Cancer Survivors' Social Context in the Return to Work Process: Narrative Accounts of Social Support and Social Comparison Information.

Purpose Returning to work is a process that is intertwined with the social aspects of one's life, which can influence the way in which that person manages their return to work and also determines the support available to them. This study aimed to explore cancer patients' perceptions of the role of their social context in relation to returning to work following treatment. Methods Twenty-three patients who had received a diagnosis of either urological, breast, gynaecological, or bowel cancer participated in semi-structured interviews examining general perceptions of cancer, work values and perceptions of the potential impact of their cancer diagnosis and treatment on work. Interviews were analysed using the iterative process of Framework Analysis. Results Two superordinate themes emerged as influential in the return to work process: Social support as a facilitator of return to work (e.g. co-workers' support and support outside of the workplace) and Social comparison as an appraisal of readiness to return to work (e.g. comparisons with other cancer patients, colleagues, and employees in other organisations or professions). Conclusions Two functions of the social context of returning to work after cancer were apparent in the participants' narrative: the importance of social support as a facilitator of returning to work and the utilisation of social comparison information in order to appraise one's readiness to return to work. The role of social context in returning to work has largely been absent from the research literature to date. The findings of this study suggest that social support and social comparison mechanisms may have a significant impact on an individual's successful return to the workplace.

Men's experience of a guided self-help intervention for hot flushes associated with prostate cancer treatment.

Up to 80% of men who receive androgen deprivation therapy report hot flushes and for many these are associated with reduced quality of life. However it is recognised that there are a number of barriers to men's engagement with support to manage symptoms and improve quality of life. This qualitative study was embedded within a larger randomised controlled trial (MANCAN) of a guided self-help cognitive behavioural intervention to manage hot flushes resulting among men receiving androgen deprivation therapy. The study aimed to explore the engagement and experiences with the guided self-help intervention. Twenty men recruited from the treatment arm of the MANCAN trial participated in a semi-structured interview exploring acceptability of the intervention, factors affecting engagement and perceived usefulness of the intervention. Interviews were audio-recorded, transcribed verbatim and analysed using a Framework approach. Over two thirds of respondents (69%) reported reading the intervention booklet in full and over 90% reporting practising the relaxation CD at least once a week. Analysis of the interviews identified three super-ordinate themes and these related to changes in hot flush symptomatology (learned to cope with hot flushes in new ways), the skills that participants had derived from the intervention (promoting relaxation and reducing stressors), and to a broader usefulness of the intervention (broader impact of the intervention and skills). The present study identified positive engagement with a guided self-help intervention and that men applied the skills developed through the intervention to help them undertake general lifestyle changes. Psycho-educational interventions (e.g. cognitive behaviour therapy, relaxation, and positive lifestyle elements) offer the potential to be both effective and well received by male cancer survivors.

Barriers to medical help-seeking among older men with prostate cancer.

OBJECTIVE: Men's disinclination to seek medical help has been linked to higher rates of morbidity and mortality compared to women. However, previous studies were conducted predominantly with healthy, young, and middle-aged men. We explored the perceived medical barriers to help-seeking in older men with prostate cancer. METHOD: 20 men with prostate cancer took part in semistructured interviews, which were analyzed using thematic analysis. RESULTS: Three themes were identified related to negative attitudes toward help-seeking: male gender role; fear of the health condition, medical and treatment procedures; and embarrassment as a consequence of medical examinations, communication with health (and nonhealth) professionals, and the disclosure of sexual-related symptoms. CONCLUSION: The barriers identified in our study strengthen the evidence for the impact of traditional masculinity on help-seeking in men.

'You know I've joined your club I'm the hot flush boy': a qualitative exploration of hot flushes and night sweats in men undergoing androgen deprivation therapy for prostate cancer.

OBJECTIVE: Hot flushes and night sweats are common amongst menopausal women, and psychological interventions for managing these symptoms have recently been developed for women. However, flushes in men with prostate cancer, which commonly occur following androgen deprivation therapy (ADT), remain under-researched. This study is a qualitative exploration of flush-related cognitive appraisals and behavioural reactions reported by a sample of these men. METHODS: Semi-structured, in-depth interviews were conducted with 19 men who were experiencing flushes after receiving ADT for prostate cancer. Framework analysis was used to generate and categorise emergent themes and explore associations between themes. RESULTS: Five main cognitive appraisals included the following: changes in oneself, impact on masculinity, embarrassment/social-evaluative concerns, perceived control and acceptance/adjustment. There were men who held beliefs about the impact of flushes on their perceptions of traditional gender roles, who experienced shame and embarrassment due to concerns about the salience of flushes and perceptions by others and who experienced feelings of powerlessness over flushes. Powerlessness was associated with beliefs about the potentially fatal consequences of discontinuing treatment. Two other dominant themes included awareness/knowledge about flushes and management strategies. Experiences of flushes appeared to be influenced by upbringing and general experiences of prostate cancer and ADT. CONCLUSIONS: The range of men's appraisals of, and reactions to, flushes generated from this qualitative exploration were broadly similar to those of menopausal women but differed in terms of the influence of masculinity beliefs. These findings could be used to inform future research and psychological interventions in this under-researched field.

A longitudinal qualitative study of the experience of working following treatment for gynaecological cancer.

OBJECTIVE: There are an increasing number of gynaecological cancer survivors for whom returning to work is a realistic outcome. There is little research to date specifically examining the return to work experience of survivors of gynaecological cancers. The aim of this study was to explore gynaecological cancer survivors' experience of work over a 1-year period post-treatment. METHODS: A total of 55 gynaecological cancer survivors completed a semi-structured interview following completion of their treatment and of these 36 also completed a follow-up interview 12 months later. In total, 91 interviews were recorded and transcribed verbatim. Framework analysis of the transcripts was undertaken. RESULTS: Three super-ordinate themes were identified and these were labelled 'Meaning of work', 'Disclosure of cancer diagnosis' and 'Readjustment'. Overall, there were few changes in working patterns between the two interview points with the majority of women returning to the same role. Although a desire to make work-related changes was expressed at baseline, few women had initiated such changes 1-year post-treatment. CONCLUSIONS: Employees may experience difficulties due to residual symptoms, such as continuing fatigue, or as a result of unrealistic expectations about returning to full employment soon after treatment has completed. The results highlight the need for an intervention to support gynaecological cancer survivors to cope with long-term residual symptoms and manage expectations about returning to work.

Cancer survivors' and employers' perceptions of working following cancer treatment.

BACKGROUND: Earlier diagnosis and improvements in treatment survival rates have led to an increase in the number of cancer survivors for whom returning to work is a realistic outcome. However, cancer survivors face a number of challenges when returning to the workplace. Little is known about how patients' illness and treatment beliefs affect return to work or of employers' beliefs about the impact of cancer on work. AIMS: To determine patient and employers' beliefs about the impact of cancer on returning to work and to identify differences in the beliefs held by patients and employers. METHODS: Patients absent from work due to breast, urological, gynaecological or head and neck cancers completed a questionnaire within 4 weeks of completing treatment. Unlinked employer respondents from medium to large organizations completed the same questionnaire. The questionnaire focused on the perceived impact of cancer and its treatment on work and an adapted version of the Brief Illness Perceptions Questionnaire. RESULTS: One hundred and ninety four patients (response rate of 82%) and 252 employers (response rate 31%) completed the questionnaire. Organizational respondents consistently reported more negative beliefs about the impact of cancer and treatment on work and in general held more negative illness perceptions about cancer in relation to work. CONCLUSIONS: A discrepancy between beliefs of organizational respondents and cancer survivors could impact on an employees' management of their work and on employers' responsiveness to the needs of survivors. Therefore, it is important that return to work plans include the elicitation of employee beliefs.

A systematic review of acculturation, obesity and health behaviours among migrants to high-income countries.

Objective There is extensive evidence for weight gain among people migrating from low/middle-income to high-income countries, which may be due, in part, to acculturation factors. This review aimed to identify associations between acculturation and body weight among immigrants to high-income countries and identify if studies accounted for the role played by health behaviours. Methods A systematic literature search using keywords was performed with three databases (Medline, PsychINFO and EMBASE). The 35 studies were included that utilised quantitative methodology and presented empirical findings focused on acculturation and body weight among adult immigrants. Findings There was evidence presented across multiple studies for an association between acculturation (measured with standard measures or as duration of stay) and obesity. Most studies were cross sectional, which did not allow the exploration of drivers of change in health behaviours and weight gain. Conclusion This is the first review to examine associations between acculturation and body weight among migrants utilising both acculturation scales and proxy measures of acculturation and to examine the role of health behaviours. Evidence from this review suggests that health interventions should target first generation migrants to promote retention of their original healthy behaviours. Recent migrant groups report healthier behaviours than comparative host country populations, and therefore interventions should be promoted at the initial stages following migration to avoid uptake of unhealthy behaviours.

Racial origin is associated with poor awareness of prostate cancer in UK men, but can be increased by simple information.

Prostate cancer is the second most common cause of cancer death in UK men. We have shown a higher incidence and disease stage in black British men (unpublished), however there is no evidence regarding their awareness of prostate cancer and screening. We assessed the level of prostate cancer awareness and attitudes in Black and White men in the UK, and to see if written information would modify awareness. Information was collected from two groups of 871 men without prostate cancer using a new, validated, prostate cancer awareness questionnaire. The first group was asked to fill in the questionnaire, whereas the second group was initially given printed information on prostate cancer and requested to fill in the questionnaire. Data were compared between the two ethnic groups using SPSS statistical package. Changes in knowledge and attitudes after providing prostate health education were analysed. There was a significantly lower response from Black men. In the first group, Black men were unaware of their increased risk of developing the disease and demonstrated poor knowledge about the symptoms of prostate cancer (P<0.001) and also more negative attitudes about its control and treatment (P<0.01). In the second group, there were significant improvements in knowledge, risk awareness and attitudes following targeted education: this was true for Black and White men. Although Black British men have a high risk of prostate cancer, their knowledge of the disease is poor. Simple education methods can significantly improve awareness and knowledge in both Black and White men.

Satisfaction with outcome and attitudes towards scarring among women undergoing breast reconstructive surgery.

OBJECTIVE: Surgical breast reconstruction following mastectomy often results in scarring not only to the breast but often to the donor-site area. However, few studies have been devoted to the potential effects of scarring among women who underwent breast reconstruction. The aim of the study was to explore these women's attitudes towards scarring. METHOD: Fifteen women who had undergone Transversus Abdominis Myocutaneous (TRAM) flap breast reconstruction surgery (mean age 50 years) took part in a semi-structured qualitative interview. The interview examined their experiences of breast reconstruction surgery, post-surgical adjustment and the impact of scarring. RESULTS: Scarring, particularly donor-site scarring, emerged as the main area of dissatisfaction with the breast reconstruction process. Expectations of the surgery and information provided prior to surgery were also found to relate to women' reports of overall satisfaction. CONCLUSION: This study highlighted that satisfaction with breast reconstruction surgery included relief at not needing to wear prostheses and increased body confidence. However, some women reported unrealistic expectations regarding the outcomes of breast reconstruction surgery including extended recovery time and donor-site scarring. PRACTICE IMPLICATIONS: Future patients may therefore benefit from a patient-centred evaluation of their information needs incorporating both their preferences for type and amount of information at each stage of treatment and recovery as well as their understanding and interpretation of the information given to them.

Beliefs about illness and quality of life among men with erectile dysfunction.

The objective of the study was to apply an illness representations framework to examine patients' beliefs about erectile dysfunction (ED) and the association between those beliefs and reported quality of life. A total of 41 patients attending two secondary care clinics at a teaching hospital completed questionnaires examining quality of life, sexual functioning, illness representations (cause, time-line, coherence, consequences, cure, control and emotion) and perceptions of masculinity. Masculinity, sexual function, emotions and beliefs about consequences were found to be significantly correlated with quality of life. Multiple regression analysis revealed a model that accounted for almost 35% of the variance in quality of life of ED patients. The strongest predictor of higher quality of life was better sexual functioning (beta = -0.342, P < 0.05) followed by more positive beliefs about the effects of ED on masculinity (beta = 0.323, P < 0.05). The results suggest that when assessing the quality of life of men with ED, patients' illness representations should be considered along with their level of sexual functioning and the effects of ED on masculinity. Patients may benefit from an intervention programme that includes an educational component, thereby providing patients with more information about treatment options and available support.

The idiosyncratic relationship between diagnostic delay and stage of oral squamous cell carcinoma.

Approximately half of patients with oral cancer present with advanced lesions when five-year survival rates are as low as 20%, however, diagnostic delay has repeatedly been found to be unrelated to the stage of oral cancer at diagnosis. The aim of this study was to investigate why diagnostic delay is frequently unrelated to the stage of oral cancer at diagnosis. The odds ratio (OR) of early versus advanced oral squamous cell carcinoma was calculated for 245 consecutive patients with untreated oral squamous cell carcinoma. Being female (OR=0.40; 0.19-0.80; p<0.05) and married (OR=0.27; 0.11-0.66; p<0.01) was predictive of early stage disease. Being non-white (OR=5.42; 1.66-17.67; p<0.01) was predictive of advanced stage disease. There is no evidence that these patient demographics are associated with faster growing tumours, yet it is possible that those who are male, unmarried and non-white may not notice an oral lesion until it is advanced in stage. It is concluded that differences in tumour biology are not a likely explanation for the absence of a delay-stage relationship but instead, a proportion of tumours may be silent until advanced in stage.

Elevated visual motion detection thresholds in adults with acquired ophthalmoplegia.

AIMS: To test the hypothesis that in patients with acquired chronic bilateral ophthalmoplegia, abnormal retinal image slippage during head movements would result in abnormal thresholds for visual perception of motion. METHODS: Five patients (two males and three females) with ophthalmoplegia were included in the study. The average age was 44 years (range 30-69 years). The aetiology of ophthalmoplegia was myasthenia gravis (MG; n=2), chronic progressive external ophthalmoplegia (CPEO; n=2), and chronic idiopathic orbital inflammation. Visual motion detection thresholds were assessed using horizontal and vertical gratings (spatial frequency) set at thresholds for visibility. The grating was then accelerated at 0.09 deg/s(2). The subject's task was to detect the drift direction of the stimulus. RESULTS: Visual motion detection thresholds were raised to a mean of 0.434 deg/s (SD 0.09) (mean normal value 0.287 deg/s (SD 0.08)) for horizontal motion; and to a mean of 0.425 deg/s (SD 0.1) (mean normal value 0.252 deg/s (SD 0.08)) for vertical motion. The difference in values for both horizontal and vertical motion detection were statistically significant when compared with age matched controls; p <0.023 for horizontal motion and p<0.07 for vertical motion (two tailed t test). CONCLUSION: Abnormally raised visual motion thresholds were found in patients with ophthalmoplegia. This may represent a centrally mediated adaptive mechanism to ignore excessive retinal slip and thus avoid oscillopsia during head movements.

The effect of habituation and plane of rotation on vestibular perceptual responses.

A technique was applied to assess vestibular sensation without reference to external spatial, position cues. The stimuli were stopping responses to velocity-steps of 90 deg/s in the dark. Subjects indicated their perceived angular velocity by turning a flywheel connected to a tachogenerator. Two separate experiments were conducted. In one, subjects were rotated in yaw about an earth-vertical axis before and after prolonged rotational or visual (optokinetic) stimuli. In the second experiment, subjects were rotated in roll supine, with either the head ('roll centred') or the feet ('roll eccentric') on the axis of rotation. The two aims of the paper were to (i) examine the effect of repetitive vestibular and optokinetic stimulation on the time constant of decay of vestibular sensation in yaw; (ii) to compare vestibular sensation responses to rotation in roll both with and without the addition of a Z-axis centrifugal force. The pre-habituation sensation response in yaw decayed exponentially with a median time constant of 12.8 s. The duration of the sensation responses were significantly reduced following both prolonged vestibular and optokinetic stimulation. The reduction in vestibular responses following prolonged visual and vestibular stimuli, 1) is likely to occur in velocity storage mechanisms mediating ocular and perceptual responses, 2) may represent a mechanism for reducing the disorientating consequences of visual-vestibular conflict and 3) supports the use of optokinetic stimuli as a treatment for vestibular patients. The time constant of the sensation responses in roll was shorter and not significantly influenced by head position: 5.7 s in the head-centred position compared to 4.7 s in the eccentric head position. Therefore, perceptual as well as ocular responses to rotation in roll are determined primarily by cupula dynamics and not influenced by velocity storage.

Developing ways to encourage early detection and presentation of oral cancer: what do high-risk individuals think?

The aim of this pilot research was to improve understanding of individuals at risk of oral cancer, to determine their attitudes towards and responses to early detection interventions. In-depth interviews with the target group (n = 25) were used to determine their views, attitudes and requirements for an intervention to encourage early detection of oral cancer. This data was used in combination with theory-based constructs to develop written material that aimed to increase awareness of oral cancer, encourage mouth self-examination (MSE) and early presentation. A second pilot study used a think-aloud protocol to assess the target groups' (n = 14) reactions to the written information. In both studies the tape-recorded responses were analysed using framework analysis. The target group had limited knowledge about oral cancer, particularly the signs and symptoms. Participants saw benefits in performing MSE but noted the main barriers were not knowing what signs to look for or where to look. The written information was generally well-received but required some modifications. In particular, the target group required further persuasion that their lifestyle contributed to an increased risk of oral cancer. The results of these pilot studies have informed the development of a theory-based intervention for the early detection of oral cancer.

Patient delay in oral cancer: a qualitative study of patients' experiences.

Up to 30% of patients delay seeking the advice of a healthcare professional after self-discovery of symptom(s) of oral cancer. Reasons for this patient delay are poorly understood. The aim of the present study was to explore patients' initial experiences and reactions to developing symptoms of oral cancer, and to identify factors influencing their decision to consult a health care professional. In-depth semi-structured interviews were conducted with 17 consecutive patients who had received a diagnosis of oral squamous cell carcinoma, but had yet to start treatment. Participants were asked about their beliefs about their symptoms over the course of the disease and their decision to seek help. The tape-recorded interviews were transcribed verbatim and analysed using 'Framework analysis'. Oral symptoms were rarely attributed to cancer and were frequently interpreted as minor oral conditions. As a result of these beliefs, patients tended to postpone seeking help or fail to be concerned over their symptoms. Prior to seeking help, patients responded to symptoms by using self-medication, changing the way they ate and disclosing their discovery of symptoms to friends or family. Problems with access to healthcare professionals and patients' social responsibilities acted as barriers to prompt help-seeking. This study has documented that an individual's interpretation of oral cancer symptoms may be misguided and this can adversely affect subsequent help-seeking behaviour.

Screening for depression among neuro-otology patients with and without identifiable vestibular lesions.

The experience of depression and anxiety among a sample of 91 patients with complaints of vertigo or dizziness was assessed using a widely available screening instrument, the Hospital Anxiety and Depression Scale (HADS). Questionnaires to assess reported symptoms, self-esteem and social support were also administered. On the basis of clinical vestibular testing, 53% of participants were classified as having a labyrinthine disorder (canal paresis or positional vertigo), 22% as having a vestibular imbalance (spontaneous nystagmus or directional preponderance), and 251% as having no identifiable vestibular abnormality (negative test results). Based on the self-report measures using the screening instrument, 17% of the sample could be classified as depressed, and 29% as anxious. The presence of a vestibular lesion (based on clinical findings) was not associated with reported depression (F (3, 72) = 0.98, p = 0.41). The variables were entered into a hierarchical multiple regression analysis with depression as the dependent variable. A model emerged which accounted for 50% of the variance. Three variables comprised the final model: anxiety (beta = 0.44, p < 0.001), self-esteem (beta = 0.27, p < 0.01), and satisfaction with social support (beta = 0.25, p < 0.01). The results demonstrate the value of identifying psychosocial factors, as well as disease characteristics, among patients presenting at neurootology clinics. In particular, the findings highlight the importance of screening for emotional distress in this patient group, regardless of clinical test results or severity of self-reported symptoms.

Quality of life following microsurgery, radiosurgery and conservative management for unilateral vestibular schwannoma.

The best way to manage small and medium-sized vestibular schwannomas is currently a matter of heated debate. As these tumours are not immediately life-threatening, patients are invariably concerned about how management would affect their quality of life. Until now, no study has compared the three treatment modalities in terms of physical, psychological and social wellbeing. This study is based on a retrospective database analysis and postal questionnaire survey of unilateral vestibular schwannoma patients who had either been managed conservatively, or treated with microsurgery or radiosurgery. The results showed that: quality of life (measured by the Glasgow Benefit Inventory) deteriorated after microsurgery, particularly for small tumours; conservative management did not lead to a change in quality of life, and there was a trend towards poorer quality of life following radiosurgery. The findings suggest that a conservative management approach may be more appropriate for small tumours, and that patients who are due to undergo microsurgery or radiosurgery may benefit from counselling about the potential impact of treatment on quality of life.

Adaptation to oscillopsia: a psychophysical and questionnaire investigation.

In this study we explore the reasons why patients with bilateral vestibular failure report disparate degrees of oscillopsia. Twelve bilateral labyrinthine-defective (LD) subjects and twelve normal healthy controls were tested using a self- versus visual-motion psychophysical experiment. The LD subjects also completed a questionnaire designed to quantify the severity of handicap caused by oscillopsia. Additional standardized questionnaires were completed to identify the role of personality, personal beliefs and affective factors in adaptation to oscillopsia. During the psychophysical experiment subjects sat on a motorized Barany chair whilst viewing a large-field projected video image displayed on a screen in front of them. The chair and video image oscillated sinusoidally at 1 Hz in counter-phase at variable amplitudes which were controlled by the subject but constrained, so that the net relative motion of the chair and video image always resulted in a sinusoid with a peak velocity of 50 degrees /s. The subject's task was to find the ratio of chair versus video image motion that subjectively produced the 'most comfortable visual image'. Eye movements were recorded during the experiment in order that the net retinal image slip at the point of maximum visual comfort could be measured. The main findings in the LD subjects were that, as a group, they selected lower chair motion amplitude settings to obtain visual comfort than did the normal control subjects. Responses to the questionnaires highlighted considerable variation in reported handicap due to oscillopsia. Greater oscillopsia handicap scores were significantly correlated with a greater external locus of control (i.e. the perception of having little control over one's health). Retinal slip speed was negatively correlated with oscillopsia handicap score so that patients who suffered the greatest retinal slip were those least handicapped by oscillopsia. The results suggest that adaptation to oscillopsia is partly related to the patient's personal attitude to the recovery process and partly associated with the development of tolerance to the movement of images on the retina during self-motion. The latter is likely to be related to previously described changes in visual motion sensitivity in these patients.

Women's knowledge and beliefs regarding breast cancer.

Approximately 20-30% of women delay for 12 weeks or more from self-discovery of a breast symptom to presentation to a health care provider, and such delay intervals are associated with poorer survival. Understanding the factors that influence patient delay is important for the development of an effective, targeted health intervention programme to shorten patient delay. The aim of the study was to elicit knowledge and beliefs about breast cancer among a sample of the general female population, and examine age and socio-economic variations in responses. Participants were randomly selected through the Postal Address File, and data were collected through the Office of National Statistics. Geographically distributed throughout the UK, 996 women participated in a short structured interview to elicit their knowledge of breast cancer risk, breast cancer symptoms, and their perceptions of the management and outcomes associated with breast cancer. Women had limited knowledge of their relative risk of developing breast cancer, of associated risk factors and of the diversity of potential breast cancer-related symptoms. Older women were particularly poor at identifying symptoms of breast cancer, risk factors associated with breast cancer and their personal risk of developing the disease. Poorer knowledge of symptoms and risks among older women may help to explain the strong association between older age and delay in help-seeking. If these findings are confirmed they suggest that any intervention programme should target older women in particular, given that advancing age is a risk factor for both developing breast cancer and for subsequent delayed presentation.

Vestibular perception in patients with acquired ophthalmoplegia.

Using a perceptual technique it is shown that patients with chronic external ophthalmoplegia have shortened vestibular responses. It is postulated that this is secondary to the retinal image slip experienced by these patients during head movements and a useful compensatory mechanism to suppress motion-induced sickness and spatial disorientation.