Changes in rural caregivers' health behaviors while supporting someone with cancer: A qualitative study.

PURPOSE: Caring for someone with cancer has a significant impact on usual routines, including caregivers' ability to maintain their own health and wellbeing. Caregivers living in rural areas face additional challenges in supporting someone with cancer, and little is known about the impact of caregiving on the health behaviors of rural caregivers. Therefore, this study explored how caring for someone with cancer affected rural caregivers' health behaviors. METHODS: Through semi-structured interviews, 20 rural caregivers described changes in their health behaviors while caring for someone with cancer and the factors underlying these changes. Specific prompts were provided for diet, physical activity, alcohol, smoking, sleep, social connection and leisure, and accessing health care when needed. Interviews were audio-recorded and transcribed verbatim. Content analysis was used to identify changes in health behaviors and the factors underlying these changes. The factors identified were mapped to the socioecological framework, identifying areas for intervention across multiple levels (individual, interpersonal, organizational, community, and policy). RESULTS: Rural caregivers reported both positive and negative changes to their diet, physical activity, alcohol, and smoking. Sleep, social connection and leisure, and accessing health care were negatively impacted since becoming a caregiver. CONCLUSIONS: Designing interventions to address rural caregivers' coping strategies, reduce carer burden and fatigue, improve access to cooking and exercise facilities and social support while away from home, reduce the need to travel for treatment, and increase the financial support available could yield widespread benefits for supporting the health and wellbeing of rural caregivers.

What are the mechanisms underlying the delivery of survivorship care information in Australia? A realist review.

OBJECTIVE: Quality survivorship information is an essential component of cancer care. However, survivors often report not receiving this information and healthcare professionals report limited practical guidance on how to effectively deliver survivorship information. Therefore, this study used realist review methods to identify mechanisms reported within the published literature for communicating survivorship information and to understand the contextual factors that make these mechanisms effective. METHODS: Full-text papers published in CINAHL, PubMed, Web of Science, Scopus, Cochrane Library, and Academic Search Ultimate were included. Studies included in this review were conducted in Australia between January 2006 and December 2023, and reported on how information regarding survivorship care was communicated to adult cancer survivors living in the community. This review utilized realist methodologies: text extracts were converted to if-then statements used to generate context-mechanism-outcome theories. RESULTS: Fifty-one studies were included and six theories for mechanisms that underpin the effective delivery of survivorship information were formed. These include: (1) tailoring information based on the survivors' background, (2) enhancing communication among providers, (3) employing dedicated survivorship staff, (4) providing survivorship training, (5) reducing the burden on survivors to navigate their care, and (6) using multiple modalities to provide information. CONCLUSIONS: Findings can inform practical guidance for how survivorship care information is best delivered in practice. Clinicians can apply this guidance to improve their individual interactions with cancer survivors, as can policymakers to develop healthcare systems and procedures that support effective communication of cancer survivorship information.

A Scoping Review of Group Nutrition Education and Cooking Programs for People Affected by Cancer.

BACKGROUND: Group nutrition education and cooking programs for people affected by cancer have the potential to address commonly reported unmet needs for dietary information, as well as provide opportunities for practical and social support. OBJECTIVE: To report the nutrition-related content, delivery methods, and outcomes measured in group nutrition education and cooking programs for people affected by cancer in the published literature, and describe how these programs were developed, implemented, and evaluated. METHODS: A scoping review of academic literature is reported using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews guidelines. Key terms such as cancer, nutrition education, and cooking were searched across 4 databases (PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, and Web of Science) on June 1, 2023, for records published over the past 10 years. Records were independently screened by 2 reviewers. Data extracted included program participants, components, nutrition-related content, delivery methods, outcomes measured, and information about how the program was developed, implemented, and evaluated. RESULTS: Of 2,254 records identified, 41 articles met eligibility criteria, reporting on 37 programs. Most programs were designed for adult cancer survivors (89%) and conducted after primary treatment (81%). Four programs invited caregivers to attend. Almost all programs (97%) included a nutrition education component, and more than half (59%) included cooking activities, with a predominant focus on recommendations and practical skills for healthy eating. Most programs were delivered byregistered dietitians and/or nutritionists (54%) and included group discussions (57%) and active involvement in cooking activities (57%) in program delivery. The participant outcomes that were measured covered dietary, psychosocial, clinical, and anthropometric domains. Many programs were developed with cancer survivors, dietitians or nutritionists, and researchers. No studies reported on sustainability of program implementation or overall costs. Programs were evaluated using data from surveys, focus groups, interviews, and field notes, with articles typically reporting on participation rates, reasons for nonparticipation, program acceptability, aspects of the nutrition-related programs valued by participants, and suggestions for improvement. CONCLUSIONS: Future research should prioritize assessing the effectiveness of these programs for participants. Future development, implementation, and evaluation of these programs should include family members and friends and assess the sustainability of program delivery, including cost-effectiveness.

Mental health and diet quality after primary treatment for ovarian cancer.

AIMS: To investigate anxiety and depression after primary treatment for ovarian cancer in relation to diet quality and intake. METHODS: In a cohort of women with ovarian cancer in Australia, levels of anxiety and depression (normal, subclinical, and clinical) were assessed using the Hospital Anxiety and Depression Scale at 9 months post-diagnosis. Dietary intake was assessed using a validated food frequency questionnaire at 12 months post-diagnosis and scored using the Healthy Eating Index 2015. Multinomial logistic regression and bivariate analyses were used to investigate relationships between levels of anxiety and depression and subsequent diet quality and intake of food groups. RESULTS: Of 595 women, anxiety and depression were identified among 128 (21%) and 80 (13%) women, respectively. Compared to women without anxiety or depression, women with subclinical anxiety (odds ratio = 0.49, 95% confidence interval: 0.25-0.98) and those with clinical depression (odds ratio = 0.25, 95% confidence interval: 0.07-0.93) were less likely to score in the highest quartile for diet quality. Separate adjustment for age, education, employment, disease stage, body mass index, and smoking status did not attenuate these associations. In bivariate analyses, women with subclinical anxiety were more likely to report higher intakes of sweet foods. Those with clinical depression were more likely to report lower intakes of orange vegetables and wholegrains, higher intakes of sweetened beverages, and not consume alcohol or soya foods. CONCLUSIONS: Anxiety or depression after primary treatment for ovarian cancer may be associated with poorer diet quality. Efforts to improve diet quality post-treatment should consider support for mental health.

What are the post-treatment information needs of rural cancer survivors in Australia? A systematic literature review.

OBJECTIVE: To conduct a systematic literature review to critically assess the met and unmet post-treatment information needs of cancer survivors living in rural communities in Australia, to inform the improvement of survivors' transition from treatment in major cities to community care. METHODS: Cumulative index of nursing and allied health literature, PubMed, Web of Science, Scopus, Cochrane CENTRAL and Academic Search Ultimate databases and websites of 118 cancer organisations were searched for relevant Australian studies published since 2006. Key search terms included 'rural', 'remote', 'regional', 'cancer', 'survivor*', 'living with', and 'post-treatment'. Data reflecting study source, aims, methodology, and reported information needs were extracted and summarised. Study quality was assessed using Joanna Briggs Institute tools. RESULTS: Fifty-two articles met eligibility criteria. Only six of these specified a primary aim of understanding information needs for rural cancer survivors. Information on prognosis and recovery; managing treatment side effects; healthy lifestyle choices; referrals to support services, and face-to-face and written delivery of information at multiple time points were reported as needed and often lacking for rural cancer survivors. CONCLUSIONS: Co-ordinated, multi-step provision of information to support health and recovery after cancer treatment and beyond is likely to be particularly important for rural cancer survivors given their broad range of needs and reduced access to health care services. Findings provide useful recommendations to facilitate patients' transition home to rural communities after cancer treatment in major cities, however, an increased understanding of the information needs of rural survivors is required to inform the development of guidelines that can be used in clinical practice.

Association of Protein Intake with Recurrence and Survival Following Primary Treatment of Ovarian Cancer.

BACKGROUND: Malnutrition is common during treatment of ovarian cancer, and 1 in 3 patients report multiple symptoms affecting food intake after primary treatment. Little is known about diet posttreatment in relation to ovarian cancer survival; however, general recommendations for cancer survivors are to maintain a higher level of protein intake to support recovery and minimize nutritional deficits. OBJECTIVES: To investigate whether intake of protein and protein food sources following primary treatment of ovarian cancer is associated with recurrence and survival. METHODS: Intake levels of protein and protein food groups were calculated from dietary data collected ∼12 mo postdiagnosis using a validated FFQ in an Australian cohort of women with invasive epithelial ovarian cancer. Disease recurrence and survival status were abstracted from medical records (median 4.9 y follow-up). Cox proportional hazards regression was used to calculate adjusted HRs and 95% CIs for protein intake and progression-free and overall survival. RESULTS: Among 591 women who were progression-free at 12 mo follow-up, 329 (56%) subsequently experienced cancer recurrence and 231 (39%) died. A higher level of protein intake was associated with better progression-free survival (>1-1.5 compared with ≤1 g/kg body weight, HRadjusted: 0.69, 95% CI: 0.48, 1.00; >1.5 compared with ≤1 g/kg, HRadjusted: 0.61, 95% CI: 0.41, 0.90; >20% compared with ≤20% total EI from protein, HRadjusted: 0.77, 95% CI: 0.61, 0.96). There was no evidence for better progression-free survival with any particular protein food sources. There was a suggestion of better overall survival among those with higher total intakes of animal-based protein foods, particularly dairy products (HR: 0.71; 95% CI: 0.51, 0.99 for highest compared with lowest tertiles of total dairy intake). CONCLUSIONS: After primary treatment of ovarian cancer, a higher level of protein intake may benefit progression-free survival. Ovarian cancer survivors should avoid dietary practices that limit intake of protein-rich foods.

Discussing diet, nutrition, and body weight after treatment for gynecological cancer: a conversation analytic study of outpatient consultations.

PURPOSE: To generate direct observational evidence for understanding how diet, nutrition, and weight-related topics are discussed during follow-up after treatment for gynecological cancer, as recommended by survivorship care guidelines. METHODS: Conversation analysis of 30 audio-recorded outpatient consultations, involving 4 gyne-oncologists, 30 women who had completed treatment for ovarian or endometrial cancer, and 11 family members/friends. RESULTS: From 21 instances in 18 consultations, diet, nutrition, or weight-related talk continued beyond initiation if the issue raised was ostensibly relevant to the clinical activity being undertaken at the time. These instances led to care-related outcomes (i.e., general dietary recommendations, referral to support, behavior change counseling) only when the patient identified needing further support. Diet, nutrition, or weight-related talk was not continued by the clinician if it was not apparently related to the current clinical activity. CONCLUSIONS: The continuation of diet, nutrition, or weight-related talk during outpatient consultations after treatment for gynecological cancer, and the subsequent delivery of care-related outcomes, depends on its immediate clinical relevance and the patient indicating needing further support. The contingent nature of these discussions means there can be missed opportunities for the provision of dietary information and support post-treatment. IMPLICATIONS FOR CANCER SURVIVORS: If seeking information or support for diet, nutrition, or weight-related issues post-treatment, cancer survivors may need to be explicit regarding their need for this during outpatient follow-up. Additional avenues for dietary needs assessment and referral should be considered to optimize the consistent delivery of diet, nutrition, and weight-related information and support after treatment for gynecological cancer.

Support-seeking by cancer caregivers living in rural Australia.

OBJECTIVE: Rural cancer caregivers report poor wellbeing and high unmet needs for support. This study investigates sources of support sought by cancer caregivers living in rural Australia, and factors associated with support-seeking. METHODS: Informal caregivers of people with cancer completed a questionnaire assessing sociodemographic characteristics, caregiver factors and support-seeking. Descriptive statistics, bivariate analyses and logistic regression were used to identify common sources of support and factors associated with support-seeking. Alluvial and radar plots were used to identify and describe support-seeking profiles. FINDINGS: Of 244 rural caregivers, 64% reported seeking support for themselves, 72% for the cancer patient, and 22% did not seek any support. The most common sources of support were general practitioners and online. Higher caregiver burden, higher income, caring for someone with anxiety/depression or caring for someone who has difficulty completing their usual activities were associated with seeking support from a greater number of sources. The 'No support-seekers' profile had the highest proportions of caregivers who were male, caring for someone <12 months post-diagnosis and lower income earners. CONCLUSIONS: Many rural caregivers seek support for themselves and the cancer patient, commonly from medical and online sources. IMPLICATIONS FOR PUBLIC HEALTH: Further work may be needed to reduce caregiver burden and support caregivers who are male, caring for someone recently diagnosed, and those with lower incomes.

Dietary Practices After Primary Treatment for Ovarian Cancer: A Qualitative Analysis From the OPAL Study.

BACKGROUND: Little is known about the dietary practices of women who have completed primary treatment for ovarian cancer, many of whom will go on to have cancer recurrence and further treatment. Knowledge of dietary practices is needed to optimize care. OBJECTIVE: Our aim was to identify dietary practices after primary treatment for ovarian cancer and evaluate how these practices differ by disease recurrence and treatment status. DESIGN: Women with invasive epithelial ovarian cancer were provided with the following open-ended question after completing a food frequency questionnaire: "Is there anything we haven't asked you about your diet in the last 1 to 2 months that you feel is important?" PARTICIPANTS/SETTING: Participants were from the OPAL (Ovarian Cancer Prognosis and Lifestyle) Study in Australia. MAIN OUTCOMES: The main outcomes were dietary practices after primary treatment for ovarian cancer and factors affecting these practices. ANALYSIS: Participants' responses were analyzed using content analysis. Individual content codes were categorized and reported by recurrence and treatment status at questionnaire completion. RESULTS: Two hundred eighty-six women provided responses on 363 questionnaires. Those undergoing further treatment for recurrence commonly reported dietary regimens with clinical indications (eg, low fiber to avoid bowel obstructions, high energy/protein to minimize nutritional deficits). Those not undergoing further treatment frequently reported "popular" diets (eg, organic, plant-based, and alkaline). For women with cancer recurrence, dietary practices were affected by poor appetite and late effects of treatment. For women without recurrence, other comorbidities, geographical location, family, and friends appeared to influence dietary practices. In both groups, nutrition information sources and personal beliefs informed dietary practices. Participant responses that referenced media or online sources often included misinformation. CONCLUSIONS: After primary treatment for ovarian cancer, women report dietary practices that may not be captured in standard food frequency questionnaires. Dietary practices and factors affecting these practices likely differ by treatment and recurrence status. Improved access to evidence-based dietary information and support is needed.

Cancer survivors' perspectives of dietary information provision after cancer treatment: A scoping review of the Australian context.

ISSUE ADDRESSED: To support survivor-centred care in Australia, this review maps current knowledge regarding adult cancer survivors' perspectives of dietary information provision post-treatment. METHODS: A scoping review of research conducted in Australia within the past decade reported using PRISMA-ScR guidelines. Seven databases were searched (01/01/2009-05/06/2020) and records were independently screened by two researchers using eligibility criteria. Papers in the peer-reviewed literature with dietary information post-treatment as a primary and secondary outcome were eligible for inclusion. Data charting included participant characteristics, study methodology and cancer survivors' reports of dietary information provision post-treatment. RESULTS: Of 531 records identified, 12 met eligibility criteria. Most studies included breast (58%) and colorectal (42%) cancer survivors within 5 years post-diagnosis (84%). Three studies were conducted amongst specific ethnic groups (Indigenous Australians, Chinese-Australians, Greek-Australians). Participants in the included studies commonly reported limited or ineffective dietary information from healthcare providers post-treatment. Cancer survivors identified a need for individualised information regarding dietary strategies to manage ongoing symptoms, professional support for weight management, and practical skills for healthy eating. Amongst ethnic groups, there was a need for dietary information that considers traditional foods and cultural beliefs, and is available in their native language. Cancer survivors valued ongoing dietary follow-up and support post-treatment, and suggested a variety of face-to-face and online delivery modes. Those residing in rural and remote areas reported barriers to accessing dietary information post-treatment including time, cost, and availability of local services. CONCLUSIONS: There is scope to improve dietary information provision after cancer treatment in Australia. SO WHAT?: Dietary guidance post-treatment should consider individual needs, cultural background, and opportunity for ongoing follow-up and support.

Dietitian encounters after treatment for ovarian cancer.

BACKGROUND: After ovarian cancer treatment, women report health issues that may be amenable to change with dietary support. The present study investigated how many women encounter a dietitian post-treatment and the factors associated with dietitian service use. METHODS: We used data from a cohort of women with invasive epithelial ovarian cancer to identify socio-economic, clinical and personal factors associated with dietitian encounter after treatment completion. Data were collected at regular intervals using validated questionnaires up to 4 years post-treatment completion. Logistic regression (LR) and generalised linear mixed models (GLMM) were used to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) to assess factors associated with dietitian encounter at any time-point post-treatment (LR), as well as in the 3 months prior to a follow-up questionnaire (GLMM) to assess time-varying factors. RESULTS: Of 819 women, 97 (12%) reported seeing a dietitian post-treatment. Factors associated with dietitian encounter were being overweight (ORLR  = 1.7, CI = 1.1-2.8), having poorer self-rated health (ORLR  = 2.5, CI = 1.2-5.2; ORGLMM  = 2.3, CI = 1.2-4.4) or poorer diet quality (ORLR  = 0.5, CI = 0.2-1.0) pre-diagnosis, treatment within the public health system (ORGLMM  = 1.8, CI = 1.2-2.7), previous support from dietetic (ORLR  = 3.1, CI = 1.8-5.4; ORGLMM  = 2.8, CI = 1.8-4.2) or other allied health services (ORLR  = 2.0, CI = 1.2-3.2; ORGLMM  = 3.7, CI = 2.4-5.5), and having progressive disease at follow-up (ORGLMM  = 2.2, CI = 1.4-3.3). Most women (86%) with ≥ 3 moderate-to-severe nutrition impact symptoms did not report a dietitian encounter post-treatment. CONCLUSIONS: Few women encounter a dietitian post-treatment for ovarian cancer, including those with multiple nutrition impact symptoms. Further work is needed to engage those likely to benefit from dietitian support but less likely to seek or receive it.

Needs, preferences, and experiences of adult cancer survivors in accessing dietary information post-treatment: A scoping review.

INTRODUCTION: To support provision of healthy lifestyle information tailored to patients' needs and preferences, this review maps adult cancer survivors' self-reported needs, preferences, and experiences accessing dietary information post-treatment. METHODS: A scoping review of research published within the past decade conducted using PRISMA-ScR guidelines. Seven databases were searched in June 2020. RESULTS: Of 15,973 articles identified, 57 met eligibility criteria. Studies most frequently included survivors of breast cancer (49%), persons aged 40+ years (95%), ≤5 years post-diagnosis (54%), and residing in North America (44%). Cancer survivors commonly identified needing information regarding healthy eating, particularly practical skills, and support in changing dietary behaviours. Preferences included specific recommendations, direct communication with healthcare professionals, and peer support from other cancer survivors. In practice, survivors frequently reported receiving generic advice from healthcare professionals, limited dietary follow-up, and lack of referral to support. Unmet needs in healthcare settings led to dietary information-seeking elsewhere; however, survivors indicated difficulty identifying credible sources. Personal beliefs and desire for involvement in care motivated dietary information-seeking post-treatment. CONCLUSION: Cancer survivors' experiences accessing dietary information post-treatment do not align with needs and preferences. Less is known about survivors who are young adults, >5 years post-diagnosis, and living in rural areas.

Properties of a fungicidal product formed from a reaction between L-cystine and pyridoxal.

Previously we found that three components of a commonly used mammalian cell culture medium incorporated into agar killed cryptococci (Granger and Call 2019). The components were L-cystine, iron [Fe(III)], and pyridoxal (CIP). We now report on a buffered solution at neutral pH of the three components, which was highly fungicidal without agar. We showed that CIP fungicidal activity, identical to the findings with cell culture medium, was inactivated by visible light and was unstable with storage in the dark. Congeners replacing either pyridoxal or L-cystine in CIP revealed structural requirements for fungicidal activity. Replacing pyridoxal in CIP with 2-hydroxy-5-nitrobenzaldehyde produced a solution that was equally fungicidal and maintained fungicidal activity upon storage in the dark for up to 50 days. We employed methods for excluding iron from CIP and found that fungicidal activity was not affected. Upon mixing L-cystine and pyridoxal in buffer at pH 7.0, diode array spectroscopy revealed a red-shift of absorbance maximum from 391 nm to 398 nm. Our findings point to Schiff base reaction between the pyridoxal aldehyde group of C1 with the alpha amino group(s) of cystine to yield a fungicidal compound. Light at wave length approximately 400 nm inactivates this complex accompanied by bleaching of the pyridine ring of pyridoxal. Our findings may be useful for design of a class of fungicidal compounds formed through Schiff base reaction of disulfide compounds with aromatic ring-bearing aldehydes.

Major extremity amputation for nodal metastasis from squamous cell carcinoma.

The regional lymph node basin is usually the first site of spread in cutaneous squamous cell carcinoma (SCC). Regional metastases are usually treated with comprehensive nodal dissection, sometimes followed by radiation and/or chemotherapy. Occasionally, when disease recurs after these conventional therapies, major extremity amputation may be the only way to render patients free of disease. We present three cases for which major extremity amputation was necessary. One patient underwent forequarter amputation for nodal metastasis, which had invaded the brachial plexus. Another patient underwent hip disarticulation for femoral bony invasion from inguinal nodal metastasis. The third patient underwent a hemipelvectomy for nodal metastasis, which had eroded the femoral artery and pelvic bone. These cases show that major extremity amputation can be both palliative and curative in patients with SCC.