When the risks are high: psychological adjustment among melanoma survivors at high risk of developing new primary disease

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.

The impacts of unmet supportive care needs of cancer survivors in Australia: A qualitative systematic review

INTRODUCTION

Cancer incidence and survivorship are increasing worldwide. With more people living through and beyond cancer, there is a subsequent increase in their supportive care needs. This systematic review of qualitative studies aimed to describe the impacts of unmet supportive care needs on cancer survivors in Australia.

METHODS

Databases MEDLINE, EMBASE and Scopus were searched, and after screening and applying eligibility criteria, 27 qualitative studies were included. Findings were synthesised according to the Supportive Care Framework for Cancer Care, including informational, physical, practical, emotional, psychological, social and spiritual need domains.

RESULTS

The systematic review identified impacts of unmet informational, physical, practical, emotional and psychological needs. Frequently identified impacts of unmet informational needs were feelings of abandonment and isolation, distress, confusion and regret. Common impacts of unmet physical and practical needs were financial burden and return-to-work difficulties. Over half of all unmet supportive care needs caused emotional and psychological impacts.

CONCLUSIONS

Findings identify the detrimental emotional and psychological impacts resulting from a range of unmet supportive care needs. The review highlights the interconnections between supportive care need domains thereby enhancing the understanding of the impacts of unmet SCNs. Findings may inform policy and practice change to improve supportive cancer care.

Fear of cancer recurrence in patients with non-metastatic melanoma: Spanish validation and disease-related factors

INTRODUCTION

It is essential for clinicians to understand the phenomenon of fear of cancer recurrence (FCR) in order to understand the psychological impact it has on patients with melanoma.

OBJECTIVES

To validate an FCR questionnaire in Spanish for patients with non-metastatic melanoma and to describe the clinical and demographic variables associated with FCR in these patients.

METHODS

Patients diagnosed with non-metastatic melanoma were selected. The questionnaire was translated and adapted to Spanish following international guidelines. The internal consistency, construct validity, and temporal stability of the questionnaire were analysed using Cronbach's alpha, confirmatory factor analysis, and test-retest reliability, respectively. Following this, the correlation between FCR scores and the study variables was evaluated.

RESULTS

A total of 123 patients were included in the study. The translated and adapted questionnaire showed high reliability (overall Cronbach's alpha 0.834), temporal stability (intraclass correlation coefficient 0.8), and unidimensionality. The mean FCR score was 16.1 ± 6.7. The highest FCR scores were observed in women and young patients (p < 0.01). Patients with a personal history of cancer, facial melanoma, or skin graft reconstruction also obtained a high FCR score (p < 0.05). No differences were found between FCR and other tumour characteristics, such as the Breslow index or the time since diagnosis.

CONCLUSIONS

This validated questionnaire is suitable for evaluating FCR. We also identified factors that tend to increase FCR scores, thus allowing clinicians to identify patients at risk and start preventive measures.

Experiences of Patient-Led Surveillance, Including Patient-Performed Teledermoscopy, in the MEL-SELF Pilot Randomized Controlled Trial: Qualitative Interview Study

BACKGROUND

Current clinician-led melanoma surveillance models require frequent routinely scheduled clinic visits, with associated travel, cost, and time burden for patients. Patient-led surveillance is a new model of follow-up care that could reduce health care use such as clinic visits and medical procedures and their associated costs, increase access to care, and promote early diagnosis of a subsequent new melanoma after treatment of a primary melanoma. Understanding patient experiences may allow improvements in implementation.

OBJECTIVE

This study aims to explore patients' experiences and perceptions of patient-led surveillance during the 6 months of participation in the MEL-SELF pilot randomized controlled trial. Patient-led surveillance comprised regular skin self-examination, use of a mobile dermatoscope to image lesions of concern, and a smartphone app to track and send images to a teledermatologist for review, in addition to usual care.

METHODS

Semistructured interviews were conducted with patients previously treated for melanoma localized to the skin in New South Wales, Australia, who were randomized to the patient-led surveillance (intervention group) in the trial. Thematic analysis was used to analyze the data with reference to the technology acceptance model.

RESULTS

We interviewed 20 patients (n=8, 40% women and n=12, 60% men; median age 62 years). Patients who were more adherent experienced benefits such as increased awareness of their skin and improved skin self-examination practice, early detection of melanomas, and opportunities to be proactive in managing their clinical follow-up. Most participants experienced difficulty in obtaining clear images and technical problems with the app. These barriers were overcome or persevered by participants with previous experience with digital technology and with effective help from a skin check partner (such as a spouse, sibling, or friend). Having too many or too few moles decreased perceived usefulness.

CONCLUSIONS

Patients with melanoma are receptive to and experience benefits from patient-led surveillance using teledermoscopy. Increased provision of training and technical support to patients and their skin check partners may help to realize the full potential benefits of this new model of melanoma surveillance.

Protocol for the implementation of a stepped-care model to address fear of cancer recurrence in patients previously diagnosed with early-stage (0-II) melanoma

INTRODUCTION

Fear of cancer recurrence (FCR) is commonly reported by patients diagnosed with early-stage (0-II) melanoma and can have a significant impact on daily functioning. This study will pilot the implementation of the Melanoma Care Program, an evidence-based, psychological intervention to reduce FCR, into routine practice, using a stepped-care model.

METHODS AND ANALYSIS

Intervention effectiveness and level of implementation will be investigated using a hybrid type I design. Between 4 weeks before and 1 week after their next dermatological appointment, patients with melanoma will be invited to complete the Fear of Cancer Recurrence Inventory Short-Form, measuring self-reported FCR severity. Using a stepped-care model, clinical cut-off points will guide the level of support offered to patients. This includes: (1) usual care, (2) Melanoma: Questions and Answers psychoeducational booklet, and (3) three or five psychotherapeutic telehealth sessions. This longitudinal, mixed-methods pilot implementation study aims to recruit 108 patients previously diagnosed with stage 0-II melanoma. The primary effectiveness outcome is change in FCR severity over time. Secondary effectiveness outcomes include change in anxiety, depression, stress, health-related quality of life and melanoma-related knowledge over time. All outcomes are measured at baseline, within 1 week of the final telehealth session, and 6 and 12 months post-intervention. Implementation stakeholders at each study site and interested patients will provide feedback on intervention acceptability and appropriateness. Implementation stakeholders will also provide feedback on intervention cost, feasibility, fidelity and sustainability. These outcomes will be measured throughout implementation, using questionnaires and semistructured interviews/expert group discussions. Descriptive statistics, linear mixed-effects regression and thematic analysis will be used to analyse study data.

ETHICS AND DISSEMINATION

Ethics approval was granted by the Sydney Local Health District-Royal Prince Alfred Zone (2020/ETH02518), protocol number: X20-0495. Results will be disseminated through peer-reviewed journals, conference presentations, social media and result summaries distributed to interested participants. TRIAL REGISTRATION DETAILS: (ACTRN12621000145808).

Identifying the 'Active Ingredients' of an Effective Psychological Intervention to Reduce Fear of Cancer Recurrence: A Process Evaluation

Purpose: Psychological interventions targeting fear of cancer recurrence (FCR) are effective in reducing fear and distress. Process evaluations are an important, yet scarce adjunct to published intervention trials, despite their utility in guiding the interpretation of study outcomes and optimizing intervention design for broader implementation. Accordingly, this paper reports the findings of a process evaluation conducted alongside a randomized controlled trial of a psychological intervention for melanoma patients. Methods: Men and women with a history of Stage 0-II melanoma at high-risk of developing new primary disease were recruited via High Risk Melanoma Clinics across Sydney, Australia and randomly allocated to receive the psychological intervention (n = 80) or usual care (n = 84). Intervention participants received a tailored psycho-educational resource and three individual psychotherapeutic sessions delivered via telehealth. Qualitative and quantitative data on intervention context, processes, and delivery (reach, dose, and fidelity), and mechanisms of impact (participant responses, moderators of outcome) were collected from a range of sources, including participant surveys, psychotherapeutic session audio-recordings, and clinical records. Results: Almost all participants reported using the psycho-educational resource (97%), received all intended psychotherapy sessions (96%), and reported high satisfaction with both intervention components. Over 80% of participants would recommend the intervention to others, and a small proportion (4%) found discussion of melanoma-related experiences confronting. Perceived benefits included enhanced doctor-patient communication, talking more openly with family members about melanoma, and improved coping. Of potential moderators, only higher FCR severity at baseline (pre-intervention) was associated with greater reductions in FCR severity (primary outcome) at 6-month follow-up (primary endpoint). Conclusions: Findings support the acceptability and feasibility of a psychological intervention to reduce FCR amongst individuals at high risk of developing another melanoma. Implementation into routine melanoma care is an imperative next step, with FCR screening recommended to identify those most likely to derive the greatest psychological benefit.

Unemployment and Health-Related Quality of Life in Melanoma Patients During the COVID-19 Pandemic

The outbreak of coronavirus disease-2019 (COVID-19) ineluctably caused social distancing and unemployment, which may bring additional health risks for patients with cancer. To investigate the association of the pandemic-related impacts with the health-related quality of life (HRQoL) among patients with melanoma during the COVID-19 pandemic, we conducted a cross-sectional study among Chinese patients with melanoma. A self-administered online questionnaire was distributed to melanoma patients through social media. Demographic and clinical data, and pandemic-related impacts (unemployment and income loss) were collected. HRQoL was determined by the Functional Assessment of Cancer Therapy-General (FACT-G) and its disease-specific module (the melanoma subscale, MS). A total of 135 patients with melanoma completed the study. The mean age of the patients was 55.8 ± 14.2 years, 48.1% (65/135) were male, and 17.04% (34/135) were unemployed since the epidemic. Unemployment of the patients and their family members and income loss were significantly associated with a lower FACT-G score, while the MS score was associated with the unemployment of the patients' family members. Our findings suggested that unemployment is associated with impaired HRQoL in melanoma patients during the COVID-19 epidemic.

Neurocognitive Function, Psychosocial Outcome, and Health-Related Quality of Life of the First-Generation Metastatic Melanoma Survivors Treated with Ipilimumab

Purpose

To assess neurocognitive function (NCF), psychosocial outcome, health-related quality of life (HRQoL), and long-term effects of immune-related adverse events (irAE) on metastatic melanoma survivors treated with ipilimumab (IPI).

Methods

Melanoma survivors were identified within two study populations (N = 104), at a single-center university hospital, and defined as patients who were disease-free for at least 2 years after initiating IPI. Data were collected using 4 patient-reported outcome measures, computerized NCF testing, and a semistructured interview at the start and 1-year follow-up.

Results

Out of 18 eligible survivors, 17 were recruited (5F/12M); median age is 57 years (range 33-86); and median time since initiating IPI was 5.6 years (range 2.1-9.3). The clinical interview revealed that survivors suffered from cancer-related emotional distress such as fear of recurrence (N = 8), existential problems (N = 2), survivor guilt (N = 2), and posttraumatic stress disorder (N = 6). The mean EORTC QLQ-C30 Global Score was not significantly different from the European mean of the healthy population. Nine survivors reported anxiety and/or depression (Hospitalization Depression Scale) during the survey. Seven survivors (41%) reported fatigue (Fatigue Severity Scale). Seven patients (41%) had impairment in NCF; only three out of seven survivors had impairment in subjective cognition (Cognitive Failure Questionnaire). Anxiety, depression, fatigue, and neurocognitive symptoms remained stable at the 1-year follow-up. All cases of skin toxicity (N = 8), hepatitis (N = 1), colitis (N = 3), and sarcoidosis (N = 1) resolved without impact on HRQoL. Three survivors experienced hypophysitis; all suffered from persistent fatigue and cognitive complaints 5 years after onset. One survivor who experienced a Guillain-Barré-like syndrome suffered from persisting depression, fatigue, and impairment in NCF.

Conclusion

A majority of melanoma survivors treated with IPI continue to suffer from emotional distress and impairment in NCF. Timely detection in order to offer tailored care is imperative, with special attention for survivors with a history of neuroendocrine or neurological irAE. The trial is registered with B.U.N. 143201421920.

Patient-reported outcomes in melanoma survivors at 1, 3 and 5 years post-diagnosis: a population-based cross-sectional study

PURPOSE

There is a lack of population-based data describing patient reported outcomes (PROs) in melanoma survivors which could guide the development of interventions and resources. This study assessed overall quality of life (QoL), self-reported symptoms and unmet information needs in melanoma survivors 1, 3 or 5 years post-diagnosis.

METHODS

A cross-sectional postal survey was conducted in Victoria, Australia, with eligible melanoma survivors identified from a population-based cancer registry. Patient-reported outcome measures included the EuroQoL 5-Dimension 5-Level (EQ-5D-5L), and self-reported symptoms, difficulties and information needs. Associations between demographic, disease and care-related factors and QoL were also assessed.

RESULTS

A total of 476 melanoma survivors participated in the study (response rate 46.5%). Anxiety and depressive symptoms were more prevalent in survivors compared to the general population (30.7% vs 21.6%; p < 0.01). Fear of cancer recurrence (48.3%) and fear of cancer spreading (37.8%) were the most commonly reported symptom items, and approximately one in five melanoma survivors had unmet information needs related to psychological aspects of living with melanoma. Recurrent melanoma, living in a nursing home, chronic comorbidities, and melanoma diagnosed at > 2 mm thickness were associated with lower QoL.

CONCLUSION

A large proportion of melanoma survivors reported ongoing quality of life deficits, fear of cancer recurrence, as well as unmet information needs up to 5 years after diagnosis. Patients may benefit from tailored informational resources and interventions that address the psychological aspects of living with and beyond melanoma.

The Role of Culture/Ethnicity in Communicating with Cancer Patients About Mental Health Distress and Suicidality

To explore the role of culture in communicating with cancer patients about mental health distress and suicidality. The Grounded Theory method of data collection and analysis was used. Healthcare professionals (HCPs) reported that language competency was a facilitator while being unable to speak the language or understand the nuances of their patient's communication could be a barrier. HCPs noted that being culturally matched with their patients helped them communicate effectively. HCPs also spoke about religious taboos on suicide as being a barrier to having conversations, either because patients did not feel comfortable discussing these issues, or because they perceived that this was not a topic they could bring up. Some HCPs reported that the culture/ethnicity of their patients had no effect on their ability to communicate effectively with them about mental health distress or suicidality. Advancing effective cross-cultural communication is a challenge faced by HCPs. Raising awareness about communication styles is an important step in addressing communication gaps about mental health and suicide with cancer patients. Training should facilitate skill development to engage in a culturally humble approach to cross-cultural communication including diversity training which encourages asking and actively listening to patients' needs and preferences.

Cost-Effectiveness of a Psycho-Educational Intervention Targeting Fear of Cancer Recurrence in People Treated for Early-Stage Melanoma

OBJECTIVE

This study aimed to evaluate the cost effectiveness of a newly developed psycho-educational intervention to reduce fear of cancer recurrence (FCR) in early-stage melanoma patients.

METHODS

A within-trial cost-effectiveness and cost-utility analysis was conducted from the Australian health system perspective using data from linked Medicare records. Outcomes included FCR, measured with the severity subscale of the FCR Inventory; quality-adjusted life years (QALYs) measured using the preference-based instrument, Assessment of Quality of Life-8 Dimensions (AQoL-8D) and 12-month survival. An incremental cost-effectiveness ratio (ICER) was calculated for two economic outcomes: (1) cost per additional case of 'high' FCR avoided and (2) cost per QALY gained. Means and 95% CIs around the ICER were generated from non-parametric bootstrapping with 1000 replications.

RESULTS

A total of 151 trial participants were included in the economic evaluation. The mean cost of the psycho-educational intervention was AU$1614 per participant, including intervention development costs. The ICER per case of high FCR avoided was AU$12,903. The cost-effectiveness acceptability curve demonstrated a 78% probability of the intervention being cost effective relative to the control at a threshold of AU$50,000 per extra person avoiding FCR. The ICER per QALY gained was AU$116,126 and the probability of the intervention being cost effective for this outcome was 36% at a willingness to pay of AU$50,000 per QALY.

CONCLUSION

The psycho-educational intervention reduced FCR at 12 months for people at high risk of developing another melanoma and may represent good value for money. For the QALY outcome, the psycho-educational intervention is unlikely to be cost effective at standard government willingness-to-pay levels. The trial was prospectively registered in the Australian and New Zealand Clinical Trials Registry (CTRN12613000304730).

Fatigue in survivors of malignant melanoma and its determinants: a register-based cohort study

PURPOSE

Fatigue has found increasing attention as a debilitating and lasting condition of cancer patients. However, it has remained unclear to what degree long-term survivors of malignant melanoma suffer from fatigue. Therefore, this study aimed to determine fatigue and its link with quality of life, aftercare behavior, and mental and physical symptoms among melanoma survivors.

METHODS

A register-based sample of 684 long-term survivors an average of 8.4 (SD = 1.72; range 5.67-12.17) years after diagnosis was compared to 2049 participants from a representative survey by the Multidimensional Fatigue Inventory. In a hierarchical linear regression, statistical predictors for fatigue were ascertained.

RESULTS

Overall fatigue was not increased in melanoma survivors except for younger melanoma survivors under 40 years. As in the general population, fatigue increased with age, and it was higher in women compared to men. Fatigue was associated with decreased quality of life, reduced functioning, and increased physical and mental symptoms. Substantial predictors (30% explained variance) were higher age, additional chronic illness, self-blame, detrimental interactions and lack of social support, and also fear of recurrence. There was neither an effect of medical parameters (clinical stage, time since diagnosis) nor of participation in follow-up care.

CONCLUSIONS

Fatigue needs to be taken seriously in the aftercare of melanoma survivors as it is associated with multiple functional and quality of life impairments and heightened distress. Reduction of fatigue in melanoma patients should address younger survivors (under 40 years) and older survivors (over 60 years) with additional chronic illness and focus on illness coping and social support.

Long-Term Survival, Quality of Life, and Psychosocial Outcomes in Advanced Melanoma Patients Treated with Immune Checkpoint Inhibitors

Immune checkpoint inhibitors have become a standard of care option for the treatment of patients with advanced melanoma. Since the approval of the first immune checkpoint (CTLA-4) inhibitor ipilimumab in 2011 and programmed death-1 (PD-1) blocking monoclonal antibodies pembrolizumab and nivolumab thereafter, an increasing proportion of patients with unresectable advanced melanoma achieved long-term overall survival. Little is known about the psychosocial wellbeing, neurocognitive function, and quality of life (QOL) of these survivors. Knowledge about the long term side-effects of these novel treatments is scarce as long-term survivorship is a novel issue in the field of immunotherapy. The purpose of this review is to summarize our current knowledge regarding the survival and safety results of pivotal clinical trials in the field of advanced melanoma and to highlight potential long-term consequences that are likely to impact psychosocial wellbeing, neurocognitive functioning, and QOL. The issues raised substantiate the need for clinical investigation of these issues with the aim of optimizing comprehensive health care for advanced melanoma survivors.

Fear of cancer recurrence: A qualitative systematic review and meta-synthesis of patients' experiences

Fear of cancer recurrence (FCR) is a significant issue for most cancer survivors, with nearly half of cancer survivors reporting it at moderate to high levels of intensity. We aimed to further explore the experience of having FCR from the point of view of patients by systematically reviewing qualitative studies. Following PRISMA guidelines, 87 qualitative studies were selected. All participants' quotes about FRC were extracted, then analysed using a conceptual framework based on the emotion-focused therapy theory of emotion schemes, which consist of experienced/implicit emotions, along with perceptual-situational, bodily-expressive, symbolic-conceptual and motivational-behavioral elements. According to participant descriptions, FCR was found to be an intense, difficult, multi-dimensional experience. Considering the diversity of experiences identified, it is useful to look at FCR as an emotional experience that extends along a continuum of adaptive and maladaptive responses. For some participants, FCR was described in trauma-like terms, including forms of re-experiencing, avoidance, negative thoughts and feelings, and arousal or reactivity related to cancer-related triggers or memories. Vivid metaphors expressing vulnerability and conflict also reflect the strong impact of FCR in patients' lives and can help therapists empathize with their clients.

Needs and preferences of patients regarding basal cell carcinoma and cutaneous squamous cell carcinoma care: a qualitative focus group study

BACKGROUND

Despite the high and rising incidence rate of keratinocyte cancer (KC) and the importance of incorporating patient values into evidence-based care, few studies have focused on the perspectives of patients with KC.

OBJECTIVES

To identify the needs and preferences of patients with basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) regarding care.

METHODS

A qualitative study was conducted consisting of three focus groups with patients with BCC and three focus groups with patients with SCC. In total 42 patients participated. In each focus group, the patients' needs and preferences regarding treatment and follow-up were discussed, using a predefined topic list. All sessions were transcribed verbatim and analysed by two researchers.

RESULTS

The following needs and preferences were identified: (i) the need to receive all relevant, tailored information; (ii) a physician who takes you seriously and communicates well; (iii) a short waiting period and the best treatment with direct results; (iv) to be seen by the same physician; a preference for a dermatologist during (v) treatment and (vi) follow-up; (vii) a general need for structured follow-up care and (viii) a full-body skin examination during follow-up. Patients with BCC additionally expressed the need for openness and transparency and wanting to participate in shared decision making.

CONCLUSIONS

It is advocated to organize skin cancer care that is better tailored to the needs of patients with KC, providing patient-centred care. This should include investing in the patient-physician relationship, and personalizing the type and form of information and the follow-up schedules. Adding the patient's perspective to current guidelines could facilitate this process.

Oncologists' Treatment Responses to Mental Health Distress in Their Cancer Patients

The objectives of this study were to identify how oncologists respond to mental health distress in their patients, what specific strategies they use in treating this distress, and what barriers they report responding to their patients' emotional distress. Twenty-three oncologists at two cancer centers were interviewed. The grounded theory method of data collection and analysis was used. Oncologists varied in their response to patients' emotional distress. Strategies used in responding to patients' distress included creating supportive relationships and prescribing medications, while barriers included patient reluctance, a lack of protocol on how to respond to patients, limited psychosocial resources, and a lack of time. Developing and adopting clear guidelines to addressing mental health distress among cancer patients is critical in assuring quality care for the whole patient and reduce the risk for poor quality of life and potential disease-related morbidity and mortality.

Fear of cancer progression in patients with stage IA malignant melanoma

We aimed to determine the prevalence and importance of fear of cancer progression (FoP) in melanoma patients with stage IA tumours to assess psychosocial and demographic factors associated with severity of FoP and to determine the relationship of FoP and quality of life (QoL). One hundred and thirty-six patients with stage IA melanoma completed the short version of the Fear of Progression Questionnaire (FoP-Q-SF), the Hospital Anxiety and Depression Scale (HADS) and the EORTC-QLQ-C30. We found a mean FoP-Q-SF sum score of 30.2 points (±8.4 points SD). In this study, 33% of patients reported high FoP at or above the cutoff-value of 34 points. Higher FoP was found in women (p < 0.01), young (p = 0.03) and employed (p = 0.02) patients. Being confronted with a cancer diagnosis in closely related persons predicted higher FoP (p < 0.01). FoP correlated positively with the HADS anxiety (r = 0.50, p < 0.01) and depression scales (r = 0.26, p < 0.01) and negatively with the EORTC-QLQ-C30 global health state (r = -0.32, p < 0.01). FoP is considerably prevalent in low-risk melanoma patients and associated with reduced QoL, cancer in related persons, women sex and participation in working life. Considerably high levels of FoP, even in patients with low-risk malignancies, underline the need for psychosocial support and psychotherapeutic interventions for melanoma patients.

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.

Psychoeducational intervention for people at high risk of developing another melanoma: a pilot randomised controlled trial

INTRODUCTION

Information and psychological needs have been reported as one of the greatest areas of unmet needs for patients with melanoma. To respond to these needs, we developed the Melanoma Care Intervention, a developed psychoeducational intervention for people at high risk of developing another melanoma comprising of a newly developed melanoma educational booklet and individually tailored telephone support sessions provided by trained psychologists. The purpose of this study was to investigate the acceptability and feasibility of the Melanoma Care Intervention.

METHODS

Twenty-four adults (14 men, 10 women, mean age: 58 years, SD: 12.2) at high risk of developing a subsequent primary melanoma were recruited and randomly assigned 1:1 to the intervention (a psychoeducational booklet, a Cancer Council booklet on melanoma and up to five telephone-based sessions with a psychologist) or usual care (Cancer Council booklet only). Acceptability, feasibility, fear of cancer recurrence and secondary psychosocial outcomes were assessed at baseline, 1 and 6 months.

RESULTS

Satisfaction and perceived benefits were rated highly for all intervention components, particularly the telephone-based psychology sessions (mean satisfaction and benefits: both 9.27 out of 10, SD=2.41). The quality of information and support provided throughout the trial was rated as 'high' by the intervention group, with a mean score of 4.6 out of a possible 5 (SD=0.9) and 4.2 (SD=1.2) for the control group.

CONCLUSIONS

The intervention was feasible and acceptable for improving psychological adjustment. Timely access to effective, evidence-based, psychological care is a recognised need for people with melanoma. The intervention is designed to directly address this need in a way that is feasible in a clinical setting, acceptable to patients and health professionals.

TRIAL REGISTRATION NUMBER

The trial was registered with the Australian and New Zealand Clinical Trials Registry on 19/03/2013 (Registration Number: ACTRN12613000304730).

Exploring Knowledge, Attitudes, and Practice Associated With Meditation Among Patients With Melanoma

Aim: To explore the knowledge, attitudes, and practices associated with meditation among people with melanoma and investigate the relationship between perceived stress, trait mindfulness, and meditation. Factors associated with interest to participate in an online meditation program were also explored. Methods: A survey-based cross-sectional study of 291 patients attending a melanoma outpatient clinic assessed knowledge of meditation, attitudes toward meditation using Determinants of Meditation Practice Inventory (DMPI), and meditation experience. Perceived stress and trait mindfulness were measured using the Perceived Stressed Scale and Cognitive and Affective Mindfulness Scale, respectively. Results: Participants who had tried meditation (43%) were likely to be younger, female, and have completed higher education or be employed. Perceived stress score was higher among women, younger participants, and those treated in the past year but did not differ by melanoma stage. Participants reported a good understanding of the potential benefits of meditation, but even among people with meditation experience, common misconceptions prevailed. The main barrier to meditation was a perceived lack of knowledge about meditation . Higher DMPI scores were associated with lower education, moderate to low access to service centers, or living in disadvantaged neighborhoods . Participants practicing meditation that involved self-reflection reported less stress and higher trait mindfulness compared with participants practicing another type of meditation. People interested in participating in an online meditation-based program reported higher perceived stress than those not interested. Conclusion: A meditation-based intervention teaching self-reflective practices, targeted at people with melanoma, may have the potential to assist them with managing their stress.

The needs and experiences of patients with skin cancer: a qualitative systematic review with metasynthesis

Skin cancer incidence is increasing worldwide. This is an update of a previous review published in 2010 that identified only two studies and found that the needs and experiences of individuals with skin cancer were under-researched. Our objective was to undertake a qualitative systematic review of the needs and experiences of people with a diagnosis of skin cancer. To update the previous review, the following databases were searched from 2010 to 30 November 2015: CINAHL PsycINFO, Medline and Embase. The methodological quality of the studies was assessed using the Joanna Briggs Institute Qualitative Assessment Review Instrument. The qualitative research findings were synthesized using a pragmatic meta-aggregative approach. A total of 14 studies (16 papers) were included. Only three studies included patients with keratinocyte carcinoma. Overall, 15 categories were identified and these resulted in four overarching synthesized findings (SFs) from diagnosis (SF1), throughout treatment (SF2) and follow-up (SF3), and then a fourth SF (SF4) that addressed patients' satisfaction with their care and their relationship with healthcare professionals. Despite the fact that patients with keratinocyte carcinoma and melanoma can have a very different prognosis, they also share similar needs and concerns especially around the time of diagnosis and follow-up/surveillance for new lesions. Healthcare professionals working with patients with skin cancer need to understand their psychosocial concerns and their information needs in order to design services appropriately. Future studies need to consider patients with keratinocyte carcinoma in addition to patients with melanoma.

Psychoeducational Intervention to Reduce Fear of Cancer Recurrence in People at High Risk of Developing Another Primary Melanoma: Results of a Randomized Controlled Trial

Purpose

People with a history of melanoma commonly report a fear of cancer recurrence (FCR), yet psychologic support is not routinely offered as part of ongoing melanoma care. This randomized controlled trial examined the efficacy of a psychoeducational intervention to reduce FCR and improve psychologic adjustment in this patient group compared with usual care.

Methods

The intervention comprised a newly developed psychoeducational resource and three telephone-based psychotherapeutic sessions over a 1-month period timed in accordance with dermatologic appointments. Participants were randomly assigned to intervention (n = 80) or usual care (n = 84). Assessments were completed at baseline, 1 month, and 6 months after dermatologic appointments. Linear mixed models were used to examine differences between treatment and control groups for patient-reported outcomes, including FCR, anxiety, stress, depression, melanoma-related knowledge, health behaviors, satisfaction with melanoma care, unmet needs, and health-related quality of life.

Results

At 6 months, the intervention group reported lower FCR severity, trigger, and distress scores than the control group in the baseline-adjusted models; the between-group mean difference was −1.9 for FCR severity (95% CI, −3.1 to −0.7; P = .002), −2.0 for FCR triggers (95% CI, −3.3 to −0.7; P = .003), and −0.7 for FCR distress (95% CI, −1.3 to −0.1; P = .03). The decrease in FCR severity (but not triggers or distress) remained statistically significant after adjustment for other covariates ( P = .04). At 6 months, the intervention group also reported lower stress (−1.6; 95% CI, −3.1 to −0.2; P = .03) and improved melanoma-related knowledge (1.7; 95% CI, 0.8 to 2.6; P < .001) compared with the control group. No differences were found between groups for other secondary outcomes.

Conclusion

This newly developed evidence-based psychoeducational intervention was effective in reducing FCR and stress and increasing melanoma-related knowledge in people at high risk for another melanoma.

The characteristics of oncology social work in Australia: Implications for workforce planning in integrated cancer care

AIMS

To describe the demographics, professional characteristics, self-reported professional development needs and research involvement of oncology social workers in Australia and to describe perceived barriers to provision of quality psychosocial care.

METHODS

A cross-sectional online survey was administered to social workers working in the oncology field who were contacted through three professional organizations; the Australian Association of Social Workers, Oncology Social Work Australia and the Psycho-oncology Co-operative Research Group, the University of Sydney. A snowball recruitment method was adopted to maximize the sample size.

RESULTS

Two thirds of respondents had over 10 years professional practice experience but with lesser experience in oncology settings. Twenty-eight percent had post-graduate qualifications. Professional development needs were reported as moderate or high by 68% of respondents. No association between professional needs and work setting was found. Years of experience in oncology practice and living in an urban area increased the likelihood of involvement in research. Barriers to psychosocial care included poor understandings of the social work role, time constraints and an inadequate number of social work positions.

CONCLUSION

In this first Australian study of the social work oncology workforce, the results demonstrated active, well-qualified and experienced social workers providing frontline services to people with cancer and their caregivers in geographically diverse locations across Australia. Inadequate resources and a lack of integrated psychosocial care were identified as barriers to comprehensive cancer care. The need for Aboriginal and Torres Strait Islander social workers was identified as an urgent workforce priority.

Psychosocial Care Needs of Melanoma Survivors: Are They Being Met?

Patients who have survived malignant melanoma for more than five years may lack the opportunity to talk about their burden. As a consequence their psychosocial care needs remain undetected and available supportive interventions may not be utilised. Therefore, the psychosocial burden of this patient group needs to be assessed using specific screening instruments. The aim of this study was to investigate the psychosocial burden of long-term melanoma survivors, their psychosocial care needs and the determinants of these needs. We wanted to find out if the use of professional support corresponds to the care needs defined by experts. Using the cancer registry of Rhineland-Palatinate, melanoma patients diagnosed at least 5 years before the survey were contacted by physicians. N = 689 former patients completed the Hornheide Questionnaire (short form HQ-S) to identify psychosocial support need (scale cut off ≥ 16 or item-based cut-off score) and the potential psychosocial determinants of these needs. Additionally, they were asked about their utilisation of the professional support system. More than one third (36%) of them was in need for professional psychosocial support. The highest burden scores concerned worry about tumour progression. Younger age (< 50), higher general fatigue, higher symptom burden, lower general health, negative social interactions and unfulfilled information needs were significant predictors of the need for psychosocial intervention. Related to the percentage of survivors identified as 'in need', the professional support system was underused. Further studies should investigate whether using the HQ-S to routinely identify burdened melanoma patients could lead to better fulfilment of their intervention needs, ultimately enhancing health-related quality of life.

The Melanoma care study: protocol of a randomised controlled trial of a psycho-educational intervention for melanoma survivors at high risk of developing new primary disease

Background

Despite a good prognosis for most melanoma survivors, many experience substantial fear of new or recurrent melanoma, worry and anxiety about the future, and unmet healthcare needs. In this protocol, we outline the design and methods of the Melanoma Care Study for melanoma survivors at high risk of developing new primary disease. The objective of this study is to evaluate the efficacy and cost-effectiveness of a psycho-educational intervention for improving psychological and behavioural adjustment to melanoma risk.

Design

The study design is a two-arm randomised controlled trial comparing a psycho-educational intervention to usual care.

Methods

The intervention is comprised of a newly-developed psycho-educational booklet and three telephone sessions delivered by a trained psychologist. A total of 154 melanoma survivors at high risk of developing new primary disease who are attending one of three melanoma high risk clinics in New South Wales, Australia, will be recruited. Participants will be assessed at baseline (6 weeks before their high risk clinic dermatological appointment), and then 4 weeks and 6 months after their appointment. If effectiveness of the intervention is demonstrated at 6 months, an additional assessment at 12 months is planned. The primary outcome is fear of new or recurrent melanoma, as assessed by the Fear of Cancer Recurrence Inventory (FCRI). Secondary outcomes include anxiety, depression, unmet supportive care needs, satisfaction with clinical care, knowledge, behavioural adjustment to melanoma risk, quality of life, and cost-effectiveness of the intervention from a health system perspective. Following the intention-to-treat principle, linear mixed models will be used to analyse the data to account for repeated measures. A process evaluation will also be carried out to inform and facilitate potential translation and implementation into clinical practice.

Discussion

This study will provide high quality evidence on the efficacy and cost-effectiveness of a psycho-educational intervention aimed at improving psychological and behavioural adjustment amongst melanoma survivors at high risk of new primary disease.

Trial registration

ACTRN 12613000304730

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

AIMS AND OBJECTIVES

To explore the patients' experience of having malignant melanoma, their related support needs and the processes that lead to these needs being met.

BACKGROUND

The number of patients attending surveillance clinics after a diagnosis of malignant melanoma is increasing. In the UK specialist nurses provide support to patients, but little evidence exists about the nature of patients' support needs or their experience of having melanoma. Melanoma has often been researched within general cancer studies, yet the support needs of melanoma patients may be different from those of patients with other skin cancers or tumour types.

DESIGN

A Grounded Theory Approach was used to guide sampling, data collection and analysis.

METHODS

In-depth interviews were conducted with eleven patients who where purposively sampled. Transcripts were read several times, coded and categorised using the constant comparative method. Emergent categories were discussed with participants.

RESULTS

Three emergent categories related to a core category of melanoma-related worry which formed a substantive theory about the strategies patients use to control this. Participants reported needing to have their concerns believed by others prior to and after diagnosis. They discussed discerning whom to share their concerns with depending upon who they felt would not perceive assisting them as being burdensome. They also sought ways to reassure themselves.

CONCLUSIONS

Patients need to have their fear and worries acknowledged by others. This includes nurses, healthcare professionals and family members. Patients will also use self-examination and the absence of symptoms to reassure themselves.

RELEVANCE TO CLINICAL PRACTICE

Nurses play key roles throughout the patient's care; therefore they need to be sensitive to the fact that patients may consider them a primary source of support. When teaching self-examination it is important that nurses discuss that this may ease worry and aid coping.

Depression, anxiety and quality of life in long-term survivors of malignant melanoma: a register-based cohort study

AIM

The purpose of the study was to determine anxiety and depression, quality of life, and their determinants in long-term survivors of malignant melanoma.

METHODS

In a state cancer registry a cohort of survivors of malignant melanoma was contacted via the physician registered. Of 1302 contactable patients, 689 (52.2%) completed a questionnaire including the Patient Health Questionnaire with generalized anxiety (GAD-7) and depression (PHQ-9) and the EORTC Quality of Life Questionnaire (EORTC QLQ 30). Based on multiple regression analysis, predictors of quality of life and distress were identified. Comparison data were assessed in two waves of representative face-to-face household surveys of the adult German population.

RESULTS

An average of 8.4 (5.7 to 12.2) years after diagnosis, distress was higher in women compared to men and in middle adulthood (vs. older patients). Symptoms were higher in women than in men, and there was a decline of functioning and increase of symptoms across the age range of both genders. Compared to the general population, there were slightly increased depression and anxiety (only women), but no impaired global quality of life. Yet, survivors evidenced functional decline and more physical symptoms. Distress and reduced quality of life were consistently predicted by lack of social support, fear of recurrence, pessimism and self-blame. Distress was increased by a family history of melanoma, and additional mental and somatic diseases.

CONCLUSION

Overall, long-term survivors have adjusted well achieving a global quality of life comparable to the general population. Yet, compromised functional dimensions, physical symptoms and distress indicate the need for integrating psychooncological screening into oncological follow-up, which might be guided by predictors such as family history or social support. Further prospective study is needed to determine the course of adaptation to the disease and corroborate the risk factors identified.

It's more than dollars and cents: the impact of childhood cancer on parents' occupational and financial health

Few studies have evaluated the impact of childhood cancer on parents' occupational/financial status. This study explored parents' occupational/financial experiences posttreatment. Semistructured interviews were administered to 78 parents (44 mothers) of childhood cancer survivors diagnosed in the preceding 5 years. Transcripts were organized into themes using QSR NVivo8. Parents reported familial, psychological, and practical factors affecting their ability to return to work. Prioritizing family, reinstigating career progression, and negative workplace attitudes were particularly challenging. Parents of children with cancer experience substantial work-family conflict after their child's physical recovery from cancer. Family friendly policies and further research are recommended.

Health behaviors and needs of melanoma survivors

PURPOSE

Little is known about melanoma survivors' long-term symptoms, sun protection practices, and support needs from health providers.

METHODS

Melanoma survivors treated at Stanford Cancer Center from 1995 through 2011 were invited to complete a heath needs survey. We compared responses of survivors by sex, education, time since diagnosis (long-term vs. short-term survivors), and extent of treatment received (wide local excision (WLE) alone versus WLE plus additional surgical or medical treatment (WLE+)).

RESULTS

One hundred sixty melanoma survivors (51 % male; 61 % long-term; 73 % WLE+) provided evaluable data. On average, patients were 62 years of age (SD = 14), highly educated (75 % college degree), and Caucasian (94 %). Overall, participants rated anxiety as the most prevalent symptom (34 %). Seventy percent reported that their health provider did not address their symptoms, and 53 % requested education about melanoma-specific issues. Following treatment, women spent significantly less time seeking a tan compared with men (p = 0.01), had more extremity swelling (p = 0.014), and expressed higher need for additional services (p = 0.03). Long-term survivors decreased their use of tanning beds (p = 0.03) and time spent seeking a tan (p = 0.002) and were less likely to receive skin screening every 3-6 months (p < 0.001) compared with short-term survivors. WLE+ survivors reported greater physical long-term effects than WLE survivors (p ≤ 0.001) following treatment.

CONCLUSIONS

Melanoma survivors experience continuing symptoms long after treatment, namely anxiety, and they express a need for information about long-term melanoma effects, psychosocial support, and prevention of further skin cancer.

Psychological stress and melanoma: are we meeting our patients' psychological needs?

Approximately 30% of all patients diagnosed with melanoma report levels of psychological distress indicative of the need for clinical intervention. Despite this, the psychological and emotional needs of patients frequently go undetected and unmet. This contribution aims to provide clinicians and researchers with a succinct update on our understanding of the psychosocial challenges faced by individuals with melanoma. There is now strong evidence that psychological interventions can improve psychosocial outcomes for patients with melanoma, including reductions in general mood disturbance, depression, and anxiety. Further prospective cohort studies are required for a better understanding of the impact of psychological stress on melanoma survival and recurrence, as well as the potential psycho-neuro-immunological mechanisms involved.

β-adrenergic-blocking drugs and melanoma: current state of the art

The purpose of this review is to present the preclinical, epidemiological and clinical data relevant to the association between β-blockers and melanoma progression. Preclinical studies have shown that β-adrenergic receptor (β-AR) signaling can inhibit multiple cellular processes involved in melanoma progression and metastasis. These observations have suggested the possibility that drugs originally intended for the treatment of cardiovascular disease, the β-AR blockers, may provide new therapeutic opportunities for the control of tumor progression. A large number of observational studies demonstrated the protective effect of β-blockers in breast cancer but, more recently, similar findings were also reported in other cancers such as prostate cancer and melanoma. With regard to melanoma, two recently published studies demonstrated a great reduction in the risk of disease progression for each year of treatment with β-blockers. The results from these studies have suggested a potential role for targeting the β-AR pathway in melanoma patients. Questions regarding the type of β-blocker or tumor characteristics, appropriate treatment paradigms and, most importantly, efficacy must be answered in randomized clinical studies before β-blockers can be considered a therapeutic option for patients with melanoma.