Experience and supportive care needs of metastatic lung cancer survivors living with uncertainty: a brief qualitative report

Why and How to Integrate Early Palliative Care Into Cutting-Edge Personalized Cancer Care

Early palliative care, palliative care integrated with oncology care early in the course of illness, has myriad benefits for patients and their caregivers, including improved quality of life, reduced physical and psychological symptom burden, enhanced prognostic awareness, and reduced health care utilization at the end of life. Although ASCO and others recommend early palliative care for all patients with advanced cancer, widespread implementation of early palliative care has not been realized because of barriers such as insufficient reimbursement and a palliative care workforce shortage. Investigators have recently tested several implementation strategies to overcome these barriers, including triggers for palliative care consultations, telehealth delivery, navigator-delivered interventions, and primary palliative care interventions. More research is needed to identify mechanisms to distribute palliative care optimally and equitably. Simultaneously, the transformation of the oncology treatment landscape has led to shifts in the supportive care needs of patients and caregivers, who may experience longer, uncertain trajectories of cancer. Now, palliative care also plays a clear role in the care of patients with hematologic malignancies and may be beneficial for patients undergoing phase I clinical trials and their caregivers. Further research and clinical guidance regarding how to balance the risks and benefits of opioid therapy and safely manage cancer-related pain across this wide range of settings are urgently needed. The strengths of early palliative care in supporting patients' and caregivers' coping and centering decisions on their goals and values remain valuable in the care of patients receiving cutting-edge personalized cancer care.

Survivorship in Advanced Lung Cancer: Understanding a New Landscape and Opportunities

People with advanced lung cancer represent a distinct group whose needs remain understudied, especially compared with people diagnosed with limited-stage disease. Fortunately, novel treatments such as tyrosine kinase inhibitors and immune checkpoint inhibitors are leading to significant advances in prognosis and survival, even among those with advanced disease at the time of diagnosis. However, there are known gaps in symptom management, psychosocial and nutritional support, complex care coordination, health behavior coaching, and health care delivery efforts among patients living with advanced lung cancer. Many of these patients would benefit from survivorship and palliative care approaches. In particular, survivorship care may include health care maintenance, treatment of immune-related adverse events and late- or long-term effects, frailty assessment and rehabilitation, and care coordination. Palliative care may be best suited to discuss ongoing symptom management, advanced care planning, and end-of-life considerations, as well as psychosocial well-being. To this end, we share a review of the current status of the palliative and survivorship care infrastructure for patients with advanced lung cancer and provide suggestions across the care continuum for this diverse group of patients and families.

Perspectives and experiences of leisure-time physical activity in adults with stage 4 cancer: a qualitative interpretive-description study

PURPOSE

Leisure-time physical activity (LTPA) can be beneficial for individuals with advanced cancer, but little is known on how to tailor rehabilitation strategies targeting LTPA in cancer care. Our objective was to explore perspectives and experiences of LTPA in people with stage 4 cancer.

MATERIALS AND METHODS

Guided by interpretive-description methodology, our qualitative study consisted of individual, semi-structured interviews with 20 Canadian adults diagnosed with stage 4 cancer. Interviews were transcribed verbatim and analyzed inductively.

RESULTS

The participants' median age was 51.5 (range, 35-73) years. Cancer types included breast (n = 12), lung (n = 4), and other (n = 4). Participants highlighted their experiences of LTPA as diverse and complex, impacted by individual and cancer-related factors. They emphasized being intentional with LTPA through activity planning and modification. LTPA participation was linked to physical well-being, social connections, and meanings of accomplishment and loss. Many participants desired personalized support related to LTPA, that is integrated, interprofessional, and accessible in cancer care.

CONCLUSION

The experiences of LTPA for people with stage 4 cancer are personal and connected to health and psychosocial meanings. Further efforts in rehabilitation are needed to address the challenges faced by people with advanced cancer and optimize safe, meaningful participation in LTPA.IMPLICATIONS FOR REHABILITATIONExperiences of leisure-time physical activity in individuals with stage 4 cancer are personal and linked to health benefits and psychosocial meanings.Activity participation frequently involves consideration of cancer-related symptoms, management of risks, and intentional planning and modification of activities.Trained rehabilitation professionals integrated in cancer care may be well suited to support people with stage 4 cancer through personalized activity recommendations.This research can help inform future clinical, research, and educational efforts in rehabilitation aimed at targeting physical activity in individuals with advanced cancer.

What patients with advanced cancer experience as helpful in navigating their life with a long-term response: a qualitative study

PURPOSE

Despite improved survival for people with advanced cancer due to new medical treatments, a growing group of long-term responders (LTRs) has to learn to live with uncertainties that affect several life domains. At the core of their experience, they neither feel like a patient nor feel healthy. Despite growing awareness of LTRs' experiences, learning more about how they cope with their long-term response can provide insight into how to best support them. Our study aimed to gain a deeper understanding what LTRs experience as helpful in navigating life with a long-term response.

METHODS

We conducted an exploratory qualitative study using thematic data analysis. Semi-structured in-depth interviews were conducted with 17 participants with advanced melanoma or lung cancer with confirmed response or long-term stable disease while on immuno- or targeted therapy.

RESULTS

LTRs reported several strategies to navigate life with a long-term response, for example, by involving the social environment, seeing uncertainty as an opportunity, and being present in the moment. This helped them to reclaim a sense of control, alter their perspective, and reshape their lives according to their values.

CONCLUSION

Using different coping strategies enables LTRs to acknowledge both their sick and healthy side. Striking a healthy balance between being oriented on feeling sick or feeling healthy can help LTRs and their close others to navigate life with a long-term response. Healthcare professionals can provide support by recognizing whether LTRs are oriented at feeling sick or healthy, and by actively involving close others during medical appointments.

Content Quality of YouTube Videos About Metastatic Breast Cancer in Young Women: Systematic Assessment

BACKGROUND

Young women with metastatic breast cancer (MBC) are part of a digitally connected generation yet are underserved in terms of information needs. YouTube is widely used to find and identify health information. The accessibility of health-related content on social media together with the rare and marginalized experiences of young women with MBC and the digital media practices of younger generations imply a considerable likelihood that young women with MBC will seek information and community on the internet.

OBJECTIVE

This study aims to assess the content quality of MBC YouTube videos and to identify themes in the experiences of young women with MBC based on YouTube videos.

METHODS

A systematic assessment of MBC YouTube videos using the search term "metastatic breast cancer young" was conducted in August 2021. The search was performed in an incognito browser and with no associated YouTube or Google account. Search results were placed in order from most to least views. Title, date uploaded, length, poster identity, number of likes, and number of comments were collected. Understandability and actionability were assessed using the Patient Education Materials Assessment Tool (PEMAT); information reliability and quality were assessed with DISCERN. Themes, sponsorships, and health care professionals' and patients' narratives were reported.

RESULTS

A total of 101 videos were identified. Of these, 78.2% (n=79) included sponsorships. The mean PEMAT scores were 78.8% (SD 15.3%) and 43.1% (SD 45.2%) for understandability and actionability, respectively. The mean DISCERN score was 2.44 (SD 0.7) out of 5. Identified themes included treatment (n=67, 66.3%), family relationship (n=46, 45.5%), and motherhood (n=38, 37.6%).

CONCLUSIONS

YouTube videos about young women with MBC are highly understandable but demonstrate moderate rates of actionability, with low reliability and quality scores. Many have a commercial bias. While web-based materials have limitations, their potential to provide patient support is not fully developed. By acknowledging their patients' media habits, health care professionals can further develop a trusting bond with their patients, provide a space for open and honest discussions of web-based materials, and avoid any potential instances of confusion caused by misleading, inaccurate, or false web-based materials.

Evaluation of Managing Cancer and Living Meaningfully (CALM) in people with advanced non-small cell lung cancer treated with immunotherapies or targeted therapies: protocol for a single-arm, mixed-methods pilot study

INTRODUCTION

People with advanced non-small cell lung cancer (NSCLC) treated with immunotherapies (IT) or targeted therapies (TT) may have improved outcomes in a subset of people who respond, raising unique psychological concerns requiring specific attention. These include the need for people with prolonged survival to reframe their life plans and tolerate uncertainty related to treatment duration and prognosis. A brief intervention for people with advanced cancer, Managing Cancer and Living Meaningfully (CALM), could help people treated with IT or TT address these concerns. However, CALM has not been specifically evaluated in this population. This study aims to evaluate the acceptability and feasibility of CALM in people with advanced NSCLC treated with IT or TT and obtain preliminary evidence regarding its effectiveness in this population.

METHODS AND ANALYSIS

Twenty people with advanced NSCLC treated with IT or TT will be recruited from Peter MacCallum Cancer Centre, Melbourne, Australia. Participants will complete three to six sessions of CALM delivered over 3-6 months. A prospective, single-arm, mixed-methods pilot study will be conducted. Participants will complete outcome measures at baseline, post-intervention, 3 months and 6 months, including Patient Health Questionnaire, Death and Dying Distress Scale, Functional Assessment of Cancer Therapy General and Clinician Evaluation Questionnaire. The acceptability of CALM will be assessed using patient experiences surveys and qualitative interviews. Feasibility will be assessed by analysis of recruitment rates, treatment adherence and intervention delivery time.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Peter MacCallum Cancer Centre Human Research Ethics Committee (HREC/82047/PMCC). Participants with cancer will complete a signed consent form prior to participation, and carers and therapists will complete verbal consent. Results will be made available to funders, broader clinicians and researchers through conference presentations and publications. If CALM is found to be acceptable in this cohort, this will inform a potential phase 3 trial.

Application of a revised model for coping with advanced cancer to qualitatively explore lung cancer survivors' experiences of ongoing physical effects, novel treatments, uncertainty, and coping

PURPOSE

Lung cancer remains underrepresented in cancer survivorship research. This study aimed to understand survivors' physical/psychological challenges, experiences of immunotherapy (IO) and targeted therapy (TT), and psychological adjustment through application of the Roberts et al. (2017) advanced cancer adaptation of Folkman and Greer's appraisal and coping model.

METHODS

Adults 6-24 months post-initial treatment completion were recruited via an Australian cohort study. Participant demographic, clinical, quality of life, and distress data were obtained through the cohort database. Qualitative interviews were conducted and analyzed using Framework methods. Roberts et al. (2017)'s model informed data interpretation and presentation.

RESULTS

Twenty interviews were conducted (10 females; average age 69 years). Participants' diagnostic stages varied (stage I = 2, stage II = 4, stage III = 8, stage IV = 6); most had received IO/TT (n = 14) and were on average 17 months (range 10-24) post-diagnosis. Three themes were identified and mapped to the Roberts' framework: (1) Ongoing illness events: most participants reported functioning well despite ongoing physical effects. Those on IO/TT reported side effects; some were unexpected/serious. (2) Adjusting to life with lung cancer: most expressed hope for the future while simultaneously preparing for disease progression. Those receiving IO/TT experienced uncertainty given limited survival information. (3) Learning to live with lung cancer: participants described emotion, problem, and meaning based on coping strategies.

CONCLUSIONS

Findings may guide development of supportive care resources/interventions focused on uncertainty, IO/TT communication and decision-making, and coping.

IMPLICATIONS FOR CANCER SURVIVORS

Many people with lung cancer are living well with their ongoing illness. Despite challenges, many survivors are adapting to issues as they arise and are maintaining a sense of hope and optimism.

Supportive Care Needs Trajectories in Patients With Advanced Non-Small-Cell Lung Cancer Receiving Chemotherapy: A Longitudinal Study

BACKGROUND

The supportive care needs trajectories in patients with advanced non-small-cell lung cancer (NSCLC) during chemotherapy and the related factors have yet to be explored or addressed in the literature.

PURPOSE

This study was designed to investigate supportive care needs trajectories in patients with advanced NSCLC receiving chemotherapy and the association between the sociodemographic and disease characteristics of these patients over the four cycles of chemotherapy.

METHODS

For this longitudinal study, 95 patients with advanced NSCLC were recruited using convenience sampling at a medical center in Taiwan. The supportive care needs of the participants were assessed in each of the four chemotherapy cycles using the Needs Evaluation Questionnaire-Chinese version (NEQ-C) with 23 dichotomous items on the day before and the seventh day after the end of each cycle. Group-based trajectory modeling was applied to identify the classes of supportive care needs trajectories, whereas chi-square tests were used to examine the factors related to these classes.

RESULTS

Seventy-one participants completed all eight questionnaire sessions across the four cycles. The mean NEQ-C scores for these participants ranged between 14.4 and 14.6. Three classes of supportive care needs trajectories (low, moderate, and high) were identified for the entire NEQ-C and for each domain. Marital status was found to be associated with the classes of trajectories related to supportive care and assistance/care needs, spouse as the primary caregiver was found to be associated with the classes of trajectories related to information needs, and educational level was found to be associated with the classes of trajectories related to psychoemotional support needs.

CONCLUSIONS

The results of this study indicate that marital status and spouse as primary caregiver relate significantly to supportive care needs trajectories in patients with advanced NSCLC during chemotherapy. Healthcare professionals should provide continuous, tailored supportive care interventions that address the needs of patients and their spouses/partners.

Examining the needs of survivors of critical illness through the lens of palliative care: A qualitative study of survivor experiences

OBJECTIVE

To examine the needs of adult survivors of critical illness through a lens of palliative care.

RESEARCH METHODOLOGY

A qualitative study of adult survivors of critical illness using semi-structured interviews and framework analysis.

SETTING

Participants were recruited from the post-intensive care unit clinic of a mid-Atlantic academic medical center in the United States.

FINDINGS

Seventeen survivors of critical illness aged 34-80 (median, 66) participated in the study. The majority of patients were female (64.7 %, n = 11) with a median length of index ICU stay of 12 days (interquartile range [IQR] 8-19). Interviews were conducted February to March 2021 and occurred a median of 20 months following the index intensive care stay (range, 13-33 months). We identified six key themes which align with palliative care principles: 1) persistent symptom burden; 2) critical illness as a life-altering experience; 3) spiritual changes and significance; 4) interpreting/managing the survivor experience; 5) feelings of loss and burden; and 6) social support needs.

CONCLUSION

Our findings suggest that palliative care components such as symptom management, goals of care discussions, care coordination, and spiritual and social support may assist in the assessment and treatment of survivors of critical illness.

Prognostic communication about lung cancer in the precision oncology era: A multiple-perspective qualitative study

BACKGROUND

Although most patients with cancer prefer to know their prognosis, prognostic communication between oncologists and patients is often insufficient. Targeted therapies for lung cancer improve survival yet are not curative and produce variable responses. This study sought to describe how oncologists communicate about prognosis with patients receiving targeted therapies for lung cancer.

METHODS

This qualitative study included 39 patients with advanced lung cancer with targetable mutations, 14 caregivers, and 10 oncologists. Semistructured interviews with patients and caregivers and focus groups or interviews with oncologists were conducted to explore their experiences with prognostic communication. One oncology follow-up visit was audio-recorded per patient. A framework approach was used to analyze interview transcripts, and a content analysis of patient-oncologist dialogue was conducted. Themes were identified within each source and then integrated across sources to create a multidimensional description of prognostic communication.

RESULTS

Six themes in prognostic communication were identified: Patients with targetable mutations develop a distinct identity in the lung cancer community that affects their information-seeking and self-advocacy; oncologists set high expectations for targeted therapy; the uncertain availability of new therapies complicates prognostic discussions; patients and caregivers have variable information preferences; patients raise questions about progression by asking about physical symptoms or scan results; and patients' expectations of targeted therapy influence their medical decision-making.

CONCLUSIONS

Optimistic patient-oncologist communication shapes the expectations of patients receiving targeted therapy for lung cancer and affects their decision-making. Further research and clinical guidance are needed to help oncologists to communicate uncertain outcomes effectively.

Building Awareness of Diagnosis Together: Ambiguity During Progression-Free Survival Experienced by Patients With Lung Cancer and Caregivers in China

BACKGROUND

Lung cancer, as a multistep and multifactorial disease, is among the most fatal cancers worldwide. As new therapies are developed and early screening increases, patients tend to experience progression-free survival (PFS) as a coexistence of living and dying simultaneously.

OBJECTIVE

The aim of this study was to explore the awareness context experienced by Chinese elderly patients and family members.

METHODS

Interviews were conducted with 20 interviewees, including 13 elderly patients with lung cancer and 7 caregivers that were recruited using purposive sampling. Semistructured, face-to-face, in-depth interviews were conducted using a qualitative descriptive approach.

RESULTS

Ambiguity was commonly experienced by patients with lung cancer with PFS. Three themes emerged from the data analysis: "ambiguity in cancer diagnosis," "ambiguity in prognostic awareness," and "ambiguity in identity." In this case, ambiguity refers to a situation or context in which patients are uncertain about whether there will be a recurrence of their cancer and when it might occur.

CONCLUSIONS

The findings highlighted that patients experienced ambiguity in response to unclear diagnoses, uncertain prognoses, and identity crises during PFS.

IMPLICATIONS FOR PRACTICE

Healthcare teams should be equipped with psychosocial knowledge and communication skills to manage ambiguity in diagnosis and prognosis for patients with PFS.

Patient-Centered Palliative Care for Patients With Advanced Lung Cancer

The evidence base demonstrating the benefits of an early focus on palliative care for patients with serious cancers, including advanced lung cancer, is substantial. Early involvement of specialty-trained palliative care clinicians in the care of patients with advanced lung cancer improves patient-reported outcomes, such as quality of life, and health care delivery, including hospice utilization. Since the time that many of these palliative care trials were conducted, the paradigm of cancer care for many cancers, including lung cancer, has changed dramatically. The majority of patients with advanced lung cancer are now treated with immune checkpoint inhibitors or targeted therapies, both of which have had a significant impact on patient's experience and outcomes. With this changing landscape of lung cancer therapeutics, patients are facing new and different challenges, including dealing with novel side effect profiles and coping with greater uncertainty regarding their prognosis. Patients who are living longer with their advanced cancer also struggle with how to address survivorship issues, such as sexual health and exercise, and decision making about end-of-life care. Although palliative care clinicians remain well-suited to address these care needs, they may need to learn new skills to support patients treated with novel therapies. Additionally, as the experience of patients with advanced lung cancer is becoming more varied and individualized, palliative care research interventions and clinical programs should also be delivered in a patient-centered manner to best meet patient's needs and improve their outcomes. Tailored and technology-based palliative care interventions are promising strategies for delivering patient-centered palliative care.

Developments in systemic therapies for the management of lung cancer

Lung cancer accounts for approximately 1 in 10 new cancer diagnoses annually and is responsible for the most cancer-associated deaths in Australia. Despite such figures, there is reason for optimism with many practice-changing developments to report for the management of patients with thoracic malignancies over the last few years. We outline such changes, including the emerging role of immunotherapy in the neoadjuvant and adjuvant setting for patients with localised non-small-cell lung cancer, as well as the established standard of consolidation immunotherapy following definitive chemoradiotherapy for those with locally advanced disease. In the metastatic setting, combination chemotherapy-immunotherapy approaches have become the new paradigm for most patients in the absence of a recognised driver mutation. A range of novel targeted therapies now exist and are Pharmaceutical Benefits Scheme (PBS)-subsidised for targets such as EGFR, ALK and ROS1, with many others, such as KRAS G12C, NTRK, MET, RET and HER2, also with therapies rapidly being developed. Even among patients with small-cell lung cancer, who account for the worst prognoses and until recently have received a chemotherapy regimen that has remained unchanged in over 20 years, there is a new standard-of-care in combination chemotherapy-immunotherapy. Furthermore, immunotherapy and potentially anti-vascular endothelial growth factor agents now also play a role in mesothelioma treatment. Last, given recent developments in immunotherapy, targeted therapy and combination approaches in the non-small-cell lung cancer space, there is an increasing recognition of the diversity of lived experience for such patients and need for survivorship programmes to acknowledge such nuances.

Health behaviors and well-being among those "living" with metastatic cancer in Alabama

BACKGROUND

Approximately 5 million Americans are living with metastatic cancer. Metastatic cancer survivors (MCS) are at risk for poor health behaviors, which may negatively influence well-being.

METHODS

Using a modified Dillman protocol, 542 MCS were mailed a survey querying physical and mental health (PROMIS® measures), health behaviors, and supportive care interest. Returned surveys were double-key entered into REDCap®. Data were analyzed using SPSS.

RESULTS

Two hundred seventy-seven surveys were returned (51% response). Respondents (51% female; 88% Caucasian; 12% African-American; Mage = 65 years; Msurvivorship = 38 months; 23% female cancers, 23% melanoma, 21% gastrointestinal, 15% genitourinary, 12% pulmonary, and 6% other) reported low daily fruit and vegetable (F&V) intake (M = 4.1) and weekly minutes of moderate-to-vigorous physical activity (PA) (M = 41.9), with 66% of respondents having overweight or obesity. While mean scores for physical (M = 43.6) and mental (M = 47.7) health were considered "good," scores in the "fair" to "poor" ranges were observed (40% physical; 23% mental). MCS meeting PA (≥ 150 min per week) and dietary (≥ 5 daily servings of F&V) guidelines reported better physical (p = .003; p = .056) and mental (p = .033, p = .549) health, respectively, compared to MCS who were not. While current supportive care use was low (12%), future interest was high (57%), with greatest interest for nutrition (46%), MCS support group (38%), and gardening (31%).

CONCLUSIONS

Our findings suggest that engaging in regular PA and consuming more F&Vs may enhance physical and mental health among MCS. Future research may explore supportive care approaches with high interest, such as gardening, to aid MCS in improving key health behaviors.