Positive aspects of having had cancer: A mixed-methods analysis of responses from the American Cancer Society Study of Cancer Survivors-II (SCS-II).

OBJECTIVE: This study focused on understanding positive aspects of cancer among a large, national sample of survivors, 2, 5, and 10 years' postcancer diagnosis, who responded to the American Cancer Society Study of Cancer Survivors - II (SCS-II) survey "Please tell us about any positive aspects of having cancer." METHODS: A sequential mixed methods approach examined (1) thematic categories of positive aspects from cancer survivors (n = 5149) and (2) variation in themes by sociodemographics, cancer type, stage of disease, and length of survivorship. RESULTS: Themes comprised 21 positive aspects within Thornton's typology of benefits that cancer survivors attribute to their illness: life perspectives, self, and relationships. New themes pertaining to gratitude and medical support during diagnosis and treatment, health-related changes, follow-up/surveillance, and helping others emerged that are not otherwise included in widely used existing benefit finding cancer scales. Gratitude and appreciation for life were the most frequently endorsed themes. Sociodemographics and stage of disease were associated with positive aspect themes. Themes were not associated with survivor cohorts. CONCLUSIONS: No differences in perceived positive aspects across survivor cohorts suggest that positive aspects of cancer may exist long after diagnosis for many survivors. However, variation across sociodemographics and clinical variables suggests cancer survivors differentially experience positive aspects from their cancer diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: This analysis provides new information about cancer survivors' perceptions of positive aspects from their cancer and factors associated with benefit finding and personal growth. This information can be useful in further refining quality-of-life measures and interventions for cancer survivors.

The Cancer Survivorship Journey: Models of Care, Disparities, Barriers, and Future Directions.

Although the number of long-term cancer survivors has increased substantially over past years, the journey of survivorship does not always include high-quality, patient-centered care. A variety of survivorship care models have evolved based on who provides this care, the survivor population, the site of care, and/or the capacity for delivering specific services. Other areas of survivorship care being explored include how long follow-up care is needed, application of a risk-based approach to survivorship care, and the role of the survivor in his or her own recovery. However, there is little evidence indicating whether any models improve clinical or patient-reported outcomes. A newer focus in survivorship care has included assessment of potential disparities; the sociodemographic characteristics of population subgroups associated with barriers to receiving high-quality cancer treatment may also affect the survivorship period. Developing policies and programs to address disparities in survivorship care is not simple, and examining how financial hardship affects cancer outcomes, reducing economic barriers to care, and increasing incorporation of patient-centered strategies may be important components. Here too, there is little evidence regarding the best strategies to address these disparities. Barriers to providing high-quality, patient-centered survivorship care include lack of evidence, lack of a trained survivorship workforce, lack of reimbursement structures/insurance coverage, and lack of a health care system that reduces fragmented care. Future research needs to focus on developing a survivorship care evidence base, exploring strategies to facilitate provision of survivorship care, and disseminating best survivorship care practices to diverse and international audiences.

Counseling by Family Physicians: Implications for Training.

BACKGROUND AND OBJECTIVES: This study explored family physicians' practice of providing psychosocial interventions in the form of counseling, their beliefs about the efficacy of their counseling, their preferences of who should provide counseling, the skills involved in counseling, and their training experiences in learning how to counsel. METHODS: A total of 230 faculty and residents completed written surveys at 11 family medicine residency programs in Florida. RESULTS: Eighty-one percent of study participants regularly offered counseling to their patients, 85% did so for psychosocial problems, and 94% did so for health behavior change. Compared to residents, faculty reported greater use of counseling and a greater willingness to counsel patients for depression or anxiety. Fifty-six percent of the sample stated that their counseling for mental health problems was effective. Sixty percent reported that their training provided them with a basic knowledge of counseling skills; training involved primarily observing a counselor or acting as a co-counselor with an identified counselor. Cognitive Behavioral Therapy, Motivational Interviewing, and the Stages-of-Change Model were the most widely taught counseling approaches. CONCLUSIONS: Family physicians regularly provide counseling for psychosocial problems and health behavior change, and a modest number believe counseling is effective. Residents counsel less regularly and are less confident in the effectiveness of their counseling compared to faculty. Training in counseling skills generally involves direct observation and learning several counseling techniques. Future research should explore whether models of family physician counseling are practical, which techniques should be taught and how.

Current unmet needs of cancer survivors: analysis of open-ended responses to the American Cancer Society Study of Cancer Survivors II.

BACKGROUND: Cancer survivors may continue to experience psychosocial and physical needs related to their cancer experience for many years after treatment. The specification of these needs across cancer types and by survivor characteristics may lead to better prevention approaches and clinical responses. Mixed methods were used to examine responses to an open-ended question about current unmet needs from a survey of 2-, 5-, and 10-year cancer survivors. METHODS: Qualitative techniques were used to code themes of unmet needs from open-ended responses. These themes were then examined with quantitative techniques to describe the frequency of unmet needs across disease subgroups and demographic subgroups of survivors. RESULTS: There were 1514 responses to the open-ended question on unmet needs. Respondents ranged in age from 24 to 97 years and included proportionately more women, and 18% were minorities (black and Hispanic). Sixteen themes of unmet needs were identified. The number and type of unmet needs were not associated with the time since cancer treatment. Breast cancer survivors identified more unmet needs than other survivors. Male survivors and especially prostate cancer survivors identified personal control problems as current needs. Older cancer survivors identified fewer unmet needs on average than younger survivors. CONCLUSIONS: This analysis of an open-ended question on unmet needs extends our understanding of how cancer survivors perceive problems related to cancer. How cancer-related needs change over time and differ by sex, race, and ethnicity and how problems with personal control become manifest are areas of inquiry requiring further research.

Mental health treatment by family physicians: current practices and preferences.

BACKGROUND AND OBJECTIVES: Family physicians are trained to assess mental health symptoms and provide some mental health interventions to their patients. Because of obstacles to referring patients to mental health specialists, many family physicians independently provide outpatient mental health treatment such as brief office counseling. Questions exist regarding physicians' interest in, perceived competence with, and their actual practice of brief office counseling in family medicine. METHODS: Surveys were administered to physicians at 11 family medicine residency programs in Florida. RESULTS: Physicians regularly evaluate, diagnose, and treat patients with mild to moderate mental health disorders. Physicians prefer to evaluate patients themselves but refer patients who require counseling to specialists. However, physicians often provide brief office counseling themselves. Physicians believe they have the knowledge and skills to competently and effectively provide brief office counseling to their patients. They also believe that patients are receptive to and prefer to receive brief office counseling from their family physician rather than from a mental health specialist. CONCLUSIONS: Physicians are willing and feel competent to identify and treat patients with mental disorders in the family medicine outpatient setting, including the provision of brief office counseling. Further research is needed to understand what effective mental health interventions can efficiently be taught to family physicians. Having family physicians treat mental health disorders may lead to greater patient satisfaction, improved chronic care management, and a positive impact on quality of care.

Distress screening: an opportunity for enhancing quality cancer care and promoting the oncology social work profession.

Throughout its history, social work has played a critical role in major client/patient care initiatives because of its unique perspective, wisdom, and skills. The new screening standards set forth by the American College of Surgeons' Commission on Cancer place oncology social workers at the forefront of developing and implementing procedures for distress screening. Our profession is again challenged to work across disciplines and change systems of care to improve the health and welfare of patients with cancer and their families. Indeed, emerging research suggests that the use of psychosocial screening instruments results in reductions in emotional distress, better quality of life, and improved patient-provider communication. As an introduction to this special issue on distress screening, this article offers a brief overview of issues related to distress screening that are covered by papers authored in this special issue by Association of Oncology Social Work members. Topics addressed include a review of the historical context driving distress screening implementation, barriers and challenges to oncology social workers trying to implement distress screening, statistical and cultural considerations for selecting screening tools, best practice models, and future considerations. This special issue is intended to be a primer and serves to promote oncology social workers' involvement and leadership in the development and implementation of distress screening.

An analysis of Social Work Oncology Network Listserv Postings on the Commission of Cancer's distress screening guidelines.

This is a qualitative study of listserv postings by members of the Social Work Oncology Network (SWON) in response to the Commission on Cancer's 2011 guidelines for distress screening of cancer patients. Archived listserv postings for the period of December 2010 to November 2011 were deidentified and a sample was derived by a list of keywords for the analysis. Aims of the study included describing the general categories and themes of the postings devoted to the new distress screening standard and examining the process of facilitation of mutual support and information exchange by oncology social workers in response to the new screening standards. During the 12-month timeframe there were 242 unique listserv postings sampled for the analysis. Oncology social worker (OSW) discussion of the distress screening guidelines remained a constant topic over the 12 months, and major themes that emerged from the data included processes of implementation of distress screening in cancer centers, screening policies and protocols, screening tool choice, and oncology social worker professional identity. The SWON listserv members used the listserv as a mechanism to post their requests for information on screening, to share their experiences in the beginning stages of implementing the guidelines, and to build support for legitimizing oncology social workers as the lead profession in the implementation of the guidelines in member cancer centers.

The effect of lecture and a standardized patient encounter on medical student rape myth acceptance and attitudes toward screening patients for a history of sexual assault.

BACKGROUND: Most physicians fail to routinely screen patients for a history of sexual assault. PURPOSES: This study aimed to gauge medical student support for routinely screening patients for a history of sexual assault, examine potential barriers to screening, and determine if attitudes can be changed through educational interventions. METHODS: One hundred three 2nd-year medical students completed a survey before and after a lecture on sexual assault (response rate = 94/103 and 90/103, respectively). The questionnaire was administered a third time following a standardized patient encounter with a female rape victim (response rate = 102/103). RESULTS: Most medical students agreed that patients should be screened for sexual victimization. Students showed low levels of rape myth acceptance. Agreement with rape myths correlated with increased screening hesitancy. Statistically significant gender differences were observed. Following educational sessions, students expressed less rape myth acceptance and more comfort screening. CONCLUSIONS: Sexual assault education can diminish rape myth acceptance and promote screening for sexual assault.

Barriers to accessing quality health care for cancer patients: a survey of members of the association of oncology social work.

The present article reports data from a cross-sectional survey of members of the Association of Oncology Social Work (AOSW) completed in May 2006. The purpose of the survey was to gather information on AOSW members' practice roles, the clients they serve, and their views on barriers cancer patients face in obtaining quality cancer care. The survey instrument was a self-administered 18-page survey disseminated online and by U.S. mail to members who did not provide e-mail addresses. The response rate to the survey was 62.3% (622/999). Reported barriers to quality cancer care are presented here in three categories: health system, social/environmental, and individual-level barriers. The majority of respondents reported health system barriers, specifically inadequate health insurance, as the major barrier to accessing quality health care for cancer patients. Among social/environmental barriers, inability to pay for treatment-related expenses was the major barrier. Among individual-level barriers, patients' fears and distress were the major barriers. The conclusions from this survey point to the critical role of oncology social workers in assisting cancer patients in overcoming the barriers to quality care and achieving optimum quality of life.

The potential of survivorship care plans in primary care follow-up of minority breast cancer patients.

BACKGROUND: When the clinical care of minority breast cancer survivors is transferred from oncology settings to primary care, quality of care may be compromised if their primary care providers do not have adequate cancer treatment records and follow-up care guidelines. Survivorship care plans (SCPs) given to survivors before they transition to primary care settings are designed to improve the transfer of this information. This study examined these issues in a sample of minority breast cancer survivors. DESIGN: During four focus groups with minority breast cancer survivors, data were collected about the types of information survivors remember receiving from their oncologists about follow-up health care needs. Survivors were also asked their opinions on the value and content of a survivorship care plan. RESULTS: Minority breast cancer survivors received variable amounts of information about their cancer treatments. They were dissatisfied with the amount of information they received on cancer-related side-effects, including race-specific information. The American Society of Clinical Oncology's breast cancer survivorship care plan was viewed as important, but too highly technical and limited in information on side-effects and self-care approaches. CONCLUSIONS: Survivorship care plans may help increase information transfer from oncologists to patients and primary care providers, but the content of care plans needs to be adapted to minority patients' concerns. Primary care physicians may be challenged by survivors to explain recommended surveillance guidelines and to respond to untreated physical and psychosocial problems.

Understanding the scope and practice of behavioral medicine in family medicine.

BACKGROUND AND OBJECTIVES: Family medicine integrates psychosocial factors (behavioral, psychological, cognitive, social, and cultural) into the comprehensive medical care of patients. Behavioral medicine is the discipline representing the contribution of the behavioral sciences to medicine and encompasses a broad field of knowledge and practice. This research explores the understanding of the scope and practice of behavioral medicine among academic family physicians. METHODS: Surveys were administered to physicians at nine family medicine residency programs in Florida. RESULTS: Study participants reported being trained in and using behavioral medicine techniques and consultants with patients. Behavioral medicine was valued as a collection of techniques for the prevention and treatment of physical and psychiatric illness. Physicians emphasized the utility of behavioral specialists' skills in conditions with strong psychological components compared to other chronic medical conditions. Behavioral medicine techniques were associated with traditional psychotherapeutic interventions and often provided by nonpsychiatric physicians. Many physicians categorized behavioral medicine as a type of complementary and alternative medicine. CONCLUSIONS: Behavioral medicine is valued but not strongly identified as a distinct discipline, which might affect its use. This may explain why behavioral medicine skills were differentially valued for the prevention and treatment of psychiatric illness compared to medical illness.

Oncology social worker competencies and implications for education and training.

A mailed and online survey of 622 members of the Association of Oncology Social Workers (AOSW) indicated their proportion of time committed to certain aspects of practice and to certain population groups, and the extent to which they feel competent in various practice areas. Respondents indicated high levels of competence in 17 topic areas, including promotion of patient coping skills, end-of-life issues, and group work. Topic areas in which at least one third of respondents indicated little to no competence included pain assessment and management, cognitive behavioral therapy, complementary and alternative practices, and political advocacy. Although respondents indicated that they spend approximately 10% of their time with non-English-speaking populations, 50% of the sample indicated that they have little to no competence working with this population. Differences in levels of competence by years of experience and work setting were noted across many areas. Findings from this survey may be useful in the development of curriculum for preparing oncology social workers for practice in today's changing health care environment.

Family medicine physicians' advice about use of nonconventional modalities for menopausal symptom management.

AIMS: This study explores the beliefs and practices of family medicine physicians regarding the use of nonconventional modalities for menopausal symptom management. METHODS: Anonymous self-administered questionnaires were distributed to faculty and residents from eight participating family medicine residency programs around Florida, with an overall response rate of 66% (212 respondents). The survey explored what physicians report about patterns of patient inquiries and their responses to patients' inquiries about nonconventional modalities for specific menopausal symptoms and what physicians' report on their advice to patients about using specific herbs and supplements for menopausal symptom relief. RESULTS: Behavioral approaches were encouraged more than herbal therapies, acupuncture, and body therapies for the treatment of most of the menopausal symptoms. However, the most frequent response category was No advice. Resident physicians were significantly more likely than faculty to encourage acupuncture. Faculty physicians were more likely than residents to recommend particular herbal remedies. The majority of the respondents believed there was not sufficient evidence for recommending any of the herbs and supplements listed. CONCLUSIONS: These data reveal some important trends about how family medicine physicians respond to nontraditional approaches for menopausal symptom management. Because family medicine physicians typically receive some training in behavioral and psychotherapeutic approaches and there is some evidence for the effectiveness of behavioral strategies in menopausal symptom management, it is not surprising that they are more likely to endorse these approaches. Most family medicine physicians, however, have little or no training in the other nonconventional modalities, and our data show that these modalities received lower levels of endorsement, suggesting that physicians are not clear on their advantages or disadvantages.

Treatment of menopausal symptoms in family medicine settings following the Women's Health Initiative findings.

PURPOSE: This study explores trends in treatment of menopausal symptoms and use of hormone replacement therapy (HRT) in family medicine settings subsequent to the release of the Women's Health Initiative (WHI) findings. METHODS: Anonymous self-administered questionnaires were distributed to family medicine residents and faculty from 8 participating family medicine residency programs in the state of Florida. The survey asked physicians how they typically treated common menopausal symptoms in otherwise healthy menopausal women, and how their practice patterns had changed since the release of the WHI findings. We analyzed survey responses from 62 faculty and 148 residents (66% of eligible respondents). RESULTS: HRT is still prominent for treating irregular menses, vaginal dryness, vasomotor symptoms, and decreased libido. Faculty physicians were significantly more likely than residents to use HRT for menopausal symptoms. Female physicians were more likely than male physicians to say their treatment patterns had changed as a result of the WHI. CONCLUSIONS: After weighing the evidence of potential risks of HRT from the WHI study, family medicine physicians altered and broadened their strategies for treating common menopausal symptoms. Although HRT remains a prominent treatment approach, there is now more physician-patient discussion of individual risks and benefits than occurred before the WHI's release of findings.

Evaluation of a quality improvement intervention for diabetes management.

The purpose of this study was to develop and test two interventions designed to improve provider compliance with diabetes management guidelines: the use of a diabetes management flowsheet inserted into patient charts and the use of a diabetes management flowsheet plus quarterly provider feedback about compliance levels. Diabetic patient charts from six family practice clinics were randomly selected and audited at baseline and at 12 months. The analysis indicated that the use of the flowsheet was associated with improved provider compliance in the completion of foot examinations only. Providers involved in the study believed that the process of the flowsheet plus feedback contributed to their greater awareness of diabetes management guidelines.