Inequalities in Financial Distress, Symptoms, and Quality of Life Among Patients with Advanced Cancer in France and the U.S.

BACKGROUND: Financial distress (FD) is common among patients with advanced cancer. Our purpose was to compare the frequency and intensity of FD and its associations with symptom distress and quality of life (QOL) in these patients in France and the U.S. MATERIALS AND METHODS: In this secondary analysis of two cross-sectional studies, we assessed data on 292 patients who received cancer care at a public hospital or a comprehensive cancer center in France (143 patients) or the U.S. (149 patients). Outpatients and hospitalized patients over 18 years of age with advanced lung or breast or colorectal or prostate cancer were included. Diagnosed cognitive disorder was considered a noninclusion criterion. Advanced cancer included relapse or metastasis or locally advanced cancer or at least a second-line chemotherapy regimen. Patients self-rated FD and assessed symptoms, psychosocial distress, and QOL on validated questionnaires. RESULTS: The average patient age was 59 years, and 144 (49%) were female. FD and high intensity were reported more frequently in U.S. patients than in French (respectively 129 [88%] vs. 74 [52%], p < .001; 100 [98%] vs. 48 [34%], p < .001,). QOL was rated higher by the U.S. patients than by the French (69 [SD, 18] vs. 63 [SD, 18], p = .003). French patients had more psychological symptoms such as anxiety (8 [SD, 4] vs. 6 [SD, 5], p = .008). Associations were found between FD and U.S. residence, FD and single status (0.907, p = .023), and FD and metastasis (1.538, p = .036). In contrast, negative associations were found between FD and older age (-0.052, p = .003) and FD and France residence (-3.376, p = .001). CONCLUSION: Regardless of health care system, FD is frequent in patients with advanced cancer. U.S. patients were more likely to have FD than French patients but reported better QOL. Further research should focus on factors contributing to FD and opportunities for remediation. IMPLICATIONS FOR PRACTICE: Suffering is experienced in any component of the lives of patients with a life-threatening illness. Financial distress (FD) is one of the least explored cancer-related symptoms, and there are limited studies describing its impact on this frail population. This study highlights the high frequency and severity of FD in patients with advanced cancer in the U.S. and France as well as its impact on their physical and emotional symptoms and their quality of life in these different health care systems. It is necessary for all health care providers to explore and evaluate the presence of FD in patients living with life-threatening illnesses.

Financial distress in patients with advanced cancer.

PURPOSE: We examined the frequency and severity of financial distress (FD) and its association with quality of life (QOL) and symptoms among patients with advanced cancer in France. DESIGN: In this cross-sectional study, 143 patients with advanced cancer were enrolled. QOL was assessed using the Functional Assessment of Cancer General (FACT-G) and symptoms assessed using Edmonton Assessment System (ESAS) and Hospital Anxiety and Depression Scale (HADS). FD was assessed using a self-rated numeric scale from 0 to 10. RESULTS: Seventy-three (51%) patients reported having FD. Patients reported having FD were most likely to be younger (53.8 (16,7SD) versus 62 (10.5SD), p<0.001), single (33 (62%) versus 40(44%), p = 0.03) and had a breast cancer (26 (36%), p = 0.024). Patients with FD had a lower FACT-G score (59 versus 70, p = 0.005). FD decreased physical (14 versus 18, p = 0.008), emotional (14 versus 16, p = 0.008), social wellbeing (17 versus 19, p = 0.04). Patients with FD had higher HADS-D (8 versus 6 p = 0.007) and HADS-A (9 versus 7, p = 0.009) scores. FD was linked to increased ESAS score (59 (18SD) versus 67 (18SD), p = 0.005) and spiritual suffering (22(29SD) versus 13(23SD), p = 0.045). CONCLUSION: The high rate of patient-reported FD was unexpected in our studied population, as the French National Health Insurance covers specific cancer treatments. The FD was associated with a poorer quality of life. Having a systematic assessment, with a simple tool, should lead to future research on interventions that will increase patients' QOL.

Financial Distress and Its Associations With Physical and Emotional Symptoms and Quality of Life Among Advanced Cancer Patients.

OBJECTIVE: There are limited data on the effects of financial distress (FD) on overall suffering and quality of life (QOL) of patients with advanced cancer (AdCa). In this cross-sectional study, we examined the frequency of FD and its correlates in AdCa. PATIENTS AND METHODS: We interviewed 149 patients, 77 at a comprehensive cancer center (CCC) and 72 at a general public hospital (GPH). AdCa completed a self-rated FD (subjective experience of distress attributed to financial problems) numeric rating scale (0 = best, 10 = worst) and validated questionnaires assessing symptoms (Edmonton Symptom Assessment System [ESAS]), psychosocial distress (Hospital Anxiety and Depression Scale [HADS]), and QOL (Functional Assessment of Cancer Therapy-General [FACT-G]). RESULTS: The patients' median age was 60 years (95% confidence interval [CI]: 58.6-61.5 years); 74 (50%) were female; 48 of 77 at CCC (62%) versus 13 of 72 at GPH (18%) were white; 21 of 77 (27%) versus 32 of 72 (38%) at CCC and GPH, respectively, were black; and 7 of 77 (9%) versus 27 of 72 (38%) at CCC and GPH, respectively, were Hispanic (p < .0001). FD was present in 65 of 75 at CCC (86%; 95% CI: 76%-93%) versus 65 of 72 at GPH (90%; 95% CI: 81%-96%; p = .45). The median intensity of FD at CCC and GPH was 4 (interquartile range [IQR]: 1-7) versus 8 (IQR: 3-10), respectively (p = .0003). FD was reported as more severe than physical distress, distress about physical functioning, social/family distress, and emotional distress by 45 (30%), 46 (31%), 64 (43%), and 55 (37%) AdCa, respectively (all significantly worse for patients at GPH) (p < .05). AdCa reported that FD was affecting their general well-being (0 = not at all, 10 = very much) with a median score of 5 (IQR: 1-8). FD correlated (Spearman correlation) with FACT-G (r = -0.23, p = .0057); HADS-anxiety (r = .27, p = .0014), ESAS-anxiety (r = .2, p = .0151), and ESAS-depression (r = .18, p = .0336). CONCLUSION: FD was very frequent in both groups, but median intensity was double among GPH patients. More than 30% of AdCa rated FD to be more severe than physical, family, and emotional distress. More research is needed to better characterize FD and its correlates in AdCa and possible interventions. IMPLICATIONS FOR PRACTICE: Financial distress is an important and common factor contributing to the suffering of advanced cancer patients and their caregivers. It should be suspected in patients with persistent, refractory symptom expression. Early identification, measurement, and documentation will allow clinical teams to develop interventions to improve financial distress and its impact on quality of life of advanced cancer patients.

Agreement for depression diagnosis between DSM-IV-TR criteria, three validated scales, oncologist assessment, and psychiatric clinical interview in elderly patients with advanced ovarian cancer.

BACKGROUND: Depression, a major outcome in cancer patients, is often evaluated by physicians relying on their clinical impressions rather than patient self-report. Our aim was to assess agreement between patient self-reported depression, oncologist assessment (OA), and psychiatric clinical interview (PCI) in elderly patients with advanced ovarian cancer (AOC). METHODS: This analysis was a secondary endpoint of the Elderly Women AOC Trial 3 (EWOT3), designed to assess the impact of geriatric covariates, notably depression, on survival in patients older than 70 years of age. Depression was assessed using the Geriatric Depression Scale-30 (GDS), the Hospital Anxiety Depression Scale, the distress thermometer, the mood thermometer, and OA. The interview guide for PCI was constructed from three validated scales: the GDS, the Hamilton Depression Rating Scale, and the Montgomery Asberg Depression Rating Scale (MADRS). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, revised (DSM) criteria for depression were used as a gold standard. RESULTS: Out of 109 patients enrolled at 21 centers, 99 (91%) completed all the assessments. Patient characteristics were: mean age 78, performance status ≥2: 47 (47%). Thirty six patients (36%) were identified as depressed by the PCI versus 15 (15%) identified by DSM. We found moderate agreement for depression identification between DSM and GDS (κ=0.508) and PCI (κ=0.431) and high agreement with MADRS (κ=0.663). We found low or no agreement between DSM with the other assessment strategies, including OA (κ=-0.043). Identification according to OA (yes/no) resulted in a false-negative rate of 87%. As a screening tool, GDS had the best sensitivity and specificity (94% and 80%, respectively). CONCLUSION: The use of validated tools, such as GDS, and collaboration between psychologists and oncologists are warranted to better identify emotional disorders in elderly women with AOC.

[Consultations in oncological supportive care mono-, multi-, ou interdisciplinary: What should we favour?]. / Consultations en soins de support oncologiques mono-, multi-, ou interdisciplinaires : que privilégier ?

According to the point 7.6 and 7.7 of the Cancer Plan 2014, all cancer patients should have access to supportive care. Indeed, the supportive care consultation in oncology is an important tool for the symptom management of cancer patients at all times of treatment. This consultation can be mono-disciplinary or multi-disciplinary (with different professions: physician, nurse, psychologist, social service assistant…) with or without integration (multidisciplinary or interdisciplinary). There are few studies focusing on the types of consultations (mono- or multidisciplinary) to promote based on their expected outcomes. After describing the different types of consultations (initial, follow-up, unscheduled, discharge) and having highlighted the main issues of these consultations, we will present the possible configurations. Our discussion will concern then the advantages and disadvantages of monodisciplinarity and different types of multidisciplinary highlighting the possible improvements. At the end of this work, after a brief synthesis of the different outcomes associated with each type of consultation, we would like to discuss the type of consultation to choose according to the outcomes.

Family conferences in palliative care: a survey of health care providers in France.

CONTEXT: Family conferences are conducted to assist with end-of-life discussions and discharge planning. OBJECTIVES: This study describes the current practices of family conferences in palliative care units (PCUs) in France. METHODS: A cross-sectional descriptive survey was sent to each PCU in France (n = 113). Members of the interdisciplinary health care team (palliative care physician, nurse, psychologist, and social worker) who were active in each PCU at the time of the survey were asked to respond. RESULTS: Two hundred seventy-six of 452 responses (61%) were obtained from members of the health care team in 91 units (81%). Two hundred seventy-two of 276 health care providers (HCPs) (99%) reported conducting family conferences in their clinical practice. Only 13 participants (5%) reported that they followed a structured protocol. Most respondents completed the questionnaire: palliative care physicians (n = 225; 82%), nurses (n = 219; 79%), and psychologists (n = 181; 66%). The three primary goals of family conferences were to allow family members to express their feelings (n = 240; 87%), identify family caregivers (n = 233; 84%), and discuss the patient's plan of care (n = 219; 79%). The primary reasons for conducting a family conference were: the patient's illness was terminal (n = 216; 78%), family caregivers requested a conference (n = 208; 75%), or terminal sedation was required (n = 189; 69%). One hundred six of 452 HCPs (38%) reported that patients were not invited to participate. The primary indications and goals for a family conference were significantly different among the four health care disciplines. CONCLUSION: Most HCPs in our study conducted family conferences. However, most of the family conferences had no structured protocol, half of the participants preferred no patient participation, and a significant variation was noted in the primary indications and goals among disciplines.

Depression assessment by oncologists and palliative care physicians.

OBJECTIVE: Depression is a frequent problem in cancer patients, which is known to reduce quality of life; however, many cancer patients with depression are not treated because of the difficulties in assessing depression in this population. Our aim was to evaluate and improve the depression assessment strategies of palliative care (PC) physicians and oncologists. METHOD: We invited all medical oncologists and PC physicians from three cancer centers to participate in this multicenter prospective study. They were asked to classify 22 symptoms (related and specific to depression in cancer patients, related but not specific, and unrelated) as "very important," "important," "less important," or "not important" for the diagnosis of depression in cancer patients, at three different time points (at baseline, after a video education program, and after 4 weeks). They were also asked to complete a questionnaire exploring physicians' perceptions of depression and of their role in its systematic screening. RESULTS: All 34 eligible physicians participated. Baseline performance was good, with >70% of participants correctly classifying at least seven of nine related and specific symptoms. We found no significant improvement in scores in the immediate and 4-week follow-up tests. Additionally, 24 (83%) and 23 (79%) participants expressed support for systematic depression screening and a role for oncologists in screening, respectively. SIGNIFICANCE OF RESULTS: Oncologists had good baseline knowledge about depression's main symptoms in cancer patients and a positive attitude toward being involved in screening. Underdiagnosis of depression is probably related to problems associated with the oncology working environment rather than the physicians' knowledge.