Factors influencing adherence to cancer treatment in older adults with cancer: a systematic review

BACKGROUND

Cancer is a disease that mostly affects older adults. Treatment adherence is crucial to obtain optimal outcomes such as cure or improvement in quality of life. Older adults have numerous comorbidites as well as cognitive and sensory impairments that may affect adherence. The aim of this systematic review was to examine factors that influence adherence to cancer treatment in older adults with cancer.

PATIENTS AND METHODS

Systematic review of the literature published between inception of the databases and February 2013. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of cancer treatment adherence were included. Data sources included MEDLINE, EMBASE, PsychINFO, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, ASSIA, Ageline, Allied and Complementary Medicine (AMED), SocAbstracts and the Cochrane Library. Two reviewers reviewed abstracts and abstracted data using standardized forms. Study quality was assessed using the Mixed Methods Appraisal Tool 2011.

RESULTS

Twenty-two manuscripts were identified reporting on 18 unique studies. The quality of most studies was good. Most studies focused on women with breast cancer and adherence to adjuvant hormonal therapy. More than half of the studies used data from administrative or clinical databases or chart reviews. The adherence rate varied from 52% to 100%. Only one qualitative study asked older adults about reasons for non-adherence. Factors associated with non-adherence varied widely across studies.

CONCLUSION

Non-adherence was common across studies but little is known about the factors influencing non-adherence. More research is needed to investigate why older adults choose to adhere or not adhere to their treatment regimens taking into account their multimorbidity.

To tell or not to tell: patterns of disclosure among men with prostate cancer

This paper draws on the results of a longitudinal, qualitative study of men with prostate cancer (treated with prostatectomy) and their spouses. Interviews were conducted separately and simultaneously with men and their spouses, at three points in time (pre-surgery, 8-10 weeks post-surgery and 11-13 months post-surgery). The primary focus in the paper is on men's responses to questions about their decisions to share information (or not) with others about their diagnosis and ongoing medical situation. Most men with prostate cancer avoided disclosure about their illness where possible, and placed great importance on sustaining a normal life. Factors related to limiting disclosure included men's low perceived need for support, fear of stigmatization, the need to minimize the threat of illness to aid coping, practical necessities in the workplace, and the desire to avoid burdening others. This study contributes to an understanding of disclosure issues related to prostate cancer, and raises issues about how best to be helpful to men, given their tendency to minimize the impact of illness, and the need for support.

Individual correlates of health service utilization and the cost of poor adjustment to chronic illness

It was conjectured that a small group of chronically ill in tertiary ambulatory clinics consume a large amount of health resources and that, from the perspective of the patient, psychosocial rather than disease variables would most explain their health service utilization and subsequent cost. New referrals with a chronic illness (N = 215) to one of three clinics (oncology, rheumatology, and gastroenterology) consented to participate in a subsequent trial of a psychosocial intervention designed to promote their adjustment to illness and, conceivably, to reduce their health service utilization. At baseline an inventory to describe the disease, treatment, functional capacity, prognosis, and socioeconomic situation of consenting subjects was completed. In addition, subjects completed the Psychosocial Adjustment to Illness Inventory (PAIS-SR), the Family Assessment Device (FAD), the Meaning of Illness Questionnaire (MIQ), and a Health Service Utilization Inventory designed to assess direct and indirect costs of health resources. These data were entered into a concurrent analytic survey design. Participating subjects represented a more socioeconomically advantaged and better-adjusted group of chronically ill patients compared with others referred to the tertiary clinics. They were representative of all new referrals in their use of the majority of health services. However, once hospitalized, participating subjects stayed longer and used specialists less. There was no important relationship between disease severity or prognosis and any type of service utilization, including hospitalization. Because the strongest correlate of all types of health services consumed was psychosocial adjustment to illness (r = 0.28 to 0.33), patients were partitioned into one of three categories of adjustment to illness: good, fair, and poor. The total annual cost per patient was $23,883, if poorly adjusted, compared with $9,791 if well adjusted. If cash transfers (benefits paid by different types of insurance) are added, the average 1987 annual cost per poorly adjusted subject was $31,291 per patient, compared with $13,771 for a patient well adjusted to the illness. There was a statistically significant and economically important linear gradient in 1987 treatment costs per category of adjustment. The possible economic implications for psychosocial intervention are highlighted.

Nutrient utilization by cells isolated from rat jejunum, cecum and colon

Cells isolated from the jejunum, cecum and colon of rats were used to study the oxidation of nutrients by quantifying the production of 14CO2 from 5 mmols/L 14C-labeled exogenous substrate. In colonic cells, the decreasing order of oxidation was as follows: butyrate greater than acetate greater than propionate, glucose and glutamine. Acetate and butyrate significantly suppressed oxidation of both glucose and glutamine. In cells taken from the cecum, butyrate was oxidized at a greater rate than all other substrates. Cells taken from the jejunum produced CO2 from exogenous substrates in decreasing order as follows: glutamine greater than glucose much greater than acetate, propionate and butyrate. Butyrate oxidation was significantly reduced in colonic cells by 3-hydroxybutyrate, and it was reduced in cecal cells by glucose. Comparisons among the three gut segments showed no differences in glutamine oxidation. Glucose oxidation was greater in cells taken from the colon than from the cecum or jejunum, which were similar. Butyrate and acetate were oxidized at higher rates in cells taken from the cecum and colon than in cells taken from the jejunum, and propionate was oxidized at a greater rate in cells taken from the colon than from the jejunum. These studies demonstrate that relative rates of substrate oxidation differ along the intestinal tract of rats.

Managing the Impact of Illness: The Experiences of Men with Prostate Cancer and their Spouses

This qualitative study explored issues of support and coping for couples where the man had been diagnosed with prostate cancer. Thirty-four men with prostate cancer and their spouses were interviewed separately at three points in time: prior to surgery; 8 to 10 weeks post-surgery; and 11 to 13 months post-surgery. The core category for the couples' experience with diagnosis and treatment for prostate cancer was Managing the Impact of Illness. Five major domains emerged, including: dealing with the practicalities; stopping illness from interfering with everyday life; keeping relationships working; managing feelings; and making sense of it all. While it was clearly important for couples to manage illness and to reduce its potential intrusion into everyday life, this strategy had psychological costs as well as benefits. Men struggled to stay in control of their emotions and their lives, typically vacillating between the pulls of fierce self-reliance and fearful neediness. Women were constrained from employing their usual strategies of coping and were distressed by the complicated requirements of being supportive while also honoring their partners' need for self-reliance.

A qualitative study of breast cancer self-help groups

This study reports on the experience of women in four community breast cancer self-help groups in Ontario, Canada. Semi-structured interviews were conducted with 24 women, asking them about benefits and limitations of their group involvement, and about their perspectives on group processes and structures. Overall, participants reported their group involvement to be extremely helpful for navigating the short and long-term impact of breast cancer. Emotional support benefits included connecting with other breast cancer survivors, feeling understood and sharing experiences, providing hope, and sharing healing laughter. Informational and practical support benefits included sharing of important information and learning how to get what you want. Even where there were concerns about limitations or tensions of group experience, these occurred against a backdrop of appreciation and commitment. From the discussion of group processes and structures, a number of issues were identified as problematic. Most notable were how to deal with deaths of group members and how to balance the group's primary purpose of providing mutual support with secondary goals of dealing with group business and engaging in meaningful advocacy.

The information needs of well, longer-term survivors of breast cancer

Nine focus groups for well, longer-term survivors of breast cancer were held in Ontario, Canada. Prevalent themes identified through analysis of focus group transcripts fell into two broad categories, one reflecting the context within which women seek information and the other reflecting the content of information desired and sought. Themes related to context included: the ongoing impact on women of their initial disease experience and continued uncertainty about possible recurrence; womens' lack of information and understanding about processes involved in developing medical knowledge; prevailing mistrust about the impact of cost curtailment policies; and, concerns related to how professional communication can aid or hinder the goal of obtaining information. Themes related to content issues included: follow-up protocols, tamoxifen, detecting signs of possible recurrence, prevention for daughters, neglected side effects of treatment, insurance, lifestyle, and unconventional therapies.

The efficacy, challenges, and facilitators of telemedicine in post-treatment cancer survivorship care: an overview of systematic reviews

BACKGROUND

Telemedicine services have been increasingly used to facilitate post-treatment cancer survivorship care, including improving access; monitoring health status, health behaviors, and symptom management; enhancing information exchange; and mitigating the costs of care delivery, especially since the COVID-19 pandemic. To inform guidance for the use of telemedicine in the post-COVID era, the aim of this overview of systematic reviews (SRs) was to evaluate the efficacy of, and survivor engagement in, telemedicine interventions in the post-treatment survivorship phase, and to consider implementation barriers and facilitators.

METHODS

PubMed, Cochrane CENTRAL, CINAHL, Embase, and Web of Science databases were searched. SRs that examined the use of telemedicine in the post-treatment phase of cancer survivorship, published between January 2010 and April 2021, were included. Efficacy data were synthesized narratively. Implementation barriers and facilitators were synthesized using the Consolidated Framework for Implementation Research.

RESULTS

Twenty-nine SRs were included. A substantive body of evidence found telemedicine to benefit the management of psychosocial and physical effects, particularly for improving fatigue and cognitive function. There was a lack of evidence on the use of telemedicine in the prevention and surveillance for recurrences and new cancers as well as management of chronic medical conditions. This overview highlights a range of diverse barriers and facilitators at the patient, health service, and system levels.

CONCLUSIONS

This review highlights the benefits of telemedicine in addressing psychosocial and physical effects, but not in other areas of post-treatment cancer survivorship care. This large review provides practical guidance for use of telemedicine in post-treatment survivorship care.

One-on-one peer support and quality of life for breast cancer patients

The Canadian Cancer Society's Reach to Recovery program provides one-on-one support for breast cancer patients that is delivered by breast cancer survivors. Professionally-led social support programs have generally been found to influence positively the quality of life of cancer patients. However, there is a lack of evidence on the benefits of one-on-one peer support programs. An evaluation of the Reach to Recovery program was completed in 1995 to determine if cancer patients who received the program were satisfied with the program and to determine if participation in Reach to Recovery affected the quality of life of program participants compared to patients who did not receive the program. We found that Reach to Recovery program participants were generally satisfied with the program they received and that the program has incremental benefits to the quality of life of patients with breast cancer. Peer-led, volunteer breast cancer support programs can be effective in enhancing the quality of life of breast cancer patients.

A qualitative study of patient perspectives on colorectal cancer

OBJECTIVES

The purpose of this study was to use qualitative methods to contribute to a complete patient perspective on the psychosocial impact of colorectal cancer.

MATERIALS AND METHODS

A qualitative descriptive study was conducted in 20 patients attending a gastrointestinal follow-up clinic at the Toronto-Sunnybrook Regional Cancer Centre. The data documented included patient satisfaction and perceptions regarding to quality of care, information received, involvement in decision making, and long-term management of the illness.

RESULTS

Overall, patients were satisfied with their treatment, including the quality and timeliness of the information they received, the quality of their healthcare, and the level of involvement in decision making. However, some patients were dissatisfied with information concerning long-term management of their illness. Patient care, including information and social support, was provided by cancer specialists, family physicians, family, and friends. Patients looked to cancer specialists as their primary source of information, but relied on family physicians to fill in gaps in understanding, to provide support, to manage overall care, and to act as a sounding board for ideas and treatment options. Social support was also provided by family and friends. All patients had a relatively positive outlook on their illness experience, although those with colostomies had some added difficulty. Despite the focus on positive change, many patients acknowledged difficulty coping with the side effects of treatment.

CONCLUSIONS

These data indicate that patient information needs to be provided in the most common terms and the most straightforward language. Information also may need to be repeated and should include attention to long-term management of the illness. Health professionals should assume that patients may have difficulty in illness management and should encourage a discussion of patients' concerns.

Virus Coat Protein Transgenic Papaya Provides Practical Control of Papaya ringspot virus in Hawaii

Since 1992, Papaya ringspot virus (PRSV) destroyed nearly all of the papaya hectarage in the Puna district of Hawaii, where 95% of Hawaii's papayas are grown. Two field trials to evaluate transgenic resistance (TR) were established in Puna in October 1995. One trial included the following: SunUp, a newly named homozygous transformant of Sunset; Rainbow, a hybrid of SunUp, the nontransgenic Kapoho cultivar widely grown in Puna, and 63-1, another segregating transgenic line of Sunset. The second trial was a 0.4-ha block of Rainbow, simulating a near-commercial planting. Both trials were installed within a matrix of Sunrise, a PRSV-susceptible sibling line of Sunset. The matrix served to contain and trace pollen flow from TR plants, and as a secondary inoculum source. Virus infection was first observed 3.5 months after planting. At a year, 100% of the non-TR control and 91% of the matrix plants were infected, while PRSV infection was not observed on any of the TR plants. Fruit production data of SunUp and Rainbow show that yields were at least three times higher than the industry average, while maintaining percent soluble solids above the minimum of 11% required for commercial fruit. These data suggest that transgenic SunUp and Rainbow, homozygous and hemizygous for the coat protein transgene, respectively, offer a good solution to the PRSV problem in Hawaii.

Television and families: what do young children watch with their parents?

A sample of 271 3- and 5-year-olds and their families participated in a 2-year longitudinal study of television viewing patterns. 5 1-week diaries for all family members were collected at 6-month intervals. Programs were categorized as: (1) child informative, (2) child entertainment, (3) news and informative, (4) sports, (5) comedy, (6) drama, (7) action-adventure, and (8) variety-game. The majority of child programs were viewed without parents, while the majority of adult programs were watched with parents. Coviewing patterns of adult programs were predicted from parents' individual viewing habits, but not from the child's. Coviewing declined with age. Parental encouragement and regulation of viewing were orthogonal. Children whose parents encouraged viewing watched more child informative programming; children of restrictive parents watched less entertainment programming. Encouraging parents coviewed more than nonencouraging parents. Results support the assertion that parental viewing preferences, habits, and orientations toward television influence children's viewing, both with and without parents.

Pigeons learn the concept of an "A"

Pigeons learned to discriminate between "A"S and "2"s in eighteen different typefaces. They subsequently showed excellent transfer to twenty-two typefaces that they had not previously seen; one pigeon was tested with handwritten letters and responded correctly to them also. Pigeons' responses to "A's and "2's with parts removed suggested that their performance was controlled by several features, none of which alone could be considered necessary or sufficient. A test in which birds were shown other letters of the alphabet supported this conclusion. It appears that the original discrimination was learned as what Ryle calls a "polymorphous concept".

Absorption of short-chain fatty acids from the rat cecum in vivo

Absorption of the short-chain fatty acids (SCFA), acetate, propionate and butyrate, was studied in vivo by measuring their disappearance from the washed cecum of anesthetized rats. The SCFA seemed to be absorbed predominantly by simple passive diffusion, because there was linear absorption over a wide concentration range, and no evidence of competition or enhancement of absorption when more than one SCFA was present in the lumen. Absorption of these three SCFA was independent of chain length. Their absorption was clearly limited by the lipid membrane, because permeability through the unstirred water layers was much greater than through the lipid membrane. Absorption was unaffected by altering the pH of the luminal infusate between 5.4 and 7.4. Based on our observation that, during absorption, there were increases in pH, total CO2 and HCO3- but no change in pCO2, we suggest that SCFA are absorbed primarily via diffusion involving anionic exchange with HCO3-.

Prevalence and correlates of family dysfunction and poor adjustment to chronic illness in specialty clinics

This study estimated the prevalence of poor adjustment and family dysfunction among three chronically ill clinic patient populations and assessed the biological, situational, social and psychological variables which most explained poor adjustment. Recently referred subjects were approached and 216 chronically ill subjects (from oncology, rheumatology and gastroenterology clinics) completed a Meaning of Illness Questionnaire, the McMaster Family Assessment Device, and the Psychosocial Adjustment to Illness Self-report Scale. In addition, information describing their biological, disease and socioeconomic status was obtained from the clinic record. Respondents were generally representative of other new referrals to the clinics (ineligible for the subsequent trial) in disease characteristics but uniformly came from a more advantaged socioeconomic situation and were better adjusted to illness. Subjects from the three clinics were comparable on meaning, family function and adjustment variables. The proportion of subjects with family dysfunction was 30% and with poor adjustment to illness was 36%, high by community standards. Nevertheless, healthy family functioning and high levels of positive adjustment to chronic illness prevailed and were remarkably similar across clinic settings. Severity or type of disease was not related to adjustment outcomes nor to the level of observed disability. Rather, as hypothesized, meaning given the illness, followed by family function, and disability variables combined to explain 57% of the variance in adjustment outcomes. An intervention designed to improve family function and the meaning given illness was judged suitable.

In vivo absorption of medium-chain fatty acids by the rat colon exceeds that of short-chain fatty acids

BACKGROUND AND AIMS

Short-chain fatty acids (SCFAs) are main fuels of the colonic epithelium, and are avidly absorbed by the colon of animal and man. The current knowledge on colonic metabolism and absorption of medium-chain fatty acids (MCFAs) is limited. In some clinical situations, colonic absorption of high-energy substances could compensate for reduced absorptive capacity because of a shortened or malfunctioning small bowel. We evaluated and compared colonic absorption and metabolism of MCFAs (octanoate, decanoate, and dodecanoate), SCFAs (acetate and butyrate), and long-chain fatty acids (LCFAs) (oleate).

METHODS

Rats were surgically operated on to cannulate a 7-cm segment of proximal colon, isolate the vasculature, and cannulate the right colic vein draining this segment. The lumen was perfused with (14)C-labeled substrates for 100 minutes. Right colic vein blood was analyzed for total (14)C, (14)CO(2), and metabolites by scintillation counting and high-performance liquid chromatography.

RESULTS

The transport from the colonic lumen to mesenteric blood of substrate carbon from MCFAs exceeded by 2-13-fold that of SCFAs and LCFAs. The CO(2) production from the oxidation of MCFAs was as high as or higher than that from SCFAs. CO(2) produced from the LCFA, oleate, was lower than from SCFAs or MCFAs. In addition to CO(2), ketone bodies were major metabolites of SCFAs and MCFAs. Ketogenesis from butyrate and the MCFAs was significantly higher than from acetate and oleate. A substantial proportion (50%-90%) of all substrates was absorbed without being metabolized.

CONCLUSIONS

The colonic epithelium serves to absorb and partially metabolize MCFAs. For patients with a compromised small-bowel function, colonic absorption of MCFAs could represent an important way of receiving calories.

High-fiber diets: influence on characteristics of cecal digesta including short-chain fatty acid concentrations and pH

The effects of two sources of dietary fiber on the characteristics of cecal contents were assessed directly with miniature swine cannulated to facilitate frequent collections of cecal digesta. The short-chain fatty acid (SCFA) concentrations increased and the pH decreased at the same time that meal constituents entered the cecum; PEG was used as a dietary marker. The bean diet resulted in higher concentrations of acetate and total SCFA in cecal digesta, lower concentrations of butyrate, a larger SCFA pool size, and a more acidic pH than did the bran diet. Thus, we conclude that SCFA concentrations and acidity of the digesta are directly related and that dietary fibers can affect simultaneously several variables that are implicated as factors influencing colonic health.

An innovative art therapy program for cancer patients

Art therapy is a healing art intended to integrate physical, emotional, and spiritual care by facilitating creative ways for patients to respond to their cancer experience. A new art therapy program was designed to provide cancer patients with opportunities to learn about the McMichael Canadian Art Collection and to explore personal feelings about their cancer experience through combined gallery and studio components. The role of the facilitator was to assist in the interpretation of a participant's drawing in order to reveal meaning in the art. This paper presents patients' perspectives about the new art therapy program. Content analysis of participant feedback provided information about the structure, process, and outcomes of the program. Evaluation of the art therapy/museum education program demonstrated many benefits for cancer patients including support, psychological strength, and new insights about their cancer experience.

Glucose and glutamine provide similar proportions of energy to mucosal cells of rat small intestine

The objectives of this study were to establish a reliable method for quantifying glycolytic flux in intestinal epithelial cells, to determine the proportion of energy provided to small intestine epithelial cells by glucose vs. glutamine, and to determine whether there was an energetic advantage to having both substrates present simultaneously. There was substantial retention of 3H in alanine and lactate when [2-(3)H]glucose was used as tracer for quantifying glycolysis, and the magnitude of the 3H retention was influenced by the presence of other substrates and metabolites. Detritiation was at least 99% complete, however, when [3-(3)H]glucose was used as tracer in this system and the tritium was recovered as 3H2O. Glycolytic flux was six- to sevenfold higher in cells of the proximal than distal small intestine but was not significantly different for young adult (4 mo) vs. aged adult (24 mo) rats. Net ATP production from exogenous substrates was higher when both glucose and glutamine were present simultaneously than when either substrate was present alone, and glucose was calculated to provide 50-60% of the net ATP produced from these two substrates. Most of the energy produced from glucose was produced via the anaerobic metabolic pathways (78% for glucose alone, 95% with glucose and glutamine). Net energy production was calculated to be 10% lower in cells from aged animals than in those from young animals, since CO2 production from these major substrates was lower in cells from aged animals.

Qualitative assessment of patient experiences related to extended pelvic resection for rectal cancer

BACKGROUND

Patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) represent a complex management challenge. While there is potential for cure in a subset of patients, the cost in terms of morbidity can be high. Few descriptions of the physical, psychological, social, and emotional experiences of these patients exist.

METHODS

Face-to-face interviews were completed with ten LARC and LRRC patients treated with multimodal therapy that included surgery. Patient opinions and experiences were explored in depth until information redundancy and common themes were delineated using qualitative research methods. Clinical information was obtained from the database.

RESULTS

Nine of the ten patients were male, seven had LARC, and the median age was 71. Six themes were identified from the patient interviews. Themes reflected patients' highly focused desire to seek wellness and cure, but also revealed misunderstanding of their disease biology, probability of cure, therapeutic options, and treatment morbidity.

CONCLUSIONS

Patient experiences confirm that this is challenging treatment to complete, and that patient understanding of pre-operative information is incomplete. Our findings underscore the need for a multidisciplinary approach when managing this patient population, with emphasis on both supportive care needs and the technically skilled delivery of surgery, chemotherapy, and radiotherapy.

ESMO expert consensus statements on the screening and management of financial toxicity in patients with cancer

BACKGROUND

Financial toxicity, defined as both the objective financial burden and subjective financial distress from a cancer diagnosis and its treatment, is a topic of interest in the assessment of the quality of life of patients with cancer and their families. Current evidence implicates financial toxicity in psychosocial, economic and other harms, leading to suboptimal cancer outcomes along the entire trajectory of diagnosis, treatment, supportive care, survivorship and palliation. This paper presents the results of a virtual consensus, based on the evidence base to date, on the screening and management of financial toxicity in patients with and beyond cancer organized by the European Society for Medical Oncology (ESMO) in 2022.

METHODS

A Delphi panel of 19 experts from 11 countries was convened taking into account multidisciplinarity, diversity in health system contexts and research relevance. The international panel of experts was divided into four working groups (WGs) to address questions relating to distinct thematic areas: patients with cancer at risk of financial toxicity; management of financial toxicity during the initial phase of treatment at the hospital/ambulatory settings; financial toxicity during the continuing phase and at end of life; and financial risk protection for survivors of cancer, and in cancer recurrence. After comprehensively reviewing the literature, statements were developed by the WGs and then presented to the entire panel for further discussion and amendment, and voting.

RESULTS AND DISCUSSION

A total of 25 evidence-informed consensus statements were developed, which answer 13 questions on financial toxicity. They cover evidence summaries, practice recommendations/guiding statements and policy recommendations relevant across health systems. These consensus statements aim to provide a more comprehensive understanding of financial toxicity and guide clinicians globally in mitigating its impact, emphasizing the importance of further research, best practices and guidelines.