Effects of a communication training for oncologists on early addressing palliative and end-of-life care in advanced cancer care (PALLI-COM): a randomized, controlled trial.

INTRODUCTION: In advanced cancer care, early communication about palliative care (PC) and end-of-life (EoL)-related issues is recommended, but is often impeded by physicians' communication insecurities. We investigated the effect of a newly developed compact communication skills training 'PALLI-COM' on oncologists' competencies to early address PC/EoL-related issues. MATERIALS AND METHODS: We conducted a randomized, controlled trial (RCT) with an intervention group (IG; 2 × 90 min training) and a wait list control group (CG) at five sites. At two assessment points, participating oncologists led videotaped medical consultations with simulated patients (SPs) via a privacy compliant video conference platform. SPs were represented by trained actors. The taped conversations were rated for primary outcome (communication skills assessed by adapted COM-ON-checklist and COM-ON-coaching rating scales) by raters blinded for study group. Secondary outcomes included oncologists' self-reported communication skills (Self-Efficacy in Palliative Care Scale, Thanatophobia-Scale, Communication about End of Life Survey, study-specific items) as well as external rating of the SPs. Univariate analyses of covariance with baseline adjustment were used to analyze intervention effects. RESULTS: A total of 141 oncologists [age: mean (standard deviation) = 32.7 (6.3) years, 60% female (nIG = 73, nCG = 68)] participated. Following intervention, the IG showed significantly more improvement in four out of five assessed communication skills: 'reacting to emotions and showing empathy', 'pointing out opportunities and giving hope', 'addressing the EoL' and 'explaining the concept of PC'. IG participants also improved more than CG participants in almost all secondary outcomes assessed by participants and SPs: oncologists' self-efficacy, attitudes towards caring for terminally ill patients, communication strategies and confidence in dealing with PC/EoL-related issues as well as communication quality from the SPs' perspective. CONCLUSION: Findings indicate that the compact communication skills training PALLI-COM increases oncologists' competencies in early addressing PC/EoL-related issues from different perspectives. Implementation in routine oncology residency might improve advanced cancer care by strengthening these communication skills.

Comprehensive assessments and related interventions to enhance the long-term outcomes of child, adolescent and young adult cancer survivors - presentation of the CARE for CAYA-Program study protocol and associated literature review.

BACKGROUND: Improved, multimodal treatment strategies have been shown to increase cure rates in cancer patients. Those who survive cancer as a child, adolescent or young adult (CAYA), are at a higher risk for therapy-, or disease-related, late or long-term effects. The CARE for CAYA-Program has been developed to comprehensively assess any potential future problems, to offer need-based preventative interventions and thus to improve long-term outcomes in this particularly vulnerable population. METHODS: The trial is designed as an adaptive trial with an annual comprehensive assessment followed by needs stratified, modular interventions, currently including physical activity, nutrition and psycho-oncology, all aimed at improving the lifestyle and/or the psychosocial situation of the patients. Patients, aged 15-39 years old, with a prior cancer diagnosis, who have completed tumour therapy and are in follow-up care, and who are tumour free, will be included. At baseline (and subsequently on an annual basis) the current medical and psychosocial situation and lifestyle of the participants will be assessed using a survey compiled of various validated questionnaires (e.g. EORTC QLQ C30, NCCN distress thermometer, PHQ-4, BSA, nutrition protocol) and objective parameters (e.g. BMI, WHR, co-morbidities like hyperlipidaemia, hypertension, diabetes), followed by basic care (psychological and lifestyle consultation). Depending on their needs, CAYAs will be allocated to preventative interventions in the above-mentioned modules over a 12-month period. After 1 year, the assessment will be repeated, and further interventions may be applied as needed. During the initial trial phase, the efficacy of this approach will be compared to standard care (waiting list with intervention in the following year) in a randomized study. During this phase, 530 CAYAs will be included and 320 eligible CAYAs who are willing to participate in the interventions will be randomly allocated to an intervention. Overall, 1500 CAYAs will be included and assessed. The programme is financed by the innovation fund of the German Federal Joint Committee and will be conducted at 14 German sites. Recruitment began in January 2018. DISCUSSION: CAYAs are at high risk for long-term sequelae. Providing structured interventions to improve lifestyle and psychological situation may counteract against these risk factors. The programme serves to establish uniform regular comprehensive assessments and need-based interventions to improve long-term outcome in CAYA survivors. TRIAL REGISTRATION: Registered at the German Clinical Trial Register (ID: DRKS00012504, registration date: 19th January 2018).

Socioeconomic status and quality of life in patients with locally advanced head and neck cancer.

PURPOSE: Socioeconomic aspects play an important role in health care. Patients with locally advanced head and neck cancer (LAHNC) experience detrimental effects on their quality of life (QoL). This prospective study examines QoL differences between patients with different socioeconomic status (SES) after intensity-modulated radiation therapy (IMRT). PATIENTS AND METHODS: In all, 161 patients were questioned at the end of IMRT and at 12 and 24 months follow-up using the questionnaires of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-30 and QLQ-HN35. Patients' QoL 2 years after IMRT was compared to a population reference sample and QoL of patients from lower, middle, and higher social class 2 years after IMRT was analyzed by ANCOVA using baseline QoL (end of radiation treatment) as a covariate. RESULTS: Patients with high SES report worse QoL at the end of IMRT in the domains global health status (-15.2; p = 0.005), role function (-23.8; p = 0.002), and social function (-19.4; p = 0.023) compared to patients with middle and low SES. QoL improved during the first 12 and 24 months. However, 2 years after IMRT, middle and low SES patients report lower QoL in the domains global health status, physical function, and role function, and report a higher general (fatigue, pain, dyspnea) and head and neck cancer-specific symptom burden (pain, swallowing, senses, speech, social eating, opening mouth, and felt ill) than patients with high SES. CONCLUSION: After IMRT for LAHNC, patients with high SES report worse QoL compared to patients with middle or low SES. There is a marked improvement within the first 24 months in many domains. However, the magnitude of improvement in patients with middle or low SES is significantly smaller compared to patients with high SES.

[Rehabilitation Processes in Out- and Inpatient Rehabilitation after Radical Prostatectomy]. / Rehabilitationsprozesse in ambulanter und stationärer Rehabilitation nach radikaler Prostatovesikulektomie.

We evaluated processes in in- and outpatient rehabilitation after radical prostatectomy. Overall, we analyzed motivation and expectations of 119 in- and 719 outpatients (aged≤64) at the beginning of rehabilitation as well as satisfaction and the amount of interventions at the end. Compared to inpatients outpatients had a higher socio-economic status and better physical condition. Both groups reported similar outcomes regarding motivation, expectation and satisfaction. Furthermore in- and outpatients got a comparable amount of interventions, but both groups differed to some extent in regard to the kind of interventions. In- and outpatients are comparable in regard to their received amount of interventions. Discrepancies concerning the kind of interventions are due to differences between in- and outpatients. The results indicate specific patients' characteristics in both settings, but more research is needed to verify these findings.

[Current Developments of the Interdisciplinary Subject Rehabilitation, Physical Medicine, Naturopathic Treatment in the German Medical Faculties: Results of the DGRW Faculty Survey in 2015]. / Aktuelle Entwicklungen der rehabilitationsbezogenen Lehre in den humanmedizinischen Studiengängen in Deutschland: Ergebnisse der DGRW-Fakultätenbefragung 2015.

To ascertain the current development of the rehabilitation-related medical teaching in the interdisciplinary subject Rehabilitation, Physical Medicine, Naturopathic Treatment (Q12) regarding its execution, content, exams and evaluation of teaching at the Medical Faculties the German Society of Rehabilitation Science conducted another faculty survey in 2015. Representatives of all degree courses of human medicine in German Universities (n=41) received a pseudonymised standardised questionnaire in summer 2015. The response rate was 76% (n=31). Half of the faculties (48%) stated that they had a teaching and research unit for at least 1 of the 3 subjects of the interdisciplinary Q12. The Q12-teaching of faculties including these units partially differed from the other faculties. Model medical education programmes provide on average 2 semesters more for Q12-teaching in comparison to the traditional programmes. More than 3 quarters of the traditional programmes and all other courses include other medical professionals besides physicians as lecturers. Multiple choice questions still constitute the most common examination type (94%). Nearly all Medical Faculties evaluate the rehabilitation-related teaching but only half of all them have implemented a financial gratification based on the evaluation results. Even 10 years after the implementation of Q12, major variations were demonstrated regarding the execution, content and methods of medical education in rehabilitation. In the future the influence of the National Competence Based Catalogues of Learning Objectives for Undergraduate Medical Education on the Q12-development and the Q12-teaching in medical university education in Germany with foreign qualification will be of particular interest.

[Development of a Set of Rehabilitation Related Multiple-choice-questions in Medical Education]. / Entwicklung eines Prüfungsfragenpools für die rehabilitationsbezogene Lehre im Studiengang Humanmedizin.

In the rehabilitation related teaching as in other subjects of the medical training multiple choice (MC) examinations are the most frequent type of examinations. Compared to other subjects only a few MC questions are available for the interdisciplinary subject Rehabilitation. Therefore an internet-based online platform "Pool of rehabilitation related MC questions" was developed to assist teachers regarding the provision, design and organization of high-quality rehabilitation related MC questions. A total of 502 existing MC questions were collected from 12 German Medical Faculties. After removal of 59 questions not suitable for formal and content reasons a total of 443 questions were presented to 6 reviewers for triple reviews (a total of 1 329 expert reviews received). Of the 502 questions 335 (67%) were included in the final pool including short cases with 46 case studies. The questions refer to the following learning objectives: principles of rehabilitation (40%), rehabilitative interventions (20%), diagnosis and assessment (18%), initiation and control of the rehabilitation process (12%) and methods/quality of rehabilitative interventions (10%). The use of the online platform modules resp. the questions are for free for lecturers. This includes the compilation and output of complete examinations, the statistical evaluation, and other audit-related materials. This examination pool counteracts the current lack of quality-assured rehabilitation-related MC questions and contributes to set common standards for the Medical Faculties to rehabilitation related examinations.

[Evaluation of a Vocationally Oriented Concept within Inpatient Oncological Rehabilitation]. / Evaluation eines berufsbezogenen Konzepts im Rahmen der stationären onkologischen Rehabilitation.

AIM OF THE STUDY: We evaluated an occupation-related rehabilitation program, which has been designed to enhance the return to work of cancer patients. As return to work plays an important role to get back to normalcy after suffering from cancer, there is a substantial need for support and evaluated programs. METHODS: The study had a quasi-experimental design with an intervention group (IG) and a comparison group (CG). We defined performance-related outcomes (e. g. return to work, self-assessed working capacity), asked patients if they needed further vocational advice and how helpful they estimated the rehabilitation treatment. 1 year after the end of rehabilitation 309 employed patients had completed the study (65%). We addressed our research questions using non-parametric tests, t-tests, analyses of variance and logistic regressions. RESULTS: Of the 309 patients 58% started rehabilitation not later than 14 days after the end of acute treatment while the other 42% had finished their treatments at least some weeks or even months ago. Patients of the IG evaluated the work-related rehabilitation offers significantly better and needed less additional vocational advice after the end of rehabilitation (n. s.). Regarding the patients, who started rehabilitation not later than 14 days after the end of acute treatment (beginning of rehabilitation n=269, 12 months after rehabilitation n=174), the IG achieved a slightly higher return-to-work-rate 12 months after the end of rehabilitation (81% IG, 76% CG, n. s.). Above that the IG estimated their subjective working capacity significantly more often as fully re-established (IG 46%; CG 29%, p=0,030). CONCLUSIONS: A high percentage of the patients return to work (78%). These results show the success of oncological rehabilitation in helping patients to return to work. In addition, the occupation-related rehabilitation program enhances subjective variables as the satisfaction of the patients regarding the information and the improvement of the patients' working-capacity.

[Parents with cancer and their minor children--a nationwide survey of outpatient psychosocial cancer counselling service regarding needs and its utilisation]. / Krebskranke Eltern und ihre minderjährigen Kinder--eine bundesweite Befragung ambulanter psychosozialer Krebsberatungsstellen zu Bedarf und Inanspruchnahme.

OBJECTIVES: Children of cancer patients have an increased risk for developing emotional problems. While psychosocial cancer counselling services are available all over the country, it is unclear if parents seek for help and if specific approaches for families are offered. METHODS: A survey was made of outpatient cancer counselling services in Germany (n=228). The response rate was 56%. Descriptive and content analyses of the data have been used. RESULTS: Providers estimate that 55% of their patients are between 18 and 55 years with 18% of them having minor children. However, only 53% do regularly ask their patients if they have minor children. Family- or child-settings are not provided regularly. Over 60% of providers would welcome special courses on this subject. CONCLUSION: Although psychosocial care of minor children is mentioned in outpatient psychosocial cancer counselling guidelines, children are not included regularly. A stronger emphasis on this topic in further education has to be made.

Global quality of life during the acute toxicity phase of multimodality treatment for patients with head and neck cancer: can we identify patients most at risk of profound quality of life decline?

PURPOSE: Treatment intensification has improved outcomes for patients with head and neck cancer (HNC), but little has been reported on health-related quality of life (QoL) consequences. We investigated changes in QoL after (chemo)radiotherapy to identify patient characteristics that predict those whose QoL deteriorates most profoundly in the acute post-treatment period. MATERIALS AND METHODS: Patients with locally advanced HNC treated with curative intent received intensity-modulated radiotherapy (60-70 Gy) in this prospective study. (Chemo)radiotherapy was either definitive or adjuvant. Induction chemotherapy consisted of three cycles of docetaxel, cisplatin, and 5-fluorouracil; responders received (chemo)radiotherapy; nonresponders underwent salvage surgery followed by (chemo)radiotherapy if appropriate. Patients completed the EORTC QLQ-C30 and HNC-specific HN35 module before and at the end of (chemo)radiotherapy and 6-8 weeks after therapy completion. RESULTS: Ninety-five patients participated. At baseline, patients reported significantly lower Global health status, functioning, and symptom scale scores than a reference German population (all p<0.001). At the end of (chemo)radiotherapy, patients had significantly lower QoL scores vs. baseline on all functioning scales (p<0.05). Most symptom and HN35 scores worsened during (chemo)radiotherapy but many recovered 6-8 weeks post-treatment. QoL deteriorated more in patients with high vs. low baseline QoL; no clinical or sociodemographic characteristics of patients most likely to experience a significant deterioration in QoL during treatment were identified. CONCLUSION: These standard QoL instruments did not predict patients at risk of profound global QoL impairments during acute treatment. Other than baseline QoL, no patient characteristics associated with significant QoL deterioration were identified.

[Gender-related aspects of returning to work in cancer survivors. A systematic review]. / Geschlechtsspezifische Aspekte der Rückkehr zur Arbeit bei Patientinnen und Patienten mit einer Krebserkrankung. Ein systematisches Review.

Due to improved prognosis most cancer survivors are nowadays able to return to work. This review explored gender-related differences in work-related outcomes after cancer. A systematic search of studies on work-related issues in cancer survivors published between January 2001 and July 2011 was conducted. 44 original publications met the inclusion criteria (adult cancer survivors, focus on work-related outcomes, gender-specific report of results). The results of these studies indicate that impaired work ability is more common among female cancer survivors than among male cancer survivors as well as the reduction of working hours and income losses. Supportive work environments seem to be particularly helpful for the successful and long-lasting re-integration of female survivors. More systematic research and separate analyses for women and men are needed to fully comprehend gender differences in work-related outcomes. Broader knowledge can then be helpful in creating gender-specific return-to-work interventions.

[Return to work--experiences and expectations of cancer patients during inpatient rehabilitation]. / Rückkehr zur Arbeit--Erfahrungen und Erwartungen von Patientinnen und Patienten in der stationären onkologischen Rehabilitation.

AIMS: Returning to work after cancer frequently plays an important role for patients of working age. Accordingly, occupation and return to work are key issues for these patients during rehabilitation. So far there is only little empirical evidence from Germany concerning the expectations cancer patients in inpatient rehabilitation hold in relation to their return to work. Negative expectations may hamper returning to work. The context of rehabilitation offers the opportunity to work on potential problems to prepare a successful re-entry into employment. The aim of this study is to analyze the expectations of patients towards getting back to work and how helpful in this respect they estimate the work-related therapies provided during rehabilitation. Furthermore we asked whether professional support should be offered already before getting into inpatient rehabilitation and to what extent they have experienced that kind of help. METHODS: We conducted semi-structured qualitative interviews with 32 cancer patients who participated in inpatient cancer rehabilitation. All patients had been recruited within the same clinic. Interviews were analyzed based on Mayring's "Qualitative Content Analysis". RESULTS: The majority of the patients experienced positive reactions from their occupational environment after learning about the diagnosis. Most of them are optimistic to get help from colleagues and supervisors when returning to work. Prior to their rehabilitation stay 47% had received counseling on cancer and return to work from general practitioners or oncologists. Regarding the occupation-related offers during rehabilitation, the results suggest that women and men have different needs. Women consider them to be more helpful than men. CONCLUSIONS: The results indicate that after having received their diagnosis most cancer patients do not experience negative reactions from their work environment and consequently report few worries with regard to returning to work. The different views on work-related offers during rehabilitation indicate that the concepts of occupation-related therapies within cancer rehabilitation might be optimized by taking the different needs of male and female patients into account.

[Psychosocial predictors of utilization of medical rehabilitation services among prostate cancer patients]. / Psychosoziale Einflussfaktoren für die Inanspruchnahme medizinischer Rehabilitationsmaßnahmen bei Patienten mit einer Prostatakrebserkrankung.

PURPOSE: Prostate cancer patients often suffer from treatment-associated morbidities which lead to severe physical and mental impairments. Nevertheless, only a relatively small percentage of this patient population uses medical rehabilitation services; there is still a lack of evidence concerning possible factors causing use and non-use of services. Therefore, this study exploratively aims at the identification of predictors of the use of rehabilitation services in a cohort of prostate cancer patients. METHOD: In a prospective multicentre study to evaluate outpatient oncological rehabilitation services, n=242 prostate cancer patients who used outpatient or inpatient rehabilitation services ("users") were compared with n=253 prostate cancer patients who did not use rehabilitation ("non-users") at measure point 1. At the beginning of the rehabilitation programme and at the end of primary treatment, respectively, patients completed a self-report questionnaire consisting of standardized instruments designed to assess the following independent variables: autonomy striving (TPF), self-efficacy expectancy (GSE), distress (distress thermometer), anxiety and depression (HADS-D), quality of life (SF-8), social support (SSUK), rehabilitation motivation: readiness to change, knowledge, scepticism regarding rehabilitation services (PAREMO-20). Illness- and treatment-related variables (tumour state, comorbidity, primary therapies) were documented by the attending oncologists. RESULTS: Only few significant and effective differences between rehabilitation users and non-users are observed: Non-users are suffering more often from gastrointestinal comorbidities (18% vs. 2%, w=0.25). Both patient groups report severe quality-of-life impairments, particularly with respect to their physical functioning. Non-users achieve significantly higher scores on the scale "scepticism" (PAREMO-20) than users (eta²=0.19). The scale "scepticism" is also identified as the dominant predictor of utilization of rehabilitation services (R²=0.23). Suffering from comorbid diseases of the digestive system, self-efficacy expectation and employment status emerge as further significant predictors (R²=0.12, and R²=0.02 each). With increasing scepticism and in case of comorbidity the probability of rehabilitation utilization was decreasing. CONCLUSION: Besides illness-related variables prostate cancer patients' expectancies regarding the effectiveness of rehabilitation services to alleviate their medical conditions seem to be more relevant for rehabilitation utilization than sociodemographic variables or psychosocial distress. Further studies should investigate the replicability of these results and should focus on the doctor-patient-communication and the amount of information about goals and concepts of rehabilitation services prostate cancer patients are told. For clinical practice of information-giving about rehabilitation services it can be recommended not only to assess patients' physical and mental conditions but also to explore their expectations and concerns about rehabilitative treatment options in order to remove any doubts and to be able to optimize oncological care.

[Psychooncological care for breast cancer patients in hospitals and in the outpatient sector]. / Psychoonkologische Versorgung von Brustkrebspatientinnen im Krankenhaus und im ambulanten Sektor.

BACKGROUND: Psycho-oncological care is nowadays an integral part of patient-oriented health care in oncology. Psycho-oncological services are considered in the formulation of guidelines and the existence of such services is a precondition for the certification of organ centres. METHODS: For a status quo analysis of psycho-oncological health-care services for breast cancer patients in inpatient and outpatient care, 101 hospitals (inpatient care) and 124 health-care professionals in outpatient psycho-oncological services were questioned by mail. RESULTS: Psycho-oncological care in the hospital setting is mainly carried out by psychologists and physicians. 2-100% (median: 32.5%) of breast cancer patients receive psycho-oncological treatment. The proportion of psycho-oncological treatment performed by psychologists is higher in bigger hospitals and in hospitals which are part of a breast centre. In outpatient care, psycho-oncological treatment is mainly carried out by psychologists. Most of the interventions are individual therapy sessions (group therapy: median 20%). Most of the participants in the outpatient sector are psychodynamic (43%) or behavioural (23%) therapists, 40% report other therapeutic backgrounds. CONCLUSION: Both the inpatient and the outpatient sectors show a high heterogeneity in psycho-oncological care. The results for the inpatient setting indicate increasing professionalisation and orientation towards certification criteria and treatment guidelines. The heterogeneity in outpatient psycho-oncological care can be interpreted as desirable diversity which allows for the consideration of the varying needs of patients with different diagnoses, disease stages, and treatments.

Stressful life events and cancer risk.

In a prospective cohort study in Denmark of 8736 randomly selected people, no evidence was found among 1011 subjects who developed cancer that self-reported stressful major life events had increased their risk for cancer.

[Expectations, concerns and therapeutic goals of patients at the beginning of oncologic rehabilitation]. / Erwartungen, Befürchtungen und Therapieziele von Patienten zu Beginn einer onkologischen Rehabilitationsmassnahme.

The study focuses on the outcome of oncological rehabilitation in the inpatient setting. An oncology-specific questionnaire for the measurement of individual therapy goals was developed within the perspective of a goal-oriented evaluation concept. The article focuses on the first time-point of measurement (beginning of the rehabilitation measure) within a longitudinal study. 407 patients were studied either directly following their initial hospital treatment or at a later time-point during the course of the cancer illness. The presentation of the results include firstly a description and analysis of the patients' medical and psychosocial situation (including variables such as the perceived state of health and quality of life), as well as individual rehabilitation goals formulated by the patients themselves. Moreover, an analysis is performed of the expectations, hopes and fears of patients at the beginning of an oncological rehabilitation measure in the inpatient setting. Subgroup analyses focus on the influence of sociodemographic and emotional variables on the patients' expectations and goals.

[Concept definition in medical rehabilitation: an instrument for quality assurance]. / Konzepterfassung in der medizinischen Rehabilitation: Ein Instrument der Qualitätssicherung.

A survey of organizational aspects of rehabilitation clinics was part of the Pension Insurance quality assurance programme in medical rehabilitation. The goal of this survey was to strengthen the awareness for these organizational dimensions and to initiate discussion with the goal of optimizing the efficiency of the clinical working process. For the structured description of various conceptual aspects a questionnaire "Dokumentationsbogen-Konzepte" was developed and its appropriateness for the indication groups orthopaedics, cardiology and psychosomatics was examined. The focus of this examination was development of different possibilities to give feedback to the clinics. The questionnaire was appropriate for the description of conceptual aspects. Differences both between and within the indication groups were discovered. The instrument can be used in the quality assurance process.