A comparative descriptive study examining the perceptions of cancer patients, family caregivers, and nurses on patient symptom severity in Turkey

Cancer symptoms: do patients, family caregivers and professionals agree?

OBJECTIVES

To assess the level of agreement among patients, their family caregivers and health professionals regarding the symptoms presented by patients with cancer.

METHODS

This is a cross-sectional study carried out in patients with cancer admitted to a hospital in Brazil from December 2019 to July 2020. One family caregiver for each patient was included in the study. In addition, nurses and physicians involved in patient care were included. Patients, family caregivers and health professionals responded to the Palliative Outcome Scale (POS).

RESULTS

Sixty-one patients with their family caregivers, 18 nurses and 8 physicians were included. Physicians reported a lower mean POS score than patients (p=0.008). In general, physicians and nurses underestimated the anxiety of the patient and the anxiety of the family caregivers and how much the patient feels that his or her life is worthwhile. Intraclass correlation coefficient showed moderate and good levels of agreement between patients' and family caregivers' responses (0.61). Agreement between patient and nurse (0.02) and physician (0.21) responses was poor.

CONCLUSIONS

The level of agreement between patients and healthcare professionals was very poor regarding patients' symptoms. However, the caregiver's perception of the patient's symptoms can be a reliable source of information.

The potential impact of proxy reports for symptom experience and care quality and experience in advanced cancer

OBJECTIVES

As the US tests models of care for the seriously ill, patient perceptions of the quality of care are important. Proxies are often needed for this group. We sought to understand the potential impact of proxy reports for the assessment of care quality and experience in cancer.

METHODS

Secondary data analysis of a deidentified prospective study that included surveys of perceived care quality, including symptom management, from patients with advanced cancer receiving chemotherapy and their caregivers. Surveys were administered at diagnosis (time 1) and treatment (time 2), with top-box scoring used for analysis. Overall concordance was assessed using metrics including Gwet's AC1. The proportion of the highest scores by respondent type within 2 subgroups were examined: (1) symptom burden and (2) practice setting.

RESULTS

Data from 83 dyads were analyzed. Proxies and patients frequently reported the highest scores for quality (time 1: proxies: 77% and patients: 80%). At time 1, 14% of proxies and 10% of patients reported an unmet need for symptom palliation. Most patients reporting an unmet need gave the top score for quality (75%), but fewer proxies did so (45%). Proxy and patient reports were similar within practice settings. Concordance was at least moderate (nearly all outcomes >0.5 and some >0.8) by Gwet's AC1.

SIGNIFICANCE OF RESULTS

Findings of at least moderate concordance and similar experience outcomes within subgroups suggest the use of proxies may not change estimates substantially. However, consideration should be taken when evaluating symptom management, particularly if such evaluations inform assessment of provider performance.

Patient-Proxy Agreement Regarding Health-Related Quality of Life in Survivors with Lymphoma: A Propensity-Score Matching Analysis

Objective: To assess the difference between lymphoma survivors' self- and proxy-reported health-related quality of life (HRQoL) and its association with socioeconomic and health statuses. Methods: The data used in this study were obtained from a nationwide cross-sectional online survey in 2019. Information about participants' demographics, health status and HRQoL were collected. The propensity-score matching (PSM) method was used to control the effect of potential confounders on selection bias. A chi-squared test, one-way analysis of variance, and multiple linear regression models were used to assess the relationship between HRQoL and response type adjusted to respondents' background characteristics. Results: Out of the total 4400 participants, data of 2350 ones were elicited for analysis after PSM process. Patients' self-reported outcomes indicated a slightly better physical, role and emotional functioning than proxy-reported outcomes. Regression analysis showed that patients, who were older, unemployed, and who received surgery, were more likely to report a lower HRQoL. Further analysis demonstrated that proxy-reported patients who had completed treatment were more likely to report a higher HRQoL than those who were being treated. Conclusions: Our study demonstrates that the agreement between self- and proxy-reported HRQoL is low in patients with lymphoma and the heterogeneities of HRQoL among patients with different types of aggressive NHL (Non-Hodgkin's lymphoma) is large. Differences in self- and proxy-reported HRQoL should be considered by oncologists when selecting and deciding the optimal care plan for lymphoma survivors.

Care Burden and Quality of Life in Family Caregivers of Palliative Care Patients

This research was conducted for the purpose of examining the care burden and quality of life in family caregivers of palliative care patients. The research design was a descriptive correlational study conducted with the caregivers of 163 patients residing in palliative care units. Data were collected via a demographic survey, The Zarit Burden Interview (ZBI) and the World Health Organization Quality of Life Assessment (WHOQOL). The results showed that there was a negative correlation between ZBI and WHOQOL scores. Further, there was a significant negative correlation between many subdimensions of the ZBI (general quality of life, general perception of health, being satisfied with daily life skills, home conditions, energy and self-satisfaction) and the WHOQOL. Quality of life thus appeared to be reduced in family members with a high level of care burden and that the quality of life of caregivers depends on the individual characteristics of the caregiver. Social workers, nurses and physicians should regularly assess the burden and quality of life of caregivers.

Validation of an instrument to assess informal caregivers' perceptions about the delivery of patient-centred care to people with intellectual disabilities in residential settings

Background

Validated instruments are needed to assess the delivery of patient-centred care (PCC) to people with intellectual disabilities (PWIDs) needing 24-h care in residential settings. Eight dimensions of PCC have been identified: taking patients’ preferences into account; access to care; emotional support; physical comfort; information and education; involvement of family and friends; coordination of care; and continuity and secure transition. Objective of this study is to validate an instrument to assess these eight PCC dimensions among informal caregivers of PWIDs in residential settings (institutional settings as well as group homes in the community). The original 24-item instrument was developed and validated among professionals providing care to PWIDs.

Methods

This study was conducted in a disability care centre in the Netherlands. All informal caregivers of PWIDs living in institutional settings or group homes in the community in need of 24-h care were invited to participate (n = 941). The response rate was 31% (n = 289). We tested the instrument using structural equation modelling, and examined its validity and reliability.

Results

Confirmatory factor analyses revealed good indices of fit and overall internal consistency, as represented by Cronbach’s alpha values. All eight dimensions of PCC were related positively to satisfaction with care (all p ≤ 0.001). As expected, informal caregivers were less critical of PCC and its underlying dimensions, except for information and education, than were professionals working in the same disability care centre.

Conclusions

The psychometric properties of the 24-item PCC instrument for informal caregivers (PCC-IC) were satisfactory, indicating that the PCC-IC is valid and reliable for the assessment of the eight dimensions of PCC among informal caregivers of PWIDs in residential settings.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4358-9) contains supplementary material, which is available to authorized users.

Parents and Physiotherapists Recognition of Non-Verbal Communication of Pain in Individuals with Cerebral Palsy

Pain assessment is difficult in individuals with cerebral palsy (CP). This is of particular relevance in children with communication difficulties, when non-verbal pain behaviors could be essential for appropriate pain recognition. Parents are considered good proxies in the recognition of pain in their children; however, health professionals also need a good understanding of their patients' pain experience. This study aims at analyzing the agreement between parents' and physiotherapists' assessments of verbal and non-verbal pain behaviors in individuals with CP. A written survey about pain characteristics and non-verbal pain expression of 96 persons with CP (45 classified as communicative, and 51 as non-communicative individuals) was performed. Parents and physiotherapists displayed a high agreement in their estimations of the presence of chronic pain, healthcare seeking, pain intensity and pain interference, as well as in non-verbal pain behaviors. Physiotherapists and parents can recognize pain behaviors in individuals with CP regardless of communication disabilities.

A modified Edmonton Symptom Assessment Scale for symptom clusters in radiation oncology patients

Patient‐reported outcomes regarding symptom burden may provide valuable information in addition to physician assessment. Systematic collection of patient‐reported outcomes may be an important metric to identify unmet needs and improve quality of patient care. To understand common symptoms of patients seen in radiation oncology clinic, we examined the prospectively collected modified Edmonton Symptom Assessment Scale (ESAS‐r) data to explore symptom clusters. Our clinic established use of a modified Edmonton Symptom Assessment Scale in August 2015. All outpatients presenting for radiation oncology services completed the form at each clinic visit. Symptom clusters are defined by two or more symptoms that are interrelated and occur simultaneously with a high degree of predictability. A sample of 916 de‐identified surveys was assessed statistically using principal component analysis (PCA) with varimax rotation to determine independent clustering between the symptoms queried. We found four major clusters of symptoms: Tiredness (tired, drowsiness; PC1), Loss of Appetite (nausea, lack of appetite; PC2), Low Well‐Being (overall & spiritual well‐being; PC3), and Depression (depression, anxiety; PC4). These accounted for 46%, 9.2%, 7.6%, and 7% of total variance, respectively. Internal consistency using Cronbach's alpha was 0.87, 0.7, 0.82, and 0.87, respectively. The most frequent write‐in item was itchiness, present in 24% of the 148 patients responding. Assessment of patients seen in a large radiation oncology clinic revealed several symptom clusters. {Tiredness and drowsiness} represents a major symptom cluster. Itchiness may be underrecognized.

Symptom clusters during palliative chemotherapy and their influence on functioning and quality of life

INTRODUCTION

Symptom management in patients undergoing palliative chemotherapy is challenging, as patients may suffer from cancer symptoms as well as symptoms related to chemotherapy. Symptom clusters are interrelated symptoms occurring simultaneously that exert a negative impact on survival. Identification of symptom clusters and effective symptom management for patients receiving palliative chemotherapy is crucial.

OBJECTIVES

The purpose of this study was to identify symptom clusters among cancer patients undergoing palliative chemotherapy and examine the relationship between symptom clusters and functioning and quality of life (QOL) in these patients.

METHODS

A total of 300 patients undergoing palliative chemotherapy participated in the study. Symptom experience during previous palliative chemotherapy was evaluated using a symptom questionnaire including 20 symptoms. The European Organization for Research and Treatment of Cancer Quality of Life-C30 was used to measure patients' symptoms, functioning and QOL. Factor and hierarchical cluster analyses were performed to identify symptom clusters. Structural equation modeling was used to identify relationships between symptom clusters, functioning and QOL in patients.

RESULTS

Four symptoms clusters including 14 symptoms were identified of the 20 symptoms experienced by patients undergoing palliative chemotherapy. The emotional cluster had negative influence on role and social functioning. The nausea and vomiting/appetite/taste change cluster had a negative impact on role functioning. The fatigue/cognitive and other cluster (dyspnea, pain, constipation, neuropathy, and sleep disturbance) negatively influenced physical functioning. Among the functioning subscales, only role functioning had a direct influence on QOL. Indirect relationships between symptom clusters and QOL were mediated by physical and role functioning. The final model, which consisted of four symptom clusters and three functioning subscales, accounted for 23.3% of the variance in the QOL.

CONCLUSIONS

Four symptom clusters occurring during palliative chemotherapy demonstrated negative influences on functioning and QOL. Differential contributions of symptom clusters to functioning were identified that eventually contributed to QOL through role functioning. The identified symptom clusters and their relationships with functioning and QOL may help guide approaches to symptom management. Implementation of interventions targeting symptom clusters would contribute to improving functioning and QOL in patients.

Impact of neurocognitive deficits on patient-proxy agreement regarding health-related quality of life in low-grade glioma patients

PURPOSE

Clinical trials in glioma patients with neurocognitive deficits face challenges due to lacking or unreliable patient self-reports on their health-related quality of life (HRQOL). Patient-proxy data could help solve this issue. We determined whether patient-proxy concordance levels were affected by patients' neurocognitive functioning.

METHODS

Patient and patient-by-proxy HRQOL ratings were assessed via SF-36 and EORTC QLQ-BN20, respectively, in 246 patients. Data on neurocognitive functioning were collected on a subgroup of 195 patients. Patient-proxy agreement was measured using the Bland-Altman limit of agreement, the mean difference, the concordance correlation coefficient (CCC), and the percentage difference (PD, ±0, 5, or 10 points). We defined patients to be cognitively impaired (n = 66) or cognitively intact (n = 129) based on their neurocognitive performance.

RESULTS

Patients rated their physical function and general health to be better than their proxies did, while at the same time, patients reported more visual disorders, communication deficits, itchy skin, and problems with bladder control. The cognitively impaired subgroup reported poorer physical functioning, more visual disorders, headaches, itchy skin, and issues with bladder control. In the cognitively intact group, no statistical significant differences were observed between patients and proxies. Not surprisingly, Bland-Altman plots revealed a high agreement between the patient and patient-by-proxy rating in all HRQOL domains ranging from 95 to 99 %. The CCC was fairly high in all HRQOL domains (0.37-0.80), and the percentage of perfect agreement (PD ± 0) ranged from 8.5 to 76.8 %. In the cognitively impaired patients, the mean difference between patients and proxies was overall larger, and accordingly, agreement based on Bland-Altman plots was lower.

CONCLUSIONS

The level of agreement between patient and patient-by-proxy ratings of low-grade glioma patients' HRQOL is generally high. However, patient-proxy agreement is lower in patients with neurocognitive deficits than in patients without neurocognitive deficits.

Psychological distress and loneliness in caregiver of advanced oncological inpatients

The objective of this study is to compare and examine the relationships between levels of loneliness, anxiety, depression, and other variables on primary caregivers and cancer inpatients. The study involved 100 Turkish primary caregivers of inpatients with advanced or terminal stages of cancer. Loneliness and anxiety scores were significantly higher for the primary caregivers of inpatients with terminal stage of cancer than primary caregivers of inpatients with advanced stage of cancer. Excluding the cancer stage, loneliness and anxiety were primarily associated with the socio-demographic factors of primary caregivers rather than the characteristics of patients.

Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis

CONTEXT

Cancer pain has a severe impact on quality of life and is associated with numerous psychosocial responses. Recent studies suggest that treatment of cancer pain has improved during the last decade.

OBJECTIVES

The aim of this review was to examine the present status of pain prevalence and pain severity in patients with cancer.

METHODS

A systematic search of the literature published between September 2005 and January 2014 was performed using the databases PubMed, Medline, Embase, CINAHL, and Cochrane. Articles in English or Dutch that reported on the prevalence of cancer pain in an adult population were included. Titles and abstracts were screened by two authors independently, after which full texts were evaluated and assessed on methodological quality. Study details and pain characteristics were extracted from the articles with adequate study quality. Prevalence rates were pooled with meta-analysis; meta-regression was performed to explore determinants of pain prevalence.

RESULTS

Of 4117 titles, 122 studies were selected for the meta-analyses on pain (117 studies, n = 63,533) and pain severity (52 studies, n = 32,261). Pain prevalence rates were 39.3% after curative treatment; 55.0% during anticancer treatment; and 66.4% in advanced, metastatic, or terminal disease. Moderate to severe pain (numerical rating scale score ≥5) was reported by 38.0% of all patients.

CONCLUSION

Despite increased attention on assessment and management, pain continues to be a prevalent symptom in patients with cancer. In the upcoming decade, we need to overcome barriers toward effective pain treatment and develop and implement interventions to optimally manage pain in patients with cancer.

Cancer Care Professionals' Attitudes Toward Systematic Standardized Symptom Assessment and the Edmonton Symptom Assessment System After Large-Scale Population-Based Implementation in Ontario, Canada

CONTEXT

Cancer patients experience a high symptom burden throughout their illness. Despite this, patients' symptoms and needs are often not adequately screened for, assessed, and managed.

OBJECTIVES

This study investigated the attitudes of cancer care professionals toward standardized systematic symptom assessment and the Edmonton Symptom Assessment System (ESAS) and their self-reported use of the instrument in daily practice in a large healthcare jurisdiction where this is routine.

METHODS

A 21-item electronic survey, eliciting both closed and open-ended anonymous responses, was distributed to all 2806 cancer care professionals from four major provider groups: physicians, nurses, radiotherapists, and psychosocial oncology (PSO) staff at the 14 Regional Cancer Centres across Ontario, Canada.

RESULTS

A total of 1065 questionnaires were returned (response rate: 38%); 960 were eligible for analysis. Most respondents (88%) considered symptom management to be within their scope of practice. Sixty-six percent of physicians considered the use of standardized tools to screen for symptoms as "best practice," compared to 81% and 93% of nurses and PSO staff, respectively. Sixty-seven percent of physicians and 85% of nurses found the ESAS to be a useful starting point to assess patients' symptoms. Seventy-nine percent of physicians looked at their patient's ESAS scores at visits either "always" or "often," compared to 29%, 66%, and 89% of radiotherapists, PSO staff, and nurses, respectively. Several areas for improvement of ESAS use and symptom screening were identified.

CONCLUSION

Findings show significant albeit variable uptake across disciplines in the use of the ESAS since program initiation. Several barriers to using the ESAS in daily practice were identified. These need to be addressed.

Healthcare providers' accuracy in assessing patients' pain: A systematic review

OBJECTIVE

Healthcare providers satisfy an important role in providing appropriate care in the prevention and management of acute and chronic pain, highlighting the importance of providers' abilities to accurately assess patients' pain. We systematically reviewed the literature on healthcare providers' pain assessment accuracy.

METHODS

A systematic literature search was conducted in PubMed and PsycINFO to identify studies addressing providers' pain assessment accuracy, or studies that compared patients' self-report of pain with providers' assessment of pain.

RESULTS

60 studies met the inclusion criteria. Healthcare providers had moderate to good pain assessment accuracy. Physicians and nurses showed similar pain assessment accuracy. Differences in pain assessment accuracy were found according to providers' clinical experience, the timing of the pain assessment, vulnerable patient populations and patients' pain intensity.

CONCLUSION

Education and training aimed at improving providers with poor pain assessment accuracy is discussed especially in relation to those with limited clinical experience (<4 years) or a great deal of clinical experience (>10 years) and those providing care for vulnerable patient populations.

PRACTICE IMPLICATIONS

More research on characteristics that influence providers' pain assessment accuracy and trainings to improve pain assessment accuracy in medical and continuing education may improve pain treatment for patients.

Social support and quality of life in Turkish patients with gynecologic cancer

The aim of this study was to determine the level of social support and quality of life in Turkish patients with gynecologic cancer using a cross-sectional survey design. A total of 108 patients admitted to the gynecologic oncology clinic at a university hospital from September 2011 to January 2012 were included. Data were collected using patient information forms, the Multidimensional Scale of Perceived Social Support (MSPSS) and The Quality of Life-Cancer Survivors Instrument (QOL-CS). Average age was 54.5±10.8 years and it was determined that 65.7% of patients had ovarian cancer and 19.4% had cervical cancer. The total QOL-CS mean score was 5.59±1.10. Average score of total MSPSS was found to be 69.7±14.64. Comparing socio-demographic and clinical characteristics of patients and average scores of QOL-CS and MSPSS, it was found that there was not a statisticaly significant corelation (p>0.05). Statistically significant relation was found between the average scores of QOL-CS and MSPSS. These results showed that quality of life was moderate and perceived social support was high in Turkish patients with gynecologic cancer.

Assessing Health-Related Quality of Life in the Greek Home Health Care Setting

The study’s aim was to evaluate the agreement between patients’ and nurses’ ratings of patients’ health-related quality of life (HRQoL) and to identify factors that affect their level of agreement. A total of 150 home health care cancer patients from Greece and all nurses ( N = 5) who worked in the home health care units completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire–Core 30 (EORTC QLQ-C30). Intraclass correlation coefficients varied between .45 and .87, indicating a moderate to excellent agreement. Median absolute difference on QLQ-C30 scores ranged from 0.00 to 16.66 points on the 0 to 100 scale. Cohen’s d varied between −0.15 and 0.59. Nurses’ higher educational level was associated with greater agreement ( p = .05). Nurses assessed lower the QoL of patients who were completely disabled than the patients themselves did ( p = .005). Our findings suggest that Greek home health care nurses estimate patients’ QoL in a reliable and valid way.

Quality of life during chemotherapy and satisfaction with nursing care in Turkish breast cancer patients

This descriptive cross-sectional study aimed to evaluate quality of life for breast cancer patients (n = 105) undergoing chemotherapy, and to assess their satisfaction with nursing care. It also explored relationships between quality of life, satisfaction with nursing care, and demographic and disease-related characteristics. Ethics approval for this study was provided. The research was carried out between October 2011 and June 2012. Quality of life and satisfaction with nursing care were assessed using the Functional Assessment of Cancer Therapy-General Scale, the Memorial Symptom Assessment Scale and the Newcastle Satisfaction with Nursing Scale. We found that emotional well-being was the area most negatively affected, with patients reporting being afraid of death, feeling sad and being worried about their health. Patients were overall quite satisfied with the nursing care they received at the hospital. We found a positive correlation between total scores on the Newcastle Satisfaction with Nursing Scale and social and family well-being scores. Breast cancer patients have fears and concerns about their health and need support during chemotherapy for coping with negative changes in their emotional well-being, physical and functional well-being.

Botulinum toxin injection and phenol nerve block for reduction of end-of-life pain

BACKGROUND

Injectable antispasticity agents have been utilized for the reduction of pain. However, there are no reports of its use for end-of-life pain.

PATIENT CASE

A 62-year-old female with a history of progressive left frontotemporal glioblastoma status post gross total resection, radiation, and chemotherapy presented to the physical medicine and rehabilitation (PM&R) clinic for management of spastic quadriplegia and pain. At the time of presentation to the PM&R clinic she was no longer eligible for further cancer treatment. The patient had been declining neurologically with cognitive changes, weakness, and increasing spasticity. The patient had an Edmonton Symptom Assessment Scale (ESAS) pain score of 8/10 at her visit, as reported by her husband. She exhibited mild to moderate spasticity during the exam. Cognitively, she was unable to follow commands and would fluctuate between being awake for a few minutes and sleeping during the exam. She was not on any oral muscle relaxants and none were started due to her state of hypoarousal. Nine days after the initial consultation she received 700 units of onabotulinum toxin into her bilateral upper limbs and left thigh and a phenol nerve block to her left tibial nerve. At a follow-up visit 28 days later in the palliative care clinic, the ESAS pain score was 0. The patient died 51 days post-injection.

CONCLUSION

The case report demonstrates the use of injectable antispasticity agents in the reduction of end-of-life pain in a glioblastoma patient.