Dyadic coping in specialized palliative care intervention for patients with advanced cancer and their caregivers: Effects and mediation in a randomized controlled trial.

OBJECTIVE: Specialized palliative care (SPC) interventions increasingly include patient-caregiver dyads, but their effects on dyadic coping are unknown. We investigated whether an SPC and dyadic psychological intervention increased aspects of dyadic coping in patients with advanced cancer and their caregivers, whether dyad characteristics moderated effects and whether aspects of dyadic coping mediated significant intervention effects on caregivers' anxiety and depression. METHODS: We randomized 258 patients with incurable cancer and their caregivers to care as usual or accelerated transition from oncological treatment to home-based SPC and dyadic psychological support. In secondary outcome analyses, using mixed-effects models, we estimated intervention effects and 95% confidence intervals (CIs) for communication of stress and common coping, and moderation by dyad type and demographics. In path analyses, we investigated whether stress communication and common coping mediated intervention effects on caregivers' symptoms of anxiety and depression. (Clinicaltrials.gov NCT01885637). RESULTS: The intervention significantly increased common coping in patients and caregivers in couples (estimated difference, 0.68; 95% CI, 0.11 to 1.24) and stress communication by partner caregivers (0.97; 0.24 to 1.24). We found some support for different intervention effects for spouses and other dyads, but no evidence of mediation. CONCLUSIONS: Specialized palliative care and dyadic psychological intervention may affect aspects of dyadic coping. Common coping and stress communication did not mediate the previously found significant intervention effects on caregiver anxiety and depression, indicating that other mechanisms may have been central in the intervention.

Do people improve health behavior after their partner is diagnosed with cancer? A prospective study in the Danish diet, Cancer and Health Cohort.

Background: The cancer diagnosis is regarded as a stressful life event that is thought to trigger a teachable moment to induce health behavior changes among cancer patients. However, this may also hold true for their partners. We assessed if partners of cancer patients make more health behavior changes compared to persons whose partner remained cancer-free. Methods: Lifestyles was assessed in the prospective Danish Diet, Cancer and Health study. Logistic regression analyses were used to assess health behavior change among partners of cancer patients (n = 672) compared to partners of persons who remained cancer-free (n = 5534). Additionally, associations in two subgroups were assessed: bereaved partners and partners of patients who remained alive after cancer. Results: Partners of cancer patients were more likely to decrease their alcohol intake compared to partners of persons who remained cancer free. This finding could mainly be attributed to bereaved partners. Moreover, bereaved partners were also more likely to decrease their BMI. In contrast to our hypothesis, bereaved partners were more likely to decrease fruit intake and increase sugared beverages compared to partners of persons who remained cancer free. In general, men tended to improve their physical activity, while women tended to worsen their physical activity following the cancer diagnosis of their partner. Conclusions: A cancer diagnosis in the partner does seem to improve health behavior change only for alcohol intake. Bereaved partners tend to worsen dietary behaviors after the patient's death.

Effect of home-based specialised palliative care and dyadic psychological intervention on caregiver anxiety and depression: a randomised controlled trial.

BACKGROUND: Specialised palliative care trials often fail to address intervention effects on caregiver anxiety and depression, particularly in bereavement. We evaluate effects of specialised palliative care and dyadic psychological intervention on caregiver anxiety and depression in a randomised controlled trial (RCT). METHODS: Patients with incurable cancer and limited antineoplastic treatment options and their caregivers, recruited from a university hospital oncology department, were randomised (1:1) to care as usual or accelerated transition from oncological treatment to home-based specialised palliative care. We assessed caregivers' symptoms of anxiety and depression with the Symptom Checklist-92 up to six months after randomisation and 19 months into bereavement, and estimated intervention effects in mixed effects models. RESULTS: The 'Domus' trial enrolled 258 caregivers. The intervention significantly attenuated increases in caregivers' symptoms of anxiety overall (estimated difference, -0.12; 95% confidence interval, -0.22 to -0.01, p = 0.0266), and symptoms of depression at eight weeks (-0.17; -0.33 to -0.02; p = 0.0314), six months (-0.27; -0.49 to -0.05; p = 0.0165), and in bereavement at two weeks (-0.28; -0.52 to -0.03; p = 0.0295) and two months (-0.24; -0.48 to -0.01; p = 0.0448). CONCLUSIONS: This first RCT evaluating specialised palliative care with dyadic psychological support significantly attenuated caregiver anxiety and depression before and during bereavement. (Clinicaltrials.gov: NCT01885637).

Risk for use of antidepressants, anxiolytics, and hypnotics in partners of glioma patients-A nationwide study covering 19 years of prescriptions.

OBJECTIVE: Suffering from malignant brain tumor is a stressful condition, for patients and their partners. In a retrospective cohort study using nationwide registries, we examined partners' risk for first use of antidepressants, anxiolytics, or hypnotics. METHODS: We followed all 4373 partners of adults with glioma, diagnosed in 1998 to 2013 in Denmark and a cohort of 43 808 partners of glioma-free persons matched 1:10. In Cox proportional hazard models, we estimated hazard ratios (HRs) for a first prescription of psychotropic medications (antidepressants, anxiolytics, or hypnotics) according to the partner's glioma status. Among partners of glioma patients, we further estimated HRs for a first prescription of psychotropic medication according to disease characteristics, sociodemographic factors, and bereavement. RESULTS: Two years after diagnosis, 29% of female and 21% of male partners of glioma patients had had a first prescription of psychotropic medication compared with 10% in female and 8% in male partners of glioma-free persons. Partners of glioma patients had a significantly increased, 4-fold higher risk for a first prescription of psychotropic medications in the first year after diagnosis than partners of glioma-free persons (HR 4.10, 95% CI, 3.80:4.43). Among partners of glioma patients, the risk was significantly reduced in bereaved compared with non-bereaved partners. CONCLUSIONS: We have documented, for the first time, that the psychological impact of a diagnosis of glioma is such a severe stress exposure that it increases the risk for having medication prescribed to treat symptoms of anxiety, sleep problems, and depression.

Dyadic psychological intervention for patients with cancer and caregivers in home-based specialized palliative care: The Domus model.

ABSTRACTObjective:Patients with incurable cancer and their informal caregivers have numerous psychological and psychosocial needs. Many of these patients wish to receive their care and die at home. Few home-based specialized palliative care (SPC) interventions systematically integrate psychological support. We present a psychological intervention for patient-caregiver dyads developed for an ongoing randomized controlled trial (RCT) of home-based SPC, known as Domus, as well as the results of an assessment of its acceptability and feasibility. METHOD: The Domus model of SPC for patients with incurable cancer and their caregivers offered systematic psychological assessment and dyadic intervention as part of interdisciplinary care. Through accelerated transition to SPC, the aim of the model was to enhance patients' chances of receiving care and dying at home. Integration of psychological support sought to facilitate this goal by alleviating distress in patients and caregivers. Psychologists provided needs-based sessions based on existential-phenomenological therapy. Feasibility and acceptability were investigated by examining enrollment, nonparticipation, and completion of psychological sessions. RESULTS: Enrollment in the RCT and uptake of the psychological intervention indicated that it was feasible and acceptable to patients and caregivers. The strengths of the intervention included its focus on dyads, psychological distress, and existential concerns, as well as interdisciplinary collaboration and psychological interventions offered according to need. Its main limitation was a lack of an intervention for other family members. SIGNIFICANCE OF RESULTS: Our results show that psychological intervention can be systematically integrated into SPC and that it appears feasible to provide dyadic needs-based sessions with an existential therapeutic approach. The Domus RCT will provide evidence of the efficacy of a novel model of multidisciplinary SPC.

The impact of a breast cancer diagnosis on health-related quality of life. A prospective comparison among middle-aged to elderly women with and without breast cancer.

Background The improved survival after breast cancer has prompted knowledge on the effect of a breast cancer diagnosis on health-related quality of life (HQoL). This study compared changes in HQoL among women from before to after breast cancer diagnosis with longitudinal changes among women who remained breast cancer-free. Material and methods The Danish Diet, Cancer and Health study included 57 053 cancer-free persons aged 50-64 years at baseline (1993-1997). We used data from first follow-up (1999-2002) and second follow-up (2010-2012) on HQoL [Medical Outcomes Survey, short form (SF-36)] obtained from 542 women aged 64-82 years with primary breast cancer (stages I-III) and a randomly matched sample of 729 women who remained breast cancer-free. Linear regression models were used to estimate the differences in changes in HQoL between women with and without breast cancer; the analyses were repeated with stratification according to age, comorbidity, partner support and time since diagnosis. Results Women with breast cancer reported significantly larger decreases in HQoL from before to after diagnosis than those who remained breast cancer-free (physical component summary, -2.0; 95% CI -2.8; -1.2, mental component summary, -1.5, 95% CI -2.3; -0.6). This association was significantly modified by comorbidity and time since diagnosis. Conclusions Women with breast cancer reported significantly larger HQoL declines than breast cancer-free women. Breast cancer diagnosis seems to have the greatest impact on HQoL closest to diagnosis and in women with comorbidity indicating that this group should be offered timely and appropriate follow-up care to prevent HQoL declines.

The DOMUS study protocol: a randomized clinical trial of accelerated transition from oncological treatment to specialized palliative care at home.

BACKGROUND: The focus of Specialized Palliative Care (SPC) is to improve care for patients with incurable diseases and their families, which includes the opportunity to make their own choice of place of care and ultimately place of death. The Danish Palliative Care Trial (DOMUS) aims to investigate whether an accelerated transition process from oncological treatment to continuing SPC at home for patients with incurable cancer results in more patients reaching their preferred place of care and death. The SPC in this trial is enriched with a manualized psychological intervention. METHODS/DESIGN: DOMUS is a controlled randomized clinical trial with a balanced parallel-group randomization (1:1). The planned sample size is 340 in- and outpatients treated at the Department of Oncology at Copenhagen University Hospital. Patients are randomly assigned either to: a) standard care plus SPC enriched with a standardized psychological intervention for patients and caregivers at home or b) standard care alone. Inclusion criteria are incurable cancer with no or limited antineoplastic treatment options. DISCUSSION: Programs that facilitate transition from hospital treatment to SPC at home for patients with incurable cancer can be a powerful tool to improve patients' quality of life and support family/caregivers during the disease trajectory. The present study offers a model for achieving optimal delivery of palliative care in the patient's preferred place of care and attempt to clarify challenges. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01885637.

Equity in the use of publicly subsidized psychotherapy among elderly Danish cancer patients--a register-based cohort study.

UNLABELLED: Approximately 30% of cancer patients suffer from psychological distress, and psychotherapy has been shown to be effective in alleviating it. Based on the 'Behavioral Model of Health Service Use', we investigated equity in the use of publicly subsidized psychotherapy in a cohort of Danish cancer patients. We present descriptive data on patients' use of psychotherapy and examine characteristics of those who used this service. MATERIAL AND METHODS: The study population comprised 3646 participants in the prospective Diet, Cancer and Health cohort, diagnosed with a first cancer between 2003 and 2009, aged 56-80 years. Data on cancer diagnosis, psychotherapy use and comorbid conditions were obtained from registers, whereas data on demographics, social support and health status were obtained from questionnaires. Cox proportional hazards regression was used to identify factors related to use, which were subsequently evaluated with regard to equity. RESULTS: Subsidized psychotherapy was used by 2.3% of the cancer patients. Longer education (> 10 years compared to < 8) was associated with greater likelihood of initiating psychotherapy [hazard ratio (HR), 1.97; 95% confidence interval (CI), 1.06-3.65], as was previous psychotherapy use compared to no previous use (2.86; 1.32-6.20). Patients with partners who did not reliably provide emotional support were significantly more likely to use psychotherapy than those without a partner (2.36; 1.05-5.30), a difference not found for those with partners who did provide support. Further, a higher SF-36 mental component score (0.96; 0.94-0.98, per point increase), and older age were associated with less use (65-69 years: 0.43; 0.21-0.89, 70-74 years: 0.17, 0.07-0.41; > 74 years: 0.07, 0.01-0.57, compared to < 60 years). CONCLUSIONS: The results allow several possible interpretations. We found that mental health plays a role for accessing subsidized psychotherapy, suggesting that use of psychotherapy is predicted by need and thus characterized by equity. However, education and previous psychotherapy use also play a role, suggesting elements of inequity.

Unmet needs of women with breast cancer during and after primary treatment: a prospective study in Denmark.

UNLABELLED: Integrated plans will be required to ensure care and rehabilitation for the growing number of cancer survivors. Information is lacking, however, about the extent to which patients' rehabilitation needs are being met, and characteristics of patients who experience unmet needs after their diagnosis and throughout the disease trajectory. MATERIAL AND METHODS: Consecutive women with newly diagnosed breast cancer, undergoing surgery at the Breast Surgery Clinic, Rigshospitalet, Denmark, between 2008 and 2009 (N = 261), completed questionnaires on their unmet needs, anxiety, physical functioning, social support and demographic factors at the time of surgery and four and eight months after diagnosis. Associations between demographic and clinical factors at baseline and unmet needs four and eight months after diagnosis were examined in logistic regression models. RESULTS: The percentage of women with unmet needs remained stable between four (42%) and eight months (40%). Unmet needs were reported for patient education, counselling and alternative treatment. The factors significantly associated with having unmet needs were younger age (OR 0.92; 95% CI 0.89-0.95), higher education (OR 2.49; 95% CI 1.14-5.44), not having a partner (OR 2.25; 95% CI 1.22-4.17) and anxiety (OR 1.13; 95% CI 1.05-1.20) at four months; and age (OR 0.91; 95% CI 0.87-0.94), not having a partner (OR 2.21; 95% CI 1.10-4.46) and having had one or more unmet needs at four months (OR 6.83, 95% CI 3.55-13.16) at eight months. CONCLUSION: A total of 53% of women with breast cancer had unmet needs at some time between diagnosis and the end of primary treatment (eight months after diagnosis). A contextual understanding of unmet needs is necessary for planning cancer rehabilitation, as not only factors such as anxiety, physical functioning and previous unmet needs but also age, education and relationship status are associated with unmet needs.

Causes of Hospital Admissions in Domus: A Randomized Controlled Trial of Specialized Palliative Cancer Care at Home.

CONTEXT: Avoidable hospital admissions are important negative indicators of quality of end-of-life care. Specialized palliative care (SPC) may support patients remaining at home. OBJECTIVES: Therefore, the purpose of this study was to investigate if SPC at home could prevent hospital admissions in patients with incurable cancer. METHODS: These are secondary results of Domus: a randomized controlled trial of accelerated transition to SPC with psychological intervention at home (Clinicaltrials.gov: NCT01885637). Participants were patients with incurable cancer and limited antineoplastic treatment options and their caregivers. They were included from the Department of Oncology, Rigshospitalet, Denmark, between 2013 and 2016. The control group received usual care. Outcomes were hospital admissions, causes thereof, and patient and caregiver perceptions of place of care (home, hospital, etc.) at baseline, four weeks, eight weeks, and six months. RESULTS: During the study, 340 patients were randomized and 322 were included in modified intention-to-treat analyses. Overall, there were no significant differences in hospital admissions between the groups. The intervention group had more admissions triggered by worsened general health (22% vs. 16%, P = 0.0436) or unmanageable home situation (8% vs. 4%, P = 0.0119). After diagnostics, admissions were more often caused by clinical symptoms of cancer without progression in the intervention group (11% vs. 7%, P = 0.0493). The two groups did not differ significantly in overall potentially avoidable admissions. Both groups felt mostly safe about their place of care. CONCLUSION: The intervention did not prevent hospital admissions. Likely, any intervention effects were outweighed by increased identification of problems in the intervention group leading to hospital admissions. Overall, patients and caregivers felt safe in their current place of care.

Maladaptive coping in adults who have experienced early parental loss and grief counseling.

This study compares maladaptive coping, measured as substance use, behavioral disengagement, self-blame, and emotional eating, among adults (>18 years) who have experienced early parental loss ( N = 1465 women, N = 331 men) with non-bereaved controls ( N = 515 women, N = 115 men). We also compared bereaved adults who received grief counseling ( N = 822 women, N = 190 men) with bereaved controls who had not ( N = 233 women, N = 66 men). Bereaved adults reported significantly more substance use, behavioral disengagement, and emotional eating than non-bereaved adults. Counseling participants reported significantly more substance use and self-blame than non-participants. Our results suggest that early loss may negatively impact the development of adulthood coping.