New paradigms in planning cancer rehabilitation and survivorship

ePRO-based individual follow-up care for women treated for early breast cancer: impact on service use and workflows

PURPOSE

The increasing population of breast cancer survivors highlights the need to (re)consider how we utilize available services for survivorship care in oncology clinics. Electronic Patient-Reported Outcomes (ePROs) can be used to identify patients' individual care needs and triage them to the right services. We examined the impact on service use, workflow and workload following the introduction of an ePRO-based individual follow-up (PIFU) for women treated for early breast cancer.

METHODS

A multi-method approach was used. In a pilot randomized controlled trial, the use of consultations, telephone calls, and specialist referrals were systematically recorded. Comparison was done between PIFU and standard follow-up care (SFU). Focus group interviews with nurse navigators evaluated the impact on workflow and workload qualitatively.

RESULTS

The 64 women randomized to attend SFU used a mean of 3.8 (95% CI: 3.5-4.1) planned consultations during the 2-year study period compared with a mean of 1.9 consultations (95% CI: 1.4-2.4) for the 60 women randomized to PIFU (P < 0.001). Urgent appointments were more frequent in SFU (mean of 0.47 vs 0.22 per patient, P = 0.03). No statistically significant differences were observed in the use of telephone calls and specialist referrals. The nurse navigators did not experience an increase in their workload, but implementation of PIFU may require a re-structured workflow.

CONCLUSIONS

The ePRO-based individual follow-up could change organization of care and re-allocate services for those in need of it.

IMPLICATIONS FOR CANCER SURVIVORS

ePRO-based individual follow-up could potentially ensure more time for those most in need of face-to-face care.

A Cross-Sectional Study Evaluating Potential Differences in the Need for Cancer Survivorship Care in Relation to Patients' Socioeconomic Status

Background

There seems to be inequity within cancer survivorship care in primary care settings related to gender, shorter education, and early poor health, but there is uncertainty regarding the character of the needs in hospital and in primary care settings and whether there is inequity regarding meeting these needs. This study aims to describe potential differences in needs among patients in hospital and in primary care settings, and to assess the need for survivorship care and rehabilitation in patients with cancer in relation to socioeconomic status.

Methods

In a cross-sectional study including patients in hospital (n = 89) and primary care settings (n = 99), information from needs assessments was linked with population-based data on socioeconomic status via unique personal identification numbers. The association between socioeconomic status and stated needs was analyzed separately for patients in hospital and primary care settings, with adjustment for age and gender.

Results

A total of 90% patients expressed one or more needs in the physical area, 51% in the emotional area, and 40% in the practical area. Patients in primary care expressed more needs than patients in hospital. Men expressed more needs than women in primary care (adjusted odds ratio (OR) (95% confidence interval (CI)): 2.66 (1.04 - 6.79)). The results indicate that higher socioeconomic status is associated with fewer stated needs.

Conclusions

This study suggests that the association between gender and stated needs may depend on healthcare setting and confirms that higher socioeconomic status in relation to civil status, educational level, income, and labor market status is associated with fewer stated needs.

Lung cancer among native and foreign-born Swedes: histopathology, treatment, and survival

BACKGROUND

Lung cancer (LC) is the leading cause of cancer-related death worldwide, including Sweden. Several studies have shown that socioeconomic status affects the risk, treatment, and survival of LC. Due to immigration after Second World War, foreign-born people constitute 12.5% of the Swedish population. We wanted to investigate if there were any differences in LC management, treatment and survival among the foreign-born Swedes (FBS) compared to the native Swedish population (NatS) in Stockholm.

MATERIAL AND METHODS

A retrospective analysis of all patients diagnosed with non-small cell lung cancer (NSCLC) at the Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Solna from 1 January 2003 to 31 December 2008 was made. In all, 2041 cases of LC were diagnosed, thereof 1803 with NSCLC. Of these, 211 (11.7%) were FBS.

RESULTS

The mean age of NatS and FBS patients was 69.9 years, median 70 (range 26-96) and 66.0 years, median 66 (range 38-94), respectively (p < 0.001). In all, 89.8% of NatS and 90.0% of FBS were either smokers or former smokers. Adenocarcinoma was the most common subtype in both groups (NatS 54.7%, FBS 48.3%). In 140 (8.8%) of the NatS and 17 (8.1%) of the FBS the diagnosis was clinical only. There were no significant differences in stage at diagnosis, nor in performance status (PS) or different therapies between the groups. The median overall survival time for the NatS was 272 days and for FBS 328 days, again no significant difference. However, the median overall survival time for female NatS was 318 days and for female FBS 681 days (p = 0.002).

CONCLUSION

FBS patients were significantly younger than NatS at diagnosis, and female FBS lived longer than female NatS, but otherwise there were no significant differences between NatS and FBS patients with LC regarding diagnosis, treatment, and survival.

Distress after a psychosocial cancer rehabilitation course. Main effects and effect modification in a randomised trial at 12 months of follow-up

BACKGROUND

In 2002, the Danish Cancer Society opened a rehabilitation centre in which cancer patients were offered a free, six-day, multidimensional residential course. Our previous studies of the effects of this course at one and six months of follow-up showed no positive effect on distress. We investigated long-term effects at 12 months of follow-up and whether subgroups with fewer psychosocial resources received more benefit from the intervention than patients with better resources.

MATERIAL AND METHODS

In two Danish counties, 507 patients with breast, prostate, colon or rectum cancer diagnosed within the past two years who had completed primary treatment were randomised to a six-day, multidimensional residential rehabilitation course or to standard care. Of these, 208 patients received the allocated intervention and 244 received the allocated control condition and were included in the analyses. Patients in both groups completed questionnaires at baseline and at one, six and 12 months of follow-up, including the 'Profile of Mood States short form', the 'General Self-efficacy' scale and a question on emotional support. At 12 months of follow-up, 179 participants in the intervention group and 195 in the control group provided data.

RESULTS

No effect of the intervention was found on distress at 12 months of follow-up, even in subgroups with fewer psychosocial resources at baseline, i.e. greater baseline distress, poorer self-efficacy and less emotional support.

CONCLUSION

Multidimensional rehabilitation programmes may not be effective in the treatment of distress. During the past few decades, studies of psychotherapy or psycho-education in cancer patients have shown small to moderate effects. More focused rehabilitation programmes may be more effective.

Predictors of continuous tobacco smoking in a clinical cohort study of Danish laryngeal cancer patients smoking before treated with radiotherapy

BACKGROUND

Many cancer patients who are smokers when starting cancer therapy continue smoking despite evidence of tobacco smoking as a risk factor for poor treatment response and secondary primary cancers. Small samples and inconsistent results in previous studies warrant further research to identify predictors of being a continuous smoker during and after radiotherapy.

MATERIAL AND METHODS

In the clinical database of the Danish Head and Neck Cancer Group (DAHANCA), we identified 1455 patients diagnosed with laryngeal cancer between 2000 and 2010, who were all smokers at date of diagnosis and treated with primary radiotherapy. Information on the socio-economic characteristics of the study cohort was obtained from Statistics Denmark the year prior to diagnosis. Logistic regression analyses were applied.

RESULTS

In the cohort of laryngeal cancer patients smoking before starting radiotherapy, 50% still smoked one year after radiotherapy similar to the percentage of smokers during treatment. Being younger than 60 years (OR 1.39, 95% CI 1.00-1.91), commenced smoking before the age of 15 (OR 1.77, 95% CI 1.32-2.38), having a poor WHO Performance status (OR 3.09, 95% CI 1.71-5.61), low income (OR 2.21, 95% CI 1.23-3.98) and living alone (OR 1.56, 95% CI 1.13-2.14) were associated with increased risk of continuous smoking during treatment. Similar findings were found two months and one year after radiotherapy, however, no association with living alone (OR 1.08, 95% CI 0.73-1.59) at the one-year follow-up. Tumor stage and the average number of cigarettes smoked per day before radiotherapy were not associated with being a continuous smoker.

CONCLUSION

Younger patients, who had an early smoking initiation, a poor performance status, low income and lived alone, were most likely to continue smoking. Continuous smoking was not related to the extent of disease.

Influence of metabolic indicators, smoking, alcohol and socioeconomic position on mortality after breast cancer

BACKGROUND

Factors differently distributed among social groups like obesity, metabolic syndrome, diabetes, smoking, and alcohol intake predict survival after breast cancer diagnosis and therefore might mediate part of the observed social inequality in survival.

MATERIAL AND METHODS

We conducted a cohort study among 1250 postmenopausal breast cancer patients identified among 29 875 women in the Danish Diet, Cancer and Health Study. Participants completed questionnaires and anthropometric measurements were made at enrollment. Information on survival, socioeconomic position, and comorbidity was obtained by linkage to national Danish registries. Clinical information was obtained from the nationwide Danish Breast Cancer Database. Selected information was obtained from hospital records at time of diagnosis. All analyses were based on Cox proportional hazard models, using death from all causes as outcome.

RESULTS

Median follow-up was 9.6 years [interquartile range (IQR), 2.2-17.0 years]. The hazard ratio (HR) for death from all causes increased with lower education (p for trend, 0.01). Adjustment for disease-related prognostic factors, comorbidity and metabolic indicators measured as BMI, waist circumference and diabetes, and smoking and alcohol affected but did not explain the social gradient.

CONCLUSION

The findings indicate that these factors explain some but not all the social inequality in survival after breast cancer and that improvement of lifestyle to some extent would improve survival among women with low socioeconomic position.

Socioeconomic position and stage at diagnosis of head and neck cancer - a nationwide study from DAHANCA

BACKGROUND

Socioeconomic differences in survival after head and neck squamous cell carcinoma (HNSCC) are among the greatest for any malignancy. To improve our understanding of the mechanisms by which socioeconomic position influences HNSCC survival, we investigated the association between socioeconomic position and advanced stage HNSCC at diagnosis.

MATERIAL AND METHODS

Men and women with HNSCC diagnosed between 1992 and 2008 were identified in the Danish Head and Neck Cancer Group (DAHANCA) database, which contains detailed information on all cases of HNSCC treated in Denmark. Individual information on the following four socioeconomic indicators: highest attained educational level, cohabitation status, disposable income and degree of urbanisation were obtained from Statistics Denmark. For the 9683 cases on which there was full information, we estimated odds ratios (ORs) for a diagnosis of advanced stage (TNM III-IV) HNSCC in multivariate logistic regression models by site (glottic, non-glottic larynx, oropharynx, hypopharynx and oral cancer), with adjustment for age, gender, period of diagnosis, education, income, cohabitation status, degree of urbanisation and comorbidity in accordance with a causal diagram.

RESULTS

For all HNSCC sites, the ORs for advanced stage at diagnosis were increased for patients with low income and for men living alone. For glottic and oral cancers, the ORs for advanced stage HNSCC increased systematically by decreasing length of education. Increased ORs were found for hypopharynx cancer patients living in rural areas or provincial cities. Having one or more comorbid conditions was associated with an increased OR for advanced stage oral cancer but with a decreased OR for oropharynx cancer.

CONCLUSION

In this nationwide population-based study, socioeconomic differences in stage at diagnosis were found for all HNSCC subsites. Focus on the high risk for advanced stage HNSCC among vulnerable patients may be beneficial during referral and diagnosis in order to improve HNSCC outcomes.

Wage-subsidised employment as a result of permanently reduced work capacity in a nationwide cohort of patients diagnosed with haematological malignancies

BACKGROUND

Patients with haematological malignancies have a poorer labour market prognosis than the general population. We have previously found that they have low rates of return to work, and a higher risk of being granted disability pension, than individuals without a history of these diseases. The aim of this study was to further investigate the labour market prognosis for these patients, by comparing the risk of being granted wage-subsidised (WS) employment as a result of permanently reduced work capacity among patients diagnosed with haematological malignancies to a reference cohort, and to determine if relative risks differ between subtypes of haematological malignancies.

MATERIAL AND METHODS

We combined data from national registers on Danish patients diagnosed with haematological malignancies between 2000 and 2007 and a reference cohort without a history of these diseases. A total of 3194 patients and 28 627 reference individuals were followed until they were granted WS employment, disability pension, anticipatory pension, old age pension, emigration, death or until 26 February 2012, whichever came first.

RESULTS

A total of 310 (10%) patients and 795 (3%) reference individuals had their work capacity permanently reduced to an extent that they were granted WS employment during the follow-up period. Age- and gender-adjusted relative risks differed significantly between the subgroups of haematological malignancies, and four years after diagnosis they ranged from 2.47 (95% CI 1.46-4.16) for patients with Hodgkin lymphoma to 10.83 (95% CI 7.15-16.40) for patients with chronic myeloid leukaemia.

CONCLUSION

All eight subtypes of haematological malignancies were associated with an increased risk of being granted WS employment due to permanently reduced work capacity compared to the reference cohort. The relative risks differed according to haematological malignancy subtype, and the highest was found for patients with chronic myeloid leukaemia.

Socioeconomic position and survival after lung cancer: Influence of stage, treatment and comorbidity among Danish patients with lung cancer diagnosed in 2004-2010

BACKGROUND

To address social inequality in survival after lung cancer, it is important to consider how socioeconomic position (SEP) influences prognosis. We investigated whether SEP influenced receipt of first-line treatment and whether socioeconomic differences in survival could be explained by differences in stage, treatment and comorbidity.

MATERIAL AND METHODS

In the Danish Lung Cancer Register, we identified 13 045 patients with lung cancer diagnosed in 2004-2010, with information on stage, histology, performance status and first-line treatment. We obtained age, gender, vital status, comorbid conditions and socioeconomic information (education, income and cohabitation status) from nationwide population-based registers. Associations between SEP and receipt of first-line treatment were analysed in multivariate logistic regression models and those with overall mortality in Cox regression models with stepwise inclusion of possible mediators.

RESULTS

For both low- and high-stage lung cancer, adjusted ORs for first-line treatment were reduced in patients with short education and low income, although the OR for education did not reach statistical significance in men with high-stage disease. Patients with high-stage disease who lived alone were less likely to receive first-line treatment. The socioeconomic difference in overall survival was partly explained by differences in stage, treatment and comorbidity, although some differences remained after adjustment. Among patients with high-stage disease, the hazard ratio (HR) for death of those with low income was 1.12 (95% CI 1.05-1.19) in comparison with those with high income. Among patients with low-stage disease, those who lived alone had a 14% higher risk for dying (95% CI 1.05-1.25) than those who lived with a partner. The differences in risk for death by SEP were greatest in the first six months after diagnosis.

CONCLUSION

Socioeconomic differences in survival after lung cancer are partly explained by social inequality in stage, first-line treatment and comorbidity. Efforts should be made to improve early diagnosis and adherence to first-line treatment recommendations among disadvantaged lung cancer patients.

Adaptation of the chronic disease self-management program for cancer survivors: feasibility, acceptability, and lessons for implementation

Self-management in chronic disease has been shown to improve patient-reported and health care-related outcomes. However, relatively little information about its utility in cancer survivorship is known. We evaluated the feasibility and acceptability of the delivery of an adaptation of the evidence-based Chronic Disease Self-management Program (Stanford) called Cancer Thriving and Surviving (CTS). Triangulated mixed methods were used to capture baseline characteristics and post-program experiences using a combination of closed- and open-ended survey items; emergent coding and simple descriptive statistics were used to summarize the data. Twenty-seven workshops were delivered by 22 CTS leaders to 244 participants between August 2011 and January 2013 in a variety of settings (48 % community, 30 % health care, 22 % regional/community cancer center). Representing a variety of cancer types, about half the participants were 1-3 years post-diagnosis and 45 % were 4 or more years from diagnosis. Program attendance was high with 84 % of participants attending four or more of the six sessions in the workshop. Overall, 95 % of the participants were satisfied with the program content and leaders, and would recommend the program to friends and family. These results confirm the feasibility and acceptability of delivery of a high-fidelity, peer-led model for self-management support for cancer survivors. Expansion of the CTS represents a powerful tool toward improving health-related outcomes in this at-risk population.

Lean body mass and muscle function in head and neck cancer patients and healthy individuals--results from the DAHANCA 25 study

INTRODUCTION

Loss of lean body mass is common following radiotherapy in patients with head and neck squamous cell carcinoma (HNSCC) and may reduce maximal muscle strength and functional performance. However, the associations between lean body mass, muscle strength and functional performance are unclear and no studies in HNSCC patients have compared the levels of these variables to the levels seen in healthy individuals.

PURPOSE

The purpose of the present study was to investigate the associations between lean body mass, maximal muscle strength and functional performance in HNSCC patients and to compare the levels of these variables after radiotherapy and after progressive resistance training with the levels in healthy individuals.

MATERIAL AND METHODS

Lean body mass (dual energy X-ray absorptiometry), maximal muscle strength (isokinetic dynamometry) and functional performance (10 m max gait speed, 30 s chair rise, 30 s arm curl, stair climb) from HNSCC patients from the DAHANCA 25 trials and data from 24 healthy individuals were included.

RESULTS

Lean body mass and maximal muscle strength were significantly associated according to the gender and age-adjusted linear regression model (p < 0.0001). In addition, maximal muscle strength were associated with 30 s arm curl performance, 10 m max gait speed and 30 s chair rise (p < 0.0001). Multiple regression analyses showed that HNSCC patients expressed significant lower levels of the investigated variables after radiotherapy than healthy individuals (p < 0.0001), and that all differences were evened out after training.

CONCLUSIONS

Significant associations were found between lean body mass, maximal muscle strength and functional performance in HNSCC patients. Patients expressed lower levels of these variables compared with healthy individuals, suggesting that lean body mass is a clinically relevant health factor in HNSCC patients.