Exploring the experience of recurrence with advanced cancer for people who perceived themselves to be cancer free: a grounded theory study

PURPOSE

Advances in cancer treatment have led to longer cancer-free periods and overall survival. This study aimed to understand patients' experiences of transitioning out of a state of believing to be cancer free into incurable recurrence with advanced disease.

METHODS

Using constructivist grounded theory with in-depth interviews patients (n = 15) with solid tumors from a major US cancer center participated. Theoretical sampling enabled concepts to be developed until theme saturation. Constant comparative analysis used initial and focused coding to develop themes and concepts to describe this specific period from extended time cancer free and transition to advanced incurable disease.

RESULTS

Three interrelated concepts were identified: reluctant acceptance, seeking survival through continuous treatment, and hope in the face of an uncertain future. A conceptual model of the experience was developed encompassing anger and sadness, at initial recurrence, to reluctant acceptance, and, finally, a cycle of seeking continuous treatment to prolong life leading to a sense of hope in the face of an uncertain future.

CONCLUSION

The cycle between treatment and hope creates a state of personal equilibrium, which provides insights into the importance of treatment for this population. This study provides direction for future research to understand the expectations of people experiencing advanced cancer recurrence.

IMPLICATIONS FOR CANCER SURVIVORS

Many cancer survivors live with advanced cancer. Assessing their needs as they transition from survivor with no disease to survivor with advanced disease requires a new conceptualization of the experience which recognizes expectations and priorities for care of this patient group.

Bonus time: A gay man's experience as a long-term HIV survivor

The time after diagnosis of a terminal illness can be demanding. It requires adjusting to change while trying to maintain some sense of normalcy. The purpose of this qualitative case study was to gain an understanding of how one person lived his life while facing death. During the interview, the researchers used photo elicitation to contextualize events in the participant's life. Thematic analysis identified three main themes: Finding Life's Purpose, Being (In)visible, and Illusion of Control. To better understand the participant's struggles and triumphs as he created a new existence, the researchers applied Parse's Theory of Human Becoming to the study's findings.

Patients' spirituality perspectives at the end of life: a qualitative evidence synthesis

BACKGROUND

Understanding patient perceptions of their spiritual needs when approaching the end of life is essential to support the delivery of patient-centred care.

AIM

To conduct a qualitative evidence synthesis on spirituality and spiritual care needs at the end of life in all healthcare settings from the patients' perspective.

DESIGN

Studies were included where they were primary qualitative studies exploring spirituality in patients with a life expectancy of 12 months or less in any setting. Two reviewers independently screened titles, extracted data and conducted methodological quality appraisal. A thematic synthesis was conducted. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) - Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to summarise the certainty of the evidence.

DATA SOURCES

Six databases (Medline, Embase, Cochrane, CINAHL, PsycINFO, Applied Social Science Index and Abstracts) were searched from inception up to January 2019.

RESULTS

Fifty papers (42 unique datasets), incorporating data from 710 patients were included. Studies recruited from a mix of inpatient, outpatient, hospice and community settings across 12 different countries. Three overarching themes were generated: the concept of spirituality, spiritual needs and distress, and spiritual care resources. Relationships were an intrinsic component of spirituality.

CONCLUSION

Meeting patients' spiritual needs is an integral part of end-of-life care. This work emphasises that supporting relationships should be a central focus of spiritual care for patients at the end of life.

PROSPERO REGISTRATION NUMBER

CRD42019122062.

Psychosocial interventions for cancer survivors: A meta-analysis of effects on positive affect

PURPOSE

Positive affect has demonstrated unique benefits in the context of health-related stress and is emerging as an important target for psychosocial interventions. The primary objective of this meta-analysis was to determine whether psychosocial interventions increase positive affect in cancer survivors.

METHODS

We coded 28 randomized controlled trials of psychosocial interventions assessing 2082 cancer survivors from six electronic databases. We calculated 76 effect sizes for positive affect and conducted synthesis using random effects models with robust variance estimation. Tests for moderation included demographic, clinical, and intervention characteristics.

RESULTS

Interventions had a modest effect on positive affect (g = 0.35, 95% CI [0.16, 0.54]) with substantial heterogeneity of effects across studies ([Formula: see text]; I² = 78%). Three significant moderators were identified: in-person interventions outperformed remote interventions (P = .046), effects were larger when evaluated against standard of care or wait list control conditions versus attentional, educational, or component controls (P = .009), and trials with survivors of early-stage cancer diagnoses yielded larger effects than those with advanced-stage diagnoses (P = .046). We did not detect differential benefits of psychosocial interventions across samples varying in sex, age, on-treatment versus off-treatment status, or cancer type. Although no conclusive evidence suggested outcome reporting biases (P = .370), effects were smaller in studies with lower risk of bias.

CONCLUSIONS

In-person interventions with survivors of early-stage cancers hold promise for enhancing positive affect, but more methodological rigor is needed.

IMPLICATIONS FOR CANCER SURVIVORS

Positive affect strategies can be an explicit target in evidence-based medicine and have a role in patient-centered survivorship care, providing tools to uniquely mobilize human strengths.

What is Symptom Burden: A Qualitative exploration of Patient Definitions

Current definitions of “symptom burden” are largely derived from clinicians, and there are many variations in the way the term is used, defined, and operationalized. The aim of this study was to explore patient perceptions of symptom burden in the context of advanced and incurable disease. A group of 58 cancer patients followed by a palliative care team answered a single open-ended question: “Please define ‘symptom burden.”’ Three authors independently coded and analyzed patient responses using a grounded theory approach. They identified six themes, the most frequently coded of which were: “can't do usual activities,” “psychological suffering,” and “specific severe symptoms.” Our findings indicate that the concept of symptom burden is complex and extends beyond numerical symptom-scoring systems. In addition to inquiring about specific symptoms, it may be important to directly ask patients about their overall burden or experience of symptoms.

A snapshot of Australian social workers in palliative care and their work with estranged clients

This paper describes a mixed method survey that was administered to a group of Australian palliative care social workers (n = 27). Specifically, it aimed to investigate the ways that social workers understood and worked with clients who were estranged from family at the end of life. Respondents suggested that estrangement potentially impacted clients emotionally, practically, and existentially. They were challenged to make clear assessments, provide emotional support, encourage news ways of thinking about estrangement, to manage practical issues, work with the client's family, and monitor their own professional role. Theories and models of intervention and levels of training are also discussed.

Opening Life's Gifts: Facing Death for a Second Time

Prior to the development of effective antiretroviral therapy, persons diagnosed with HIV thought they were going to die. Now, long-term survivors are contemplating death again as they age and develop other chronic diseases. The purpose of our study was to understand the experiences of adults living with HIV for 20 or more years as they faced death for a second time. Hermeneutic phenomenology guided the research as participants shared their lived experience through storytelling. Each person's story was audiotaped and transcribed verbatim. Transcript analysis occurred as data were collected. Three common themes from the narratives were identified: Making Choices, Transformation of Fear, and Meaning of Death. Positive and negative pathways influenced each participants' decision-making. Over time, fear of dying was transformed and energy was directed toward living. Even though the participants in this study were facing death again, they recognized it as a natural part of life.

The lived experience of physicians dealing with patient death

Background

A growing body of research indicates that physicians suffer high levels of stress, depression and burnout. Related literature has found that physician stress can negatively impact patient care. This study builds upon previous research that found some dying patients experienced ‘iatrogenic suffering’ caused by the way physicians communicated with them regarding terminal diagnoses and palliative treatment. The goal of this research was to explore physicians’ experiences of dealing with patient death in order to understand how such experiences affect them and their communication with patients.

Methods

This study used qualitative methods to conduct and analyse 10 individual, semistructured interviews with senior physicians from several specialty areas at a large, tertiary care hospital. The resulting themes were validated using member checks and expert review.

Results

This article presents five essential themes that provide a concise description of the lived experience of patient death for these physicians. Interpretation: These themes indicate that physicians can experience very strong and lasting emotional reactions to some patient deaths, and also that patient death can elicit intense experiences related to professional responsibility and competence. A key finding is the description of a complex process of managing the balance between personal and professional reactions in the face of patient death. The implication is that difficulties negotiating this balance may lead to unintended lapses in compassion and suboptimal outcomes in patient care.