Lung cancer diagnosed following an emergency admission: exploring patient and carer perspectives on delay in seeking help.

PURPOSE: Compared to others, patients diagnosed with lung cancer following an emergency, unplanned admission to hospital (DFEA) have more advanced disease and poorer prognosis. Little is known about DFEA patients' beliefs about cancer and its symptoms or about their help-seeking behaviours prior to admission. METHODS: As part of a larger single-centre, prospective mixed-methods study conducted in one University hospital, we undertook qualitative interviews with patients DFEA and their carers to obtain their understanding of symptoms and experiences of trying to access healthcare services before admission to hospital. Interviews were recorded and transcribed. Framework analysis was employed. RESULTS: Thirteen patients and 10 carers plus 3 bereaved carers took part in interviews. Three patient/carer dyads were interviewed together. Participants spoke about their symptoms and why they did not seek help sooner. They described complex and nuanced experiences. Some (n = 12) had what they recalled as the wrong symptoms for lung cancer and attributed them either to a pre-existing condition or to ageing. In other cases (n = 9), patients or carers realised with hindsight that their symptoms were signs of lung cancer, but at the time had made other attributions to account for them. In some cases (n = 3), a sudden onset of symptoms was reported. Some GPs (n = 6) were also reported to have made incorrect attributions about cause. CONCLUSION: Late diagnosis meant that patients DFEA needed palliative support sooner after diagnosis than patients not DFEA. Professionals and lay people interpret health and illness experiences differently.

Can body composition be used to optimize the dose of platinum chemotherapy in lung cancer? A feasibility study.

PURPOSE: Current methods of dosing platinum-based chemotherapy are suboptimal. Potentially, taking lean body mass into account may help. To inform the design of a future study, we first examined the feasibility and acceptability of such an approach using dual-energy X-ray absorptiometry (DEXA) and explored aspects suggestive of over- and under-dosing. METHODS: Patients with lung cancer offered platinum-based chemotherapy over 1 year were identified and, if eligible, invited to take part in a prospective feasibility study. Questionnaires examined acceptability of the DEXA scan and of a future study that randomized between traditional dosing and one adjusted according to body composition. Dose-limiting toxicity (DLT) and a lack of neutropenia explored potential over- and under-dosing, respectively. RESULTS: Of the 173 patients offered chemotherapy, 123 (71%) were ineligible, mostly because of failing entry criteria (84, 49%). Of the 50 approached, 18 (36%) participated, most receiving carboplatin, with 17 providing data. All found a DEXA scan acceptable; other assessments were fully completed, except nadir and pre-chemotherapy blood counts. Most (94%) were prepared to take part in a future study, although the additional hospital visits for a nadir blood count were unpopular with some. Five (29%) patients experienced six episodes of DLT which resulted in discontinuation (3), dose reduction (2) or change to a less toxic regimen (1). Nine (60%) patients experienced either no (2) or inconsistent (7) neutropenia. CONCLUSIONS: A randomized trial appears acceptable and feasible in patients receiving carboplatin. Adjustment of our entry criteria and avoiding a hospital visit for a nadir blood count should aid recruitment.

Occupational therapy needs of patients with thoracic cancer at the time of diagnosis: findings of a dedicated rehabilitation service.

PURPOSE: Guidelines recommend screening patients with cancer to identify their rehabilitation needs. To help quantify this area of need and associated workload from an occupational therapy perspective in patients with thoracic cancer, we report the experiences of a dedicated rehabilitation service. METHODS: Consecutive patients were screened soon after diagnosis using items associated with occupational performance in the Sheffield Profile for Assessment and Referral for Care questionnaire. Those reporting predetermined levels of distress underwent a full occupational therapy evaluation; this generated a problem list from which individualised goals and interventions were instigated. RESULTS: Of 540 patients screened, 273 (51 %) reported levels of distress which warranted a full occupational therapy assessment. Of these, 260 (95%) reported a total of 681 problems (median of 4 [2-5] per patient). Mostly these lay within the domain of self care (553, 78%) in the categories of transfers, functional mobility and bathing/showering. A total of 646 goals (median of 2 [1-3] per patient) were formulated, resulting in 652 individual interventions, most frequently the provision of equipment (79%) or advice (32%) and referral to another professional/agency (23%). Patients considered that most goals were achieved (98%) and that the provision of equipment was useful (97%). CONCLUSIONS: About half of patients with thoracic cancer screened have occupational therapy needs around the time of diagnosis. Problems are mostly in the area of self-care, with equipment provision the most frequent intervention provided. Future work should examine the efficacy of occupational therapy interventions further.

Holistic Needs of People with Thoracic Cancer Identified by the Sheffield Profile for Assessment and Referral to Care Questionnaire©.

Background: A holistic needs assessment is recommended in people with cancer at key stages, including soon after diagnosis. For people with thoracic cancer, there is a lack of data obtained routinely at this time point. Objective: To identify the most common and/or distressing supportive and palliative needs present soon after diagnosis using a specifically developed questionnaire. Methods: As part of a local rehabilitation service, patients within three to six weeks of a diagnosis of thoracic cancer were invited to complete the Sheffield Profile for Assessment and Referral to Care (SPARC©) questionnaire. Results: For a 26-month period, 738 patients completed the questionnaire, representing about 70% of all patients diagnosed with thoracic cancer during this time. Respondents had a median [interquartile range] of 15 (11-21) symptoms or issues, with 2 (0-5), 4 (2-7), and 7 (5-11) causing "very much," "quite a bit," and "a little" distress or bother, respectively. The top five most frequent needs causing any degree of distress or bother were physical, present in 68%-80% of patients: feeling tired, shortness of breath, cough, feeling sleepy in the day, changes in weight. Two psychological issues followed: worrying about effects of the illness on others, feeling anxious, both present in 67%. Despite most patients reporting talking to health professionals about their condition, 20%-30% wanted further information. Conclusions: These findings represent the largest cohort of patients with thoracic cancer completing the SPARC questionnaire soon after diagnosis, and provide detailed information on the high level of need that thoracic oncology services must be able to respond to.

Lung cancer diagnosed following an emergency admission: Mixed methods study of the management, outcomes and needs and experiences of patients and carers.

BACKGROUND: In the UK, although 40% of patients with lung cancer are diagnosed following an emergency admission (EA), data is limited on their needs and experiences as they progress through diagnostic and treatment pathways. METHODS: Prospective data collection using medical records, questionnaires and in-depth interviews. Multivariate logistic regression explored associations between diagnosis following EA and aspects of interest. Questionnaire responses with 95% confidence intervals were compared with local and national datasets. A grounded theory approach identified patient and carer themes. RESULTS: Of 401 patients, 154 (38%) were diagnosed following EA; 37 patients and six carers completed questionnaires and 13 patients and 10 carers were interviewed. Compared to those diagnosed electively, EA patients adjusted results found no difference in treatment recommendation, treatment intent or place of death. Time to diagnosis, review, or treatment was 7-14 days quicker but fewer EA patients had a lung cancer nurse present at diagnosis (37% vs. 62%). Palliative care needs were high (median [IQR] 21 [13-25] distressing or bothersome symptoms/issues) and various information and support needs unmet. Interviews highlighted in particular, perceived delays in obtaining investigations/specialist referral and factors influencing success or failure of the cough campaign. CONCLUSIONS: Presentation as an EA does not appear to confer any inherent disadvantage regarding progress through lung cancer diagnostic and treatment pathways. However, given the frequent combination of advanced disease, poor performance status and prognosis, together with the high level of need and reported short-fall in care, we suggest that a specialist palliative care assessment is routinely offered.

Providing nutritional support to patients with thoracic cancer: findings of a dedicated rehabilitation service.

BACKGROUND: National guidelines recommend screening patients with thoracic cancer to identify those requiring nutritional support. To help quantify this area of need, the associated workload and explore its impact, we report findings from a dedicated rehabilitation service. METHODS: Patients were screened soon after diagnosis to determine the prevalence of malnutrition, and various aspects compared between malnourished and not malnourished groups. A nutritional care plan was instigated and all contacts recorded, together with follow-up body weight. RESULTS: Of 243 patients seen, 35% were malnourished which was associated with a palliative treatment intent (P < 0.05) and a reduced survival (median 155 days less, 1-year survival 19% vs. 41%; P < 0.01 for both); nonetheless, for about one-fifth, treatment intent was curative. Overall, about two-thirds of patients were failing to meet their daily recommended energy intake. The dietitian provided over 870 episodes of care, a median of three per patient. More of the malnourished group received oral nutritional supplements, but also experienced problems tolerating them. Over one month, neither the pattern nor magnitude of the change in weight differed between malnourished and not malnourished groups. Overall, weight was stable, increased or decreased in 52 (27%), 80 (42%) and 59 (31%) respectively, with no difference in overall survival (P = 0.16). CONCLUSION: Our data provides a pragmatic insight into the implications of following national guidance on nutritional screening and support in this patient group. Nutritional support failed to prevent weight loss in some patients, and did not appear to impact on survival; new assessments and treatments for cachexia are required.