk recurrences or second primaries. Consequently, patients receive regular hospital follow-up, but this can be burdensome to attend and not optimally timed to detect arising problems. Total skin self-examination (TSSE) supports improved clinical outcomes from melanoma via earlier detection of recurrences and second primaries, and digital technology has the potential to support TSSE. Recent research with app-based interventions aimed at improving the well-being of older adults has found that they can use the technology and benefit from it, supporting the use of digital health care in diverse demographic groups. Thus, the Achieving Self-directed Integrated Cancer Aftercare (ASICA) digital health care intervention was developed. The intervention provided melanoma survivors with a monthly prompt to perform a TSSE as well as access to a dermatology nurse who provided them with feedback on photographs and descriptions of their skin.

OBJECTIVE

We aimed to explore participants' attitudes, beliefs, and experiences regarding TSSE practices. Furthermore, we explored how participants experienced technology and how it influenced their practice of TSSE. Finally, we explored the practical and technical experiences of ASICA users.

METHODS

This was a nested qualitative evaluation within a dual-center randomized controlled trial of the ASICA intervention. We conducted semistructured telephone interviews with the participants during a randomized controlled trial. The participants were purposively sampled to achieve a representative sample with representative proportions by age, sex, and residential geography. Interviews were transcribed verbatim and analyzed using a framework analysis approach applied within NVivo 12.

RESULTS

A total of 22 interviews were conducted with participants from both groups. In total, 40% (9/22) of the interviewed participants were from rural areas, and 60% (13/22) were from urban areas; 60% (13/22) were from the intervention group, and 40% (9/22) were from the control group. Themes evolved around skin-checking behavior, other people's input into skin checking, contribution of health care professionals outside ASICA and its value, ideas around technology, practical experiences, and potential improvements. ASICA appeared to change participants' perceptions of skin checking. Users were more likely to report routinely performing TSSE thoroughly. There was some variation in beliefs about skin checking and using technology for health care. Overall, ASICA was experienced positively by participants. Several practical suggestions were made for the improvement of ASICA.

CONCLUSIONS

The ASICA intervention appeared to have positively influenced the attitudes and TSSE practices of melanoma survivors. This study provides important qualitative information about how a digital health care intervention is an effective means of prompting, recording, and responding to structured TSSE by melanoma survivors. Technical improvements are required, but the app offers promise for technologically enhanced melanoma follow-up in future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03328247; https://clinicaltrials.gov/ct2/show/NCT03328247?term=ASICA&rank=1.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3453-x.

Perception of information to Swedish melanoma patients in routine clinical practice - a cross-sectional survey

Background

Comprehensible, relevant information empowers patients, allowing them to take an active part in their care. We aim to investigate how Swedish melanoma patients perceive information provided in routine clinical practice and explore the correlation between satisfaction with information, symptoms and functioning scales, and quality of life.

Methods

A cross-sectional study where EORTC QLQ-C30, EORTC QLQ-INFO25 and EQ-5D-3L questionnaires were sent to 1213 patients by post and 792 responded (65%).

Results

Only 0.5% reported that they wished to have received less information. The amount of information received and the satisfaction with that information was age-dependent, where older patients reported receiving less information than younger patients. Middle-aged patients were more satisfied with the information compared to both younger and older patients. The perception of having received sufficient information correlated negatively with anxiety. Higher satisfaction with the information also correlated positively with scores for functioning scales and negatively with degree of symptoms. No difference was perceived in information levels between disease stage apart from the scale “information about other services”, where patients with more severe disease reported receiving more information. Men and women reported equal satisfaction concerning the information received.

Conclusions

Patients lack sufficient information and age affects the perception of it. It is of utmost importance to tailor the information to suit the individual needs of a given patient, as satisfaction with the information received correlates with the patient’s well-being.

Understanding the Lived Experience of Patients with Melanoma: Real-World Evidence Generated through a European Social Media Listening Analysis (Preprint)

Background

Cutaneous melanoma is an aggressive malignancy that is proposed to account for 90% of skin cancer–related mortality. Individuals with melanoma experience both physical and psychological impacts associated with their diagnosis and treatment. Health-related information is being increasingly accessed and shared by stakeholders on social media platforms.

Objective

This study aimed to assess how individuals living with melanoma across 14 European countries use social media to discuss their needs and provide their perceptions of the disease.

Methods

Social media sources including Twitter, forums, and blogs were searched using predefined search strings of keywords relating to melanoma. Manual and automated relevancy approaches filtered the extracted data for content that provided patient-centric insights. This contextualized data was then mined for insightful concepts around the symptoms, diagnosis, treatment, impacts, and lived experiences of melanoma.

Results

A total of 182,400 posts related to melanoma were identified between November 2018 and November 2020. Following exclusion of irrelevant posts and using random sampling methodology, 864 posts were identified as relevant to the study objectives. Of the social media channels included, Twitter was the most commonly used, followed by forums and blogs. Most posts originated from the United Kingdom (n=328, 38%) and Spain (n=138, 16%). Of the relevant posts, 62% (n=536) were categorized as originating from individuals with melanoma. The most frequently discussed melanoma-related topics were treatment (436/792, 55%), diagnosis and tests (261/792, 33%), and remission (190/792, 24%). The majority of treatment discussions were about surgery (292/436, 67%), followed by immunotherapy (52/436, 12%). In total, 255 posts discussed the impacts of melanoma, which included emotional burden (n=179, 70%), physical impacts (n=61, 24%), effects on social life (n=43, 17%), and financial impacts (n=10, 4%).

Conclusions

Findings from this study highlight how melanoma stakeholders discuss key concepts associated with the condition on social media, adding to the conceptual model of the patient journey. This social media listening approach is a powerful tool for exploring melanoma stakeholder perspectives, providing insights that can be used to corroborate existing data and inform future studies.

Assessing the Educational and Supportive Care Needs of Canadian Metastatic Melanoma Patients and Survivors Attending an Outpatient Clinic

The rapid development of metastatic melanoma treatment options has significantly improved overall survival, but paralleled patient educational and supportive care resources have fallen behind. Particularly, the need for grassroots programs targeting environments outside urban centers has grown. Accordingly, an environmental scan of the Durham region in Ontario, Canada, showed the lack of melanoma-specific resources for outpatients. The goal of this study was to identify the needs of metastatic melanoma patients and survivors attending a large outpatient clinic in Durham, and then develop a patient-reviewed intervention plan. Needs were assessed in 5 domains through a melanoma-specific supportive care needs assessment survey. Among 75 surveyed melanoma patients and survivors, high-level needs were identified in 3 domains: psychological, health system information, and melanoma-specific information. Furthermore, domain-specific needs were heightened in specific sociodemographic groups. Based on these survey results, a multifaceted intervention plan was developed to mitigate future needs. The intervention plan was patient-reviewed in focus groups prior to implementation, refining the developed intervention plan.

Life Interrupted: Experiences of adolescents, young adults and their family living with malignant melanoma

AIM

Melanoma is one of the most common human malignancies; yet, it is often thought of as a disease of adulthood rather than one affecting adolescents and young adults. This study sought to understand the experiences of adolescents, young adults and their family living with malignant melanoma.

DESIGN

A qualitative study using Interpretive Phenomenological Analysis, through a multi-perspective design.

METHODS

Data collection was conducted between January and August 2018 in each participant's Primary Care Centre when they were attending for an outpatient appointment. Each young person and a nominated family member were interviewed (n = 10) either individually (n = 4) or as a dyad (n = 6) according to their personal choice. In-depth semi-structured interviews were conducted and audio-recorded with the participant's consent. Interview data were transcribed verbatim and analysed.

FINDINGS

The metanarrative 'Life Interrupted' was the core conceptual thread woven throughout the findings. It represents the interconnections and interrelationships between the adolescent or young adult and their family. Being able to recognize the disease and seek support was challenging with often limited physical, emotional or social support resulting in feelings of fear and isolation. Four super-ordinate themes were identified: (a) 'Is it Serious', (b) 'Too Much too Young', (c) 'Not the Same' and (d) 'Time to Live'.

CONCLUSIONS

With the rising incidence of MM in the adolescents and young adults population globally, there are demands to improve healthcare professionals and nurse's knowledge and understanding of MM. As young people with MM experience their journey outside specialist cancer services, the care delivery for this patient group and their families require stronger links between services.

IMPACT

This study will inform the improvement of care delivery for MM in order that this patient group is provided with the same access to service delivery as other adolescents and young adults with cancer.

Exploring the Experiences of People Treated With Immunotherapies for Advanced Melanoma and Those Caring for Them: "Real-World" Data

BACKGROUND

Recent advances in the development of immunotherapy drugs have resulted in durable responses and improved overall survival for a proportion of patients with advanced melanoma; however, toxicities can be potentially life-threatening. The patients' family and friends (carers) are relied upon to support patients at home post treatment; however, we know little about their experiences.

OBJECTIVES

This study aimed to understand the experiences of patients with advanced melanoma who received immunotherapy and their carers; and to explore the impact of immunotherapy treatment on patients' and carers' quality of life (QoL).

METHODS

A cross-sectional, exploratory design was employed. Semi-structured interviews were conducted with patients: diagnosed with stage IV melanoma, attending an Australian public cancer hospital, had completed or were receiving treatment with immunotherapies; and the people caring for them at home.

RESULTS

Patients (n = 22) described how immunotherapy impacted emotional health, functional ability; and had damaging economic consequences. Fatigue was reported consistently as having a considerable negative influence across all domains of QoL. Carers (n = 9) were anxious about their ability to correctly identify, report and manage side effects at home.

CONCLUSIONS

Results demonstrate how immunotherapy can impact the QoL of both patients and carers, either directly through toxicities or indirectly through mechanisms such as stress, financial toxicity, or fatigue that limits participation in life activities.

IMPLICATIONS FOR PRACTICE

Supportive care resources and interventions are needed for those receiving immunotherapy to minimise negative impacts on QoL. Carers likewise require better preparation and information to assist in identifying potential treatment toxicities and ensure patient safety.

Unmet information needs of patients with melanoma in Germany

There is a scarcity of available data on unmet information needs (UINs) of melanoma patients (MPs) from Germany and of MPs with clinical stage IV. In a multicenter cross-sectional survey, we explored the UINs of 529 MPs by applying a standardized questionnaire. Subgroup differences in scope and contents of UINs were determined by univariate analyses. Predictors of the presence of UINs were identified by binary logistic regression. Overall, 55% of MPs reported UINs. Most MPs felt poorly or not informed about psychosocial support (24-31%). In MPs currently receiving medical treatment [odds ratio (OR): 1.9; P=0.017], MPs aging of at least 55 years (OR: 1.7; P=0.029), and in MPs who generally had a high need for information on their condition (OR: 2.4; P=0.001), the presence of UINs was significantly more likely than in post-treatment MPs, MPs more than 55 years of age, and those whose general information need was low. Most UINs concerned treatment-related information and were reported by MPs with tumor progression. Presence and scope of UINs did not differ significantly between metastatic and nonmetastatic MPs (57 vs. 53%; P=0.436). We highlighted differences in the presence, scope, and contents of UINs between MP subgroups, which should be considered when educating them in medical consultations and providing information via media. In particular, MPs felt insufficiently informed about psychosocial support and desired more treatment information.

Digital Health in Melanoma Posttreatment Care in Rural and Remote Australia: Systematic Review

Background

The melanoma incidence and mortality rates in rural and remote communities are exponentially higher than in urban areas. Digital health could be used to close the urban/rural gap for melanoma and improve access to posttreatment and support care services.

Objective

The aim of this review was to understand how digital health is currently used for melanoma posttreatment care and determine the benefits for Australian rural and remote areas.

Methods

A systematic search of PubMed, Medline, PsycINFO, and Scopus was conducted in March 2018. Findings were clustered per type of intervention and related direct outcomes.

Results

Five studies met the inclusion criteria, but none investigated the benefits of digital health for melanoma posttreatment care in rural and remote areas of Australia. Some empirical studies demonstrated consumers’ acceptance of digital intervention for posttreatment care. The findings did not take into consideration individual, psychological, and socioeconomic factors, even though studies show their significant impacts on melanoma quality of aftercare.

Conclusions

Digital interventions may be used as an adjunct service by clinicians during melanoma posttreatment care, especially in regions that are less-resourced by practitioners and health infrastructure, such as rural and remote Australia. Technology could be used to reduce the disparity in melanoma incidence, mortality rates, and accessibility to posttreatment care management between urban and rural/remote populations.

Vlogging Cancer: Predictors of Social Support in YouTube Cancer Vlogs

Social support research has demonstrated the physical and psychological benefits of social support for patients, but has done little to identify successful strategies for eliciting social support. However, contemporary digital channels offer new ways to examine this issue. In particular, this study explores vlogging as a coping strategy for cancer patients and a context in which to explore predictors of online social support. A content analysis of 69 YouTube vlogs and 869 associated comments was performed. A series of multilevel binomial logistic regression analyses revealed that narrative features that position the cancer patient as protagonist-including providing an explanation of the diagnosis experience, agentive problem solving, and positive reappraisal of the situation-were associated with receiving empathic support. In contrast, moralizing pleads for audience checkups decreased the likelihood of receiving empathic support. Findings contribute to an undertheorized body of research that also has translational value for patients, doctors, and designers of supportive online spaces who might eventually recommend narrative vlogging in clinical settings.

When Patients Tell Their Own Stories: A Meta-Narrative Study of Web-Based Personalized Texts of 214 Melanoma Patients' Journeys in Four Countries

Malignant melanoma is an aggressive, recalcitrant disease. Its impact on people can be compounded by the physical and psychosocial consequences of medical management. Providing melanoma patients with patient-centered care that is effective, safe, and supportive throughout their journey requires knowledge of patients' progressive experiences and evolving perspectives. With ethical approval, we undertook a meta-narrative study of 214 experiential accounts of melanoma collected from the personal story sections of melanoma and cancer support websites. Using a narrative approach, we qualitatively examined the care experiences represented in these accounts and identified needs for supportive care in a framework reflective of the personal patient journey. We differentiate these across three key periods: lead-up to diagnosis; diagnosis, treatment, and recovery; and posttreatment and recurrence, and provide a visual representation of the patient journey. This article contributes to the growing body of work that utilizes Internet content as sources of qualitative, experiential health care data.

Psychosocial consequences of skin cancer screening

Screening for melanoma may save lives, but may also cause patient distress. One key reason that preventative visual skin examinations for skin cancer are not currently recommended is the inadequate available evidence to assess potential harm to psychosocial wellbeing. We investigated potential psychological harms and benefits of skin examinations by conducting telephone surveys in 2015 of 187 screened participants; all were ≥35 years old. Participants had their skin examined by practitioners who had completed INFORMED, a validated web-based training for detection of skin cancers, particularly melanoma. Participants underwent the Spielberger State-Trait Anxiety Inventory (STAI), Psychological Consequences of Screening (PCQ), Hospital Anxiety and Depression (HAD) scale, and the 12-Item Short Form Health Survey (SF-12). Analyses were conducted in 2017. Of the entire study sample, 40% were thoroughly screened as determined by patient-reported level of undress and skin areas examined. Participants who were thoroughly screened: did not differ on negative psychosocial measures; scored higher on measures of positive psychosocial wellbeing (PCQ); and were more motivated to conduct monthly self-examinations and seek annual clinician skin examinations, compared to other participants (p < 0.05). Importantly, thoroughly screened patients were more likely to report skin prevention practices (skin self-examinations to identify a concerning lesion, practitioner provided skin exam), recommend skin examinations to peers, and feel satisfied with their skin cancer education than less thoroughly screened individuals (p < 0.01). Our results suggest that visual screening for skin cancer does not worsen patient psychosocial wellbeing and may be associated with improved skin cancer-related practices and attitudes.

Variations in supportive care needs of patients after diagnosis of localised cutaneous melanoma: a 2-year follow-up study

PURPOSE

We aimed to describe variations in unmet supportive care needs of patients diagnosed with localised melanoma at high risk of recurrence and factors associated with initial and persisting moderate-to-high needs.

METHODS

We ascertained 386 patients diagnosed with clinical stage IB-II melanoma and administered surveys every 6 months for 2 years. The proportion experiencing at least one moderate-to-high need was assessed among salient subgroups: 306 patients with no previous melanoma and 80 with previous melanoma at enrolment, 30 who experienced disease recurrence during follow-up and 31 who developed another primary. Baseline factors associated with (a) needs at enrolment and (b) persistent needs over 2 years (or as long as disease-free) were identified by logistic regression analyses.

RESULTS

The proportion of patients with needs substantially declined over the first 6 months (if no previous melanoma, from 48 to 22 %, p < 0.001; previous melanoma, 35 to 17 %, p = 0.007), and in those remaining disease-free, needs declined further by 24 months (to 14 and 6 % respectively). By contrast, 50 % of those experiencing recurrence, and 39 % of those who developed another primary, reported needs. Stressful life events and anxiety were associated with needs at enrolment. At least one need, mainly fear of recurrence, persisted in 22 % of disease-free participants. Persistent needs were predicted by age, depression, anxiety and other stressful life events.

CONCLUSIONS

Melanoma patients' needs peak when first diagnosed and if disease recurs. Younger people or those experiencing additional stressful events, anxiety or depression are more likely to experience persistent needs and may benefit from tailored support.