Quality of life among long-term survivors of non-Hodgkin lymphoma: a follow-up study

Impairment of vocational activities and financial problems are frequent among German blood cancer survivors

Little is known about changes in the personal living conditions of long-term blood cancer survivors in Germany. To gather information about social relationships, work life, overall well-being, and religion, we performed a questionnaire-based retrospective study on 1551 survivors who had been on follow-up for ≥ 3 years (median, 9 years). Most survivors reported that marital status and relationships with relatives and friends remained constant before and after blood cancer. Vocational activities were temporarily impaired for 47.5%, with a median time of 11 months to return to work. More than a third of the patients (35.6%) discontinued work permanently, with disability and retirement pension rates of 7.9% and 38.1%, respectively, at the time of the survey. Financial problems due to reduced income were reported by 26.2%, in particular after relapse or allogeneic transplantation. Patient reports addressing their quality of life showed large variations. It was best in acute leukemia survivors without a history of allogeneic transplantation and worst in patients with myeloproliferative disorders. Religion tended to become more important after blood cancer. In conclusion, vocational impairment and financial problems are frequent among German blood cancer survivors. Efforts should be made at an early stage to reestablish the patients' ability to work.

The relationship between loneliness, psychological resilience, quality of life and taste change in cancer patients receiving chemotherapy

PURPOSE

This study aimed to determine the correlation between taste change, nutritional intake and quality of life in cancer patients receiving chemotherapy. A total of 610 (F = 314, M = 296) volunteers aged 19 and 65 who received outpatient chemotherapy treatment participated in the study.

METHODS

Individuals' general information was obtained, anthropometric measurements were carried out, malnutrition status (Patient-Generated Subjective Global Assessment PG-SGA), loneliness (Cancer Loneliness Scale), psychological resilience (Psychological Resilience Scale), quality of life (Quality of Life Scale (EORT QLQ-C30) and taste changes were scrutinized [Chemotherapy-Induced Taste Alteration Scale (CiTAS)].

RESULTS

There was a negative correlation between the Cancer Loneliness Scale and PG-SGA and General Health Status (r = -0.494, p = 0.000; r = -0.406, p = 0.000) and a positive correlation with Symptom Scales (r = 0.484, p = 0.000; r = 0.506, p = 0.000) (p < 0.05). There was a positive correlation between the Psychological Resilience Scale and General Health Status (r = 0.393, P = 0.000), Functional Scales (r = 0.349, P = 0.000), and a negative correlation between Symptom Scales (r = -0.302, p = 0.000) (p < 0.05). 70.9% of men and 70.7% of women had severe malnutrition. General Taste Changes, General Health and Symptom Scale values were significant predictors of severe malnutrition status (p < 0.05).

CONCLUSION

The symptoms that develop during the treatment process cause many psychological problems. Before starting treatment, patients should be evaluated comprehensively, depression anxiety levels and quality of life levels should be determined, and precautions should be taken accordingly.

Experiences of and preferences for self-management among low grade non-Hodgkin's lymphoma survivors: A qualitative interview study

PURPOSE

Supporting self-management is one strategy to help cancer survivors optimise their quality of life. Low grade non-Hodgkin's lymphoma is often incurable with a chronic disease trajectory requiring lifelong self-management. This study explored the views on self-management and preferences for self-management support among survivors of low grade non-Hodgkin's lymphoma and their informal caregivers more than 6 months after completion of systemic anti-cancer therapy.

METHOD

In-depth semi-structured telephone interviews were conducted. Key themes and subthemes were determined using inductive and deductive thematic analysis.

RESULTS

The sample included eight survivors of low grade non-Hodgkin's lymphoma and two family caregivers. There were four themes. 1) The chronic nature of low grade non-Hodgkin's lymphoma shapes perceptions of self-management; participants described their cancer as a chronic condition and self-management strategies reflected this. 2) Social networks enable self-management; participants emphasised the importance of making low grade non-Hodgkin's lymphoma survivors aware of social networks. 3) Support and monitoring are needed immediately after the initial treatment phase ends. 4) Preferred components of self-management support; this included regular review with monitoring, advice on diet, and strategies to manage the psychosocial consequences of low grade non-Hodgkin's lymphoma.

CONCLUSIONS

Providing self-management support to those diagnosed with low grade non-Hodgkin's lymphoma is relevant given the chronic trajectory of the disease. Findings suggest that necessary components of a self-management support programme for those with low grade non-Hodgkin's lymphoma should include regular review with monitoring and practical support around facilitating engagement with social networks.

Incremental health care expenditures for non-Hodgkin lymphoma in comparison with other cancers: Analysis of national survey data

BACKGROUND: Non-Hodgkin lymphoma (NHL) is among the most common cancers in the United States, with an estimated annual incidence of more than 80,000 and a high survival rate. However, limited national data exist regarding the health care burden of NHL. OBJECTIVE: To evaluate the incremental health care expenditures among patients with NHL using the Medical Expenditure Panel Survey (MEPS) data compared with patients with other cancers. METHODS: This observational cross-sectional study included all patients with NHL (≥ 18 years) and all individuals diagnosed with other cancers from the MEPS 2014-2019. The components of health care expenditures included hospital inpatient care, office-based visits, outpatient care, emergency department, prescription medications, dental, home health, and other expenditures. Patients with NHL and those diagnosed with other cancers were identified from the full-year consolidated MEPS Household Component 2014-2019. Descriptive weighted analysis was used to compare the health care expenditure components between individuals with NHL and all other cancers. A 2-part model using probit and generalized linear models with a log link function was used to estimate the incremental increase in total health care expenditures for NHL compared with all other cancers. RESULTS: According to the MEPS, there were 0.74 million patients with NHL (95% CI = 0.62-0.86) and 27.91 million patients with other cancers (95% CI = 26.69-29.13) annually. Most of the patients with NHL were White (78.36%), male (60.67%), and older than 65 years (45.8%). The unadjusted analysis indicated a total annual expenditure of $21,698 (95% CI = $16,752-$26,645) for NHL, which was significantly higher than the annual expenditure for patients with other cancers ($15,029 [95% CI = $14,476-$15,582]). Most of the total health expenditure of both the NHL group and the other cancers group was distributed in 3 categories of hospital inpatient care (29.15% vs 26.29%), office-based visits (28.10% vs 25.08%), and prescription medications (19.03% vs 22.57%). Based on the 2-part model adjusted for all covariates, the annual health care expenditure for NHL was $7,284 (95% CI = $1,432-$13,135), higher than the expenditure of patients diagnosed with all other cancers. Among the health care expenditure components, the office-based visits were $2,641 higher for patients with NHL compared with the other cancers group (95% CI = $1,129-$4,153). CONCLUSIONS: The economic burden of NHL is higher compared with other cancers. Most of the NHL expenditures were attributable to hospital inpatient services and office-based visits. The study findings can inform value-based care considerations because of a better understanding of utilization and care patterns for NHL. DISCLOSURES: Dr Aparasu has received research funding from Astellas Inc., Incyte Corp., Gilead, and Novartis Inc. for projects unrelated to the current work. The other authors declare no conflicts of interest for this article. We confirm that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere.

Factors associated with long-term functional and psychosocial outcomes in patients with non-Hodgkin lymphoma

OBJECTIVE

To assess the long-term functional, psychosocial and participation outcomes in an Australian cohort of non-Hodgkin lymphoma (NHL) survivors.

METHODS

A cross-sectional sample of adult NHL survivors at the Peter MacCallum Cancer Centre (between 2015 and 2020), participated by completing validated questionnaires. A series of analyses described their current level of function, psychosocial well-being, and participation.

RESULTS

Of 129 participants (mean (M) ± standard deviation (SD) age: 62.5 ± 8.8 years), the majority (58%) had aggressive NHL and grade III-IV (72%), with time since diagnosis of 4.6 ± 1.2 years. Participants reported ongoing issues after completion of treatment: fatigue (63%), bladder dysfunction (61%), cognitive impairment (53%), and NHL-related pain (46%). Most made good functional recovery (M ± SD) (Functional Independent Measure-Motor: 79.5 ± 8.2), reported minimal change in their negative emotional states, and NHL-specific quality of life (QoL) (Functional Assessment of Cancer Therapy-Lymphoma: 133.5 ± 22.1). Participants were "well" adjusted to community living (Community Integration Measure: 42.2 ± 7.4) and satisfied with their current life (Satisfaction with Life Scale: 26.3 ± 6.0). Factors significantly associated with the poorer current level of function were: age at diagnosis < 60 years, time since NHL diagnosis > 4.5 years, and aggressive NHL type.

CONCLUSION

Despite good functional recovery and adjustment in the community, NHL survivors report the presence of ongoing residual impairments and cognitive issues, which requires long-term rehabilitation-inclusive management.

Long-Term Health-Related Quality of Life of Autologous Hematopoietic Cell Transplantation Patients and Nontransplant Patients With Aggressive Lymphoma: A Prospective Cohort Analysis

PURPOSE

This study assessed the long-term quality of life (QOL) of patients with aggressive lymphoma subtypes treated with autologous hematopoietic cell transplant (autoHCT) compared with those without history of transplant.

METHODS

Patient-reported QOL measures were prospectively gathered from patients enrolled in the Iowa/Mayo Specialized Program of Research Excellence Molecular Epidemiology Resource cohort with aggressive lymphoma subtypes. QOL was measured using the Functional Assessment of Cancer Therapy-General (FACT-G), Functional Assessment of Chronic Illness Therapy-Fatigue Scale, State-Trait Anxiety Inventory (STAI), and Profile of Mood States instruments and with a numeric rating scale for overall QOL and spiritual QOL. The autoHCT group and no HCT groups were compared at 3 years (FU3) and 6 years (FU6) after lymphoma diagnosis.

RESULTS

In total, 980 patients with lymphoma (106 autoHCT and 874 no HCT) diagnosed between 2002 and 2013 were included for analysis. The mean FACT-G total score was similar in the autoHCT and no HCT groups at FU3 (89.9 v 90.1, P = .64) and also at FU6 (91.5 v 89.6, P = .44). No differences between the autoHCT and no HCT groups were identified in the FACT subscales. The STAI identified lower anxiety in the autoHCT group by mean STAI1 (state) at FU3 (30.1 v 33.4, P < .01) and by mean STAI2 (trait) at FU6 (30.1 v 33.5, P = .02). No other clinically meaningful differences were identified between the two groups using the other QOL instruments.

CONCLUSION

Patients remaining in remission at 3 and 6 years after diagnosis had a high level of QOL with no significant differences associated with history of treatment with autoHCT.

Exploring the relationship between social support and mental health status among lymphoma survivors: Does patient-centered communication really matter? A brief report

The purpose of this study was to explore whether patient-centered communication (PCC) would partially mediate the relationship between social support and mental health status among adult survivors of non-Hodgkin's lymphoma (NHL). Methods: Secondary analysis of self-administered questionnaires mailed to 682 adults with NHL who were assumed living and had completed the baseline 2005 study (83% response rate). Adult NHL survivors (n = 566) and data were analyzed using descriptive statistics and the Sobel test. Results: PCC partially mediated the relationship between social support and three measures of mental health outcomes (SF-36 Mental Component Summary [SF36-MCS], Post-Traumatic Stress Disorder Checklist-Civilian Version [PCL-C], Impact of Cancer - Negative Impact Summary [IOCv2 NIS]). Results of the conservative Sobel test were significant (p < .01) in three mediation models. Conclusions: Future research should focus on testing interventions that target PCC and identifying additional mediators and moderators between social support and mental health outcomes among cancer survivors.

Persistent symptoms of fatigue, neuropathy and role-functioning impairment among indolent non-Hodgkin lymphoma survivors: A longitudinal PROFILES registry study

Little is known about the long-term health-related quality of life (HRQoL) and persistence of symptoms among patients with indolent non-Hodgkin lymphoma (iNHL). This large population-based longitudinal study therefore investigated the long-term HRQoL and persistence of symptoms and identified associated sociodemographic, clinical and psychological factors. Patients diagnosed between 1999 and 2014 and four or more months after diagnosis were invited to participate in a longitudinal survey. Sociodemographic and clinical data were obtained from the Netherlands Cancer Registry. The EORTC QLQ-C30 and CLL-16 were completed by 669 patients (74% response rate). Patients completed on average four questionnaires. Primary treatment was active surveillance (52%), systemic therapy (31%) or radiotherapy (13%). Respectively, 36% reported persistent fatigue, 33% persistent neuropathy and 25% persistent role-functioning impairment. This was 2-3 times higher than in the age- and sex-matched normative population. Up to 10 years after diagnosis, scores remained relatively stable without clinically relevant changes. Comorbidities, psychological distress, shorter time since diagnosis, systemic therapy, younger age, education level and having no partner were associated with worse outcomes (all ps < 0.05). Up to a third of patients with iNHL experience long-term persistent symptoms which do not improve over time. Early recognition of symptoms will help in providing tailored supportive care for those in need.

Worsening Quality of Life in Indolent Non-Hodgkin Lymphoma and Chronic Lymphocytic Leukemia Patients in Active Surveillance: A 12-Month Longitudinal Study

INTRODUCTION

Newly diagnosed indolent non-Hodgkin lymphoma and chronic lymphocytic leukemia (NHL/CLL) patients are often monitored for disease progression to delay the impact of cancer-directed therapy on patients' quality of life. However, research on quality of life in patients under active surveillance versus in cancer-directed treatment has yielded mixed results. This study examined distress and quality of life in indolent NHL/CLL patients in active surveillance or cancer-directed treatment over the first-year post-diagnosis.

PATIENTS AND METHODS

Adult patients (≥21 years) with newly diagnosed indolent NHL/CLL completed electronic self-report measure of distress and quality of life every 4 months over the course of a year for a total of 4 surveys. Fisher's exact test and t-tests were used to examine demographic and disease differences between patients receiving different treatments. Mixed-effect models were also used to compare overall differences between treatment status over time, accounting for missing values.

RESULTS

The sample consisted of 64 patients with known baseline treatment status who did not change treatments over the course of the study. Total quality of life and physical, social and functional quality of life improved over time in patients receiving cancer-directed treatment and decreased over time in patients under active surveillance. Relative to patients in active treatment, overall, social, and functional quality of life in patients under surveillance changed more slowly over time.

DISCUSSION

Active surveillance may have negative implications for patient quality of life, despite that a common goal of active surveillance is to delay the impact of treatment (e.g., appointments, toxicities) on quality of life.

Cardiovascular diseases among diffuse large B-cell lymphoma long-term survivors in Asia: a multistate model study

BACKGROUND

We modeled the clinical course of a cohort of diffuse large B-cell lymphoma (DLBCL) patients with no prior cardiovascular diseases (CVDs) using a multistate modeling framework.

PATIENTS AND METHODS

Data on 2600 patients with DLBCL diagnosed between 2000 and 2018 and had received chemotherapy with or without radiotherapy were obtained from a population-wide electronic health database of Hong Kong. We used the Markov illness-death model to quantify the impact of doxorubicin and various risk factors (therapeutic exposure, demographic, comorbidities, cardiovascular risk factors, and lifestyle factors which included smoking) on the clinical course of DLBCL (transitions into incident CVD, lymphoma death, and other causes of death).

RESULTS

A total of 613 (23.6%) and 230 (8.8%) of 2600 subjects died of lymphoma and developed incident CVD, respectively. Median follow-up was 7.0 years (interquartile range 3.8-10.8 years). Older ages [hazard ratio (HR) for >75 versus ≤60 years 1.88; 95% confidence interval (CI) 1.25-2.82 and HR for 61-75 versus ≤60 years 1.60; 95% CI 1.12-2.30], hypertension (HR 4.92; 95% CI 2.61-9.26), diabetes (HR 1.43; 95% CI 1.09-1.87), and baseline use of aspirin (HR 5.30; 95% CI 3.93-7.16) were associated with an increased risk of incident CVD. In a subgroup of anticipated higher-risk patients (aged 61-75 years, smoked, had diabetes, and received doxorubicin), we found that they remained on average 7.9 (95% CI 7.2-8.8) years in the DLBCL state and 0.1 (95% CI 0.0-0.4) years in the CVD state, if they could be followed up for 10 years. The brief time in the CVD state is consistent with the high chance of death in patients who developed CVD. Other causes of death have overtaken DLBCL-related death after about 5 years.

CONCLUSIONS

In this Asian population-based cohort, we found that incident CVDs can occur soon after DLBCL treatment and continued to occur throughout survivorship. Clinicians are advised to balance the risks and benefits of treatment choices to minimize the risk of CVD.

Underestimated Needs for Lymphoma Patients: An Assessment Issue

BACKGROUND AND AIM OF THE WORK

The aim of the current study was to explore under-considered psychosocial needs for lymphoma cancer group. A model of the role of psychosocial factors and Stressful Life Events was operationalized.

METHOD

We used Discriminant Analysis to test predictive power of the model. 103 oncological patients (gender: 42.7 % vs 49.3 % of females 55.2 ±15.6 vs 53.7±14.9) were matched with 140healthy control groups in the study. The following instruments were utilized to conduct the study: the Florence Psychiatric Interview, Hospital Anxiety Depression Scale, Multidimensional Scale of Perceived Social Support, Beck Depression Inventory I, and Sense of Mastery.

RESULTS

The model satisfied the assumption criteria and were significant (Ʌ= .665, χ2= 105.83, p< .001).

CONCLUSION

Stressful events, depression and anxiety were adequate markers of the psychological status of lymphoma patients. Our results point out the relevance of taking into account psychosocial factors in hematology.

Long-term quality of life of patients with acute promyelocytic leukemia treated with arsenic trioxide vs chemotherapy

Patients with APL treated with ATRA-ATO reported better long-term quality of life outcomes than patients treated with chemotherapy.

Late comorbidity and health problem prevalence was similar between patients with APL previously treated with ATRA-ATO or chemotherapy.

The main objective of this study was to compare the long-term health-related quality of life of patients with acute promyelocytic leukemia (APL) treated with all-trans retinoic acid (ATRA) plus arsenic trioxide (ATO) vs ATRA plus standard chemotherapy. Patients previously enrolled in the randomized controlled trial APL0406 were considered eligible for this follow-up study. The following patient-reported outcome measures were used: the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core30 (EORTC QLQ-C30), the EORTC Quality of Life Questionnaire Chemotherapy-Induced Peripheral Neuropathy 20 (QLQ-CIPN20), and the Short Form Health Survey 36 (SF-36). The prevalence of late comorbidities and health problems was also assessed. The clinical significance of differences was evaluated based on predefined thresholds. A total of 161 of 232 potentially eligible patients were analyzed, of whom 83 were treated with ATRA-ATO and 78 were treated with ATRA chemotherapy. The median time since diagnosis of the study sample was 8 years. The 2 largest clinically meaningful differences in the EORTC QLQ-C30 were observed for role functioning (Δ = 8.4; 95% confidence interval [CI], 0.5 to 16.3) and dyspnea (Δ = −8.5; 95% CI, −16.4 to −0.7), favoring patients treated with ATRA-ATO. With regard to the SF-36 results, a clinically relevant better physical component score (Δ = 4.6; 95% CI, 1.3 to 7.8) was observed in patients treated with ATRA-ATO, but this was not the case for the mental component score. The 2 groups showed similar profiles in the scores of the EORTC QLQ-CIPN20 scales and in the prevalence of late comorbidities. Overall, our findings suggest that the greater and more sustained antileukemic efficacy of ATRA-ATO is also associated with better long-term patient-reported outcomes than ATRA chemotherapy. This study was registered at www.clinicaltrials.gov as #NCT03096496.

Experiences of Young Adults With Lymphoma During the COVID-19 Pandemic

PURPOSE

To investigate the experiences of young adults with lymphoma during the COVID-19 pandemic.

PARTICIPANTS & SETTING

8 young adults with Hodgkin or non-Hodgkin lymphoma from one National Cancer Institute-designated cancer center in the northeastern United States.

METHODOLOGIC APPROACH

Secondary data analysis of a study that investigated the experiences of young adults with lymphoma during acute survivorship was used. Thematic analysis was chosen for the secondary data analysis methodology.

FINDINGS

Three themes define the experiences of young adults with lymphoma during the COVID-19 pandemic.

IMPLICATIONS FOR NURSING

Nurse-led survivorship care and education of young adults with cancer may mitigate COVID-19-related anxiety and threats.

Doxorubicin and subsequent risk of cardiovascular diseases among survivors of diffuse large B-cell lymphoma in Hong Kong

Evidence regarding the dose-related impact of doxorubicin on subsequent cardiovascular diseases (CVDs) in Asian patients with diffuse large B-cell lymphoma (DLBCL) without preexisting CVDs is lacking. From a territory-wide electronic database in Hong Kong, we identified adults who were diagnosed with DLBCL and treated with chemotherapy between 2000 and 2018. We evaluated the patients for incident CVDs (including ischemic heart disease, heart failure, and cardiomyopathy). We evaluated the cause-specific cumulative incidence (csCI) of CVD with levels of doxorubicin exposure by using flexible parametric competing risk analysis and adjusting for demographics, comorbidities, therapeutic exposure, cardiovascular risk factors, and lifestyle factors. Controls were age- and sex-matched to DLBCL patients. We analyzed 2600 patients and 13 000 controls. The adjusted cause-specific hazard ratio (HR) for CVD in patients treated with >500 mg doxorubicin compared with non-doxorubicin regimens was 2.65 (95% confidence interval [CI], 1.23-5.74; P = .013). The 5-, 10-, and 15-year csCIs were 8.2%, 11.3%, and 12.8% in patients vs 3.1%, 4.4%, and 5.2% in controls, respectively. Hypertension (HR, 6.20; 95% CI, 0.79-48.44; P = .082) and use of aspirin/angiotensin-converting enzyme inhibitor/beta-blocker at baseline (HR, 2.13-4.63; P < .001 to .002) might confer a higher risk of subsequent CVDs. In this Hong Kong population-based study, doxorubicin exposure (absolute dose >500 mg), together with hypertension or baseline use of medication for cardiovascular risk factors, was found to be associated with an increase in csCIs of CVDs. Tailoring therapeutic strategies to underlying CVD risk factors and risk-adapted monitoring and follow-up of susceptible DLBCL patients are advisable.

Exploring health-related quality of life among non-Hodgkin's lymphoma survivors after completion of primary treatment: a cross-sectional study in Thailand

PURPOSES

To investigate health-related quality of life (HR-QoL) and its influencing factors among non-Hodgkin's lymphoma (NHL) survivors after completion of primary treatment.

METHODS

A cross-sectional study with 312 NHL survivors after completing primary treatment using self-reported data collected through face-to-face interviews or postal survey between May 2019 and December 2019. Sociodemographic factors, clinical characteristics, physical symptom distress, anxiety, depression, unmet supportive care needs, and adaptation (post-traumatic growth and post-traumatic stress disorder) were assessed. Data analysis included ANOVA tests to investigate HR-QoL among NHL survivors at different time points and GEE to assess predictors of HR-QoL.

RESULTS

The mean score of HR-QoL was 136.05 (SD 19.12). HR-QoL scores reported by NHL survivors in phase I (6 months or less post-treatment) were significantly lower than those in phase II (> 6 months-4 years), phase III (> 4-9 years), and phase IV (over 9 years post-treatment). Regarding HR-QoL domains, NHL survivors in phase I had significantly lower physical well-being and functional well-being scores than those in phases II, III, and IV; and significantly lower lymphoma domain score than those in phase III. GEE analysis showed that physical symptom distress, anxiety, depression, unmet supportive care needs, poor adaptation, and receiving chemotherapy disrupted HR-QoL (all P < .001).

CONCLUSIONS

Healthcare providers should re-prioritize intervention guidelines and survivorship care planning to promote HR-QoL among NHL survivors, particularly in phase I, through reducing physical and psychological symptom distress, addressing unmet needs, and enhancing adaptation outcomes.

A Meta-Ethnography of the Experiences of Adults with Lymphoma During Acute and Chronic Survivorship

OBJECTIVES

The acute and chronic phases of cancer survivorship are the periods of treatment, post-treatment, and early remission. During acute and chronic survivorship, adults with lymphoma have reported both positive and negative changes in health-related quality of life. This meta-ethnography aims to appraise the experiences of adults with lymphoma at the acute and chronic survivorship phases.

DATA SOURCES

This qualitative review used the established meta-ethnography framework from Noblit and Hare and is outlined following the meta-ethnography reporting guidance (eMERGe). A systematic literature search using four unique databases was completed, including the Cumulative Index to Nursing and Allied Health Literature, PubMed, Ovid Emcare, and Clarivate Web of Science.

CONCLUSION

In total, nine research studies were included in this review. Study characteristics and sample evidence were extracted from the included studies to produce the synthesis. The review and synthesis formed three main themes and six subthemes that reflect the challenges of cancer treatment and post-treatment, the communication and support from others, and how lymphoma patients reframe and reprioritize during and following treatment.

IMPLICATIONS FOR NURSING PRACTICE

This meta-ethnography provides a comprehensive analysis of adults' experiences with lymphoma at the acute and chronic survivorship phases. Several approaches for the management and care of lymphoma patients were found in this review, including integrating patient support groups from diagnosis through post-treatment, tailored psychological health care services, personalized care and delivery pathways at post-treatment, and the promotion of strategies to cope with cancer in remission. Additional research should examine younger and older adults to discover age-related issues in lymphoma populations in addition to disparities among minority patients with lymphoma and those from low socioeconomic backgrounds.

Cancer survivorship and quality of life outcomes of adolescents and young adults with lymphoma: An integrative review

PURPOSE

Lymphoma is a common hematologic malignancy of adolescents and young adults. Cancer survivorship and quality of life are two outcomes studied to measure the types and scope of problems cancer patients experience leading to diagnosis, treatment, and long-term survivorship. This integrative literature review aims to review published literature in the adolescent and young adult lymphoma population, emphasizing cancer survivorship and quality of life outcomes.

METHODS

The integrative review framework by Whittemore and Knafl was used as the guideline for this study. A literature search of three relevant health science databases, including PubMed, the Cumulative Index to Nursing and Allied Health Literature, and Ovid Emcare, was completed.

RESULTS

Twelve publications were included in the review, including ten quantitative and two qualitative studies. The studies consisted of sample populations from the United States, England, Germany, and the Netherlands; one study was an international, Children's Oncology Group study. The included studies detailed the cancer survivorship and quality of life outcomes of young adults with lymphoma by quantitative retrospective and longitudinal analysis; two studies used descriptive qualitative and grounded theory methods. The limited qualitative and longitudinal research in adolescents and young adults with lymphoma demonstrates a gap in the lived experience of this cancer population and the adherence to long-term survivorship recommendations.

CONCLUSION

Future research in adolescents and young adults with lymphoma should employ longitudinal and qualitative designs to examine the quality of life from diagnosis through extended survivorship, and the experiences at diagnosis, treatment, post-treatment, and long-term follow up.

Disability, psychological distress and quality of life in relation to cancer diagnosis and cancer type: population-based Australian study of 22,505 cancer survivors and 244,000 people without cancer

BACKGROUND

Improved survival means that cancer is increasingly becoming a chronic disease. Understanding and improving functional outcomes are critical to optimising survivorship. We quantified physical and mental health-related outcomes in people with versus without cancer, according to cancer type.

METHODS

Questionnaire data from an Australian population-based cohort study (45 and Up Study (n = 267,153)) were linked to cancer registration data to ascertain cancer diagnoses up to enrolment. Modified Poisson regression estimated age- and sex-adjusted prevalence ratios (PRs) for adverse person-centred outcomes-severe physical functional limitations (disability), moderate/high psychological distress and fair/poor quality of life (QoL)-in participants with versus without cancer, for 13 cancer types.

RESULTS

Compared to participants without cancer (n = 244,000), cancer survivors (n = 22,505) had greater disability (20.6% versus 12.6%, respectively, PR = 1.28, 95%CI = (1.25-1.32)), psychological (22.2% versus 23.5%, 1.05 (1.02-1.08)) and poor/fair QoL (15.2% versus 10.2%; 1.28 (1.24-1.32)). The outcomes varied by cancer type, being worse for multiple myeloma (PRs versus participants without cancer for disability 3.10, 2.56-3.77; distress 1.53, 1.20-1.96; poor/fair QoL 2.40, 1.87-3.07), lung cancer (disability 2.81, 2.50-3.15; distress 1.67, 1.46-1.92; poor/fair QoL 2.53, 2.21-2.91) and non-Hodgkin's lymphoma (disability 1.56, 1.37-1.78; distress 1.20, 1.05-1.36; poor/fair QoL 1.66, 1.44-1.92) and closer to those in people without cancer for breast cancer (disability 1.23, 1.16-1.32; distress 0.95, 0.90-1.01; poor/fair QoL 1.15, 1.05-1.25), prostate cancer (disability 1.11, 1.04-1.19; distress 1.09, 1.02-1.15; poor/fair QoL 1.15, 1.08-1.23) and melanoma (disability 1.02, 0.94-1.10; distress 0.96, 0.89-1.03; poor/fair QoL 0.92, 0.83-1.01). Outcomes were worse with recent diagnosis and treatment and advanced stage. Physical disability in cancer survivors was greater in all population subgroups examined and was a major contributor to adverse distress and QoL outcomes.

CONCLUSIONS

Physical disability, distress and reduced QoL are common after cancer and vary according to cancer type suggesting priority areas for research, and care and support.

Quantifying the Effect of Financial Burden on Health-Related Quality of Life among Patients with Non-Hodgkin's Lymphomas

Simple Summary

Financial burdens result from the growing out-of-pocket costs associated with cancer care to help patients regain physical and psychological health-related quality of life (HRQoL) are dramatically intensified. The aim of our study was to assess the association of HRQoL with financial burden using both subjective and objective methods among patients with non-Hodgkin’s lymphoma (NHL) in China. A majority of the patients reported suffering moderate to high financial burdens. A significant relationship between increased financial burden and reduced HRQoL was identified. Patients tended to report a poorer HRQoL when using objective method than using subjective method to estimate financial burden. Medical professionals should involve patients and their families into the clinical decision making and provide them cost-effective plans.

Abstract

Objective: This study aimed to assess the association of health-related quality of life (HRQoL) with financial burden among patients with non-Hodgkin’s lymphoma (NHL) in China. Methods: The data used for the analyses came from a nationwide survey to investigate the health status of patients with lymphomas in China. The EQ-5D and EORTC QLQ-C30 were used to assess the patients’ HRQoL. The financial burden was calculated using both subjective and objective methods. The chi-squared test, Kruskal–Wallis one-way analysis of variance, ordinal least squared model, and Tobit regression model were used to estimate the relationship between financial burden and HRQoL. Results: Data from 1549 patients who reported living with 11 subtypes of NHL were elicited for our analysis. Approximately 60% of respondents reported suffering moderate to high financial burdens. A significant relationship between increased financial burden and reduced HRQoL scores, including the EQ-Index, physical, emotional, and social functioning, was identified. Compared with using an objective method to measure financial burden, patients with NHL indicated a poorer HRQoL when using a subjective method to measure financial burden. Conclusion: Medical professionals should select highly cost-effective treatments and ensure that patients understand the potential financial consequences of those treatments.

The association of health behaviors with quality of life in lymphoma survivors

The impact of change in health behaviors (physical activity [PA], alcohol and smoking) on quality of life (QOL) in lymphoma survivors is not well understood. We evaluated the associations of health behaviors with QOL domains at diagnosis and at 3-year follow-up (FU3) in 2805 lymphoma survivors. We report clinically significant QOL score differences, defined as scores that exceeded a minimally important difference threshold and were statistically significant. Current smoking was associated with lower QOL at baseline (p < 0.01) and at FU3 (p < 0.01). Meeting the American Cancer Society PA guidelines was associated with better functional wellbeing and overall QOL at FU3 (p < 0.01). An increase in PA from baseline to FU3 was associated with improvement in physical, functional wellbeing and overall QOL at FU3 compared to baseline (p < 0.01). Thus, QOL in lymphoma survivors is associated with their health behaviors and active interventions to promote positive lifestyle changes in lymphoma survivors are needed.

Relaxation versus exercise for improved quality of life in lymphoma survivors-a randomised controlled trial

Purpose

Lymphoma survivors experience persisting needs as a consequence of disease and treatment, which have an impact on quality of life (QoL). There is evidence supporting the use of relaxation and exercise to improve QoL, but there is no agreement on which is more beneficial. This study aims to compare a relaxation intervention versus an exercise intervention to determine which has a greater impact on QoL post-chemotherapy.

Methods

Eligible participants (n = 46) were randomised to a relaxation or exercise intervention for 12 weeks. QoL was assessed at baseline, 6 weeks and post-intervention using the European Organisation for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC QLQ-C30) questionnaire, which is a valid and reliable tool. The summary score and all EORTC domains were assessed.

Results

There was a significant difference in QoL post-intervention between groups (p = 0.029) while adjusting for baseline QoL, with the exercise group demonstrating a larger improvement. Within-group QoL significantly improved pre- to post-intervention in both the relaxation (p = 0.036) and exercise (p = 0.004) groups.

Conclusions

A self-management intervention of either exercise or relaxation can help significantly improve QoL in lymphoma survivors following chemotherapy. While exercise is preferred, a relaxation intervention would also have a beneficial impact on QoL.

Implications for Cancer Survivors

Lymphoma survivors should be routinely screened and those with decreased QoL referred for an exercise programme, or relaxation for survivors who are unable to exercise or choose not to. A home-based programme can have a significant positive impact on QoL and is a feasible and effective method in the current climate.

Trial registration number

Clinical Trials ID NCT02272751

Chronic medical conditions and late effects following non-Hodgkin lymphoma in HIV-uninfected and HIV-infected adolescents and young adults: a population-based study

Little is known about the incidence of late effects following non-Hodgkin lymphoma (NHL) among adolescent and young adult (AYA, 15-39 years) survivors. Using data from the California Cancer Registry linked to hospital discharge, we estimated the cumulative incidence of late effects at 10 years among AYAs diagnosed with NHL during 1996-2012, who survived ≥2 years. Cox proportional-hazards models were used to investigate the influence of sociodemographic and clinical factors on the occurrence of late effects. Of 4392 HIV-uninfected patients, the highest incident diseases were: endocrine (18·5%), cardiovascular (11·7%), and respiratory (5·0%), followed by secondary primary malignancy (SPM, 2·6%), renal and neurologic (2·2%), liver/pancreatic (2·0%), and avascular necrosis (1·2%). Among the 425 HIV-infected survivors, incidence was higher for all late effects, especially over threefold increased risk of SPM, compared to HIV-uninfected patients (8·1% vs. 2·6%). In multivariable models for HIV-uninfected patients, public or no health insurance (vs. private), residence in lower socioeconomic neighbourhoods (vs. higher), and receipt of a haematopoietic stem cell transplant were associated with a greater risk of most late effects. Our findings of substantial incidence of late effects among NHL AYA survivors emphasise the need for longterm follow-up and appropriate survivorship care to reduce morbidity and mortality in this vulnerable population.

Quality of Life and Impact of Cancer: Differences in Rural and Nonrural Non-Hodgkin's Lymphoma Survivors

PURPOSE

People living in rural areas experience greater health disparities than their nonrural counterparts, but little is known about the association between rural status and quality of life (QOL) in non-Hodgkin's lymphoma (NHL) survivors. We compared self-reported quality of life and impact of cancer in rural and nonrural NHL survivors.

METHODS

This study is a secondary analysis of 566 NHL cancer survivors recruited from cancer registries at 2 large academic medical centers in 1 state. Standardized measures collected information on demographics and clinical characteristics, quality of life (QOL; SF-36), and the Impact of Cancer (IOCv2). Rural residence was determined by Rural-Urban Commuting Area (RUCA) codes designated as nonmetropolitan. Multiple linear regression analysis, adjusted for demographic and clinical covariates, was used to evaluate the relationship between rural residence and QOL and impact of cancer.

FINDINGS

Among the 566 participants (83% response rate), rural residence was independently associated with lower SF-36 physical component summary scores and the physical function subscale (all P < .05). Rural residence was also associated with higher IOCv2 positive impact scores and the subscales of altruism/empathy and meaning of cancer scores in the adjusted models (all P < .05).

CONCLUSIONS

Given documented rural cancer disparities and the lack of resources in rural communities, study findings support the continued need to provide supportive care to rural cancer survivors to improve their QOL. Consistent with previous research, rural residence status is associated with increased positive impact following cancer diagnosis.

Sustained degradation of quality of life in a subgroup of lymphoma survivors: a two-year prospective survey

Background

Previous studies have suggested that lymphoma survivors commonly display altered Health-Related Quality of Life (HRQoL). Because these were predominantly cross-sectional studies, the dynamic of events as well as the factors which influence HRQoL remain to be determined.

Methods

We conducted a prospective study on a cohort of 204 Hodgkin and non-Hodgkin lymphoma survivors who remained disease-free 2 years after undergoing chemotherapy (referred to the M0-M12-M24 periods).

Results

We found that although Physical and Mental Component Scores (PCS and MCS) of HRQoL significantly improved from M0 to M24 in the vast majority of patients (favorable group), approximately 20% of patients displayed severe alterations in HRQoL (global SF-36 scores < 50) extending over the 2-year period (unfavorable group). Low M24 PCSs were associated with Post-Traumatic Stress Disorder (PTSD), depression, cardiovascular events and neuropathy. In contrast social determinants, comorbidity and infections, as well as several other parameters related to the disease or to the treatment itself were not associated with low M24 PCSs. Low M24 MCSs were associated with a low educational level, aggressive histology, infections, cardiovascular events and PTSS. However, the most predictive risk factor for low SF-36 scores at M24 was a low SF-36 score at M12. The unfavorable group also displayed a low incidence of return to work.

Conclusions

Although the HRQoL of lymphoma survivors generally improved over time, persistent and severe HRQoL alterations still affected approximately one fifth of patients, resulting in important social consequences. This specific group, which presents with identifiable risk factors, may benefit from early, targeted psycho-social support.

Cost Effectiveness of Chimeric Antigen Receptor T-Cell Therapy in Multiply Relapsed or Refractory Adult Large B-Cell Lymphoma

PURPOSE

Two anti-CD19 chimeric antigen receptor T-cell (CAR-T) therapies are approved for diffuse large B-cell lymphoma, axicabtagene ciloleucel (axi-cel) and tisagenlecleucel; each costs $373,000. We evaluated their cost effectiveness.

METHODS

We used a decision analytic Markov model informed by recent multicenter, single-arm trials to evaluate axi-cel and tisagenlecleucel in multiply relapsed/refractory, adult, diffuse large B-cell lymphoma from a US health payer perspective over a lifetime horizon. Under a range of plausible long-term effectiveness assumptions, each therapy was compared with salvage chemoimmunotherapy regimens and stem-cell transplantation. Main outcomes were undiscounted life years, discounted lifetime costs, discounted quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (3% annual discount rate). Sensitivity analyses explored uncertainty.

RESULTS

In an optimistic scenario, assuming a 40% 5-year progression-free survival (PFS), axi-cel increased life expectancy by 8.2 years at $129,000/QALY gained (95% uncertainty interval, $90,000 to $219,000). At a 30% 5-year PFS, improvements in life expectancy were more modest (6.4 years) and expensive ($159,000/QALY gained [95% uncertainty interval, $105,000 to $284,000]). In an optimistic scenario, assuming a 35% 5-year PFS, tisagenlecleucel increased life expectancy by 4.6 years at $168,000/QALY gained (95% uncertainty interval, $105,000 to $414,000/QALY). At a 25% 5-year PFS, improvements in life expectancy were smaller (3.4 years) and more expensive ($223,000/QALY gained [95% uncertainty interval, $123,000 to $1,170,000/QALY]). Administering CAR-T to all indicated patients would increase US health care costs by approximately $10 billion over 5 years. Price reductions to $250,000 and $200,000, respectively, or payment only for initial complete response (at current prices) would allow axi-cel and tisagenlecleucel to cost less than $150,000/QALY, even at 25% PFS.

CONCLUSION

At 2018 prices, it is possible that both CAR-T therapies meet a less than $150,000/QALY threshold. This depends on long-term outcomes compared with chemoimmunotherapy and stem-cell transplantation, which are uncertain. Widespread adoption would substantially increase non-Hodgkin lymphoma health care costs. Price reductions or payment for initial response would improve cost effectiveness, even with modest long-term outcomes.

Treat patient, not just the disease: holistic needs assessment for haematological cancer patients

Haematological malignancies can have devastating effects on the patients' physical, emotional, psycho-sexual, educational and economic health. With the improvement of therapies patients with these malignancies are living longer, however significant proportion these patient show poor quality of life (QoL) due to various physical and psychological consequences of the disease and the treatments. Health-related QoL (HRQoL) is multi-dimensional and temporal, relating to a state of functional, physical, psychological and social/family well-being. Compared with the general population, HRQoL of these patients is worse in most dimensions. However without routine holistic need assessment (HNA), clinicians are unlikely to identify patients with clinically significant distress. Surviving cancer is a chronic life-altering condition with several factors negatively affecting their QoL, such as psychological problems, including depression and excessive fear of recurrence, as well as social aspects, such as unemployment and social isolation. These need to be adequately understood and addressed in the healthcare of long-term survivors of haematological cancer. Applying a holistic approach to patient care has many benefits and yet, only around 25% of cancer survivors in the UK receive a holistic needs assessment. The efforts of the last decade have established the importance of ensuring access to psychosocial services for haematological cancer survivors. We need to determine the most effective practices and how best to deliver them across diverse settings. Distress, like haematological cancer, is not a single entity, and one treatment does not fit all. Psychosocialoncology needs to increase its research in comparative effectiveness.

Nurses attitudes and practices towards provision of survivorship care for people with a haematological cancer on completion of treatment

PURPOSE

The purpose of this study is to assess cancer nurses' perceptions of responsibility, confidence levels and practice in relation to survivorship care for people with a haematological malignancy on completion of treatment.

METHODS

A prospective cross-sectional survey was conducted. An online survey was distributed to members of two Australian professional bodies.

RESULTS

A total of 310 cancer nurses participated in the study, representing a response rate of 28%. The participants generally agreed that all survivorship care items were part of their role. Of the 17 survivorship care items, the three items receiving the lowest confidence scores were discussing fertility issues, discussing employment and financial issues and discussing how to identify signs of cancer recurrence. The least performed survivorship care items were discussing fertility issues, communicating survivorship care with primary healthcare team (i.e. general practitioners) and discussing sexuality issues. Older age, more years of experience, having a post-graduate qualification and working in non-metropolitan area were associated with higher levels of perception of responsibilities and confidence (p < 0.05). The top ranked barriers to survivorship care were reported to be lack of end-of-treatment consultation dedicated to survivorship care, time and an appropriate physical space for delivering care.

CONCLUSIONS

Cancer nurses perceive key aspects of survivorship care to be part of their role, however there remains variations in practice and confidence with respect to implementation of survivorship care practices.

IMPLICATIONS FOR CANCER SURVIVORS

Interventions that focus on enhancing the capability of cancer nurses and eliminating barriers identified in this study have the potential to improve quality survivorship care provision.

Health-Related Quality of Life in Non-Hodgkin Lymphoma Survivors: A Prospective Cohort Study

PURPOSE

We evaluated health-related quality of life (HRQOL) in long-term survivors of indolent and aggressive non-Hodgkin lymphoma (NHL).

Materials and Methods

TheHRQOLwas assessed by the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core 30 (EORTC QLQ-C30) at diagnosis in NHL patients between 2008 and 2011, and follow-up evaluation was conducted from June 2014 to February 2015 using EORTC QLQ-C30 and the quality of life in cancer survivors (QOL-CS) questionnaire. We used linear mixed models to compare changes in HRQOL between indolent and aggressive NHL over time.

RESULTS

The HRQOL of long-term survivors with aggressive NHL improved to the similar level of indolent NHL during the follow-up survey. However, survivors of NHL were found to fear the probability of relapse and second malignancy, and the degree of fear was not different between survivors with aggressive stage I/II or III/IV NHL (p > 0.05). Furthermore, a half of survivors reported impaired sense of psychosocial well-being regardless of aggressiveness and stage during follow-up survey. More than 65% of survivors thought they did not receive sufficient support from others, and patients who had financial difficulties at diagnosis were more frequently associated with suffering from insufficient support. Impaired physical and cognitive functioning at diagnosis was significantly associated with lack of life purpose in long-term survivors.

CONCLUSION

The HRQOL of aggressive NHL survivors improved to a similar level to that of indolent NHL. However, the majority of survivors still had fear of relapse, and psychosocial well-being remained unmet needs.

Patient-reported outcomes in hematology: is it time to focus more on them in clinical trials and hematology practice?

In less than 2 decades, major clinical advances have been made in various areas of hematologic malignancies. Clinicians and patients now frequently face challenging choices regarding various treatments that are often similar in regard to safety or clinical effectiveness; hence, medical decision making has grown in complexity. For example, several novel drugs have been developed as oral agents, introducing an additional challenge in patient management, such as ensuring an optimal adherence to therapy in order to maximize drug effectiveness. This rapidly changing scenario provides a rationale for a more systematic collection of patient-reported outcomes (PRO) in clinical research and routine care. In the former case, PRO may help to better understand overall treatment effectiveness of a new drug being tested. In the latter case, it may aid in making more informed, individualized treatment decisions in daily practice by obtaining more accurate information on the actual symptom burden experienced by the patient. In any case, evaluating PRO requires making several, and often challenging, decisions depending, for example, on the population being studied and the specific setting. Therefore, if PROs are to fulfill their potential of generating clinically meaningful data that robustly inform patient care, special attention should be given to methodological rigor. We outline the value of a more systematic and rigorous implementation of PRO assessment in the current hematology arena, by providing some real world examples of how PRO data have contributed in better understanding the value of new therapies. We also discuss practical considerations in PRO assessment in clinical research.

Validation of the Korean Version of the Quality of Life-Cancer Survivors (QOL-CS-K) Questionnaire in Lymphoma Survivors

PURPOSE

The objective of this study was to validate the Korean version of the Quality of Life-Cancer Survivors (QOL-CS-K) in a sample of lymphoma survivors.

MATERIALS AND METHODS

We conducted a cross-sectional survey of lymphoma survivors who had survived for at least 24 months since diagnosis. Participants were recruited at the outpatient clinics and at a hospital event in a tertiary hospital in Seoul, Korea. Survivors were asked to complete the QOL-CS-K and the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) questionnaires. To determine test-retest reliability, a second questionnaire was sent to participants who completed the first questionnaire adequately. Exploratory factor analysis and Pearson's correlations were used for evaluating reliability and validity of the QOL-CS-K.

RESULTS

Among 257 survivors, 245 (95.3%) completed all questionnaires and had no missing data. The mean age of study participants was 52.2 years, 54.9% were men, and the mean time since diagnosis was 4.0±1.6 years. The Cronbach's α for the overall QOL-CS-K was 0.90, and the α coefficients for each subscale ranged from 0.73 to 0.83. The test and retest reliability was 0.88. Moderate correlations were found between comparable subscales of the QOL-CS-K and subscales of the EORTC QLQ-C30 (r=0.51-0.55) except for the spiritual well-being subscale of the QOL-CS-K, which did not correlate with any of the EORTC QLQ-C30 subscales (-0.08 to 0.16).

CONCLUSION

The QOL-CS-K is a reliable and valid scale for measuring the QOL in long-term lymphoma survivors.

The REFRACT-LYMA cohort study: a French observational prospective cohort study of patients with mantle cell lymphoma

BACKGROUND

Mantle Cell Lymphoma (MCL) is often associated with progression, temporary response to therapy and a high relapse rate over time resulting in a poor long-term prognosis. Because MCL is classified as an incurable disease, therapeutic resistance is of great interest. However, knowledge about the biological mechanisms underlying resistance associated with MCL therapies and about associated predictors remains poor. The REFRACT-LYMA Cohort, a multicenter prospective cohort of patients with MCL, is set up to address this limitation. We here describe the study background, design and methods used for this cohort.

METHODS/DESIGN

The REFRACT-LYMA Cohort Study aims at including all patients (>18 years old) who are diagnosed with MCL in any stage of the disease and treated in specialized oncology centers in three public hospitals in Northwestern France. Any such patient providing a signed informed consent is included. All subjects are followed up indefinitely, until refusal to participate in the study, emigration or death. The REFRACT-LYMA follow-up is continuous and collects data on socio-economic status, medical status, MCL therapies and associated events (resistance, side effects). Participants also complete standardized quality of life (QOL) questionnaires. In addition, participants are asked to donate blood samples that will support ex vivo analysis of expression and functional assays required to uncover predictive biomarkers and companion diagnostics. If diagnostic biopsies are performed during the course of the disease, extracted biological samples are kept in a dedicated biobank.

DISCUSSION

To our knowledge, the REFRACT-LYMA Cohort Study is the first prospective cohort of patients with MCL for whom "real-life" medical, epidemiological and QOL data is repeatedly collected together with biological samples during the course of the disease. The integrative cohort at mid-term will be unique at producing a large variety of data that can be used to conceive the most effective personalized therapy for MCL patients. Additionally, the REFRACT-LYMA Cohort puts the medical care of MCL patients in a health and pharmacoeconomic perspective.

Addressing psychosocial issues in cancer survivorship: past, present and future

With a burgeoning population of cancer survivors, organizations in the USA and around the world are considering how to address the many long-term and late psychosocial effects of cancer and cancer treatment. This article reviews the changing landscape of survivorship care over the past 50 years, from the time when there were relatively few survivors to the future, when the number of cancer survivors in the USA alone is expected to reach close to 20 million. Institute of Medicine Reports, intra-organizational summits and accrediting standards that have influenced the development of survivorship care plans and programs and the roles of the Internet and smartphone applications along with oncology specialist and primary care providers are discussed.

Quality of Life is Similar between Long-term Survivors of Indolent and Aggressive Non-Hodgkin Lymphoma

Differences in quality of life (QOL) of long-term survivors of aggressive or indolent subtypes of non-Hodgkin lymphoma (NHL) have not been frequently evaluated. We assessed these differences by analyzing results of a large QOL survey of long-term NHL survivors. We hypothesized that the incurable nature of indolent NHL would relate to worse QOL in long-term survivors while the potentially cured long-term survivors of aggressive lymphoma would have better QOL. We found that QOL was similar between the two groups. Results suggest that patients with indolent NHL are coping well with their disease, yet experience some overall feelings of life threat.

Unmet needs of non-Hodgkin lymphoma survivors in Korea: prevalence, correlates, and associations with health-related quality of life

OBJECTIVE

We aimed to describe the prevalence and correlates of unmet needs among non-Hodgkin lymphoma (NHL) survivors in Korea and to identify their association with health-related quality of life (HRQOL).

METHODS

Participants were 826 NHL survivors from three hospitals in South Korea diagnosed at least 24 months prior to participating (mean, 6.3 years; range, 2.1-20.9 years). We used self-reported questionnaires, including the Need Scale for Cancer Patients Undergoing Follow-up Care (NS-C) developed in Korea and the EORTC QLQ-C30. We defined an unmet need as a moderate to high level of unmet need in the NS-C response scale.

RESULTS

Among six domains, unmet need prevalence ranged from 1.7% to 38.3%. Most commonly reported domains with unmet needs were 'treatment and prognosis' (38.3%) and 'keeping mind under control' (30.5%). The three most frequently reported individual unmet needs were 'being informed about prevention of recurrence' (50.7%), 'being informed about prevention of metastasis' (49.7%), and 'having self-confidence of overcoming cancer' (42.7%). Multivariate logistic analyses revealed that younger age, being unmarried, and low monthly income were associated with unmet needs of multiple domains. Participants with unmet needs demonstrated significantly poorer HRQOL, and the most clinically meaningful differences were found in social function and emotional function.

CONCLUSIONS

Korean NHL survivors have substantial unmet needs, especially those who are younger, unmarried, and have a lower income. Initiating supportive care programs for meeting unmet needs may enhance their HRQOL. Copyright © 2016 John Wiley & Sons, Ltd.

The impact of comorbidity on health-related quality of life in elderly patients with chronic myeloid leukemia

The primary objective of this study was to investigate whether the presence of comorbidities was associated with a lower health-related quality of life (HRQOL) in elderly patients with chronic myeloid leukemia (CML). A sample of 174 CML patients aged 60 years or above was analyzed. HRQOL was assessed with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). A number of pre-selected sociodemographic and disease-related factors were considered as potential confounding factors for the association between comorbidity and HRQOL. Mean age of the 174 patients analyzed was 70 years (range 60-87 years) and 55 % were male. Overall, 111 patients (64 %) reported at least one comorbidity. Analysis stratified by age group category showed a greater proportion of patients with comorbidities in the older sub-group population (≥70 years) compared to younger patients (60 to 69 years). Differences in HRQOL outcomes between patients with no comorbidity at all and those with two or more comorbid conditions were at least twice the magnitude of a clinically meaningful difference in all the physical and mental health scales of the SF-36. In multivariate analysis, after adjusting for key confounding factors, the following scales were significantly lower in those with comorbidity: general health (p < 0.001), bodily pain (p < 0.001), physical functioning (p = 0.002), and vitality (p = 0.002). Assessing comorbidity in elderly patients with CML is important to facilitate identification of those most in need of HRQOL improvements.

Ambulatory Medical Assistance--After Cancer (AMA-AC): A model for an early trajectory survivorship survey of lymphoma patients treated with anthracycline-based chemotherapy

Background

Cancer survivorship has emerged as an important aspect of oncology due to the possibility of physical and psychosocial complications. The purpose of this study was to assess the feasibility of the Ambulatory Medical Assistance for After Cancer (AMA-AC) procedure for monitoring lymphoma survivorship during the first year after chemotherapy.

Methods

AMA-AC is based on systematic general practitioner (GP) consultations and telephone interventions conducted by a nurse coordinator (NC) affiliated to the oncology unit, while an oncologist acts only on demand. Patients are regularly monitored for physical, psychological and social events, as well as their health-related quality of life (HRQoL). Inclusion criteria were patients newly diagnosed with non-Hodgkin or Hodgkin lymphomas, who had been treated with anthracycline-based chemotherapy and were in complete remission after treatment.

Results

All 115 patients and 113 collaborating GPs agreed to participate in the study. For patients who achieved one year of disease-free survival (n = 104) their assessments (438 in total) were fully completed. Eleven were excluded from analysis (9 relapses and 2 deaths). The most frequent complications when taking into account all grades were arthralgia (64.3 %) and infections (41.7 %). About one third of patients developed new diseases with cardiovascular complications as the most common. Psychological disorders such as anxiety, depression and post-traumatic stress disorder were diagnosed in 42.6 % of patients. The data collected showed that Hodgkin lymphoma patients, females, and patients with lower HRQoL (mental component) at study entry were at greater risk for developing at least one psychological disorder.

Conclusion

This study showed that AMA-AC is a feasible and efficient procedure for monitoring lymphoma survivorship in terms of GP and patient participation rates and adherence, and provides a high quality of operable data. Hence, the AMA-AC procedure may be transferable into clinical daily practice as an alternative to standard oncologist-based follow-up.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1815-7) contains supplementary material, which is available to authorized users.

Are lifestyle behavioral factors associated with health-related quality of life in long-term survivors of non-Hodgkin lymphoma?

BACKGROUND

The objective of the current study was to determine whether survivors of non-Hodgkin lymphoma are meeting select American Cancer Society (ACS) health-related guidelines for cancer survivors, as well as to examine relationships between these lifestyle factors and health-related quality of life (HRQoL) and posttraumatic stress (PTS).

METHODS

A cross-sectional sample of 566 survivors of NHL was identified from the tumor registries of 2 large academic medical centers. Respondents were surveyed regarding physical activity, fruit and vegetable intake, body weight, tobacco use, HRQoL using the Medical Outcomes Study Short Form-36, and PTS using the Posttraumatic Stress Disorder CheckList-Civilian form. Lifestyle cluster scores were generated based on whether individuals met health guidelines and multiple linear regression analysis was used to evaluate relationships between lifestyle behaviors and HRQoL scores and PTS scores.

RESULTS

Approximately 11% of participants met all 4 ACS health recommendations. Meeting all 4 healthy recommendations was related to better physical and mental QoL (standardized regression coefficient [β], .57 [P<.0001] and β, .47 [P = .002]) and to lower PTS scores (β, -0.41; P = .01).

CONCLUSIONS

Survivors of NHL who met more ACS health-related guidelines appeared to have better HRQoL and less PTS. Unfortunately, many survivors are not meeting these guidelines, which could impact their overall well-being and longevity.

Cancer survivorship programs: time for concerted action

Hematologists, specialists in cancer survivorship and patient advocates met in Bergamo, Italy (Nov 14–16, 2013) to highlight the physical, mental, psychosocial and financial challenges faced by cancer survivors and their families. Gaps in research and resources were all too apparent. This planned meeting perspective, not a formal consensus statement, reflects the key points mentioned by the participants during the discussions and the personal view of the authors. It proposes urgent action in key areas to ensure that people surviving cancer will suffer fewer long-term health problems than their predecessors and to contain costs.

Anxiety and health-related quality of life among patients with low-tumor burden non-Hodgkin lymphoma randomly assigned to two different rituximab dosing regimens: results from ECOG trial E4402 (RESORT)

PURPOSE

The purpose of this study was to compare illness-related anxiety among participants in the Rituximab Extended Schedule or Retreatment Trial (RESORT) randomly assigned to maintenance rituximab (MR) versus rituximab re-treatment (RR). A secondary objective was to examine whether the superiority of MR versus RR on anxiety depended on illness-related coping style.

PATIENTS AND METHODS

Patients (N = 253) completed patient-reported outcome (PRO) measures at random assignment to MR or RR (baseline); at 3, 6, 12, 24, 36, and 48 months after random assignment; and at rituximab failure. PRO measures assessed illness-related anxiety and coping style, and secondary end points including general anxiety, worry and interference with emotional well-being, depression, and health-related quality of life (HRQoL). Patients were classified as using an active or avoidant illness-related coping style. Independent sample t tests and linear mixed-effects models were used to identify treatment arm differences on PRO end points and differences based on coping style.

RESULTS

Illness-related anxiety was comparable between treatment arms at all time points (P > .05), regardless of coping style (active or avoidant). Illness-related anxiety and general anxiety significantly decreased over time on both arms. HRQoL scores were relatively stable and did not change significantly from baseline for both arms. An avoidant coping style was associated with significantly higher anxiety (18% and 13% exceeded clinical cutoff points at baseline and 6 months, respectively) and poorer HRQoL compared with an active coping style (P < .001), regardless of treatment arm assignment.

CONCLUSION

Surveillance until RR at progression was not associated with increased anxiety compared with MR, regardless of coping style. Avoidant coping was associated with higher anxiety and poorer HRQoL.

Patient-reported outcomes and survivorship in radiation oncology: overcoming the cons

PURPOSE

Although patient-reported outcomes (PROs) have become a key component of clinical oncology trials, many challenges exist regarding their optimal application. The goal of this article is to methodically review these barriers and suggest strategies to overcome them. This review will primarily focus on radiation oncology examples, will address issues regarding the "why, how, and what" of PROs, and will provide strategies for difficult problems such as methods for reducing missing data. This review will also address cancer survivorship because it closely relates to PROs.

METHODS

Key articles focusing on PROs, quality of life, and survivorship issues in oncology trials are highlighted, with an emphasis on radiation oncology clinical trials. Publications and Web sites of various governmental and regulatory agencies are also reviewed.

RESULTS

The study of PROs in clinical oncology trials has become well established. There are guidelines provided by organizations such as the US Food and Drug Administration that clearly indicate the importance of and methodology for studying PROs. Clinical trials in oncology have repeatedly demonstrated the value of studying PROs and suggested ways to overcome some of the key challenges. The Radiation Therapy Oncology Group (RTOG) has led some of these efforts, and their contributions are highlighted. The current state of cancer survivorship guidelines is also discussed.

CONCLUSION

The study of PROs presents significant benefits in understanding and treating toxicities and enhancing quality of life; however, challenges remain. Strategies are presented to overcome these hurdles, which will ultimately improve cancer survivorship.

Health-related quality of life in Korean lymphoma survivors compared with the general population

The objective of this study was to evaluate the health-related quality of life (HRQOL) of lymphoma survivors, to compare it with that of the general population, and to identify its predictors in lymphoma survivors. We enrolled 837 participants (mean age, 54.6 years; mean time since diagnosis, 6.3 years) with a history of Hodgkin's lymphoma (HL) (n = 58) or non-Hodgkin's lymphoma (NHL) (n = 779) who had been treated at any of three Korean hospitals from 1989 through 2010. For controls, we selected 1,000 subjects randomly from a representative Korean population. We administered the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and the Hospital Anxiety and Depression Scale. Overall, the HRQOL in both groups of survivors and the general population were comparable, but we observed clinically meaningful worse social functioning in NHL survivors (p < 0.001) and more severe fatigue in HL survivors (p < 0.001) than in the general population. Analysis of covariance revealed no clinically meaningful difference in HRQOL associated with age or sex. Survivors who received peripheral blood stem cell transplants showed clinically meaningful worse role (p = 0.001) and social (p < 0.001) functioning than those who were treated with first-line chemotherapy alone. In multivariate analyses, fatigue, depression, and financial difficulties emerged as the strongest predictors for almost all subscales of functioning and global quality of life. Interventions for alleviating fatigue, depression, and financial difficulties are needed to enhance the HRQOL of Korean lymphoma survivors.

Psychosocial factors associated with impact of cancer in longterm haematological cancer survivors

To assess the impact of cancer (IOC) on subsequent quality of life (QOL), 718 long-term haematological cancer survivors completed validated psychosocial, functional and QOL scales, including IOC. Fifteen percent reported significant psychological distress, 18% high levels of fatigue and 10% moderate to severe functional impairment. These groups of participants also showed poorer QOL. There were no significant differences in psychological distress (P = 0·76), fatigue (P = 0·23) or functional impairment (P = 0·74) across different cancer subtypes. Two separate hierarchical regression analyses examined the combined association of disease-type, psychosocial and other factors on negative and positive IOC scores respectively. Higher negative IOC scores were significantly associated (P ≤ 0·001) with medical comorbidity, psychological distress, lower social support, high fatigue levels and functional impairment. Paediatric patients (diagnosed at <17 years) had significantly higher negative IOC scores than adult patients (P = 0·001); greater years since diagnosis was significantly (P < 0·001) associated with less negative IOC. Higher positive IOC was associated with acute leukaemia (P = 0·01); lower positive IOC with paediatric patients (P < 0·001), white ethnicity (P < 0·001), higher education (P = 0·003), no partner (P = 0·01) and lower social support (P = 0·01). Screening for medical comorbidity, psychological distress and fatigue identifies those needing most support and should allow earlier interventions to address negative and positive IOC to improve the well-being of cancer survivors.