Hope, bias and survival expectations of advanced cancer patients: A cross-sectional study

The trajectory of prognostic cognition in patients with advanced cancer: is the traditional advance care planning approach desirable for patients?

Most patients with advanced cancer initially express a desire to be informed of their prognosis, and prognostic discussions between patients and their oncologists can trigger the subsequent trajectory of prognostic cognitions. On the continuum of prognostic cognition, including inaccurate/accurate prognostic awareness (awareness of incurability of cancer, terminal nature of illness or life expectancy) and prognostic acceptance (accepting one's prognosis), patients' perceptions of being informed of their prognosis by oncologists and patients' coping strategy for serious medical conditions regulate prognostic cognitions. However, nearly half of the patients with advanced cancer have poor prognostic awareness, and few patients achieve prognostic acceptance. These phenomena partly act as barriers to participation in advance care planning. When oncologists engage in advance care planning conversations, they must assess the patient's prognostic cognition and readiness for advance care planning. Considering the inaccurate prognostic awareness in a non-negligible proportion of patients and that astatic patients' preferences for future treatment and care are influenced by prognostic cognition, more research on decision-making support processes for high-quality and goal-concordant end-of-life care is needed along with research of advance care planning. In addition to making decisions regarding future medical treatment and care, oncologists must engage in continuous and dynamic goal-of-care conversations with empathic communication skills and compassion from diagnosis to end-of-life care.

Uncertainty and hope in relation to anxiety and depression in advanced lung cancer

OBJECTIVES

Intolerance of uncertainty (IU) has been linked to greater psychological distress, whereas hope appears to act as a protective factor against in patients with cancer. The aim of this study is to analyse the modifying effect of uncertainty in the presence of anxiety and depression in patients with advanced lung cancer.

METHODS

Multicentre, prospective, observational, cross-sectional study of 145 individuals with advanced lung cancer. Participants completed the following questionnaires: IU Scale, Hert Hope Index, Brief Symptom Inventory.

RESULTS

Among patients with advanced lung cancer, anxiety and depression were prevalent, 30% and 35%, respectively. Uncertainty and hope with respect to their illness negatively affected their psychological distress. Hope and uncertainty accounted for 22% of the variance in anxiety and 34% of depressive symptoms. The hypothesised modifying effects (uncertainty×hope) was not supported in the depressive and anxious symptom models.

CONCLUSIONS

Our findings indicate that hope and uncertainty are important considerations in understanding mental health in people diagnosed with advanced lung cancer. Identifying patients who lack the resources needed to manage uncertainty and hope in relation to their disease could inform psychosocial intervention provision to improve quality of life.

Hope and illness expectations: A cross-sectional study in patients with advanced cancer

BACKGROUND

The fear of taking away hope hinders clinicians' willingness to share serious news with patients with advanced disease. Unrealistic illness expectations, on the other hand, can complicate decision making and end-of-life care outcomes. Exploration of the association between hope and illness expectations can support clinicians in better communication with their patients.

AIM

The aim of this study was to explore whether realistic illness expectations are associated with reduced hope in people with advanced cancer.

DESIGN

This is a cross-sectional secondary analysis of baseline data from a primary palliative care cluster-randomized trial CONNECT (data collected from July 2016 to October 2020). Hope was measured by Herth Hope Index. Illness expectations were measured by assessing patients' understanding of their treatment goals, life expectancy, and terminal illness acknowledgement. Multivariable regression was performed, adjusting for demographical and clinical confounders.

SETTING/PARTICIPANTS

Adult patients with advanced solid cancers recruited across 17 oncology clinics.

RESULTS

Data from 672 patients were included in the study, with mean age of 69.3 years (±10.2), 53.6% were female. Proportion of patients indicating realistic expectations varied based on which question was asked from 10% to 46%. Median level of hope was 39 (IQR = 36-43). Multivariate non-inferiority regression did not find any significant differences in hope between patients with more and less realistic illness expectations.

CONCLUSIONS

Our results suggest that hope can be sustained while holding both realistic and unrealistic illness expectations. Communication about serious news should focus on clarifying the expectations as well as supporting people's hopes.

Can Oncologists Prompt Patient Prognostic Awareness to Enhance Decision-Making? Data From the NEOetic Study

INTRODUCTION

Anti-neoplastic therapy improves the prognosis for advanced cancer, albeit it is not curative. An ethical dilemma that often arises during patients' first appointment with the oncologist is to give them only the prognostic information they can tolerate, even at the cost of compromising preference-based decision-making, versus giving them full information to force prompt prognostic awareness, at the risk of causing psychological harm.

METHODS

We recruited 550 participants with advanced cancer. After the appointment, patients and clinicians completed several questionnaires about preferences, expectations, prognostic awareness, hope, psychological symptoms, and other treatment-related aspects. The aim was to characterize the prevalence, explanatory factors, and consequences of inaccurate prognostic awareness and interest in therapy.

RESULTS

Inaccurate prognostic awareness affected 74%, conditioned by the administration of vague information without alluding to death (odds ratio [OR] 2.54; 95% CI, 1.47-4.37, adjusted P = .006). A full 68% agreed to low-efficacy therapies. Ethical and psychological factors oriented first-line decision-making, in a trade-off in which some lose quality of life and mood, for others to gain autonomy. Imprecise prognostic awareness was associated with greater interest in low-efficacy treatments (OR 2.27; 95% CI, 1.31-3.84; adjusted P = .017), whereas realistic understanding increased anxiety (OR 1.63; 95% CI, 1.01-2.65; adjusted P = 0.038), depression (OR 1.96; 95% CI, 1.23-3.11; adjusted P = .020), and diminished quality of life (OR 0.47; 95% CI, 0.29-0.75; adjusted P = .011).

CONCLUSION

In the age of immunotherapy and targeted therapies, many appear not to understand that antineoplastic therapy is not curative. Within the mix of inputs that comprise inaccurate prognostic awareness, many psychosocial factors are as relevant as the physicians' disclosure of information. Thus, the desire for better decision-making can actually harm the patient.

Loneliness at end-of-life: A scoping review

AIMS AND OBJECTIVES

To map and synthesise the literature on loneliness at end-of-life and identify key knowledge gaps in loneliness research.

BACKGROUND

Declined health conditions, reduced social engagement, loss of social roles, and fear of death may lead to loneliness at end-of-life. However, systematic information about loneliness at end-of-life is scant.

METHODS

This scoping review followed the methodology proposed by Arksey and O'Malley. Nine electronic databases were searched from January 2001 to July 2022. Studies about loneliness at end-of-life were included. Two review authors independently screened and selected relevant studies and performed the data charting. The PAGER framework was employed to collate, summarise and report the results. The PRISMA-ScR checklist was included.

RESULTS

A total of 23 studies were included in this review (12 qualitative, 10 quantitative, and one mixed-methods design). There was not reliable data about the prevalence of loneliness among adults at end-of-life internationally. Three or 20-item UCLA loneliness scale was frequently used to measure loneliness. Factors predisposed adults at end-of-life to loneliness included passive and active withdrawal from social networks, inability to share emotions and to be understood, and inadequate support on spirituality. Four strategies were identified to alleviate loneliness, yet none have been substantiated in clinical trials. Interventions facilitating spirituality, social interactions and connectedness seem effective in alleviating loneliness.

CONCLUSIONS

This is the first scoping review on loneliness at end-of-life, synthesising evidence from qualitative, quantitative, and mixed-methods studies. Loneliness among adults at end-of-life is under-investigated and there is a prominent need to address existential loneliness at end-of-life.

RELEVANCE TO CLINICAL PRACTICE

All nurses should proactively assess loneliness or perceived social isolation for clients with life-limiting conditions, regardless of social networks. Collaborative efforts (e.g., medical-social collaborations) to promote self-worthiness, social engagement and connectedness with significant others and social networks are needed.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Exposure and Reactions to Cancer Treatment Misinformation and Advice: Survey Study

BACKGROUND

Cancer treatment misinformation, or false claims about alternative cures, often spreads faster and farther than true information on social media. Cancer treatment misinformation can harm the psychosocial and physical health of individuals with cancer and their cancer care networks by causing distress and encouraging people to abandon support, potentially leading to deviations from evidence-based care. There is a pressing need to understand how cancer treatment misinformation is shared and uncover ways to reduce misinformation.

OBJECTIVE

We aimed to better understand exposure and reactions to cancer treatment misinformation, including the willingness of study participants to prosocially intervene and their intentions to share Instagram posts with cancer treatment misinformation.

METHODS

We conducted a survey on cancer treatment misinformation among US adults in December 2021. Participants reported their exposure and reactions to cancer treatment misinformation generally (saw or heard, source, type of advice, and curiosity) and specifically on social media (platform, believability). Participants were then randomly assigned to view 1 of 3 cancer treatment misinformation posts or an information post and asked to report their willingness to prosocially intervene and their intentions to share.

RESULTS

Among US adult participants (N=603; mean age 46, SD 18.83 years), including those with cancer and cancer caregivers, almost 1 in 4 (142/603, 23.5%) received advice about alternative ways to treat or cure cancer. Advice was primarily shared through family (39.4%) and friends (37.3%) for digestive (30.3%) and natural (14.1%) alternative cancer treatments, which generated curiosity among most recipients (106/142, 74.6%). More than half of participants (337/603, 55.9%) saw any cancer treatment misinformation on social media, with significantly higher exposure for those with cancer (53/109, 70.6%) than for those without cancer (89/494, 52.6%; P<.001). Participants saw cancer misinformation on Facebook (39.8%), YouTube (27%), Instagram (22.1%), and TikTok (14.1%), among other platforms. Participants (429/603, 71.1%) thought cancer treatment misinformation was true, at least sometimes, on social media. More than half (357/603, 59.2%) were likely to share any cancer misinformation posts shown. Many participants (412/603, 68.3%) were willing to prosocially intervene for any cancer misinformation posts, including flagging the cancer treatment misinformation posts as false (49.7%-51.4%) or reporting them to the platform (48.1%-51.4%). Among the participants, individuals with cancer and those who identified as Black or Hispanic reported greater willingness to intervene to reduce cancer misinformation but also higher intentions to share misinformation.

CONCLUSIONS

Cancer treatment misinformation reaches US adults through social media, including on widely used platforms for support. Many believe that social media posts about alternative cancer treatment are true at least some of the time. The willingness of US adults, including those with cancer and members of susceptible populations, to prosocially intervene could initiate the necessary community action to reduce cancer treatment misinformation if coupled with strategies to help individuals discern false claims.

The relationship between hope, medical expenditure and survival among advanced cancer patients

Introduction

Among those with advanced illness, higher levels of hope may offer physiological benefits. Yet, greater levels of hope may also encourage aggressive treatments. Therefore, higher levels of hope may lead to greater healthcare utilization, higher expenditure, and longer survival. We test these hypotheses among patients with advanced cancer.

Methods

A secondary data analysis from a cross-sectional survey of 195 advanced cancer patients with high mortality risk linked to subsequent healthcare utilization (outpatient, day surgeries, non-emergency admissions), health expenditures, and death records. The survey collected data on hope, measured generally by the Herth Hope Index (HHI) and more narrowly by two questions on illness-related hope. Generalized linear regression and Cox models were used to test our hypotheses.

Results

142 (78%) survey participants died during the period of analysis, with close to half (46%) doing so within a year of the survey. Contrary to expectation, HHI scores did not have a significant association with healthcare utilization, expenditure or survival. Yet, illness-related hope, defined as those who expected to live at least 2 years, as opposed to the likely prognosis of 1 year or less as determined by the primary treating oncologist, had 6.6 more planned hospital encounters (95% CI 0.90 to 12.30) in the 12-months following the survey and 41% lower mortality risk (hazard ratio: 0.59, 95% CI 0.36 to 0.99) compared to those who were less optimistic. Secondary analysis among decedents showed that patients who believed that the primary intent of their treatment is curative, had higher total expenditure (S$30,712; 95% CI S$3,143 to S$58,282) in the last 12 months of life than those who did not have this belief.

Conclusion

We find no evidence of a relationship between a general measure of hope and healthcare utilization, expenditure, or survival among advanced cancer patients. However, greater illness-related hope is positively associated with these outcomes.

Caregivers' End-of-Life Care Goals for Persons with Severe Dementia Change Over Time

BACKGROUND

Family caregivers make end-of-life (EOL) decisions for persons with severe dementia (PWSDs). It is not known whether the family caregivers' goals change over time.

OBJECTIVE

Assess caregivers' EOL care goal for PWSDs and change in these goals over time.

METHODS

Using a prospective cohort of 215 caregivers of PWSDs, we assessed the proportion of caregivers whose EOL care goal for PWSDs changed between two consecutive time points. Mixed effects multinomial regression models assessed factors associated with caregivers' EOL care goals for PWSD (maximal, moderate, minimal life extension); and change in EOL care goal from previous time point.

RESULTS

At baseline, 20% of the caregivers had a goal of maximal life extension for their PWSD, and 59% changed their EOL care goal at least once over a period of 16 months. Caregivers of PWSDs with lower quality of life (RR: 1.15, CI: 1.06, 1.24), who expected shorter life expectancy for PWSDs (RR: 10.34, CI: 2.14, 49.99) and who had an advance care planning discussion (RR: 3.52, CI: 1.11, 11.18) were more likely to have a goal of minimal life extension for PWSD. Caregivers with higher anticipatory grief (RR: 0.96, CI: 0.93,1) were more likely to have a goal of maximal life extension. Change in PWSDs' quality of life and change in caregivers' anticipatory grief were associated with change in caregivers' EOL care goals.

CONCLUSION

Caregivers' EOL care goals for PWSDs change over time with change in PWSD and caregiver related factors. Findings have implications regarding how health care providers can engage with caregivers.

Communication of anticancer drug benefits and related uncertainties to patients and clinicians: document analysis of regulated information on prescription drugs in Europe

OBJECTIVE

To evaluate the frequency with which relevant and accurate information about the benefits and related uncertainties of anticancer drugs are communicated to patients and clinicians in regulated information sources in Europe.

DESIGN

Document content analysis.

SETTING

European Medicines Agency.

PARTICIPANTS

Anticancer drugs granted a first marketing authorisation by the European Medicines Agency, 2017-19.

MAIN OUTCOME MEASURES

Whether written information on a product addressed patients' commonly asked questions about: who and what the drug is used for; how the drug was studied; types of drug benefit expected; and the extent of weak, uncertain, or missing evidence for drug benefits. Information on drug benefits in written sources for clinicians (summaries of product characteristics), patients (patient information leaflets), and the public (public summaries) was compared with information reported in regulatory assessment documents (European public assessment reports).

RESULTS

29 anticancer drugs that received a first marketing authorisation for 32 separate cancer indications in 2017-19 were included. General information about the drug (including information on approved indications and how the drug works) was frequently reported across regulated information sources aimed at both clinicians and patients. Nearly all summaries of product characteristics communicated full information to clinicians about the number and design of the main studies, the control arm (if any), study sample size, and primary measures of drug benefit. None of the patient information leaflets communicated information to patients about how drugs were studied. 31 (97%) summaries of product characteristics and 25 (78%) public summaries contained information about drug benefits that was accurate and consistent with information in regulatory assessment documents. The presence or absence of evidence that a drug extended survival was reported in 23 (72%) summaries of product characteristics and four (13%) public summaries. None of the patient information leaflets communicated information about the drug benefits that patients might expect based on study findings. Scientific concerns about the reliability of evidence on drug benefits, which were raised by European regulatory assessors for almost all drugs in the study sample, were rarely communicated to clinicians, patients, or the public.

CONCLUSIONS

The findings of this study highlight the need to improve the communication of the benefits and related uncertainties of anticancer drugs in regulated information sources in Europe to support evidence informed decision making by patients and their clinicians.

Perceived COVID-19 pandemic impact and protective factors predicting patient-reported depression and anxiety in individuals living with cancer

BACKGROUND

The COVID-19 pandemic presents a unique, amplified threat to those living with a cancer diagnosis, but personal factors may play a role in how this affects well-being. This cross-sectional study (1) describes the impacts of COVID-19 on cancer patients' lives, and (2) explores the extent to which specific impacts of COVID-19 and noted protective factors, hope and resilience, predict two crucial patient-reported outcomes, depression and anxiety, after controlling for relevant sociodemographic and clinical factors.

METHODS

520 cancer patients and survivors in the U.S. completed an online survey during the first year of the pandemic and answered questions about COVID-19 areas of impact, psychological well-being, hope, and resilience. Hierarchical regression analyses were used to analyze the unique impact of each group of variables on patient-reported levels of depression and anxiety during the pandemic.

RESULTS

Participants strongly endorsed COVID-19 impact across several areas of life, especially social activity, well-being, and ability to acquire basic essentials. Regression models explained a substantial amount of variance in patient-reported depression (R² = .50, p < .001) and anxiety (R² = .44, p < .001), revealing COVID-19 financial impact as a significant predictor of depression (β = 0.07), and COVID-19 family impact as a significant predictor of anxiety (β = 0.14), even after controlling for the effects of relevant sociodemographic and clinical variables. Additionally, resilience and hope were the largest predictors of both depression (β = - 0.19 and - 0.37, respectively) and anxiety (β = - 0.18 and - 0.29), suggesting that they account for unique variance in patient-reported mental health during the COVID-19 pandemic and might serve as important protective factors.

CONCLUSIONS

The current results add to existing literature documenting the significant effect of COVID-19 on those living with cancer. COVID-19 impact, including financial and family well-being, as well as positive psychological constructs, hope and resilience, play a crucial role in levels of patient-reported depression and anxiety during the pandemic. As COVID-19 continues to evolve, health care providers should routinely assess psychological well-being and needs related to COVID-19 financial and family impact in an effort to appropriately align individuals with resources and support, and consider how hope and resilience can be fostered to serve as psychological buffers during this time.

Motivations and experiences of patients with advanced cancer participating in Phase 1 clinical trials: A qualitative study

BACKGROUND

Persons with advanced cancer may participate in Phase 1 clinical trials - first-in-human trials that are conducted with the main objectives of safety and dosing. The motivations for participation are not well understood and may include hope for cure.

AIM

To explore the perspectives of persons with advanced cancer in order to understand the motivations for participating in Phase 1 clinical trials, experiences while being on trial and views on palliative care provision.

DESIGN

Qualitative study with a constructivist stance, using thematic analysis based upon the grounded theory approach.

SETTING/PARTICIPANTS

20 persons with advanced cancer who were participating in a Phase 1 clinical trial.

RESULTS

Many participants described how Phase 1 clinical trial participation was their last hope, as they were cognisant of their advanced disease. Information-seeking needs differed - some needed comprehensive information while others relied on the doctor's recommendation. Participants experienced varied negative and positive physical and psycho-emotional concerns, and needed to draw on multiple sources of support such as family, friends and healthcare professionals. Some could list potential benefits of palliative care but felt they did not require it yet. The overarching theme was hope and positive thinking as a way of coping.

CONCLUSIONS

The concepts of hope as a way of coping and the supportive presence of healthcare professionals could be weaved into a future model of palliative care to improve the illness journey for patients considering Phase 1 clinical trial participation and other persons with advanced cancer.

The TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States

Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.

What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials

Objectives

To conduct an up-to-date systematic review of all randomised controlled trials assessing efficacy of advance care planning (ACP) in improving patient outcomes, healthcare use/costs and documentation.

Design

Narrative synthesis conducted for randomised controlled trials. We searched electronic databases (MEDLINE/PubMed, Embase and Cochrane databases) for English-language randomised or cluster randomised controlled trials on 11 May 2020 and updated it on 12 May 2021 using the same search strategy. Two reviewers independently extracted data and assessed methodological quality. Disagreements were resolved by consensus or a third reviewer.

Results

We reviewed 132 eligible trials published between 1992 and May 2021; 64% were high-quality. We categorised study outcomes as patient (distal and proximal), healthcare use and process outcomes. There was mixed evidence that ACP interventions improved distal patient outcomes including end-of-life care consistent with preferences (25%; 3/12 with improvement), quality of life (0/14 studies), mental health (21%; 4/19) and home deaths (25%; 1/4), or that it reduced healthcare use/costs (18%; 4/22 studies). However, we found more consistent evidence that ACP interventions improve proximal patient outcomes including quality of patient–physician communication (68%; 13/19), preference for comfort care (70%; 16/23), decisional conflict (64%; 9/14) and patient-caregiver congruence in preference (82%; 18/22) and that it improved ACP documentation (a process outcome; 63%; 34/54).

Conclusion

This review provides the most comprehensive evidence to date regarding the efficacy of ACP on key patient outcomes and healthcare use/costs. Findings suggest a need to rethink the main purpose and outcomes of ACP.

PROSPERO registration number

CRD42020184080.

Participants' experiences from group-based treatment at multidisciplinary pain centres - a qualitative study

OBJECTIVES

The aim of the study was to explore the experiences of participants in non-pharmacological group-based treatments delivered as part of a randomised controlled trial at Norwegian tertiary care pain centres.

METHODS

Individual semi-structured interviews with 15 persons were conducted. The data were analysed with a descriptive thematic cross-case analysis based on the method of systematic text condensation.

RESULTS

All participants talked about some aspects of the group-based treatments as a positive experience, but mainly the outcome was in line with their expectations; they hoped it would reduce their pain but did not expect it. There were no clear-cut differences in the experiences between the participants from the two different intervention groups. The content was experienced as both relevant and interesting but also to introduce concepts that were difficult to grasp and understand. Similarly, the experiences of participating in a group-based treatment were mostly stimulating but could also be challenging because of an expectancy of sharing personal stories. Although experiencing few changes to their pain they came away with techniques and lessons that were valuable to them.

CONCLUSIONS

In this study, taking part in group-based treatment was perceived as giving positive and valuable lessons, due to relevant content and learning from the professionals and fellow participants, but without any clear indication of reduced pain. Approval from ethical committee number 10260 REK Midt.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT04057144.