Treatment goals and changes over time in older patients with non-curable cancer.

PURPOSE: To investigate the treatment goals of older patients with non-curable cancer, whether those goals changed over time, and if so, what triggered those changes. METHODS: We performed a descriptive and qualitative analysis using the Outcome Prioritization Tool (OPT) to assess patient goals across four conversations with general practitioners (GPs) over 6 months. Text entries from electronic patient records (hospital and general practice) were then analyzed qualitatively for this period. RESULTS: Of the 29 included patients, 10 (34%) rated extending life and 9 (31%) rated maintaining independence as their most important goals. Patients in the last year before death (late phase) prioritized extending life less often (3 patients; 21%) than those in the early phase (7 patients; 47%). Goals changed for 16 patients during follow-up (12 in the late phase). Qualitative analysis revealed three themes that explained the baseline OPT scores (prioritizing a specific goal, rating a goal as unimportant, and treatment choices related to goals). Another three themes related to changes in OPT scores (symptoms, disease course, and life events) and stability of OPT scores (stable situation, disease-unrelated motivation, and stability despite symptoms). CONCLUSION: Patients most often prioritized extending life as the most important goal. However, priorities differed in the late phase of the disease, leading to changed goals. Triggers for change related to both the disease (e.g., symptoms and course) and to other life events. We therefore recommend that goals should be discussed repeatedly, especially near the end of life. TRIAL REGISTRATION: OPTion study: NTR5419.

Symptoms in long-term breast cancer survivors: A cross-sectional study in primary care.

PURPOSE: Various long-term symptoms can manifest after breast cancer treatment, but we wanted to clarify whether these are more frequent among long-term breast cancer survivors than matched controls and if they are associated with certain diagnoses. METHODS: This was a cross-sectional, population-based study of 350 breast cancer survivors treated with chemo- and/or radiotherapy ≥5 years (median 10) after diagnosis and 350 women without cancer matched by age and primary care physician. All women completed a questionnaire enquiring about symptoms, underwent echocardiography to assess the left ventricle ejection fraction, and completed the Hospital Anxiety and Depression Scale. Cardiovascular diseases were diagnosed from primary care records. In a multivariable logistic regression analysis, symptoms were adjusted for the long-term effects and compared between cohorts and within the survivor group. RESULTS: Concentration difficulties, forgetfulness, dizziness, and nocturia were more frequent among breast cancer survivors compared with controls, but differences could not be explained by cardiac dysfunction, cardiovascular diseases, depression, or anxiety. Intermittent claudication and appetite loss were more frequent among breast cancer survivors than controls and associated with cardiac dysfunction, depression, and anxiety. Breast cancer survivors treated with chemotherapy with/without radiotherapy were at significantly higher odds of forgetfulness and nocturia, but significantly lower odds of dizziness, compared with breast cancer survivors treated with radiotherapy alone. CONCLUSIONS: Intermittent claudication and appetite loss are common among breast cancer survivors and are associated with cardiac dysfunction and mood disorders. Other symptoms varied by whether the patient underwent chemotherapy with/without radiotherapy (forgetfulness and nocturia) radiotherapy alone (dizziness).

Time to diagnosis of symptomatic gastric and oesophageal cancer in the Netherlands: Where is the room for improvement?

BACKGROUND: An efficient diagnostic pathway and early stage diagnosis for cancer patients is widely pursued. This study aims to chart the duration of the diagnostic pathway for patients with symptomatic oesophageal and gastric cancer, to identify factors associated with long duration and to assess the association of duration with tumour stage at diagnosis. METHODS: This was a retrospective cohort study, using electronic health records of six routine primary care databases covering about 640,000 patients, partly linked to the Netherlands Cancer Registry. Symptomatic patients with oesophageal and gastric cancer (2010-2015) that presented in primary care were included. Duration of four diagnostic intervals was determined: patient interval; first symptoms to primary care consultation, primary care interval; consultation to referral, secondary care interval; referral to diagnosis, and the diagnostic interval; consultation to diagnosis. Characteristics associated with 'long duration' (≥P75 duration) were assessed using log-binomial regression. Median durations were stratified for tumour stages. RESULTS: Among 312 symptomatic patients with upper gastrointestinal cancer, median durations were: patient interval: 29 days (interquartile interval 15-73), primary care interval: 12 days (interquartile interval 1-43), secondary care interval: 13 days (interquartile interval 6-29) and diagnostic interval: 31 days (11-74). Patient interval duration was comparable for patients with and without alarm symptoms. Absence of cancer-specific alarm symptoms was associated with 'long duration' of primary care interval and secondary care interval: relative risk 5.0 (95% confidence interval 2.7-9.1) and 2.1 (95% confidence interval 1.3-3.7), respectively. Median diagnostic interval duration for local stage disease was 51 days (interquartile interval 13-135) versus 27 days (interquartile interval 11-71) for advanced stage (p = 0.07). CONCLUSION: In the diagnostic pathway of upper gastrointestinal cancers, the longest interval is the patient interval. Reducing time to diagnosis may be achieved by improving patients' awareness of alarm symptoms and by diagnostic strategies which better identify cancer patients despite low suspicion.

Correspondence between primary and secondary care about patients with cancer: a Delphi consensus study.

INTRODUCTION: To provide optimal care for patients with cancer, timely and efficient communication between healthcare providers is essential. In this study, we aimed to achieve consensus regarding the desired content of communication between general practitioners (GPs) and oncology specialists before and during the initial treatment of cancer. METHODS: In a two-round Delphi procedure, three expert panels reviewed items recommended for inclusion on referral and specialist letters. RESULTS: The three panels comprised 39 GPs (42%), 42 oncology specialists (41%) (i.e. oncologists, radiotherapists, urologists and surgeons) and 18 patients or patient representatives (69%). Final agreement was by consensus, with 12 and 35 items included in the GP referral and the specialist letters, respectively. The key requirements of GP referral letters were that they should be limited to medical facts, a short summary of symptoms and abnormal findings, and the reason for referral. There was a similar requirement for letters from specialists to include these same medical facts, but detailed information was also required about the diagnosis, treatment options and chosen treatment. After two rounds, the overall content validity index (CVI) for both letters was 71%, indicating that a third round was not necessary. DISCUSSION: This is the first study to differentiate between essential and redundant information in GP referral and specialist letters, and the findings could be used to improve communication between primary and secondary care.

The distress thermometer as a prognostic tool for one-year survival among patients with lung cancer.

INTRODUCTION: The use of patient-reported outcome measures is increasingly advocated to support high-quality cancer care. We therefore investigated the added value of the Distress Thermometer (DT) when combined with known predictors to assess one-year survival in patients with lung cancer. METHODS: All patients had newly diagnosed or recurrent lung cancer, started systemic treatment, and participated in the intervention arm of a previously published randomised controlled trial. A Cox proportional hazards model was fitted based on five selected known predictors for survival. The DT-score was added to this model and contrasted to models including the EORTC-QLQ-C30 global QoL score (quality of life) or the HADS total score (symptoms of anxiety and depression). Model performance was evaluated through improvement in the -2 log likelihood, Harrell's C-statistic, and a risk classification. RESULTS: In total, 110 patients were included in the analysis of whom 97 patients accurately completed the DT. Patients with a DT score ≥5 (N = 51) had a lower QoL, more symptoms of anxiety and depression, and a shorter median survival time (7.6 months vs 10.0 months; P = 0.02) than patients with a DT score <5 (N = 46). Addition of the DT resulted in a significant improvement in the accuracy of the model to predict one-year survival (P < 0.001) and the discriminatory value (C-statistic) marginally improved from 0.69 to 0.71. The proportion of patients correctly classified as high risk (≥85% risk of dying within one year) increased from 8% to 28%. Similar model performance was observed when combining the selected predictors with QoL and symptoms of anxiety or depression. CONCLUSIONS: Use of the DT allows clinicians to better identify patients with lung cancer at risk for poor outcomes, to further explore sources of distress, and subsequently personalize care accordingly.

The effect of physical activity on fatigue among survivors of colorectal cancer: a systematic review and meta-analysis.

PURPOSE: Favorable health outcomes among cancer survivors are increasingly being attributed to lifestyle factors like physical activity, which is now promoted in clinical guidelines. However, the available evidence indicates that physical activity may also reduce fatigue in this patient group. In this systematic review, we aimed to examine whether physical activity could reduce fatigue among survivors of colorectal cancer. METHODS: The databases of Medline, CINAHL, and PsycINFO were systematically searched, using combinations of MeSH and free-text terms for colorectal cancer, physical activity, and fatigue. Randomized controlled trials and cohort studies with longitudinal data collection were included. We performed a random-effect meta-analysis. RESULTS: Seven studies were included, five were randomized controlled trials, and two were cohort studies. A meta-analysis of the randomized controlled trials, which comprised 630 survivors in total, failed to show that physical activity had a significant effect on fatigue (standardized mean difference = 0.21 (- 0.07 to 0.49)); however, reduced levels of fatigue were observed in all studies. The results for the cohort studies were inconclusive: one showed that increasing levels of physical activity were significantly associated with decreasing levels of fatigue; the other showed that decreasing levels of fatigue were not associated with increasing levels of physical activity. CONCLUSIONS: Based on the data reviewed, we cannot draw definitive conclusions about the effects of physical activity on fatigue. None of the included studies were performed among fatigued survivors of colorectal cancer. More research is needed in this population, ensuring that the trials are appropriately powered to find differences in fatigue.

Patients' expectations and preferences regarding cancer follow-up care.

INTRODUCTION: Most survivors of cancer enter a follow-up routine after their treatment, the aim of which is to detect recurrence, provide psychological support, monitor treatment-related side-effects, and to evaluate care. Due to rising numbers of people with cancer and better survival of these patients, current follow-up routines are under pressure. We reviewed the literature on patients' expectations and preferences regarding this care. METHODS: We systematically searched the databases of Pubmed, CINAHL, and PsychInfo. Studies were screened and data extraction was double performed by three authors. Data were collected from quantitative and qualitative studies and described thematically. RESULTS: After screening, 12 full-text articles were included, comprising 849 patients aged from 28 to 90 years. Patients expect follow-up visits to detect recurrence of cancer. They want to undergo extensive testing to get reassurance. Furthermore, patients expect relevant information to be provided and to get advice about different aspects of their illness. Psychosocial support is also expected. Patients express a desire for consistency of care as well as continuity of care, and prefer long and intensive follow-up. DISCUSSION AND CONCLUSION: After cancer, patients appear to lose confidence in their bodies and fear cancer recurrence after the end of treatment, which may lead to intensive screening wishes. This is not desirable, since care for cancer is already under pressure due to rising numbers of survivors. We have to ensure that follow-up routines are sustainable and effective. Patients should receive good information about the need for follow-up tests. Doctors should be trained to give this information.

Primary healthcare use during follow-up after curative treatment for colorectal cancer.

The rising number of colorectal cancer (CRC) survivors is likely to impose a burden on healthcare systems. Effective resource allocation between primary and hospital care to ensure ongoing high-quality care is under discussion. Therefore, it is important to understand the current role of GPs during follow-up care of CRC. This study explores the primary healthcare use of patients 2-6 years after CRC treatment. Annual rates of face-to-face contacts, prescribed medication and referrals were compared between CRC patients and age, gender and GP matched controls in a historical prospective study. Reasons for contacts and prescribed medication were compared based on International Classification of Primary Care and Anatomical Therapeutic Chemical (ATC) Classification System codes, respectively. Negative binomial regression models and non-parametric test were used. Patients showed significantly more face-to-face contacts in the 2nd (63%), 3rd (32%) and 6th (23%) year, more drug prescriptions in the 2nd, 3rd and 6th year, and more referrals in the 2nd and 5th year after diagnosis. Differences in contacts and medication were related to the alimentary tract, blood and blood-forming organs, and psychological problems. This study suggests that GPs already play a substantial role during CRC follow-up and that there may be scope for formal services to be incorporated into the current model of GP care.