A qualitative study of patient perspectives on colorectal cancer

Real-world evidence research in metastatic colorectal cancer: raising awareness of the need for patient contributions

Real-world evidence (RWE) research helps determine whether outcomes observed in clinical trials happen in real-life clinical practice. RWE research may help patients receive more appropriate treatment, closer to their needs and wishes. RWE for metastatic colorectal cancer is currently limited. The PROMETCO RWE study is an important example of an ongoing initiative that focuses on patient-reported outcomes in metastatic colorectal cancer. Patients play an active role throughout the RWE research process, including study design, participation and results dissemination. This involvement can encourage greater patient empowerment through active engagement, potentially resulting in various benefits that can lead to improved clinical outcomes. Greater patient engagement can increase involvement in RWE, helping more patients to access the benefits of RWE research. Clinical Trial Registration: NCT03935763 (ClinicalTrials.gov).

Elective Surgery for Diverticulitis and the Risk of Recurrence and Ostomy

OBJECTIVE

To assess the comparative risk of recurrence and ostomy after elective resection or medical therapy for uncomplicated diverticulitis, incorporating outpatient episodes of recurrence.

BACKGROUND

While surgeons historically recommended colon resection for uncomplicated diverticulitis to reduce the risk of recurrence or colostomy, no prior studies have quantified this risk when considering outpatient episodes of disease. It remains to be determined whether surgery actually decreases those risks.

METHODS

Retrospective cohort study employing an adjusted time-to-event analysis to assess the relationship of medical or surgical treatment with diverticulitis recurrence and/or receipt of an ostomy. Subjects were adults with ≥1 year continuous enrollment treated for ≥2 episodes of uncomplicated diverticulitis from a nationwide commercial claims dataset (2008-2014).

RESULTS

Of 12,073 patients (mean age 56 ± 14 yr, 59% women), 19% underwent elective surgery and 81% were treated by medical therapy on their second treatment encounter for uncomplicated diverticulitis. At 1 year, patients treated by elective surgery had lower rates of recurrence (6%) versus those treated by medical therapy (32%) [15% vs 61% at 5 years, adjusted hazard ratio 0.17 (95% confidence interval: 0.15-0.20)]. At 1 year, the rate of ostomy after both treatments was low [surgery (inclusive of stoma related to the elective colectomy), 4.0%; medical therapy, 1.6%].

CONCLUSIONS

Elective resection for uncomplicated diverticulitis decreases the risk of recurrence, still 6% to 15% will recur within 5 years of surgery. The risk of ostomy is not lower after elective resection, and considering colostomies related to resection, ostomy prevention should not be considered an appropriate indication for elective surgery.

Colorectal cancer survivorship: A systematic review and thematic synthesis of qualitative research

INTRODUCTION

With rapid changes in treatments for colorectal cancer (CRC), qualitative research into CRC survivorship requires greater synthesis. This paper aims to fill this gap through a systematic review (PROSPERO CRD42019131576) and thematic synthesis of the qualitative literature on survivorship experiences across early-stage and advanced CRC survivors.

METHODS

CINAHL, Embase, MEDLINE, PsycINFO and PubMed were searched for qualitative CRC survivorship papers. Titles, abstracts and full texts were screened. Included articles (n = 81) underwent data extraction, CASP qualitative bias ratings and thematic synthesis.

RESULTS

Bowel dysfunction caused functional limitations and negative quality of life (QoL), while stomas posed threats to body image and confidence. Physical symptoms hindered return to work, increasing financial burdens. Survivors' unmet needs included information regarding symptom expectations and management, and ongoing support throughout recovery. Advanced and early-stage survivors shared similar experiences. Advanced survivors struggled with fear of cancer recurrence/progression and feelings of powerlessness. Functional limitations, financial impacts and sexuality in advanced survivors were underexplored areas.

CONCLUSION

CRC and its treatments impact survivors' QoL in all areas. A coordinated supportive care response is required to address survivors' unmet needs. Future qualitative studies should explore advanced CRC subpopulations, treatment-specific impacts on QoL and long-term (>5 years) impacts on CRC survivors.

Learning-by-doing: the importance of experiential knowledge sharing for meeting the information needs of people with colorectal cancer in Germany-a qualitative study

OBJECTIVE

The aim of this article is to understand how, when and why the topics of information and information needs arise when people diagnosed with colorectal cancer (CRC) narrate their illness experiences.

METHODS

Guided by principles of grounded theory, a qualitative interview study was conducted that collected a wide variety of illness experiences with CRC in Germany using maximum variation sampling. Sampling criteria included place of residence, age at interview, age at diagnosis, treatment, disease course and sociodemographic factors such as varying family backgrounds and professions.

SETTING AND PARTICIPANTS

Men and women diagnosed with CRC in different parts of Germany were sought via physicians, social workers and psychologists in hospital settings, organisations offering psychosocial support for patients with cancer, self-help groups, rehabilitation centres, newspapers and personal contacts. The interviewees in the final sample (n=41) had been diagnosed with CRC between 4 weeks and 36 years prior to the interview.

RESULTS

Three inter-related categories of information needs emerged from the analysis: the need for non-medical information for daily life; the challenge of integrating the bodily changes that accompany CRC in everyday life; and sources of non-medical information concerning handling daily life. Learning to live with the bodily changes of CRC in everyday life was described as a long process of learning-by-doing. While sources for medical information were clear, finding practical information was often a challenge. The best source of such information was often seen to be other people living with the disease, who shared their experiential knowledge, as well as stoma and nutritional therapists.

CONCLUSION

Information needs are part of the process and struggle to normalise everyday life after a disruptive diagnosis and treatment. Providing access to practical knowledge and information from others with CRC experience may be an important resource for patient support.

Quality of Life Among Breast and Colon Cancer Patients Before and After First-Cycle Chemotherapy

PURPOSE

This study aimed to compare the functioning, symptoms, and quality of life (QoL) of patients with breast or colon cancer before and after their first-cycle (FC) chemotherapy.

DESIGN

One-group pretest/posttest design.

METHOD

The study utilized the standardized Arabic-translated Quality of Life Questionnaire Version 3 from the European Organization for Research and Treatment of Cancer in measuring the functioning, symptoms, and QoL of 120 Saudi patients diagnosed with breast or colon cancer. Dependent t test was used in analyzing the presence of significant differences in mean scores before and after chemotherapy with periods ranging from 14 days to 21 days following the treatment protocol.

RESULTS

The findings revealed significant differences in the functioning, symptoms, and QoL among patients with breast or colon cancer before and after FC chemotherapy (p < .001). Baseline scores showed higher physical, role, emotional, cognitive, and social functioning; lesser symptoms; lower financial difficulties; and better overall global health status compared to post-FC chemotherapy.

CONCLUSION

Assessing the QoL of patients with breast or colon cancer undergoing FC chemotherapy is essential to establish a holistic care plan in supporting and alleviating the unfavorable effects of chemotherapy and implement patient-centered interventions that aid in the enhancement of their overall QoL.

Healthcare professionals' perspectives of barriers and facilitators in implementing physical activity programmes delivered to cancer survivors in a shared-care model: a qualitative study

BACKGROUND

The positive impact of physical activity programmes has been recognised, but the current uptake is low. Authorities believe delivering these programmes in a shared-care model is a future perspective. The present study aimed to identify the barriers and facilitators affecting physical activity programme implementation in a shared-care model delivered with the cooperation of all the types of healthcare professionals involved.

METHODS

Thirty-one individual interviews with primary healthcare professionals (PHPs) and four focus group interviews with 39 secondary healthcare professionals (SHPs) were undertaken. We used Grol and Flottorp's theoretical models to identify barriers and facilitators in six domains: (1) physical activity programmes, (2) patients, (3) healthcare professionals, (4) social setting, (5) organisation and (6) law and governance.

RESULTS

In the domain of physical activity programmes, those physical activity programmes that were non-tailored to the patients' needs impeded successful implementation. In the domain of healthcare professionals, the knowledge and skills pertaining to physical activity programmes and non-commitment of healthcare professionals impeded implementation. HCPs expressed their concerns about the negative influence of the patient's social network. Most barriers occurred in the domain of organisation. The PHPs and SHPs raised concerns about ineffective collaboration and networks between hospitals. Only the PHPs raised concerns about poor communication, indeterminate roles, and lack of collaboration with SHPs. Insufficient and unclear insurance coverage of physical activity programmes was a barrier in the domain of law and governance.

CONCLUSIONS

Improving the domain of organisation seems the most challenging because the collaboration, communication, networks, and interactive roles between the PHPs and SHPs are all inadequate. Survivor care plans, more use of health information technology, improved rehabilitation guidelines, and better networks might benefit implementing physical activity programmes.

Health-related quality of life in Slovenian patients with colorectal cancer: a single tertiary care center study

Background

The aim of this study was to evaluate the influence of the surgical treatment on Slovenian colorectal cancer patients’ health-related quality of life and to compare the results to the health-related quality of life of the general Slovenian population.

Patients and methods

A total of 413 patients with colorectal cancer operated on at the Abdominal Surgery Department at the Ljubljana University Medical Center between January 1st, 2016 and December 31st, 2017 were sent two standardized and validated questionnaires: the EORTC QLQ-C30 version 3 and EORTC QLQ-CR29. The questionnaires were returned by 197 patients.

Results

Compared to the general population, poorer physical (p < 0.001), role (p = 0.002), cognitive (p = 0.021), and social functioning (p < 0.001) with higher frequency of constipation (p < 0.001), diarrhea (p < 0.001), and financial difficulties (p < 0.001) were reported by the colorectal patients. Female patients reported lower cognitive (p = 0.034) and emotional (p = 0.008) functioning, as well as higher frequency of bloating (p = 0.049) and hair loss (p = 0.01). Compared to the younger group of patients, lower physical functioning (p < 0.001) and higher urinary frequency (p = 0.007), urinary incontinence (p = 0.007), buttock pain (p = 0.007), and anxiety regarding body weight (p = 0.031) were detected among the older group of colorectal patients.

Conclusions

The global health status of colorectal patients in Slovenia is comparable to that of the general Slovenian population, but there is a significantly lower level in some of the quality-of-life scales.

An interpretative phenomenological analysis of the experience of living with colorectal cancer as a chronic illness

AIMS AND OBJECTIVES

The aim of this study was to explore the lived experiences of patients living with cancer as a chronic illness.

BACKGROUND

Due to recent advances in detection and treatment, cancer is now regarded as a chronic illness. However, living with cancer as a chronic illness can lead to a number of physical and psychosocial consequences all of which can lead to uncertainty over how patients view and plan for their future.

DESIGN

A longitudinal qualitative study.

METHODS

Individuals attending oncology follow-up clinics with their clinical nurse specialist at a hospital in the North East of England were invited to participate in two semistructured interviews over a 6-month period. A total of six individuals consented to participate, of whom two were women. One participant could not be contacted for the second interview, resulting in 11 interviews. Interviews were audio recorded, transcribed verbatim and analysed using interpretative phenomenological analysis.

RESULTS

Two super-ordinate themes emerged from the analysis: physical and psychological consequences of cancer and adapting to life after treatment.

CONCLUSION

The experience of future disorientation was common among participants; however, this was impacted on by a number of factors such as functional impairment and fear of recurrence. Furthermore, future disorientation does not appear to be stable and may ease as patients begin to adjust to the uncertainty of living with colorectal cancer as a chronic illness.

Pancreatic enzyme replacement therapy following surgery for pancreatic cancer: An exploration of patient self-management

BACKGROUND

For those diagnosed with pancreatic cancer, ill-addressed pancreatic exocrine insufficiency (PEI) following surgery can result in malnutrition related complications that may impact on predict mortality and morbidity. The use of pancreatic enzyme replacement therapy (PERT) is recommended and often demands a degree of patient self-management. Understanding more about how this treatment is managed is fundamental to optimising care.

OBJECTIVE

This study aimed to explore patient self-management of PERT following surgery for pancreatic cancer.

METHODS

Semi-structured interviews were conducted with nine participants. Eligible participants included adult patients who had undergone surgery for a malignancy in the pancreatic region and were prescribed PERT post-operatively. Inductive thematic analysis was used to analyse our findings.

RESULTS

Data analysis revealed three overarching themes; the role of professional support, factors influencing decisions to use PERT in symptom management and the challenges of socializing. The difficulties negotiated by participants were considerable as they struggled with the complexities of PERT. Symptom management and subsequently reported physical repercussions and undesirable social implications were problematic. Professional support was largely inconsistent and relinquished prematurely following discharge. Consequently, this impacted on how PERT was self-managed.

CONCLUSION

Enabling patients to appropriately self-manage PERT may lessen the post-treatment burden. Our findings suggest that support should continue throughout the recovery phase and should address the patient's 'self-management journey'. Intervention by healthcare professionals, such as a specialist dietitian is likely to be beneficial. Furthermore there are focal issues, primarily explicit education and appropriately timed information that require consideration by those developing and delivering services.

Sphincter-saving proctectomy for rectal cancer with NO COIL® transanal tube and without ostoma. Clinical outcomes, cost effectiveness and quality of life in the elderly

BACKGROUND

Colorectal cancer is one of the most common invasive cancers, and it is responsible for considerable physical and psychosocial morbidity specially in older patients. However, only few reports focused on quality of life, cost-effectiveness and clinical outcomes of rectal cancer patients undergone to surgery. This retrospective study compares short-term and long-term outcomes in rectal cancer patients with more and less than 75 years of age.

METHODS

Four hundred consecutive patients underwent radical surgery for rectal adenocarcinoma and they were collected in a prospective institutional database and divided into two groups: group 1 (≥75 years, N.=98); group 2 (<75 years, N.=302). Rectal anterior resection (RAR) with sphincter-saving restorative proctectomy and with application of silicone transanal tube NO COIL® 60-80 mm long, was the only procedure considered. Main clinical and pathological data were assessed and compared.

RESULTS

Statistically significant differences between the two groups were detected regard to comorbidities and the emergency presentation. Overall survival is lower in patients over 75 age, but cancer-related survival is not different between the two groups.

CONCLUSIONS

Although advanced age is associated with higher morbidity and mortality, in our experience, itself is not a contraindication for surgical sphincter-saving proctetomy in rectal cancer patients. The absence of a stoma also improved the cost effectiveness and patients' quality of life in both groups: psychological morbidity, sexuality, levels of anxiety and depression, body image.

The Experience of Extended Bowel Resection in Individuals With a High Metachronous Colorectal Cancer Risk: A Qualitative Study

PURPOSE/OBJECTIVES

To ascertain individual experiences of extended bowel resection as treatment for colorectal cancer (CRC) in those with a high metachronous CRC risk, including the self-reported adequacy of information received at different time points of treatment and recovery.
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RESEARCH APPROACH

Qualitative.
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SETTING

Participants were recruited through the Australasian Colorectal Cancer Family Registry and two hospitals in Melbourne, Australia.
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PARTICIPANTS

18 individuals with a high metachronous CRC risk who had an extended bowel resection from 6-12 months ago.
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METHODOLOGIC APPROACH

Semistructured interviews. Data were analyzed thematically.
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FINDINGS

In most cases, the treating surgeon decided on the best option regarding surgical treatment. Participants felt well informed about the surgical procedure. Information related to surgical outcomes, recovery, and lifestyle adjustment from surgery was not always adequate. Many participants described ongoing worry about developing another cancer. 
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CONCLUSIONS

Patients undergoing an extended resection to reduce metachronous CRC risk require detailed information delivered at more than one time point and relating to several different aspects of the surgical procedure and its outcomes.
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INTERPRETATION

An increased emphasis should be given to the provision of patient information on surgical outcomes, recovery, and lifestyle adjustment. Colorectal nurses could provide support for some of the reported unmet needs.

Influential factors on treatment decision making among patients with colorectal cancer: A scoping review

PURPOSE

In recent years, a greater emphasis has been placed on shared decision-making (SDM) techniques between providers and patients with the goal of helping patients make informed decisions about their care and subsequently to improve patient health outcomes. Previous research has shown variability in treatment decision-making among patients with colorectal cancer (CRC), and there is little comprehensive information available to help explain this variability. Thus, the purpose of this study was to evaluate the current state of the literature on factors that are influential in treatment decision-making among patients with CRC.

METHOD

A priori search terms using Boolean connectors were used to examine PubMed, PsycINFO, Web of Science, CINAHL, and MEDLINE for relevant studies. Eligibility criteria for inclusion in the study included patients with CRC and examination of influences on CRC treatment decision-making. All relevant data were extracted including, author, title and year, study methodology, and study results.

RESULTS

Findings (n = 13) yielded influences in four areas: informational, patient treatment goals, patient role preferences, and relationship with provider. Quality of life and trust in physician were rated a high priority among patients when making decisions between different therapeutic options. Several studies found that patients wanted to be informed and involved but did not necessarily want to make autonomous treatment choices, with many preferring a more passive role.

CONCLUSIONS

Providers who initiate a dialog to better understand their patients' treatment goals can establish rapport, increase patient understanding of treatment options, and help patients assume their desired role in their decision-making. Overall, there were a small number of studies that met all inclusion criteria with most used a cross-sectional design.

Patients' views on general practitioners' role during treatment and follow-up of colorectal cancer: a qualitative study

PURPOSE

To clarify experiences and preferences of patients regarding the current and future role of GPs during treatment and follow-up care of colorectal cancer (CRC).

METHODS

Qualitative semi-structured, audio-recorded, face-to-face interviews in patients' homes in the north of the Netherlands were performed. Patients were sampled purposively on age, gender, time since diagnoses and primary health care use. Data were transcribed verbatim and analysed thematically by two independent researchers until saturation was reached.

RESULTS

Twenty-two patients were interviewed. GPs played a significant and highly valued role directly after surgery by proactively contacting their patients and offered support in clarification of medical issues, lifestyle advice and care for treatment-related side effects. During follow-up, GPs provided psychosocial support for patients and family members, besides routine health care. Concerning the organization of future follow-up care, most patients expressed a preference for specialist-led services; some said that primary care-led care would be more accessible and less expensive.

CONCLUSION

Although at present patients perceived their GP is involved in CRC care, they would prefer their follow-up care in a hospital setting. If, in line with recent insights, future follow-up care might become more relying on testing for markers instead of imaging, there may be scope for incorporating this care in current GP routines.

Living and dying with metastatic bowel cancer: Serial in-depth interviews with patients

Colorectal cancer is the second highest cause of cancer deaths. There are significant physical and psycho‐social effects on quality of life with advanced disease. Despite this, there are few accounts of the patient experience from advanced illness through to dying. We elicited the longitudinal experiences of living and dying with incurable metastatic colorectal cancer by conducting serial interviews with patients for 12 months or until they died. The interviews were analysed, using a narrative approach, longitudinally as case studies and then together. Thirty‐six interviews with 16 patients were conducted. Patients experience metastatic colorectal cancer in three phases; (1) Diagnosis and initial treatment; (2) Deterioration and social isolation and (3) Death and dying. Many patients initially said they hoped to survive, but, as “private” and in‐depth accounts of the experience emerged in further interviews, so did the understanding that this hope co‐existed with the knowledge that death was near. Palliative chemotherapy and the challenge of accessing private accounts of patient experience can inhibit care planning and prevent patients benefitting from an active holistic palliative care approach earlier in the disease trajectory. This study has immediate clinical relevance for health care professionals in oncology, palliative care and primary care.

Living With Cancer Alone? The Experiences of Singles Diagnosed With Colorectal Cancer

This paper seeks to understand the experiences of single colorectal cancer patients. This study consisted of 12 semi-structured interviews that were digitally voice-recorded, transcribed, and analyzed. Six main themes emerged: (a) gradual shift in view of cancer diagnosis from fatalistic to normalized, (b) perception of cancer as a nadir experience, (c) concerns of singlehood, (d) factors influencing cancer experiences, (e) factors influencing coping with cancer, and (f) range of responses towards cancer diagnosis. Singles with colorectal cancer require short- to long-term individualized care plans, and psycho-emotional support. This may help enhance their individual coping and adjustment to the diagnosis.

Health care needs of cancer survivors in general practice: a systematic review

Background

The number of cancer survivors is increasing due to improved treatments. Consequently, general practitioners will treat more and more cancer survivors in the upcoming years. Only little is known about the care needs of these survivors and guidelines to support general practitioners in their treatment of these patients are lacking. The aim of this study was to gain insight in the health care needs of cancer survivors in general practice.

Methods

A systematic review on cancer survivors’ general practice needs was conducted in PubMed, Embase and the Cochrane Library of Systematic Reviews. Eligible studies could be qualitative or quantitative studies examining cancer survivors’ needs in general practice. Studies of adult survivors, with any cancer type, considered free of active disease and no longer receiving active treatment, were included. For each study a quality score was given using a form developed specifically for this study. Statements about survivors’ general practice needs were collected and corresponding themes were grouped.

Results

Fifteen studies were included, of which twelve were qualitative. Most mentioned general practice needs were psychosocial needs, mainly being support received form the GP, followed by a need for help with medical issues, and a need for information on cancer, recovery, late treatment effects and on adjusting to life after treatment.

Conclusions

Cancer survivors have different types of general practice needs that are currently not or insufficiently met. This review provides a starting point for the development of new guidelines for general practitioners to support in cancer survivorship.

Addressing patients’ colorectal cancer needs in preoperative education

Purpose

– The purpose of this paper is to understand and develop ways to enhance patients’ experiences of preoperative education received prior to surgery for colorectal cancer.

Design/methodology/approach

– Based in the UK, three-action research cycles were undertaken to evaluate preoperative education, identify changes seen by patients and staff as likely to improve the service and to re-evaluate such changes following implementation. Data in each cycle were collected from: observations of clinic interactions; patient questionnaires; individual semi-structured interviews with multidisciplinary colorectal unit staff; longitudinal semi-structured interviews with patients and carers pre-surgery, two weeks post-surgery and 12 weeks post-surgery; patient and carer focus groups post-surgery; and existing educational material.

Findings

– In total, 138 participants shared their experiences of either giving or receiving preoperative education. Findings were themed into why patients want preoperative education, and patients’ views of the educational processes.

Practical implications

– Patients emphasised the need for educational provision to be fully understandable, comprehensive and client-centred using a range of communication processes. Patients emphasised the need for educational provision to be more fully understandable, comprehensive and client-centred and that important messages should be reinforced using a range of media. At a time of many uncertainties for patients’ lives, such education needed to encompass the experiences patients could expect, delivered by confident healthcare professionals.

Originality/value

– Contextualising understanding and facilitating their own actions, enabled patients to regain control in circumstances particularly disruptive of bodily and other life routines. Establishing a sense of control is confirmed as important for patient's wellbeing in preparing for surgery and postoperative rehabilitation.

Health related quality of life in colorectal cancer patients: state of the art

Background

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females with a progressive increase in prevalence in industrialized countries. The loss of health due to the cancer and/or the consequence of the treatment may result in psychophysical, functional and social impairment; all of these affect health-related quality of life (QoL).

Description

The most frequently CRC-specific QoL questionnaires is the FACT-C. QoL is not only important for the well-being of cancer patient but it also influences survival and response to therapy. Many studies investigated various determinants involved in the assessment of QoL in CRC, suggesting that symptoms, surgical procedures and the number of comorbidity significantly affected QoL.

Conclusion

Despite that CRC patients have a relatively good QoL compared with the general population, a wide range of intervention could be undertaken to improve their QoL. The finding of this review may be useful for cancer clinicians in taking therapy and surveillance-related decisions. However, future research should be directed to large-scale prospective studies using well validated QoL instruments to facilitate comparison of results.

Understanding the needs of colorectal cancer patients during the pre-diagnosis phase

Patients with colorectal cancer (CRC) face a number of challenges leading up to diagnosis; however, research is limited regarding their specific needs during the pre-diagnosis period. A multicenter cross-sectional survey was conducted to elicit information about the CRC experience during the pre-diagnosis phase. Across the three sites, 104 eligible patients were approached, and 82 patients completed the survey, for a total response rate of 78.9%. The needs most identified by participants during the pre-diagnosis period were informational (31.6%) and emotional (20.3%) needs; social needs were rated as the least important need for these patients (7%). The majority (84.0%) reported that these needs were met. Participants reported feeling shocked or overwhelmed on learning of their diagnosis (57.1%) and high levels of anxiety during this time (40.0%). The majority (77.9%) of participants reported that they were not directed to any resources to help address their anxiety. Informational and emotional needs are identified as the most important needs during the pre-diagnosis phase, and for most these needs are being met; however, some participants are experiencing high levels of anxiety without access to appropriate resources. Further work is required to understand the optimal mechanisms to address identified needs during this pre-diagnosis period and to assess the potential benefits and costs of addressing these needs.

Informal work and formal plans: articulating the active role of patients in cancer trajectories

Introduction

Formal pathways models outline that patients should receive information in order to experience a coherent journey but do not describe an active role for patients or their relatives. The aim of this is paper is to articulate and discuss the active role of patients during their cancer trajectories.

Methods and theory

An in-depth case study of patient trajectories at a Danish hospital and surrounding municipality using individual interviews with patients. Theory about trajectory and work by Strauss was included.

Results

Patients continuously took initiatives to organize their treatment and care. They initiated processes in the trajectories, and acquired information, which they used to form their trajectories. Patients presented problems to the healthcare professionals in order to get proper help when needed.

Discussion

Work done by patients was invisible and not perceived as work. The patients’ requests were not sufficiently supported in the professional organisation of work or formal planning. Patients’ insertion and use of information in their trajectories challenged professional views and working processes. And the design of the formal pathway models limits the patients’ active participation. When looking at integrated care from the perspective of patients, the development of a more holistic and personalized approach is needed.

Perceived information after surgery for colorectal cancer--an explorative study

AIM

With fast track surgery and shorter hospital stay, discharge from hospital after cancer surgery is becoming more challenging for the individual patient. The aim of this study was to explore how patients perceive information after surgery for colorectal cancer, what their information needs are and to determine factors affecting received information.

METHOD

A hundred patients filled in the questionnaires QLQ-C30, CR38 and INFO25 created by the European Organization for Research and Treatment of Cancer, the Eastern Cooperative Oncology Group (ECOG) instrument and the SOC (sense of coherence) instrument and provided written comments within the first 2 weeks after discharge following surgery for colorectal cancer. The questionnaires were analysed using hierarchical cluster analysis and a multiple linear regression analysis. The written comments were analysed using content analysis.

RESULTS

In all, 49% of the patients expressed a need for more information. In the written comments they specified these areas of information: they lacked information concerning their surgery, how to handle symptoms and problems at home, someone to contact after discharge and prognostic information about their future. Patients reported most received information in areas of medical tests and disease but less on other services and support in outpatient care. The variation in INFO25 was best explained by gender (P = 0.045) and preoperative health status (American Society of Anesthesiologists score 3, P = 0.022).

CONCLUSION

The results from this study indicate that women and patients with a poorer preoperative health status scored less on information received and would need more time and support to prepare for discharge. The patients expressed a desire for more information about the surgery, how to handle symptoms at home and prognostic information about their future.

Information needs across the colorectal cancer care continuum: scoping the literature

Because cancer care requires a multifaceted approach, providing useful and timely information to people with colorectal cancer may be fragmented and inconsistent. Our interest was in examining what has and has not captured the attention of researchers speaking to the information needs of people with colorectal cancer. We followed Arksey and O'Malley's framework for the methodology of scoping review. Focusing solely on colorectal cancer, we analysed 239 articles to get a picture of which information needs and sources of information, as well as the timing of providing information, were attended to. Treatment-related information received the most mentions (26%). Healthcare professionals (49%) were mentioned as the most likely source of information. Among articles focused on one stage of the care continuum, post-treatment (survivorship) received the most attention (16%). Only 27% of the articles consulted people with colorectal cancer and few attended to diet/nutrition and bowel management. This study examined the numerical representation of issues to which researchers attend, not the quality of the mentions. We ponder, however, on the relationship between the in/frequency of mentions and the actual information needs of people with colorectal cancer as well as the availability, sources and timing of information.

Patients' needs following colorectal cancer diagnosis: where does primary care fit in?

BACKGROUND

Colorectal cancer is the third most common cancer in the UK. Patients with colorectal cancer spend most of their time in the community, but the role of primary care in their management and follow-up is unclear.

AIM

To explore colorectal cancer patients' experiences of psychosocial problems and their management in primary and specialist care.

DESIGN AND SETTING

Longitudinal qualitative study of participants recruited from three hospitals in the west of Scotland and interviewed in their own homes.

METHOD

In-depth interviews with 24 participants with a new diagnosis of colorectal cancer, and then follow-up interviews 12 months later.

RESULTS

Participants' needs following a diagnosis for colorectal cancer included physical, psychological, and social issues. GPs played a key role in diagnosis, after which they were less involved. Participants valued GPs making unsolicited contact and offering support. Participants described being well supported by clinical nurse specialists who are expert in the illness, and who provide continuity of care and psychological support. A year after diagnosis, when there was less contact with GPs and clinical nurse specialists, participants still faced challenges associated with the ongoing impact of colorectal cancer.

CONCLUSION

While some patients enjoyed straightforward recoveries from surgery, others experienced longer-term implications from their disease and treatment, particularly bowel-function issues, fatigue, anxiety, and sexual problems. The potential for primary care to contribute more to the ongoing care of colorectal cancer patients was identified.

"I wish I'd told them": a qualitative study examining the unmet psychosexual needs of prostate cancer patients during follow-up after treatment

OBJECTIVE

To gain insight into patients' experiences of follow-up care after treatment for prostate cancer and identify unmet psychosexual needs.

METHODS

Semi-structured interviews were conducted with a purposive sample of 35 patients aged 59-82 from three UK regions. Partners were included in 18 interviews. Data were analyzed using constant comparison.

RESULTS

(1) Psychosexual problems gained importance over time, (2) men felt they were rarely invited to discuss psychosexual side effects within follow-up appointments and lack of rapport with health care professionals made it difficult to raise problems themselves, (3) problems were sometimes concealed or accepted and professionals' attempts to explore potential difficulties were resisted by some, and (4) older patients were too embarrassed to raise psychosexual concerns as they felt they would be considered 'too old' to be worried about the loss of sexual function.

CONCLUSION

Men with prostate cancer, even the very elderly, have psychosexual issues for variable times after diagnosis. These are not currently always addressed at the appropriate time for the patient.

PRACTICE IMPLICATIONS

Assessments of psychosexual problems should take place throughout the follow-up period, and not only at the time of initial treatment. Further research examining greater willingness or reluctance to engage with psychosexual interventions may be particularly helpful in designing future interventions.

Differences in information seeking among breast, prostate, and colorectal cancer patients: results from a population-based survey

OBJECTIVE

There is much research describing cancer patients' information needs and their use of the Internet, print media, and other sources to fulfill these needs. Yet little is known about whether patients with different types of cancer vary in their information needs and seeking behaviors. This study used population-based data to address this question.

METHODS

A sample was randomly drawn from the list of patients with breast, prostate, or colorectal cancer reported to the Pennsylvania Cancer Registry in 2005. Patients completed a mail survey (N=2010); respective response rates were 68%, 64%, and 61%.

RESULTS

Colorectal cancer patients reported consistently less information seeking than breast and prostate cancer patients. Multivariate analyses revealed that differences by cancer type were not explained by sex or other demographics, disease stage, or treatment received. These differences were most pronounced among patients with early stage cancer.

CONCLUSION

Cancer patients have myriad information needs and use a range of sources to satisfy these needs, but there appear to be important differences in information engagement by cancer type.

PRACTICE IMPLICATIONS

Understanding differences in information seeking among disease-specific populations may help guide future patient education and decision making across the care continuum.

How do cancer patients navigate the public information environment? Understanding patterns and motivations for movement among information sources

Little is known about how patients move among information sources to fulfill unmet needs. We interviewed 43 breast, prostate, and colorectal cancer patients. Using a grounded theory approach, we identified patterns and motivations for movement among information sources. Overall, patients reported using one source (e.g., newspaper) followed by the use of another source (e.g., Internet), and five key motivations for such cross-source movement emerged. Patients' social networks often played a central role in this movement. Understanding how patients navigate an increasingly complex information environment may help clinicians and educators to guide patients to appropriate, high-quality sources.

A qualitative study of patient perspectives of health-related quality of life in colorectal cancer: comparison with disease-specific evaluation tools

AIM

Little is known about the factors that patients with colorectal cancer (CRC) consider as important in shaping their health-related quality of life (HrQoL) and whether these are adequately represented by currently used HrQoL instruments. The aim of this study was to determine which areas of HrQoL are important to patients with CRC and to establish whether these areas are represented by validated questionnaires.

METHOD

Semi-structured interviews were conducted with 20 patients who were undergoing treatment or follow up for potentially curable CRC. The areas of HrQoL that were important to the patients were identified from the interview data using a qualitative thematic framework analysis. These themes were then compared with the item content of two CRC-specific HrQoL questionnaires, FACT-C and QLQ-C30/CR38.

RESULTS

The interviews identified 10 themes considered by patients to be important determinants of their HrQoL. These comprised control, normality, fatigue, uncertainty, information, emotional support, self-image, coping, symptoms and emotionally challenging events. Both HrQoL instruments contained questions that concerned some of the themes identified, but none of the FACT-C scales and only three from QLQ-C30/CR38 produced scores from which clinicians could identify problems in these areas.

CONCLUSION

Identifying and addressing areas of concern for patients may assist clinicians in improving HrQoL outcomes. However, validated instruments currently used in CRC provide little information with regard to these areas.

Adaptation process and psychosocial resources of Chinese colorectal cancer patients undergoing adjuvant treatment: a qualitative analysis

OBJECTIVES

To examine how Chinese patients with colorectal cancer (CRC) dynamically adapt to diagnosis and treatment and explore how patients evolve and deploy different resources throughout the illness trajectory.

METHODS

Semi-structured interviews were conducted on a purposive sample of 16 histologically diagnosed Chinese CRC patients about to complete or who had very recently completed all treatment without recurrence. Recorded interviews were transcribed verbatim and analyzed by using grounded theory techniques.

RESULTS

Three major adaptation-related themes were identified: (1) utilization of medical resources, (2) transition of resource utilization, and (3) continuous resistance to demands. Initial prevailing fatalistic views of diagnosis associated predominantly with frequent medical surveillance and with respondents' weighting of treatment and expertise of medical professionals. As treatment progressed, there was a shift toward reliance on personal and social resources to field cancer-related demands concurrent with a gradual distancing from medical care. Upon treatment completion, fatalism re-emerged regarding disease recurrence, which, like diagnosis, was seen as not amenable to individual control, even with close adherence to medical follow-ups and dietary adjustment. Maintaining positive states of mind and good relationships with family and friends were cores strategies respondents adopted to preserve psychological well-being.

CONCLUSIONS

Maintenance and enhancement of personal and social resources throughout the CRC trajectory may have considerably more utility than traditional descriptive studies hitherto suggested. Considering personal and social resources within dynamic rather than static models could avoid the pitfall of attributing maladaptive responses to initial dispositions and socioeconomic conditions that are seemingly unalterable and enduring over time.

Patients' and healthcare professionals' views of cancer follow-up: systematic review

BACKGROUND

Cancer follow-up places a significant burden on hospital outpatient clinics. There are increasing calls to develop alternative models of provision.

AIM

To undertake a systematic review of qualitative studies examining patients' and healthcare professionals' views about cancer follow-up.

DESIGN OF STUDY

Systematic review.

SETTING

Primary and secondary care.

METHOD

Comprehensive literature searches included: 19 electronic databases, online trial registries, conference proceedings, and bibliographies of included studies. Eligible studies included qualitative studies examining patients' and healthcare professionals' views of cancer follow-up. Studies of patients with any type of cancer, considered free of active disease, or no longer receiving active treatment were included. Findings were synthesised using thematic analysis.

RESULTS

Nineteen studies were included; seven were linked to randomised controlled trials. Eight studies examined the views of healthcare professionals (four of which included GPs) and 16 examined the views of patients. Twelve descriptive themes were identified, from which 12 perceived implications for practice were derived. Most themes related to conventional follow-up in secondary care. Some views concerning other models of care were based on participants' ideas, rather than experiences.

CONCLUSION

Patients' main concern is recurrent disease, and they find regular follow-up, expertise of specialists, and quick access to tests reassuring. Information regarding the effectiveness of follow-up is not given to patients who also have unmet information needs, which would help them to cope and be more involved. Continuity of care, unhurried consultations, and psychosocial support are important, but sometimes lacking in secondary care. GPs are thought to be unwilling and to have insufficient time and expertise to conduct follow-up.

Bowel problems, self-care practices, and information needs of colorectal cancer survivors at 6 to 24 months after sphincter-saving surgery

The aim of this study was to describe bowel problems, self-care practices, and information needs of patients who have recovered from the acute effects of sphincter-saving surgery for colorectal cancer. A retrospective, descriptive survey was conducted using a structured telephone interview and mailed questionnaires. The sample consisted of 101 patients who had undergone sphincter-saving surgery for colorectal cancer in the last 6 to 24 months. Most participants (71.3%) reported a change in bowel habits after surgery. The 6 most frequently reported gastrointestinal problems were incomplete evacuation (75.2%), excessive flatus (75.2%), urgency (73.3%), straining (61.4%), perianal soreness or itching (49.5%), and bloating (43.6%). Incontinence of feces (varying from smears to complete bowel action) was reported by 37.6% of participants. The most frequently reported information needs were related to diet (50.5%) and managing conditions such as diarrhea (31.7%), bloating/wind/gas (28.7%), pain (21.8%), and incomplete emptying of the bowel (18.8%). Patients who had recovered from the acute effects of sphincter-saving surgery for colorectal cancer reported a wide range of bowel problems and ongoing concerns about managing symptoms. Findings from this study provide valuable information to guide the development of educational resources to prevent or better manage bowel problems after surgery.

Does age really matter? Recall of information presented to newly referred patients with cancer

PURPOSE

To examine age- and age-related differences in recall of information provided during oncology consultations.

PATIENTS AND METHODS

Two hundred sixty patients with cancer diagnosed with heterogeneous cancers, seeing a medical or radiation oncologist for the first time, participated in the study. Patients completed questionnaires assessing information needs and anxiety. Recall of information provided was measured using a structured telephone interview in which patients were prompted to remember details physicians gave about diagnosis, prognosis, and treatment. Recall was checked against the actual communication in audio-recordings of the consultations.

RESULTS

Recall decreased significantly with age, but only when total amount of information presented was taken into account. This indicates that if more information is discussed, older patients have more trouble remembering the information than younger ones. In addition, recall was selectively influenced by prognosis. First, patients with a poorer prognosis recalled less. Next, the more information was provided about prognosis, the less information patients recalled, regardless of their actual prognosis.

CONCLUSION

Recall is not simply a function of patient age. Age only predicts recall when controlling for amount of information presented. Both prognosis and information about prognosis are better predictors of recall than age. These results provide important insights into intervention strategies to improve information recall in patients with cancer.

Supporting the carers of individuals affected by colorectal cancer

Colorectal cancer is one of the most common cancers, and many difficulties may be experienced as a direct consequence of the disease and its treatment. These can be alleviated and/or resolved with appropriate care. Much of this care is provided informally by the individual's family and friends, whose care needs may be practical, emotional, financial, spiritual or organizational in nature. Care requirement can, as a consequence, be variable in its responsibilities, regularity and duration, since the individual diagnosed with colorectal cancer may require a wide range of support throughout their cancer journey, or have only a few temporary care needs, depending on their disease, treatment and a multitude of other personal, interpersonal and contextual factors. This highlights the importance of regular and individualized assessment. The caregiver's role is often forgotten and hence the impact it may be having upon their own health and lives gets overlooked. Yet, a carer's ability to manage this role has an important bearing not only on patient experience but also on the level of professional involvement. To perform this role satisfactorily carers need to be prepared, supported and also assessed at key points in the patient's cancer journey. Nurses have a professional obligation to help carers by first preparing them, then maintaining sufficient contact to be able to proactively provide practical support and additional health care as needed. This article focuses on these carers and highlights the scope, associated challenges and possible consequences of the caring role. It also seeks to stimulate reflection of how current service provision for carers might be improved.

Informational needs of patients and perceived adequacy of information available before and after treatment of cancer

To examine the various concerns of patients after being diagnosed with cancer as well as the availability of information to address concerns from the time of diagnosis to the completion of treatment, we analyzed data from a longitudinal study of 731 adults recently diagnosed with cancer. Concerns about the effectiveness and side effects of treatment and family stress were most common after diagnosis. Information about the diagnosis and treatment plan was readily available to patients, but information addressing social, lifestyle, and financial concerns was less available. Significantly more information was desired regarding the long-term implications of treatment and disease.

Compliance, attitudes and barriers to post-operative colorectal cancer follow-up

RATIONALE

Meta-analyses demonstrate that surveillance following curative-intent colorectal cancer (CRC) surgery can improve survival. Our multidisciplinary team adopted a stringent CRC follow-up (FU) guideline in 2000. The purpose of this study was to assess adherence and barriers to FU for CRC.

METHODS

Patients with primary CRC aged 19-75 years, treated with curative intent surgery from July 2000 to December 2002 were identified from a prospective database. Compliance with FU was assessed primarily by chart review. We also surveyed patients and providers to explore attitudes and barriers to surveillance adherence using tenets of the Health Belief Model.

RESULTS

96 patients met inclusion criteria and were appropriate for FU. Median FU was 34 months. Guideline targets were met for 70% of clinic visits; 49% of carcinoembryonic antigen (CEA) determinations; and 62% of abdominal imaging studies. Post-operative colonoscopy did not occur in 6/93 patients. Seventy per cent of health care providers and 55% of patients completed a survey. Access to testing and confusion about which provider orders investigations were identified as important barriers to FU.

CONCLUSION

Patterns of CRC FU were widely variable despite implementation of a guideline. Despite patient and provider agreement with the principles of CRC FU, adoption was inhibited by confusion among multiple providers regarding investigation coordination.

Unmet needs in cancer patients: development of a supportive needs screening tool (SNST)

GOALS OF WORK

A diagnosis of cancer can have a profound impact on the physical, emotional, psychological, social and spiritual areas of a person's life. Supportive care services are directed towards this full range of issues associated with cancer. Identification of need is the first step in meeting supportive care concerns, but there is a lack of tools and processes regularly used in clinical practice. This article reports the first steps in the development of a supportive needs screening tool appropriate for use in an oncology outpatient setting.

MATERIALS AND METHODS

A review of the literature was undertaken, and a draft tool developed using a process of item reduction. A small pre-test followed by a pilot test with 87 patients attending Peter MacCallum Cancer Centre, Melbourne Australia was undertaken. Evaluation to identify usability and acceptability in clinical practice included descriptive statistics to profile patient needs and referrals generated by the supportive needs screening tool (SNST), interviews with a small sample of participants and surveys completed by staff.

MAIN RESULTS

The SNST was developed with 41 questions, the majority requiring a yes/no response. From the tool, a total of 1,085 needs were identified (mean = 12 needs/patient). A total of 264 referrals were generated, with 72% of patients receiving at least one referral. Patients and staff reported high acceptability.

CONCLUSIONS

The SNST has face validity and demonstrated usability in an ambulatory care oncology stetting, as first steps in instrument development. Further testing of reliability and validity are being undertaken.

Patients' experiences of completing treatment for colorectal cancer in a Scottish District General Hospital

A review of the cancer literature from 1990 to 2003 indicated that some patients with cancer felt abandoned by healthcare professionals upon completion of treatment. With this in mind, a small qualitative study was undertaken to explore the experiences of patients completing treatment for colorectal cancer within a Scottish District General Hospital. A small purposeful sample of eight participants (surgery only n = 4 and surgery with adjuvant chemotherapy n = 4) who had completed treatment were recruited. Semi-structured interviews, in a venue chosen by the participants (home n = 7; hospital n = 1), were tape-recorded and transcribed verbatim. The mean time since completion of treatment was 30 weeks (range 9-95 weeks). Transcripts were read and reread several times to identify categories. By thematic analysis, five categories were identified: physical impact of treatment, completion of treatment, support of family and friends, impact of healthcare professionals and coping mechanisms. Despite the significant physical impact of treatment patients returned to their previous lifestyles and status. Although very optimistic and positive when treatment was completed, participants reflected upon their cancer recurring. Family and friends were the main providers of support during their experiences, and healthcare professionals impacted upon participants both positively and negatively. Overall, the completion of treatment was described as a 'great feeling' and 'relief', with patients reporting that they felt adequately supported by healthcare professionals after completion of treatment.

Step by step development of clinical care pathways for older cancer patients: necessary or desirable?

Medical and nursing staff in oncology for older cancer patients are confronted with a range of problems including co-morbidity, poly-pharmacy, cognitive impairments, emotional problems, functional limitations, sensory impairment and a lack of social support. Comprehensive geriatric assessment identifies many of the existing problems and can be used to estimate life expectancy and tolerance of treatment. However, health care providers have to interpret and apply the medical and nursing information and must deal with specific problems and care needs throughout the continuum of cancer care. Imperfect interdisciplinary communication, cooperation and patient-provider communication may further complicate the care actually delivered. A clinical care pathway aims to improve continuity, increase multidisciplinary tuning and deliver appropriate patient education, treatment and care for vulnerable older cancer patients. This paper gives an overview of common problems in older cancer patients and addresses communication barriers through the development of clinical care pathways in geriatric oncology.