It's not over when it's over: long-term symptoms in cancer survivors--a systematic review

Utilization of cancer survivorship services during the COVID-19 pandemic in a tertiary referral center

BACKGROUND

All Commission on Cancer-accredited comprehensive cancer centers offer survivorship programs (SPs) to women upon completion of treatment. These SPs can include clinical and non-clinical programming such as physical rehabilitation, emotional and psychosocial support, nutrition, and exercise programming. Concern about the availability and access to these programs during the COVID-19 pandemic has been described in recent literature. We sought to identify the impact of the COVID-19 pandemic on participation in these supportive services for breast cancer patients within a single institution.

METHODS

The Ohio State University tertiary care center offers clinical and non-clinical breast cancer support services. Descriptive statistics were utilized to summarize referral and patient participation data from January 2019 through July 2021. Data from calendar year 2019 was used as a normative comparison for pre-COVID-19. In-person and telehealth use was tracked longitudinally.

RESULTS

During the lockdown due to the COVID-19 pandemic (March through May 2020), provider referrals to SPs declined by 10%, while the overall total for the calendar year modestly increased from 1195 in 2019 to 1210 in 2020, representing a 1.3% increase. Psycho-oncology referrals increased from 280 to 318 (13.5%). The most significant change of participation rates in non-clinical SPs during the pandemic was utilization of exercise content, which increased by 220% from 2019 to 2020. The total proportion of breast cancer participants choosing an exercise program increased from 16.8% in 2019 to 42.2% in 2021, making it the most selected program area overall. Previously, nutrition was the most selected program area as it comprised 42.5% of overall utilization in 2019.

CONCLUSION

The pandemic's potential to place barriers to participation in SPs is a legitimate concern. We found a modest decline in provider referrals to clinical services during the lockdown period, while patient-directed participation increased with more survivors engaging in exercise-based programs. Transitioning to virtual platforms served to maintain access for patients.

IMPLICATIONS FOR CANCER SURVIVORS

As we grapple with the COVID-19 pandemic, patients with cancer deserve increased attention due to the expected stressors associated with the diagnosis. Those in the survivorship stage utilize services for psychosocial support, and the observed increase in utilization of SPs suggests an elevated need for connectivity. To meet this need, telehealth platforms have been expanded to allow for continued participation. It remains to be seen whether this will be sustained post-COVID-19 or whether reduced human contact will create new needs for programming.

Increased microglia activation in late non-central nervous system cancer survivors links to chronic systemic symptomatology

Prolonged inflammatory expression within the central nervous system (CNS) is recognized by the brain as a molecular signal of "sickness", that has knock-on effects to the blood-brain barrier, brain-spinal barrier, blood-cerebrospinal fluid barrier, neuro-axonal structures, neurotransmitter activity, synaptic plasticity, neuroendocrine function, and resultant systemic symptomatology. It is concurred that the inflammatory process associated with cancer and cancer treatments underline systemic symptoms present in a large portion of survivors, although this concept is largely theoretical from disparate and indirect evidence and/or clinical anecdotal reports. We conducted a proof-of-concept study to link for the first time late non-CNS cancer survivors presenting chronic systemic symptoms and the presence of centralized inflammation, or neuroinflammation, using TSPO-binding PET tracer [11 C]-PBR28 to visualize microglial activation. We compared PBR28 SUVR in 10 non-CNS cancer survivors and 10 matched healthy controls. Our data revealed (1) microglial activation was significantly higher in caudate, temporal, and occipital regions in late non-central nervous system/CNS cancer survivors compared to healthy controls; (2) increased neuroinflammation in cancer survivors was not accompanied by significant differences in plasma cytokine markers of peripheral inflammation; (3) increased neuroinflammation was not accompanied by reduced fractional anisotropy, suggesting intact white matter microstructural integrity, a marker of neurovascular fiber tract organization; and (4) the presentation of chronic systemic symptoms in cancer survivors was significantly connected with microglial activation. We present the first data empirically supporting the concept of a peripheral-to-centralized inflammatory response in non-CNS cancer survivors, specifically those previously afflicted with head and neck cancer. Following resolution of the initial peripheral inflammation from the cancer/its treatments, in some cases damage/toxification to the central nervous system occurs, ensuing chronic systemic symptoms.

Long-term efficacy of a computer-tailored physical activity intervention for prostate and colorectal cancer patients and survivors: A randomized controlled trial

BACKGROUND

Physical activity (PA) can improve the physical and psychological health of prostate and colorectal cancer survivors, but PA behavior change maintenance is necessary for long-term health benefits. OncoActive is a print- and web-based intervention in which prostate and colorectal cancer patients and survivors receive automatically generated, personalized feedback aimed at integrating PA into daily life to increase and maintain PA. We evaluated the long-term outcomes of OncoActive by examining the 12-month follow-up differences between OncoActive and a control group, and we explored whether PA was maintained during a 6-month non-intervention follow-up period.

METHODS

Prostate or colorectal cancer patients were randomly assigned to an OncoActive (n = 249) or a usual care waitlist control group (n = 229). OncoActive participants received PA advice and a pedometer. PA outcomes (i.e., ActiGraph and self-report moderate-to-vigorous intensity PA (MVPA) min/week and days with ≥30 min PA) and health-related outcomes (i.e., fatigue, depression, physical functioning) were assessed at baseline, 6 months, and 12 months. Differences between groups and changes over time were assessed with multilevel linear regressions for the primary outcome (ActiGraph MVPA min/week) and all additional outcomes.

RESULTS

At 12 months, OncoActive participants did not perform better than control group participants at ActiGraph MVPA min/week, self-report MVPA min/week, or ActiGraph days with PA. Only self-report days with PA were significantly higher in OncoActive compared to the control group. For health-related outcomes only long-term fatigue was significantly lower in OncoActive. When exploratively examining PA within OncoActive, the previously found PA effects at the end of the intervention (6 months follow-up) were maintained at 12 months. Furthermore, all PA outcomes improved significantly from baseline to 12 months. The control group showed small but non-significant improvements from 6 months to 12 months (and from baseline to 12 months), resulting in a decline of differences between groups.

CONCLUSION

The majority of previously reported significant between-group differences at 6 months follow-up were no longer present at long-term follow-up, possibly because of natural improvement in the control group. At long-term follow-up, fatigue was significantly lower in OncoActive compared to control group participants. Computer-tailored PA advice may give participants an early start toward recovery and potentially contributes to improving long-term health.

Is there a need for change in cancer survivorship care? A qualitative exploration of survivor experiences and needs at the Sydney Cancer Survivorship Centre Clinic

PURPOSE

Effective cancer survivorship care is contingent on a comprehensive understanding and management of the dynamic needs of cancer survivors. The Sydney Cancer Survivorship Centre (SCSC) clinic established a holistic, multidisciplinary model of survivorship care. We aimed to explore survivors' experiences and perceptions of the clinic, and to identify their unmet needs.

METHODS

Semi-structured focus groups (FGs) involving participants recruited from the SCSC clinic were conducted by an experienced facilitator and observer using a guide covering: survivor perceptions of first SCSC clinic visit, services accessed, ongoing unmet needs, and how needs changed over time. FGs were audio-recorded and transcribed. Interpretive description using a Framework approach was undertaken and participant characteristics summarised descriptively.

RESULTS

Eight FGs were conducted involving a total of 26 participants (mean age: 60), most were female (n = 20), born in Australia (n = 14), and with breast cancer diagnoses (n = 16). Four overarching themes were identified: (i) perceptions of the SCSC clinic; (ii) patient-centred care; (iii) adjustment to illness; and (iv) external supports and resources. Participants valued the centralisation of multidisciplinary survivorship care at the SCSC clinic, which helped their recovery. Mitigating ongoing treatment sequelae, reassurance of good-health, normalisation of survivorship experiences, and handling caregiver stress represent some needs identified.

CONCLUSIONS

The SCSC clinic offers holistic, specialised care and reassurance to cancer survivors. Adjustment to the survivorship journey, inter-survivor shared experiences, and management of physical treatment sequelae were perceived as important in their recovery. Managing survivor needs is integral to improving long-term survivorship care.

Time to embed physical activity within usual care in cancer services: A qualitative study of cancer healthcare professionals' views at a single centre in England

PURPOSE

An increasing number of people affected by cancer (PABC) are living longer lives as treatment continues to advance. There is growing evidence for physical activity (PA) supporting health in this population before, during and after cancer treatment, but PA advice is not part of usual care. This study investigates views of frontline oncology healthcare professionals (HCPs) in one NHS teaching hospital in England to understand the role of PA advice across cancer services.

MATERIALS AND METHODS

This was a qualitative study interviewing HCPs and using thematic analysis.

RESULTS

Four main themes were identified: 1. Awareness of the roles of PA in cancer; 2. Patient-specific factors in rehabilitation; 3. Cancer-specific factors in rehabilitation; 4. Barriers and opportunities to integrating PA within usual care. HCPs' awareness of the role of PA in cancer rehabilitation was low overall and PA was found not to be embedded within rehabilitation. Contrastingly, there was awareness of PA's potential to impact disease and treatment-related outcomes positively. Ideas for PA integration included training for staff and giving PA advice within consultations.

CONCLUSIONS

Low awareness of benefits of PA-based rehabilitation and lack of integration in usual care contrasted with HCPs' interest in this area's potential. Training HCPs to begin the conversation with patients affected by cancer in teachable moments may increase patient access.Implications for rehabilitationIntegrating physical activity education and training for trainees and existing healthcare professionals workforce would help embed physical activity into routine clinical practice.Brief advice intervention training during every consultation, such as providing relevant individualised information and signposting, can be impactful.Physical activity within a broader cancer rehabilitation programme should be integrated as standard for every cancer patient.Individualised plans may include prehabilitation, restorative rehabilitation and palliative rehabilitation.Patient preferences and the patient experience should continue to shape service design.There is a need to ensure physical activity advice is consistent throughout healthcare settings and not fragmented between primary, secondary and tertiary care.

The association of circadian parameters and the clustering of fatigue, depression, and sleep problems in breast cancer survivors: a latent class analysis

PURPOSE

Circadian rhythms control a wide range of physiological processes and may be associated with fatigue, depression, and sleep problems. We aimed to identify subgroups of breast cancer survivors based on symptoms of fatigue, insomnia, and depression; and assess whether circadian parameters (i.e., chronotype, amplitude, and stability) were associated with these subgroups over time.

METHODS

Among breast cancer survivors, usual circadian parameters were assessed at 3-4 months after diagnosis (T0), and symptoms of fatigue, depression, and insomnia were assessed after 2-3 years (T1, N = 265) and 6-8 years (T2, N = 169). We applied latent class analysis to classify survivors in unobserved groups ("classes") based on symptoms at T1. The impact of each of the circadian parameters on class allocation was assessed using multinomial logistic regression analysis, and changes in class allocation from T1 to T2 using latent transition models.

RESULTS

We identified 3 latent classes of symptom burden: low (38%), moderate (41%), and high (21%). Survivors with a late chronotype ("evening types") or low circadian amplitude ("languid types") were more likely to have moderate or high symptom burden compared to "morning types" and "vigorous types," respectively. The majority of survivors with moderate (59%) or high (64%) symptom burden at T1 had persistent symptom burden at T2.

IMPLICATIONS FOR CANCER SURVIVORS

A late chronotype and lower circadian amplitude after breast cancer diagnosis were associated with greater symptoms of fatigue, depression, and insomnia at follow-up. These circadian parameters may potentially be novel targets in interventions aimed at alleviating symptom burden among breast cancer survivors.

Impact of post-treatment symptoms on supportive care needs among breast cancer survivors in South Korea

Objective

The aim of this study is to investigate the factors influencing the supportive care needs of survivors of breast cancer who have completed major treatment.

Methods

A total of 121 survivors of breast cancer from an online community in South Korea participated in this study. The study variables were supportive care needs, physical symptoms, anxiety, and depression. Independent t-tests, one-way Analysis of Variance (ANOVA), Pearson's correlation, and hierarchical regression analyses were performed.

Results

The highest rankings of supportive care needs of survivors of breast cancer were medical system and information needs, patient care and support needs, psychological needs, sexual needs, and physical and daily life needs. Hierarchical regression analysis revealed that the participants' supportive care needs were explained by physical symptoms (P ​< ​0.001) and anxiety (P ​< ​0.001), accounting for 52.1% of the variance.

Conclusions

Supportive care needs of survivors of breast cancer have a high level of medical system and information needs, and posttreatment conditions are related to high physical symptoms and anxiety. In the future, it will be necessary to identify supportive care needs and apply interventions to reduce their physical symptoms and anxiety.

Self-reported symptoms among cancer survivors in the Women's Health Initiative (WHI) Life and Longevity after Cancer (LILAC) cohort

PURPOSE

Due to cancer survivors living longer and morbidity associated with cancer treatments, it is necessary to understand symptoms experienced by cancer survivors. This study will analyze the symptom burden among a large cohort of survivors across multiple cancer sites.

METHODS

Data from the Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) study were used to examine the symptom burden of older cancer survivors. Poisson regression with robust standard errors was utilized to determine differences in symptoms by cancer site, treatment, and other covariates.

RESULTS

The most frequently reported symptoms among cancer survivors were fatigue (15.8%) and feeling sad or depressed (14.1%). Multivariable analyses indicated that more symptoms were reported among survivors who were younger (p = 0.002), divorced or separated (p = 0.03), and had a combination of public and private insurance (p = 0.01). Survivors who received chemotherapy (p < 0.001), radiation (p = 0.01), or hormone therapy (p = 0.02) reported more symptoms than survivors who did not receive these treatments. Survivors diagnosed with cancer < 5 years ago reported fewer symptoms than longer-term survivors, particularly those diagnosed > 10 years ago (p = 0.02).

CONCLUSIONS

Results indicate that common physical and psychological symptoms are reported across cancer types. Cancer survivors diagnosed with cancer 10 or more years ago reported more symptoms than those recently diagnosed. This suggests that symptoms may remain a problem for some survivors decades after their diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

Future research should focus on implementing active surveillance of cancer survivors. Healthcare providers and those who care for cancer survivors should understand that the symptom burden associated with cancer may persist even decades following diagnosis.

Psychosocial factors associated with workability after surgery in cancer survivors: An explorative study

This study aimed to evaluate the work ability and its associated factors in patients with glioma (II, III) and breast cancer after 6 (T0) and 12 (T1) months from surgery. A total of 99 patients were evaluated with self-reported questionnaires at T0 and T1. Correlation and Mann-Whitney tests were used to investigate the association between work ability and sociodemographic, clinical, and psychosocial factors. The Wilcoxon test was used to investigate the longitudinal change in work ability. Our sample showed a decrease in work ability level between T0 and T1. Work ability was associated with emotional distress, disability, resilience, and social support in glioma III patients at T0, and with fatigue, disability, and clinical treatments in patients with breast cancer at T0 and T1. Work ability levels decreased in patients with glioma and breast cancer and were associated with different psychosocial factors after surgery. Their investigation is suggested to facilitate the return to work.

Knowledge, Perception, and Skills, and Practices of Oncology Nurses in Cancer Survivorship Care: a Scoping Review

Survivorship care focuses on the well-being and quality of life of people affected by cancer. Oncology nurses play an essential role in survivorship care and must be equipped with the knowledge, skills, and competencies to provide survivorship care. This scoping review explored the existing literature on nurses' knowledge, perception, skills, or practices in delivering cancer survivorship care for adult cancer survivors. A scoping review was conducted through databases including PubMed, CINAHL, Scopus, Web of Science, and PsycInfo in February 2022, following the Joanna Briggs Institute methodology. Fourteen original research studies were included. Most of the studies were conducted in the USA and targeted oncology registered nurses. The studies primarily focused on the knowledge (n = 2, 14.3%), perception of responsibility (n = 8, 57.1%), and practice (n = 9, 64.3%) regarding survivorship care among oncology nurses, reporting widely varied results. Nine studies reported perceived skills, practice, and perceived barriers as the most used outcome measurements, while two assessed nurses' cancer survivorship care knowledge. The main gaps were discrepancies between oncology nurses' perceptions of responsibility and practices in delivering survivorship care. Lack of time, knowledge, and skills were reported as significant factors impeding survivorship care provision among oncology nurses. Limited research shows a gap in integrating knowledge into survivorship care practices among oncology nurses. Further studies are needed to develop educational programs on survivorship care to support the integration of survivorship care into oncology nurses' practice.

Determinants of Life Satisfaction and Quality of Life Among American Indian Women Cancer Survivors: The Role of Psychosocial Resources

PURPOSE

This study assessed the relationship of spirituality, social support, and sense of mastery to life satisfaction and quality of life to identify viable psychosocial coping resources among American Indian (AI) women cancer survivors.

METHOD

We conducted a cross-sectional survey of 73 AI women cancer survivors residing in South Dakota. A series of multivariate hierarchical regression analyses was conducted.

RESULTS

Findings indicated that lower self-rated physical health was consistently associated with lower levels of life satisfaction and quality of life. Spirituality was found to be the most influential predictor for life satisfaction, while social support and sense of mastery were two significant predictors for quality of life.

DISCUSSION

Our data underscored the importance of spirituality, social support, and sense of mastery to the well-being of AI women cancer survivors and as effective coping strategies to mitigate life stressors. Implications of this evidence for the design of cancer preventions and interventions are discussed.

The long-term burden of a symptom cluster and association with longitudinal physical and emotional functioning in breast cancer survivors

BACKGROUND

Fatigue, insomnia and pain are some of the most common and distressing symptoms experienced during breast cancer (BC) treatment and survivorship. The symptoms have been found to impact one another and to form a symptom cluster, and greater severity of the symptoms may be negatively associated with physical and emotional functioning in survivorship. In exploratory analyses from a randomized controlled trial examining the effect of progressive resistance training on the development of lymphedema after BC, we aimed to examine the burden of the symptom cluster fatigue-pain-insomnia, and its prognostic value for long-term symptom severity as well as emotional and physical functioning.

MATERIAL AND METHODS

Latent profile analysis was used to identify groups with similar severity of pain, fatigue and insomnia among 158 patients with BC two weeks after surgery. Mixed effects Tobit regression models were used to estimate fatigue, pain, insomnia, and physical and emotional functioning 20 weeks, 1 year and 3.5 years after surgery.

RESULTS

Two symptom burden groups were identified: 80% of women had a low severity while 20% of women had a high severity of the three symptoms after BC surgery. 3.5 years later, the women with high symptom burden post-surgery still had higher pain, insomnia and fatigue scores than women with low symptom burden. High symptom burden post-surgery was associated with worse physical functioning 3.5 years later, while emotional functioning was only negatively impacted during the first year.

DISCUSSION

These findings warrant larger studies investigating if symptom burden early in BC trajectory can be used for risk stratification for persistent symptoms and diminished physical functioning with the purpose of developing and implementing targeted interventions.

Exploring the independent association of employment status to cancer survivors' health-related quality of life

BACKGROUND

Having a job has been associated with better Health-Related Quality of Life (HRQOL) in cancer survivors. However, the sociodemographic and disease-related profiles characterizing the survivors being employed and those having better HRQOL largely overlap. The present study aims to discern the degree to which employment status is independently associated with cancer survivors' HRQOL or if it mainly reflects the impact of other sociodemographic and cancer-related variables.

METHODS

Cross-sectional study on a heterogeneous sample of 772 working-age survivors of adult-onset cancer. An instrument specifically designed to assess HRQOL in cancer survivors and Multivariate Variance Analysis (MANOVA) were used.

RESULTS

Survival phase, cancer type, and employment status showed the main effects on cancer survivors' HRQOL. In particular, being employed (vs unemployed) had the greatest positive association with HRQOL, affecting ten of the twelve HRQOL domains considered. Also, interaction effects highlighted the role of age (younger) and marital status (single) as risk factors for a greater negative impact of variables affecting the survivor's HRQOL.

CONCLUSIONS

The application of a multivariate methodology sheds new light on two relevant issues for the cancer survivor's HRQOL: (i) the existence of differences between diagnostic groups that are not attributed to other variables such as sex, and (ii) the important and independent role that employment status plays. Comprehensive cancer survivorship care should focus more on high-risk groups and include having a job as an essential aspect to consider and prompt. The fact that the employment status is susceptible to change represents a valuable opportunity to care for the wellbeing of this population.

Bayesian semiparametric joint modeling of a count outcome and inconveniently timed longitudinal predictors

The Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) study is an excellent resource for studying the quality of life following breast cancer treatment. At study entry, women were asked about new symptoms that appeared following their initial cancer treatment. In this article, we were interested in using regression modeling to estimate associations of clinical and lifestyle factors at cancer diagnosis (independent variables) with the number of new symptoms (dependent variable). Although clinical and lifestyle data were collected longitudinally, few measurements were obtained at diagnosis or at a consistent timepoint prior to diagnosis, which complicates the analysis. Furthermore, parametric count models, such as the Poisson and negative binomial, do not fit the symptom data well. Thus, motivated by the issues encountered in LILAC, we propose two Bayesian joint models for longitudinal data and a count outcome. Our two models differ according to the assumption on the outcome distribution: one uses a negative binomial (NB) distribution and the other a nonparametric rounded mixture of Gaussians (RMG). The mean of each count distribution is dependent on imputed values of continuous, binary, and ordinal variables at a time point of interest (e.g. diagnosis). To facilitate imputation, longitudinal variables are modeled jointly using a linear mixed model for a latent underlying normal random variable, and a Dirichlet process prior is assigned to the random subject-specific effects to relax distribution assumptions. In simulation studies, the RMG joint model exhibited superior power and predictive accuracy over the NB model when the data were not NB. The RMG joint model also outperformed an RMG model containing predictors imputed using the last value carried forward, which generated estimates that were biased toward the null. We used our models to examine the relationship between sleep health at diagnosis and the number of new symptoms following breast cancer treatment in LILAC.

How to Make Evidence-Based Integrative Medicine a Part of Everyday Oncology Practice

Integrativety oncology (IO) is a "patient-centered, evidence-informed field of comprehensive cancer care that utilizes mind-body practices, natural products, and lifestyle modifications from different traditions alongside conventional cancer treatments." There is an urgent need to educate oncology health care providers on the fundamentals of evidence-based IO to meet the needs of people with cancer. In this chapter, we aim to provide oncology professionals with actionable guidance on the basis of the Society for Integrative Oncology (SIO)-American Society of Clinical Oncology (ASCO) guidelines on integrative medicine use during oncology visits to help alleviate symptoms and side effects in people with cancer during and after treatment.

Implementation and evaluation of an expanded electronic health record-integrated bilingual electronic symptom management program across a multi-site Comprehensive Cancer Center: The NU IMPACT protocol

BACKGROUND

People with cancer experience symptoms that adversely affect quality of life. Despite existing interventions and clinical guidelines, timely symptom management remains uneven in oncology care. We describe a study to implement and evaluate an electronic health record (EHR)-integrated symptom monitoring and management program in adult outpatient cancer care.

METHODS

Our cancer patient-reported outcomes (cPRO) symptom monitoring and management program is a customized EHR-integrated installation. We will implement cPRO across all Northwestern Memorial HealthCare (NMHC) hematology/oncology clinics. We will conduct a cluster randomized modified stepped-wedge trial to evaluate patient and clinician engagement with cPRO. Further, we will embed a patient-level randomized clinical trial to evaluate the impact of an additional enhanced care (EC; cPRO plus web-based symptom self-management intervention) relative to usual care (UC; cPRO alone). The project uses a Type 2 hybrid effectiveness-implementation approach. The intervention will be implemented across seven regional clusters within the healthcare system comprising 32 clinic sites. A 6-month prospective pre-implementation enrollment period will be followed by a post-implementation enrollment period, during which newly enrolled, consenting patients will be randomly assigned (1:1) to EC or UC. We will follow patients for 12 months post-enrollment. Patients randomized to EC will receive evidence-based symptom-management content on cancer-related concerns and approaches to enhance quality of life, using a web-based tool ("MyNM Care Corner"). This design allows for within- and between-site evaluation of implementation plus a group-based comparison to demonstrate effectiveness on patient-level outcomes.

DISCUSSION

The project has potential to guide implementation of future healthcare system-level cancer symptom management programs. http://ClinicalTrials.gov # NCT03988543.

Barriers and applied activity, quality of life and self-efficacy in prostate cancer survivors 1 year after completing radiotherapy

PURPOSE

The aims of the study were to assess self-reported physical activity (PA) levels, barriers to PA, quality of life and self-efficacy to manage chronic disease of prostate cancer survivor 1 year after radiotherapy treatment.

METHODS

A cross-sectional case-control study was performed. Prostate cancer survivor patients treated with radiotherapy were recruited from the Radiation Oncology Service of the "Complejo Hospitalario Universitario" (Granada) and compared with age-matched healthy men. Outcomes included were perception of benefits for physical activity and potential barriers (Exercise Benefits/Barriers Scale), physical activity levels assessed by the International Physical Activity Questionnaire (IPAQ), quality of life (EuroQol five-dimension three-levels) and self-efficacy (Self-Efficacy to Manage Chronic Disease).

RESULTS

A total of 120 patients were included in our study. Significant differences were found between groups with worse results for the prostate cancer patient group in the variable perception of the benefit of physical activity, potential barriers, and physical activity. Regarding quality of life and self-efficacy, significant differences were also observed between groups with a greater score in the control group.

CONCLUSION

In conclusion, the results of this study reveal that self-reported PA levels, as measured using the IPAQ, were low in prostate cancer survivors after treatment. Results also showed worse perception of benefits for PA and potential barriers by the cancer survivors. Similarly, the quality of life and self-efficacy to manage chronic disease of prostate cancer survivors was lower.

Effects of Brain Wave Vibration Training on the Pain and Fatigue Disturbance Symptom Cluster in Persons with Cancer: A Randomized Controlled Trial

Pain and fatigue disturbance constitute the most common symptom cluster in persons with cancer, causing physical and psychological problems associated with a decreased quality of life. This study investigated the effects of brain wave vibration (BWV) training on the pain and fatigue disturbance symptom cluster in persons with cancer. A total of 43 participants were voluntarily recruited and randomly assigned to the experimental group (BWV with therapeutic massage, n = 25) or the control group (conventional physical therapy with spontaneous physical activity, n = 18) (Randomized controlled trial registration number: KCT0005843). BWV with therapeutic massage was performed for a total of 24 sessions (70 min/day, 2 days/week for 12 weeks). The Breakthrough Pain Assessment Tool and Brief Fatigue Inventory were used to evaluate cancer-related pain (CRP) and cancer-related fatigue (CRF), respectively. Regarding CRP variables, the experimental group demonstrated significant improvements in the worst and typical episodes of breakthrough pain, pain distress, and interference with living a normal life compared to the control group. In CRF, there was no significant difference between the groups, although BWV training with therapeutic massage resulted in a significant difference between before and after the intervention. Therefore, our study suggests that BWV training with therapeutic massage is beneficial for improving CRP and CRF in cancer survivors.

A Randomized Controlled Trial of Mindfulness in Recovery from Colorectal Cancer

OBJECTIVE

This study examined whether a 4-week group-based mindfulness intervention would be superior in reducing psychological distress in colorectal cancer (CRC) patients compared to a psychoeducation and cognitive behavioural skills learning support active control group.

METHODS

Patients with CRC were randomized via Computerised Permuted Block Randomisation to mindfulness or active control groups (2-h weekly sessions over 4 weeks). Outcomes were measured pre-intervention, and 8 weeks and 6 months post-baseline. The primary outcome was psychological distress measured by the Hospital Anxiety and Depression Scale. Secondary outcomes were generic quality of life (QoL), disease specific QoL, mindfulness, and intervention credibility and acceptability.

RESULTS

Sixty-eight participants were randomized to mindfulness (n=35) or active control group (n=33). Uptake of potentially eligible patients consenting was low (28.0%) and the dropout rate was 33.8%. Depression scores were reduced in both groups at week 8 (P=0.020). Control participants had greater improvement in generic mental QoL scores at week 8 than mindfulness (P=0.023). In disease specific QoL, there was reduction in impotence symptom in the mindfulness group (P=0.022) and reduction in faecal incontinence in the control group (P=0.019). The embarrassment symptom had a significantly lower increase in the mindfulness group at week 8 compared to the control group (P=0.009). Both groups rated the treatments as credible and acceptable.

CONCLUSIONS

Mindfulness was not superior to the active control group in terms of alleviating psychological distress but both treatments were associated with some improvements in depression. There was low uptake of both interventions. (Trial registration number: ACTRN12616001033437).

A systematic review of eHealth technologies for breast cancer supportive care

Breast cancer places a substantial burden on patient physical and mental wellbeing, and the delivery of high-quality supportive care is essential at all stages of the disease. Given the increased uptake of technology in recent years, eHealth interventions may be a convenient and accessible method for supportive care. Within this context, we conducted a systematic review to describe and quantify the use of eHealth for breast cancer supportive care. We searched MEDLINE, EMBASE, and CINAHL databases for primary research studies published from 2016 to 2021 (present) that assessed the effects of eHealth interventions on adult patients with breast cancer. We explored the effects of the interventions on patient symptoms, lifestyle, satisfaction, and barriers, as well as factors related to feasibility and implementation. The risk of bias of each study was also assessed. Findings were presented according to stage of cancer care. We identified 43 relevant studies capturing n = 6,285 patients (30 randomized controlled trials and 13 non-randomized interventional studies); 5 evaluated patients who were newly diagnosed, 16 evaluated patients undergoing active treatment, and 22 evaluated patients in post-treatment follow-up. A total of 19 studies used mobile apps, 18 used online patient portals, 5 used text messaging, and 1 used both a patient portal and text messaging. We found that patients were broadly satisfied with the eHealth interventions; however, findings were less consistent for symptom and lifestyle-related outcomes. Eight studies were judged as high risk of bias. There was substantial between-study heterogeneity, which made it challenging to discern consistent trends. Overall, future research should continue to explore the use of eHealth for breast cancer supportive care, with a focus on improving patient symptoms.

Effects of somatic acupoint stimulation on anxiety and depression in cancer patients: An updated systematic review of randomized controlled trials

OBJECTIVES

To explore the effectiveness of somatic acupoint stimulation (SAS) for cancer patients with anxiety and depression.

METHODS

Thirteen electronic databases were searched systematically until August 2022. Randomized controlled trials (RCTs) investigating SAS for anxiety and/or depression in cancer patients were retrieved. Methodological quality of the included studies was assessed by utilizing the Cochrane Back Review Group Risk of Bias Assessment Criteria. Evidence level was assessed by using the approach of Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Both meta-analysis and descriptive analysis were conducted for outcome assessment.

RESULTS

Twenty-eight records were finally included including 22 journal articles and six ongoing registered clinical trials. The overall methodological quality and level of evidence of the included studies were suboptimal, with no high-quality evidence identified. Moderate evidence showed that SAS could significantly decrease the anxiety of cancer patients (Acupuncture: [random effect model, SMD = -0.52, 95% CI = -0.79 to -0.24, p = 0.0002] and Acupressure: [random effect model, SMD = -0.89, 95% CI = -1.25 to -0.52, p < 0.00001]. While for depression, although the data analysis indicated that SAS can decrease depression significantly (Acupuncture: [random effect model, SMD = -1.26, 95% CI = -2.08 to -0.44, p = 0.003] and Acupressure: [random effect model, SMD = -1.42, 95% CI = -2.41 to -0.42, p = 0.005]), relevant evidence was rated as low. No statistically significant difference was identified between true and sham acupoints stimulation for both anxiety and depression.

CONCLUSIONS

This systematic review provides the latest research evidence to support SAS as a promising intervention for alleviating anxiety and depression in cancer patients. However, the research evidence should be interpreted prudently as methodological concerns were identified in some included studies, and some sub-group analyses were performed with a relatively small sample size. More rigorously designed large-scale RCTs with placebo-controlled comparisons are warranted to generate high-quality evidence.

REGISTRATION

The systematic review protocol has been registered with PROSPERO (CRD42019133070).

Quality of life among colorectal cancer survivors participating in a pilot randomized controlled trial of a web-based dietary intervention with text messages

PURPOSE

We aimed to estimate the effect of a 12-week web-based dietary intervention with text messages on quality of life (QoL) among colorectal cancer (CRC) survivors.

METHODS

Between 2017 and 2018, 50 CRC survivors were randomized (1:1) to receive a 12-week web-based dietary intervention with daily text messages or wait-list control. Health-related QoL was assessed using the European Organization for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30) and colorectal quality of life module (QLQ-CR29) at baseline, 12, and 24 weeks. Within- and between-group mean changes in health-related QoL with 95% confidence intervals (CI) were calculated for both arms.

RESULTS

Compared to the controls, participants receiving the intervention had an improvement in emotional functioning (mean change: 14.3; 95% CI: 3.0, 25.6) at 12 weeks and social functioning (mean change: 13.8; 95% CI: 2.1, 25.5) at 24 weeks. A decrease of fatigue from baseline was also observed in the intervention arm (mean change: - 9.1; 95% CI: - 17.1, - 1.1) at 24 weeks. No other changes in QoL scores were associated with the intervention.

CONCLUSION

CRC survivors randomized to receive a web-based dietary intervention with text messages experienced higher emotional and social functioning. Further study with a larger population may be warranted.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02965521. Registered 16 November 2016, https://clinicaltrials.gov/ct2/keydates/NCT02965521.

Systematic review of self-management programs for prostate cancer patients, a quality of life and self-efficacy meta-analysis

OBJECTIVE

To investigate the efficacy of self-management interventions on quality of life and/or self-efficacy in patients diagnosed with prostate cancer through a systematic review with meta-analysis.

METHODS

A search was conducted from database inception to March 2022 across three databases. Randomized controlled trials were included. Two reviewers performed independent data extraction and methodologic quality assessment of the studies.

RESULTS

A total of fifteen studies were included in the study. Self-management interventions were identified by the Practical Reviews in Self-Management Support. The meta-analysis showed that self-management interventions have a significant effect on self-efficacy CONCLUSION: Self-management programs could have positive effects on quality of life and improve self-efficacy in prostate cancer patients.

PRACTICE IMPLICATIONS

Self-management components may be heterogeneous but show positive results in improving self-efficacy in prostate cancer survivors. Including self-management components in the rehabilitation of prostate survivors can improve their quality of life.

Bibliometric analysis of global research on physical activity and sedentary behavior in the context of cancer

Objective

Numerous studies focusing on sedentary behavior (SB) and physical activity (PA) in the context of cancer have been reported in recent years. We analyzed and visualized studies on SB and PA in patients with cancer over the last 20 years using scientometric methods, to provide insights on gaps and deficiencies in the literature, and to inform future research guidelines.

Methods

All relevant studies in the field from 2001 to October 2022 were reviewed using bibliometric tools, including VOSviewer, Bibliometric online analysis platform, and biblioshiny, to determine the most influential countries, institutions, journals, and authors. We explored current research hotpots and potential research trends, based on keyword clustering and dynamic changes. Our research focuses on PA, SB, and cancer across the entire cancer continuum, from primary prevention to treatment to cancer survivorship.

Results

Scientometric analysis identified 4,382 relevant manuscripts on SB and PA in the context of cancer, with a 10-fold increase in articles over the past 20 years. The United States, Canada, and Australia were the most influential countries. The journal, Supportive Care in Cancer, had the highest number of publications, while Clinical Oncology had the highest H-index. K.S. Courneya was the most influential author in this field, with the highest number of publications, total citations, and H-index. Keyword analysis revealed that current research is focused on PA and SB in patients with breast cancer, quality of life, and aerobic exercise. Future frontiers include cancer prehabilitation programs and cardiorespiratory fitness, and remote intervention and social support.

Conclusion

By using bibliometrics, we conducted a comprehensive review of SB and PA in cancer-related studies. The current research focused on exercise and sedentariness in breast cancer patients and the role of PA in improving quality of life in survivorship. Emerging research foci were generally around cancer prehabilitation programs and remote intervention issues for PA. In addition, some publication deficits are noted: studies of PA and SB in less common cancers; the recommended doses and intensities of exercise for cancer; the timing of interventions for prehabilitation and the establishment of individualized exercise protocols. These deficiencies align with the needs for future research topics.

Protocol of a dyadic sleep intervention for adult patients with cancer and their sleep-partner caregivers

Background

Sleep disturbance is common and problematic among both patients with cancer and their sleep partner caregivers. Although 70% of the general adult population sleep in the same bed with a significant other, as do adult cancer patients and their spousal/partner caregivers, and one's sleep affect the partner's sleep, existing psychobehavioral interventions have targeted patients' and caregivers' sleep problems independently.

Methods

We developed a new sleep intervention, My Sleep Our Sleep (MSOS), for both adult patients with cancer and their sleep-partner caregivers together. This protocol is to test the feasibility and acceptability as well as to provide preliminary efficacy of the MSOS intervention, which is a dyadic intervention designed to reduce sleep disturbance and improving sleep quality of both adult cancer patients and their sleep-partner caregivers (dyads). The intervention will be delivered weekly for 4 weeks. Questionnaire and daily sleep logs will be collected at baseline (T1) and one-week after conclusion of the intervention (T2). Satisfaction with the intervention will be assessed weekly for 4 weeks.

Results

We estimate 43 dyads be enrolled (43 patients and 43 sleep-partner caregivers). We expect >75% of eligible and screened dyads will enroll within the enrollment period, >80% of enrolled dyads will complete the intervention, and >80% of participants will report satisfaction across all acceptability measures. We also expect MSOS will reveal a small-to-medium effect on sleep efficiency (primary outcome), overall sleep disturbance, subjective sleep quality, and insomnia severity (secondary outcomes).

Conclusions

Results will inform the feasibility and acceptability of conducting a dyadic sleep intervention, and provide preliminary efficacy data to guide further refinement of the intervention content and procedure for adult patients with cancer and their sleep-partner caregivers.

Trial registration

NCT04712604 Clinicaltrials.gov.

Symptoms and Needs Monitoring in Diverse Ambulatory Oncology Patients: Usage Characteristics and Impact on Emergency Room Visits and Hospitalization

PURPOSE

Symptoms and needs monitoring using patient-reported outcomes (PRO) is associated with improved clinical outcomes in cancer care. However, these improvements have been observed predominantly in non-Hispanic White patients using English assessments with high completion rates. The documented impact of such monitoring on system-level outcomes including emergency room (ER) visits and hospitalizations remains limited. We explored factors affecting the completion of PRO measures and evaluated clinical outcomes in an ambulatory oncology setting with a diverse racial, ethnic, and linguistic population.

METHODS

A retrospective analysis (October 2019-February 2022) was performed for patients with cancer assigned to My Wellness Check (MWC), a patient-portal-administered and electronic health record-based PRO assessment that generates automated alerts to oncology providers. Patient demographics, clinical characteristics, and clinical outcomes were collected. Logistic regression models examined factors affecting the completion of MWC questionnaires. Cumulative incidence of ER visits and hospitalization were assessed by Cox proportional hazards regression models adjusting for demographics.

RESULTS

We identified 9,553 patients; 43.1% (n = 4,117) answered one or more questions. Patients age 65 years or older (adjusted odds ratio [aOR], 0.77; P < .0001), male (aOR, 0.81; P < .0001), Hispanic/Latino ethnicity (aOR, 0.70; P < .0001), living without partners (aOR, 0.75; P < .0001), or receiving no treatment (aOR, 0.76; P < .0001) were less likely to answer MWC questionnaires. Patients who completed the entire MWC questionnaires had a reduced risk of an ER visit (adjusted hazard ratio, 0.78; P < .0001) and hospitalization (adjusted hazard ratio, 0.80; P = .0007) relative to patients who did not.

CONCLUSION

Completing electronic health record-based PRO assessments was associated with significantly better clinical outcomes in a diverse cancer population. Specific patient groups were less likely to participate. Further research is needed to identify barriers to completing PRO measures and the long-term benefits of such programs.

Prevalence of late and long-term effects of cancer (treatment) and use of complementary and alternative medicine in Norway

BACKGROUND

The increasing number of patients surviving cancer leads to more people experiencing late and long term-effects from the disease and its treatment. Fatigue, sleep disorders, early menopause, pain, and nerve damage are commonly reported. Methods helping people to recover after cancer treatment are therefore essential. The aims of this study were threefold; (1) to determine the level of cancer patients suffering from late and long-term effects of cancer diagnosis and treatment in Norway, (2) explore complementary and alternative medicine (CAM) modalities used for managing these adversities, and (3) describe self-perceived benefits and harms of the CAM interventions.

METHODS

The study was conducted in cooperation with the Norwegian Cancer Society (NCS) and consisted of an online cross-sectional study among members of the NCS user panel with present or previous cancer (n = 706). The study was carried out in September/October 2021 using a modified cancer-specific version of the International Questionnaire to Measure Use of Complementary and Alternative Medicine (I-CAM-Q). A total of 315 women and 153 men agreed to participate, resulting in a response rate of 67%.

RESULTS

Most of the participants (83%) suffered from late and long-term effects of cancer treatment; mostly fatigue (59.2%), sleep disorder (41.5%), hot flashes (39.2%), nerve damage (polyneuropathy, 38.0%), and pain (36.6%) with a mean number of 5.1 different late and long-term effects. Late and long-term effects were positively associated with younger age and college/university education. Nearly half of the participants experiencing late and long-term effects (43%) reported having used CAM to treat these complaints. Most frequently used were self-help practices (26%) such as relaxation therapy (19%), yoga (14%) and meditation (13%), but also visits to CAM providers were reported by 22%. Herbal- and other natural remedies to treat late and long-term effects were used by 13%. A high percentage of CAM users reported self-perceived improvements of their symptoms (86% for self-help practices, 90% for visits to CAM providers). Few experienced adverse effects of the CAM treatment.

CONCLUSION

A large proportion of cancer patients suffered from a wide range of late and long-term effects of cancer diagnosis and treatment, and they use CAM to treat these complaints to a rather high degree. Relaxation therapy, yoga, meditation, massage, and acupuncture were the most frequently used therapies regardless of complaint. The therapies used are generally considered to be both safe and beneficial for the respective complaint, indicating that the participants seem to be well informed about the choices they make.

Determinants of sleep quality in 5835 individuals living with and beyond breast, prostate, and colorectal cancer: a cross-sectional survey

PURPOSE

The present study aimed to quantify the level of sleep problems in 5835 breast, prostate, and colorectal cancer survivors, and explore a number of potential determinants of poor sleep quality in the present sample. BMI, diet, and physical activity were of particular interest as potential determinants.

METHODS

Participants who completed the 'Health and Lifestyle after Cancer' survey were adults who had been diagnosed with breast, prostate, or colorectal cancer (mean time since cancer diagnosis was 35.5 months, SD=13.56). Sleep quality was assessed using the Pittsburgh Sleep Quality Index. BMI was calculated from self-reported height and weight. Participants were categorised as meeting/not meeting the World Cancer Research Fund (WCRF) recommendations for fibre, fruit and vegetables, added sugar, red meat, processed meat, fat, alcohol, and physical activity. Analyses accounted for demographic and clinical factors.

RESULTS

Fifty-seven percent of those with sleep data were classified as poor sleepers (response rate 79%). Being female, having a higher number of cancer treatments, more comorbid conditions, and being more anxious/depressed increased the odds of being a poor sleeper. After adjustment for these factors, there were no associations between diet/alcohol/physical activity and sleep. However, BMI was associated with sleep. Individuals in the overweight and obese categories had 22% and 79% higher odds of being poor sleepers than individuals in the underweight/healthy weight category, respectively.

CONCLUSIONS

The findings suggest that there may be a need to develop sleep quality interventions for cancer survivors with obesity. Even after adjustment for multiple clinical and demographic factors, BMI (particularly obesity) was associated with poor sleep. Thus, researchers and health professionals should find ways to support individuals with overweight and obesity to improve their sleep quality.

IMPLICATIONS FOR CANCER SURVIVORS

The present findings highlight that poor sleep is a common issue in cancer survivors. Interventions seeking to improve outcomes for cancer survivors over the longer term should consider sleep quality.

Adapting an integrated care pathway for implementing electronic patient reported outcomes assessment in routine oncology care: Lessons learned from a case study

RATIONALE, AIMS AND OBJECTIVE

Details of the development and implementation of integrated care pathways (ICPs) in the context of electronic collection of patient reported outcomes (ePROs) for cancer patients are largely lacking in the literature. This study describes what, why and how decisions were made to adapt and implement an ePROs ICP for patients with lung cancer.

METHODS

A consensus process was utilized, with the implementation advisory group including multidisciplinary representation from three participating hospitals, to identify local champions and adapt and incorporate the ePRO ICP into the local contexts. Engagement meetings were documented via meeting transcripts, and detailed notes from October 2019 to November 2020 were content-analysed to identify decision-making themes based on the Consolidated Framework for Implementation Research; workflows and process maps were reviewed and modified to integrate ePROs.

RESULTS

In total, 55 engagement activities were held (24 meetings, 20 workshops 11 educational sessions), with n = 96 staff from multiple disciplines participating in the ePROs implementation through advisory meetings, process mapping, change management and staff education. Decisions were made regarding eligible patient cohorts to include, the process for onboarding patients onto the ePRO system, and follow-up and referral pathways. Rationales for decisions included alignment with existing workflows, utilizing available staff, minimizing staff and patient burden and maximizing patient engagement.

CONCLUSION

Existing resources, staff input and technical and logistical reasons often guided the ICP decisions, highlighting the need for in-depth engagement across all stakeholders for optimal implementation of ePRO ICPs. The ePRO implementation required substantial dialogue and systematic resolution to reach agreement on the final processes. Adapting the local ICP through rigorous engagement facilitated the successful implementation of ePROs as business-as-usual at all three cancer centres. Involving all relevant stakeholders is critical to the successful adaptation of ICPs before their introduction into routine care.

Effect of mHealth plus occupational therapy on cognitive function, mood and physical function in people after cancer: Secondary analysis of a randomized controlled trial

BACKGROUND

Medical and surgical treatments for breast cancer have various adverse effects. Both mobile health and supervised intervention strategies have been implemented to overcome these effects, but some gaps remain to be addressed. Scientific evidence for the effectiveness of occupational therapy in cancer is limited.

OBJECTIVE

To compare the clinical effectiveness of the BENECA mHealth app used alone or combined with an integral supervised rehabilitation strategy that focused on cognitive performance, mood state, functional capacity, and cancer-related pain and fatigue in overweight women after breast cancer.

METHODS

In this secondary analysis of an assessor-blinded randomized controlled clinical trial, 80 overweight women after breast cancer (stage I-IIIA) were randomly allocated to an integral approach group (IA; n=40) or a control group (CG; n=40). All participants participated in an 8-week intervention. Assessments were performed at baseline, 8 weeks, and 6 months and included cognitive performance (Trial Making Test and Wechsler Adult Intelligence Scale), psychological state (Hospital Anxiety and Depression Scale), pain (Brief Pain Inventory), fatigue (Piper Fatigue Scale), and physical function (6 min walk test). An intention-to-treat analysis was conducted with analysis of covariance.

RESULTS

Selective attention (TMT) was significantly higher in the IA group, with a moderate to large effect size for TMT A (T2: d=1.1; T 3: d=1.2), working memory and processing speed (WAIS), anxiety and general HADS score (d=1.6), and functional capacity at 8 weeks and 6 months (d=1.5). Fatigue perception (mean difference, -0.6; 95% CI -1.4 to 0.04; p=0.009) and pain (intensity level p<0.001; interference level p=0.002) were also significantly more improved in the IA group.

CONCLUSIONS

An integral strategy involving the BENECA mHealth app with a supervised, multimodal intervention improved cognitive, psychological, and functional performance in women after breast cancer more than mHealth alone. Occupational therapy has a role to play in breast cancer rehabilitation.

Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel

BACKGROUND

Patients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strain their relationships.

AIM

We convened an international panel with the aim of developing guidelines that will inform clinicians, patients and partners about the impact of prostate cancer therapies (PCT) on patients' and partners' sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship.

METHODS

The guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995-2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment, according to the nomenclature of the American Urological Association (AUA). Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR).

OUTCOMES

Guidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel.

RESULTS

The guidelines account for patients' cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side-effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship.

CLINICAL IMPLICATIONS

The guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer.

STRENGTHS & LIMITATIONS

The strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. Limitation is the variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries.

CONCLUSION

The guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation and outline areas for future research. Wittmann D, Mehta A, McCaughan E, et al. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022;19:1655-1669.

Interpreting Cancer Survivors' Perceptions of the Survivor Label Through Social Identity and Communication Accommodation Theories

This study uses social identity theory and communication accommodation theory as lenses to examine former cancer patients' perspectives of the "survivor" label, replacement labels for their experience, and use of survivor services. Semi-structured interviews of 43 former cancer patients offer insight into their unique cancer experiences and explain how these events influence their perceptions of the term survivor. Coders used constant comparison methods to capture six themes related to the participants' impressions of the survivor label. When sharing perceptions of the survivor label, participants expressed language that illustrated convergence (It means everything to me), divergence (I don't like to be called anything), convergence and divergence (Part of me is happy … Part of me is kind of aggravated), and apathy (I have no feelings toward the label). Participants also generated new labels that captured their cancer experiences and six unique themes emerged from these responses. Most of the former cancer patients were aware of survivorship programs; however, relatively few used these programs regularly and cited reasons for nonuse explained by social identity theory.

Cancer-related fatigue mediates the relationships between physical fitness and attendance and quality of life after participation in a clinical exercise program for survivors of cancer

PURPOSE

Cancer-related fatigue (CRF) is a common and limiting symptom reported by survivors of cancer, negatively impacting health-related quality of life (HRQoL). Exercise improves CRF, HRQoL, and physical fitness in survivors. Prospective research trials have shown that exercise-associated fitness improvements effects on HRQoL are mediated by CRF; however, this has not been investigated in a pragmatic real-world setting. This study utilizes data from a large heterogenous population of survivors participating in a clinical exercise program to investigate this mediation effect, as well as effects of program attendance.

METHODS

Data were collected from 194 survivors completing the BfitBwell Cancer Exercise Program (July 2016-February 2020). Changes in HRQoL, CRF, and fitness were calculated and program attendance collected. Basic correlation analyses were performed. Linear regression analyses were performed to assess mediation by CRF.

RESULTS

All measures of CRF, HRQoL, and physical fitness significantly improved following the exercise program. Improvements in physical fitness were significantly correlated with improvements in HRQoL (r = 0.15-0.18), as was program attendance (r = 0.26) and CRF (r = 0.59). The effects of physical fitness and program attendance on HRQoL were at least partially mediated by the effects of CRF.

CONCLUSION

This study extends research findings on how exercise programs improve HRQoL in survivors of cancer to a real-world setting. Results indicate that clinical exercise programs should target reductions in CRF in survivors (during or after treatment) through improvements in physical fitness to improve HRQoL and that high attendance should be encouraged regardless of fitness changes.

What are the late effects of older gastric cancer survivors? A scoping review

Objective

Older gastric cancer survivors account for a high proportion of cancer survivors. To improve their quality of life, a cancer survivorship care plan with a consideration of the late effects is required. This study aimed to understand the extent and type of evidence in relation to the late effects in older gastric cancer survivors.

Methods

We conducted a scoping review based on the JBI scoping review framework. We explored articles in the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), SCOPUS, Web of science, Excerpta Medica dataBASE (EMBASE), Research InformationSharing Service (RISS), Korean Medical dataBASE(KMBase), and National Digital Science Library (NDSL) databases published from January 1, 2012, to December 31, 2021. The keywords used for search are "gastric cancer", "aged", "survivors", and "late effect or long-term effect or late symptom or time factors". While 439 records were initially identified, 14 articles were eventually selected based on the inclusion criteria.

Results

Most studies were conducted in 2019 (4 studies, 28.6%), and more than half (8 studies, 57.1%) were conducted in Asia. In total, six definitions of cancer survivors were found in the studies. The most common age range in the studies was 60-64 years (7 studies, 50.0%). The second primary cancer risk was the most common late effects (5 studies, 20.8%). Among 14 studies, there was only one study of intervention study (7.1%).

Conclusions

It is time to shift the focus from survival to care that improve the quality of life after treatment. We suggest future studies to define cancer survivors, set the age criteria and characterize the late effects in older gastric cancer survivors.

George SM, Ream M, Antoni MH. A latent profile analysis to assess physical, cognitive and emotional symptom clusters in women with breast cancer

OBJECTIVE

Current research on the physical and psychological functioning of breast cancer survivors often takes an approach where symptoms are studied independently even though they often occur in clusters This paper aims to identify physical and psychological symptom clusters among breast cancer survivors while assessing clinical, psychosocial and demographic characteristics that predict subgroup membership.

DESIGN

Using post-surgical data collected from 240 women with stage 0-III breast cancer, symptom clusters were identified using latent profile analysis of patient-reported symptoms.

MAIN OUTCOME MEASURES

Baseline measures included the Pittsburg Sleep Quality Index, the Fatigue Symptom Inventory, the Hamilton Rating Scales for depression and anxiety and the Impact of Event Scale.

RESULTS

Three distinct classes were identified: (1) mild physical, cognitive and emotional symptoms, (2) moderate across all domains and (3) high levels of all symptoms. Lower socio-economic status, minority ethnicity, younger age, advanced disease stage along with lower self-efficacy and less internal locus of control were significantly associated with a higher likelihood of class 3 membership.

CONCLUSION

By identifying those most at risk for severe physical and psychological symptoms in the post-surgical period, our results can guide the development of tailored interventions to optimise quality of life during breast cancer treatment.

Correlation between Quality of Life under Treatment and Current Life Satisfaction among Cancer Survivors Aged 75 Years and Older Receiving Outpatient Chemotherapy in Ishikawa Prefecture, Japan

Life satisfaction is increasingly important for older cancer survivors as the global population ages and the life expectancy 29 of cancer survivors increases. This study sought to identify factors associated with physical symptoms, quality of life under treatment, and current life satisfaction in cancer survivors aged 75 years and older receiving outpatient chemotherapy. Information about treatment for cancer survivors was collected from electronic medical records, and interviews were conducted to assess life satisfaction under treatment. Participants were older cancer survivors in Ishikawa, Japan. Of the participants, 80% lived on the Noto Peninsula. The average linear distance traveled for treatment was 40.7 km. The factors associated with patients’ dissatisfaction with their current lives included general malaise (odds ratio: 9.61; 95% confidence interval: 1.28–72.22) and being less happy now than when they were younger (odds ratio: 10.559; 95% confidence interval: 1.50–74.24). In outpatient cancer treatment for survivors aged 75 years and older, support should consider the distance to the hospital. As in past studies, general malaise was shown to have a negative impact on the lives of cancer survivors aged 75 years or older. Support providers should pay attention to patients’ general malaise when providing support.

Neuropathic pain prevalence and risk factors in head and neck cancer survivors

BACKGROUND

Neuropathic pain (NP) is a debilitating symptom among head and neck cancer (HNC) survivors although few large studies report its prevalence and associated risk factors.

METHODS

A cross-sectional survey assessing demographic, behavioral, and clinical risk factors for NP. NP was assessed using the Self-administered Leeds Assessment of Neuropathic Symptoms and Signs pain scale (S-LANSS).

RESULTS

Forty-five percent (227/505) reported having pain including 13.7% (69/505) who were positive for S-LANSS. Reported pain sites were in the regions of the head and oral cavity (46.2%) and neck and throat (41.5%). Despite a higher self-reported use of analgesic medication (NP+ = 41.2%; NP- = 27.4%; p = 0.020) and alternative pain therapies (NP+ = 19.1%; NP- = 8.4%; p = 0.009), severe pain was more prevalent among those with NP (N+ = 23.2%; NP- = 13.3%; p = 0.004). Adjusted for opioid medications, ethnicity/race, age, surgery, depression, and comorbidities were risk factors for NP.

CONCLUSION

NP remains prevalent in HNC survivors highlighting the importance of routine pain surveillance.

Towards a Postgraduate Oncology Training Model for Family Medicine: Mixed Methods Evaluation of a Breast Oncology Rotation

Background: Family physicians have low knowledge and preparedness to manage patients with cancer. A breast oncology clinical rotation was developed for family medicine residents to address this gap in medical education. Objectives and Methods: A breast oncology rotation for family residents was evaluated using a pre-post knowledge questionnaire and semi-structured interviews comparing rotation (RRs) versus non-rotation (NRRs) residents. Quantitative and qualitative data were collected via a pre-post knowledge questionnaire and semi-structured interviews, respectively. Analysis: Quantitative data were analysed using descriptive statistics and paired t-tests to compare pre-post-rotation knowledge and preparedness. Qualitative data were coded inductively, analysed, and grouped into categories and themes. Data sets were integrated. Results: The study was terminated early due to the COVID-19 pandemic. Six RRs completed the study; 19 and 2 NRRs completed the quantitative and qualitative portions, respectively. RRs’ knowledge scores did not improve, but there was a non-significant increase in preparedness (5.3 to 8.4, p = 0.17) post-rotation. RRs described important rotation outcomes: knowledge of the patient work-up, referral process, and patient treatment trajectory; skills in risk assessment, clinical examination, and empathy, and comfort in counseling. Discussion and Conclusion: Important educational outcomes were obtained despite no change in knowledge scores. This rotation can be adapted to other training programs including an oncology primer to enable trainee integration of new information.

Quality of life in cancer survivorship: Sociodemographic and disease-related moderators

RATIONALE

To identify high-risk survivors in order to provide appropriate care.

PURPOSE

To analyse the quality of life (QOL) of cancer survivors using an instrument designed specifically for this population and considering different sociodemographic and disease-related characteristics as possible modulating variables.

METHODS

The Quality of Life in Adult Cancer Survivors (QLACS) was filled out by a large and heterogeneous sample of disease-free post-treatment Spanish cancer survivors (N = 1862).

RESULTS

QLACS scores were comparable to those obtained in other studies and indicative of worse QOL as a function of shorter elapsed time since the end of primary treatment. The best QOL was shown by prostate, and the worst by hematologic cancer survivors. Both systemic treatments (chemotherapy and hormone therapy) and the combination of radiotherapy and chemotherapy were associated with worse QOL. Likewise, younger age, female sex, unemployment status and not having a stable partner were associated with worse QOL.

CONCLUSION

Greater understanding of the QOL experienced by the already large and continuously growing population of cancer survivors is relevant for guiding both clinical practice and health policy. In addition, knowing the risk factors associated with worse QOL facilitates the development of targeted prevention programmes for those survivors who need it the most.

Symptoms of Survivors of Pediatric Hematopoietic Stem Cell Transplant by Age, Sex, and Transplant Type

Purpose: The purpose of this study was to describe symptoms experienced by survivors of pediatric hematopoietic stem cell transplant (HSCT), and demographic and treatment-factors associated with ongoing symptomology. Methods: Fifty pediatric survivors completed a cross-sectional pilot study. Questionnaires were administered online via REDCap to assess symptoms experienced in the last week. Survivors also consented to a medical record chart review. Results: Survivors were on average 5.4 years post-HSCT (range 1.1 to 9 years), male (58%), and Caucasian (80%) who received an allogeneic HSCT (92%). The most commonly reported symptoms were difficulty concentrating (42.5%), pain (38%), worry (38%), nervousness (37.5%), and lack of energy/fatigue (34%). Survivors reported up to 14 symptoms, with 90% of the sample experiencing at least one symptom in the previous week. Average number of symptoms varied by age group between 2.1 (8-9 years) and 6.8 (18 and older). Age and female gender were associated with higher levels of fatigue. Conclusions: The majority of survivors experienced at least one symptom in the previous week. Neuropsychological symptoms and pain endure well into survivorship that can influence outcomes such as function and health-related quality of life (HRQOL). Research is needed on biological mechanisms of ongoing symptomology, effective interventions to prevent or mitigate symptoms, and the impact of symptoms on patient outcomes including daily functioning and HRQOL. Implications Survivors of pediatric HSCT continued to experience symptoms for up to nine years. Survivors should be frequently screened for symptoms, as symptoms may affect function, learning/employment outcomes, and HRQOL.

Dietary Supplement Use among Older Cancer Survivors: Socio-Demographic Associations, Supplement Types, Reasons for Use, and Cost

Most Americans take dietary supplements (DSs) and use is even higher among cancer survivors. This secondary analysis seeks to identify types, reasons, and costs of supplements used by 367 older cancer survivors enrolled in the Harvest for Health vegetable gardening trial and evaluate associations between supplement intake and medical/socio-demographic factors. Descriptive statistics were used to identify supplement type and reasons for use. Average market price was used to estimate cost. Fifty-nine percent of the sample reported supplement use. Female (OR 2.11, 95% CI 1.35-3.30), non-Hispanic White (OR 1.77, 95% CI 1.05-3.0), and breast and gynecological survivors (OR 1.57, 1.03-2.38) were significantly more likely to report DS use compared to males, minorities, and survivors of other cancers. Use of vitamins (39%), multivitamins (23%), and minerals (12%) were the most prevalent. Commonly reported reasons for supplement use were to improve general health (47%) or treat medical conditions (39%) and cancer-related symptoms (12%). DSs daily costs ranged from USD 0.02 to 19.81, with a mean of USD 1.28 ± 1.74, a median of USD 0.78, and a mode of USD 0.34. DS use is prevalent among older cancer survivors, with overall health reported as the leading reason for use. Out-of-pocket recurrent costs can be substantial and underscore the need to promote a nutrient-rich diet whenever possible in this vulnerable population.

Australian inpatient cancer rehabilitation as seen by patients receiving care pre and post intervention: Insights into unmet needs in the cancer and rehabilitation journey

OBJECTIVE

The objective of this study is to explore both the negative and positive lived experiences of cancer survivors during specialist inpatient rehabilitation programmes.

METHODS

This phenomenological study explored the negative and positive perspectives of cancer survivors with residual disability, during their inpatient rehabilitation. Semi-structured interviews conducted with 22 inpatients on admission and discharge were analysed using the protocols of Interpretative Phenomenological Analysis.

RESULTS

Experiences of inpatient cancer rehabilitation were not independent of the whole cancer trajectory. Rather, for these inpatients, processing and ruminating upon challenges to self from the moment of cancer diagnosis and throughout treatments indicated that more emotional and psychosocial support may be useful throughout cancer rehabilitation and the whole cancer trajectory.

CONCLUSION

Understanding the concurrent sources of psychological distress and growth in these cancer survivors as they recover from life changing events provides a unique consumer evaluation of an inpatient cancer rehabilitation service and the overall cancer experience. This study has implications for developing insight into the impact that the cancer trajectory has on the individual and reinforces the importance of a holistic approach to rehabilitation that includes a supported mind, body and spirit appreciation of healing.

Assessing an Internet-Delivered, Emotion-Focused Intervention Compared With a Healthy Lifestyle Active Control Intervention in Improving Mental Health in Cancer Survivors: Protocol for a Randomized Controlled Trial

BACKGROUND

Cancer survivors are vulnerable to experiencing symptoms of anxiety and depression and may benefit from accessible interventions focused on improving emotion regulation. CanCope Mind (CM) was developed as an internet-delivered intervention adapted from the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders to improve emotion regulation and support the mental health of cancer survivors.

OBJECTIVE

This protocol aims to provide an outline of the CanCope Study, a trial comparing the efficacy of a Unified Protocol-adapted internet-delivered intervention (CM) designed for cancer survivors compared with an active control condition-an internet-delivered healthy lifestyle intervention, CanCope Lifestyle (CL). The primary aim is to assess and compare the efficacy of both interventions in improving emotion regulation, anxiety and depressive symptoms, and quality of life. The secondary aims involve assessing the mechanisms of the CM intervention.

METHODS

This trial is a 2-arm randomized controlled trial that allocates cancer survivors to either CM or CL. Both interventions comprise 4 web-based modules and are expected to take participants at least 8 weeks to complete. Participants' mental and physical health will be assessed via self-reported surveys at baseline (T0), between each module (T1, T2, and T3), immediately after the intervention (T4), and at 3-month follow-up (T5). The study aims to recruit 110 participants who have completed T4.

RESULTS

The CanCope study began recruitment in September 2020. A total of 224 participants have been randomized to the CM (n=110, 49.1%) and CL (n=114, 50.9%) groups.

CONCLUSIONS

This is one of the first trials to develop and investigate the efficacy of a web-based intervention for cancer survivors that specifically targets emotion regulation.

TRIAL REGISTRATION

Australian Clinical Trials ACTRN12620000943943; https://tinyurl.com/b3z9cjsp.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36658.

The impact of type 2 diabetes on long-term gastrointestinal sequelae after colorectal cancer surgery: national population-based study

Background

Long-term gastrointestinal sequelae are common after colorectal cancer surgery, but the impact of type 2 diabetes (T2D) is unknown.

Methods

In a cross-sectional design, questionnaires regarding bowel function and quality of life (QoL) were sent to all Danish colorectal cancer survivors, who had undergone surgery between 2001 and 2014 and had more than 2 years follow-up without relapse. The prevalence of long-term gastrointestinal sequelae among colorectal cancer survivors with and without T2D were compared while stratifying for type of surgical resection and adjusting for age, sex, and time since surgery.

Results

A total of 8747 out of 14 488 colorectal cancer survivors answered the questionnaire (response rate 60 per cent), consisting of 3116 right-sided colonic, 2861 sigmoid, and 2770 rectal resections. Of these, 690 (7.9 per cent) had a diagnosis of T2D before surgery. Survivors with T2D following rectal resection had a 15 per cent (95 per cent c.i. 7.8 to 22) higher absolute risk of major low anterior resection syndrome, whereas survivors with T2D following right-sided and sigmoid resection had an 8 per cent higher risk of constipation (P < 0.001) but otherwise nearly the same long-term risk of bowel symptoms as those without T2D. For all types of colorectal cancer resections, T2D was associated with a 6–10 per cent higher risk of severe pain (P < 0.035) and a 4–8 per cent higher risk of impaired QoL.

Conclusion

T2D at time of surgery was associated with a higher risk of long-term bowel dysfunction after rectal resection, but not after colon resection excluding a higher risk of constipation. T2D was associated with a slightly higher frequency of severe pain and inferior QoL after both rectal and colonic cancer resection.

Participation in Daily Activities Among Women 5 Years After Breast Cancer

IMPORTANCE

Understanding the long-term participation restrictions after breast cancer (BC) is crucial for developing occupation-based interventions.

OBJECTIVE

To (1) compare women's participation during the BC subacute phase (2 yr postdiagnosis) with the chronic (5 yr postdiagnosis) phase, (2) explore factors associated with participation in the chronic phase, and (3) describe strategies women use to overcome participation restrictions.

DESIGN

Descriptive longitudinal study.

SETTING

A community health service in Israel.

PARTICIPANTS

A convenience sample of 30 women (M age = 53.9 yr, SD = 8.3) diagnosed with BC (Stages 1-3).

OUTCOMES AND MEASURES

Demographic and BC-related symptom questionnaires; an adapted version of the Activity Card Sort, used to assess retained activity levels (RALs) compared with prediagnosis activity levels in sociocultural, physical, and instrumental domains; the Canadian Occupational Performance Measure; and one open-ended qualitative question, "How were you able to retain your participation in daily activities despite the long-term effects of BC?"

RESULTS

Significantly higher total RALs were found in most domains for women in the chronic (M = 0.93 RAL, SD = 0.27) compared with the subacute (M = 0.71, SD = 0.22) phase, t(29) = 4.72, p < .001. Almost half the women achieved clinically significant change in their meaningful activities. Lower levels of participation were significantly correlated with higher symptom severity. The qualitative findings indicated that coping strategies, such as positive thinking and changing priorities, helped in managing women's participation.

CONCLUSIONS AND RELEVANCE

Participation restrictions and residual BC-related symptoms 5 yr postdiagnosis demonstrated the need for a comprehensive evaluation and early occupational therapy intervention to prevent long-term restrictions. What This Article Adds: This study highlights the value of a comprehensive assessment of daily participation (i.e., participation in various activity domains and in specific individual meaningful activities) of women with BC. The combination of quantitative and qualitative analysis provided a subjective perspective and deeper understanding of the associations among long-term symptoms, participation restrictions, and coping strategies.

Supporting cancer patients to self-manage: Extent of use and perceptions of "trusted" online self-management resources

OBJECTIVES

Online resources can support patient self-management practices, but are not systematically used in routine clinical practice. We evaluated cancer patients' satisfaction with, and use of, tailored online resources.

METHODS

Patients completed monthly validated electronic patient reported outcome measures (ePROMs) of distress, unmet needs and symptoms. Patients with ePROM scores above pre-determined thresholds received an email directing them to relevant online self-management resources. Perceptions and experiences with these resources were evaluated via an online survey 3, 6 and 9 months after their initial monthly ePRO; and a subset of patients was also interviewed. Webpage use was monitored through Google Analytics and ClickMeter.

RESULTS

Overall, 221 patients completed evaluation surveys and 31 completed interviews. Patients spent 0-10 min on average accessing resources, with 93% indicating they would reuse them. The most viewed page was physical wellbeing (n = 680); exercise and nutrition resources were most popular; and 69% of patients were satisfied with information content, reporting resources were easy to understand and navigate.

CONCLUSIONS

Online resources are perceived as acceptable and useful. Design and delivery recommendations can improve their support of self-management.

PRACTICE IMPLICATIONS

Incorporating automated online self-management resources into routine clinical workflows is a viable model to support routine follow up care.

Late effects, long-term problems and unmet needs of cancer survivors

Great efforts are being made in cancer treatment, with impressive improvement in survival. The situation concerning research and care for long-term problems and late effects in the growing population of cancer survivors, however, is unsatisfactory. Therefore, in the FiX survey 1,348 disease-free survivors about 4 years after diagnosis of different cancer types were asked to rate existing burdens and support received for them along a list of 36 potential problems. Health-related quality of life (HRQoL) was assessed with the EORTC QLQ-C30. Determinants of burdens were explored using logistic regression analysis. While cancer survivors' global HRQoL, physical and role function ratings were comparable or better than age- and sex-matched reference values of the general population, emotional and cognitive function was worse, especially among women (p<.01). Most frequently reported problems with at least moderate burden were loss of physical performance (36.3%), fatigue (35.1%), sexual problems (34.7%), sleep problems (34,1%), arthralgia (33.8%), anxiety (28.0%), neuropathy (25.6%), memory problems (23.0%) and concentration problems (21.9%). Burdened survivors often rated received support as poor, especially regarding support for problems that physicians might consider medically non-threatening, or for which no effective pharmacologic or medical treatment is known. Determinants for burden included higher age, female gender, having ever received chemotherapy and overweight/obesity. In conclusion, a significant number of cancer survivors suffer from long-term or late effects and have unmet care needs. Awareness of health care professionals should be increased for these issues. The results of our study can contribute to the development of targeted survivorship plans. This article is protected by copyright. All rights reserved.

Contemporaneous symptom networks of multidimensional symptom experiences in cancer survivors: A network analysis

BACKGROUND

Symptom networks can provide empirical evidence for the development of personalized and precise symptom management strategies. However, few studies have explored the symptom networks of multidimensional symptom experiences in cancer survivors. The objectives of this study were to generate symptom networks of multidimensional symptom experiences in cancer survivors and explore the centrality indices and density in these symptom networks METHODS: Data from 1065 cancer survivors were obtained from the Shanghai CANcer Survivor (SCANS) Report. The MD Anderson Symptom Inventory was used to assess the prevalence and severity of 13 cancer-related symptoms. We constructed contemporaneous networks with all 13 symptoms after controlling for covariates.

RESULTS

Distress (r_s  = 9.18, r_c  = 0.06), sadness (r_s  = 9.05, r_c  = 0.06), and lack of appetite (r_s  = 9.04, r_c  = 0.06) had the largest values for strength and closeness. The density of the "less than 5 years" network was significantly different from that of the "5-10 years" and "over 10 years" networks (p < 0.001). We found that while fatigue was the most severe symptom in cancer survivorship, the centrality of fatigue was lower than that of the majority of other symptoms.

CONCLUSION

Our study demonstrates the need for the assessment of centrality indices and network density as an essential component of cancer care, especially for survivors with <5 years of survivorship. Future studies are warranted to develop dynamic symptom networks and trajectories of centrality indices in longitudinal data to explore causality among symptoms and markers of interventions.