Identification and Potential Use of Clusters of Patients With Colorectal Cancer and Patients With Prostate Cancer in Clinical Practice: Explorative Mixed Methods Study.

BACKGROUND: A steady increase in colorectal and prostate cancer survivors and patients with these cancers is expected in the upcoming years. As a result of primary cancer treatments, patients have numerous additional complaints, increasing the need for cancer aftercare. However, referrals to appropriate cancer aftercare remain inadequate, despite a wide range of aftercare options. Caregivers and patients often do not know which aftercare is the most appropriate for the individual patient. Since characteristics and complaints of patients within a diagnosis group may differ, predefined patient clusters could provide substantive and efficient support for professionals in the conversation about aftercare. By using advanced data analysis methods, clusters of patients who are different from one another within a diagnosis group can be identified. OBJECTIVE: This study had a 2-fold objective: (1) to identify, visualize, and describe potential patient clusters within the colorectal and prostate cancer population and (2) to explore the potential usability of these clusters in clinical practice. METHODS: First, we used cross-sectional data from patients with colorectal cancer and patients with prostate cancer provided by the population-based PROFILES (Patient-Reported Outcomes Following Initial Treatment and Long-Term Evaluation of Survivorship) registry, which were originally collected between 2008 and 2012. To identify and visualize different clusters among the 2 patient populations, we conducted cluster analyses by applying the K-means algorithm and multiple-factor analyses. Second, in a qualitative study, we presented the patient clusters to patients with prostate, patients with colorectal cancer, and oncology professionals. To assess the usability of these clusters, we held expert panel group interviews. The interviews were video recorded and transcribed. Three researchers independently performed content-directed data analyses to understand and describe the qualitative data. Quotes illustrate the most important results. RESULTS: We identified 3 patient clusters among colorectal cancer cases (n=3989) and 5 patient clusters among prostate cancer cases (n=696), which were described in tabular form. Patient experts (6/8, 75%) and professional experts (17/20, 85%) recognized the patient clustering based on distinguishing variables. However, the tabular form was evaluated as less applicable in clinical practice. Instead, the experts suggested the development of a conversation tool (eg, decision tree) to guide professionals through the hierarchy of variables. In addition, participants suggested that information about possible aftercare initiatives should be offered and integrated. This would also ensure a good overview and seemed to be a precondition for finding suitable aftercare. CONCLUSIONS: This study demonstrates that a fully data-driven approach can be used to identify distinguishable and recognizable (ie, in routine care) patient clusters in large data sets within cancer populations. Patient clusters can be a source of support for health professionals in the aftercare conversation. These clusters, when integrated into a smart digital conversation and referral tool, might be an opportunity to improve referral to cancer aftercare. TRIAL REGISTRATION: Netherlands Trial Register NL9226; https://trialsearch.who.int/Trial2.aspx?TrialID=NL9226.

Living with painful diabetic neuropathy: insights from focus groups into fears and coping strategies.

OBJECTIVE: Painful diabetic neuropathy (PDN) is known to negatively affect quality of life. Being physically active is a crucial part of successful diabetes self-management, but regimen adherence is often low. Coping strategies and fears have shown to be related to less physical activity (PA). The aim of the present study was to obtain more in-depth information on psychological risk factors leading to less PA in persons with PDN. DESIGN: Three semi-structured focus group interviews were conducted with a representative sample of persons with PDN (N = 12). Data were transcribed verbatim and analysed using a hybrid method of thematic analyses and a grounded theory approach. MAIN OUTCOME MEASURES: Fears and coping strategies related to PA in persons with PDN. RESULTS: Several specific fears were identified; fear of hypoglycaemia, fear of pain increase, fear of total exhaustion, fear of physical injury, fear of falling, fear of loss of identity, and fear of negative evaluation by others. To cope with these fears, avoidance, remaining active, cognitive distraction, and acceptance strategies were described. CONCLUSION: In persons with PDN, diabetes-related fears and pain-related fears play a role in less engagement in PA, indicating the need for new methods for improving self-management in persons with PDN.

Long-term effectiveness and moderators of a web-based tailored intervention for cancer survivors on social and emotional functioning, depression, and fatigue: randomized controlled trial.

PURPOSE: The web-based computer-tailored Kanker Nazorg Wijzer (Cancer Aftercare Guide) supports cancer survivors with psychosocial issues during cancer recovery. The current study investigates whether the 6-month effects in increasing emotional and social functioning and reducing depression and fatigue hold at 12 months from baseline. Moreover, it explores whether patient characteristics moderate the 6- and 12-month intervention effectiveness. METHODS: Cancer survivors from 21 Dutch hospitals (November 2013-June 2014) were randomized to an intervention (n = 231) or a wait-list control group (n = 231). Intervention effects on emotional and social functioning (EORTC QLQ-C30), depression (HADS), and fatigue (CIS) were evaluated through multilevel linear regression analyses. RESULTS: At 12 months from baseline, the intervention group no longer differed from the control group in emotional and social functioning, depression, and fatigue. Moderator analyses indicated that, at 6 months, the intervention was effective in improving social functioning for men (d = 0.34), reducing fatigue for participants ≤56 years (d = 0.44), and reducing depression for participants who received chemotherapy (d = 0.36). At 12 months, participants with a medium educational level reported higher social functioning (d = 0.19), while participants with a low educational level reported lower social functioning (d = 0.22) than participants with a similar educational level in the control group. CONCLUSIONS: The intervention gave cancer patients a head start to psychological recovery after the end of cancer treatment. The control group caught up in the long run. IMPLICATIONS FOR CANCER SURVIVORS: The Cancer Aftercare Guide expedited recovery after cancer treatment. Being a low intensity, easy accessible, and relatively low cost intervention, it could serve as a relevant step in recovery and stepped care.

Working mechanisms of a web-based self-management intervention for cancer survivors: a randomised controlled trial.

OBJECTIVE: The aim of this study was to investigate whether problem-solving skills and perceived personal control over cancer recovery mediated the intervention effects on depression and fatigue of a web-based computer-tailored intervention for cancer survivors - the Kanker Nazorg Wijzer (Cancer Aftercare Guide). DESIGN: Patients were recruited through 21 Dutch hospitals (November 2013-June 2014). The mediation model was tested in a randomised controlled trial with an intervention group (n = 231) and a waiting list control group (n = 231). MAIN OUTCOME MEASURES: Hypothesised mediators problem-solving skills (SPSI-R) and personal control (IPQ-R) were measured at baseline and 3 months from baseline. Outcomes depression (HADS) and fatigue (CIS) were measured at baseline and 6 months from baseline. RESULTS: The intervention effects in decreasing depression and fatigue were mediated by personal control. Problem-solving skills did not mediate the intervention effects on depression and fatigue. CONCLUSION: While personal control in the control group decreased in the first three months after baseline, levels of personal control within the intervention group were maintained. This effect partially explained the intervention effects on depression and fatigue. The results provide evidence for the relevance of addressing personal control in web-based interventions in order to improve psychosocial well-being in early cancer survivors.

Long-term effects of a web-based cancer aftercare intervention on moderate physical activity and vegetable consumption among early cancer survivors: a randomized controlled trial.

BACKGROUND: The number of cancer survivors is growing. Negative physical and psychosocial consequences of cancer treatment can occur during survivorship. Following healthy lifestyle recommendations is beneficial to increase quality of life and to reduce the risk of cancer recurrence and comorbidities. To meet individual needs, web-based interventions can supply a large population of cancer survivors with easily accessible and personalized information. Evidence concerning the long-term effects of web-based cancer aftercare interventions on lifestyle outcomes is limited. The present study evaluates the 12-month effects of a fully automated web-based cancer aftercare intervention. We investigated whether the previously determined 6-month effects on moderate physical activity and vegetable intake were maintained over 12 months. Possible moderator effects of using specific intervention modules, gender, age, and education were also explored. METHOD: A two-armed randomized controlled trial was conducted using online self-report questionnaires among survivors of various types of cancer (N = 462). The intervention group had access to the online intervention for 6 months, and the control group received access after 12-months. Multilevel linear regression analyses (complete cases and intention-to-treat) were conducted to explore 12- month effects. RESULTS: A significant intervention effect after 12 months was found for moderate physical activity (complete cases: B = 128.475, p = .010, d = .35; intention-to-treat: B = 129.473, p = .011). Age was the only significant moderator (p = .010), with the intervention being effective among participants aged younger than 57 years (B = 256.549, p = .000, d = .59). No significant intervention effect remained for vegetable consumption after 12 months (complete cases: B = 5.860, p = .121; intention-to-treat: B = 5.560, p = .132). CONCLUSION: The online cancer after care intervention is effective in increasing and maintaining moderate physical activity in the long term among early cancer survivors younger than 57 years. Short-term increases in vegetable consumption were not sustained in the long term. These findings indicate the value and potential of eHealth interventions for cancer survivors. Based on the study results, web-based self-management interventions could be recommended for younger cancer survivors (<57 years of age) as a possible method to increase physical activity. TRIAL REGISTRATION: Dutch Trial Register NTR3375 . Registered 29 March 2012.

Short-term effectiveness of a web-based tailored intervention for cancer survivors on quality of life, anxiety, depression, and fatigue: randomized controlled trial.

BACKGROUND: The aim of this study was to evaluate the short-term effectiveness of the web-based computer-tailored intervention Kanker Nazorg Wijzer (Cancer Aftercare Guide). The intervention aims to support cancer survivors with managing psychosocial and lifestyle-related issues. In this study, the impact on quality of life, anxiety, depression, and fatigue were evaluated. METHODS: Cancer survivors were recruited through 21 Dutch hospitals (November 2013-June 2014). Outcome measures included quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30), anxiety and depression (Hospital Anxiety and Depression Scale), and fatigue (Checklist Individual Strength). In a randomized controlled trial with an intervention group (n = 231) and a waiting list control group (n = 231), the short-term effectiveness was evaluated through multilevel linear regression analyses, controlling for selective dropout, baseline differences, and several demographic and disease-related characteristics. RESULTS: In total, 188 participants of the intervention group and 221 of the control group completed the 6-month measurement (dropout = 11.5%). The intervention was effective in reducing depression (B = -0.63, p = 0.007, f2 = 0.019, d = 0.21) and fatigue (B = -4.36, p = 0.020, f2 = 0.013, d = 0.21). In addition, effects were found for emotional (B = 3.47, p = 0.022, f2 = 0.013, d = 0.15) and social functioning (B = 3.95, p = 0.011, f2 = 0.017, d = 0.15), although this evidence was less strong. There were indications that the effects of fatigue and social functioning were influenced by module use. CONCLUSIONS: While effect sizes were small, they can be considered as clinically relevant. With the Cancer Aftercare Guide being an effective, low-intensive, and easy accessible intervention, it could serve as a first step in stepped care for needs assessment and initial support for psychosocial problems that are present after cancer treatment. Copyright © 2016 John Wiley & Sons, Ltd.

Abstract and Metadata Correction of: Use and Appreciation of a Tailored Self-Management eHealth Intervention for Early Cancer Survivors: Process Evaluation of a Randomized Controlled Trial.

[This corrects the article DOI: .].

Lifestyle-related effects of the web-based Kanker Nazorg Wijzer (Cancer Aftercare Guide) intervention for cancer survivors: a randomized controlled trial.

PURPOSE: The web-based Kanker Nazorg Wijzer (Cancer Aftercare Guide) responds to the needs of cancer survivors and oncology care providers to improve the counseling related to self-management of lifestyle and psychosocial challenges. In present study, overall intervention effects and the effects of using specific components were evaluated on vegetable, fruit, whole grain bread, and fish consumption, physical activity (PA), and smoking behavior. METHODS: Cancer survivors from 21 Dutch hospitals were recruited for a randomized controlled trial (N = 432). Intervention effects after 6 months were evaluated using multilevel linear regression analysis (complete cases and intention-to-treat). By conducting moderation analyses, additional effects of following the behavior-related modules were explored. The false discovery rate correction was applied to account for multiple testing. RESULTS: After 6 months, 409 participants completed follow-up (dropout = 11.5 %). Indications were found that access to the intervention may result in increases of moderate PA and vegetable intake. The moderate PA increase was meaningful: 74.74 min p/w higher increase in the intervention condition. Effect sizes of moderate PA (d = .25) and vegetable (d = .37) consumption were comparable to prior effective interventions. Visiting behavior-related modules affected moderate PA, fruit, and fish consumption. However, after correction for multiple testing, significances expired. No significant intervention effect was found on smoking behavior due to low numbers of smokers. IMPLICATIONS FOR CANCER SURVIVORS: Although the effectiveness was only shown only to a limited extend, this study provided several indications that this theory-based, comprehensive, and personalized eHealth intervention provides valuable content to complement usual cancer aftercare.

Prevalence and correlates of healthy lifestyle behaviors among early cancer survivors.

BACKGROUND: Healthy lifestyle behaviors have been demonstrated to be beneficial for positive health outcomes and the quality of life in cancer survivors. However, adherence to recommendations is low. More insight is needed in factors that may explain engagement in lifestyle behaviors to develop effective cancer aftercare interventions. This study assessed different factors, namely socio-demographic, cancer-related, psychological, social cognitive factors (attitude, social support, self-efficacy) and intention, in relationship to five lifestyle behaviors (smoking, physical activity, alcohol, and fruit and vegetable consumption). METHODS: Early survivors of various types of cancer were recruited from eighteen Dutch Hospitals (n = 255). Distal factors (socio-demographic, cancer related, psychological), proximal factors (social cognitive), intention and five lifestyle behaviors (smoking, physical activity, alcohol, fruit and vegetable consumption) were assessed through a self-reported questionnaire. Cross-sectional analyses (correlations and regression analyses) were conducted. RESULTS: The lifestyle of a small group (11%) of the cancer survivors was coherent with all five health recommendations, the majority (>80%) adhered to two, three of four recommendations, and only few (<7%) adhered to one or none recommendation. The highest prevalence in followed recommendations have been detected in physical activity (87.4%), refrain from smoking (82%), and alcohol consumption (75.4%). There was low adherence to the fruit recommendation (54.8%) and to the vegetable recommendation (27.4%). Only weak associations were found between the different behaviors. Each separate lifestyle behavior was influenced by different patterns of correlates. Self-efficacy, attitude, and intention were the strongest correlates in all examined behaviors, although with various contributions, while socio-demographic, cancer-related and psychological factors provided a much smaller contribution. CONCLUSIONS: Outcomes of engagement in healthy lifestyle behaviors were more positive in this study compared to other research in cancer survivors; however, there is room for improvements in adherence to all five lifestyle behaviors. Especially fruit consumption was poor and vegetable consumption even worse. Our findings emphasized that all examined lifestyle behaviors need to be encouraged, with taken into account that each lifestyle behavior may be influenced by a specific set of mainly social cognitive factors or intention.

Cancer survivors in the first year after treatment: the prevalence and correlates of unmet needs in different domains.

OBJECTIVE: To explore cancer survivors' unmet needs in the first year after primary treatment, and to investigate the relationship between demographic, disease-related, and psychosocial characteristics and the number of unmet needs in different domains. METHODS: Cancer survivors were recruited through eight Dutch hospitals (November 2012-January 2013). In a cross-sectional survey, 255 survivors were asked about unmet needs across several domains (CaSUN) and demographic, disease-related, and psychosocial characteristics, comprising quality of life (EORTC QLQ-C30), psychological distress (HADS), mental adjustment (MAC), and problem solving (SPSI-R:S). RESULTS: Sixty-three percent of survivors reported one or more unmet needs (M = 5.13, SD = 6.98, range = 0-34). Common unmet needs concerned emotional support (31.3%), smoking cessation (26.7% of smokers), managing side effects/complications (25.9%), fear of recurrence (23.0%), cancer care (22.0%), social support (22.0%), up-to-date information (19.8%), and carrying out work (19.6%). Regression analysis showed that age, higher education, participation in support programs, anxiety, depression, and negative adjustment style correlated positively, while being female, time since last treatment, and quality of life correlated negatively with the number of unmet needs. Lower number of unmet needs also accounted for other types of cancer (except colon cancer) than breast cancer. These relationships differed per need domain. CONCLUSIONS: The heterogeneity in unmet needs complicates the provision of adequate support for survivors.

The Kanker Nazorg Wijzer (Cancer Aftercare Guide) protocol: the systematic development of a web-based computer tailored intervention providing psychosocial and lifestyle support for cancer survivors.

BACKGROUND: After primary treatment, many cancer survivors experience psychosocial, physical, and lifestyle problems. To address these issues, we developed a web-based computer tailored intervention, the Kanker Nazorg Wijzer (Cancer Aftercare Guide), aimed at providing psychosocial and lifestyle support for cancer survivors. The purpose of this article is to describe the systematic development and the study design for evaluation of this theory and empirical based intervention. METHODS/DESIGN: For the development of the intervention, the steps of the Intervention Mapping protocol were followed. A needs assessment was performed consisting of a literature study, focus group interviews, and a survey study to get more insight into cancer survivors' health issues. This resulted in seven problem areas that were addressed in the intervention: cancer-related fatigue, return to work, anxiety and depression, social relationships and intimacy, physical activity, diet, and smoking. To address these problem areas, the principles of problem-solving therapy and cognitive behavioral therapy are used. At the start of the intervention, participants have to fill in a screening questionnaire. Based on their answers, participants receive tailored advice about which problem areas deserve their attention. Participants were recruited from November 2013 through June 2014 by hospital staff from 21 hospitals in the Netherlands. Patients were selected either during follow-up visits to the hospital or from reviews of the patients' files. The effectiveness of the intervention is being tested in a randomized controlled trial consisting of an intervention group (n = 231) and waiting list control group (n = 231) with a baseline measurement and follow-up measurements at 3, 6, and 12 months. DISCUSSION: Using the Intervention Mapping protocol resulted in a theory and evidence-based intervention providing tailored advice to cancer survivors on how to cope with psychosocial and lifestyle issues after primary treatment. TRIAL REGISTRATION: Dutch Trial Register NTR3375.