Predictive risk models are advocated in psychosocial oncology practice to provide timely and appropriate support to those likely to experience the emotional and psychological consequences of cancer and its treatments. New digital technologies mean that large scale and routine data collection are becoming part of everyday clinical practice. Using these data to try to identify those at greatest risk for late psychosocial effects of cancer is an attractive proposition in a climate of unmet need and limited resource. In this paper, we present a framework to support the development of high-quality predictive risk models in psychosocial and supportive oncology. The aim is to provide awareness and increase accessibility of best practice literature to support researchers in psychosocial and supportive care to undertake a structured evidence-based approach.
Objective: To develop a predictive risk model (PRM) for patient-reported anxiety after treatment completion for early stage breast cancer suitable for use in practice and underpinned by advances in data science and risk prediction.
Methods: Secondary analysis of a prospective survey of > 800 women at the end of treatment and again 6 months later using patient reported outcome (PRO) the hospital anxiety and depression scale-anxiety (HADS-A) and > 20 candidate predictors. Multiple imputation using chained equations (for missing data) and least absolute shrinkage and selection operator (LASSO) were used to select predictors. Final multivariable linear model performance was assessed (R2) and bootstrapped for internal validation.
Results: Five predictors of anxiety selected by LASSO were HADS-A (Beta 0.73; 95% CI 0.681, 0.785); HAD-depression (Beta 0.095; 95% CI 0.020, 0.182) and having caring responsibilities (Beta 0.488; 95% CI 0.084, 0.866) increased risk, whereas being older (Beta - 0.010; 95% CI -0.028, 0.004) and owning a home (Beta 0.432; 95% CI -0.954, 0.078) reduced the risk. The final model explained 60% of variance and bias was low (- 0.006 to 0.002).
Conclusions: Different modelling approaches are needed to predict rather than explain patient reported outcomes. We developed a parsimonious and pragmatic PRM. External validation is required prior to translation to digital tool and evaluation of clinical implementation. The routine use of PROs and data driven PRM in practice provides a new opportunity to target supportive care and specialist interventions for cancer patients.
Harris Jenny, Stansfield S A, Pike C, McManus S, Bebbington P, Brugha T, Hassiotis A, Jenkins R, Meltzer H, Moran P, Clark C Occupations, work characteristics and common mental disorder, In: PSYCHOLOGICAL MEDICINE43(5)pp. pp 961-973
CAMBRIDGE UNIV PRESS
Background. The present study aimed to assess the prevalence of common mental disorders (CMDs) by occupation in a representative sample of the English adult population. Another aim was to examine whether the increased risk of CMD in some occupations could be explained by adverse work characteristics. Method. We derived a sample of 3425 working-age respondents from the Adult Psychiatric Morbidity Survey 2007. Occupations were classified by Standard Occupational Classification group, and CMD measured by the Revised Clinical Interview Schedule. Job characteristics were measured by questionnaire, and tested as explanatory factors in associations of occupation and CMD. Results. After adjusting for age, gender, housing tenure and marital status, caring personal service occupations had the greatest risk of CMD compared with all occupations (odds ratio 1.73, 95% confidence interval 1.16–2.58). The prevalence of adverse psychosocial work characteristics did not follow the pattern of CMD by occupation. Work characteristics did not explain the increased risk of CMDs associated with working in personal service occupations. Contrary to our hypotheses, adding work characteristics individually to the association of occupation and CMD tended to increase rather than decrease the odds for CMD. Conclusions. As has been found by others, psychosocial work characteristics were associated with CMD. However, we found that in our English national dataset they could not explain the high rates of CMD in particular occupations. We suggest that selection into occupations may partly explain high CMD rates in certain occupations. Also, we did not measure emotional demands, and these may be important mediators of the relationship between occupation type and CMDs.
The widespread introduction of multidisciplinary team (MDT)-work for breast cancer management has in part evolved due to the increasing complexity of diagnostic and treatment decision-making. An MDT approach aims to bring together the range of specialists required to discuss and agree treatment recommendations and ongoing management for individual patients. MDTs are resource-intensive yet we lack strong (randomized controlled trial) evidence of their effectiveness. Clinical consensus is generally favorable on the benefits of effective specialist MDT-work. Many studies have shown the benefits of receiving treatment from a specialist center, and evidence continues to accrue from comparative studies of clinical benefits of an MDT approach, including improved survival. Patients’ views of the MDT model of decision-making (and in particular its impact on involvement in decisions about their care) have been under-researched. Barriers to effective teamwork and poor decision-making include excessive caseload, low attendance at meetings, lack of leadership, poor communication, role ambiguity, and failure to consider patients’ holistic needs. Breast cancer nurses have a key role in relation to assessing holistic needs, and their specialist contribution has also been associated with improved patient experience and quality of life. This paper examines the evidence for the benefits of MDT-work, in particular for breast cancer. Evidence is considered within a context of growing cancer incidence at a time of increased financial restraint, and it may now be important to reevaluate the structure and models of MDT-work to ensure that MDTs are an efficient use of resources.
Objective: To develop a tool for independent observational assessment of cancer multidisciplinary team meetings (MDMs), and test criterion validity, inter-rater reliability/agreement and describe performance. Design: Clinicians and experts in teamwork used a mixed-methods approach to develop and refine the tool. Study 1 observers rated pre-determined optimal/sub-optimal MDM film excerpts and Study 2 observers independently rated video-recordings of 10 MDMs. Setting: Study 2 included 10 cancer MDMs in England. Participants: Testing was undertaken by 13 health service staff and a clinical and non-clinical observer. Intervention: None. Main Outcome Measures: Tool development, validity, reliability/agreement and variability in MDT performance. Results: Study 1: Observers were able to discriminate between optimal and sub-optimal MDM performance (P ≤ 0.05). Study 2: Inter-rater reliability was good for 3/10 domains. Percentage of absolute agreement was high (≥80%) for 4/10 domains and percentage agreement within 1 point was high for 9/10 domains. Four MDTs performed well (scored 3+ in at least 8/10 domains), 5 MDTs performed well in 6–7 domains and 1 MDT performed well in only 4 domains. Leadership and chairing of the meeting, the organization and administration of the meeting, and clinical decision-making processes all varied significantly between MDMs (P ≤ 0.01). Conclusions: MDT-MOT demonstrated good criterion validity. Agreement between clinical and nonclinical observers (within one point on the scale) was high but this was inconsistent with reliability coefficients and warrants further investigation. If further validated MDT-MOT might provide a useful mechanism for the routine assessment of MDMs by the local workforce to drive improvements in MDT performance.
Purpose: To identify potential candidate predictors of anxiety in women with early stage breast cancer (BC) after adjuvant treatments and evaluate methodological development of existing multivariable models to inform the future development of a predictive risk stratification model (PRSM).
Methods: Databases (MEDLINE, Web of Science, CINAHL, CENTRAL and PsycINFO) were searched from inception to November 2015. Eligible studies were prospective, recruited women with stage 0-3 BC, used a validated anxiety outcome ≥ 3 months' post-treatment completion and used multivariable prediction models. Internationally accepted quality standards were used to assess predictive risk of bias and strength of evidence.
Results: Seven studies were identified, five were observational cohorts and two secondary analyses of RCTs. Variability of measurement and selective reporting precluded meta-analysis. Twenty-one candidate predictors were identified in total. Younger age and previous mental health problems were identified as risk factors in ≥ 3 studies. Clinical variables (e.g. treatment, tumour grade) were not identified as predictors in any studies. No studies adhered to all quality standards.
Conclusions: Pre-existing vulnerability to mental health problems and younger age increased the risk of anxiety after completion of treatment for BC survivors, but there was no evidence that chemotherapy was a predictor. Multiple predictors were identified but many lacked reproducibility or were not measured across studies, and inadequate reporting did not allow full evaluation of the multivariable models. The use of quality standards in the development of PRSM within supportive cancer care would improve model quality and performance thereby allowing professionals to better target support for patients.
Aouizerat B, Melisko M, Chen LM, Dunn L, Hu X, Kober KM, Mastick J, Levine JD, Hammer M, Wright F, Harris Jenny, Armes Jo, Furlong E, Fox P, Ream Emma, Maguire Roma, Kearney N, Cooper BA, Miaskowski C (2017)The symptom phenotype of oncology outpatients remains relatively stable from prior to through 1 week following chemotherapy., In: European Journal of Cancer Care26(3)e12437pp. 1-12
Some oncology outpatients experience a higher number of and more severe symptoms during chemotherapy (CTX). However, little is known about whether this high risk phenotype persists over time. Latent transition analysis (LTA) was used to examine the probability that patients remained in the same symptom class when assessed prior to the administration of and following their next dose of CTX. For the patients whose class membership remained consistent, differences in demographic and clinical characteristics, and quality of life (QOL) were evaluated. The Memorial Symptom Assessment Scale (MSAS) was used to evaluate symptom burden. LTA was used to identify subgroups of patients with distinct symptom experiences based on the occurrence of the MSAS symptoms. Of the 906 patients evaluated, 83.9% were classified in the same symptom occurrence class at both assessments. Of these 760 patients, 25.0% were classified as Low-Low, 44.1% as Moderate-Moderate and 30.9% as High-High. Compared to the Low-Low class, the other two classes were younger, more likely to be women and to report child care responsibilities, and had a lower functional status and a higher comorbidity scores. The two higher classes reported lower QOL scores. The use of LTA could assist clinicians to identify higher risk patients and initiate more aggressive interventions.
This study investigates potential explanations of the association between caring and common mental disorder, using the English Adult Psychiatric Morbidity Survey 2007. We examined whether carers are more exposed to other stressors additional to caring–such as domestic violence and debt–and if so whether this explains their elevated rates of mental disorder. We analysed differences between carers and non-carers in common mental disorders (CMD), suicidal thoughts, suicidal attempts, recent stressors, social support, and social participation. We used multivariate models to investigate whether differences between carers and non-carers in identifiable stressors and supports explained the association between caring and CMD, as measured by the revised Clinical Interview Schedule. The prevalence of CMD (OR= 1.64 95% CI 1.37–1.97), suicidal thoughts in the last week (OR …
Harris Jenny, Tsianakas V, Ream Emma, Van Hemelrijck M, Purushotham A, Mucci L, Green J, Robb K, Fewster J, Armes Jo (2015)CanWalk: study protocol for a randomized feasibility trial of a walking intervention for people with recurrent or metastatic cancer, In: Pilot and feasibility studies1(1)
Increasing numbers of people in the UK are living with recurrent or metastatic cancer, many of whom experience reduced quality of life resulting from the physical and psychosocial consequences of cancer and its treatment. While drug treatments are important at alleviating some symptoms, there is increasing evidence of the benefits of exercise in enhancing quality of life and health outcomes. Walking is an inexpensive and accessible form of exercise. To our knowledge, no studies have investigated whether a walking intervention is sufficient to enhance quality of life and alleviate symptoms in people with recurrent or metastatic cancer across a range of tumor types. This paper describes the CanWalk study protocol, which aims to assess the feasibility and acceptability of undertaking a randomized controlled trial of a community-based walking program to enhance quality of life and well …
Maguire Roma, Fox PA, McCann Lisa, Miaskowski C, Kotronoulas G, Miller M, Furlong E, Ream Emma, Armes Jo, Patiraki E, Gaiger A, Berg GV, Flowerday A, Donnan P, McCrone P, Apostolidis K, Harris Jenny, Katsaragakis S, Buick AR, Kearney N (2017)The eSMART Study Protocol: A Randomised Controlled Trial to Evaluate Electronic Symptom Management Using the Advanced Symptom Management System (ASyMS) Remote Technology for Patients with Cancer, In: BMJ Open7(5)e015016
Introduction While some evidence exists that real-time remote symptom monitoring devices can decrease morbidity and prevent unplanned admissions in oncology patients, overall, these studies have significant methodological weaknesses. The eSMART study (electronic Symptom Management using the Advanced Symptom Management System (ASyMS) Remote Technology) is designed to specifically address these weaknesses with an appropriately powered, repeated-measures, parallel-group stratified randomised, controlled trial (RCT) of oncology patients. Methods and analysis A total of 1,108 patients scheduled to commence first-line chemotherapy (CTX) for breast, colorectal, or haematological cancer will be recruited from multiple sites across 5 European countries. Patients will be randomised (1:1) to the ASyMS intervention (intervention group) or to standard care currently available at each site (control group). Patients in the control and intervention groups will complete a demographic and clinical questionnaire, as well as a set of valid and reliable electronic patient reported outcome measures (ePROMS) at enrolment, after each of their CTX cycles (up to a maximum of 6 cycles) and at 3, 6, 9 and 12 months after completion of their sixth cycle of CTX. Outcomes that will be assessed include: symptom burden (primary outcome), quality of life (QoL), supportive care needs, anxiety, self-care self-efficacy, work limitations, and cost effectiveness and, from a health professional perspective, changes in clinical practice (secondary outcomes). Ethics and dissemination eSMART received approval from the relevant ethics committees at all of the clinical sites across the 5 participating countries. In collaboration with the European Cancer Patient Coalition (ECPC), the trial results will be disseminated through publications in scientific journals, presentations at international conferences, and postings on the eSMART website and other relevant clinician and consumer websites.
Purpose of review
As rising numbers of people are living with the long-term impact of cancer, digital health is playing an increasingly important role in the monitoring and support of survivors and their caregivers. This article reviews current evidence, practice and developments, and identifies emerging issues and opportunities.
Digital health innovations, primarily using internet or smartphone-enabled applications, have been successfully developed, particularly in the areas of symptom management, decision-making, survivorship and follow-up care and palliative care. The research is characterized by much developmental activity, and evidence is accruing for efficacy and effectiveness. Opportunities afforded by digital health include timelier and patient-centred evidence-based care, offering improved clinical outcomes and independence. Barriers to implementation include lack of patient and professional engagement, perceived burden, depersonalization and missed care.
There is much enthusiasm for the role of digital health in monitoring and providing support to cancer survivors, but further research is needed to establish clinical efficacy and understand the mechanisms for successful implementation in practice. The role of wearables, the internet of things and big data analytics is yet to be fully explored in supportive cancer care and may present new opportunities to enhance care and survivor experience.
Background Multidisciplinary team (MDT) working is well established as the foundation for providing cancer services in the UK and elsewhere. A core activity is the weekly meeting (or case conference/tumor boards) where the treatment recommendations for individual patients are agreed. Evidence suggests that the quality of team working varies across cancer teams, and this may impact negatively on the decision-making process, and ultimately patient care. Feedback on performance by expert observers may improve performance, but can be resource-intensive to implement. This proof of concept study sought to: develop a structured observational assessment tool for use by peers (managers or clinicians from the local workforce) and explore its usability; assess the feasibility of the principle of observational assessment by peers; and explore the views of MDT members and observers about the utility of feedback from observational assessment. Methods For tool development, the content was informed by national clinical consensus recommendations for best practice in cancer MDTs and developed in collaboration with an expert steering group. It consisted of ten subdomains of team working observable in MDT meetings that were rated on a 10-point scale (very poor to very good). For observational assessment, a total of 19 peer observers used the tool (assessing performance in 20 cancer teams from four hospitals). For evaluation, telephone interviews with 64 team members and all peer observers were analyzed thematically. Results The tool was easy to use and areas for refinement were identified. Peer observers were identified and most indicated that undertaking observation was feasible. MDT members generally reported that observational assessment and feedback was useful, with the potential to facilitate improvements in team working. Conclusion This study suggests that observation and feedback by peers may provide a feasible and acceptable approach to enhance MDT performance. Further tool refinement and validation is required.
APMS 2007 included a structured clinical assessment of mental health that allowed for the reliable diagnosis of common mental disorders such as anxiety and depression. The questionnaire also covered aspects of housing conditions and financial strain related to domestic fuel use, including presence of mould, cutting back on fuel usage, lack of central heating and double-glazing, being cold at home, and fuel-related problem debt or utility disconnection. This report presents the prevalence of different aspects of poor housing in the English population and identifies which types of household are at greatest risk. It also explores how poor housing conditions and fuel related debt relate to other indicators of poverty, and goes on to examine associations with mental and physical health and disability.
Background Cancer multidisciplinary teams (MDTs) are well established worldwide and are an expensive resource yet no standardised tools exist to measure performance. We aimed to develop and test an MDT self-assessment tool underpinned by literature review and consensus from over 2000 UK MDT members about the “characteristics of an effective MDT.” Methods Questionnaire items relating to all characteristics of MDTs (particularly Leadership and Chairing; Teamworking and Culture; Patient-centred care; Clinical decision-making process; and Organisation and administration during meetings) were developed by an expert panel. Acceptability, feasibility and psychometric properties were tested by online completion of the questionnaire by 23 MDTs from 4 UK NHS Trusts followed by interviews with 74 team members including members from all teams and nonresponders. 10 of the MDTs also completed questionnaires that directly translated each characteristic to an item (for the five domains above) to test content validity. Results A total of 47 items were created, each rated for agreement on a 5-point scale. A total of 329 (52 %) of 637 team members completed the questionnaire, including representation from medical, nursing and clerical MDT members. Responses correlated well with domain-specific questionnaires (r > 0.67, p = 0.01), most domain-scales had acceptable internal consistency (Cronbach alpha > 0.60), and good item discrimination (majority of items r < 0.20). Team members were positive about its value. Conclusions Self-assessment of team performance using this tool may support MDT development.
Objectives: Walking is an adaptable, inexpensive and accessible form of physical activity. However its impact on quality of life and symptom severity in people with advanced cancer is unknown. This study aimed to assess the feasibility and acceptability of a randomised controlled trial (RCT) of a community-based walking intervention to enhance quality of life (QoL) in people with recurrent/metastatic cancer.
Design: We used a mixed-methods design comprising a two-centre RCT and nested qualitative interviews. Participants: Patients with advanced breast, prostate, gynaecological or haematological cancers randomised 1:1 between intervention and usual care.
Intervention: The intervention comprised Macmillan’s ‘Move More’ information, a short motivational interview with a recommendation to walk for at least 30 minutes on alternate days and attend a volunteer-led group walk weekly.
Outcomes: we assessed feasibility and acceptability of the intervention and RCT by evaluating study processes (rates of recruitment, consent, retention, adherence and adverse events), and using end of study questionnaires and qualitative interviews. Patient reported outcome measures (PROMS) assessing quality of life (QoL), activity, fatigue, mood and self-efficacy were completed at baseline and 6, 12 and 24 weeks.
Results: We recruited 42 (38%) of eligible participants. Recruitment was lower than anticipated (goal n=60), the most commonly reported reason being unable to commit to walking groups (n=19). Randomisation procedures worked well with groups evenly matched for age, sex and activity. By week 24, there was a 45% attrition rate. Most PROMs whilst acceptable were not sensitive to change and did not capture key benefits.
Conclusions: The intervention was acceptable, well tolerated and the study design was judged acceptable and feasible. Results are encouraging and demonstrate that exercise was popular and conveyed benefit to participants. Consequently, an effectiveness RCT is warranted, with some modifications to the intervention to include greater tailoring and more appropriate PROMs selected.
Purpose We construct validated the instrument to evaluate assessor learning curves and the feasibility and interrater reliability of MTB-MODe for assessing the decision making process using video recorded multidisciplinary tumor board meetings. Materials and Methods Multidisciplinary tumor boards are becoming standard practice for managing cancer internationally but no standards have been agreed on to assess the efficacy of such teams. The MTB-MODe tool assesses the process of multidisciplinary tumor board decision making by standardized observation (1 to 5 anchored scales) of the quality of information presented at the multidisciplinary tumor board as well as board member contributions to the case review. We assessed 683 multidisciplinary tumor board case discussions using MTB-MODe in a multiphase study, including 332 cases (9 urology boards) by 1 urologist in vivo and 224 cases (6 urology boards) by 2 urologists in vivo. The instrument was refined and subsequently used to rate 127 video recorded case discussions (5 tumor types) by a total of 8 multidisciplinary tumor boards. Results Good interrater reliability was achieved in vivo and at the video recorded multidisciplinary tumor board meetings (ICC ≥0.70). MTB-MODe scores were higher in cases that resulted in a decision than in cases in which no decision was made (mean ± SD 2.54 ± 0.47 vs 2.02 ± 0.65, p ≤0.001). Conclusions A standardized method to assess the quality of multidisciplinary tumor board discussions can enhance the quality of cancer care and the ability of the boards to self-evaluate performance, thus, promoting good practice. Video recordings offer a feasible, reliable method of assessing how multidisciplinary tumor boards work.
The benefits of physical activity for cancer survivors are increasingly recognised and smartphone applications are available to assist them to become more physically active. Cancer clinicians, however, lack confidence about which physical activity apps to recommend as evidence on their quality and content is limited. Therefore, we reviewed freely available commercial physical activity/fitness apps to systematically assess their behavioural change content and quality of their design.
Systematic searches of the app stores for Apple and Android operating systems were conducted and apps were screened to identify free apps appropriate for cancer survivors. Quality was assessed using the Mobile App Rating Scale (MARS) and behavioural content was evaluated using the Behavioural Change Techniques Taxonomy (BCTT).
Of 341 apps identified, 67 were judged appropriate for cancer survivors and 46% combined aerobic and strength/stretching content. The overall number of behavioural change techniques (BCT) included was 3.96 (SD = 2.09), with the most frequent being ‘feedback on behaviour’ and ‘goal setting behaviour’. The mean scores for objective and subjective quality were 4.11 (SD = 0.59) and 3.07 (SD = 0.91) respectively (range 0 to 5). Finally, a modest positive correlation was found between the number of BCT and the quality of engagement, awareness and knowledge as assessed by the MARS.
Only a fifth of retrieved physical activity apps contained potentially suitable content for people affected by cancer. Overall, most apps we reviewed appeared to perform well in terms of their objective quality, but less well at promoting knowledge and awareness or help seeking related to physical activity.
Implications for Cancer Survivors
Many physical activity apps are available but the combined use of MARS and BCTT suggests that not all of them are suitable to the needs is a promising and feasible approach for assessing the applicability, usability and content of physical activity of apps employed by cancer survivors and this study is a first step toward developing a guide.
This study aimed to adapt the Registered Nurse Forecast (RN4CAST) nurse survey making it appropriate to assess the working environments of ambulatory chemotherapy nurses, specifically focusing on care left undone.
A two-phase approach was used. Firstly, cognitive interviews were conducted to adapt role specific sections of the RN4CAST nurses survey. The interviews were analysed to assess comprehension, retrieval, judgement and response processes to create the RN4CAST-chemotherapy assessment tool (CAT) survey. Secondly, a single centre feasibility study was undertaken to assess acceptability of the RN4CAST-C AT survey in an ambulatory chemotherapy setting. Results of the feasibility study were analysed using descriptive statistics and compared with routinely collected patient experience data.
The cognitive interviews (n = 6) resulted in important amendments to the RN4CAST- CAT. Response rate to the feasibility study was acceptable at 57% (n = 12) and item completion rate was good (on average only 1 response missing per item). On average nurses looked after nine patients per shift, administered seven chemotherapy treatments and worked an hour and 10 min over their contracted time. Main areas of care left undone were related to verbal communication with patients and assessing patient comorbidities and toxicities.
We were able to adapt the RN4CAST to make it suitable for use in the ambulatory chemotherapy setting. Our study offers preliminary evidence that the RN4CAST-CAT and methodology are feasible and acceptable within the ambulatory chemotherapy setting. Larger scale testing is now required and if validated the RN4CAST-CAT has the potential to provide useful insights into the impact of nursing workload on staff experience, patient care and outcomes on ambulatory chemotherapy settings.
Harris Jenny, Ford E, Clark C, McManus S, Jenkins R, Bebbington P, Brugha T, Meltzer H, Stansfeld SA Common mental disorders, unemployment and welfare benefits in England, In: Public Healthpp. 675-681
Summary Objectives Individuals who are out of work have a higher rate of common mental disorders (CMD) than individuals who are employed. People who are unemployed in the UK are entitled to welfare benefits to alleviate financial strain. This study examined rates of CMD in individuals who were employed, unemployed and receiving various UK benefits. It also investigated associations between duration of unemployment, gender and CMD. Study design An analysis of 5090 working-age participants from the Adult Psychiatric Morbidity Survey 2007, a stratified probability sample survey conducted among adults aged 16 years and over living in private households in England. Methods CMD was assessed using the Clinical Interview Schedule (Revised). Information was gathered on sociodemographics, employment, income, benefits and debt. Data were analysed using logistic regression …