Supportive care for women with gynecologic cancers

Living Well: Protocol for a web-based program to improve quality of life in rural and urban ovarian cancer survivors

BACKGROUND

Ovarian cancer (OC) survivors commonly experience chronic symptoms including anxiety, depression, sleep disturbances, fatigue, physical symptoms, poor health-related quality of life (HRQOL), and a generally poor prognosis. Additionally, factors such as social isolation, stress, and depression are associated with key biological processes promoting tumor progression and poorer survival. Accessible psychosocial interventions to improve HRQOL and clinical outcomes are needed. This need is particularly true in rural settings where survivors may have less access to clinic-based support systems.

METHODS

The Living Well Study, a cluster-randomized Phase II multi-site clinical trial, is designed to evaluate the efficacy of a group-based, web-delivered psychosocial intervention (Mindful Living) verses a Health Promotion active control (Healthy Lifestyles) in increasing HRQOL and decreasing perceived stress (primary outcomes), depressive mood, anxiety, and fatigue (secondary outcomes) for 256 OC survivors who are <5 years post-primary therapy. Mindful Living targets key concerns of OC survivors and teaches stress reduction skills and coping strategies utilizing cognitive behavioral, mindfulness, and acceptance and commitment therapies. Healthy Lifestyles provides lifestyle information including exercise, nutrition, sleep, and other survivorship topics. Interventions consist of 11 consecutive weekly group sessions lasting 1.5-2 h led by trained facilitators and two booster sessions. Participants complete psychosocial questionnaires at baseline, post-intervention, at 6-months, and at 12-months. A subset completes bloodspots for analysis of inflammatory biology.

CONCLUSION

Easily accessible psychosocial interventions addressing key concerns of OC survivors are an unmet need. The Mindful Living intervention has the potential to substantially enhance HRQOL and decrease distress in OC survivors. Trial registrationclinicaltrials.gov Identifier: NCT04533763.

Vulvar Carcinoma: Standard of Care and Perspectives

PURPOSE

Treatment of vulvar carcinoma (VC) is challenging. The objectives of this review were to describe for clinicians the epidemiologic and clinical aspects of VC, the standard of care in terms of primary local treatment and systemic therapies, and the recent innovations and perspectives emerging from translational research in immuno-oncology.

DESIGN

We conducted a comprehensive review outlying the clinical aspects and biologic background of vulvar cancer, highlighting modern treatment strategies on the basis of a personalized approach.

RESULTS

Epidemiologic data showed a recent rise in incidence of VC, attributed to human papillomavirus. Surgery is the mainstay of primary treatment, but multimodal approaches are frequently required in the presence of adverse prognosis histopathologic factors. Chemoradiation is indicated when organ-sparing surgery is not feasible. However, inability to achieve high locoregional control rates in advanced cases and the morbidity associated with local treatments are still key issues. Recent clinical data showed the benefit of individualized strategies combining organ-sparing surgical strategies, less invasive lymph node staging procedures, and refinement in radiotherapy modalities. Among the most important research area, there is a sound rationale for testing modern systemic approaches such as immune checkpoint inhibitors in selected patients with recurrent and/or metastatic tumors. Although no specific data exist for VC, the role of supportive care and post-treatment rehabilitation strategies is also crucial.

CONCLUSION

There are still insufficient studies dedicated to patients with VC. Public health programs for prevention, screening, and early diagnosis are required, and clinical research should be strengthened to provide high-quality clinical evidence and improve patients' oncologic and functional outcomes.

Self-reported distress and problems after treatment for gynecological cancer - Correlation between a short screening tool and longer measures of anxiety/depression and health-related quality of life

INTRODUCTION

The National Comprehensive Cancer Network (NCCN) distress thermometer and problem list (DTPL) is a brief self-report screening measure for use in follow-up cancer care. The aims of this study were to explore the correlations between scores on the DTPL and scores on longer measures of anxiety/depression and health-related quality of life among women treated for gynecological cancer, and to define a cutoff score on the DT representing high levels of psychological distress in this patient group.

MATERIAL AND METHODS

During outpatient visits, 144 women filled in the DTPL, the Hospital Anxiety and Depression Scale (HADS) and the RAND-36-Item Short Form Health Survey (RAND-36) between October 2019 and March 2020. We assessed the agreement between the DT-scores and the HADS scores, explored variables associated with high levels of distress on the DT, and studied the associations between DTPL-scores and scores of health-related quality of life (HRQoL) from RAND-36.

RESULTS

In receiver operating characteristic curve analysis between the distress score from the DT and a HADS total score ≥15 (defining high levels of anxiety/depression symptoms), the area under the curve was 0.81 (95% CI: 0.74-0.89). Using a cutoff of ≥5 on the DT (scale 0-10), we found a balanced level of sensitivity (81%) and specificity (71%) towards a HADS total score of ≥15. The scores of distress and problems reported on the DTPL correlated significantly with the majority of HRQoL function scales from RAND-36.

CONCLUSIONS

The NCCN DTPL can be used as a screening measure for self-reported distress and problems after treatment for gynecological cancer. A score of ≥5 on DT may indicate high level of anxiety/depression as measured by HADS. The tool may help identify patients in need of referral to supportive care and rehabilitation facilities.

MASCC multidisciplinary evidence-based recommendations for the management of malignant bowel obstruction in advanced cancer

PURPOSE

To provide evidence-based recommendations on the management of malignant bowel obstruction (MBO) for patients with advanced cancer.

METHODS

The Multinational Association for Supportive Care in Cancer (MASCC) MBO study group conducted a systematic review of databases (inception to March 2021) to identify studies about patients with advanced cancer and MBO that reported on the following outcomes: symptom management, bowel obstruction resolution, prognosis, overall survival, and quality of life. The review was restricted to studies published in English, but no restrictions were placed on publication year, country, and study type. As per the MASCC Guidelines Policy, the findings were synthesized to determine the levels of evidence to support each MBO intervention and, ultimately, the graded recommendations and suggestions.

RESULTS

The systematic review identified 17,656 published studies and 397 selected for the guidelines. The MASCC study group developed a total of 25 evidence-based suggestions and recommendations about the management of MBO-related nausea and vomiting, bowel movements, pain, inflammation, bowel decompression, and nutrition. Expert consensus-based guidance about advanced care planning and psychosocial support is also provided.

CONCLUSION

This MASCC Guideline provides comprehensive, evidence-based recommendations about MBO management for patients with advanced cancer.

Distress, problems and unmet rehabilitation needs after treatment for gynecological cancer

INTRODUCTION

The prevalence of distress, problems and need for rehabilitation among women treated for gynecological cancer is largely unknown. The aims of this study were to examine the prevalence of distress, problems and unmet rehabilitation needs in the first years after treatment for gynecological cancer.

MATERIAL AND METHODS

Women treated for gynecological cancer within the last 2 years were invited. Participants responded to the National Comprehensive Cancer Network Distress Thermometer and Problem List measuring distress and problems. They also answered a questionnaire regarding physical endurance, muscle strength, and need for rehabilitation services.

RESULTS

Of 114 eligible women, 92 (81%) agreed to participate. Mean time since last treatment was 7.6 months (range 0-24.5 months). A total of 57% of the participants reported distress. The four most common problems reported were fatigue (58%), tingling in hands/feet (54%), worry (53%), and problems with memory/concentration (50%). Problems associated with distress were: dealing with partner, all emotional problems (i.e. depression, fears, nervousness, sadness, worry, and loss of interest in usual activities), appearance, memory/concentration, pain, sex, sleep, and problems with physical endurance and muscle strength. Fifty-two per cent reported unmet needs for rehabilitation services. Women with distress reported more unmet rehabilitation needs than those in the non-distressed group.

CONCLUSIONS

The prevalence of distress in this population of women treated for gynecological cancer was high. Having a high number of problems and having unmet needs for rehabilitation services were both associated with distress. Hence, measurement of distress seems to be helpful when assessing the need for rehabilitation services.

Risk factors for developing depression in women with cervical cancer: a nationwide population-based study in Taiwan

Introduction

Depression might affect women with cervical cancer and can deteriorate their quality of life or even their compliance with cancer treatments. The aim of this study was to investigate the incidence of depression and risk factors for developing depression among women with cervical cancer in Taiwan.

Patients and methods

This study enrolled patients with newly diagnosed cervical cancer from the National Health Insurance Research Database in Taiwan. From a population of 21,400,826 residents, each cervical cancer patient was matched with one subject without cervical cancer according to sex, age, and comorbidities with the same diagnostic index. The International Classification of Diseases, Ninth Revision, code 180.9 was used to identify patients with cervical cancer, and 296.0X–296.1X, 296.4X–296.8X, 296.2X–296.3X, 300.4, and 311.X codes were used to identify those with depressive disorders.

Results

In total, 19,316 newly diagnosed cervical cancer patients were enrolled from January 2000 to December 2005, and the median follow-up period was 5.23 years (1.75–8.48 years). The prevalence of depressive disorder was 4.21% (813 of 19,316) in the cervical cancer cohort, and it was 3.85% (744 of 19,316) in the control cohort. The incidence risk ratio of depressive disorders was 1.35 (95% CI =1.22–1.49, P<0.001) among these cervical cancer patients. Cervical cancer, as an independent risk factor, was associated with developing subsequent depressive disorder. In addition, being older (≥65 years old) and the comorbidities of diabetes mellitus, ischemic heart disease, and cerebrovascular disease were also risk factors for predicting depressive disorder in cervical cancer patients.

Discussion

Cervical cancer is a prominent risk factor for the development of depression in women with cervical cancer in Taiwan. The patients with comorbidities, including diabetes mellitus, ischemic heart disease, and cerebrovascular disease, have higher risks of developing depression. However, there were no significant differences among the cervical cancer treatment modalities. In conclusion, these patients require early psychological support and intervention.

Lived experiences and quality of life after gynaecological cancer-An integrative review

Aim and objectives

To review the literature on Nordic women's lived experiences and quality of life (QoL) after gynaecological cancer treatment.

Background

While incidence and survival are increasing in all groups of gynaecological cancers in the Nordic countries, inpatient hospitalisation has become shorter in relation to treatment. This has increased the need for follow‐up and rehabilitation.

Design

Integrative literature review using the Equator PRISMA guidelines.

Methods

The review was selected, allowing inclusion of both experimental and nonexperimental research. The search included peer‐reviewed articles published 1995–2017. To frame the search strategy, we applied the concept of rehabilitation, which holds a holistic perspective on health.

Results

Fifty‐five articles were included and were contextualised within three themes. Physicalwell-being in a changed body encompasses bodily changes comprising menopausal symptoms, a changed sexual life, complications in bowels, urinary tract, lymphoedema and pain, bodily‐based preparedness and fear of recurrence. Mental well-being as a woman deals with questioned womanliness, the experience of revitalised values in life, and challenges of how to come to terms with oneself after cancer treatment. Psychosocial well-being and interaction deals with the importance of having a partner or close person in the process of coming to terms with oneself after cancer. Furthermore, the women needed conversations with health professionals around the process of coping with changes and late effects, including intimate and sensitive issues.

Conclusion

Years after gynaecological cancer, women have to deal with fundamental changes and challenges concerning their physical, mental and psychosocial well‐being. Future research should focus on how follow‐up programmes can be organised to target the multidimensional aspects of women's QoL. Research collaboration across Nordic countries on rehabilitation needs and intervention is timely and welcomed.

Relevance to clinical practice

To ensure that all aspects of cancer rehabilitation are being addressed, we suggest that the individual woman is offered an active role in her follow‐up.

Needs and priorities of women with endometrial and cervical cancer

INTRODUCTION

Rehabilitation after cancer is important, and efficient rehabilitation requires knowledge of patient's needs. This study aimed to identify short-term rehabilitation needs of women with endometrial and cervical cancer.

METHODS

Ninety-six women (82.6%) were included in an exploratory questionnaire study from Odense University Hospital from September 2011 to March 2012. Needs were assessed pre-treatment and 3 months later using the three-levels-of-needs questionnaire. Furthermore, 16 women participated in focus group interviews following the treatment. The interviews were audio-recorded, transcribed verbatim and analyzed thematically.

RESULTS

Forty-four of the included women were diagnosed with cervical cancer (median age 45 years). Of these, 22 had FIGO-stage 1 disease (50%) and 23 received radiation therapy (52.3%). The remaining 52 women (median age 66.5 years) were diagnosed with endometrial cancer. Of these, 38 had FIGO-stage 1 disease (73.1%) and 25 were treated with laparoscopic surgery (48.1%). Emotional functioning was significantly worse prior to treatment in both the cancers (p < 0.001 cervical and p = 0.002 endometrial) and worry constituted an unmet need in 70.7% of cervical and 34.7% of endometrial cancer patients. Both the patient groups experienced significant lymphedema post-treatment [endometrial cancer (p = 0.006) and cervical cancer (p = 0.002)]. Further, urological problems were more prevalent post-treatment in endometrial cancer patients (p = 0.018), while sexual problems were of specific concern for cervical cancer patients (p = 0.029). However, in both cancer groups, the mean problem intensity scores were comparable to normative data, suggesting that the majority of patients will not require extensive rehabilitation. Qualitative analysis indicated that treatment modality and marital status severely impacted on coping, suggesting that irradiated and single women are at higher risk of developing rehabilitation needs. Additionally, women younger than 55 years more often requested help dealing with sexual and psychological complications.

DISCUSSION

Women with endometrial and cervical cancer experience emotional problems prior to therapy and lymphedema, and urological and sexual problems following treatment. An awareness of these problems may facilitate early identification of women with unmet needs and enable individualized follow-up adjusted for such patient's needs. Interventions aimed at improving sexual and psychological functioning should be available.

Quality of life research in endometrial cancer: what is needed to advance progress in this disease site? Methodological considerations from the Gynecologic Cancer InterGroup Symptom Benefit Working Group brainstorming session, Leiden 2012

BACKGROUND

Quality of life (QoL) in endometrial cancer (EC) is understudied. Incorporation of QoL questionnaires and patient-reported outcomes in clinical trials has been inconsistent, and the tools and interpretation of these measures are unfamiliar to most practitioners. In 2012, the Gynecologic Cancer InterGroup Symptom Benefit Working Group convened for a brainstorming collaborative session to address deficiencies and work toward improving the quality and quantity of QoL research in women with EC.

METHODS

Through literature review and international expert contributions, we compiled a comprehensive appraisal of current generic and disease site-specific QoL assessment tools, strengths and weaknesses of these measures, assessment of sexual health, statistical considerations, and an exploration of the unique array of histopathologic and clinical factors that may influence QoL outcomes in women with EC.

RESULTS

This collaborative composition is the first publication specific to EC that addresses methodology in QoL research and the components necessary to achieve high quality QoL data in clinical trials. Future recommendations regarding (1) the incorporation of patient-reported outcomes in all clinical trials in EC, (2) definition of an a priori hypothesis, (3) utilization of validated tools and consideration of new tools corresponding to new therapies or specific symptoms, (4) publication within the same time frame as clinical outcome data, and (5) attempt to correct for disease site-specific potential confounders are presented.

CONCLUSIONS

Improved understanding of methodology in QoL research and an increased undertaking of EC-specific QoL research in clinical trials are imperative if we are to improve outcomes in women with EC.

Coping With Cancer: Examining the Supports Available to Women With Gynecologic Cancer at Saskatoon Cancer Center

Objective

When women are diagnosed and treated for gynecologic cancer, they must find ways to cope. Cancer is both a physically and emotionally challenging disease. This study aims to identify existing coping strategies in women diagnosed with gynecologic cancer throughout their cancer journey and to add to these supports to help women cope with their cancer.

Methods

Women with gynecologic cancer were interviewed individually according to focus group principles during scheduled clinic visits at Saskatoon Cancer Center to identify coping strategies following diagnosis and treatment of cancer. Interviews were used to inform researchers before preparing a survey about coping with cancer. During 8 weeks, women receiving care were surveyed. Questions explored diagnosis, therapy phase, feelings, attitudes, and support.

Results

Sixteen women were interviewed; questionnaires were distributed to 75 women with cervical (20.7%), uterine (22.2%), ovarian (60.3%), and vulvar cancer (1.6%). After diagnosis, the major support was family in 96.8%, and talking helped in 71.4%. All women found their gynecologic oncologist and nurse were easy to talk to/supportive. Only 12.7% attended counseling, 17.5% attended workshops/patient education sessions, and 9.5% attended support groups. Reasons for not receiving supportive counseling were voiced. A small number of alternative therapies tried by 60.3% were deemed helpful in 97.4%. Parking at the cancer center was a stressor in 81%. Participants felt that the Saskatoon gynecologic cancer care team fulfilled their needs emotionally. Patients want information about workshops, support meetings, and other modalities to improve their quality of life during their cancer journey.

Conclusion

Providing better quality and type of available supports may enhance the experience of women following diagnosis and during therapy for cancer and will help women to cope with cancer more effectively.

Use of psychosocial services increases after a social worker-mediated intervention in gynecology oncology patients

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.

Exploring the relationship between physical well-being and healthy lifestyle changes among European- and Latina-American breast and cervical cancer survivors

BACKGROUND

Cancer and its treatments have a lingering and often negative impact on survivors' physical well-being. The physical sequelae impinge on daily functioning and overall HRQOL, and perhaps influence lifestyle changes post-cancer. This study aims to examine: (1) physical well-being items that are associated with low overall health-related quality of life; and (2) the relationship between physical well-being outcomes and healthy lifestyle changes by cancer type.

METHODS

This study employed a cross-sectional design with mixed sampling methods. In total 922 European- (n=452) and Latina-American (n=470) breast (BCS) or cervical cancer survivors (CCS) were recruited from the California Cancer Surveillance Program and Los Angeles area hospital registries. Item responses from survivors in the lowest quartile of total quality of life scores and percentages reflecting low physical well-being levels were calculated.

RESULTS

A statistical approach to individual items provides unique and valuable measurement and clinical information above and beyond physical well-being total scores. Physical well-being item responses varied according to ethnicity, income, and education. BCS and CCS showed different patterns in the relationship between physical well-being items and lifestyle changes. Specifically, exercise was significantly related to physical well-being items for BCS, while diet changes were significantly associated with physical well-being for CCS.

CONCLUSIONS

Results reveal unique correlates of physical well-being items by cancer type, ethnicity, and lifestyle changes. Clinically, this study highlights the need for greater consideration of individual and medical characteristics in developing culturally sensitive and patient responsive interventions to promote healthy lifestyles and improve survivorship outcomes.

Assessment of factors that contribute to decreased quality of life in Gynecologic Oncology Group ovarian cancer trials

BACKGROUND

The objective of this study was to assess which quality-of-life (QOL) line items on the Functional Assessment of Cancer Therapy-Ovarian (FACT-O) were associated with low QOL in women who were receiving chemotherapy for ovarian cancer.

METHODS

Patients with stage III or IV ovarian cancer on Gynecologic Oncology Group Protocols 152 and 172 who underwent primary surgery followed by intravenous paclitaxel and cisplatin completed the FACT-O. The FACT scale includes the 4 domains of physical, functional, social, and emotional well being (PWB, FWB, SWB, EWB, respectively). Women who had overall FACT-O scores in the lowest quartile (Q1) were compared with women in the upper 3 quartiles (Q2-Q4). The proportions of women in each group that selected the 2 worst categories for each item were compared. The level of significance was set at P<.005.

RESULTS

Before Cycle 4, 361 patients (86.4%) provided valid QOL assessments. For PWB, a significantly greater proportion of women in Q1 versus Q2 through Q4 selected the 2 worst categories of several physical symptoms (nausea, pain, feeling ill, and being bothered by the side effects of treatment). For FWB, significant differences included being able to work, being content with the quality of their life, and sleeping well. For EWB, there were significant differences in feeling nervous and worrying about dying. There were virtually no differences between groups in SWB. Low interest in sex was reported by 56% to 88% of all patients (Q1-Q4).

CONCLUSIONS

A large proportion of women with FACT-O scores in the lowest quartile reported problems that potentially were amenable to clinical interventions, such as symptom management and psychosocial support.