Are cancer survivors willing to participate in research?

Sexual Activity in Couples Dealing With Breast Cancer. A Cohort Study of Associations With Patient, Partner and Relationship-Related Factors

Objective

Breast cancer may profoundly affect a couple’s sex life. The present study examines whether patient-, partner- and relationship-related characteristics are associated with sexual activity of couples following breast cancer diagnosis in the treatment phase and over time.

Methods

Women with breast cancer and their male cohabiting partners participated in a longitudinal study in Denmark. Logistic regression was used to examine associations of patient-, partner- and relationship-related characteristics at baseline (≤4 months following surgery) with couples’ sexual activity at baseline, 5 and 12 months later. The longitudinal analyses were stratified for couples’ sexual activity status at baseline.

Results

A total of 722, 533 and 471 couples were included in the analyses at baseline, 5- and 12-months follow-up, respectively. Older age, depressive symptoms and lower vitality of patients were associated with lower odds of couples’ sexual activity at baseline; chemotherapy treatment and older age of patients were associated with lower odds at 5-months follow-up in couples who were not sexually active at baseline. Higher ratings of emotional closeness, affectionate behavior and satisfaction with dyadic coping were associated with higher odds for sexual activity at baseline and over time in couples who were sexually active at baseline.

Conclusion

Sexual counseling during cancer treatment and rehabilitation should include a couple perspective. Relationship-related variables may be a protective factor for remaining sexually active after breast cancer diagnosis. Interventions could focus on strengthening these factors. Health professionals also need to consider the patients’ breast cancer treatment, vitality, and emotional distress in counselling on sexuality.

Comparison of Young Adult Female Cancer Survivors Recruited from a Population-Based Cancer Registry to Eligible Survivors

BACKGROUND

Population-based cancer registries provide a resource to recruit young adult cancer survivors who may not be easily identified otherwise.

METHODS

We compared demographic and cancer-related characteristics of participants in a cohort of female young adult cancer survivors to those of eligible survivors in the Georgia Cancer Registry, a population-based registry in the United States. We examined associations between survivor characteristics and nonparticipation using logistic regression and associations between survivor characteristics and different types of nonparticipation (refusal, unable to contact, or unresolved vs. interviewed) using polytomous regression.

RESULTS

The Georgia Cancer Registry was able to contact 60% of eligible women (3,061/5,137). Of those, 78% agreed to study contact (n = 2,378), and of those, 56% were interviewed (n = 1,342). Participation was similar across age at contact and at diagnosis but varied across cancer type from 17% for cervical cancer to 32% for breast cancer. White women were slightly more likely to be interviewed (28%) than African American women (23%), which was mostly attributable to greater difficulty in contacting African American women (odds ratio 1.7, 95% confidence interval: 1.5-2.1).

CONCLUSIONS

The greatest challenge to recruiting women was contacting them, which differed across some but not all demographic and cancer-related characteristics. When successfully contacted, most survivors agreed to participate.

IMPACT

Population-based cancer registries can serve as an invaluable resource to recruit representative samples of young adult cancer survivors, who are otherwise difficult to identify.

Quality of life in long-term and very long-term cancer survivors versus population controls in Germany

BACKGROUND

With the increasing number and diversity of cancer survivors, studies of survivors' physical, emotional, and social health are of growing importance. While there is a growing body of literature on the quality of life (QoL) of cancer patients during the early years past diagnosis, less is known regarding QoL in long-term survivors (LTS) (5 + years past diagnosis) and particularly in very long-term survivors (VLTS) (10 + years past diagnosis). The objective of our study is to: (1) compare QoL of long-term cancer survivors and population norms; and (2) assess whether any deficits in QoL of survivors observed 5-10 years past diagnosis persist beyond the 10th year past diagnosis.

METHODS

In total 6952 long-term cancer survivors (5-16 years past diagnosis of breast, colorectal, or prostate cancer) from Germany recruited in the context of the population-based CAESAR + study were compared with 1878 population-based controls without a history of cancer. QoL was assessed with the EORTC QLQ-C30. Differences in QoL between survivors and controls were assessed via multiple regression while controlling for age, gender, education, and case mix for survivors 5-9 years and 10 + years past diagnosis separately.

RESULTS

Overall QoL in long-term cancer survivors was comparable to population norms but specific deficits in social, role, emotional, cognitive, and physical functioning and symptoms such as insomnia, fatigue, dyspnea, constipation, diarrhea, and financial difficulties were more prevalent in LTSs. Detriments in QoL persisted during the observation period and affected particularly cancer survivors at younger ages (<50 years). Non-significant aggravations in QoL with longer time since diagnosis were observed in very young and very old cancer survivors.

CONCLUSIONS

Detriments in health-related quality of life persist over more than a decade and affect predominantly younger patients. Improvements both in early and long-term follow-up care of cancer survivors seem warranted.

Depressive symptom trajectories in women affected by breast cancer and their male partners: a nationwide prospective cohort study

PURPOSE

The purpose of this study was to identify subgroups of breast cancer patients and their partners based on distinct trajectories of depressive symptoms, to examine how relationship quality and medical and sociodemographic factors were associated with these trajectories, and to explore whether patients and partners had similar trajectories.

METHODS

A nationwide, population-based cohort of couples dealing with breast cancer was established in Denmark. Participants completed the Center for Epidemiologic Studies-Depression Scale at baseline and 5 and 12 months later. Sociodemographic and medical characteristics were retrieved from registers. A trajectory finite mixture model was used to identify trajectories.

RESULTS

The trajectories of depressive symptoms over time were analyzed in 546 patients and 508 partners. Among patients, 13 % had a high stable trajectory, 38 % an intermediate decreasing trajectory, and 49 % a low trajectory. Similar trajectories were found for partners (11, 22, and 67 %, respectively). Compared to the low trajectory, trajectories with higher depressive symptoms were associated with poorer relationship quality and previous use of antidepressants for patients and partners and with younger age, comorbidity, basic education, and chemotherapy for patients. The trajectories of patients and their partners were weakly correlated.

CONCLUSIONS

A considerable minority of patients and partners had a persistently high level of depressive symptoms. Poorer relationship quality and previous antidepressant use most consistently characterized patients and partners with higher depressive symptom trajectories.

IMPLICATIONS FOR CANCER SURVIVORS

In clinical practice, attention to differences in depressive symptom trajectories is important to identify and target patients and partners who might need support.

Cancer patients' participation in population-based health surveys: findings from the HUNT studies

Background

The magnitude of participation bias due to non-participation should be considered for cancer patients invited to population-based surveys. We studied participation rates among persons with and without cancer in a large population based study, the Nord-Trøndelag Health Study (HUNT).

Methods

Citizens 20 years or above living in the Nord-Trøndelag County of Norway have been invited three times to comprehensive health surveys. The invitation files with data on sex, invitation date and participation were linked to the Cancer Registry of Norway. In a first step unadjusted crude participation rates (participants/invited persons) were estimated for cancer patients (CaPts) and non-cancer persons (NonCaPers), followed by logistic regression analyses with adjustment for age and sex. To evaluate the “practical” significance of the estimated odds ratios in the cancer diagnosis group, relative risks were also estimated comparing the observed rates to the estimated rates under the counterfactual assumption of no earlier cancer diagnosis among CaPts.

Results

Overall 3 % of the participants in the three HUNT studies were CaPts and 59 % of them had been diagnosed with their first life-time cancer >5 years prior to each survey. In each of the three HUNT surveys crude participation rates were similar for CaPts and NonCaPers. Adjusted for sex and age, CaPts’ likelihood to participate in HUNT1 (1984–86) and HUNT2 (1995–97), but not in HUNT3 (2006–2008), was statistically significantly reduced compared to NonCaPers, equaling a relative risk of 0.98 and 0.96, respectively. The lowest odds ratio emerged for CaPts diagnosed during the last 2 years preceding a HUNT invitation. Only one-third of CaPts participating in a survey also participated in the subsequent survey compared to approximately two-thirds of NonCaPers, and 11 % of CaPts participated in all three HUNT surveys compared to 37 % of NonCaPers.

Conclusion

In the three HUNT surveys no or only minor participation bias exist as to CaPts’ participation rates. In longitudinal studies selection bias as to long-term cancer survivorship should be taken into account, the percentage of repeatedly participating CaPts diminishing more strongly than among NonCaPers.

Participation in questionnaire studies among couples affected by breast cancer

OBJECTIVE

Participation bias may be a problem in couple-based psychosocial studies. Therefore, it is important to investigate the characteristics associated with participation. The aim of this study was to analyze whether participation in a longitudinal psychosocial questionnaire study among couples affected by breast cancer was associated with socioeconomic, breast cancer-specific, and other health-related characteristics of the patients and partners.

METHODS

The analyzes are based on 2254 couples who were invited to participate in a nationwide survey on psychosocial adjustment among couples dealing with breast cancer. Participating couples (N = 792) were compared with non-participating couples (N = 1462) with regard to socioeconomic and health-related characteristics obtained from nationwide clinical and administrative registers.

RESULTS

Associations were seen between various socioeconomic variables and couple participation. The patient characteristics older age (OR = 0.15 [95% CI = 0.07-0.55]), low education (OR = 1.95 [95% CI = 1.46-2.68]), disability pension (OR = 0.59 [95% CI = 0.39-0.55]), or non-western ethnicity (OR = 0.36 [95% CI = 0.15-0.82]) reduced couple participation. The partner characteristics older age (OR = 0.23 [95% CI = 0.15-0.43]), low education (OR = 1.67 [95% CI = 1.25-2.22]), receiving disability pension (OR = 0.46 [95% CI = 0.25-0.82]), non-western ethnicity (OR = 0.17 [95% CI = 0.06-0.49]), or high morbidity (OR = 0.76 [95% CI = 0.60-0.96]) also reduced couple participation. Furthermore, couples with low income (OR = 1.49 [95% CI = 1.16-1.95]) had reduced participation. No associations were found between couple participation and breast cancer-related variables.

CONCLUSIONS

Socioeconomic characteristics of patients and partners, and morbidity of partners may influence participation in couple-based psychosocial breast cancer research. Breast cancer-related characteristics do not seem to influence participation.

Educating low-SES and LEP survivors about breast cancer research: pilot test of the Health Research Engagement Intervention

The Health Research Engagement Intervention (HREI) aims to reduce information and access disparities for breast cancer research opportunities among low-socioeconomic status (SES) and limited English proficient (LEP) breast cancer survivors by providing neutral, non-trial-specific information about health research via a trusted patient navigator. Qualitative methods in the context of a community-based participatory research design were used to iteratively design the HREI in collaboration with community-based care navigators from a trusted community organization, Shanti Project, and to locate appropriate research studies in collaboration with a web-based trial-matching service, BreastCancerTrials.org (BCT). Navigators were first trained in clinical trials and health research and then to deliver the HREI, providing feedback that was incorporated into both the HREI design and BCT's interface. Our intervention pilot with low SES and LEP survivors (n = 12) demonstrated interest in learning about "health research." All 12 participants opted to obtain more information when offered the opportunity. Post-intervention questionnaires showed that three of 11 (27 %) participants independently pursued additional information about research opportunities either online or by phone in the week following the intervention. Post-intervention navigator questionnaires indicated that navigators could confidently and efficiently deliver the intervention. LEP patients who pursued information independently faced language barriers. The HREI is a promising and potentially scalable intervention to increase access to neutral information about breast cancer research opportunities for low-SES and LEP individuals. However, in order for it to be effective, systems barriers to participation such as language accessibility at sources of health research information must be addressed.

Smoking, alcohol, diabetes, obesity, socioeconomic status, and the risk of colorectal cancer in a population-based case-control study

PURPOSE

Although previous research has identified factors that may determine willingness to participate in research, relatively few studies have attempted to quantify the impact non-participation may have on exposure-disease associations. The aims of this study were to (a) investigate the associations between smoking, alcohol, diabetes, obesity, and socioeconomic status and the risk of colorectal cancer in a case-control study (59.7 and 47.2 % response fractions among cases and controls, respectively); and (b) perform sensitivity analyses to examine the possible influence of non-participation.

METHODS

Logistic regression was used to estimate the exposure-disease associations. We then investigated the associations between various demographic and health factors and the likelihood that an individual would participate in the case-control study and then performed two sensitivity analyses (sampling weights and multiple imputation) to examine whether non-participation bias may have influenced the exposure-disease associations.

RESULTS

The exposures alcohol, smoking, and diabetes were associated with an increased risk of colorectal cancer. We found some differences between cases and controls when examining the factors associated with the participation in the study, and in the sensitivity analyses, the exposure-disease associations were slightly attenuated when compared with those from the original analysis.

CONCLUSION

Non-participation may have biased the risk estimates away from the null, but generally not enough to change the conclusions of the study.

Rethinking the therapeutic misconception: social justice, patient advocacy, and cancer clinical trial recruitment in the US safety net

Background

Approximately 20% of adult cancer patients are eligible to participate in a clinical trial, but only 2.5-9% do so. Accrual is even less for minority and medically underserved populations. As a result, critical life-saving treatments and quality of life services developed from research studies may not address their needs. This study questions the utility of the bioethical concern with therapeutic misconception (TM), a misconception that occurs when research subjects fail to distinguish between clinical research and ordinary treatment, and therefore attribute therapeutic intent to research procedures in the safety net setting. This paper provides ethnographic insight into the ways in which research is discussed and related to standard treatment.

Methods

In the course of two years of ethnographic fieldwork in a safety net hospital, I conducted clinic observations (n = 150 clinic days) and in-depth in-person qualitative interviews with patients (n = 37) and providers (n = 15). I used standard qualitative methods to organize and code resulting fieldnote and interview data.

Results

Findings suggest that TM is limited in relevance for the interdisciplinary context of cancer clinical trial recruitment in the safety net setting. Ethnographic data show the value of the discussions that happen prior to the informed consent, those that introduce the idea of participation in research. These preliminary discussions are elemental especially when recruiting underserved and vulnerable patients for clinical trial participation who are often unfamiliar with medical research and how it relates to medical care. Data also highlight the multiple actors involved in research discussions and the ethics of social justice and patient advocacy they mobilize, suggesting that class, inequality, and dependency influence the forms of ethical engagements in public hospital settings.

Conclusion

On the ground ethics of social justice and patient advocacy are more relevant than TM as guiding ethical principles in the context of ongoing cancer disparities and efforts to diversify clinical trial participation.

Primary Care Provider Evaluation of Cancer Survivorship Care Plans Developed for Patients in their Practice

OBJECTIVE

Survivorship care plans (SCP), which describe a cancer survivor's diagnosis, treatment and follow-up, are recommended. The study objective was to evaluate primary care providers' (PCP) responses to SCPs developed for breast and colorectal cancer survivors in their practice and to determine whether PCP response to the SCPs varied according to characteristics of the practitioner and their practice.

METHOD

SCPs were created using the Journey Forward® Care Plan for breast and colorectal cancer patients in rural and urban settings. The SCP and a survey were sent to PCPs.

PARTICIPANTS

Primary care physicians.

MAIN MEASURES

Attitudes regarding survivorship care plans.

RESULTS

Thirty-nine (70.9% response rate) surveys were completed. Most felt the SCP was useful (90%), that it enhanced understanding (75%) and that detail was sufficient (>80%). However, 15% disagreed that the care plan helped them understand their role, a perception especially prevalent among PCPs in the rural setting. Among PCPs with ≤ 18 years in practice, 95% agreed that the SCP would improve communication with patients, contrasted with 60% of those with >21 years in practice. The most common barrier to providing follow-up care was limited access to survivors.

CONCLUSIONS

While SCPs appear to improve PCPs understanding of a cancer diagnosis and treatment, clear delineation of each provider's role in follow-up care is needed. Additional detail on which tests are needed and education on late and long term effects of cancer may improve coordination of care.

Geographic residency status and census tract socioeconomic status as determinants of colorectal cancer outcomes

OBJECTIVES

We examined the impact of geographic residency status and census tract (CT)-level socioeconomic status (SES) on colorectal cancer (CRC) outcomes.

METHODS

This was a retrospective cohort study of patients diagnosed with CRC in Georgia for the years 2000 through 2007. Study outcomes were late-stage disease at diagnosis, receipt of treatment, and survival.

RESULTS

For colon cancer, residents of lower-middle-SES and low-SES census tracts had decreased odds of receiving surgery. Rural, lower-middle-SES, and low-SES residents had decreased odds of receiving chemotherapy. For patients with rectal cancer, suburban residents had increased odds of receiving radiotherapy, but low SES resulted in decreased odds of surgery. For survival, rural residents experienced a partially adjusted 14% (hazard ratio [HR] = 1.14; 95% confidence interval [CI] = 1.07, 1.22) increased risk of death following diagnosis of CRC that was somewhat explained by treatment differences and completely explained by CT-level SES. Lower-middle- and low-SES participants had an adjusted increased risk of death following diagnosis for CRC (lower-middle: HR = 1.16; 95% CI = 1.10, 1.22; low: HR = 1.24; 95% CI = 1.16, 1.32).

CONCLUSIONS

Future efforts should focus on developing interventions and policies that target rural residents and lower SES areas to eliminate disparities in CRC-related outcomes.

The impact of cancer diagnosis on employment: is there a difference between rural and urban populations?

PURPOSE

To determine if living in a rural or urban area influences the impact of cancer diagnosis on employment.

METHOD

Surveys that asked about changes in employment status related to a cancer diagnosis or treatment were sent to 2,005 cancer survivors enrolled in the Vermont Cancer Survivor Surveillance Registry. Data on cancers were obtained from hospital cancer registries. Respondents indicating that they were working at the time of diagnosis were included in this study for a total of 1,155 participants. Associations between rural or urban residence and changes in employment were assessed by chi-square tests and logistic regression.

RESULTS

There were no statistically significant differences in the proportions of rural and urban survivors working fewer hours, experiencing a career change or unable to work. However, a larger proportion of rural than urban patients retired early after their diagnosis (11.1 vs. 7.2%, p = 0.031). There were also fewer rural patients that reported that they went on paid disability during cancer treatment (12.3 vs. 17.0%, p = 0.030).

CONCLUSIONS

While many patients will return to work after treatment for a cancer diagnosis, it appears that rural patients may be less likely to receive paid disability and more likely to retire early. It is possible that rural populations engage in more physically demanding jobs that they are unable to continue after their cancer treatment. Additionally the types of manual labor available in rural areas rarely offer disability benefits, increasing the impact of cancer diagnosis for this population.

IMPLICATIONS FOR CANCER SURVIVORS

A cancer diagnosis may have a greater impact on employment among rural residents. Cancer programs should recognize this disparity and enhance return to work and disability counseling in patients from rural areas.

A cross-cultural perspective on challenges facing comparative cancer survivorship research

Cancer survivorship research includes the study of physical, psychosocial, and economic consequences of cancer diagnosis and treatment among pediatric and adult cancer survivors. Historically, the majority of cancer survivorship studies were from the United States, but survivorship issues are increasingly being addressed in other developed countries. Cross-cultural studies remain, however, scarce. The degree to which knowledge attained may or may not be transferred across cultures, countries, or regions is not known. Some important challenges for comparative research are therefore discussed in a cross-cultural perspective. Several substantive and methodological challenges that complicate the execution of cross-cultural cancer survivorship research are presented with examples and discussed to facilitate comparative research efforts in the establishment of new survivorship cohorts and in the planning and implementation of survivorship studies. Comparative research is one key to understanding the nature of cancer survivorship, distinguishing modifiable from nonmodifiable factors at individual, hospital, societal, and system levels and may thus guide appropriate interventions. Lastly, suggested future courses of action within the field of comparative cancer survivorship research are provided.