Barriers to rehabilitation of colorectal cancer patients

Labor Market Attachment 2 Years After Colorectal Cancer Surgery: A Population-based Study

Objectives

To investigate the association between clinical/sociodemographic factors and labor market attachment, and to estimate employment probability 2 years after colorectal cancer (CRC) surgery.

Background

A rising prevalence of younger CRC survivors commands a stronger focus on labor market attachment. The association between clinical factors like type of surgery and CRC survivors' labor market attachment remains poorly investigated.

Methods

National registries provided information on employment status and clinical/sociodemographic variables for all 20- to 60-year-old CRC patients without previous cancer diagnosed in Denmark from 2001 to 2014, undergoing surgery and being attached to the labor market. Associations between clinical/sociodemographic factors and labor market attachment were investigated in multiple logistic regression analyses.

Results

A total of 5755 CRC patients were included. Two years after surgery, 59.7% were working. Factors significantly associated with a higher probability of working were being in the 46 to 50 years age group, male gender, higher educational level, no comorbidity, working at the time of diagnosis, lower Union for International Cancer Control stage, and undergoing surgery in the most recent of four time-periods. Two years after undergoing surgery, the probability of working was significantly higher for left-sided than for right-sided colon resections, higher for low anterior resection (LAR)/high tumor than for LAR/low tumor, and higher for abdominoperineal resection than for Hartmann's procedure. Of the 4798 (86.8%) patients alive 2 years after surgery, 68.8% were working, 7.8% had retired, whereas 23.4% were on temporary benefits, sick leave, or disability pension.

Conclusions

Clinical/sociodemographic factors were associated with the probability of working 2 years after surgery. This knowledge can be used to inform patients and target interventions towards patients with low post-CRC probability of working.

Differences in work participation between incident colon and rectal cancer patients-a 10-year follow-up study with matched controls

PURPOSE

Work-related issues have become increasingly relevant for colorectal cancer (CRC) patients, since the cancer is detected at an earlier age due to screening. The aim was to evaluate work participation up to 10 years after colon or rectal cancer diagnosis compared between diagnosis and to a matched cancer-free population.

METHODS

In this national register-based cohort study, all first-time CRC patients in the period 2000-2015 with no previous cancer, between 20 and 60 years, were identified in the Danish Cancer Registry. A control group with no previous cancer was matched on gender, age, education, and income. For each year a mean Work Participation Score (WPS) was calculated (a percentage of weeks working) for individuals part of the labour market.

RESULTS

A total of 5625 colon cancer patients and 3856 rectal cancer patients and 25,341 and 17,256 matched controls were included in the study, respectively. The WPS increased for colon cancer patients from 45.69% after 1 year to 83.94% after 4 years, while rectal cancer patients had a score of 38.07% after 1 year and 80.07% after 4 years. The WPS was lower for cancer patients compared with controls, but the difference decreased after 4 years.

CONCLUSION

CRC patients had a lower work participation up to 10 years after diagnosis compared with controls, while rectal cancer patients had a lower participation the first 7 years after diagnosis compared with colon cancer patients.

IMPLICATIONS FOR CANCER SURVIVORS

Work-related issues should be considered in the early stage of rehabilitation to increase work participation and thereby improve quality of life.

Clinically Integrated Physical Therapist Practice in Cancer Care: A New Comprehensive Approach

Best practice recommendations in cancer care increasingly call for integrated rehabilitation services to address physical impairments and disability. These recommendations have languished primarily due to a lack of pragmatic, generalizable intervention models. This perspective paper proposes a clinically integrated physical therapist (CI-PT) model that enables flexible and scalable services for screening, triage, and intervention addressing functional mobility. The model is based on (1) a CI-PT embedded in cancer care provider clinics, and (2) rehabilitation across the care continuum determined by the patient's level of functional mobility. The CI-PT model includes regular screening of functional mobility in provider clinics via a patient-reported mobility measure-the Activity Measure for Post-Acute Care, a brief physical therapy evaluation tailored to the specific functional needs of the individual-and a tailored, skilled physical therapist intervention based on functional level. The CI-PT model provides a pragmatic, barrier-free, patient-centric, data-driven approach to integrating rehabilitation as part of standard care for survivors of cancer. The model standardizes CI-PT practice and may be sufficiently agile to provide targeted interventions in widely varying cancer settings and populations. Therefore, it may be ideal for wide implementation among outpatient oncological settings. Implementation of this model requires a shared approach to care that includes physical therapists, rehabilitation administrators, cancer care providers, and cancer center administrators.

Information needs and information seeking behaviour of patients during follow-up of colorectal cancer in the Netherlands

Purpose

Adequately informing patients is considered crucial in cancer care, but need for information and information seeking behaviour of colorectal cancer (CRC) patients in the Netherlands are currently not well known.

Methods

In a prospective study, patients participating in a specialty, hospital-based follow-up program completed three consecutive surveys over a 6-month period to analyse their information need and information seeking behaviour.

Results

Patients (n = 259) felt well informed about their treatment (86%), disease (84%), and follow-up program (80%), but less well informed about future expectations (49%), nutrition (43%), recommended physical activity (42%), and heredity of cancer (40%). The need for more information on these subjects remained constant over the first five postoperative years. Patients who were younger, who had undergone chemotherapy, or who had comorbid conditions needed more information on several subjects. One in three patients searched for information themselves, mostly on the Internet. One in four patients consulted a health care provider for information, mostly their GP. Younger and more educated patients more often searched for information themselves, while patients undergoing chemotherapy more often consulted the hospital nurse. Information seeking behaviour remained constant over time.

Conclusions

This study showed where current information provision is perceived as adequate and on which subject improvements can be made. It identifies information seeking behaviour and proposes ways to personalize information provision.

Implications for Cancer Survivors

The GP is most frequently consulted for information; involving GPs in CRC follow-up could improve information provision on several subjects for several patients.

Electronic Health Program to Empower Patients in Returning to Normal Activities After General Surgical and Gynecological Procedures: Intervention Mapping as a Useful Method for Further Development

Background

Support for guiding and monitoring postoperative recovery and resumption of activities is usually not provided to patients after discharge from the hospital. Therefore, a perioperative electronic health (eHealth) intervention (“ikherstel” intervention or “I recover” intervention) was developed to empower gynecological patients during the perioperative period. This eHealth intervention requires a need for further development for patients who will undergo various types of general surgical and gynecological procedures.

Objective

This study aimed to further develop the “ikherstel” eHealth intervention using Intervention Mapping (IM) to fit a broader patient population.

Methods

The IM protocol was used to guide further development of the “ikherstel” intervention. First, patients’ needs were identified using (1) the information of a process evaluation of the earlier performed “ikherstel” study, (2) a review of the literature, (3) a survey study, and (4) focus group discussions (FGDs) among stakeholders. Next, program outcomes and change objectives were defined. Third, behavior change theories and practical tools were selected for the intervention program. Finally, an implementation and evaluation plan was developed.

Results

The outcome for an eHealth intervention tool for patients recovering from abdominal general surgical and gynecological procedures was redefined as “achieving earlier recovery including return to normal activities and work.” The Attitude-Social Influence-Self-Efficacy model was used as a theoretical framework to transform personal and external determinants into change objectives of personal behavior. The knowledge gathered by needs assessment and using the theoretical framework in the preparatory steps of the IM protocol resulted in additional tools. A mobile app, an activity tracker, and an electronic consultation (eConsult) will be incorporated in the further developed eHealth intervention. This intervention will be evaluated in a multicenter, single-blinded randomized controlled trial with 18 departments in 11 participating hospitals in the Netherlands.

Conclusions

The intervention is extended to patients undergoing general surgical procedures and for malignant indications. New intervention tools such as a mobile app, an activity tracker, and an eConsult were developed.

Trial Registration

Netherlands Trial Registry NTR5686; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5686 

Insights in work rehabilitation after minimally invasive esophagectomy

BACKGROUND

Little is known about work rehabilitation after totally minimally invasive esophagectomy. The goal of this study was to further objectify the postoperative work rehabilitation. Not only duration of sick leave, but also the extent of return to work will be assessed.

METHODS

This retrospective multicenter study was conveyed between January 2009 and April 2014. Eighty-six preoperatively employed patients were included. Data regarding patients' preoperative occupation, actual job status, and postoperative duration until return to work were retrieved. Potential prognostic factors for work rehabilitation were analyzed. Complaints that could impede rehabilitation were questioned (based on EORTC QLQ-C30 and QLQ-OES18). Work activity, defined as either partially or fully resumed professional activity as compared to the preoperative status, was measured at 3, 6, 12, and 18 months postoperatively.

RESULTS

At 6-month follow-up, 40.2% of patients reached partial and 14.6% had full professional recovery and after 12 months 28.2% and 40.8%, respectively. After 18 months, a stagnation was seen (19.0% partial; 43.1% full recovery). Median follow-up was 18 months (IQR 12-18). Self-employment was a significant predictor for full professional recovery (p = 0.005, OR 2.45 95% CI 1.32-4.56). The median time to full professional recovery was shorter for this group. The most common complaint among all patients was fatigue. This complaint did not significantly differ between working (fully and partially) and non-working groups (p = 0.727).

CONCLUSIONS

Only approximately 40% of patients reached full professional recovery 1 year after totally minimally invasive esophagectomy. Barely any progression toward return to work was seen after 1 year postoperatively. Roughly 30% of patients never returned to work. Self-employed workers had a higher percentage of restoration to full professional activity, as well as shorter duration to return. These findings highlight the importance of adequate counseling of patients in order to prepare them for the impact of this procedure on professional activities.

Development of a tailored work-related support intervention for gastrointestinal cancer patients

Aim is the development of a work-related support intervention, tailored to the severity of work-related problems of patients diagnosed with gastrointestinal (GI) cancer treated with curative intent. Two methods were used: (1) Work-related problems were identified from the literature and submitted to an expert panel during a modified Delphi study. Experts allocated work-related problems into degrees of severity: mild, severe or complex. In addition, experts indicated which health care professional should provide the tailored support: (2) These outcomes were combined with existing interventions to design the tailored intervention. Semi-structured interviews with experts were conducted to assess whether the intervention was comprehensive, and feasible for daily practice. A decision diagram measuring severity of work-related problems was developed based on the modified Delphi study with 44 experts, encompassing social, disease and occupational problems. Based on the degree of severity, support was provided by: an oncological nurse (mild), oncological occupational physician (severe) or multidisciplinary team (complex). The intervention encompassed three individual meetings in the clinical setting and was considered comprehensive and feasible by 12 experts. The intervention is innovative in combining oncological and occupational care in the clinic and being tailored to the needs of GI cancer patients with specific work-related problems.

Design of a multicentre randomized controlled trial to evaluate the effectiveness of a tailored clinical support intervention to enhance return to work for gastrointestinal cancer patients

Background

Gastrointestinal (GI) cancer is frequently diagnosed in people of working age, and many GI cancer patients experience work-related problems. Although these patients often experience difficulties returning to work, supportive work-related interventions are lacking. We have therefore developed a tailored work-related support intervention for GI cancer patients, and we aim to evaluate its cost-effectiveness compared with the usual care provided. If this intervention proves effective, it can be implemented in practice to support GI cancer patients after diagnosis and to help them return to work.

Methods/Design

We designed a multicentre randomized controlled trial with a follow-up of twelve months. The study population (N = 310) will include individuals aged 18–63 years diagnosed with a primary GI cancer and employed at the time of diagnosis. The participants will be randomized to the intervention or to usual care. ‘Usual care’ is defined as psychosocial care in which work-related issues are not discussed. The intervention group will receive tailored work-related support consisting of three face-to-face meetings of approximately 30 min each. Based on the severity of their work-related problems, the intervention group will be divided into groups receiving three types of support (A, B or C). A different supportive healthcare professional will be available for each group: an oncological nurse (A), an oncological occupational physician (B) and a multidisciplinary team (C) that includes an oncological nurse, oncological occupational physician and treating oncologist/physician. The primary outcome measure is return to work (RTW), defined as the time to a partial or full RTW. The secondary outcomes are work ability, work limitations, quality of life, and direct and indirect costs.

Discussion

The hypothesis is that tailored work-related support for GI cancer patients is more effective than usual care in terms of the RTW. The intervention is innovative in that it combines oncological and occupational care in a clinical setting, early in the cancer treatment process.

Trial registration

METC protocol number NL51444.018.14/Netherlands Trial Register number NTR5022. Registered 6 March 2015.

Treatment options to improve anorectal function following rectal resection: a systematic review

AIM

Common problems after rectal resection are loose stools, faecal incontinence, increased frequency and evacuation difficulties, for which there are various therapeutic options. A systematic review was conducted to assess the outcome of treatment options aimed to improve anorectal function after rectal surgery.

METHOD

Publications including a therapeutic approach to improve anorectal function after rectal surgery were searched using the following databases: MEDLINE, PubMed, EMBASE, Pedro, CINAHL, Web of Science, PsychInfo and the Cochrane Library. The focus was on outcome parameters of symptomatic improvement of faecal incontinence, evaluation of defaecation and quality of life.

RESULTS

The degree of agreement on eligibility and methodological quality between reviewers calculated with kappa was 0.85. Fifteen studies were included. Treatment options included pelvic floor re-education (n=7), colonic irrigation (n=2) and sacral nerve stimulation (SNS) (n=6). Nine studies reported reduced incontinence scores and a decreased number of incontinent episodes. In 10 studies an improvement in resting and squeeze pressure was observed after treatment with pelvic floor re-education or SNS. Three studies reported improved quality of life after pelvic floor re-education. Significant improvement of the Fecal Incontinence Quality of Life Scale was found in three studies after SNS.

CONCLUSION

Conservative therapies such as pelvic floor re-education and colonic irrigation can improve anorectal function. SNS might be an effective solution in selected patients. However, methodologically qualitative studies are limited and randomized controlled trials are needed to draw evidence-based conclusions.

The transition between work, sickness absence and pension in a cohort of Danish colorectal cancer survivors

OBJECTIVES

The aim of this study was to evaluate the impact of socioeconomic and clinical factors on the transitions between work, sickness absence and retirement in a cohort of Danish colorectal cancer survivors.

DESIGN

Register-based cohort study with up to 10 years of follow-up.

SETTING

Population-based study with use of administrative health-related and socioeconomic registers.

PARTICIPANTS

All persons (N=4343) diagnosed with colorectal cancer in Denmark during the years 2001-2009 while they were in their working age (18-63 years) and who were part of the labour force 1 year postdiagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

By the use of multistate models in Cox proportional hazards models, we analysed the HR for re-employment, sickness absence and retirement in models including clinical as well as health-related variables.

RESULTS

1 year after diagnosis, 62% were working and 58% continued until the end of follow-up. Socioeconomic factors were found to be associated with retirement but not with sickness absence and return to work. The risk for transition from work to sickness absence increased if the disease was diagnosed at a later stage (stage III) 1.52 (95% CI 1.21 to 1.91), not operated curatively 1.35 (95% CI 1.11 to 1.63) and with occurrence of postoperative complications 1.25 (95% CI 1.11 to 1.41). The opposite was found for the transition from sickness absence back to work.

CONCLUSIONS

This nationwide study of colorectal cancer patients who have survived 1 year shows that the stage of disease, general health condition of the individual, postoperative complications and the history of sickness absence and unemployment have an impact on the transition between work, sickness absence and disability pension. This leads to an increased focus on the rehabilitation process for the more vulnerable persons who have a combination of severe disease and a history of work-related problems with episodes outside the working market.

Transitioning from active treatment: colorectal cancer survivors' health promotion goals

OBJECTIVE

The purpose of this study is to describe the post-treatment goals of colorectal cancer (CRC) survivors. We sought to determine whether goals were a salient concept during the period immediately following treatment, and whether a goal-setting intervention might be feasible and acceptable to these patients.

METHOD

Semi-structured qualitative interviews were administered to a convenience sample of 41 CRC patients who were 0-24 months post-treatment. Topics discussed included expectations and goals for future health, cancer prevention awareness, health-promoting behavior-change goals, and post-treatment cancer issues. Content analysis was used to explore emergent themes.

RESULTS

Overall, participants' health-related goals were: being healthy, getting back to normal, and not having a cancer recurrence. Most of the CRC survivors reported being proactive with their health by maintaining healthy behaviors or making healthy behavior changes, or had goals to change their behavior. All respondents had plans to maintain follow-up care and regular screening appointments. Some patients were managing treatment side effects or non-cancer issues that limited their functional abilities. Many respondents were satisfied with the care they received, and felt it was now their responsibility to do their part in taking care of themselves.

SIGNIFICANCE OF RESULTS

CRC survivors talk about goals, and many of them are either making or have an interest in making health behavior changes. Self-management support could be an appropriate strategy to assist patients with achieving their health goals post-treatment. Patients may need help addressing lingering treatment side effects or non-cancer issues. Healthcare providers should consider assessing patients' goals to help patients resolve post-treatment issues and promote healthy behaviors.

Information needs across the colorectal cancer care continuum: scoping the literature

Because cancer care requires a multifaceted approach, providing useful and timely information to people with colorectal cancer may be fragmented and inconsistent. Our interest was in examining what has and has not captured the attention of researchers speaking to the information needs of people with colorectal cancer. We followed Arksey and O'Malley's framework for the methodology of scoping review. Focusing solely on colorectal cancer, we analysed 239 articles to get a picture of which information needs and sources of information, as well as the timing of providing information, were attended to. Treatment-related information received the most mentions (26%). Healthcare professionals (49%) were mentioned as the most likely source of information. Among articles focused on one stage of the care continuum, post-treatment (survivorship) received the most attention (16%). Only 27% of the articles consulted people with colorectal cancer and few attended to diet/nutrition and bowel management. This study examined the numerical representation of issues to which researchers attend, not the quality of the mentions. We ponder, however, on the relationship between the in/frequency of mentions and the actual information needs of people with colorectal cancer as well as the availability, sources and timing of information.

Exploring access to rehabilitation services from allied health professionals for patients with primary high-grade brain tumours

Primary brain tumours account for less than 2% of cancer diagnoses in the UK but more people under 40 die from a brain tumour than from any other cancer. Despite developments in some treatment options, survival remains poor and patients suffer with considerable functional and cognitive deficits. Rehabilitation for patients with primary brain tumours produces statistically and clinically significant improvements in function. When compared, similar functional gains are made following rehabilitation for brain tumour patients and for those following stroke and traumatic brain injury. There have been very few studies looking at access to rehabilitation for this group of patients as a primary objective. However, existing studies and clinical experience suggest that patients with brain tumours do not access rehabilitation services frequently or easily, either locally or nationally. Therefore, this qualitative study addressed the reasons for this through semi-structured interviews of healthcare professionals, investigating their experiences of rehabilitation for this patient group and describing commonly identified barriers under key themes. The interviews gauged the views of eight healthcare professionals representing three professions in different settings, including hospital and community based. The resultant barriers fell under the following themes: professional knowledge and behaviours; services and systems; and the disease and its effects. Suggested solutions were wide ranging and included education, multidisciplinary meetings and specialist clinicians to co-ordinate care. The barriers to accessing rehabilitation for this group of patients are complex, but some of the solutions could be reached through education and co-ordination of services. Further research into the benefits of, and access to, rehabilitation for this group of patients is essential to ensure that patients with brain tumours are given opportunity to gain from the benefits of rehabilitation in the same way as other diagnoses, both cancer and non-cancer.

Prognostic value of quality of life and pain in patients with locally recurrent rectal cancer

BACKGROUND

Care of patients with locally recurrent rectal cancer (LRRC) requires careful patient selection. While curative resection offers survival benefits, significant trade-offs exist for the patient. Knowledge of patient-reported outcomes will help inform treatment decisions.

METHODS

Quality of life (QOL) and pain were prospectively assessed in 105 patients treated for LRRC at a single institution, using the validated Functional Assessment of Cancer Therapy-Colorectal (FACT-C) and Brief Pain Inventory (BPI) questionnaires. In 54 patients enrolled and followed from diagnosis of LRRC, relationship between pretreatment pain, QOL, and overall survival (OS) were examined.

RESULTS

Patients underwent curative surgical resection (C, 59%), noncurative surgery (NC, 12%) or nonsurgical treatment (NS, 28%). Median OS was 7.1, 1.4, and 1.9 years, respectively (C versus NC: p < 0.001; C versus NS: p = 0.006; NC versus NS: p = 0.261). Physical well-being QOL differed over time (p = 0.042), with greatest difference between C and NC surgery patients (p = 0.049). The remaining QOL domain scores and pain scores demonstrated no significant time or treatment effect. For the 54 patients assessed from diagnosis, median OS was independently predicted by treatment group (C, NC, NS: 4.3, 1.7, versus 2.4 years; p < 0.001) and pretreatment pain intensity (score ≤ 4 versus > 4: 3.8 versus 2.0 years; p = 0.001).

CONCLUSION

Curative surgery offered prolonged survival, but significant pain exists among long-term survivors and should be a focus of survivorship care. Noncurative surgery did not offer apparent advantages over nonsurgical palliation. Patient's pretreatment pain has prognostic value, and should be assessed, treated, and considered in treatment decisions.