Nina Rottmann

Impact of symptom burden on health related quality of life of cancer survivors in a Danish cancer rehabilitation program: A longitudinal study

Abstract Introduction. Little research has been conducted on the effect of self-reported rating of symptom severity on quality of life (QoL) among cancer survivors. The aim of the study was to examine the prevalence of symptoms and whether information about self-reported symptom severity adds value to QoL measurements. Material and methods. A questionnaire including the EORTC QLQ-C30 and an empirically derived symptom check-list was completed by 2 486 cancer survivors participating in a rehabilitation program at baseline and at 1, 6 and 12 months’ follow-up. We used multivariate linear regression models to evaluate the association between QoL and the dichotomous variables for perceived symptom severity (high vs. low) and cancer stage (high vs. low), with adjustment for age, gender, education and time since diagnosis. Results. Of the 2 379 participants who reported having one or more symptoms, 1 479 (62%) considered the reported symptom to be severe. This subgroup had significantly poorer QoL at baseline for all sites, ranging from −15.9 to −10.2, compared to those who did not regard their symptom as severe. Significantly lower baseline levels on all functional subscales were seen for all sites in association with high perceived symptom severity (range from −9.9 to −3.0 (physical functioning), from −21.1 to −13.0 (social functioning), from −18.8 to −8.5 (emotional functioning), and from −18.4 to −9.6 (cognitive functioning). The impairment of physical, social, emotional, and cognitive functioning persisted through 12 months for participants with cancer of the breast, lung and those with lymphomas, although not all reached significance. Discussion. Cancer survivors, irrespective of cancer site, experience a high burden of symptoms. Thorough monitoring and assessment of symptoms and careful scrutiny of cancer survivors’ perceptions of how symptoms affect their lives is critical for clinical identification of patients who might benefit from enhanced medical attention and may be an important supplement to QoL measures.

Association between unmet needs and quality of life of cancer patients: A population-based study

Abstract Background. Two conceptually different morbidity outcomes unmet needs and health-related quality of life are used to identify cancer patients in need of clinical attention and to evaluate rehabilitation programmes. The knowledge on the interrelation between unmet needs and health-related quality of life is scarce. This paper studies the hypothesis that patient-perceived unmet needs of rehabilitation during the cancer trajectory are associated with decreased quality of life. Material and methods. Based on registers, a Danish population-based cohort of adult, incident, mixed-site cancer patients diagnosed between 1 October 2007 and 30 September 2008 was established. At 14 months following diagnosis participants completed a questionnaire including health-related quality of life (EORTC QLQ C-30), psychological distress (POMS-SF), and unmet needs with regard to physical, emotional, family-oriented, sexual, work-related, and financial problems. Unmet needs were assessed through six ad hoc questions. Results. Questionnaires were received from 3439 of 4947 patients, resulting in a response rate of 70%. The three most frequent cancer types were breast (28.4%), prostate (14.6%) and colorectal cancer (15.2%). Overall, 60.1% expressed an unmet need of rehabilitation in at least one area, physical and emotional problems being the most frequent (40.0% and 37.5%). For all scales of the EORTC QLQ C-30 and POMS, significant adjusted mean differences were observed between patients with unmet needs in at least one area and patients with no unmet needs (p-values < 0.001). These differences were well above levels usually considered clinically relevant. Further, impairment increased with increasing number of areas in which unmet needs were reported. Discussion. We confirmed the hypothesis that patient-perceived unmet needs of rehabilitation during the cancer trajectory are associated with decreased quality of life. This study supports the use of unmet needs questions to identify patients in need of clinical attention. Interventions reducing cancer patients’ perceived needs of rehabilitation may enhance quality of life.

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’.

Social inequality and incidence of and survival from cancers of the colon and rectum in a population-based study in Denmark, 1994-2003

We investigated the effects of socioeconomic indicators, demographic indicators and health-related indicators on the incidence of and survival from colon cancer and rectal cancer diagnosed in 1994-2003 with follow-up through 2006 in Denmark using information from nationwide registers. The analyses were based on data on 9958 patients with colon cancer and 7411 patients with rectal cancer in a cohort of 3.22 million people born between 1925 and 1973 and aged >or=30 years. Higher incidences of colon and rectal cancers were associated with greater social disadvantage, predominantly amongst men, in regard to cohabiting status, housing tenure, dwelling size and affiliation to the work market. Comorbidity was associated with a higher incidence of colon cancer in both sexes. Short- and long-term relative survival from both colon and rectal cancers decreased with poorer education, disposable income, affiliation to the work market, housing tenure, dwelling size and cohabiting status.

Unmet needs in cancer rehabilitation during the early cancer trajectory – a nationwide patient survey

Abstract Background. A cancer diagnosis may lead to psychosocial problems and physical symptoms that can be relieved during rehabilitation. The aim of this study was to analyse patient-perceived unmet needs of rehabilitation close to time of diagnosis, i.e. frequencies of unmet needs and the association with sociodemographic characteristics, cancer type and treatment. Material and methods. All adult residents of Denmark diagnosed with cancer for the first time from 1 May to 31 August 2010 were mailed a patient questionnaire two to five months following diagnosis. The study population was identified by use of national administrative registers. Data on rehabilitation, family situation, education, and cancer treatment were obtained from the questionnaire, while sex, birth year and cancer type were obtained from the Danish National Patient Registry. The association between each type of unmet needs and the variables sex, age, cancer diagnosis, treatment, education, cohabitation status, and children (living at home and away from home) was analysed using multiple logistic regression. Results. Among the 4346 participants (64.7%) unmet needs were reported with regard to talking to patients in the same situation (24.1%), counselling with a psychologist (21.4%), physical rehabilitation (18.8%), practical help (17.3%), and counselling related to work or education (14.8%). Differences were observed with regard to type of unmet needs, sociodemographic and clinical characteristics, but generally, young age, male sex, low educational level and living alone increased the adjusted odds ratios of unmet needs. Breast cancer and to some extent melanoma cancer decreased the odds. Conclusion. Unmet needs of rehabilitation are frequent during the early cancer trajectory and sociodemographic and clinical inequalities exist. The results support guideline recommendations of integration of cancer rehabilitation from the beginning of the cancer trajectory. Early interventions tailored to men, patients with low educational level, living alone, or treated with chemotherapy may help counterbalancing social and clinical inequalities in the long run.

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.

Post-traumatic growth among elderly women with breast cancer compared to breast cancer-free women

Abstract Background. Although breast cancer (BC) may have negative psychological sequelae, it may also be experienced as an existential challenge, which can derive personal growth. Only one study has been conducted, however, on whether women with BC experience more post-traumatic growth (PTG) than BC-free women. We examined PTG in women with and without BC and whether the characteristics and treatment of BC were associated with PTG. Material and methods. We used data from the questionnaire administered in the Diet, Cancer and Health cohort and included 774 women with BC and 666 randomly sampled BC-free women aged 63–81 years. PTG was measured with the PTG inventory, for which the women identified their own traumatic or life-changing event. Linear regression was used to compare PTG in women with and without BC and to examine the association between BC characteristics and treatment and PTG. Results. Although women with BC experienced significantly more PTG in the domains ‘appreciation of life’ and ‘relating to others’ compared to BC-free women, no statistically significant difference in overall PTG was observed according to BC status, indicating that PTG is not limited to women with BC. Tumor size, number of positive lymph nodes, having undergone mastectomy and having received endocrine treatment were positively associated with overall PTG and/or specific PTG domains, implying that the severity of disease plays a role in the development of PTG. Conclusion. In order to avoid unnecessary pressure for personal growth, healthcare professionals should not expect that women with BC experience more PTG than BC-free women.

Patients’ Needs and Experiences at Breast Cancer Diagnosis: How Perceived Threat Influences the Physician–Patient Interaction

Physician–patient interaction at breast cancer diagnosis can only succeed if physicians know what patients want. To investigate patients’ needs and experiences we conducted semistructured interviews with eight patients. Verbatim transcripts were analyzed according to grounded theory and a typological approach. Patients’ needs and experiences concurred with a patient-centered approach in many aspects. The threat perceived by patients following diagnosis strongly influenced their needs and experiences. Three different types of patients were identified: emotionally needy, active, and trustful, adaptive. The typology identified in this study may help physicians to adequately adapt their behavior.

No change in health behavior, BMI or self-rated health after a psychosocial cancer rehabilitation: Results of a randomized trial

Abstract Introduction. The aim of cancer rehabilitation is to enable patients to attain and maintain optimal physical, psychological and social functioning. We evaluated the effect on health behavior, BMI and self-rated health of a residential psychosocial rehabilitation course for cancer patients. Material and methods. Patients with a primary cancer of the breast, prostate, colon or rectum were randomized to either a six-day multi-focus psychosocial residential rehabilitation intervention that included lectures, discussions and peer group discussions on issues related to treatment and life with cancer or to usual care. The end points were changes in smoking, alcohol consumption, physical activity, body mass index and self-rated health between baseline and follow-up after one and six months. The primary analyses included all participants who received their allocated condition. The two follow-up times were analyzed separately in general linear and logistic regression models for continuous and dichotomous outcomes, respectively. The analyses were adjusted for baseline outcome score, cancer site, time since diagnosis, age and education. Results. Of the 507 participants who were randomly assigned, 452 were included in the analysis, of whom 404 completed the one month and 394 completed the six month assessment. The intervention group showed slightly more positive changes in health behavior, BMI and self-rated health than the usual care group, but the differences between the groups were small and not significant. Discussion. Participation in a six-day cancer rehabilitation course did not significantly influence health behavior, BMI or self-rated health among cancer patients.

Satisfaction with sex life in sexually active heterosexual couples dealing with breast cancer : a nationwide longitudinal study

Abstract Background: A breast cancer (BC) diagnosis can profoundly affect the sex life of patient and partner within a couple. The purpose of the present study is to examine whether individual and partner sexual functioning, affectionate behavior, emotional closeness and depressive symptoms are associated with change over time in satisfaction with sex life of sexually active heterosexual couples dealing with BC and to explore whether the associations differ between patients and partners after adjustment for basic sociodemographic characteristics, comorbidity and BC treatment. Material and methods: Women with BC and their male partners participated in a longitudinal study (Time 1, ≤4 months after surgery; Time 2, 5 months later). Participants completed items from the PROMIS® Sexual Function and Satisfaction measure (version 1.0), two items measuring affectionate behavior, a single item measuring emotional closeness and the Center for Epidemiologic Studies-Depression Scale. Registers provided sociodemographic and medical information. Multilevel models were used, which take the interdependency of couples’ scores into account. Results: A total of 287 sexually active couples were included in the analyses. Less vaginal discomfort and more vaginal lubrication were associated with increases in patients’ satisfaction with sex life. Patients’ and partners’ satisfaction increased with higher ratings of their own orgasm ability and of partners’ timing of ejaculation. Patients’ reports of affectionate behavior were positively associated with their partners’ satisfaction, and vice versa for partners. Patients’ satisfaction increased the more emotional closeness their partner experienced. Partners’ depressive symptoms were negatively associated with their satisfaction. Sociodemographic factors and BC treatment were not significantly associated with change in satisfaction. Conclusion: Satisfaction with sex life in sexually active couples dealing with BC needs to be seen as a couple issue. Health professionals should take the partner into account when addressing sexuality issues. Couples’ functioning and relationship-related factors may be promising targets for couple interventions.