Differences in health-related quality of life between native and foreign-born gynaecological cancer patients in Sweden: a five-year cross-sectional study

PURPOSE

To examine differences in health-related quality of life (HRQoL) between native and foreign-born gynaecological cancer patients in Sweden, taking into account clinical, demographic, and socioeconomic factors.

METHODS

The 30-item European Organisation for Research and Treatment of Cancer quality of life questionnaire (QLQ-C30) and a study-specific questionnaire covering demographic and socioeconomic factors were answered by 684 women aged ≥ 18 years old, diagnosed in 2014, 2016, or 2018 with gynaecological cancer in the Stockholm-Gotland health care region, Sweden. Clinical data were obtained from the Swedish Cancer Register. Data were analysed using the Kruskal-Wallis test and linear regression.

RESULTS

The women had a mean age of 65.4 years, with 555 (81.1%) born in Sweden, 54 (7.9%) in other Nordic countries (ONC), 43 (6.3%) in other European countries (OEC), and 32 (4.7%) in non-European countries (NEC). HRQoL differed significantly between the four groups for 14 of the 15 QLQ-C30 scales/items. On average, Swedish-born women scored 2.0, 15.2, and 16.7 points higher for QoL/functioning scales/items and 2.2, 14.1, and 18.7 points lower for symptom scales/items, compared with ONC-, OEC-, and NEC-born women, respectively. In adjusted analyses, none of the differences between Swedish-born and ONC-born women were significant, while for OEC- and NEC-born women the differences were significant for most QLQ-C30 scales/items.

CONCLUSION

HRQoL differs between native and foreign-born gynaecological cancer patients in Sweden, with lower HRQoL the further from Sweden the women are born. A more individualised cancer care, with tailored support to optimize HRQoL is needed for this vulnerable group of patients.

Patient participation in tele-emergencies - experiences from healthcare professionals in northern rural Sweden

INTRODUCTION

Telemedicine provides opportunities for access to health care in remote and underserved areas. In parts of northern rural Sweden telemedicine is used to connect a remote physician by a video-conference system to an emergency room, staffed by nurses during on-call hours. This can be called 'tele-emergency'. Patient participation, often described as mutual information exchange, a trustful relationship and involvement in decision-making, is challenged in emergency care by short encounters, deteriorating patients and a stressful work situation. Nevertheless, patient participation may be important for the patients' experience. Healthcare professionals (HCPs) have been identified as 'gatekeepers' for patient participation, therefore putting their perspective in focus is important. As emergency care in rural areas is increasingly turning toward telemedicine, patient participation in tele-emergencies needs to be better understood. The aim of this study was to explore and characterise HCPs' perspectives of patient participation in tele-emergencies in northern rural Sweden.

METHODS

A qualitative design based on interviews was used. HCPs working in cottage hospitals in northern rural Sweden were included. Semi-structured interviews were performed, first, in multidisciplinary groups of three informants. Later, because of limited experience of tele-emergencies in the groups, individual interviews with HCPs with substantial experience were added. A qualitative content analysis of the interview transcripts was conducted.

RESULTS

A total of 44 HCPs from northern inland Sweden participated in the interviews. The content analysis resulted in two themes, six categories and 19 subcategories. Theme 1, 'To see, understand, and to build trust through the digital barrier', contains descriptions of the interpersonal relationship between the patient and the HCPs, and the challenges when interacting with the patient during a tele-emergency. The informants also described a need for boundaries between the professional team and the patient. The categories in theme 1 are 'understanding the patient's point of view', 'building a trustful relationship', and 'needing a private space without the patient'. Theme 2, 'The (im)balance of power - tele-emergency reinforces the positions', mirrors the power asymmetry in the patient-professional relationship, and the potential impact of the tele-emergency on the different roles. Tele-emergencies were described as a risk that potentially could weaken the patient's position, but also as providing an opportunity to share power. Categories in theme 2 are 'medical conditions limit patient participation', 'patient involvement in decision-making requires understanding' and 'the inferior patient and the superior professionals'.

CONCLUSION

This study sheds light on patient participation in tele-emergencies in a remote rural setting from the HCP's perspective. The tele-emergency set-up affected patient participation by interfering with familiar patient-HCP relationships and changing group dynamics in interactions with the patient. Due to the extensive changes of the conditions for patient participation imposed in tele-emergencies, suggestions for actions improving patient participation are made.

Patients with low activation level report limited possibilities to participate in cancer care

Background

Cancer care trajectories are often complex, with potent multimodality treatments and multiple interactions with health care providers. Communication and coordination are challenging and the patients' responsibilities to take on more active roles in their own care are increasing.

Objective

This study aimed to investigate associations between patient activation level and participation in cancer care, sociodemographic characteristics, clinical data, health‐related quality of life (HRQoL) and helpfulness of received information.

Methods

In this cross‐sectional population‐based study, patients completed questionnaires on patient activation, perceived participation, HRQoL, helpfulness of received information and sociodemographic characteristics. Responses to the patient activation measures (PAMs) were classified into four levels (higher levels indicating more activation). Data on age, sex and cancer diagnosis were collected from the Swedish Cancer Register.

Results

Data from 682 patients were analysed. On comparing patients at PAM levels 1 and 4, the latter reported significantly higher possibilities to influence care decisions (46.6% vs. 20.8%) and to ask questions regarding treatment and care (93.4% vs. 68.4%). Patients at PAM level 4 reported wanting to influence decision‐making to a higher extent, compared with patients at other PAM levels, and reported clinically significantly higher HRQoL. No significant differences were found regarding sociodemographic characteristics.

Conclusion

We found strong associations between perceived patient participation and activation levels, with limited possibility for participation among those with lower activation levels.

Patient or Public Contribution

Discussions with patient representatives have raised the importance of participation. The preliminary findings were presented and discussed in a workshop with representatives from 21 cancer patient advocacy groups.

Patient participation in gastrointestinal endoscopy - From patients' perspectives

Background

Patient participation is associated with satisfaction and improved health‐related outcomes. In gastrointestinal endoscopy, patient participation is an underexplored area.

Objective

To gain understanding on patients' experiences, attitudes and preferences concerning patient participation in the endoscopy pathway.

Methods

Semi‐structured interviews with endoscopy patients (n = 17, female n = 8, male n = 9, ages 19‐80 years) were performed. Interview transcripts were analysed using qualitative content analysis. Participants were recruited by purposive sampling from an endoscopy unit in a Swedish university hospital. Inclusion:≥ 18 years, fluency in Swedish and recent experience of endoscopy at the unit.

Results

Five generic categories emerged, two within the area of the patient's role, which was described as active or passive/included or excluded. Another three generic categories related to factors, critical to active participation, including organizational aspects, impressions of staff and individual circumstances were identified. In this context, patient participation described in the interviews was on a low to basic level, although sometimes reaching a higher level when staff ‘invited’ patients in decision making.

Discussion

This study contributes to the understanding of patient participation in endoscopy. Patients are in an inferior position and need support from the staff for an active role in their care. Although there were variations on the perceived importance of different factors, a heavy responsibility lies on the endoscopy staff to acknowledge the patients' individual needs and to facilitate patient participation.

Conclusions

Endoscopy staff has a key role in supporting patient participation. In endoscopy settings, patient participation is vulnerable to multiple factors.

Older patients' attitudes towards, and perceptions of, preoperative physical activity and exercise prior to colorectal cancer surgery-a gap between awareness and action

Purpose

Time for preoperative optimisation prior to colorectal cancer surgery is limited and older people tend to decline exercise interventions. This study sought to describe attitudes towards, and perceptions of, preoperative physical activity and exercise in older people prior to colorectal cancer surgery.

Methods

This is a qualitative interview study, analysed with inductive content analysis. Seventeen participants scheduled for colorectal surgery were recruited as a purposeful sample from two hospitals in Stockholm, Sweden. Individual semi-structured interviews were conducted, face-to-face (n = 8) or by telephone (n = 9).

Results

Nine participants were male, median age was 75 years (range 70–91). The theme, ‘a gap between awareness and action’, was identified based on two main categories: ‘Attitudes towards preoperative physical exercise have a multifactorial base’ and ‘Preoperative physical exercise is possible with a push in the right direction’. The material described a gap between awareness of the benefits of physical activity and reports of performing physical activity. The reasons for the gap between thoughts and action in this respect seem to be multifactorial. Support from others emerged as an important possibility for overcoming the gap.

Conclusions

A gap between the patients’ awareness and action appeared in our material. Understanding this can guide healthcare professionals (HCPs) as to the support needed preoperatively. Advice on physical exercise before surgery should be specific, and individually tailored support for action should be offered. This support should also consider the individual’s current physical activity and preoperative attitude towards physical exercise.

Improved patient satisfaction 2 years after introducing person-centred handover in an oncological inpatient care setting

AIMS AND OBJECTIVES

To investigate patients' satisfaction with care, 2 years after the introduction of person-centred handover (PCH) in an oncological inpatient setting, and to describe patients' perceptions of individualised care.

BACKGROUND

To obtain higher levels of patient satisfaction, bedside nursing handovers have been evaluated with positive results. One such model is PCH, which blends aspects of person-centred care with the bedside report and provides the opportunity for nursing staff and patients to perform the handover together.

DESIGN

A survey-based design was used with one data collection period. Patient satisfaction scores were compared with baseline data from a previous study that has been conducted in the same wards.

METHOD

Patient satisfaction was measured with the EORTC IN-PATSAT32 questionnaire, and individualised care was assessed with the Individualized Care Scale. A total of 120 adult patients with cancer were invited to participate from August 2017-March 2018. Of these, 90 chose to participate. The STROBE checklist for cross-sectional studies was used when preparing the paper.

RESULTS

Compared to the previous study, statistically significant improvements in patient satisfaction were observed in the subscales "Exchange of information between caregivers" and "Nurses' information provision" postimplementation of PCH. Regarding patients' perceptions of individualised care, the highest scores were in the ICS-A subscale "Clinical situation" and ICS-B "Decisional control," while "Personal life situation" scored the lowest overall.

CONCLUSIONS

Person-centred handover seems to have sustainable positive effects on important outcomes regarding patient satisfaction. A novel finding is the positive impact on nurses' information provision, indicating that PCH can facilitate effective information exchange between patients and nurses.

RELEVANCE TO CLINICAL PRACTICE

Person-centred handover seems to improve patients' satisfaction with nurses' provision and exchange of information. Nurses and managers should carefully consider the implementation process of PCH and evaluate its long-term effects. PCH can be recommended in the oncology inpatient setting.

Observations of nursing staff compliance to a checklist for person-centred handovers - a quality improvement project

Nursing shift‐to‐shift handovers are important as they impact the care quality indicators such as safety, patient satisfaction and continuity. However, nurses’ handovers have also been criticised and described as unstructured and ineffective. To improve the handovers and involve patients and their loved ones in the process, a person‐centred handover (PCH) model performed at bedside has been developed and tested at Karolinska University Hospital, Sweden. This study reports on the nursing staffs’ compliance to a checklist used for the newly introduced PCH model. A total of 43 PCH sessions were observed at two acute care wards, using a structured observation protocol. None of the observed handover sessions included all the 13 PCH checklist subcomponents. The checklist was used in 18 (44%) of the observed handover sessions. A statistically significant higher number of subcomponents were observed when the nurses used the PCH checklist (6.4 vs. 4.5 subcomponents, p < 0.05). The mean time spent on each PCH was 6 minutes. In 56% of the sessions, the patients were observed to actively participate in the handover. Overall, the nursing staffs’ compliance to the PCH checklist needs to be improved. The observations suggest that training on communication‐oriented tasks would be beneficial to establish a person‐centred handover process.

Person-centered endoscopy safety checklist: Development, implementation, and evaluation

AIM

To describe the development and implementation of a person-centered endoscopy safety checklist and to evaluate the effects of a “checklist intervention”.

METHODS

The checklist, based on previously published safety checklists, was developed and locally adapted, taking patient safety aspects into consideration and using a person-centered approach. This novel checklist was introduced to the staff of an endoscopy unit at a Stockholm University Hospital during half-day seminars and team training sessions. Structured observations of the endoscopy team’s performance were conducted before and after the introduction of the checklist. In addition, questionnaires focusing on patient participation, collaboration climate, and patient safety issues were collected from patients and staff.

RESULTS

A person-centered safety checklist was developed and introduced by a multi-professional group in the endoscopy unit. A statistically significant increase in accurate patient identity verification by the physicians was noted (from 0% at baseline to 87% after 10 mo, P < 0.001), and remained high among nurses (93% at baseline vs 96% after 10 mo, P = nonsignificant). Observations indicated that the professional staff made frequent attempts to use the checklist, but compliance was suboptimal: All items in the observed nurse-led “summaries” were included in 56% of these interactions, and physicians participated by directly facing the patient in 50% of the interactions. On the questionnaires administered to the staff, items regarding collaboration and the importance of patient participation were rated more highly after the introduction of the checklist, but this did not result in statistical significance (P = 0.07/P = 0.08). The patients rated almost all items as very high both before and after the introduction of the checklist; hence, no statistical difference was noted.

CONCLUSION

The intervention led to increased patient identity verification by physicians - a patient safety improvement. Clear evidence of enhanced person-centeredness or team work was not found.

Phase III study of the European Organisation for Research and Treatment of Cancer satisfaction with cancer care core questionnaire (EORTC PATSAT-C33) and specific complementary outpatient module (EORTC OUT-PATSAT7)

Advances in cancer care delivery require revision and further development of questionnaires assessing patients' perceived quality of care. This study pre-tested the revised EORTC satisfaction with cancer care core questionnaire applicable in both the cancer inpatient and outpatient settings, and its new, outpatient-specific complementary module. The process of revision, development of the extended application, and pre-testing of these questionnaires was based on phases I to III of the "EORTC Quality of Life Group Module Development Guidelines." In phase III, patients in 11 countries in four European regions, South America and Asia completed provisional versions of the questionnaires. Fifty-seven relevant issues selected from literature reviews and input from experts were operationalized into provisional items, and subsequently translated into ten languages. Assessment of understanding, acceptability, redundancy and relevance by patients (n = 151) from oncology inpatient wards, and outpatient chemotherapy, radiotherapy and consultation settings, led to retention of, deletion of and merging of 40, 14 and 6 items respectively. Cronbach's alpha coefficients for hypothesized questionnaire scales were above 0.80. Our results provide preliminary support for the 33-item EORTC Satisfaction with cancer care core questionnaire and the 7-item complementary module specific for the outpatient care setting. A large scale phase IV cross-cultural psychometric study is now underway.

Patient satisfaction after implementation of person-centred handover in oncological inpatient care - A cross-sectional study

Effective nurse shift-to-shift handover is a prerequisite for high-quality inpatient care. Combining person-centeredness with the need for improved handover rituals, we introduced and evaluated person-centered handover (PCH) in an oncological inpatient setting. PCH is the shift-to-shift nursing report performed together with the patient according to a set structure focused on patient participation, relevant clinical information, and patient safety. Non-verbal handover, standard at the department, is conducted via the electronic health record, in absence of the patient, and without a set structure. The aim of the study was to compare person-centered handover with non-verbal handover in an oncological inpatient setting with regard to patient satisfaction. A cross-sectional design featuring two points of measurement at one intervention ward and two control wards was applied. The EORTC IN-PATSAT32 questionnaire was used for measuring patient satisfaction. Baseline measurements were taken during the spring of 2014, when all three wards used a non-verbal handover model, and included responses from 116 patients. Follow-up measurements (comparing PCH and non-verbal handover) involved 209 patients and were on-going from September 2014 to May 2015. After the introduction of PCH, one change in patient satisfaction was detected regarding the subscale measuring exchange of information between caregivers. Patients from the intervention ward scored statistically higher after the implementation of PCH when compared to the control wards (p = .0058). The difference remained after a multivariate regression analysis controlling for clinical variables. In conclusion, PCH is feasible in oncological inpatient care but does not seem to affect patient satisfaction.

International field testing of the psychometric properties of an EORTC quality of life module for oral health: the EORTC QLQ-OH15

PURPOSE

This international EORTC validation study (phase IV) is aimed at testing the psychometric properties of a quality of life (QoL) module related to oral health problems in cancer patients.

METHODS

The phase III module comprised 17 items with four hypothesized multi-item scales and three single items. In phase IV, patients with mixed cancers, in different treatment phases from 10 countries completed the EORTC QLQ-C30, the QLQ-OH module, and a debriefing interview. The hypothesized structure was tested using combinations of classical test theory and item response theory, following EORTC guidelines. Test-retest assessments and responsiveness to change analysis (RCA) were performed after 2 weeks.

RESULTS

Five hundred seventy-two patients (median age 60.3, 54 % females) were analyzed. Completion took <10 min for 84 %, 40 % expressed satisfaction that these issues were addressed. Analyses suggested a revision of the phase III hypothesized scale structure. Two items were deleted based on a high degree of item misfit, together with negative patient feedback. The remaining 15 items formed one eight-item scale named OH-QoL score, a two-item information scale, a two-item scale regarding dentures, and three single items (sticky saliva/mouth soreness/sensitivity to food/drink). Face and convergent validity and internal consistency were confirmed. Test-retest reliability (n = 60) was demonstrated as was RCA for patients undergoing chemotherapy (n = 117; p = 0.06). The resulting QLQ-OH15 discriminated between clinically distinct patient groups, e.g., low performance status vs. higher (p < 000.1), and head-and-neck cancer versus other cancers (p < 0.03).

CONCLUSION

The EORTC module QLQ-OH15 is a short, well-accepted assessment tool focusing on oral problems and QoL to improve clinical management.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01724333.

Patients' knowledge and perceived understanding - Associations with consenting to participate in cancer clinical trials

Recruitment to clinical trials is essential. The aims of the study were to investigate associations between patients' informed consent to participate in a cancer clinical trial and knowledge and perceived understanding of the trial. Furthermore, associations between demographic factors and consent to participate and knowledge and perceived understanding of information about the trial were studied.

Methods

The patients were recruited in connection to a visit at the oncology clinic for information about a drug trial. The Quality of Informed Consent questionnaire was mailed to the patients after they had decided about participation in the trial. The associations of demographic factors and "knowledge" and "perceived understanding" were analysed using linear regression models.

Results

A total of 125 patients were included. Higher levels of "knowledge" and "understanding" were found to be associated with consent to participate in a clinical trial, both in the univariate and multivariate analyses (p = 0.001). None of the tested demographic factors were related to consent to participate. No statistically significant associations between any of the demographic factors and knowledge or perceived understanding scores were found.

Conclusion

The results indicate that interventions that increase patients' knowledge and perceived understanding might improve participation rates in clinical trials.

Anxiety and depressive symptoms measured by the Hospital Anxiety and Depression Scale as predictors of time to recurrence in localized cutaneous melanoma

The purpose of this study was to investigate anxiety and depression as predictors for recurrence-free survival in cutaneous melanoma, when corrected for known prognostic factors. The association between known prognostic factors and anxiety and depression were also studied. Consecutive patients (n = 437) completed the Hospital Anxiety and Depression Scale (HAD) approximately three months after diagnosis of melanoma. Neither anxiety, nor depression turned out to be prognostic factors for time to recurrence. A higher proportion of young patients, women, patients without ulcerated tumours, patients with tumours with low mitotic index and Clark's level II tumours scored > or = 8 (possible clinical levels of anxiety) on the anxiety scale. Furthermore, on the depression scale, a higher proportion of young patients scored > or = 8 (possible clinical level of depression). Using the HAD scale, a well-validated instrument for assessing anxiety and depression in patients with somatic diseases, our data did not show any associations between anxiety or depression and outcome in terms of recurrence in patients with localized disease.

Audio-recorded information to patients considering participation in cancer clinical trials - a randomized study

BACKGROUND

Patient information in cancer clinical trial is challenging. The value of audio-recording interventions for patients considering participating in clinical trials is unclear. The primary aim of this randomized study was to investigate effects of audio-recorded information on knowledge and understanding in patients considering participation in a clinical trial.

MATERIAL AND METHODS

Patients scheduled for information about a phases 2 or 3 trial by one of the 13 participating oncologists at the Department of Oncology during the study period (2008-2013) were eligible. The intervention consisted of an audio-recording on compact disc (CD) of the information at the medical consultation in which the patients were informed about a trial. Knowledge and understanding was measured by the questionnaire, Quality of Informed Consent.

RESULTS

A total of 130 patients were randomized, 70% of the calculated sample size (n = 186). Sixty-seven patients were randomized to the intervention. In total, 101 patients (78%) completed questionnaires. No statistical significant differences were found between the groups with respect to knowledge and understanding. The level of knowledge was relatively high, with the exceptions of the risks associated with, and the unproven nature of, the trial. Overall, patients who declined participation scored statistically significant lower on knowledge.

CONCLUSION

The present study was underpowered and the results should therefore be interpreted with caution. Still, 130 patients were included with a response rate of 78%. A CD including the oral information about a clinical trial did not show any effects on knowledge or understanding. However, the levels of knowledge were high, possible due to the high levels of education in the study group. Information on risks associated with the trial is still an area for improvement.

No differences between Calendula cream and aqueous cream in the prevention of acute radiation skin reactions--results from a randomised blinded trial

PURPOSE

The purpose of this blinded, randomized clinical trial was to compare two topical agents (Calendula Weleda cream vs. Essex cream) in reducing the risk of severe acute radiation skin reactions (ARSR) in relation to adjuvant radiotherapy (RT) for breast cancer.

METHOD

The primary endpoint was the difference in proportion of patients with ARSR, assessed with the Radiation Therapy Oncology Group/The Organization for Research and Treatment of Cancer Acute Radiation Morbidity Scoring Criteria (RTOG/EORTC scale) at follow-up. The secondary endpoints included patient reported outcome measures; Quality of Life Questionnaire (QLQ-C30), Sleep disturbances (MOS-sleep questionnaire) and symptoms from the irradiated area (visual analogue scale). Patients' experiences and adherence to the topical agents were also evaluated.

RESULTS

A total of 420 patients were randomised and 411 were analysed. With the exception of previous chemotherapy, the treatment groups were well balanced, both regarding treatment- and patient-related factors. The incidence of severe ARSR (RTOG/EORTC grade ≤2) at the follow-up visit was 23% (n = 45) in the Calendula group and 19% (n = 38) in the Essex group. We found no difference in severe ARSR between the groups at any point of assessment. The patients reported low levels of skin related symptoms and no statistically significant differences between the groups were found.

CONCLUSIONS

No differences in ARSR between patients randomised to Calendula or Essex cream was found. ARSR seem to be a relatively limited problem, probably more influenced by treatment related factors than by choice of skin care products in this patient group.

Cancer rehabilitation: A Nordic and European perspective

BACKGROUND

The increasing incidence of cancer combined with prolonged survival times seen throughout the western world increases the need for rehabilitation. Diagnosis and treatment for cancer may have substantial effects on the patients' physical, psychological, social and existential well-being. The aim of this paper is to describe the current situation in cancer rehabilitation in the Nordic countries, the Netherlands and Germany.

MATERIAL AND METHODS

Description of the current situation in cancer rehabilitation in the Nordic countries and literature review.

RESULTS

Rehabilitation as defined by multiple organizations covers a multidimensional view on chronic disease and its effect on the patient's life. The rehabilitation systems in Denmark, Finland, Sweden, Germany and the Netherlands differ depending on the differing social security and health-care systems, but rehabilitation provided is largely based on a similar, multidimensional and multidisciplinary understanding of cancer rehabilitation. Research on rehabilitation efforts in European countries indicates that there is substantial evidence with regard to single interventions which can be part of cancer rehabilitation.

DISCUSSION

In order to assure patients and families continuing quality of life, rehabilitation should be an integral and continuous part of all cancer care.

Levels of knowledge and perceived understanding among participants in cancer clinical trials - factors related to the informed consent procedure

BACKGROUND

An informed consent from patients participating in cancer clinical trials is mandatory according to international and national guidelines and laws. Insufficient knowledge and understanding by trial participants have been reported in several studies.

PURPOSE

The aims of this study were to investigate factors of importance for knowledge and understanding about cancer clinical trials among trial participants.

METHODS

All patients consenting to a phase II or III clinical trial during 1 year were invited (n = 325). Data on knowledge and perceived understanding were collected by a questionnaire, Quality of Informed Consent.

RESULTS

are based on data from 268 patients (82%). Associations between knowledge and perceived understanding as well as clinical, socio-economic factors, and factors related to the informed consent procedure were tested. Results In the multivariate analysis no statistically significant associations were found between knowledge and any of the factors. Patients who reported longer time for trial information before their decision to participate, those who found the decision easy to take, and patients who reported use of other information sources had statistically significant higher perceived understanding. No differences in mean scores for knowledge or perceived understanding were found for any of the clinical factors (age, gender, diagnostic group, trial phase), socio-economic factors (education, marital status), and the following factors related to the informed consent procedure; presence of relative or nurse at information about the trial or previous participation in clinical trials.

LIMITATIONS

No study specific questions were included due to the number of trials (n = 35).

CONCLUSION

Strategies to increase patients' knowledge needs to be elaborated in order to improve the fulfilment of the requirements of informed consent in participants in cancer clinical trials.

Surgical resection margins do not influence health related quality of life or emotional distress in patients with cutaneous melanoma: results of a prospective randomised trial

In a prospective randomised Scandinavian trial, patients with localised invasive cutaneous melanoma of the trunk or extremities with tumours more than 2 mm thick were randomly assigned to excision with narrow (2 cm) or wide (4 cm) margins after primary surgery. The aims of the present study were to find out if there were any differences in health-related quality of life (QoL) and emotional distress between patients in the two arms over time. Patients were assessed at four time points: before randomisation, and at 3, 9, and 15 months after inclusion, using the EORTC QLQ-C30, the Hospital Anxiety and Depression Scale and the Impact of Event Scale. A study-specific questionnaire was used to assess patient-reported problems related to the scar. A total of 144 patients were included; 70 randomised to narrow excision and 74 to wide excision margins. The response rate was >85% at all assessment points. No differences between the two arms were found for health-related QoL or emotional distress. Emotional functioning, insomnia, anxiety, intrusion, and avoidance improved over time (p <or= 0.0001). Thirty patients (32%) reported problems with the scar but there was no difference between the two arms. No differences in health-related QoL or emotional distress were found between the two arms, indicating that resection margins have limited impact on these variables.

An international validation study of the EORTC QLQ-INFO25 questionnaire: an instrument to assess the information given to cancer patients

AIM

The EORTC Quality of Life (QOL) Group has developed an instrument to evaluate the information received by cancer patients. This study assessed the psychometric characteristics of the EORTC INFO module in a large international/multi-cultural sample of cancer patients.

METHODS

The provisional 26-item information module (EORTC INFO26) was administered with the EORTC QLQ-C30 and the information scales of the inpatient satisfaction module EORTC IN-PATSAT32 on two occasions during the patients' treatment and follow-up period. Questionnaire-hypothesised scale structure, reliability, validity and responsiveness to changes were evaluated through standard psychometric analyses. Patient acceptability was assessed with a debriefing questionnaire.

RESULTS

The study comprised 509 patients from 8 countries (7 European countries and Taiwan) with different cancers and disease stages. Multi-trait scaling analysis led to the deletion of one item but confirmed the hypothesised 4 multi-item scales (information about disease, medical tests, treatment and other services) and eight single items. Internal consistency for all scales was good (α>0.70), as was test-retest reliability (intraclass correlations>0.70). All items can be combined to generate a single score (α>0.90). Convergent validity was supported by significant correlations with related areas of IN-PATSAT32 (r>0.40). Low correlations with EORTC QLQ-C30 scales confirmed divergent validity (r<0.30) The EORTC INFO-25 module discriminated among groups based on gender, age, education, levels of anxiety and depression, information wishes and satisfaction. Only one scale captured changes over time.

CONCLUSIONS

The EORTC QLQ-INFO 25 is a reliable and valid self-reported instrument. The module can be used in cross-cultural observational and intervention studies.

Family members' perceptions of genetic testing for malignant melanoma--a prospective interview study

PURPOSE

The aim was to prospectively explore experiences related to genetic testing for malignant melanoma among unaffected previously untested members of melanoma-prone families in which germline CDKN2A mutations had been identified.

METHOD

Consecutive members of families with CDKN2A mutation attending a pigmented lesion clinic (n=11) were interviewed and completed questionnaires at four occasions: before genetic testing, at disclosure of genetic test result and six months and one year after disclosure. The following areas were measured: anxiety and depression, risk perception, and sun-related habits.

RESULTS

Disclosure of the test result did not seem to change family members' perception of their risk of developing melanoma. Few members reported anxiety of clinical significance and no one were depressed. All family members with biological children expressed concerns regarding their children and emphasized the importance of sun protection and surveillance. Sun burns and blisters were rather commonly reported by the family members. Routines regarding the procedure for conveying test result were requested.

CONCLUSION

Genetic testing of the members of melanoma families with CDKN2A mutations attending a pigmented lesion clinic did not appear to induce behavioral changes related to sun habits or emotional problems. Concerns about the future of their children were commonly expressed by participants.

Improvements in patient satisfaction at an outpatient clinic for patients with breast cancer

The present study prospectively investigated changes in patient satisfaction at an outpatient clinic for patients with breast cancer. Consecutive patients were asked to anonymously complete a questionnaire after their medical examination. The questionnaire consisted of 12 multiple-choice items concerning waiting time, interpersonal skills of physician and nurse, continuity of care, length of medical visit, communication and expectations. Finally, patients were asked for suggestions for improvements at the clinic in an open-ended question. The first measurement was conducted in 2000/2001 and the last in 2004, and between the two points of assessments efforts to develop care were introduced. Statistically significant improvements were found in eight of the 12 items: waiting time, length of medical visit, information, expectations and continuity of care. In conclusion, the questionnaire captured positive changes in patient satisfaction between the two measurements. Further changes for the better were still requested concerning continuity of care despite reported improvement.

Knowledge and understanding among cancer patients consenting to participate in clinical trials

The aim of this study was to explore the fulfilment of the requirements of informed consent in patients participating in cancer clinical trials. All patients consenting to a phase II or III clinical trial during one year were included (n=325, 176 women, 54%). Data were collected by a questionnaire, Quality of Informed Consent. The response rate was 87%. High levels of knowledge (>80%) were found for items concerning voluntariness, randomisation, benefits for future patients, participation in a research trial, and the right to withdraw. Less than 50% responded correctly to items about risks associated with the trial, the unproven nature of the trial and issues about insurances. High levels of perceived understanding were reported. Despite high levels of knowledge and perceived understanding in the majority of elements of informed consent, improvements are warranted regarding knowledge about risks, the unproven nature of the treatment and the duration of treatment.

Monitoring of Kindreds With Hereditary Predisposition for Cutaneous Melanoma and Dysplastic Nevus Syndrome: Results of a Swedish Preventive Program

Purpose

To evaluate a program initiated in 1987 by the Swedish Melanoma Study Group aiming to provide preventive surveillance to kindreds with hereditary cutaneous melanoma and dysplastic nevus syndrome.

Patients and Methods

Overall, 2,080 individuals belonging to 280 melanoma families were followed for 14 years between 1987 and 2001 at 12 participating centers. Data were registered in a central database.

Results

Among 1,912 skin lesions excised during follow-up, 41 melanomas were removed in 32 individuals. Of these, 15 (37%) were in situ melanomas and 26 (63%) invasive melanomas. The median tumor thickness of invasive melanomas was 0.5 mm. Ulceration was absent in 24 of 26 invasive melanomas (92%) and 12 (46%) lacked vertical growth phase. Compared with melanomas in the general Swedish population, the melanomas identified in these kindreds during follow-up had better prognostic characteristics. All melanomas except one were diagnosed in families with two or more first-degree relatives with melanoma. Diagnosis of melanoma occurred in three of eight kindreds with germline CDKN2A mutations, supporting that families with such mutations are at increased risk for melanoma development. Of the 32 individuals who developed melanoma during follow-up, 21 (66%) had had at least one previously diagnosed melanoma.

Conclusion

This study shows that a coordinated program aimed at detecting and offering skin surveillance in kindreds with hereditary cutaneous melanoma results in a low incidence of melanomas during the follow-up period and that the tumors that do arise have favorable prognostic characteristics.

Life, illness and death—Existential reflections of a Swedish sample of patients who have undergone curative treatment for breast or prostatic cancer

The aim of this study is to describe cancer patients' existential reflections and how these reflections were met by the nursing staff. A qualitative method of data collection was used. Ten patients with breast- or prostate cancer who had completed curative treatment were interviewed. The results showed that the cancer diagnosis resulted in existential reflections in some of the patients. These reflections concerned the meaning of life, God/a higher power, health, work, relations and sexuality. Reflections on the cancer consisted in beliefs about the causes of cancer, treatment and cancer and sexuality. It could also be seen that loss of important life values, such as health and sexuality could lead to loss of meaning of life. Explicit reflections on sexuality were only made by two of the men in the study. The patients reported a need of existential support as well as obstacles for giving such support. Obstacles could be lack of time and lack of continuity, as well as lack of knowledge resulting in an inability to identify existential issues. Some of the patients had wanted existential support from nurses, while others received the support they needed from family and friends.

Detection of nodular and superficial spreading melanoma with tumour thickness < or = 2.0 mm--an interview study

Differences regarding signs and symptoms between nodular melanoma (NM) and superficial spreading melanoma (SSM) with a tumour thickness < or = 2.00 mm were studied. Reasons for seeking medical attention were also investigated. Semi-structured interviews were conducted with 22 patients with NM diagnosed between 1994 and 1999 and 32 patients with SSM, matched to the NM patients with respect to age at diagnosis, gender and tumour thickness. NM were smaller in diameter, and 5 of 6 patients reporting a diameter <5 mm had NM. NM were more often new lesions than SSM, which more often had developed from pre-existing naevi. In most cases (61%), the melanoma was first detected by the patient and in 17% it was detected by the patient in combination with a family member. The most important reasons to seek medical attention were a change in the lesion or a symptom (65%), followed by encouragement from others to seek medical attention. Twenty-four patients (44%) had no symptoms of melanoma prior to diagnosis. Our results have important implications for prevention. It should be emphasized in public education that melanomas may have a diameter <6 mm and that family members have an important role in detection of melanoma and in motivating medical advice.

Sunbathing and sun-protection behaviors and attitudes of young Swedish adults with hereditary risk for malignant melanoma

The aim of the study was to describe attitudes toward sunbathing and sun protection, to examine sun-related behaviors, and to present an effort to change sun-related behaviors among young adults without a cancer diagnosis in melanoma-prone families. Ten patients were interviewed, and questionnaires were sent on 3 occasions during a 15-month period to the total population (n = 87) meeting the inclusion criteria. Data from interviews and questionnaires showed extensive ultraviolet-exposure behaviors in this high-risk group for melanoma, although not always expressed in terms of sunbathing. When asked about sunbathing, 1/3 reported sunbathing "Often" or "Very often," despite a decrease in sunbathing during the study period. In addition, 35% reported current sun bed use. The most important reason for sunbathing was attractiveness. The risk of getting skin cancer was the most important reason to refrain from sunbathing. The majority estimated their own risk for melanoma as equal or lower compared with the general population. The planned intervention failed due to low attendance. Ultraviolet exposure is extensive. The individual perception of personal risk and the motivation to change behaviors are important factors to consider when designing a preventive program. Interest for group information was low in this age group.

Nodular histogenetic type -- the most significant factor for thick melanoma: implications for prevention

Tumour thickness is the most important prognostic factor in malignant melanoma. To reduce the melanoma-related mortality, factors related to the presentation of thick melanoma have to be identified. Three samples of melanoma patients (n=694) were studied for this purpose. Histogenetic type was the only factor which differentiated between 'thin' (< or = 0.8 mm) and 'thick' (> 2.0 mm) lesions. During a 10-year period only 3% of the nodular lesions were 'thin' at diagnosis. Differences in knowledge about melanoma or the location of the lesion (either 'easy' or 'difficult' for the patient to observe) did not explain differences in tumour thickness. The most common tumour site irrespective of histogenetic type and gender was 'back of the trunk'. 'Increase in diameter' and 'bleeding' were the symptoms most frequently reported by patients with 'thick' melanoma. 'Thick' lesions were diagnosed in older age groups and in men to a greater extent. Considering these results, melanoma prevention should also be targeted to older age groups and attention should be paid to symptoms such as 'increase in diameter' even in the absence of other characteristic symptoms of melanoma. An increased proportion of nodular melanoma diagnosed as 'thin' lesions can be interpreted as a step forward in secondary prevention.

Factors related to non-attendance in a population based melanoma screening program

A total of 127 non-attenders in a population-based melanoma screening program, 58 women and 69 men, were asked in a telephone interview about reasons for non-attendance. Of those, 105 also completed a mailed questionnaire, measuring perceived susceptibility to and knowledge about melanoma. During the same period, attenders (n = 286) at the screening clinic completed the same questionnaire. The most commonly reported reasons for non-attendance were 'I forgot about it', 'lack of time' and 'no need for examination'. A majority of non-attenders held a positive attitude towards preventive programs in general and to the present invitation. Most of the improvements suggested by the non-attenders were strategies to reduce practical barriers. Non-attenders scored lower than attenders on perceived susceptibility. High and equal levels of knowledge about melanoma were found among attenders and non-attenders. Men were more likely to be non-attenders. Higher perceived susceptibility and a higher level of knowledge about melanoma were found among women as compared to men. The results suggests that there is potential to increase attendance in future melanoma programs by reducing practical barriers.

Six-month follow-up of effects of an information programme for patients with malignant melanoma

Using a randomized design, the effects of an information programme for melanoma patients were studied. The programme consisted of a group meeting and a brochure. The present study reports on the six-month follow-up of the effects of the programme. A total of 128 patients participated in the programme, 55 before and 73 after the first medical control visit. Questionnaires regarding knowledge about melanoma, psychological and psychosomatic variables were completed at the first medical control visit and six months later by mail. A questionnaire concerning patients attitudes to the programme was included after six months. Knowledge about melanoma increased and a majority of patients were satisfied with the information brochure, the group meeting and the group leader, but 40% considered that too few participants attended in their group meeting. No effects on psychological or psychosomatic variables were found. Men and women participated to the same extent.

Prevalence of primary acquired melanosis and nevi of the conjunctiva and uvea in the dysplastic nevus syndrome. A case-control study

PURPOSE

To investigate whether conjunctival and uveal nevi and primary acquired melanosis are more common in individuals with the dysplastic nevus syndrome than in control subjects derived from the general population.

METHODS

Power calculations were used to determine the sample size. After invitation, 162 individuals with the dysplastic nevus syndrome and 119 control subjects, matched for sex and age but otherwise randomized from the Stockholm county census file, were entered into the study. All individuals were examined in a masked fashion by the same ophthalmologist, and the presence of conjunctival and uveal melanocytic lesions and the iris color, skin type, and hair color of each individual were recorded. Contingency tables and odds ratios were used for statistical evaluation.

RESULTS

The proportions of individuals with the dysplastic nevus syndrome featuring primary acquired melanosis of the conjunctiva, or nevi of the iris and choroid were not significantly different from those of control subjects. However, individuals with the dysplastic nevus syndrome appeared to have a more sun-sensitive skin type and a reddish or blond hair color more often than control subjects.

CONCLUSION

In contrast to previous reports, this study suggests that ocular melanocytic lesions are no more common in individuals with the dysplastic nevus syndrome than in the general population. Therefore, this work does not provide support that periodic ophthalmic surveillance of individuals with the dysplastic nevus syndrome for the purpose of detecting conjunctival or uveal melanomas, or their precursors, is meaningful.

Information to patients with malignant melanoma: a randomized group study

An information programme for patients with cutaneous malignant melanoma, Stage 1, aiming at increasing satisfaction with information, was carried out at the Department of Oncology (Radiumhemmet). The programme consisted of a group meeting and a brochure. A total of 231 consecutive patients were included, and 149 (65%) reported interest in participation and were randomized to the Information group (n = 77) or to the Control group. A total of 67 patients (29%) were not interested (the NI-group). To evaluate the programme, the patients in the three groups completed questionnaires regarding satisfaction with information, knowledge of melanoma and psychological and psychosomatic variables before randomization and at the first visit for follow-up at Radiumhemmet. After the information programme, the Information group was significantly more satisfied with information, had a higher level of knowledge and a lower proportion requested further information as compared with the Control group. No differences were found on the psychological and psychosomatic variables.

Psychological effects of participation in a prevention programme for individuals with increased risk for malignant melanoma

The Swedish Melanoma Study Group runs a programme aimed at prevention and early detection of premalignant and malignant melanoma in families with two or more members having malignant melanoma. Psychological consequences of participation in this programme were studied. A questionnaire containing items concerning cognitive and emotional responses to the programme was completed by 115 consecutive individuals at their first visit to the clinic. The same questionnaire was administered by mail 7 months later. The levels of psychological and psychosomatic problems were relatively low at both points of assessment. No negative psychological effects were found, neither in the group with dysplastic naevus syndrome (DNS) with increased risk for malignant melanoma, nor in the group without dysplastic naevi. Only one variable, "emotional responses to the visit" differentiated between the groups, with higher scores in the group without DNS. A majority of the individuals expressed positive attitudes to the clinic.