Looking at individual symptoms: the dynamic network structure of depressive symptoms in cancer survivors and their preferences for psychological care.

PURPOSE: The majority of depressed cancer survivors do not receive psychological care, possibly because offered care does not align with their experiences and preferences. We examined (1) which depressive symptoms cancer survivors would like to receive psychological care for; (2) how distinct depressive symptoms are related to each other in the contemporaneous and temporal network of depressive symptoms; and (3) whether survivors' care needs correspond to the interconnectedness of these specific symptoms. METHOD: Fifty-two cancer survivors suffering from at least mild depressive symptoms and were not receiving psychological care filled out a baseline questionnaire about their care needs for distinct depressive symptoms, followed by ecological momentary assessments (EMA) assessing depressive symptoms (14 days, five times a day). Multi-level vector autoregression analysis was used to estimate associations between distinct depressive symptoms as well as their centrality within the network. RESULTS: Cancer survivors most strongly preferred to receive care for fatigue, feeling down, little enjoyment, and sleep problems. Fatigue, together with worry and lack of concentration, most strongly predicted the onset of other symptoms. Little enjoyment and feeling down were two of the most central symptoms (i.e., strongly connected to other symptoms) in the contemporaneous network and were most strongly influenced by other symptoms in the temporal network. CONCLUSIONS: Clinicians can offer specific interventions that target fatigue, as these played an important role in the onset of symptoms and would align with survivors' needs. IMPLICATIONS FOR CANCER SURVIVORS: Offering such symptom-specific care may increase the uptake of psychological interventions in cancer survivors.

Work-specific cognitive symptoms and the role of work characteristics, fatigue, and depressive symptoms in cancer patients during 18 months post return to work.

OBJECTIVE: Cancer patients can experience work-specific cognitive symptoms post return to work. The study aims to (1) describe the course of work-specific cognitive symptoms in the first 18 months post return to work and (2) examine the associations of work characteristics, fatigue and depressive symptoms with work-specific cognitive symptoms over time. METHODS: This study used data from the 18-month longitudinal "Work Life after Cancer" cohort. The Cognitive Symptom Checklist-Work Dutch Version (CSC-W DV) was used to measure work-specific cognitive symptoms. Linear mixed models were performed to examine the course of work-specific cognitive symptoms during 18-month follow-up; linear regression analyses with generalized estimating equations were used to examine associations over time. RESULTS: Working cancer patients examined with different cancer types were included (n = 378). Work-specific cognitive symptoms were stable over 18 months. At baseline, cancer patients reported more working memory symptoms (M = 32.0; CI, 30.0-34.0) compared with executive function symptoms (M = 19.3; CI, 17.6-20.9). Cancer patients holding a job with both manual and nonmanual tasks reported less work-specific cognitive symptoms (unstandardized regression coefficient b = -4.80; CI, -7.76 to -1.83) over time, compared with cancer patients with a nonmanual job. Over time, higher depressive symptoms were related to experiencing more overall work-specific cognitive symptoms (b = 1.27; CI, 1.00-1.55) and a higher fatigue score was related to more working memory symptoms (b = 0.13; CI, 0.04-0.23). CONCLUSIONS: Job type should be considered when looking at work-specific cognitive symptoms over time in working cancer patients. To reduce work-specific cognitive symptoms, interventions targeted at fatigue and depressive symptoms might be promising.

Fatigue and depressive symptoms improve but remain negatively related to work functioning over 18 months after return to work in cancer patients.

PURPOSE: The aims of this study are to investigate the course of work functioning, health status, and work-related factors among cancer patients during 18 months after return to work (RTW) and to examine the associations between these variables and work functioning over time. METHODS: Data were used from the 18-month longitudinal "Work Life after Cancer" (WOLICA) cohort, among 384 cancer patients who resumed work. Linear mixed models were performed to examine the different courses during 18-month follow-up. Linear regression analyses with generalized estimating equations (GEE) were used to examine the associations and interactions. RESULTS: Cancer patients reported an increase of work functioning and a decrease of fatigue and depressive symptoms in the first 12 months, followed by a stable course between 12 and 18 months. Cognitive symptoms were stable during the first 18 months. Working hours increased and social support decreased during the first 6 months; both remained stable between 6 and 18 months. Fatigue, depressive, and cognitive symptoms were negatively associated with work functioning over time; working hours and supervisor social support were positively associated. CONCLUSIONS: Interventions to improve cancer patients' work functioning over time might be promising if they are aimed at reducing fatigue, depressive symptoms, cognitive symptoms, and encouraging supervisor social support. IMPLICATIONS FOR CANCER SURVIVORS: It is important to monitor cancer patients not only in the period directly after RTW but up to 18 months after RTW, allowing for timely interventions when needed.

Factors influencing work functioning after cancer diagnosis: a focus group study with cancer survivors and occupational health professionals.

PURPOSE: Cancer survivors (CSs) frequently return to work, but little is known about work functioning after return to work (RTW). We aimed to identify barriers and facilitators of work functioning among CSs. METHODS: Three focus groups were conducted with CSs (n = 6, n = 8 and n = 8) and one focus group with occupational health professionals (n = 7). Concepts were identified by thematic analysis, using the Cancer and Work model as theoretical framework to structure the results. RESULTS: Long-lasting symptoms (e.g. fatigue), poor adaptation, high work ethics, negative attitude to work, ambiguous communication, lack of support and changes in the work environment were mentioned as barriers of work functioning. In contrast, staying at work during treatment, open dialogue, high social support, appropriate work accommodations and high work autonomy facilitated work functioning. CONCLUSIONS: Not only cancer-related symptoms affect work functioning of CSs after RTW but also psychosocial and work-related factors. The barriers and facilitators of work functioning should be further investigated in studies with a longitudinal design to examine work functioning over time.

The Cognitive Symptom Checklist-Work in cancer patients is related with work functioning, fatigue and depressive symptoms: a validation study.

PURPOSE: The study objectives are to translate the 21-item Cognitive Symptom Checklist-Work (CSC-W21) to Dutch (CSC-W DV) and to validate the CSC-W DV in working cancer patients. METHODS: The CSC-W21 was cross-culturally translated and adapted to a Dutch version. In this 19-item version, the dichotomous response option was changed to an ordinal five-point scale. A validation study of the CSC-W DV was conducted among cancer patients who had returned to work during or following cancer treatment. Internal consistency (Cronbach's α), structural validity (exploratory factor analysis) and construct validity (hypothesis testing) were evaluated. RESULTS: In a cohort of 364 cancer patients, 341 (94 %) completed the CSC-W DV (aged 50.6 ± 8.6 years, 60 % women). Exploratory factor analysis revealed two subscales 'working memory' and 'executive function'. The internal consistency of the total scale and subscales was high (Cronbach's α = 0.93-0.95). Hypothesis testing showed that self-reported cognitive limitations at work were related to work functioning (P < 0.001), fatigue (P = 0.001) and depressive symptoms (P < 0.001), but not to self-rated health (P = 0.14). CONCLUSIONS: The CSC-W DV showed high internal consistency and reasonable construct validity for measuring work-specific cognitive symptoms in cancer patients. The CSC-W DV was associated in expected ways with work functioning, fatigue and depressive symptoms. IMPLICATIONS FOR CANCER SURVIVORS: It is important to enhance knowledge about cognitive symptoms at work in cancer patients, to guide and support cancer patients as good as possible when they are back at work and to improve their work functioning over time.

The impact of age on changes in quality of life among breast cancer survivors treated with breast-conserving surgery and radiotherapy.

BACKGROUND: The purpose of the study was to determine the impact of young age on health-related quality of life (HRQoL) by comparing HRQoL of younger and older breast cancer patients, corrected for confounding, and of young patients and a general Dutch population. METHODS: The population consisted of breast cancer survivors (stage 0-III) after breast-conserving surgery and radiotherapy. Health-related quality of life was prospectively assessed using the EORTC QLQ-C30 and QLQ-BR23 questionnaires. The association between age (⩽50; 51-70; ⩾70 years) and HRQoL over time was analysed with mixed modelling. The clinical relevance of differences between/within age groups was estimated with Cohen's D and consensus-based guidelines. The HRQoL data from the young patient cohort were compared with Dutch reference data at 3 years after radiotherapy. RESULTS: A total of 1420 patients completed 3200 questionnaires. Median follow-up was 34 (range 6-70) months. Median age was 59 (range 28-85) years. Compared with older subjects, young women reported worse HRQoL in the first year after radiotherapy, but clinical relevance was limited. Three years after radiotherapy, HRQoL values in the younger group were equal to those in the reference population. Pain and fatigue after radiotherapy improved, with medium clinical relevance. CONCLUSIONS: Three years after radiotherapy for breast cancer, young age was not a risk factor for decreased HRQoL.

Perceived health after kidney transplantation: a cross-sectional comparison of long-term and short-term cohorts.

Although increased longevity of grafts has led to a growing number of long-term kidney transplant recipients, knowledge about the perceived health of these patients remains limited. A cross-sectional sample of 609 patients (60% response) was stratified into a short-term (≤1 year), midterm (>1 and ≤8 years), and long-term cohort (>8 and ≤15 years posttransplantation). Cohorts were compared for perceived health (Visual Analogue Scale of the EQ-5D), number of symptoms, and number of comorbidities by analysis of variance/covariance and multivariate regression analyses. Long-term patients reported more symptoms, (F[2, 606] = 3.09, P = .046) and more comorbidities, (F[2, 588] = 4.75, P = .009) but similar levels of perceived health, (F[2, 550] = 2.37, P > .05). Furthermore, symptoms were less influential for perceived health among long- versus short-term (z = -2.08, P = .038) or midterm cohorts (z = -2.60, P = .009). Previously identified predictors of perceived health accounted for less variance in the long-term as opposed to short-term (z = 4.30, P < .001) and midterm cohort (z = 2.07, P = .039). Despite more symptoms and comorbidities, the perceived health of long-term kidney transplant recipients was comparable to the short- and midterm, possibly due to selective survival or patient adjustment. Because kidney function and symptoms were predominantly associated with short-term perceived health, there is an urgent need to identify variables associated with long-term perceived health.

Coping with adverse drug events in patients with heart failure: Exploring the role of medication beliefs and perceptions.

This study describes coping strategies that patients with heart failure (HF) use to manage adverse drug events (ADEs). The included coping strategies were social support seeking, information seeking, non-adherence and taking alleviating medication. The role of beliefs about medication and ADE perceptions in explaining these coping strategies was assessed using the Self-Regulation Model. We performed a cross-sectional study including 250 HF patients who experienced an ADE. Patients completed validated questionnaires assessing their coping strategies, ADE perceptions and medication beliefs. Social support (60%) and information seeking (32%) were the most commonly used strategies to cope with ADEs. Non-adherence was reported by 7% of the patients. Multivariate linear regression analysis showed that demographics, clinical factors and medication beliefs explained only a small amount of the variance in coping strategies, whereas ADE perceptions explained a substantial amount of variance. Path analysis showed that patients' perceptions about the timeline, consequences and controllability of ADEs by the health care provider were directly related to their coping behaviour. The effect of patients' medication beliefs on their coping strategies was consistent with mediation through their ADE perceptions. Our results support the value of the Self-Regulation Model in understanding patients' coping behaviour with regard to ADEs.

Measuring somatic symptoms with the CES-D to assess depression in cancer patients after treatment: comparison among patients with oral/oropharyngeal, gynecological, colorectal, and breast cancer.

There is a high prevalence of depression after cancer treatment. In the literature, several authors have raised questions about assessing somatic symptoms to explore depression after cancer treatment. These somatic sequelae are a consequence of cancer treatment and should cause higher depression rates in cancer patients. In this study, the Somatic domain on a depression questionnaire, the Center for Epidemiologic Studies-Depression scale (CES-D) was analyzed in different cancer patients after treatment, as compared with a control group. Data from 566 cancer patients (oral/oropharyngeal, gynecological, colorectal, and breast cancer) and 255 randomly chosen comparison patients were analyzed. The total score on the CES-D domain of Somatic Retarded Activity significantly differed between the cancer and comparison groups; but the cancer groups showed both less somatic morbidity (colorectal cancer) and more somatic morbidity (oral/oropharyngeal, breast) than the comparison group. In the analyses of the CES-D with and without the Somatic domain, the prevalence of depression symptoms with the Somatic domain is lower for the cancer groups. Authors conclude that cancer patients are not a homogenous group as regards somatic sequelae. Evidence for removing Somatic items from the CES-D for patients after cancer treatment was not confirmed.

Paroxysmal atrial fibrillation, quality of life and neuroticism.

BACKGROUND: Paroxysmal atrial fibrillation (AF) is associated with significant impairment of quality of life (QoL), which is to a large extent independent of objective measures of disease severity. We sought to investigate the potential role of neuroticism in the impairment of QoL in patients with paroxysmal AF. METHODS: The study group (AF group) comprised 73 patients with paroxysmal AF (mean age 55.5 +/- 113.3 years, 50 males). On average, patients had a three-year history of one symptomatic paroxysm a week lasting two hours. QoL was assessed using the Medical Outcomes Study Short Form (SF-36) and neuroticism was assessed using the short-scale Eysenck Personality Questionnaire (EPQ). RESULTS: The degree of neuroticism in the AF patient group did not differ from the degree of neuroticism in a group of age- and sex-matched controls (mean EPQ score on neuroticism 4.1 +/- 3.0 and 3.9 +/- 3.1, respectively; p = NS). Within the AF group, multivariate regression analyses showed that QoL in the physical domain (SF-36 physical functioning, physical role function, vitality and pain subscales) was not related the degree of neuroticism. In contrast, significant inverse relations were observed between scores on the mental health and social functioning subscales and the degree of neuroticism (beta coefficients p < .05), independent of age, sex and symptoms. CONCLUSION: Based on the present study, patients with paroxysmal AF appear to have on average a degree of neuroticism similar to age- and sex-matched controls. However, the impairment of QoL in these patients, in particular regarding social functioning and mental health, seems to be related to a relatively high degree of neuroticism, independent of age and sex.

Low control beliefs, classical coronary risk factors, and socio-economic differences in heart disease in older persons.

The objective of this study was to examine whether it is through their low control beliefs that low socio-economic status groups have higher risks of heart disease, and to examine whether this mechanism is more substantial than and independent of the mechanism via classical coronary risk factors. In a population-based prospective cohort study, participants were selected from 27 general practices in the north-eastern part of The Netherlands. In 1993, there were 3888 men and women, 57 years and older, who were without prevalent heart disease. During the 5-year follow-up period, 287 cases of incident heart disease (acute myocardial infarction and/or congestive heart failure) were registered (7%). Persons with a low socio-economic status had higher risks of heart disease (RR = 1.45 (95% CI: 1.06 - 1.99)) compared with their high status counterparts. On average, 4 percent of the socio-economic differences were accounted for by the classical coronary risk factors (e.g. smoking, hypertension) compared with 30 percent by the control beliefs. The contribution of the latter was largely independent of the former. Our findings support the hypothesis that socio-economic inequalities in heart disease-at least in middle-aged and older persons-may be based upon differences in control beliefs, more than upon differences in smoking rates and other classical risk factors.

The relative contribution of domains of quality of life to overall quality of life for different chronic diseases.

This study examined the contribution of the quality of life (QoL) domains physical, social and psychological functioning to the explanation of overall QoL. Various disorders may differentially affect QoL domains due to disease-specific factors and, consequently, the relationship between QoL domains and overall QoL may vary between diseases. We therefore studied this relationship for several diseases as well as the differential impact of these diseases on QoL. The present study had a cross-sectional design. We selected patients (aged 57 years and older) with one of the following eight chronic medical conditions: lung disorder, heart condition, hypertension, diabetes mellitus, back problems, rheumatoid arthritis, migraine, or dermatological disorders. The total group of respondents included 1457 patients and 1851 healthy subjects. Regression analyses showed that the domain of psychological functioning contributed to overall QoL for all disorders, whereas physical and social functioning contributed to overall QoL for some disorders. Differences were found between most patient groups and healthy subjects with respect to physical functioning; with respect to social and psychological functioning some groups differed from the healthy group. Explanations for the findings and implications for clinical practice are discussed.

Pre-morbid predictors of psychological adjustment to cancer.

This study examined the potential role of social support, neuroticism, and self-efficacy as predictors of the short-term and long-term adaptation to the diagnosis of cancer. Psychological adjustment was defined in terms of psychological distress. It is argued that these factors may provide insights that might be helpful in the provision of medical care to patients. We hypothesized that they would be especially predictive of long-term psychological adjustment. The study was conducted in a truly prospective design with one pre-morbid assessment and two post-morbid assessments used in the present analyses. Participants of a baseline assessment among 5279 subjects (aged 57 years and older) in 1993 were monitored for cancer incidence by their general practitioners. The study sample included 99 cancer patients who had completed all pre-morbid and post-morbid assessments. Multivariate analyses revealed that high neuroticism was associated with higher levels of distress in the short- and long-term. Higher levels of social support were associated with higher levels of distress in the long-term. The direction of this association was opposite to what might be expected on the basis of the literature. Implications of the findings for health care as well as explanations for the social support findings are discussed.

Gender-specific changes in quality of life following cardiovascular disease: a prospective study.

Gender-specific changes in Quality of Life (QoL) following cardiovascular disease (CVD) were studied in 208 patients to determine whether gender-related differences in postmorbid QoL result from differences in disease severity, premorbid QoL, or different CVD-related recovery. Premorbid data were available from a community-based survey. Follow-ups were done at 6 weeks, 6 months, and 12 months after diagnosis. Results showed that females had worse QoL at all three postmorbid assessments compared to males. However, multivariate analyses adjusting for premorbid gender differences and disease severity showed no significant gender-related differences for physical and psychologic functioning. Therefore, gender differences in QoL following CVD mainly result from premorbid differences in QoL, age, comorbidity, and disease severity at the time of diagnosis, and do not appear to be the consequence of gender-specific recovery. However, in clinical practice it is important to acknowledge the poorer QoL of females following CVD.

Chronic disease in elderly couples: are women more responsive to their spouses' health condition than men?

OBJECTIVE: The aim of the present study is to increase knowledge regarding associations between couples' health condition and psychological distress in both spouses considering gender as well as patient/spouse status. METHOD: We examined a community-based sample of 995 elderly couples in which either both spouses were healthy, one of them suffered from chronic disease or both spouses were ill. Both spouses filled out the Hospital Anxiety and Depression Scale. RESULTS: In line with our hypotheses, the results showed an association between women's psychological distress and their own as well as their spouse's health condition, whereas men's psychological distress was associated only with their own health condition. CONCLUSION: The findings demonstrate the need for awareness of gender and patient/spouse differences in psychological distress among elderly couples confronted with chronic disease.

Changes in health-related quality of life in older patients with acute myocardial infarction or congestive heart failure: a prospective study.

OBJECTIVES: To study changes in health-related quality of life (HR-QL) following acute myocardial infarction (AMI) or congestive heart failure (CHF) in older people (> or = 57 yr). DESIGN: Prospective cohort study. SETTING: Primary healthcare registers. PARTICIPANTS: Patients were enrolled on the basis of primary healthcare records. Eighty-nine AMI patients (mean age = 69.5) and 119 CHF patients (mean age = 74.5) were included for analysis. MEASUREMENTS: HR-QL was conceptualized and measured by means of physical (activities of daily living (ADL), instrumental activities of daily living (IADL)), psychological (depressive symptoms, anxiety), social, and role functioning. Premorbid data (TO) were available from a 1993 community-based survey. Incident AMI and CHF cases, developed after 1993, were prospectively followed for 12 months. Assessments were performed at 6 weeks (T1) and 6 (T2) and 12 months (T3) after diagnosis. RESULTS: At the premorbid assessment, AMI patients did not significantly differ on HR-QL from a reference group of older people, whereas CHF patients were on average older and had worse HR-QL compared to the reference group. Although CHF had not yet been diagnosed at TO, symptoms were already present and resulted in decreased levels of functioning. At T1, all HR-QL measures showed worse functioning compared with TO, except for depressive symptoms that presented later (at T2). In contrast to the delay in depressive symptoms, a significant increase in anxiety was already seen at T1. The effect of the somatic conditions was the largest on physical functioning. Effects on psychological and social functioning were less pronounced but still significant. Effects were maintained during the 12 months of follow-up. CONCLUSION: The negative consequences on HR-QL in both AMI and CHF patients are not temporary. No recovery of function was seen in AMI patients, and functioning of CHF patients continued to decline in the first year after diagnosis.

Social predictors of recovery in late middle-aged and older persons after injury to the extremities: a prospective study.

OBJECTIVES: The impact of educational level and social support on short-term and long-term recovery of activities of daily living and instrumental activities of daily living after injuries to the extremities was examined in a prospective study concerning late middle-aged and older persons. METHODS: Patients (N = 171) who had sustained fall-related injuries (hip fractures, other fractures, or sprains and dislocations) participated in the study. Disability scores were collected at baseline (before the injury) and 8 weeks, 5 months, and 12 months after the injury. The authors used analysis of variance to assess possible differences between 3 levels of education and social support with respect to changes in disability scores from baseline to the 3 follow-up measurements while adjusting for covariates. RESULTS: Preinjury assessed educational level or social support did not play a role in short-term changes in disability. In the long term (5 and 12 months after the injury), recovery was significantly associated with social support: Those with higher levels of support had a better recovery. Although patients with high levels of education most closely approached their pre-event level of disability as well, differences did not reach statistical significance. Short-term changes in disability appeared to be determined by the severity of the injury. Social support began to influence recovery only when the impact of severity expired. DISCUSSION: Patients recovering from fall-related injuries who had reported high levels of social support before their injury had recovered better at 5 and 12 months. Encouragement and special attention given by health professionals to maintain social support may be beneficial for rehabilitation after fall-related injuries in older persons.

The evaluation of the Center for Epidemiologic Studies Depression (CES-D) scale: Depressed and Positive Affect in cancer patients and healthy reference subjects.

This study examined the reliability and validity of a two-factor structure of the Center for Epidemiologic Studies Depression (CES-D) scale. The study was conducted in a large group of cancer patients (n = 475) and a matched reference group (n = 255). Both groups filled in a questionnaire at two points in time; patients 3 and 15 months after diagnosis. Factor analysis confirmed our hypothesis that the 16 negatively and four positively formulated items measure two relatively independent factors, i.e. Depressed Affect and Positive Affect. Therefore, these items should not be combined into an overall sumscore. In both groups, Depressed Affect proved to be a reliable and valid measure of depressive symptomatology, as indicated by its good internal consistency, its strong correlations with other measures of psychological distress and neuroticism, and its effectiveness in discriminating patients from the reference group on depressive symptomatology. In contrast, the validity of the Positive Affect factor could not be confirmed, since it was only weakly related to other measures of psychological distress and extraversion. Depressed and Positive Affect were about equally related to self-esteem, life satisfaction, and quality of life. These findings support the use of a sumscore based on the 16 negatively formulated CES-D items as a more valid measure of depressive symptomatology, in cancer patients and in healthy individuals from the general population.

Morbidity and quality of life and the moderating effects of level of education in the elderly.

The moderating effect of level of education (as an indicator of socioeconomic status) on the associations between chronic medical morbidity and six domains of health-related quality of life (physical function, role function, social function, health perceptions, bodily pain and mental health) is studied in a large community-dwelling elderly sample (N = 5279). The results showed that health-related quality of life is substantially affected by chronic medical morbidity, and that level of education has weak, but significant unique contributions to physical function, social function, health perceptions, and mental health. We did not find substantial evidence for the differential vulnerability hypothesis. At best, low education might amplify the negative effects of the number of chronic medical conditions on mental health only, but this result was not confirmed in four specific disease groups.

The stability of lifestyle behaviour.

BACKGROUND: The stability of lifestyle behaviour has been studied over a 4-year period in a sample of 1400 men in The Netherlands. The influence of both socioeconomic status and age was studied in relation to lifestyle behaviour change. METHODS: Lifestyle behaviour was analysed by means of index scores, each covering one of four domains: smoking, alcohol consumption, physical activity and dietary habits. Changes in lifestyle behaviour were analysed at individual and group level, using different statistical methods. RESULTS: Smoking behaviour remained highly constant, whereas alcohol consumption had only moderate stability. Physical activity and dietary habits had greater variability over this time period. Age and socioeconomic status are related to the prevalence of lifestyle behaviour, whereas only age is related to the stability of lifestyle behaviour. Socioeconomic status did not relate to changes in lifestyle behaviour. CONCLUSIONS: The four lifestyle behaviours differed in the degree of variation over a 4-year period. Only a small group (11%) changed two or more lifestyle behaviours. This implies that lifestyle behaviour is not a unified concept and should not be treated in that way in public health campaigns.