Living in the twilight zone: a qualitative study on the experiences of patients with advanced cancer obtaining long-term response to immunotherapy or targeted therapy

The Co-Creation of a Psychosocial Support Website for Advanced Cancer Patients Obtaining a Long-Term Response to Immunotherapy or Targeted Therapy

Due to new treatment options, the number of patients living longer with advanced cancer is rapidly growing. While this is promising, many long-term responders (LTRs) face difficulties adapting to life with cancer due to persistent uncertainty, feeling misunderstood, and insufficient tools to navigate their "new normal". Using the Person-Based Approach, this study developed and evaluated a website in co-creation with LTRs, healthcare professionals, and service providers, offering evidence-based information and tools for LTRs. We identified the key issues (i.e., living with uncertainty, relationships with close others, mourning losses, and adapting to life with cancer) and established the website's main goals: acknowledging and normalizing emotions, difficulties, and challenges LTRs face and providing tailored information and practical tools. The prototype was improved through repeated feedback from a user panel (n = 9). In the evaluation phase (n = 43), 68% of participants rated the website's usability as good or excellent. Interview data indicated that participants experienced recognition through portrait videos and quotes, valued the psycho-education via written text and (animated) videos, and made use of the practical tools (e.g. conversation aid), confirming that the main goals were achieved. Approximately 90% of participants indicated they would recommend the website to other LTRs. The Dutch website-Doorlevenmetkanker (i.e., continuing life with cancer) was officially launched in March 2025 in the Netherlands.

Development of the SCNS-TARGET: a new tool to assess unmet needs in cancer patients utilising immuno-, biological or precision therapies

PURPOSE

Develop an instrument to assess unmet needs in cancer patients using immuno-, biological and precision (IBP) therapies.

METHODS

Development followed COSMIN guidance. Instruments to assess unmet needs of advanced cancer patients were identified, and quality and content were evaluated in a systematic review (Phase 1). Semi-structured interviews with patients utilising IBP therapies (n = 31) and healthcare professionals (n = 22) explored supportive care needs (Phase 2). Phase 3 selected a base instrument to adapt, generated new items and iteratively refined these through six meetings involving professionals (n = 8) and public and patient involvement representatives (n = 9) and patient cognitive interviews (n = 16). Phase 4 piloted the new instrument (n = 50 patients).

RESULTS

Twenty-four instruments were identified; none was developed for patients utilising IBP therapies (Phase 1). Ten domains of unmet needs were identified from the interview data (Phase 2). SCNS-SF34 was selected as the base instrument. Informed by interview data, an "add-on module" (SCNS-TARGET) was developed for patients utilising IBP therapies comprising 25 questions (psychological domain, 7 items; information, 6; healthcare, 5; economic, 3; role, 2; physical, 1; social, 1; Phase 3). Levels of missingness were low; reliability varied across questions, and, on average, patients reported 7.40 (standard deviation = 8.43) unmet needs on SCNS-TARGET (Phase 4).

CONCLUSIONS

SCNS-TARGET is designed for use alongside SCNS-SF34 to assess unmet needs in those using IBP therapies. Content and face validity have been established.

IMPLICATIONS FOR CANCER SURVIVORS

SCNS-TARGET can help researchers and healthcare professionals determine unmet needs and inform requirements for new services and interventions, among patients using IBP therapies.

Factors influencing clinical decision-making and health-related quality of life changes in colorectal cancer patients receiving targeted therapy: a multicenter study in China

OBJECTIVES

The aim of this paper is to assess the current clinical application of targeted therapy in colorectal cancer (CRC), identify factors influencing patients' acceptance of targeted therapy, and evaluate its impact of targeted therapy on patients' health-related quality of life (HRQoL).

METHODS

This study was based on a national multi-center survey. From March 2020 to March 2021, involved 19 tertiary hospitals across seven regions in China through multi-stage stratified sampling. CRC patients who underwent genetic testing participated. Data on demographic and clinical characteristics, disease knowledge, medical service utilization, medical expenditure, and HRQoL before and after treatment were collected through face-to-face interviews. Logistic regression identified factors affecting therapy acceptance, while the HRQoL changes in pre-and post-treatment were compared by the Mann-Whitney U test.

RESULTS

Among 1,468 eligible patients, 79.7% were aged 50+, 60% male, and 31.5% retired. Secondary education was the most common level (30.3%). A total of 62.7% of patients received targeted therapy. Multivariable analysis showed that metastasis at diagnosis, out-of-pocket expenses, and reimbursement ratio were positively associated with targeted therapy (P < 0.05), while initial diagnosis stage, region, and genetic testing reimbursement were negatively associated (P < 0.05). Post-therapy, patients' quality of life declined significantly (P < 0.001), especially in fatigue and financial burden.

CONCLUSIONS

Our study revealed multiple factors influencing CRC patients' acceptance of targeted therapy and found that targeted therapy may adversely affect HRQoL. These findings emphasize the necessity of implementing more comprehensive patient management strategies to optimize the clinical application of targeted therapy and improve patients' quality of life.

"Oh when's your treatment ending?" "Never!" The unmet needs of cancer patients treated with immunological, biological and precision therapies: A qualitative interview study

PURPOSE

To explore the unmet supportive care needs of patients with advanced cancer receiving immuno-, biological and precision (IBP) therapies.

METHODS

We conducted semi-structured interviews with: (1) adults diagnosed with advanced cancer (lung, colorectal, ovary, breast, renal, melanoma) treated with an IBP therapy (e.g. tyrosine kinase inhibitors, monoclonal antibodies, immunotherapy), for at least one month; (2) healthcare professionals involved in providing hospital care for patients receiving IBP therapies. Interviews were audio-recorded, transcribed and analysed using the Framework Analysis approach; the framework comprised of 11 domains of unmet need: activities of daily living, autonomy, economic, healthcare, information, physical, psychological, role, sexual, social; and an "other" category (to capture data relating to unmet needs that did not fit within pre the-defined domains).

RESULTS

Thirty-one patients and 22 healthcare professionals were interviewed. Ten domains of unmet needs (exceptions: spiritual, other) were evident in the data. Identified unmet needs related to: (1) utilising the IBP therapies (e.g. specific treatment side effects [physical domain], living long-term with uncertainty [psychological], others not understanding why they were not cured [social]; and (2) living with (advanced) cancer (e.g. retiring from work [role], loss of independence [autonomy]).

CONCLUSIONS

Patients with advanced cancer being treated with IBP therapies have a diverse range of often inter-related unmet needs. It is vital that healthcare professionals involved in the care of cancer patients using IBP therapies are alert to the unmet needs among this patient group. Interventions and services should be developed to address these needs.

Selecting Immune Checkpoint Inhibitor Side Effects for Real-Time Monitoring in Routine Cancer Care: A Modified Delphi Study

PURPOSE

Electronic patient-reported outcome (ePRO) symptom monitoring may support the safe delivery of immune checkpoint inhibitors (ICI). There is no consensus on which side effects should be monitored in routine care. We aimed to develop a prioritized list of ICI side effects to include in ePRO systems and compare this to existing ICI-specific patient-reported outcome measures (PROMs).

METHODS

We conducted a two-round modified Delphi survey. Participants were patients (or their carers) who had received/were receiving ICI or managing health care professionals (HCPs). Round 1 (R1) side effects were generated from a literature review and existing PROMs. In R1, participants rated the importance of 63 ICI side effects in an ePRO system on a five-point Likert scale. In round 2 (R2), participants ranked the 10 most important side effects from 36 side effects. Content mapping of the prioritized list against existing PROMs was conducted.

RESULTS

In R1, 47 patients, nine carers, and 58 HCPs responded. Twenty-eight side effects were rated important (I)/very important (VI) by >75% of participants and included in R2. Ten were rated I/VI by <50% of participants and excluded. Twenty-five were rated I/VI by 50%-75% of participants and discussed at an HCP roundtable to determine inclusion in R2. In R2, 39 patients, 11 carers, and 42 HCPs ranked seizures, shortness of breath, chest pain, diarrhea, and rash as the most important side effects for monitoring. Content mapping showed significant differences between the prioritized list and existing PROMs.

CONCLUSION

We developed a consumer- and clinician-driven prioritized list of 36 ICI side effects to include in future ePRO systems. This process highlights the importance of broad stakeholder engagement in side-effect selection and rigorously identifying clinically important side effects to ensure content validity and clinical utility.

Perspectives of patients, partners, primary and hospital-based health care professionals on living with advanced cancer and systemic treatment

PURPOSE

An emerging group of patients lives longer with advanced cancer while receiving systemic treatment. This study aimed to investigate psychosocial aspects of living longer with advanced cancer, and experiences with psychosocial care, from the perspectives of patients, partners, and health care professionals (HCPs).

METHODS

From May to December 2020, participants were purposively selected. In-depth, semi-structured interviews were conducted by video or phone call, containing open questions regarding psychosocial aspects and psychosocial care in oncology. The data was analysed following thematic analysis, leading to overarching psychosocial themes and indications for optimal organisation of psycho-oncological care.

RESULTS

Fifteen patients, seven partners and eleven HCPs were interviewed. The main psychosocial aspects were increasing loss in several life domains, complexity of making life choices, ongoing uncertainty, and fluctuating fear and hope. Partners were affected by their loved ones' condition and reported to put themselves second for longer periods of time, while sometimes missing adequate support. HCPs were challenged by addressing the altering psychosocial needs of patients, and tools to identify those in need for psychosocial support are currently lacking.

CONCLUSIONS

Living longer with advanced cancer presents unique challenges for patients and their partners, as well as for HCPs in delivering optimal psychosocial care.

IMPLICATIONS FOR CANCER SURVIVORS

Identifying and addressing patients' psychosocial needs from an early stage on, appointing a central hospital-based contact person, limiting the waiting time between scans and consultations, and addressing the partners' wellbeing are suggestions to organise optimal psychosocial support in advanced cancer.

From decision to reflection: understanding the experiences and unmet care needs of patients treated with immunotherapy for melanoma in the adjuvant or metastatic setting

BACKGROUND

Despite increased use of immune checkpoint inhibitors (ICIs) in patients with advanced melanoma, little is known about patient experiences during this treatment. This study aimed to gain an in-depth understanding of experiences and unmet care needs of patients treated in the adjuvant or metastatic setting for advanced melanoma regarding their ICI treatment trajectory.

METHODS

Interviews and focus groups were conducted among 35 patients treated with ICIs in the adjuvant setting for completely resected stage III (n = 14), or in the metastatic setting for irresectable stage IV (n = 21) melanoma. A thorough thematic content analysis was conducted.

RESULTS

Three main themes were identified. When (1) dealing with uncertainty in the decision-making process, adjuvant patients explored the pros and cons, whereas metastatic patients considered immunotherapy their only viable option. Both groups expressed the need for additional guidance. In (2) navigating the immunotherapy course, both perceived the trajectory as intense, experienced a major impact on their and their (close) relatives' lives, and felt the need to (re)gain control. When (3) looking back on the immunotherapy experience, metastatic patients generally felt relieved, while among adjuvant patients, feelings of doubt regarding their choice for ICIs were also reported.

CONCLUSIONS

ICI treatment is perceived as intensive for both patient groups, facing both comparable and distinct challenges throughout the treatment trajectory, underscoring the need for stage-specific, individualised guidance. Options regarding flexible follow-ups, low-threshold contact and psychosocial support throughout the treatment trajectory should be explored.

Carrying on with life as a lung cancer survivor: a qualitative study of Australian survivors' employment, finances, relationships, and healthcare experiences

Background

With novel therapies, more individuals are living longer with lung cancer (LC). This study aimed to understand the impacts of LC on life domains such as employment, finances, relationships, and healthcare needs.

Methods

Individuals 18+, diagnosed with LC, 6-24 months post-treatment were recruited through an Australian LC cohort study (Embedding Research and Evidence in Cancer Healthcare-EnRICH). Demographic, clinical, quality-of-life and distress data were obtained through the EnRICH study database. Participants completed telephone interviews. Qualitative data were analysed via Framework methods.

Results

Twenty interviews (10 females) were conducted. Most participants were diagnosed with advanced LC (Stage III =8, Stage IV =6), and were on average 17 (range, 10-24) months post-diagnosis. Four themes related to "carrying on with life" as a LC survivor were identified: (I) the winding path back to work: those working pre-diagnosis discussed challenges of maintaining/returning to employment, and the meaning and satisfaction derived from work. (II) Vulnerability versus protection: managing the financial impacts of LC: wide variations in financial impacts, some described lost income and high healthcare expenses, others felt financially protected. (III) Connection and loneliness: navigating relationships as a survivor: some experienced lost friendships due to their diagnosis, others noted more meaningful connections. (IV) Still under the umbrella: healthcare during survivorship: participants noted the importance of ongoing oncology team connection and the vital role of cancer care coordinators.

Conclusions

Many individuals living with LC want to "carry on" with life. Participants spoke of challenges and opportunities across life domains of relationships, work, and finances, and noted the importance of continued specialist healthcare throughout survivorship.

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.

The Symptom Experience of Patients with Advanced Melanoma Undergoing Immune Checkpoint Inhibitor (ICI) Therapy

OBJECTIVES

The advent of immune checkpoint inhibitor (ICI) therapy has vastly improved outcomes for patients with advanced melanoma. However, the symptom burden and intensity with their impact on quality-of-life (HRQoL) and functionality are heterogeneous and unpredictable. We used descriptive exploratory content analysis from interviews to capture the patient experience after they had completed quantitative data collection of their symptom burden and interference with the use of two patient-reported outcome (PRO) instruments.

DATA SOURCES

Participants from a single center with advanced melanoma (n = 19) who are undergoing ICI therapy completed the Modified MD Anderson Symptom Inventory and Functional Assessment of Cancer Therapy-Melanoma and recorded semistructured interviews. Interpretive description informed the inductive and iterative analysis approach.

CONCLUSION

Participants had a heterogenous experience of ICI and melanoma-related symptoms: distress (84%), fatigue (68%), rash or skin changes (53%), pain (30%), diarrhea (30%), itching (26%), and shortness of breath (21%), with varying interference within HRQoL domains, mood (47%), relations with other people (26%), and activity (21%). Some noted a lack of physical interference (79%). Uncertainty was a pervasive theme in the interviews (68%) despite the majority having positive thoughts about ICI therapy (58%) and expectations of the success of therapy (53%). The physical and emotional burden of a melanoma diagnosis, undergoing therapy, and the uncertainty of the outcomes are pervasive for patients.

IMPLICATIONS FOR NURSING PRACTICE

Communication surrounding the diagnosis, prognosis, treatment options, and outcomes need to be clear and acknowledge there are unknowns. Nurses may benefit from using a validated PRO instrument to help document and understand the patient's symptom experience while undergoing ICI therapy.

Attitudes, expectations, and lived experiences of cancer patients receiving dendritic cell vaccine therapy in Japan

Objective

Immunotherapeutic approaches to cancer, such as dendritic cell vaccine therapy, promise to improve survival rate but may present unique challenges to patients. However, there is no research on the lived experiences of cancer patients receiving dendritic cell vaccine therapy. The aim of this study was to explore the attitudes, expectations, and experiences of cancer patients receiving dendritic cell vaccine therapy in Japan.

Methods

This was an exploratory qualitative study. A descriptive phenomenological approach was used to investigate the experiences of eight advanced-stage cancer patients (median age: 59.5 years). Data were collected between July 2018 and March 2020 using in-depth semi-structured interviews. Data were analyzed according to Colaizzi's seven-step phenomenological strategy, and EQUATOR's Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for qualitative studies were followed.

Results

Four themes emerged from the data analysis: strong concerns about chemotherapy, faith in dendritic cell vaccine therapy, motivation to succeed, and physical and mental changes. The first two themes related to pretreatment attitudes and expectations. The latter two themes expressed participants' experiences during and after therapy.

Conclusions

Dendritic cell vaccine therapy patients expressed fears about the effects of standard treatment, and hope and uncertainty regarding immunotherapy treatment decisions and efficacy. The findings suggest that such patients require nursing care that includes prevention and reduction of chemotherapy side effects, careful observation of patients' well-being, management of patients' expectations and uncertainty, formation of patient-health care practitioner partnerships, and team medicine.

A qualitative study on the healthcare experiences of adolescents and young adults (AYA) with an uncertain or poor cancer prognosis

PURPOSE

Treatment advancements have improved life expectancy for adolescents and young adults (AYAs) with an uncertain and/or poor cancer prognosis (UPCP) and change clinical practice. This improved survival requires a different approach and specific expertise to meet the needs of this group. The aim of this study is to explore the health care experiences of AYAs with a UPCP.

METHODS

We conducted a multicenter qualitative study using semi-structured interviews and elements of the grounded theory by Corbin and Strauss.

RESULTS

Interviews were conducted with 46 AYAs with a UPCP. They were on average 33.4 years old (age range 23-44), and most of them were woman (63%). Additionally, five AYAs with a UPCP participated as AYA research partners in two focus groups. They were on average 31.8 years old and four of them were woman. AYAs with a UPCP reported four pillars for a satisfied healthcare experience: (1) trust, (2) tailored communication, (3) holistic empathic open attitude, and (4) care being offered (pro-)actively. They reported both optimal and suboptimal experiences about distrust based on a delay in diagnostic trajectory, lack of tailored communication and discussion of sensitive topics, preference for a holistic approach, and struggles with finding the way to get additional healthcare support.

CONCLUSION

For AYAs with a UPCP, it is important that both age-specific issues and issues related to the UPCP are understood and addressed; however, this seems not yet optimally implemented in clinical practice. This emphasizes the importance of providing this patient group with tailored care incorporating both aspects. Healthcare professionals need to be supported with training and tools to understand the healthcare needs of AYAs with a UPCP. AYAs can be empowered to take more control over their own healthcare needs.

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.