[Does the announcement of cancer at the time of Non Muscle-Invasive Bladder Cancer diagnosis affect quality of life and adherence of patients? Data from the French prospective cohort VICAN]

INTRODUCTION

The information provided at the time of diagnosis of Non Muscle-Invasive Bladder Cancer (NMIBC) is highly variable. Well-informed patient are more involved in shared decisions. The objective of our study was to assess the information perceived by the patient at the time of NMIBC diagnosis and its impact on quality of life.

METHODS

The VICAN french cohort involved a representative sample of 4174 cancer patients and 5 years survivors. Patients reported outcomes (PROs) were collected by phone and self-questionnaire. Among the 118 NMIBC patients, the term used to define the pathology at diagnosis was prospectively evaluated. The impact on quality of life (using SF-12, EORTC-QLQ-C30 and HAD scale) and on adherence to the care protocol (endoscopic monitoring) has been assessed.

RESULTS

Only 26.8% of patients reported hearing the word « Cancer » at the time of NMIBC diagnosis. Conversely, 73.2% of them reported others terms, including « Tumor » (22%), « Polyp » (24%), and « Carcinoma » (17.1%). There was no difference in terms of physical, mental quality of life and anxiety, regardless of the term used. Adherence to the follow-up endoscopic protocol was better in the group of patients hearing the word "Cancer".

CONCLUSION

Three quarters of patients treated for NMIBC did not integrate the concept of « Cancer » at the time of diagnosis. Quality of life and anxiety did not differ significantly depending on the term used at diagnosis. However, adherence to care protocol appears to be higher when using the word "Cancer".

LEVEL OF EVIDENCE

3.

Returning to work by thyroid cancer survivors 5 years after diagnosis: the VICAN survey

PURPOSE

Return to work (RTW) following cancer diagnosis is a challenge for both the patient and society. As thyroid cancer (TC) incidence is increasing, this study aims to assess difficulties in returning to work and income changes in TC survivors 5 years post-diagnosis.

METHODS

This study belongs to the national VICAN survey conducted in France among TC patients diagnosed between January and June 2010. Data were collected through phone interviews, medical surveys and from the national medico-administrative register in 2012 and 2015. We used multivariate logistic regressions to investigate TC impact on employment and income changes.

RESULTS

Of 146 patients, 121(82.9%) were women; the mean age was 42 years (SD = 8.34), 119 (81.3%) were diagnosed at an early stage, and 142(97.6%) underwent thyroidectomy. At 5 years post-diagnosis, 116 (79.7%) of the TC survivors were professionally active, 22 (15.4%) were unemployed and 8 (4.90%) were receiving disability. Among the patients employed at the time of diagnosis (n = 122), 15 (12.3%) had not returned to work 5 years post-diagnosis. Between 2 and 5 years post-diagnosis, there was no significant improvement in rates of RTW. At 5 years post-diagnosis, 90 (61.6%) reported an income decline. All TC survivors who have not returned to work were women and declared higher fatigue. Moreover, in multivariate analyses, not returning to work was associated with weight gain (OR = 8.41 (1.21; 58.23)) and working arrangements (6.90 (1.18-38.48)), while income decline was associated with comorbidities (OR = 2.28 (1.07; 4.86)) and to be engaged in manual work (OR = 2.28 (1.07; 4.88)).

CONCLUSION

This study highlights that, despite a good prognostic, up to 12.3% of TC survivors had not returned to work and 61.6% reported an income decline, 5 years post-diagnosis. Weight gain, fatigue, to be a woman and working-type arrangement were associated with higher probability of not returning to work.

IMPLICATIONS FOR CANCER SURVIVORS

TC affects a young working population. Our study identified potentially vulnerable TC survivors and important modifiable factors which may help TC survivors to be professionally active and, therefore, increase their overall quality of life.

Physical activity and body weight of breast cancer survivors – VICAN national survey

Background

Cancer recurrence and poor quality of life are major challenges of the growing population of breast cancer (BC) survivors. International guidelines encourage survivors to engage in regular physical activity (PA) and to maintain a healthy body weight (BW), as both have a proven benefit on survival. Our aims were (1) to describe PA and BW 5 years after a BC diagnosis and (2) to define the predictors of long-term engagement in healthy lifestyle, in a representative sample of French survivors.

Methods

The French National VICAN surveys were implemented in 2012 and 2015 among cancer survivors. This analysis focused on 723 women with BC, without progression at 5 years, and who participated in both surveys. The questionnaires dealt with several topics including socioeconomic status, treatments and side effects, psychometric scales and lifestyle habits.

Results

Five years after diagnosis, 26% of women reported regular PA, 61% occasional PA and 14% no PA. Moreover, 27% reported a weight gain ≥5kg, and 10% a weight loss ≥5kg. Half of the women had decreased or stopped PA since diagnosis. In logistic regression, long-term regular PA was associated with better mental quality of life (aOR=1.04; 1.01-1.07), no depression (aOR=3.42; 1.21-9.65), higher Post Traumatic Growth Inventory score (aOR=1.02; 1.01-1.04), normal arm mobility (aOR=3.7; 1.6-8.4) and healthy and stable BW since diagnosis (aOR=4.47; 1.61-12.37). Weight gain ≥5kg was associated with younger age (aOR=0.96; 0.93-0.99), higher BW at diagnosis (aOR=1.02; 1.01-1.04), and lymphedema 5 years after diagnosis (aOR=1.69; 1.02-2.83).

Conclusions

For BC survivors, mental well-being is essential for successful long-term investment in healthy habits. More psychological and dietary support, and a better management of sequelae are needed in this population.

Key messages

For breast cancer survivors, mental well-being is essential for successful long-term investment in healthy habits. More psychological and dietary support, and better sequelae management are needed to help breast cancer survivors to persist in healthy lifestyle.

Trajectories of adherence to adjuvant endocrine therapy for 5 years in women with breast cancer

Background

Adjuvant endocrine therapy (AET) is a daily oral medication prescribed for women with hormone-sensitive breast cancer (BC) to reduce recurrence and mortality risks. However, many women do not take AET daily or do not persist with AET for the recommended duration of at least 5 years. Our aims were to identify: 1) trajectories of AET adherence for the 5 years; 2) factors associated with these trajectories.

Methods

The French Cancer Cohort includes data on hospitalizations, ambulatory care and drug claims for all cancers diagnosed in France (SNDS database). Women diagnosed with a 1st non-metastatic BC in 2011 who had ≥ 1 AET claim within 12 months of surgery were included. For each woman, we estimated the monthly proportion of days covered (PDC) by an AET for 5 years after the first AET. Monthly PDCs were used to model AET adherence trajectories using group-based trajectory modeling. Statistical criteria were used to assess the suitability of the selected model. The factors associated with the trajectories were identified using multinomial logistic regressions.

Results

33,260 women were included. A 6-trajectory model was selected: 1) Stop of AET in the 1st year (6.6%), 2) Adherence for 1 year and stop (5.7%), 3) Adherence for 2.5y and stop (6.3%), 4) High adherence for 4.5y and stop (8.3%), 5) Sub-optimal adherence for 5y (4.3%), 6) Very high adherence for 5y (68.8%). Factors associated with non-adherence trajectories are mainly extreme age (>70y) and switch in AET.

Conclusions

About 70% of women had an optimal adherence for 5 years. Our results showed that women who changed AET during the treatment course were at higher risk of non-adherence. Among non-adherent women, the switch in AET is frequent and probably often related to the management of side effects. Interventions to detect and manage these side effects may help to support women with AET use. Effective management of these effects during all the 5 years could be needed to maintain adherence.

Key messages

About 70% of women had an optimal adherence for 5 years. Women who changed AET during the treatment course were at higher risk of non-adherence.

The positive effect of workplace accommodations on employment five years after a cancer diagnosis

Background

Each year, almost 400,000 new individuals are diagnosed with cancer in France and nearly half of them are in the working age. The disease was found to have a negative impact on professional life, especially for the most vulnerable cancer survivors. Literature reviews have pointed out the lack of studies focusing on the evaluation of interventions. In France, workstation layouts are recommended by the French law, but not mandatory to facilitate return to work. The aim of this study was to explore the effect of having a workstation layout after a cancer diagnosis on maintenance in employment five years after diagnosis.

Methods

We used the French VICAN survey carried out in 2015/2016 on living conditions five years after a cancer diagnosis. Using propensity score matching, we matched two subsamples (with and without workstation layout) to investigate the effect of workstation layout taking into account the characteristics associated with the access to these arrangements.

Results

Among the 1,514 individuals aged between 18 and 54 at diagnosis and employed in a salaried job at this time, three in five (61.2%) had a workstation layout within the five years following the diagnosis: 35.5% had a position type layout, 41.5% had a schedule layout, and 49.2% had a working time layout. Among those who had a workstation layout, 89.7% were still in employment five years after diagnosis against only 77.8% of those who did not so (p.value<0,001). After matching, having a workstation layout increased maintenance in employment from 77.8% to 95.0% (Average workstation layout effect on the treated of 0.172, 95% CI = [0.114; 0.229]).

Conclusions

Having a workstation layout after a cancer diagnosis strongly increases maintenance in employment of five years cancer survivors. More research is needed to better understand the differences in access to these arrangements and the related selection effect.

Key messages

Workstation layout increases maintenance in employment of survivors five years after a cancer diagnosis. Therefore, it should be used more systematically to facilitate work with a chronic disease. Having a workstation layout may constitute a disadvantageous selection bias for more vulnerable workers. It can also lead to discrimination feelings.

Opinions toward pain management and palliative care: Comparison between HIV specialists and oncologists

Despite the introduction of HAART, pain is still a common symptom in people living with HIV/AIDS. For these persons, pain management supplied by palliative care teams may support standard HIV care. This study compares opinions toward palliative care of 83 HIV specialists and 217 oncologists (French national survey: Palliative Care 2002). Data were collected by phone questionnaire. A cluster analysis was carried out in order to identify contrasted profiles of opinions toward palliative care. A logistic regression was performed to test the relationships between identified clusters and physicians' characteristics. With a two-cluster partition, we observed a profile corresponding to a restrictive conception of palliative care. Within this profile, physicians were more prone to consider that palliative care should be used only for terminally-ill patients, and only after all curative treatments have failed, with a restrained prescriptive power for physicians providing palliative care. This conception was associated with reluctance toward morphine analgesia. Once controlled for other physicians' characteristics, HIV specialists were more likely than oncologists to endorse this restrictive conception (OR=1.9, CI 95% [1.1; 3.3]). Thus French HIV specialists should be more informed about the utility of providing palliative care, even for patients who are not in terminal stage.

French hospital nurses' opinion about euthanasia and physician-assisted suicide: a national phone survey

BACKGROUND

Hospital nurses are frequently the first care givers to receive a patient's request for euthanasia or physician-assisted suicide (PAS). In France, there is no consensus over which medical practices should be considered euthanasia, and this lack of consensus blurred the debate about euthanasia and PAS legalisation. This study aimed to investigate French hospital nurses' opinions towards both legalisations, including personal conceptions of euthanasia and working conditions and organisation.

METHODS

A phone survey conducted among a random national sample of 1502 French hospital nurses. We studied factors associated with opinions towards euthanasia and PAS, including contextual factors related to hospital units with random-effects logistic models.

RESULTS

Overall, 48% of nurses supported legalisation of euthanasia and 29%, of PAS. Religiosity, training in pallative care/pain management and feeling competent in end-of-life care were negatively correlated with support for legalisation of both euthanasia and PAS, while nurses working at night were more prone to support legalisation of both. The support for legalisation of euthanasia and PAS was also weaker in pain treatment/palliative care and intensive care units, and it was stronger in units not benefiting from interventions of charity/religious workers and in units with more nurses.

CONCLUSIONS

Many French hospital nurses uphold the legalisation of euthanasia and PAS, but these nurses may be the least likely to perform what proponents of legalisation call "good" euthanasia. Improving professional knowledge of palliative care could improve the management of end-of-life situations and help to clarify the debate over euthanasia.

French district nurses' opinions towards euthanasia, involvement in end-of-life care and nurse patient relationship: a national phone survey

OBJECTIVES

To assess French district nurses' opinions towards euthanasia and to study factors associated with these opinions, with emphasis on attitudes towards terminal patients.

DESIGN AND SETTING

An anonymous telephone survey carried out in 2005 among a national random sample of French district nurses.

PARTICIPANTS

District nurses currently delivering home care who have at least 1 year of professional experience. Of 803 district nurses contacted, 602 agreed to participate (response rate 75%).

MAIN OUTCOME MEASURES

Opinion towards the legalisation of euthanasia (on a five-point Likert scale from "strongly agree" to "strongly disagree"), attitudes towards terminal patients (discussing end-of-life issues with them, considering they should be told their prognosis, valuing the role of advance directives and surrogates).

RESULTS

Overall, 65% of the 602 nurses favoured legalising euthanasia. Regarding associated factors, this proportion was higher among those who discuss end-of-life issues with terminal patients (70%), who consider competent patients should always be told their prognosis (81%) and who value the role of advance directives and surrogates in end-of-life decision-making for incompetent patients (68% and 77% respectively). Women and older nurses were less likely to favour legalising euthanasia, as were those who believed in a god who masters their destiny.

CONCLUSIONS

French nurses are more in favour of legalising euthanasia than French physicians; these two populations contrast greatly in the factors associated with this support. Further research is needed to investigate how and to what extent such attitudes may affect nursing practice and emotional well-being in the specific context of end-of-life home care.

Attitudes toward palliative care, conceptions of euthanasia and opinions about its legalization among French physicians

We assume that actors of the professionalization process of palliative care make a special effort to demarcate it from euthanasia, and that such an effort has a significant impact on beliefs and attitudes toward euthanasia among the whole medical profession. We investigated concurrently attitudes toward palliative care, conceptions of euthanasia and opinion toward its legalization among a sample of 883 French general practitioners, oncologists and neurologists. We found four contrasted profiles of attitudes toward palliative care, which were closely correlated with being in touch with palliative care providers. Attitudes toward palliative care were closely correlated with beliefs about which medical practices should be labelled euthanasia, and these beliefs were in turn strongly associated with opinions toward euthanasia legalization. Our results suggest that the relationship between palliative care and euthanasia mixes semantic and strategic aspects, beyond cognitive and conative ones.

Disclosure of Prognosis to Terminally Ill Patients: Attitudes and Practices Among French Physicians

BACKGROUND

Disclosure of the prognosis to terminally ill patients is a strong prerequisite for integrating the physical, psychological, spiritual, and social aspects of end-of-life care.

OBJECTIVE

This study aimed to assess French physicians' general attitudes and effective practices (with patients followed up to death recently) toward such disclosure.

DESIGN/SUBJECTS

We used data from a cross-sectional survey conducted among a national sample of 917 French general practitioners, oncologists, and neurologists.

RESULTS

A majority of respondents opted for prognosis disclosure only at patients' request, very few opted for systematic disclosure without patient's request, and a significant minority opted for systematic concealment. Concerning deceased patients described by respondents, 44.5% of competent patients were informed of prognosis by their physician, 27.3% were informed by someone else, 9.0% refused to be informed, and 19.2% were simply not informed. Concealment was more frequent for older patients, and physicians involved in a nongovernmental organization (NGO) for patients' support were more likely to disclose the prognosis, even without patient's request.

CONCLUSIONS

Disclosure of the prognosis to terminally ill patients is still far from systematic in France. Further research is needed to better understand the motivations of French physicians' disclosure practices, which are probably culturally shaped.

The prescription of opioid analgesics to terminal cancer patients: impact of physicians' general attitudes and contextual factors

OBJECTIVE

This study aimed to examine factors associated with the prescription of opioid analgesics to terminal cancer patients, including physicians' general attitudes toward morphine and contextual factors.

METHODS

A survey was conducted among a sample of French general practitioners (GPs) and oncologists. Respondents were asked to describe the last three terminally ill patients they had followed up to death.

RESULTS

Overall, 526 GPs and oncologists (global response rate: 57%) described 1,082 cancer patients, among whom 85.4% received opioid analgesics. Among other significant predictors (patient age, cancer type, family assistance), this prescription was less frequent for female patients followed by male physicians (OR = 0.53), and more frequent for patients followed by physicians trained in palliative care (OR = 2.70). On the other hand, physicians' attitudes toward morphine were not associated with prescription of morphine and other opioid analgesics.

SIGNIFICANCE OF RESULTS

Although nonprescription of opioid analgesics is only a crude proxy measure for undertreatment of cancer pain, our findings suggest the need to develop training in palliative care in order to standardize practices among GPs and specialists. Our results also highlight the necessity to study pain assessment as an interaction between the physician and the patient, and to consider patients' and physicians' respective genders as a key variable within this interaction.

Post-exposure prophylaxis after occupational and non-occupational exposures to HIV: an overview of the policies implemented in 27 European countries

The aim of this survey, which was part of an English-French project supported by the Commission of the European Communities, was to compare access to HIV post-exposure prophylaxis (PEP) in the occupational and non-occupational contexts in 27 European countries. A protocol was designed in May 1998 in collaboration with all country consultants. Data were collected at country level by each consultant through interviews, review of local and national recommendations and results of national or local surveys. The final comparative analysis was carried out from the individual country reports and a review of the literature. The large majority of European countries have detailed procedures regarding occupational PEP: 20/27 have produced national guidelines, three have adopted the US CDC recommendations and only four have no official recommendations. Although no standard protocol exists, the more common one is a four-week implementation of a triple combination therapy. In the context of non-occupational exposure to HIV, only five countries have guidelines with specific recommendations and one country has adopted the CDC recommendations. In the majority of cases (13 countries), PEP is never recommended but is only available in a few circumstances, sometimes with major limitations. In the last eight countries, such PEP is not currently available. Although the estimations of HIV transmission risks in occupational and non-occupational contexts are really comparables, easy access to PEP after accidental sexual or blood exposures is not guaranteed for the general population in the majority of European countries.