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Luigjes-Huizer YL, van der Lee ML, Richel C, Masselink RA, de Wit NJ, Helsper CW. Patient-reported needs for coping with worry or fear about cancer recurrence and the extent to which they are being met: a survey study. J Cancer Surviv 2024; 18:791-799. [PMID: 36585574 PMCID: PMC9803402 DOI: 10.1007/s11764-022-01326-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/16/2022] [Indexed: 12/31/2022]
Abstract
PURPOSE Many cancer patients and survivors experience fear or worry about cancer recurrence (FCR). Evidence suggests support for FCR is their largest unmet need. We aimed to assess which types of support are needed, which providers are preferred and to what extent patients' needs are being met. METHODS Together with the Dutch Federation of Cancer Patient Organisations (NFK), a purpose-designed questionnaire was distributed online via e-mail, newsletters and social media. All questions were multiple choice or Likert scales, except for an open-ended question about the preferred provider of care. RESULTS Out of 5323 respondents, 4511 had experienced FCR and were included. Among them, 94% indicated a need for support. The required types of support that were reported the most were talking about FCR (69%), enjoyable activities for distraction (56%) and psychological help or coaching (40%). On average, younger respondents and women wanted more support than older respondents and men. Eighty-five percent of respondents received at least one type of support they wanted. Practical tips about FCR and additional medical check-ups were most often missed. Social contacts provided an important part of support, especially with talking and distracting activities. For other types of support, respondents usually preferred professionals. CONCLUSIONS Almost all patients who experience FCR have a need for support. Even though most receive some support, several gaps remain. IMPLICATIONS FOR CANCER SURVIVORS Many report an unmet need for psychological help or practical tips about FCR. We recommend for healthcare providers to discuss FCR with patients and inform them about the support available.
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Affiliation(s)
- Yvonne L Luigjes-Huizer
- Helen Dowling Institute, Professor Bronkhorstlaan 20, 3723 MB, Bilthoven, The Netherlands.
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands.
| | - Marije L van der Lee
- Helen Dowling Institute, Professor Bronkhorstlaan 20, 3723 MB, Bilthoven, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Carol Richel
- Dutch Federation of Cancer Patient Organisations, Utrecht, The Netherlands
| | - Roel A Masselink
- Dutch Federation of Cancer Patient Organisations, Utrecht, The Netherlands
| | - Niek J de Wit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Charles W Helsper
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
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2
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Al-Sharman A, Al-Sarhan A, Aburub A, Shorman R, Bani-Ahmad A, Siengsukon C, Bani Issa W, Abdelrahim DN, Hijazi H, Khalil H. Quality-of-life among women with breast cancer: application of the international classification of functioning, disability and health model. Front Psychol 2024; 15:1318584. [PMID: 38362250 PMCID: PMC10867976 DOI: 10.3389/fpsyg.2024.1318584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/04/2024] [Indexed: 02/17/2024] Open
Abstract
Background This study aimed to identify the factors that influence Breast Cancer (BC) women's quality of life (QoL) based on the International Classification of Functioning, Disability and Health (ICF) framework. Method A cross-sectional study was conducted among 188 women with BC. The dependent variable, QoL, was measured using the Quality of Life Index (QLI-c). The independent variables were measured using the following Arabic-validated questionnaires: Pittsburgh Sleep Quality Index (PSQI), Female Sexual Function Index (FSFI), Modified Fatigue Impact Scale (MFIS), Hospital Anxiety and Depression Scale (HADS), and the International Physical Activity Questionnaire (IPAQ). Results There was a significant positive correlation between monthly income (r = 0.17, p = 0.016) and QoL, and significant negative correlation between the stage of disease (r = -0.221, p = 0.002) and duration of first diagnosis (r = -0.280, p = 0.004) with QoL. Poor sleep quality, sexual dysfunction, fatigue, depression, and anxiety had significant negative correlations with QoL (p < 0.01). Multiple regression analysis revealed that among the various factors that might affect QoL, sexual dysfunction, poor sleep quality, depression, and anxiety were significant predictors of QoL (p ≤ 0.05). Conclusion The ICF provided an excellent framework to explore the factors influencing QoL among women with BC. This study has given evidence for the relationship of demographic, clinical, and body functional factors with QoL among women with BC. Interestingly, sexual dysfunction, poor sleep quality, depression, and anxiety factors are predictors of QoL. Awareness of these factors that predict QoL will guide healthcare professionals to improve the health and QoL of BC women.
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Affiliation(s)
- Alham Al-Sharman
- Department of Physiotherapy, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
- Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
- Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Areen Al-Sarhan
- Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Ala Aburub
- Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Raid Shorman
- Department of Allied Medical Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Ali Bani-Ahmad
- Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Catherine Siengsukon
- Department of Physical Therapy, Rehabilitation Science, & Athletic Training, University of Kansas Medical Center, Kansas City, KS, United States
| | - Wegdan Bani Issa
- Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
- Department of Nursing, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Dana N. Abdelrahim
- Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Heba Hijazi
- Department of Health Care Management, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
- Department of Health Management and Policy, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Hanan Khalil
- Department of Rehabilitation Sciences, College of Health Sciences, QU Health, Doha, Qatar
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Jones KF, Magee LW, Fu MR, Bernacki R, Bulls H, Merlin J, McTernan M. The Contribution of Cancer-Specific Psychosocial Factors to the Pain Experience in Cancer Survivors. J Hosp Palliat Nurs 2023; 25:E85-E93. [PMID: 37402212 PMCID: PMC10524730 DOI: 10.1097/njh.0000000000000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Palliative care teams are increasingly called up to manage chronic pain in cancer survivors. Chronic pain is common in cancer survivors and is heavily influenced by biopsychosocial factors. This study aimed to determine the relative contribution of unique cancer-specific psychosocial factors, pain catastrophizing, and multisite pain to the pain experience in 41 cancer survivors who completed curative cancer treatment. To test the research hypotheses, a series of nested linear regression models were used with likelihood ratio testing to test the individual and collective contribution of cancer-specific psychosocial factors (fear of cancer recurrence, cancer distress, cancer-related trauma), pain catastrophizing, and the number of pain sites on the pain experience. The results indicate pain catastrophizing and multisite pain explained a significant degree of variance in pain interference scores ( P < .001) and pain severity ( P = .005). Cancer-specific psychosocial factors did not significantly predict variability in pain interference ( P = .313) or pain severity ( P = .668) over and above pain catastrophizing and the number of sites of pain. In summary, pain catastrophizing and multisite pain contribute to the chronic cancer-related pain experienced by cancer survivors. Palliative care nurses are well positioned to improve chronic pain among cancer survivors by assessing and treating pain catastrophizing and multisite pain.
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Affiliation(s)
- Katie Fitzgerald Jones
- Boston College, William F. Connell School of Nursing and Massachusetts General Hospital Center for Aging and Serious Illness
| | | | - Mei R. Fu
- Rutgers University School of Nursing-Camden
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Riveros C, Chalfant V, Elshafei A, Bandyk M, Balaji KC. Does care fragmentation in patients with bladder cancer lead to worse outcomes? Urol Oncol 2023; 41:147.e7-147.e14. [PMID: 36631369 DOI: 10.1016/j.urolonc.2022.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 10/18/2022] [Accepted: 10/30/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Care fragmentation may influence oncologic outcomes. The impact of care fragmentation on the outcomes of patients receiving neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) is not well defined. We aimed to compare outcomes between patients who received fragmented care (FC) versus non-fragmented care (NFC). METHODS The National Cancer Database was queried for adult (≥18 years old) patients with cT2-T4aN0M0 urothelial carcinoma of the bladder receiving NAC followed by RC between 2004 and 2017. Patients were dichotomized based on whether they received FC (defined as receiving NAC at a different facility from where RC was performed) or NFC (defined as receiving NAC and RC at a single facility). The main outcome of interest was overall survival (OS). Secondary outcomes included time from diagnosis to treatment (NAC and RC) and perioperative outcomes. Kaplan-Meier survival estimates were calculated after stratifying by type of care received. Multivariable Cox regression analysis was performed to evaluate the association between FC and OS in the context of other clinically relevant covariates. RESULTS A total of 2223 patients were included: 1035 (46.6%) received FC whereas 1188 (53.4%) received NFC. Factors associated with FC included greater travel distance, higher comorbidity burden, and surgical treatment at a high-volume facility. Patients who received FC had a slightly longer median time to RC (160 vs. 154 days, P = 0.001). However, on Kaplan-Meier analysis no differences in median OS were found between the two groups. On multivariable Cox regression analysis, factors associated with worse OS included age, advanced TNM stage, lymphovascular invasion, and positive surgical margins; yet FC was not associated with worse OS (hazard ratio [HR] 1.02; 95% confidence interval [CI] 0.88-1.17). On subgroup analysis, we found that FC received at academic facilities (HR 0.76; 95% CI 0.58-0.99), as well as NFC received at high-volume centers (HR 0.65; 95% CI 0.43-0.98), were associated with a decrease in overall mortality. CONCLUSIONS Fragmented care is not associated with worse survival outcomes in patients with MIBC receiving NAC followed by RC.
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Affiliation(s)
- Carlos Riveros
- Department of Urology, University of Florida, Jacksonville, FL
| | - Victor Chalfant
- Department of Urology, University of Florida, Jacksonville, FL
| | - Ahmed Elshafei
- Department of Urology, University of Florida, Jacksonville, FL
| | - Mark Bandyk
- Department of Urology, University of Florida, Jacksonville, FL
| | - K C Balaji
- Department of Urology, University of Florida, Jacksonville, FL.
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Hallet J, Sutradhar R, Isenberg-Grzeda E, Noel CW, Mahar AL, Vigod SN, Bolton J, Deleemans J, Chan WC, Coburn NG, Eskander A. Association of Patient-Reported Outcomes With Subsequent Nonfatal Self-injury After a New Cancer Diagnosis. JAMA Oncol 2022; 8:e220203. [PMID: 35357419 DOI: 10.1001/jamaoncol.2022.0203] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Nonfatal self-injury (NFSI) is a patient-centered manifestation of severe distress occurring in 3 out of 1000 patients after cancer diagnosis. How to identify patients at risk for NFSI remains unknown. Objective To examine the associations between patient-reported outcome measures and subsequent NFSI in patients with cancer. Design, Setting, and Participants This population-based matched case-control study included adults with a new cancer diagnosis reporting an Edmonton Symptom Assessment System (ESAS) score within 36 months of diagnosis in Ontario, Canada, 2007 to 2019. Data analysis was performed January 2007 to December 2019. Main Outcomes and Measures Cases included patients with NFSI, and controls were patients without NFSI. Cases and controls were matched 1:4. Multivariable conditional logistic regression assessed the association between moderate to severe ESAS symptom scores and total ESAS (t-ESAS, range 0-90) score with NFSI in the subsequent 180 days. Results Of 408 858 patients reporting 1 or more ESAS assessments, 425 patients experienced NFSI and reported an ESAS score in the preceding 180 days. Of those, 406 cases were matched to 1624 control patients without an NFSI. Cases reported a higher proportion of moderate to severe symptoms and higher t-ESAS score than controls prior to the event. After adjustment, moderate to severe anxiety (odds ratio [OR], 1.61; 95% CI, 1.14-2.27), depression (OR, 1.66; 95% CI, 1.20-2.31), and shortness of breath (OR, 1.65; 95% CI, 1.18-2.31) and each 10-point increase in t-ESAS score (OR, 1.51; 95% CI, 1.40-1.63) were independently associated with higher odds of subsequent NFSI. Conclusions and Relevance In this case-control study, reporting moderate to severe anxiety, depression, and shortness of breath and an increasing t-ESAS score after cancer diagnosis were associated with higher odds of NFSI in the following 180 days. These data support the prospective use of routine ESAS screening as a means of identifying patients at higher risk for NFSI to improve supportive care.
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Affiliation(s)
- Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Surgical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Elie Isenberg-Grzeda
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Psychosocial Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Christopher W Noel
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Canada
| | - Alyson L Mahar
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Simone N Vigod
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Women's College Hospital and Research Institute, Toronto, Ontario, Canada
| | - James Bolton
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Deleemans
- Division of Psychosocial Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Surgical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Antoine Eskander
- Division of Surgical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Canada
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Harnas SJ, Knoop H, Bennebroek Evertsz F, Booij SH, Dekker J, van Laarhoven HWM, van der Lee M, Meijer E, Sharpe L, Sprangers MAG, van Straten A, Zweegman S, Braamse AMJ. Personalized versus standard cognitive behavioral therapy for fear of cancer recurrence, depressive symptoms or cancer-related fatigue in cancer survivors: study protocol of a randomized controlled trial (MATCH-study). Trials 2021; 22:696. [PMID: 34641961 PMCID: PMC8507219 DOI: 10.1186/s13063-021-05657-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/27/2021] [Indexed: 11/12/2022] Open
Abstract
Background Fear of cancer recurrence, depressive symptoms, and cancer-related fatigue are prevalent symptoms among cancer survivors, adversely affecting patients’ quality of life and daily functioning. Effect sizes of interventions targeting these symptoms are mostly small to medium. Personalizing treatment is assumed to improve efficacy. However, thus far the empirical support for this approach is lacking. The aim of this study is to investigate if systematically personalized cognitive behavioral therapy is more efficacious than standard cognitive behavioral therapy in cancer survivors with moderate to severe fear of cancer recurrence, depressive symptoms, and/or cancer-related fatigue. Methods The study is designed as a non-blinded, multicenter randomized controlled trial with two treatment arms (ratio 1:1): (a) systematically personalized cognitive behavioral therapy and (b) standard cognitive behavioral therapy. In the standard treatment arm, patients receive an evidence-based diagnosis-specific treatment protocol for fear of cancer recurrence, depressive symptoms, or cancer-related fatigue. In the second arm, treatment is personalized on four dimensions: (a) the allocation of treatment modules based on ecological momentary assessments, (b) treatment delivery, (c) patients’ needs regarding the symptom for which they want to receive treatment, and (d) treatment duration. In total, 190 cancer survivors who experience one or more of the targeted symptoms and ended their medical treatment with curative intent at least 6 months to a maximum of 5 years ago will be included. Primary outcome is limitations in daily functioning. Secondary outcomes are level of fear of cancer recurrence, depressive symptoms, fatigue severity, quality of life, goal attainment, therapist time, and drop-out rates. Participants are assessed at baseline (T0), and after 6 months (T1) and 12 months (T2). Discussion To our knowledge, this is the first randomized controlled trial comparing the efficacy of personalized cognitive behavioral therapy to standard cognitive behavioral therapy in cancer survivors. The study has several innovative characteristics, among which is the personalization of interventions on several dimensions. If proven effective, the results of this study provide a first step in developing an evidence-based framework for personalizing therapies in a systematic and replicable way. Trial registration The Dutch Trial Register (NTR) NL7481 (NTR7723). Registered on 24 January 2019.
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Affiliation(s)
- Susan J Harnas
- Department of Medical Psychology, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Hans Knoop
- Department of Medical Psychology, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Floor Bennebroek Evertsz
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Sanne H Booij
- Department of Developmental Psychology, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, the Netherlands.,Center for Integrative Psychiatry, Lentis, Groningen, the Netherlands
| | - Joost Dekker
- Department of Psychiatry, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marije van der Lee
- Research Department, Center for Psycho-Oncology, Helen Dowling Institute, Bilthoven, the Netherlands.,Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic disorders (CoRPS), Tilburg University Tilburg School of Social and Behavioral Sciences, Tilburg, the Netherlands
| | - Ellen Meijer
- Department of Hematology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Louise Sharpe
- School of Psychology, Faculty of Science, University of Sydney, Sydney, New South Wales, Australia
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Annemieke van Straten
- Department of Clinical, Neuro and Developmental Psychology & Amsterdam Public Health Research Institute, VU University, Amsterdam, the Netherlands
| | - Sonja Zweegman
- Department of Hematology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Annemarie M J Braamse
- Department of Medical Psychology, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Caminiti C, Annunziata MA, Verusio C, Pinto C, Airoldi M, Aragona M, Caputo F, Cinieri S, Giordani P, Gori S, Mattioli R, Novello S, Pazzola A, Procopio G, Russo A, Sarobba G, Zerilli F, Diodati F, Iezzi E, Maglietta G, Passalacqua R. Effectiveness of a Psychosocial Care Quality Improvement Strategy to Address Quality of Life in Patients With Cancer: The HuCare2 Stepped-Wedge Cluster Randomized Trial. JAMA Netw Open 2021; 4:e2128667. [PMID: 34648011 PMCID: PMC8517739 DOI: 10.1001/jamanetworkopen.2021.28667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE Many patients with cancer who would benefit from psychosocial care do not receive it. Implementation strategies may favor the integration of psychosocial care into practice and improve patient outcomes. OBJECTIVE To evaluate the effectiveness of the Humanization in Cancer Care (HuCare) Quality Improvement Strategy vs standard care as improvement of at least 1 of 2 domains (emotional or social function) of patient health-related quality of life at baseline and 3 months. A key secondary aim included investigation of the long-term effect. DESIGN, SETTING, AND PARTICIPANTS HuCare2 was a multicenter, incomplete, stepped-wedge cluster randomized clinical trial, conducted from May 30, 2016, to August 28, 2019, in three 5-center clusters of cancer centers representative of hospital size and geographic location in Italy. The study was divided into 5 equally spaced epochs. Implementation sequence was defined by a blinded statistician; the nature of the intervention precluded blinding for clinical staff. Participants included consecutive adult outpatients with newly diagnosed cancer of any type and stage starting medical cancer treatment. INTERVENTIONS The HuCare Quality Improvement Strategy comprised (1) clinician communication training, (2) on-site visits for context analysis and problem-solving, and (3) implementation of 6 evidence-based recommendations. MAIN OUTCOMES AND MEASURES The primary outcome was the difference between the means of changes of individual scores in emotional or social functions of health-related quality of life detected at baseline and 3-month follow-up (within each group) and during the postintervention epoch compared with control periods (between groups). Long-term effect of the intervention (at 12 months) was assessed as a secondary outcome. Intention-to-treat analysis was used. RESULTS A total of 762 patients (475 [62.3%] women) were enrolled (400 HuCare Quality Improvement Strategy and 362 usual care); mean (SD) age was 61.4 (13.1) years. The HuCare Quality Improvement Strategy significantly improved emotional function during treatment (odds ratio [OR], 1.13; 95% CI, 1.04-1.22; P = .008) but not social function (OR, 0.99; 95% CI, 0.89-1.09; P = .80). Effect on emotional function persisted at 12 months (OR, 1.05; 95% CI, 1.00-1.10; P = .04). CONCLUSIONS AND RELEVANCE In this trial, the HuCare Quality Improvement Strategy significantly improved the emotional function aspect of health-related quality of life during cancer treatment and at 12 months, indicating a change in clinician behavior and in ward organization. These findings support the need for strategies to introduce psychosocial care; however, more research is needed on factors that may maximize the effects. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03008993.
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Affiliation(s)
- Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, Parma, Italy
| | | | - Claudio Verusio
- Department of Oncology, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | - Carmine Pinto
- Medical Oncology Unit, Clinical Cancer Center, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Mario Airoldi
- Second Medical Oncology Division, AOU Città della Salute e della Scienza of Turin, Turin, Italy
| | - Marcello Aragona
- Medical Oncology Unit, Department of Human Pathology of Adult and Evolutive Age, University of Messina, Messina, Italy
| | | | - Saverio Cinieri
- Oncology Unit, San Antonio Perrino Hospital, Brindisi, Italy
| | - Paolo Giordani
- Medical Oncology Unit, Ospedali Riuniti Marche Nord, Pesaro and Fano, Italy
| | - Stefania Gori
- Medical Oncology Division, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Rodolfo Mattioli
- Medical Oncology Unit, Ospedali Riuniti Marche Nord, Pesaro and Fano, Italy
| | - Silvia Novello
- Department of Oncology, University of Turin, AOU San Luigi Orbassano, Italy
| | - Antonio Pazzola
- Medical Oncology Unit, University-Hospital of Sassari, Sassari, Italy
| | - Giuseppe Procopio
- Department of Medical Oncology, National Cancer Institute of Milan, Milan, Italy
| | - Antonio Russo
- Medical Oncology Unit, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Giuseppina Sarobba
- Oncology Unit, San Francesco Hospital, ATS Sardegna ASSL Nuoro, Nuoro, Italy
| | | | - Francesca Diodati
- Research and Innovation Unit, University Hospital of Parma, Parma, Italy
| | - Elisa Iezzi
- Research and Innovation Unit, University Hospital of Parma, Parma, Italy
| | - Giuseppe Maglietta
- Research and Innovation Unit, University Hospital of Parma, Parma, Italy
| | - Rodolfo Passalacqua
- Medical Oncology Division, Department of Oncology, ASST of Cremona, Cremona, Italy
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How do radiation therapists detect and manage patients experiencing anxiety in the radiation oncology setting? A vignette study. Support Care Cancer 2021; 29:5973-5981. [PMID: 33770258 DOI: 10.1007/s00520-021-06133-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Anxiety is commonly observed in oncology patients but infrequently screened, assessed or addressed. According to psychosocial guidelines, all healthcare professionals, including radiation therapists, are responsible for the psychosocial care of patients. Radiation therapists (RTs) interact with patients daily throughout treatment; however, little research exists to evaluate RTs' ability to identify and manage patients' psychosocial needs. This study aimed to determine if RTs can detect and manage patient anxiety. METHOD A cross-sectional, mixed-methods survey containing two clinically relevant vignettes was developed. Two fictitious patients were presented to elicit responses reflective of RTs' experiences and judgements in the recognition and management of anxiety. Surveys were distributed via email in Australia, New Zealand and Canada. Ethical approval was obtained from the University of Sydney (2016/227) and informed consent was obtained from participants. RESULTS Eligible and complete surveys were received from 582 respondents (240 (41.2%) from Australia; 78 (13.4%) New Zealand; 264 (45.4%) Canada). Almost all respondents endorsed a relevant descriptor of anxiety (vignette 1, 577 (99.1%); vignette 2, 579 (99.5%)). For both vignettes, the most frequently endorsed management strategy was to acknowledge the patients' feelings and encourage them to express their concerns (vignette 1, 548 (94.2%); vignette 2, 455 (78.2%)). CONCLUSION RTs in Australia, New Zealand and Canada are able to detect anxiety and endorse a strategy to manage patients experiencing anxiety depicted in written vignettes. Exploring RTs' abilities to detect and manage patient anxiety whilst in the high-pressure clinical environment is an important next step.
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Mohamed NE, Shah QN, Kata HE, Sfakianos J, Given B. Dealing With the Unthinkable: Bladder and Colorectal Cancer Patients' and Informal Caregivers' Unmet Needs and Challenges in Life After Ostomies. Semin Oncol Nurs 2021; 37:151111. [PMID: 33423864 DOI: 10.1016/j.soncn.2020.151111] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES We examined patient and informal caregiver unmet needs to identify areas for targeted supportive care interventions and programs to enhance both patient and informal caregiver experience. DATA SOURCES A total of 30 patients who underwent ostomy surgeries for bladder or colorectal cancers and 13 informal caregivers participated in the study. Patients were enrolled at the Icahn School of Medicine at Mount Sinai between 2017 and 2018. Qualitative data were collected by individual interviews, audiotaped, and transcribed verbatim. Transcribed data were iteratively analyzed using Atlas.ti to explore patient and caregiver unmet needs. RESULTS Patients and informal caregivers reported having insufficient psychological preparation for ostomy surgeries, and very limited hands-on training on stoma care and utility of stomal appliances. Unmet psychological needs related to depression, anxiety, and distress caused by changes in body image and sexual, urinary, and bowel function were reported. Patients and caregivers also reported significant patient medical needs in the acute postoperative period including pain, fatigue, sleep disturbance, inflammation, and complications resulting in hospital readmissions. Colorectal cancer patients specifically experienced significant challenges with changes in diet and nutrition that contributed to ostomy care burden. Both patients and caregivers recommended seeking psychological and social support to enhance both patient and caregiver emotional adjustment to life after ostomies. CONCLUSION Meeting patient and informal caregiver unmet informational and supportive care needs is imperative to improve their quality of life and adjustment. IMPLICATIONS FOR NURSING PRACTICE An effective supportive care plan should be designed and utilized in clinical care to improve ostomy patients' and caregivers' outcomes.
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Affiliation(s)
- Nihal E Mohamed
- Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Qainat N Shah
- Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medical Education, Albany Medical College, 43 New Scotland Ave, Albany, New York
| | - Holden E Kata
- Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John Sfakianos
- Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Barbara Given
- College of Nursing, Michigan State University, 1355 Bogue St, East Lansing, Michigan
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Ratnasekera N, Perera I, Kandapolaarachchige P, Surendra G, Jayasuriya N, Gajanayake C, Ratnapreya S. Capacity building of Public Health Nursing Officers on delivering psychosocial oncology care in Sri Lanka. Psychooncology 2020; 30:138-142. [PMID: 33084140 DOI: 10.1002/pon.5578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Nadisha Ratnasekera
- Preventive Oral Health Unit, National Dental Hospital (Teaching) Sri Lanka, Colombo, Sri Lanka
| | - Irosha Perera
- Preventive Oral Health Unit, National Dental Hospital (Teaching) Sri Lanka, Colombo, Sri Lanka
| | | | - Gayan Surendra
- Office of Deputy Director, National Dental Hospital (Teaching) Sri Lanka, Colombo, Sri Lanka
| | - Nadeena Jayasuriya
- Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka
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Hallet J, Davis LE, Isenberg-Grzeda E, Mahar AL, Zhao H, Zuk V, Moody L, Coburn NG. Gaps in the Management of Depression Symptoms Following Cancer Diagnosis: A Population-Based Analysis of Prospective Patient-Reported Outcomes. Oncologist 2020; 25:e1098-e1108. [PMID: 32100906 DOI: 10.1634/theoncologist.2019-0709] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 01/23/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND One of the most common psychological morbidities of cancer is depression. Routine depression symptoms screening (DSS) is recommended, but its ability to lead to psychosocial interventions in clinical practice is limited. We examined the use of and factors associated with psychosocial interventions for positive DSS following cancer diagnosis. MATERIALS AND METHODS We conducted a population-based cohort study of patients with diagnoses from 2010 to 2017 who reported ≥1 patient-reported Edmonton Symptom Assessment System (ESAS) score. Positive DSS was defined as ESAS ≥2 out of 10 for the depression item within 6 months of diagnosis. Outcomes were psychosocial interventions around the time of positive DSS: palliative care assessment, psychiatry/psychology assessment, social work referral, and antidepressant therapy (in patients ≥65 years of age with universal drug coverage). We examined reduction in depression symptom score (≥1 point) following intervention. Modified Poisson regression examined factors associated with interventions. RESULTS Of 142,270 patients, 65,424 (46.0%) reported positive DSS at a median of 66 days (interquartile range: 34-105) after diagnosis. Of those with depression symptoms, 17.1% received palliative assessment, 1.7% psychiatry/psychology assessment, 8.4% social work referral, and 4.3% antidepressant therapy. Depression symptom score decreased in 67.2% who received palliative assessment, 63.7% with psychiatry/psychology assessment, 67.3% with social work referral, and 71.4% with antidepressant therapy. On multivariable analysis, patients with older age, rural residence, lowest income quintile, and genitourinary or oropharyngeal cancer were more likely to not receive intervention other than palliative care. CONCLUSION The proportion of patients reporting positive DSS after cancer diagnosis receiving psychosocial intervention is low. We identified patients vulnerable to not receiving interventions, who may benefit from additional support. These data represent a call to action to modify practice and optimize the usefulness of systematic symptom screening. IMPLICATIONS FOR PRACTICE Patient-reported depression symptoms screening should be followed by targeted interventions to improve symptoms and patient-centered management.
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Affiliation(s)
- Julie Hallet
- Division of Surgical Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Laura E Davis
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Elie Isenberg-Grzeda
- Division of Psycho-Social Services, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Natalie G Coburn
- Division of Surgical Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Cancer Care Ontario, Toronto, Ontario, Canada
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Is care really shared? A systematic review of collaborative care (shared care) interventions for adult cancer patients with depression. BMC Health Serv Res 2019; 19:120. [PMID: 30764822 PMCID: PMC6376792 DOI: 10.1186/s12913-019-3946-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 02/04/2019] [Indexed: 01/07/2023] Open
Abstract
Background Collaborative care involves active engagement of primary care and hospital physicians in shared care of patients beyond usual discharge summaries. This enhances community-based care and reduces dependence on specialists and hospitals. The model, successfully implemented in chronic care management, may have utility for treatment of depression in cancer. The aim of this systematic review was to identify components, delivery and roles and responsibilities within collaborative interventions for depression in the context of cancer. Methods Medline, PsycINFO, CINAHL, Embase, Cochrane Library and Central Register for Controlled Trials databases were searched to identify studies of randomised controlled trials comparing a treatment intervention that met the definition of collaborative model of depression care with usual care or other control condition. Studies of adult cancer patients with major depression or a non-bipolar depressive disorder published in English between 2005 and January 2018 were included. Cochrane checklist for risk of bias was completed (Study Prospero registration: CRD42018086515). Results Of 8 studies identified, none adhered to the definition of ‘collaborative care’. Interventions delivered were multi-disciplinary, with care co-ordinated by nurses (n = 5) or social workers (n = 2) under the direction of psychiatrists (n = 7). Care was primarily delivered in cancer centres (n = 5). Care co-ordinators advised primary care physicians (GPs) of medication changes (n = 3) but few studies (n = 2) actively involved GPs in medication prescribing and management. Conclusions This review highlighted joint participation of GPs and specialist care physicians in collaborative care depression management is promoted but not achieved in cancer care. Current models reflect hospital-based multi-disciplinary models of care. Protocol registration The protocol for this systematic review has been registered with PROSPERO. The registration number is CRD42018086515. Electronic supplementary material The online version of this article (10.1186/s12913-019-3946-z) contains supplementary material, which is available to authorized users.
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13
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Nairn RC, Merluzzi TV. Enhancing coping skills for persons with cancer utilizing mastery enhancement: a pilot randomized clinical trial. J Behav Med 2018; 42:423-439. [PMID: 30552531 DOI: 10.1007/s10865-018-0004-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022]
Abstract
The purpose of this project was to develop a short-term, theory-based intervention for patients with self-reported limited self-efficacy to perform coping behaviors. Cancer patients with low coping self-efficacy were randomly assigned to a treatment (N = 66) or control condition (N = 68). The treatment, Mastery Enhancement Therapy, was based on self-regulation and self-efficacy theories. Measures of coping self-efficacy, functional status, depression, quality of life, and adjustment were administered at baseline, after session two, after the final (fourth) session, and at 3 months post-treatment. Control participants completed the measures at about the same time intervals. Treatment participants reported highly significant immediate post-treatment improvement in self-efficacy for coping compared to controls, although controls improved by 3 months post-treatment. However, treatment participants with lower levels of functional status benefited more than controls on depression and adjustment at follow-up. Mastery Enhancement Therapy is a time-limited treatment that increases coping efficacy and subsequently adjustment during active medical treatment, and appears to warrant a large-scale RCT with patients with below average coping self-efficacy and moderate to high symptoms.
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14
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Elsner KL, Naehrig D, Halkett GKB, Dhillon HM. Development and pilot of an international survey: 'Radiation Therapists and Psychosocial Support'. J Med Radiat Sci 2018; 65:209-217. [PMID: 29877630 PMCID: PMC6119728 DOI: 10.1002/jmrs.286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 04/17/2018] [Accepted: 05/09/2018] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Up to one third of radiation therapy patients are reported to have unmet psychosocial needs. Radiation therapists (RTs) have daily contact with patients and can provide daily psychosocial support to reduce patient anxiety, fear and loneliness. However, RTs vary in their values, skills, training, knowledge and involvement in providing psychosocial support. The aims of this study were to: (1) develop an online survey instrument to explore RT values, skills, training and knowledge regarding patient anxiety and psychosocial support, and (2) pilot the instrument with RT professionals to assess content validity, functionality and length. METHOD An online cross-sectional survey, titled 'Radiation therapists and psychosocial support' was developed. Items included patient vignettes, embedded items from RT research, and the Professional Quality of Life Scale (ProQOL5). Four radiation oncology departments volunteered to pilot the survey; each nominated four RT staff to participate. Survey data were analysed descriptively and qualitative feedback grouped and coded to determine whether the survey needed to be refined. RESULTS Thirteen of sixteen RTs completed the pilot survey and feedback form. Median time to completion was 35 mins, with 54% of respondents stating this was too long. Respondents reported content, questions and response options were relevant and appropriate. Feedback was used to: refine the survey instrument, minimise responder burden and drop out and improve functionality and quality of data collection. CONCLUSION This pilot of the 'Radiation therapists and psychosocial support' survey instrument demonstrated content validity and usability. The main survey will be circulated to a representative sample of RTs for completion.
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Affiliation(s)
- Kelly L. Elsner
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Diana Naehrig
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Georgia K. B. Halkett
- School of Nursing, Midwifery and ParamedicineFaculty of Health SciencesCurtin UniversityPerthWestern AustraliaAustralia
| | - Haryana M. Dhillon
- Centre for Medical Psychology and Evidence‐based Decision‐making, School of PsychologyUniversity of SydneySydneyNew South WalesAustralia
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15
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Building psychosocial capacity through training of front-line health professionals to provide brief therapy: lessons learned from the PROMPT study. Support Care Cancer 2017; 26:1105-1112. [DOI: 10.1007/s00520-017-3929-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
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16
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Caminiti C, Iezzi E, Passalacqua R. Effectiveness of the HuCare Quality Improvement Strategy on health-related quality of life in patients with cancer: study protocol of a stepped-wedge cluster randomised controlled trial (HuCare2 study). BMJ Open 2017; 7:e016347. [PMID: 28988170 PMCID: PMC5640062 DOI: 10.1136/bmjopen-2017-016347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Our group previously demonstrated the feasibility of the HuCare Quality Improvement Strategy (HQIS), aimed at integrating into practice six psychosocial interventions recommended by international guidelines. This trial will assess whether the introduction of the strategy in oncology wards improves patient's health-related quality of life (HRQoL). METHODS AND ANALYSIS Multicentre, incomplete stepped-wedge cluster randomised controlled trial, conducted in three clusters of five centres each, in three equally spaced time epochs. The study also includes an initial epoch when none of the centres are exposed to the intervention, and a final epoch when all centres will have implemented the strategy. The intervention is applied at a cluster level, and assessed at an individual level with cross-sectional model. A total of 720 patients who received a cancer diagnosis in the previous 2 months and about to start medical treatment will be enrolled. The primary aim is to evaluate the effectiveness of the HQIS versus standard care in terms of improvement of at least one of two domains (emotional and social functions) of HRQoL using the EORTC QLQ-C30 (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 items) questionnaire, at baseline and at 3 months. This outcome was chosen because patients with cancer generally exhibit low HRQoL, particularly at certain stages of care, and because it allows to assess the strategy's impact as perceived by patients themselves. The HQIS comprises three phases: (1) clinician training-to improve communication-relational skills and instruct on the project; (2) centre support-four on-site visits by experts of the project team, aimed to boost motivation, help with context analysis and identification of solutions; (3) implementation of Evidence-Based Medicine (EBM) recommendations at the centre. ETHICS AND DISSEMINATION Ethics committee review approval has been obtained from the Ethics Committee of Parma. Results will be disseminated at conferences, and in peer-reviewed and professional journals intended for policymakers and managers. TRIAL REGISTRATION NUMBER NCT03008993; Pre-results.
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Affiliation(s)
- Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, Parma, Italy
| | - Elisa Iezzi
- Research and Innovation Unit, University Hospital of Parma, Parma, Italy
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17
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Elsner K, Naehrig D, Halkett GKB, Dhillon HM. Reduced patient anxiety as a result of radiation therapist-led psychosocial support: a systematic review. J Med Radiat Sci 2017; 64:220-231. [PMID: 28160448 PMCID: PMC5587663 DOI: 10.1002/jmrs.208] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 11/10/2016] [Accepted: 11/17/2016] [Indexed: 11/12/2022] Open
Abstract
Up to 49% of patients attending radiation therapy appointments may experience anxiety and distress. Anxiety is heightened during the first few visits to radiation oncology. Radiation therapists (RT) are the only health professionals in direct daily contact with patients during treatment, placing them in a unique position to explore patients' psychosocial needs. This review aims to synthesise literature regarding the effect of RT-led psychosocial support on patient anxiety. In May 2015, we searched the following electronic databases: Medline, PsycINFO, Embase, CINAHL, PubMed and Cochrane library. Radiation therapy-specific journals were hand-searched, and reference lists of identified studies searched. This review complies with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search identified 263 articles, of which 251 were excluded based on non-English language, duplicate article or relevance. A total of 12 articles involving 1363 patients were included and categorised into three broad themes: 'Patient Perspectives' 3 articles, 'Patient Information and Education' 5 articles and 'Screening and Needs Assessment' 4 articles. Two publications referred to the same sample and data. Quality ratings were mixed, with one study rated 'high' quality, seven 'moderate' and four 'low'. Methodological weaknesses were identified in relation to workflow, sample size and responder bias. RTs have a role in psychosocial support through increased communication and information sharing, which can benefit both patients and staff. RT-led practices such as relationship building, patient education sessions and screening and needs assessments are feasible and can reduce anxiety.
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Affiliation(s)
- Kelly Elsner
- Central Clinical School, Sydney Medical SchoolUniversity of SydneySydneyAustralia
| | - Diana Naehrig
- School of Psychology, Faculty of ScienceUniversity of SydneySydneyAustralia
| | - Georgia K. B. Halkett
- School of Nursing, Midwifery and Paramedicine, Faculty of Health SciencesCurtin UniversityPerthWestern AustraliaAustralia
| | - Haryana M. Dhillon
- School of Psychology, Faculty of ScienceUniversity of SydneySydneyAustralia
- Centre for Medical Psychology and Evidence‐based Decision‐makingUniversity of SydneySydneyAustralia
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18
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Buckland N, Mackenzie L. Exploring the role of occupational therapy in caring for cancer survivors in Australia: A cross sectional study. Aust Occup Ther J 2017; 64:358-368. [DOI: 10.1111/1440-1630.12386] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | - Lynette Mackenzie
- Discipline of Occupational Therapy; University of Sydney; Lidcombe New South Wales Australia
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19
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Cortis LJ, Ward PR, McKinnon RA, Koczwara B. Integrated care in cancer: What is it, how is it used and where are the gaps? A textual narrative literature synthesis. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28426142 DOI: 10.1111/ecc.12689] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 11/30/2022]
Abstract
Integrated care is an underpinning concept of contemporary health care policy proffered as a strategy to overcome the fragmentations in care encountered by people with complex care needs (Shaw et al. [2011] What is Integrated Care? An Overview of Integrated Care in the NHS). Cancer patients have potential to benefit from such policy, often having needs that extend beyond cancer. This paper seeks to understand how the concept of integrated care is used in the cancer literature. A search of leading databases was conducted for original research relating to integrated care or an integration intervention aiming to improve outcomes of cancer patients, and analysed using textual narrative synthesis. 38 papers were included, each with a focus on improving cancer-specific aspects of care enhancing the capabilities of the cancer multidisciplinary team. Of the eight studies involving integration between the cancer service and other care providers, all focused on utilising the external provider to deliver aspects of cancer care or placed them in a passive role, as survey participant, a recipient of cancer-related clinical information or as the comparator "usual care" arm. Within the cancer literature, integration is predominantly used to describe initiatives to improve cancer-related aspects of care. Less attention is given to integration initiatives that enhance coordination across levels of the healthcare system or service providers.
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Affiliation(s)
- L J Cortis
- Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, SA, Australia
| | - P R Ward
- Discipline of Public Health, School of Health Sciences, Flinders University, Adelaide, SA, Australia
| | - R A McKinnon
- Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, SA, Australia
| | - B Koczwara
- Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, SA, Australia
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20
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Lozano-Lozano M, Martín-Martín L, Galiano-Castillo N, Álvarez-Salvago F, Cantarero-Villanueva I, Fernández-Lao C, Sánchez-Salado C, Arroyo-Morales M. Integral strategy to supportive care in breast cancer survivors through occupational therapy and a m-health system: design of a randomized clinical trial. BMC Med Inform Decis Mak 2016; 16:150. [PMID: 27887610 PMCID: PMC5124301 DOI: 10.1186/s12911-016-0394-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/22/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Technological support using e-health mobile applications (m-health) is a promising strategy to improve the adherence to healthy lifestyles in breast cancer survivors (excess in energy intake or low physical activity are determinants of the risk of recurrence, second cancers and cancer mortality). Moreover, cancer rehabilitation programs supervised by health professionals are needed due to the inherent characteristics of these breast cancer patients. Our main objective is to compare the clinical efficacy of a m-health lifestyle intervention system alone versus an integral strategy to improve Quality of Life in breast cancer survivors. METHODS This therapeutic superiority study will use a two-arm, assessor blinded parallel RCT design. Women will be eligible if: they are diagnosed of stage I, II or III-A breast cancer; are between 25 and 75 years old; have a Body Mass Index > 25 kg/m2; they have basic ability to use mobile apps; they had completed adjuvant therapy except for hormone therapy; and they have some functional shoulder limitations. Participants will be randomized to one of the following groups: integral group will use a mobile application (BENECA APP) and will receive a face-to-face rehabilitation (8-weeks); m-health group will use the BENECA app for 2-months and will received usual care information. Study endpoints will be assessed after 8 weeks and 6 months. The primary outcome will be Quality of Life measured by The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core and breast module. The secondary outcomes: body composition; upper-body functionality (handgrip, Disability of the Arm, Shoulder and Hand questionnaire, goniometry); cognitive function (Wechsler Adult Intelligence Scale, Trail Making Test); anxiety and depression (Hospital Anxiety and Depression Scale); physical fitness (Short version of the Minnesota Leisure Time Physical Activity Questionnaire, Self-Efficacy Scale for Physical Activity); accelerometry and lymphedema. DISCUSSION This study has been designed to seek to address the new needs for support and treatment of breast cancer survivors, reflecting the emerging need to merge new low cost treatment options with much-needed involvement of health professionals in this type of patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02817724 (date of registration: 22/06/2016).
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Affiliation(s)
- Mario Lozano-Lozano
- Department Physical Therapy, University of Granada, Granada, Spain.,Mixed University Sport and Health Institute (iMUDS), Granada, Spain
| | | | - Noelia Galiano-Castillo
- Department Physical Therapy, University of Granada, Granada, Spain.,Institute for Biomedical Research ibs.GRANADA, University Hospital Complex of Granada/ University of Granada, Granada, Spain
| | | | - Irene Cantarero-Villanueva
- Department Physical Therapy, University of Granada, Granada, Spain.,Mixed University Sport and Health Institute (iMUDS), Granada, Spain.,Institute for Biomedical Research ibs.GRANADA, University Hospital Complex of Granada/ University of Granada, Granada, Spain
| | - Carolina Fernández-Lao
- Department Physical Therapy, University of Granada, Granada, Spain.,Mixed University Sport and Health Institute (iMUDS), Granada, Spain.,Institute for Biomedical Research ibs.GRANADA, University Hospital Complex of Granada/ University of Granada, Granada, Spain
| | | | - Manuel Arroyo-Morales
- Department Physical Therapy, University of Granada, Granada, Spain. .,Mixed University Sport and Health Institute (iMUDS), Granada, Spain. .,Institute for Biomedical Research ibs.GRANADA, University Hospital Complex of Granada/ University of Granada, Granada, Spain.
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21
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A tiered multidisciplinary approach to the psychosocial care of adult cancer patients integrated into routine care: the PROMPT study (a cluster-randomised controlled trial). Support Care Cancer 2016; 25:17-26. [DOI: 10.1007/s00520-016-3382-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/08/2016] [Indexed: 11/26/2022]
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22
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Sleight AG, Duker LIS. Toward a Broader Role for Occupational Therapy in Supportive Oncology Care. Am J Occup Ther 2016; 70:7004360030p1-8. [PMID: 27295001 PMCID: PMC4904498 DOI: 10.5014/ajot.2016.018101] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Supportive care in oncology helps people cope with cancer and its psychological, physical, and emotional side effects. However, cancer survivors report dissatisfaction with supportive care and a need for more psychosocial and self-management services. Occupational therapy practitioners represent an integral part of the supportive care team because their scope of practice emphasizes function. Through a focus on function, practitioners address the full spectrum of physical and psychosocial care. Currently, conceptualizations of occupational therapy for cancer survivors often focus solely on physical interventions and, therefore, do not represent the unique involvement of the profession in supportive oncology care. We advocate for a focused framework for occupational therapy practitioners in oncology as experts in function and providers of both physical and psychosocial treatments. Barriers to a focus on function are identified, and strategies are suggested for expanding involvement for the profession in supportive oncology care.
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Affiliation(s)
- Alix G Sleight
- Alix G. Sleight, OTD, OTR/L, is PhD Student, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles;
| | - Leah I Stein Duker
- Leah I. Stein Duker, PhD, OTR/L, is Research Assistant Professor, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles
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23
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Bunnell AE, Garby CA, Pearson EJ, Walker SA, Panos LE, Blum JL. The Clinical Utility of Next Generation Sequencing Results in a Community-Based Hereditary Cancer Risk Program. J Genet Couns 2016; 26:105-112. [PMID: 27276934 DOI: 10.1007/s10897-016-9985-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 05/31/2016] [Indexed: 01/07/2023]
Abstract
Since the 2013 Supreme Court ruling on BRCA1/BRCA2 patenting, hereditary cancer gene panels now include BRCA1 and BRCA2, making these panels an option for first-tier testing. However, questions remain about the clinical utility and implications of these panels for medical management with inclusion of genes of unknown to moderate penetrance. To better understand how use of these panels affected our practice, we reviewed patients who underwent testing in our clinic from July 1, 2013 through May 23, 2014. Indications for testing included personal and/or family history of breast and/or ovarian cancer. A total of 136 patients underwent panel testing via a single commercial laboratory; 12 (8.8 %) patients were positive for a pathogenic or likely pathogenic mutation (four BRCA2 mutations, two TP53 mutations, one CDH1 mutation, two ATM mutations, and one patient each with a CHEK2, NBN, or PALB2 mutation). Of these positive patients, 100 % met the National Comprehensive Cancer Network (NCCN) guidelines for Hereditary Breast and Ovarian Cancer genetic testing (2.2014). Mutations in seven of twelve (58 %) patients led to changes in medical management; three of seven (43 %) had a non-BRCA1 or BRCA2 gene mutation. Our findings suggest that there is clinical utility of panels that include genes of unknown to moderate penetrance.
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Affiliation(s)
- A E Bunnell
- Baylor Charles A. Sammons Cancer Center, Baylor University Medical Center, 3410 Worth St, Dallas, TX, 75248, USA
| | - C A Garby
- Baylor Charles A. Sammons Cancer Center, Baylor University Medical Center, 3410 Worth St, Dallas, TX, 75248, USA
| | - E J Pearson
- Baylor Charles A. Sammons Cancer Center, Baylor University Medical Center, 3410 Worth St, Dallas, TX, 75248, USA
| | - S A Walker
- Baylor Charles A. Sammons Cancer Center, Baylor University Medical Center, 3410 Worth St, Dallas, TX, 75248, USA
| | - L E Panos
- Ambry Genetic Laboratories, Aliso Viejo, CA, 92656, USA
| | - Joanne L Blum
- Baylor Charles A. Sammons Cancer Center, Baylor University Medical Center, 3410 Worth St, Dallas, TX, 75248, USA. .,Texas Oncology, Baylor Charles A. Sammons Cancer Center, 3410 Worth St, Dallas, TX, 75248, USA.
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Barker D, McElduff P, D'Este C, Campbell MJ. Stepped wedge cluster randomised trials: a review of the statistical methodology used and available. BMC Med Res Methodol 2016; 16:69. [PMID: 27267471 PMCID: PMC4895892 DOI: 10.1186/s12874-016-0176-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials. METHODS Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design. RESULTS This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used. CONCLUSIONS Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.
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Affiliation(s)
- D Barker
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - P McElduff
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - C D'Este
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, 0200, Australia
| | - M J Campbell
- Medical Statistics Group, ScHARR, University of Sheffield, Sheffield, UK
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Yates P. Innovative and Pragmatic Research Designs Are Critical to Advance Nursing Science. Cancer Nurs 2016; 39:251-2. [PMID: 27081921 DOI: 10.1097/ncc.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Patsy Yates
- Author Affiliation: School of Nursing and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Australia
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Brebach R, Sharpe L, Costa DSJ, Rhodes P, Butow P. Psychological intervention targeting distress for cancer patients: a meta-analytic study investigating uptake and adherence. Psychooncology 2016; 25:882-90. [PMID: 26893285 DOI: 10.1002/pon.4099] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 01/18/2016] [Accepted: 01/18/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Although cancer care guidelines recommend screening for distress among cancer patients and offering psychological support when indicated, many patients decline offers of such support. This study aimed to quantify uptake and adherence to psychological support and to identify predictors of each. METHODS Searches were conducted in Embase, Medline, PsychInfo and Scopus to identify studies reporting uptake or adherence rates for individual psychological interventions targeting distress, anxiety or depression for cancer patients or survivors. RESULTS Across the 53 included studies reporting uptake and/or adherence rates for 12 323 cancer patients, the uptake and adherence rates were 60.1% and 90.4%, respectively. Patients screened and identified as distressed were less likely to accept intervention than unselected patients (50.3% compared with 66.3%, Q(1) = 4.66, P = 0.031). Uptake of therapy was higher for interventions delivered by telephone rather than face-to-face (71.2% compared with 53.8%, Q(1) = 4.91, P = 0.027) and when therapy was offered prior to medical treatment compared with later (72.9% compared with 56.8%, Q(1) = 5.60, P = 0.018). Patients were more likely to accept intervention from nurses than other allied health professionals (68.3% compared with 50.5%, Q(1) = 5.76, P = 0.016). CONCLUSIONS Patients appeared more receptive to interventions offered near diagnosis, over the telephone and by nurses. Although this suggests higher acceptability of such interventions, evidence of their greater efficacy is lacking, and this merits further investigation. Research is needed to understand barriers to acceptance of psychological support, particularly because uptake rates were lower for distressed patients. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Rachel Brebach
- School of Psychology, The University of Sydney, Sydney, New South Wales, Australia
| | - Louise Sharpe
- School of Psychology, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel S J Costa
- School of Psychology, The University of Sydney, Sydney, New South Wales, Australia
| | - Paul Rhodes
- School of Psychology, The University of Sydney, Sydney, New South Wales, Australia
| | - Phyllis Butow
- School of Psychology, The University of Sydney, Sydney, New South Wales, Australia.,PoCoG & CeMPED, School of Psychology, The University of Sydney, Sydney, New South Wales, Australia.,SoURCe, Institute of Surgery, Sydney, New South Wales, Australia
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Fitch MI, Maamoun J. Besoins en soins de soutien non comblés et désir de recevoir de l’aide de patients recevant de la radiothérapie : répercussions sur l’infirmière en oncologie. Can Oncol Nurs J 2016; 26:60-67. [PMID: 31148694 DOI: 10.5737/236880762616067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Margaret I Fitch
- Professeure, Faculté des sciences infirmières, Université de Toronto, Toronto, ON Courriel:
| | - John Maamoun
- Radiothérapeute, Service de radiothérapie, Centre de cancérologie Odette, Centre des sciences de la santé Sunnybrook, Toronto, ON
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Fitch MI, Maamoun J. Unmet supportive care needs and desire for assistance in patients receiving radiation treatment: Implications for oncology nursing. Can Oncol Nurs J 2016; 26:53-59. [PMID: 31148742 DOI: 10.5737/236880762615359] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Unmet supportive care needs can contribute to emotional distress and reduced quality of life for cancer patients. We undertook a supportive care needs assessment for patients undergoing radiation therapy to provide a basis for program planning. A self-report supportive care needs survey was completed by a convenience sample of 115 patients on days five, seven and 16 during their course of radiation. The most frequently identified physical unmet needs at all three times were fatigue (33%-49%), dry and itchy skin (24%-37%), and sleep difficulties (23%-30%). The number of patients citing these unmet needs increased significantly over the study time period. Within the emotional domain, worry (34.5%) was cited most frequently on day five. The number of individuals expressing worry did not decrease significantly by day 16. Across all domains and individual items, there was wide variation in the percentage of individuals who had an unmet need and also indicated they wanted help with that unmet need. This pattern remained consistent over time. This study emphasizes the need for a defined or intentional process to assess supportive care needs and patient desire for assistance or help with unmet needs.
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Affiliation(s)
- Margaret I Fitch
- Professor, Faculty of Nursing, University of Toronto, Toronto, ON,
| | - John Maamoun
- Radiation Therapist, Department of Radiation Therapy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
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Beard E, Lewis JJ, Copas A, Davey C, Osrin D, Baio G, Thompson JA, Fielding KL, Omar RZ, Ononge S, Hargreaves J, Prost A. Stepped wedge randomised controlled trials: systematic review of studies published between 2010 and 2014. Trials 2015; 16:353. [PMID: 26278881 PMCID: PMC4538902 DOI: 10.1186/s13063-015-0839-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/01/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In a stepped wedge, cluster randomised trial, clusters receive the intervention at different time points, and the order in which they received it is randomised. Previous systematic reviews of stepped wedge trials have documented a steady rise in their use between 1987 and 2010, which was attributed to the design's perceived logistical and analytical advantages. However, the interventions included in these systematic reviews were often poorly reported and did not adequately describe the analysis and/or methodology used. Since 2010, a number of additional stepped wedge trials have been published. This article aims to update previous systematic reviews, and consider what interventions were tested and the rationale given for using a stepped wedge design. METHODS We searched PubMed, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Web of Science, the Cochrane Library and the Current Controlled Trials Register for articles published between January 2010 and May 2014. We considered stepped wedge randomised controlled trials in all fields of research. We independently extracted data from retrieved articles and reviewed them. Interventions were then coded using the functions specified by the Behaviour Change Wheel, and for behaviour change techniques using a validated taxonomy. RESULTS Our review identified 37 stepped wedge trials, reported in 10 articles presenting trial results, one conference abstract, 21 protocol or study design articles and five trial registrations. These were mostly conducted in developed countries (n = 30), and within healthcare organisations (n = 28). A total of 33 of the interventions were educationally based, with the most commonly used behaviour change techniques being 'instruction on how to perform a behaviour' (n = 32) and 'persuasive source' (n = 25). Authors gave a wide range of reasons for the use of the stepped wedge trial design, including ethical considerations, logistical, financial and methodological. The adequacy of reporting varied across studies: many did not provide sufficient detail regarding the methodology or calculation of the required sample size. CONCLUSIONS The popularity of stepped wedge trials has increased since 2010, predominantly in high-income countries. However, there is a need for further guidance on their reporting and analysis.
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Affiliation(s)
- Emma Beard
- Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - James J Lewis
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Andrew Copas
- MRC Clinical Trials Unit at University College London, 175 Tottenham Court Road, London, W1T 7NU, UK.
| | - Calum Davey
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Gianluca Baio
- Department of Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Jennifer A Thompson
- MRC Clinical Trials Unit at University College London, 175 Tottenham Court Road, London, W1T 7NU, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Katherine L Fielding
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Rumana Z Omar
- Department of Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
| | - James Hargreaves
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Audrey Prost
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
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Turner J. The changing landscape of cancer care - the impact of psychosocial clinical practice guidelines. Psychooncology 2015; 24:365-70. [DOI: 10.1002/pon.3803] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Jane Turner
- University of Queensland; Brisbane Australia
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31
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Ulrich CM. Who am I? Reflections on self-image among patients with cancer in clinical trials. Clin J Oncol Nurs 2015; 17:E68-70. [PMID: 24305493 DOI: 10.1188/13.cjon.e68-e70] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with cancer who participate in research face difficult challenges. Their lives change in many ways, and they often question their self-image. Self-image includes how patients see themselves and who they want to become. The current commentary addresses the issue of self-image in patients with cancer who participate in clinical trials and how their sense of who they were changes as they shift from patients with cancer to research participants. Patients with cancer who participate in research may suffer from multiple identity transitions, ranging from physical alterations in appearance and bodily capabilities to psychological burdens of job loss and the inability to contribute financially to their families. The author aims to provide insight as to how researchers can help patients find meaning in their lives during the process of participation in clinical trials as they undergo identity transitions.
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Affiliation(s)
- Connie M Ulrich
- New Courtland Center for Transitions and Health, University of Pennsylvania in Philadelphia
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Dilworth S, Higgins I, Parker V, Kelly B, Turner J. Patient and health professional's perceived barriers to the delivery of psychosocial care to adults with cancer: a systematic review. Psychooncology 2014; 23:601-12. [PMID: 24519814 DOI: 10.1002/pon.3474] [Citation(s) in RCA: 174] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 11/29/2013] [Accepted: 12/10/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To explore the barriers experienced and perceived by health professionals and patients in the delivery of psychosocial care to adults with cancer. METHODS Systematic searches were undertaken using the PsychInfo, Medline and CINAHL electronic databases, up to October 2013. Research reporting health professional or patient experiences and perceptions of barriers to psychosocial care are included in the review. The systematic review includes studies that have non-experimental, exploratory and observational designs, as is appropriate to answer the review question. Included studies were critically appraised. The results of individual quantitative studies were aggregated. Qualitative content analysis was used to analyse the qualitative results. RESULTS Twenty-five papers met the pre-specified inclusion criteria for the final review. The most commonly perceived barrier for patients relates to receiving adequate support from elsewhere and a lack of perceived need for psychosocial care. Health professionals report barriers at an organisational level most frequently followed by cultural and then individual clinician-related barriers. CONCLUSIONS Barriers exist on a variety of levels. People with cancer need clear appropriate information and communication about psychosocial services, including information about the role of psychosocial care in addition to existing supports. Interventions that target the complex interplay of individual, organisational and cultural factors need to be developed. Strategies that improve health professional communication skills, identify clear referral pathways, improve acceptability of interventions and clearly identify the need for services could address many of the barriers identified in this review.
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Affiliation(s)
- Sophie Dilworth
- School of Nursing and Midwifery, University of Newcastle, Callaghan, Australia
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Maheu C, Bouhnik AD, Nogues C, Mouret-Fourme E, Stoppa-Lyonnet D, Lasset C, Berthet P, Fricker JP, Caron O, Luporsi E, Gladieff L, Julian-Reynier C. Which factors predict proposal and uptake of psychological counselling after BRCA1/2 test result disclosure? Psychooncology 2013; 23:420-7. [DOI: 10.1002/pon.3435] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 09/19/2013] [Accepted: 09/22/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Christine Maheu
- INSERM; UMR912; Marseille France
- Aix-Marseille Université; UMR912; Marseille France
- IRD; UMR912; Marseille France
- McGill University; Montreal Canada
| | - Anne-Deborah Bouhnik
- INSERM; UMR912; Marseille France
- Aix-Marseille Université; UMR912; Marseille France
- IRD; UMR912; Marseille France
| | - Catherine Nogues
- Hôpital René Huguenin; Saint Cloud France
- Institut Curie; Paris France
| | | | | | | | | | | | | | | | | | - Claire Julian-Reynier
- INSERM; UMR912; Marseille France
- Aix-Marseille Université; UMR912; Marseille France
- IRD; UMR912; Marseille France
- Institut Paoli-Calmettes; UMR912; Marseille France
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Maamoun J, Fitch MI, Di Prospero L. The Evaluation of a New Supportive Care Screening Tool for Radiation Therapy Patients. J Med Imaging Radiat Sci 2013; 44:141-149. [PMID: 31052038 DOI: 10.1016/j.jmir.2013.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 02/28/2013] [Accepted: 03/11/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Individuals undergoing radiation therapy for cancer may experience a wide range of supportive care needs that are frequently not addressed. A screening tool was designed and tested for psychometric properties (technical characteristics) to assist radiation therapists to quickly identify those patients who require additional intervention during the course of their radiation treatment, allowing early and timely referral and facilitating the provision of quality, in-depth, and patient-centred supportive care. METHODOLOGY A comprehensive and itemized screening tool was designed to identify the patient concerns and distress level, capture the patient desire to be helped with specific concerns, and inform the centre of alternative help provided. The tool was administered simultaneously with the standardized instrument quality-of-life questionnaire. One hundred and fifteen radiation therapy patients completed both instruments on three occasions; the first two were 2 days apart, and the third, 2 weeks later. To test the new tool for reliability and sensitivity, the agreement between the responses on the first two occasions and those between the first and third occasions were analysed for both instruments. Correlations between the responses on the two instruments were also examined for concurrent validity. RESULTS McNemar's test and the simple kappa coefficient both showed high agreement between item scores on the new screening tool when the first and the second occasions were compared. When the first and the third occasions were compared, the former test showed a shift from high agreement to lesser agreement across the item scores. The latter showed a shift in more than 97.7% of the items from a higher agreement to a lesser agreement. The new tool's sensitivity to change was further reinforced by the data from the validated quality-of-life questionnaire, which showed a similar change over time; the Pearson product moment correlation coefficient fell on average from 0.75 to 0.58 for the first and the second comparisons respectively, with all P values less than .0001. Concurrent validity was found to be acceptable. CONCLUSIONS The new screening tool was found to be reliable and sensitive, with acceptable validity. It is anticipated that the screening intervention will allow radiation therapists to standardize and formalize their approach to supportive care in radiation therapy outpatient clinics and enhance their capacity to identify and address patient concerns in a timely manner.
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Affiliation(s)
- John Maamoun
- Department of Radiation Therapy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| | - Margaret I Fitch
- Department of Oncology Nursing, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Di Prospero
- Department of Radiation Therapy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Cancer distress screening data: Translating knowledge into clinical action for a quality response. Palliat Support Care 2013; 12:39-51. [PMID: 23942274 DOI: 10.1017/s1478951513000382] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectives:The purpose of this paper is to summarize the use of the knowledge to action framework for adapting guidelines for practice and the evidence for effective implementation interventions to promote a quality response to cancer distress screening data.Methods:We summarize progress in screening implementation in Ontario, Canada and the application of a systematic approach for adapting knowledge to practice and use of evidence-based knowledge translation interventions to ensure the uptake of best practices to manage distress.Results:While significant progress has been made in the uptake of distress screening it is less clear if this has resulted in improvements in patient outcomes, i.e., reduced distress. The use of evidence-based knowledge translation strategies tailored to barriers at many levels of care delivery is critical to facilitate the uptake of distress screening data by the primary oncology team.Significance of results:There is a wealth of knowledge about the approaches that can be applied to translate knowledge into practice to improve psychosocial care and promote evidence-based distress management by the primary care oncology team. However, further implementation research is needed to advance knowledge about the most effective strategies in the context of cancer care.
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Dilworth S, Higgins I, Parker V, Kelly B, Turner J. Examining clinical supervision as a mechanism for changes in practice: a research protocol. J Adv Nurs 2013; 70:421-30. [PMID: 23865463 DOI: 10.1111/jan.12211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2013] [Indexed: 11/26/2022]
Abstract
AIM This paper describes the research protocol for a study exploring if and how clinical supervision facilitates change in practice relating to psychosocial aspects of care for Health Professionals, who have been trained to deliver a psychosocial intervention to adults with cancer. BACKGROUND There is a recognized need to implement care that is in line with clinical practice guidelines for the psychosocial care of adults with cancer. Clinical supervision is recommended as a means to support Health Professionals in providing the recommended psychosocial care. DESIGN A qualitative design embedded within an experimental, stepped wedge randomized control trial. METHODS The study will use discourse analysis to analyse audio-recorded data collected in clinical supervision sessions that are being delivered as one element of a large randomized control trial. The sessions will be attended primarily by nurses, but including physiotherapists, radiation therapists, occupational therapists. The Health Professionals are participants in a randomized control trial designed to reduce anxiety and depression of distressed adults with cancer. The sessions will be facilitated by psychiatrists experienced in psycho-oncology and the provision of clinical supervision. DISCUSSION The proposed research is designed specifically to facilitate exploration of the mechanisms by which clinical supervision enables Health Professionals to deliver a brief, tailored psychosocial intervention in the context of their everyday practice. This is the first study to use discourse analysis embedded within an experimental randomized control trial to explore the mechanisms of change generated within clinical supervision by analysing the discourse within the clinical supervision sessions.
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Affiliation(s)
- Sophie Dilworth
- School of Nursing and Midwifery, University of Newcastle, Callahan, New South Wales, Australia
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The benefits of psychosocial interventions for cancer patients undergoing radiotherapy. Health Qual Life Outcomes 2013; 11:121. [PMID: 23866850 PMCID: PMC3721996 DOI: 10.1186/1477-7525-11-121] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 07/08/2013] [Indexed: 01/04/2023] Open
Abstract
Background Many patients with cancer experience depression and anxiety, and an associated decrease in quality of life (QOL) during radiation therapy (RT). The main objective of the study was to determine the benefits of psychosocial interventions for cancer patients who received RT. Methods Patients with cancer (n = 178) who agreed to participate in the study were randomized to the intervention arm (n = 89) or the control arm (n = 89). Patients in the intervention group received psychosocial care during RT, whereas the control group received RT only. The benefits of the intervention were evaluated using the Zung Self-rating Depression Scale (SDS) to measure depression, the Self-rating Anxiety Scale (SAS) to assess anxiety, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) to survey health-related QOL. The association between intervention and survival was also assessed. Results Patients randomly assigned to the intervention arm showed significant improvements on symptoms of depression (p < 0.05) and anxiety (p < 0.05), health-related QOL (p < 0.05) (i.e. better global health status, and physical and emotional functioning, and less insomnia) when compared with controls. In the subset analysis, female patients, those that received high dose irradiation, and those that underwent adjuvant chemotherapy could benefit more from psychosocial intervention. There was no difference between the two groups in disease-free survival (DFS) (2-year DFS 79.8% in the intervention arm and 76.4% in the control arm; p = 0.527) and overall survival (OS) (2-year OS 83.1% in the intervention arm and 84.3% in the control arm; p = 0.925) Conclusions Psychosocial intervention is a cost-effective approach that can improve a patient’s mood and QOL both during and after RT. However, the intervention was not found to reduce the risk of cancer recurrence and death. Trial registration ChiCTR-TRC-12002438
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Training oncology and palliative care clinical nurse specialists in psychological skills: evaluation of a pilot study. Palliat Support Care 2013; 13:537-42. [PMID: 23759219 DOI: 10.1017/s1478951513000163] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE National guidelines in the United Kingdom recommend training Clinical Nurse Specialists in psychological skills to improve the assessment and intervention with psychological problems experienced by people with a cancer diagnosis (National Institute for Health and Clinical Excellence, 2004). This pilot study evaluated a three-day training program combined with supervision sessions from Clinical Psychologists that focused on developing skills in psychological assessment and intervention for common problems experienced by people with cancer. METHODS Questionnaires were developed to measure participants' levels of confidence in 15 competencies of psychological skills. Participants completed these prior to the program and on completion of the program. Summative evaluation was undertaken and results were compared. In addition, a focus group interview provided qualitative data of participants' experiences of the structure, process, and outcomes of the program. RESULTS Following the program, participants rated their confidence in psychological assessment and skills associated with providing psychological support as having increased in all areas. This included improved knowledge of psychological theories, skills in assessment and intervention and accessing and using supervision appropriately. The largest increase was in providing psycho-education to support the coping strategies of patients and carers. Thematic analysis of interview data identified two main themes including learning experiences and program enhancements. The significance of the clinical supervision sessions as key learning opportunities, achieved through the development of a community of practice, emerged. SIGNIFICANCE OF RESULTS Although this pilot study has limitations, the results suggest that a combined teaching and supervision program is effective in improving Clinical Nurse Specialists' confidence level in specific psychological skills. Participants' experiences highlighted suggestions for refinement and development of the program. Opportunities for further research and developments in this area are discussed.
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Schofield P, Ugalde A, Gough K, Reece J, Krishnasamy M, Carey M, Ball D, Aranda S. A tailored, supportive care intervention using systematic assessment designed for people with inoperable lung cancer: a randomised controlled trial. Psychooncology 2013; 22:2445-53. [PMID: 23733720 DOI: 10.1002/pon.3306] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 03/27/2013] [Accepted: 04/22/2013] [Indexed: 11/12/2022]
Abstract
OBJECTIVE People with inoperable lung cancer experience higher levels of distress, more unmet needs and symptoms than other cancer patients. There is an urgent need to test innovative approaches to improve psychosocial and symptom outcomes in this group. This study tested the hypothesis that a tailored, multidisciplinary supportive care programme based on systematic needs assessment would reduce perceived unmet needs and distress and improve quality of life. METHODS A randomised controlled trial design was used. The tailored intervention comprised two sessions at treatment commencement and completion. Sessions included a self-completed needs assessment, active listening, self-care education and communication of unmet psychosocial and symptom needs to the multidisciplinary team for management and referral. Outcomes were assessed with the Needs Assessment for Advanced Lung Cancer Patients, Hospital Anxiety and Depression Scale, Distress Thermometer and European Organization of Research and Treatment of Cancer Quality of Life Q-C30 V2.0. RESULTS One hundred and eight patients with a diagnosis of inoperable lung or pleural cancer (including mesothelioma) were recruited from a specialist facility before the trial closed prematurely (original target 200). None of the primary contrasts of interest were significant (all p > 0.10), although change score analysis indicated a relative benefit from the intervention for unmet symptom needs at 8 and 12 weeks post-assessment (effect size = 0.55 and 0.40, respectively). CONCLUSION Although a novel approach, the hypothesis that the intervention would benefit perceived unmet needs, psychological morbidity, distress and health-related quality of life was not supported overall.
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Affiliation(s)
- Penelope Schofield
- Department of Cancer Experiences Research, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia; School of Behavioural Science, The University of Melbourne, Parkville, Australia; School of Nursing, The University of Melbourne, Parkville, Australia
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Abbott Y, Shah NR, Ward KK, McHale MT, Alvarez EA, Saenz CC, Plaxe SC. Use of psychosocial services increases after a social worker-mediated intervention in gynecology oncology patients. HEALTH & SOCIAL WORK 2013; 38:113-121. [PMID: 23865288 DOI: 10.1093/hsw/hlt006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The purpose of this study was to determine whether the introduction of psychosocial services to gynecologic oncology outpatients by a social worker increases service use. During the initial six weeks (phase I), patients were referred for psychosocial services by clinic staff. During the second six weeks (phase II), a nurse introduced available services to each patient with a brochure. During the final 12 weeks (phase III), a social worker introduced services to each patient. The authors then compared psychosocial service referral rates. The sample included 196 patients. During phase III, the probability of a patient-initiated referral increased 3.4-fold (95 percent confidence interval [CI] [1.1, 10.4], p = .04) compared with baseline; the probability of any referral rose 2.7-fold (95 percent CI [1.1, 6.3], p = .03). The mean time to referral decreased from 79.4 days at baseline to 3.9 days during phase III (p < .001). The phase III intervention was accomplished only in 34 patients (39 percent) because of scheduling conflicts. Of these, eight requested referral, resulting in a 24 percent patient-initiated referral rate after meeting with a social worker. The introduction of psychosocial services by a social worker to gynecologic oncology outpatients increases referral rates and expedites evaluation.
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Affiliation(s)
- Yuko Abbott
- Department of Reproductive Medicine, University of California, San Diego, Moores Cancer Center, La Jolla, CA 92093, USA
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O'Hea EL, Cutillo A, Dietzen L, Harralson T, Grissom G, Person S, Boudreaux ED. Randomized controlled trial to test a computerized psychosocial cancer assessment and referral program: methods and research design. Contemp Clin Trials 2013; 35:15-24. [PMID: 23395772 DOI: 10.1016/j.cct.2013.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 01/22/2013] [Accepted: 02/01/2013] [Indexed: 11/30/2022]
Abstract
The National Cancer Coalition Network, National Cancer Institute, and American College of Surgeons all emphasize the need for oncology providers to identify, address, and monitor psychosocial needs of their patients. The Mental Health Assessment and Dynamic Referral for Oncology (MHADRO) is a patient-driven, computerized, psychosocial assessment that identifies, addresses, and monitors physical, psychological, and social issues faced by oncology patients. This paper presents the methodology of a randomized controlled trial (RCT) that tested the impact of the MHADRO on patient outcomes at 2, 6, and 12 months. Patient outcomes including overall psychological distress, depression, anxiety, functional disability, and use of psychosocial resources will be presented in future publications after all follow-up data is gathered. Eight hundred and thirty six cancer patients with heterogeneous diagnoses, across three comprehensive cancer centers in different parts of the United States, were randomized to the MHADRO (intervention) or an assessment-only control group. Patients in the intervention group were provided detailed, personalized reports and, when needed, referrals to mental health services; their oncology provider received detailed reports designed to foster clinical decision making. Those patients who demonstrated high levels of psychosocial problems were given the option to authorize that a copy of their report be sent electronically to a "best match" mental health professional. Demographic and patient cancer-related data as well as comparisons between patients who were enrolled and those who declined enrollment are presented. Challenges encountered during the RCT and strategies used to address them are discussed.
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Affiliation(s)
- Erin L O'Hea
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, United States
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Griffiths P, Richardson A, Blackwell R. Outcomes sensitive to nursing service quality in ambulatory cancer chemotherapy: Systematic scoping review. Eur J Oncol Nurs 2012; 16:238-46. [DOI: 10.1016/j.ejon.2011.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 05/31/2011] [Accepted: 06/12/2011] [Indexed: 11/29/2022]
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