Exploring patients\u27 advance care planning needs during the annual 75+ health assessment: Survey of Australian GPs\u27 views and current practice

Background: The 75+ health assessment has been identified as a suitable trigger to introduce advance care planning (ACP) to general practice patients. Australian general practitioners (GPs) were surveyed to explore their perceptions, attitudes and practices in introducing ACP during 75+ health assessments. Methods: A cross-sectional postal survey of Australian GPs covering their personal, professional and workplace characteristics, their current practice regarding ACP within a 75+ health assessment, and their attitude towards ACP. Multivariate logistic regression was used to analyse the factors associated with routinely discussing ACP as part of the 75+ health assessment. Results: A total of 185 (19.2%) out of 964 eligible GPs returned a completed survey. Most GPs reported that patients interested in ACP were supported by the GPs or the practice nurse. Two factors, (1) attitude that ACP is an essential component of the 75+ health assessment, and (2) regional or rural location of the practice, had a statistically and clinically significant association with the GP\u27s self-reported discussion of ACP during 75+ health assessments. Conclusions: GPs showed a high level of support and involvement in discussing ACP during 75+ health assessments. ACP support during 75+ health assessments was often provided directly by the GP or via the practice nurse. Given the international evidence that ACP training programs improve skills and knowledge, and foster positive attitudes towards ACP, there is an important need to continue funding ACP training programs for GPs and practice nurses

The many faces of preventative care in the practice of oncology

Prevention in the oncology setting has traditionally focused on the progression of cancer, recurrence and development of new cancers. Increasingly, the focus has moved to a more holistic view of prevention that pursues prevention of suffering and maintaining quality of life. The cancer treatment team has the opportunity to play an active role in the promotion of healthy lifestyles for patients, and the relatives for whom the patient’s cancer conveys risk. Assisting patients to adhere to ‘non-cancer’ care is important for their mortality and morbidity. Given patient’s reluctance to disclose physical and emotional side-effects they may be experiencing, there is a need for health providers to regularly initiate discussions with their patients about their needs. Similarly, an oncology service that actively seeks to understand patient preferences will be better equipped to provide individualised care. A systems-minded approach to prevention may ensure that cancer care is organised to anticipate and to prevent of poor quality care. As the cancer treatment team will continue to play a more complex role in prevention, they must be supported by organisational factors that facilitate evidence-based practice

Travelling all over the countryside: travel-related burden and financial difficulties reported by cancer patients in New South Wales and Victoria

Objective: To describe travel burden and travel-related financial burden experienced by cancer patients over the first year after diagnosis. Design, setting, participants: Population-based longitudinal cohort of recent adult cancer patients diagnosed with the eight most incident cancers recruited from New South Wales and Victorian Cancer Registries. Self-report survey data were collected at 6 and 12 months after diagnosis from 1410 participants (city: n = 890; regional/remote: n = 520). Main outcome measures: Travel time to cancer treatment, living away from home for treatment, travel-related treatment decisions, extent of financial issues, unmet need for financial help. Results: During the first 12 months after diagnosis, outer regional/remote residents had the greatest travel burden; 61% (n = 79) travelled at least 2 hours one way to receive treatment, and 49% (n = 66) lived away from home to receive treatment. Strongest associates of travel burden were living in regional/remote areas (odds ratio (OR) = 18.9–135.7), having received surgery (OR = 6.7) or radiotherapy (OR = 3.6). Between 6 and 12 months after diagnosis, 2% (n = 24) of patients declined cancer treatment because of the time it would take to get to treatment. Patients who travelled more than 2 hours or lived away for treatment reported significantly greater financial difficulties (38%; 40%) than those who did not (12%; 14%), even after adjusting for covariates. Conclusions: Travel burden is greatest for rural patients, and is associated with greater financial burden. Appropriate and adequate provision of travel and accommodation assistance schemes remains paramount to achieving equitable delivery of cancer services

All's well that ends well?: quality of life and physical symptom clusters in long-term cancer survivors across cancer types

Context: Little is known about the presentation of multiple concurrent symptoms (symptom clusters) in long-term cancer survivors, with few studies adequately powered to compare quality of life (QoL) and symptom presentation by cancer type. Objectives: This research aimed to 1) assess patient-reported QoL and 2) identify clusters of cancer-related physical symptoms by cancer type among long-term breast, prostate, colorectal, and melanoma cancer survivors. Methods: A population-based cross-sectional sample of 863 adult cancer survivors five to six years post-diagnosis completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), assessing global QoL and frequency of presentation of cancer-related physical symptoms. Results: Long-term survivors reported higher levels of global QoL than 1) the general population (age-adjusted mean = 79.4 vs. 71.1, small clinical difference) and 2) cancer patients early in the care trajectory (age-adjusted mean = 77.1 vs. 61.3, moderate clinical difference). The majority (71%) did not report any cancer-related physical symptoms; 18% reported multiple (two or more) symptoms in the past month. Factor analysis found that cognitive functioning, fatigue, insomnia, pain, dyspnea, appetite loss, constipation, diarrhea, nausea, and vomiting formed a cluster (α = 0.48). No symptom clusters were identified that were specific to just one cancer type. However, individual symptoms (including diarrhea, pain, constipation, and insomnia) modestly discriminated between cancer types. Conclusion: Contrary to expectations, no symptom clusters specific to one type of cancer were identified and survivors reported few cancer-related symptoms and high QoL. These results convey a strong “good news” message, providing health professionals with a sound foundation for making encouraging predictions about their patients’ long-term physical recovery after cancer. Cancer patients also will welcome the news that only a minority of five-year survivors experience long-term and late effects

Rasch analysis of the Mini-Mental Adjustment to Cancer Scale (mini-MAC) among a heterogeneous sample of long-term cancer survivors: a cross-sectional study

Background: The mini-Mental Adjustment to Cancer Scale (mini-MAC) is a well-recognised, popular measure of coping in psycho-oncology and assesses five cancer-specific coping strategies. It has been suggested that these five subscales could be grouped to form the over-arching adaptive and maladptive coping subscales to facilitate the interpretation and clinical application of the scale. Despite the popularity of the mini-MAC, few studies have examined its psychometric properties among long-term cancer survivors, and further validation of the mini-MAC is needed to substantiate its use with the growing population of survivors. Therefore, this study examined the psychometric properties and dimensionality of the mini-MAC in a sample of long-term cancer survivors using Rasch analysis. Methods: RUMM 2030 was used to analyse the mini-MAC data (n=851). Separate Rasch analyses were conducted for each of the original mini-MAC subscales as well as the over-arching adaptive and maladaptive coping subscales to examine summary and individual model fit statistics, person separation index (PSI), response format, local dependency, targeting, item bias (or differential item functioning -DIF), and dimensionality. Results: For the fighting spirit, fatalism, and helplessness-hopelessness subscales, a revised three-point response format seemed more optimal than the original four-point response. To achieve model fit, items were deleted from four of the five subscales – Anxious Preoccupation items 7, 25, and 29; Cognitive Avoidance items 11 and 17; Fighting Spirit item 18; and Helplessness-Hopelessness items 16 and 20. For those subscales with sufficient items, analyses supported unidimensionality. Combining items to form the adaptive and maladaptive subscales was partially supported. Conclusions: The original five subscales required item deletion and/or rescaling to improve goodness of fit to the Rasch model. While evidence was found for overarching subscales of adaptive and maladaptive coping, extensive modifications were necessary to achieve this result. Further exploration and validation of over-arching subscales assessing adaptive and maladaptive coping is necessary with cancer survivors

Anxiety and depression among long-term survivors of cancer in Australia: results of a population-based survey

Objective: To assess the prevalence and predictors of anxiety and depression among a heterogeneous sample of long-term adult cancer survivors. Design and participants: Cross-sectional survey of 863 adults diagnosed with a new histologically confirmed cancer (local or metastatic) between 1 April and 30 November 1997 and still alive in 2002, living in NSW, able to read and understand English adequately, physically and mentally capable of participating, and aware of their cancer diagnosis, who were randomly selected from the New South Wales Central Cancer Registry. Main outcome measures: Prevalence of anxiety and depression assessed by the Hospital Anxiety and Depression Scale; and factors (patient, disease, and treatment characteristics; coping style; social support) predicting clinical or borderline levels of anxiety and depression. Results: Levels of anxiety and depression were low; only 9% of participants reported clinically important levels of anxiety and 4% reported depression. The strongest predictive factors of borderline or clinical anxiety were previous treatment for psychological illness, maladaptive coping styles (helplessness-hopelessness, anxious preoccupation) and poor social support. Borderline or clinical depression was most strongly predicted by previous treatment for psychological illness, being an invalid pensioner, maladaptive coping style (helplessness-hopelessness) and poor positive social interaction. Conclusions: By 5 years after diagnosis, most survivors had adjusted well to their cancer experience, with levels of anxiety and depression similar to those of the general population. Nevertheless, a small and important group of long-term survivors continue to experience adverse psychological effects and need assistance. Monitoring of psychological wellbeing and referring patients when appropriate need to be integrated into routine care for cancer survivors

Sun protection attitudes and behaviours among first generation Australians with darker skin types: results from focus groups

Despite residing in a country that has the highest rates of skin cancer in the world, little is known about the knowledge, attitudes and sun protection practices of first generation Australian-born individuals with olive and darker skin types. Six focus groups with first generation Australian-born individuals of Asian, Mediterranean, Middle Eastern and Indian background were conducted. Participants had good knowledge of the dangers of skin cancer. Most correctly perceived darker skin types as protective and believed they were at low risk of skin cancer. Most participants could recall high profile mass media sun protection campaigns. Several participants suggested that greater representation of ethnic minorities and/or individuals with darker skin types would increase the personal relevance of campaigns. Beliefs that sun protection is not necessary on the basis of skin type highlights the need for further studies to explore fundamental differences in attitudes and practices between those with olive and darker skin and the general Australian population

System-Wide and Group-Specific Health Service Improvements: Cross-Sectional Survey of Outpatient Improvement Preferences and Associations with Demographic Characteristics

Efficient patient-centred quality improvement requires an understanding of the system-wide areas of dissatisfaction along with evidence to identify the programs which can be strategically targeted according to specific patient characteristics and preferences. This cross-sectional study reports the proportion of chronic disease outpatients selecting 23 patient-centred improvement initiatives. Using univariate tests and multivariable logistic regressions, this multi-site study also identifies initiatives differentially selected by outpatients according to clinical and demographic characteristics. A total of 475 outpatients participated (49% response). Commonly selected initiatives included: reducing wait-times (22.3%); convenient appointment scheduling (16.0%); and receiving up-to-date treatment information (16.0%). Within univariate tests, preferences for information and service accessibility initiatives were not significantly associated with specific subgroups. However, seven initiatives were preferred according to age, gender, diagnosis status, and chronic disease type within multivariate models. For example, neurology outpatients were more likely to select assistance to manage psychological symptoms when compared to oncology outpatients (OR: 2.89). Study findings suggest that system-wide programs to enhance information provision are strategic approaches to improve experiences across patient characteristics. Furthermore, a few initiatives can be targeted to specific groups and emphasized the importance of detailed scoping analyses and tailored implementation plans when designing patient-centred quality improvement programs

A narrative review of the potential for self- tanning products to substitute for solaria use among people seeking a tanned appearance

Skin cancers including melanoma and non-melanoma skin cancers are a high-cost and largely preventable form of cancer. While limiting exposure to solar ultraviolet (UV) light via outdoor activities is a focus of public health efforts, indoor UV exposure via solaria or ‘tanning booths’ has also become a cause for concern. In recent decades the availability of less harmful non-UV self-tanning products such as sprays and lotions has increased. This review explores (i) the available data regarding the prevalence and behavioural factors associated with use of solaria and self-tanning products and (ii) data that may shed light on the likelihood of solaria users substituting self-tanning products as a less harmful alternative to solaria exposure. While there are insufficient data on which to draw a firm conclusion about the potential for substitution, it appears unlikely that most solaria users would readily substitute self-tanning products in place of solaria exposure. Public health advocates may need to consider whether a robust research study of the cost-effectiveness of encouraging substitutional use of self-tanners is desirable, or whether efforts to severely restrict access to solaria may be a better approach

Medical oncology outpatients’ preferences and experiences with advanced care planning: a cross-sectional study

Abstract Background Medical oncology outpatients are a group for whom advance care planning (ACP) activities are particularly relevant. Patient views can help prioritise areas for improving end of life communication. The study aimed to determine in a sample of medical oncology outpatients: (1) the perceived importance of participating in ACP activities; (2) the proportion of patients who have ever participated in ACP activities; and (3) the proportion of patients who had not yet participated in ACP activities who were willing to do so in next month. Methods Adult medical oncology outpatients in two Australian cancer treatment centres were consecutively approached to complete a pen-and-paper survey. Items explored perceived importance, previous participation, and willingness to participate across key ACP activities including: discussing wishes with their family or doctor; recording wishes in a written document; appointing a substitute decision maker (SDM); and discussing life-expectancy. Results 185 participants completed the survey (51% consent rate). Most patients agreed it was important to: discuss end of life wishes with family (85%) and doctors (70%) and formally record wishes (73%). Few had discussed end of life wishes with a doctor (11%), recorded their wishes (15%); chosen a SDM (28%); discussed life expectancy (30%); or discussed end of life wishes with family (30%). Among those who had not participated in ACP, most were willing to discuss life expectancy (66%); discuss end of life wishes with family (57%) and a doctor (55%); and formally record wishes (56%) in the next month. Fewer wanted to appoint a SDM (40%). Conclusion Although medical oncology outpatients perceive ACP activities are important, rates of uptake are relatively low. The willingness of many patients to engage in ACP activities suggests a gap in current ACP practice. Efforts should focus on ensuring patients and families have clarity about the legal and other ramifications of ACP activities, and better education and training of health care providers in initiating conversations about end of life issues