Oncologist recommendation matters!-Predictors of psycho-oncological service uptake in oncology outpatients.

OBJECTIVE: Highly distressed cancer patients often do not use psycho-oncological services (POS). Research on predictors of POS uptake has mainly focused on patient-related variables and less on communication variables, so we examined the link between patient-oncologist communication (ie, talking about psychosocial distress, providing detailed information, and recommending POS) and POS uptake. METHODS: We conducted a prospective, observational study in an Oncology Outpatient Clinic in Switzerland. Predictors (ie, patient-related variables and patient's reports of the patient-oncologist communication) were assessed via semistructured interviews, and information on outpatient POS uptake was assessed after 4 months. For statistical analysis, a multivariate logistic regression was performed. RESULTS: Of 333 participants (mean age 61 years; 55% male; 54% distress thermometer ≥5), 77 (23%) had used POS during a 4-month period. Patients who reported an oncologist-recommended POS (odds ratio [OR] = 6.27, 95% confidence interval [CI] = 3.14-12.85) and those who were not sure if they had received a recommendation (OR = 4.64, 95% CI = 1.83-11.97) were more likely to attend POS than those who reported receiving no recommendation. Talking about psychosocial distress (OR = 0.74, 95% CI = 0.38-1.46) and providing detailed information about POS did not predict POS uptake (OR = 1.06, 95% CI = 0.46-2.38). CONCLUSIONS: Oncologists' expert recommendations to attend POS were strongly associated with patients' uptake of POS. The central role played by oncologists should be accounted for in stepped psycho-oncological care when POS referral pathways are defined.

[Standardized distress screening programs do not replace discussing distress and psychosocial care needs with patients]. / Entwicklung in der integrierten psychoonkolgischen Versorgung.

Standardized distress screening programs do not replace discussing distress and psychosocial care needs with patients Abstract. Recommendations regarding the communication with the patient on the basis of the distress thermometer. In accordance with international standards, one of the high priority objectives is to introduce routine distress screening during cancer care in order to accurately identify those patients who are most in need of psycho-oncological treatment and to ensure that patients have access to appropriate supportive care services. The practice has been shown to increase the effectiveness of identifying comorbidities such as depression and anxiety, and to increase the number of referrals to psycho-oncological care. However, only a moderate proportion of the distressed patients also accepts referral to or utilizes psycho-oncological support. To optimize distress screening programs, patients' supportive care needs should be addressed and discussed in routine clinical practice. The present manuscript offers recommendations regarding the actual communication with the patient on the basis of a screening tool such as the distress thermometer.

The Oncological Patient in the Palliative Situation.

Palliative care approaches patients and their suffering with a bio-psycho-social-spiritual model. Thus, it is the strength of palliative care to complement the diagnosis driven approach of medical cancer care by a problem and resources-based assessment, participatory care plan and person-directed interventions. Interventions need to reflect timely prognosis, target population (the patient, the family carer, the professional) and level of trust and remaining energy. In palliative care the relevance of psycho-oncological aspects in the care of the terminally ill is considerable in the understanding of the overall suffering of patients approaching death and their loved ones and in their care and support. There is little evidence to date in terms of clinical benefit of specific psycho-oncological interventions in the last months or weeks of life, but there is evidence on effects of stress reduction and reduced anxiety if locus of control can stay within the patient as long as possible. One major challenge in psychosocial and palliative care research, however, is defining patient relevant outcomes.

Understanding why cancer patients accept or turn down psycho-oncological support: a prospective observational study including patients' and clinicians' perspectives on communication about distress.

BACKGROUND: International standards prioritize introducing routine emotional distress screening in cancer care to accurately identify patients who most need psycho-oncological treatment, and ensure that patients can access appropriate supportive care. However, only a moderate proportion of distressed patients accepts referrals to or uses psycho-oncological support services. Predictors and barriers to psycho-oncological support service utilization are under-studied. We know little about how patients and oncologists perceive the discussions when oncologists assess psychosocial distress with a screening instrument. We aim to 1) assess the barriers and predictors of uptake of in-house psycho-oncological support along the distress screening pathway in cancer patients treated at a University Oncology Outpatient Clinic and, 2) determine how patients and clinicians perceive communication about psychosocial distress after screening with the Distress Thermometer. METHODS: This is a quantitative prospective observational study with qualitative aspects. We will examine medical and demographic variables, cancer patient self-reports of various psychological measures, and aspects of the patient-clinician communication as variables that potentially predict uptake of psycho-oncological support service. We will also assess the patients' reasons for accepting or refusing psycho-oncological support services. We assess at three points in time, based on paper-and-pencil questionnaires and two patient interviews during the study period. We will monitor outcomes (psycho-oncology service uptake) four months after study entry. DISCUSSION: The study will improve our understanding of characteristics of patients who accept or refuse psycho-oncological support, and help us understand how patients' and oncologists perceive communication about psychosocial distress, and referral to a psycho-oncologist. We believe this is the first study to focus on factors that affect uptake or rejection of psycho-oncological support services along the screening and referral pathway. The study 1) combines standard assessment with qualitative data collection, 2) embraces patient and oncologist perspectives, and, 3) focuses on patient-clinician communication about psychosocial issues raised by a standard screening instrument. Our results may improve routine practices and eliminate barriers to adequate health care, and make it easier to recognize patients with high distress levels who underuse the service.

Mutual associations between patients' and partners' depression and quality of life with respect to relationship quality, physical complaints, and sense of coherence in couples coping with cancer.

PURPOSE: The aim of this article is to examine the mutual associations between patients' and partners' depression and quality of life (QOL) in couples facing cancer with respect to potential resources (sense of coherence and relationship quality (RQ)) and stressors (physical complaints). PATIENTS AND METHODS: Questionnaires rating depression, QOL, sense of coherence, RQ, and physical complaints were completed by 207 couples facing different cancer types and stages. Multiple regression models were used to assess the mutual associations between patient and partner variables. RESULTS: In female patients, 40.7% of the variance in depression score was explained by male partners' stressors and resources, whereas only 3.5% of the variance in male patients' depression was explained by female partners' stressors and resources. In male and female partners, respectively, the patients' stressors and resources explained 34.9% versus just 15.8% of the variance in depression. Regarding QOL in female patients, 30.1% of the variance was explained by the partners' stressors and resources, versus only 3.7% in male patients. Meanwhile, in male and female partners, respectively, the patients' stressors and resources explained 25.6% and 12.9% of the variance in QOL. CONCLUSIONS: These findings support a couples-centered approach to psycho-oncological counseling and treatment. Particularly in depressed couples with low RQ, couples therapy or counseling should be considered because of the mutual adverse association between depression and QOL in these couples.

A mindfulness-based program for improving quality of life among hematopoietic stem cell transplantation survivors: feasibility and preliminary findings.

Health-related quality of life (HRQoL) is often substantially reduced among individuals who have undergone hematopoietic stem cell transplantation (HSCT), and incidences of depression, fatigue, and anxiety are elevated. We examined effects of a mindfulness-based intervention (MBI) compared to psycho-oncological telephone consultation upon HRQoL, depression, anxiety, and fatigue among HSCT survivors. Sixty-two medically stable patients participated in the study; they had completed HSCT ≥6 months previously. Thirty-two were randomly assigned to intervention arms, and 30 were offered their treatment preference. MBI consisted of a structured 8-week program of mindfulness training. Assessments were made at baseline, post-intervention and 3 months follow-up. Primary outcome was HRQoL. Depression, fatigue, anxiety, and personal goal attainment were secondary measures. Non-completion of interventions was low in both groups (9 %, MBI; 7 % control). Employing intention-to-treat analysis, MBI, compared with comparison procedure, improved HRQoL and reduced depression and anxiety at post-intervention (p's < 0.05); Cohen's d effect sizes, 0.6-0.7; 3-month follow-up benefits were modest. These findings demonstrate broad feasibility and acceptance of, as well as satisfaction and adherence with, a program of mindfulness training for HSCT survivors; findings also suggest improved HRQoL and well-being as a consequence of MBI. Nevertheless, this is a preliminary study; a larger trial with more prolonged intervention phase is warranted.

The oncological patient in the palliative situation.

Palliative care approaches the patient and his or her suffering with a biopsychosocial-spiritual model. Thus, it is the strength of palliative care to complement the diagnosis driven approach of medical cancer care by a problem and resources-based assessment, participatory care plan, and patient-directed interventions. Interventions need to reflect timely prognosis, target population (the patient, the family carer, the professional), and level of trust and remaining energy. In palliative care the relevance of psycho-oncological aspects in the care of the terminally ill is considerable in the understanding of the overall suffering of patients approaching death and their loved ones and in their care and support. There is little evidence to date in terms of clinical benefit of specific psycho-oncological interventions in the last months or weeks of life, but there is evidence on effects of stress reduction and reduced anxiety if locus of control can stay within the patient as long as possible. One major difficulty in psychosocial research at the end-of-life, however, is defining patient relevant outcomes.

Changes in close relationships between cancer patients and their partners.

PURPOSE: Distress caused by cancer may have an important impact on the quality of a couple's relationship. This investigation examined perceived relationship changes in a sample of cancer patients and their partners, accounting for gender and role (i.e., patient or partner). PATIENTS AND METHODS: A total of 209 patients with different cancer types and stages and their partners completed questionnaires with items on psychological distress (anxiety and depression), quality of life, and perceptions regarding positive and negative relationship changes. RESULTS: A total of 149 patients (71.3%) and 156 partners (74.6%) reported that the diagnosis of cancer had changed their relationship. Of these, 121 (57.9%) patients and 116 (55.5%) partners reported positive changes only, whereas eight patients (3.8%) and 18 partners (8.6%) indicated negative changes only. Twenty patients (9.6%) and 22 partners (10.5%) had experienced both positive and negative changes. In male patients and partners, negative dyadic changes were associated with lower quality of life and higher levels of anxiety and depression. This finding was similar in female partners, but not in female patients. The association between perceived negative relationship changes and both increased psychological distress and reduced quality of life remained significant even when controlled for gender and congruency of perception. CONCLUSIONS: Although most couples in our sample reported growing closer while dealing with cancer, a small but sizeable percentage observed negative changes in their relationships, and these negative changes resulted in increased psychological distress and worse quality of life. Female partners were at greatest risk for these negative perceptions.

Adopting a family approach to theory and practice: measuring distress in cancer patient-partner dyads with the distress thermometer.

OBJECTIVE: Significant others are central to patients' experience and management of their cancer illness. Building on our validation of the Distress Thermometer (DT) for family members, this investigation examines individual and collective distress in a sample of cancer patients and their matched partners, accounting for the aspects of gender and role. METHOD: Questionnaires including the DT were completed by a heterogeneous sample of 224 couples taking part in a multisite study. RESULTS: Our investigation showed that male patients (34.2%), female patients (31.9%), and male partners (29.1%) exhibited very similar levels of distress, while female partners (50.5%) exhibited much higher levels of distress according to the DT. At the dyad level just over half the total sample contained at least one individual reporting significant levels of distress. Among dyads with at least one distressed person, the proportion of dyads where both individuals reported distress was greatest (23.6%). Gender and role analyses revealed that males and females were not equally distributed among the four categories of dyads (i.e. dyads with no distress; dyads where solely the patient or dyads where solely the partner is distressed; dyads where both are distressed). CONCLUSION: A remarkable number of dyads reported distress in one or both partners. Diverse patterns of distress within dyads suggest varying risks of psychosocial strain. Screening patients' partners in addition to patients themselves may enable earlier identification of risk settings. The support offered to either member of such dyads should account for their role- and gender-specific needs.

Posttraumatic growth in cancer patients and partners--effects of role, gender and the dyad on couples' posttraumatic growth experience.

BACKGROUND/AIM: Little is known about factors influencing positive effects in couples facing a cancer diagnosis. METHODS: A heterogeneous sample of 224 couples from a multi-site study (four oncology units) completed questionnaire surveys including the Posttraumatic Growth Inventory (PTGI) as a measure of positive psychological effects. RESULTS: The data demonstrated that all three investigated factors--gender, role (patient vs partner) and the dyad (belonging to any of the 224 couples)--significantly contributed to variation in PTGI total scores and subscales. Variability between couples (factor dyad) appeared stronger than variability between patient and partner participants (factor role) and between male and female participants (factor gender). Role and gender analysis showed that patients demonstrated higher levels of posttraumatic growth than partners; and female participants scored higher on PTGI than males. Male patient-female partner pairs show greater association in their experience of posttraumatic growth than female patient-male partner pairs. Correlations also suggested that, regardless of the gender and role composition, patients and partners may experience parallel growth. CONCLUSIONS: Our findings indicate that positive psychological experiences may be shared by partners affected by cancer in similar ways as have been shown for negative psychological effects. Intra-couple similarities or processes may have a more important function in experiencing benefits than factors like gender or being the patient or the partner. These results underline the importance of a family approach to understanding negative and positive psychological effects of cancer.

Screening cancer patients' families with the distress thermometer (DT): a validation study.

Although family members of cancer patients are at great risk of experiencing psychological distress, clinical tools to assist with recognizing and intervening with appropriate psychosocial care are sparse. This study reports on the first validation of the distress thermometer (DT) as a screening instrument for symptoms of depression and anxiety in family members of cancer patients. The DT was administered with the Hospital Anxiety and Depression Scale (HADS) in a sample of 321 family members. Receiver operating characteristics (ROC) demonstrated that the DT has good diagnostic utility relative to the HADS (area under the curve= 0.88 relative to the HADS anxiety scale; 0.84 relative to the HADS depression scale, respectively). The ROC curves indicate that using a cut-off of 4/5 maximizes sensitivity (86.2% HADS anxiety scale; 88.2% HADS depression scale) and specificity (71.2% HADS anxiety scale; 67.6% HADS depression scale); however, the alternative lower cut-off of 3/4 increases sensitivity (94.1% for both scales) and hence reduces the risk of missing distressed family members (specificity is 62.9% for HADS anxiety scale; 59.1% for HADS depression scale). The results offer validation of the DT for screening family members of cancer patients and support its use for clinical assessment. Distress screening with DT for family members of cancer patients is a promising and efficient approach to integrating family members in the program of care and provides the first step toward meeting their unmet needs with referral for supportive services.

Quality of life and psychiatric morbidity in patients successfully treated for oral cavity squamous cell cancer and their wives.

PURPOSE: To assess quality of life (QOL) and psychiatric morbidity in successfully treated oral cavity squamous cell cancer (OC-SCC) survivors and their wives. PATIENTS AND METHODS: Thirty-one men successfully treated for OC-SCC (mean, 3.7 years since diagnosis; UICC stages I to IV) together with their wives were assessed by questionnaires referring to QOL (WHOQOL-BREF), physical complaints (EORTC QOL-H&N35), and symptoms of anxiety and depression (HADS). Prevalence of psychiatric disorders was assessed by the Mini International Neuropsychiatric Interview (M.I.N.I.). RESULTS: Irrespective of tumor stage, a considerably high global QOL both in OC-SCC survivors and their wives could be detected when compared with an age-matched cancer-free population. No significant difference between the mean scores of 4 domains of the QOL (exception: environmental domain) was found between patients and their wives. In patients, lower QOL was associated with more physical complaints (social eating, swallowing, and pain) and higher levels of psychological distress (HADS); whereas in wives, QOL was found to be related to levels of psychological distress. In the M.I.N.I., a high prevalence of psychiatric disorders, particularly anxiety disorders, was found in wives (38.7%); but was lower in patients (16.2%). Patients and wives diagnosed with a psychiatric disorder reported significantly lower QOL. CONCLUSION: Both in OC-SCC patients and their wives a considerably high overall QOL can be found. "Social eating," "swallowing," and "sexuality" in patients and psychiatric disorders in wives seem to be strongly related to global QOL. The high prevalence of anxiety disorders in wives, however, should alert clinicians and the health care community. Thus, surgical improvement of somatic problems and treatment of psychiatric disorders should be addressed in individuals reporting an impaired global QOL.

Psychiatric morbidity and quality of life in wives of men with long-term head and neck cancer.

The diagnosis of cancer not only affects the lives of patients but also the lives of their relatives. The aim of this study was to investigate the prevalence of psychiatric disorders and quality of life (QoL) among wives of patients treated for head and neck cancer (HNC). We examined 31 wives of patients treated for HNC from January 1998 to December 2004 (meantime since diagnosis 3.7 years) by questionnaires with regard to quality of life (WHOQOL-BREF), quality of the relationship (Dyadic Adjustment Scale), and affective symptoms (Hospital Anxiety and Depression Scale, HADS). Prevalence of psychiatric morbidity was measured by the Mini International Neuropsychiatric Interview (MINI). Results indicated that QoL and satisfaction with the relationship were comparable to the normal population. HADS mean scores showed no clinically relevant levels of depression and anxiety. A high prevalence of psychiatric disorders (38.7%, particularly agoraphobia) was found in the MINI. Wives diagnosed with an anxiety disorder reported significantly lower QoL compared to those without. The results of this study suggest that agoraphobia is a frequent psychiatric disorder seen in wives of HNC patients. Diagnosis of HNC can have a strong impact on the mental health of the spouse and should be taken in account in counselling of HNC patients.