Birgitte Goldschmidt Mertz

Accuracy of the Danish version of the ‘distress thermometer’

Objective: Short screening instruments have been suggested to improve the detection of psychological symptoms. We examined the accuracy of the Danish version of the ‘Distress Thermometer’.

Unmet needs of women with breast cancer during and after primary treatment: A prospective study in Denmark

Abstract Integrated plans will be required to ensure care and rehabilitation for the growing number of cancer survivors. Information is lacking, however, about the extent to which patients’ rehabilitation needs are being met, and characteristics of patients who experience unmet needs after their diagnosis and throughout the disease trajectory. Material and methods. Consecutive women with newly diagnosed breast cancer, undergoing surgery at the Breast Surgery Clinic, Rigshospitalet, Denmark, between 2008 and 2009 (N = 261), completed questionnaires on their unmet needs, anxiety, physical functioning, social support and demographic factors at the time of surgery and four and eight months after diagnosis. Associations between demographic and clinical factors at baseline and unmet needs four and eight months after diagnosis were examined in logistic regression models. Results. The percentage of women with unmet needs remained stable between four (42%) and eight months (40%). Unmet needs were reported for patient education, counselling and alternative treatment. The factors significantly associated with having unmet needs were younger age (OR 0.92; 95% CI 0.89–0.95), higher education (OR 2.49; 95% CI 1.14–5.44), not having a partner (OR 2.25; 95% CI 1.22–4.17) and anxiety (OR 1.13; 95% CI 1.05–1.20) at four months; and age (OR 0.91; 95% CI 0.87–0.94), not having a partner (OR 2.21; 95% CI 1.10–4.46) and having had one or more unmet needs at four months (OR 6.83, 95% CI 3.55–13.16) at eight months. Conclusion. A total of 53% of women with breast cancer had unmet needs at some time between diagnosis and the end of primary treatment (eight months after diagnosis). A contextual understanding of unmet needs is necessary for planning cancer rehabilitation, as not only factors such as anxiety, physical functioning and previous unmet needs but also age, education and relationship status are associated with unmet needs.

Trajectories of distress, anxiety, and depression among women with breast cancer: Looking beyond the mean

Abstract Objective. Little is known about the development of psychological wellbeing over time among women who have been treated for breast cancer. The aim of this study was to identify distinct patterns of distress, anxiety, and depression in such women. Methods. We invited 426 consecutive women with newly diagnosed primary breast cancer to participate in this study, and 323 (76%) provided information on distress (‘distress thermometer’) and on symptoms of anxiety and depression (‘hospital anxiety and depression scale’). Semiparametric group-based mixture modeling was used to identify distinct trajectories of distress, anxiety, and depressive symptoms assessed the week before surgery and four and eight months later. Logistic regression analysis was used to evaluate the characteristics of women in the distinct groups. Results. Although no sub-group of women with chronic severe anxiety or depressive symptoms was found, we did identify a sub-group of 8% of the women who experienced continuously severe distress. Young age, having a partner, shorter education, and receiving chemotherapy but not radiotherapy might characterize women whose psychological symptoms remain strong eight months after diagnosis. Conclusion. By looking beyond the mean, we found that 8% of the women experienced chronic severe distress; no sub-groups with chronic severe anxiety or depression were identified. Several socio-demographic and treatment factors characterized the women whose distress level remained severe eight months after diagnosis. The results suggest that support could be focused on relatively small groups of patients most in need.

Implementation of an ultra-short hospital stay for breast cancer patients

Although it is well known that early discharge and day surgery has been successfully carried out in other countries (de Kok et al., 2007, 2008; Kehlet andWilmore, 2008) it has been commonpractice in Denmark that patients were hospitalized for 3–5 days following breast cancer surgery. Postoperative nausea and vomiting has been one of the main reasons why the patient had to stay in hospital, psychosocial aspects and the need of care and counselling another. Furthermore, tradition and the force of habit have played a major part. The average admission time for patients undergoing breast cancer surgery at a large university hospital in Denmark has been reduced from 3.6 days to 1.2 days. It has been a challenging process for the nursing staff to enhance psychosocial support and counsellingwhile reducing the length of stay. A quality improvement project was designed, focusing on nursing care and emotional aspects.

Pain, sensory disturbances and psychological distress are common sequelae after treatment of ductal carcinoma in situ: a cross-sectional study

Abstract Sequelae such as pain, sensory disturbances and psychological distress are well known after treatment for invasive breast cancer (IBC). Patients treated for ductal carcinoma in situ (DCIS) receive a similar treatment as low-risk IBC. The aim of this cross-sectional study was to describe prevalence of postoperative pain, sensory disturbances, psychological distress and rehabilitation needs among Danish women with DCIS. Methods: A total of 574 women treated for DCIS in Denmark in 2013 and 2014 were enrolled and 473 (82%) completed a detailed questionnaire on demographic factors, pain, sensory disturbances, psychological aspects and rehabilitation needs 1–3 years after surgery. Results: Median age was 60 years. A total of 33% of patients reported any pain and 12% reported moderate to severe pain in the area of surgery. Younger age (<50 years OR 4.7 (95% CI: 1.6–14.0, p = 0.006)), aged 50 to 65 years OR 2.8 (95% CI: 1.1–7.0, p = 0.02) and anxiety and depression (measured by HADStotal >15 OR of 3.1 (95% CI: 1.5–6.3, p = 0.003)) were significantly associated with moderate to severe pain. Approximately one-third of the patients reported sensory disturbances such as pins and needles (32%), numbness (37%) and painful itch (30%) and 94 women (20%) reported anxiety ≥8, 26 (6%) depression and 51 (11%) reported distress. Conclusions: This cross-sectional study showed that women treated for DCIS suffered from pain, sensory disturbances and psychological impairment and had unmet rehabilitation needs. Further research is warranted, specifically addressing rehabilitation after diagnosis and treatment of DCIS.

The effects of individually tailored nurse navigation for patients with newly diagnosed breast cancer: a randomized pilot study

Abstract Aim: Our aim was to determine the feasibility and effectiveness of an individual, nurse-navigator intervention for relieving distress, anxiety, depression and health-related quality of life in women who have been treated for breast cancer (BC) and are experiencing moderate-to-severe psychological and physical symptoms. Methods: Fifty women with newly diagnosed BC who reported distress (score ≥7 on distress thermometer) before surgery were included consecutively in a pilot study and randomized 1:1 to the intervention or the control group. The intervention comprised repeated screening with patient reported outcome measures and nurse navigation. A total of 66 women who were not distressed (score <7) were followed longitudinally as an observational group. Participants filled in four questionnaires, at baseline, after 6 months and 12 months. The primary outcome was psychological distress and the secondary outcomes were anxiety, depression, health-related quality of life and feasibility of the intervention. Results: Women in the intervention group reported significantly greater satisfaction with treatment and rehabilitation and lower levels of distress (mean 2.7 vs. 5.1, p<.01), anxiety (mean 5.1 vs. 7.8, p = .02) and depression (mean 2.2 vs. 4.4, p = .04) after 12 months compared to the control group. No significant effects were seen on health-related quality of life. Conclusions: The study shows promising feasibility of the individually tailored nurse-navigation intervention and while no significant effects were observed after 6 months, we did find statistically significant effects on distress, anxiety and depression 12 months after diagnosis. Our results will assist in developing rehabilitation to the most vulnerable patients.

Tailored nurse navigation for women treated for breast cancer: Design and rationale for a pilot randomized controlled trial

Women with breast cancer may experience a number of psychological and physical symptoms during treatment [1]. Although some symptoms attenuate over time, certain patients may have continuously severe symptoms even after the end of treatment [2]. In Denmark, a municipal rehabilitation system is used to help manage such symptoms, in collaboration with hospitals and general practitioners. Nevertheless, breast cancer patients still report that they need support and symptom management [3]. The greatest challenges in cancer care reported by patients, caregivers and care providers are: delay and lack of coordination of care, lack of information and inadequate management of psychological and social problems [4]. Attempts to optimize and integrate cancer rehabilitation have included patient-reported outcomes (PRO) and patient navigation. PROs may improve communication between patients and health professionals [5] and potentially also symptoms [6], but overall only a small-to-moderate effect has been reported on symptoms [7]. Originally, patient navigation was conceived to overcome that African–Americans were diagnosed at a disproportionately later cancer stage than whites, by providing timely medical services by lay health workers [8]. Today nurse navigation often implies being the general patient’s advocate and source of support emphasizing skills in empathic listening, assessing and addressing patients’ symptoms [9]. Three randomized controlled trials (RCTs) have evaluated oncology navigation programs [4,10,11], lay people were used as navigators in one [10] and nurses in the other two [9,11]. Although the studies show positive patient experience and fewer problems in care, none of the studies indicates reduction in patient-reported psychological or physical symptoms, perhaps due to that all women were invited to participate independent of distress level [9,11]. In a previous study, we found that about 40% of the women were distressed already at diagnosis [12–14] and while many are able to manage their symptoms through existing cancer care services, some experienced continuous symptoms. Thus, evidence-based models tested in high-quality RCTs are required for optimal management of these cancer-related symptoms. We describe here the rationale behind the design, delivery and evaluation of a screening-based nurse navigation program for optimizing rehabilitation of women with breast cancer. To justify ethically a large RCT with potential generalizability to the Danish population of women with breast cancer, we decided first to obtain results in a pilot study. Data collection after 12 months’ follow-up will be reported in late 2016. Methods and analysis