Predicting anxiety in cancer survivors presenting to primary care - A machine learning approach accounting for physical comorbidity.

BACKGROUND: The purpose of this study was to explore predictors for anxiety as the most common form of psychological distress in cancer survivors while accounting for physical comorbidity. METHODS: We conducted a secondary data analysis of a large study within the German National Cancer Plan which enrolled primary care cancer survivors diagnosed with colon, prostatic, or breast cancer. We selected candidate predictors based on a systematic MEDLINE search. Using supervised machine learning, we developed a prediction model for anxiety by splitting the data into a 70% training set and a 30% test set and further split the training set into 10-folds for cross-validating the hyperparameter tuning step during model selection. We fit six different regression models, selected the model that maximized the root mean square error (RMSE) and fit the selected model to the entire training set. Finally, we evaluated the model performance on the holdout test set. RESULTS: In total, data from 496 cancer survivors were analyzed. The LASSO model (α = 1.0) with weakly penalized model complexity (λ = 0.015) slightly outperformed all other models (RMSE = 0.370). Physical symptoms, namely, fatigue/weakness (ß = 0.18), insomnia (ß = 0.12), and pain (ß = 0.04), were the most important predictors, while the degree of physical comorbidity was negligible. CONCLUSIONS: Prediction of clinically significant anxiety in cancer survivors using readily available predictors is feasible. The findings highlight the need for considering cancer survivors' physical functioning regardless of the degree of comorbidity when assessing their psychological well-being. The generalizability of the model to other populations should be investigated in future external validations.

Granting Leave to Patients in Bavarian Forensic-Psychiatric Hospitals: A Survey to Describe the Current Process and Develop Guidelines.

Forensic-psychiatric patients reoffending or absconding during the leave granted to them (hereafter referred to as "granted leave") have gained increased attention by researchers and the general public. The patients' right to freedom on the one hand and the need for protection of the general public from serious harm on the other hand represent broadly discussed ethical issues. Thus, demands on quality regarding decisions on patients' granted leaves might be high. Despite such requirements, research on decision-making processes regarding granting leave in forensic psychiatry is very limited and focuses primarily on particular aspects. The present study aims at providing a first overview of the decision-making processes regarding granted leave in forensic psychiatry as a whole. Furthermore, the link between the particular steps of the process and absconding should be explored. In this way, the study results should contribute to provide a theoretical framework for the development of guidelines concerning granted leave in forensic psychiatry. A combination of qualitative and quantitative approaches will be used to collect data: information about risk assessment, decisions on granted leave, and documentation systems in forensic psychiatry will be collected via semi-structured interviews and quantified for further analyses using a checklist developed for this study; data on the implementation of risk assessment tools and documented patient information will be obtained via two self-constructed questionnaires; information about the absolute number of abscondences per hospital will be obtained from the Bavarian Authority for Forensic Commitment. The sample will include staff from all 13 forensic-psychiatric hospitals in Bavaria (Germany) comprising six professional groups: hospital directors, security officers, complementary therapists, psychiatrists, psychologists, social workers, and nursing staff. In each hospital, at least one member of each professional group should participate in the study. In total, 151 interviews will be held. As the study goals are descriptive, there are no pre-formulated hypotheses. Developing guidelines would be the first step towards further standardization of the granted leave decisional process in forensic psychiatry and to make it more transparent for patients, staff members, hospital directors, and the government.

Cancer Patients' Preferences for either Quality of Life or a Longer Life Determine Their Willingness to Talk about Forgoing Cancer-Specific Treatment.

BACKGROUND: Cancer patients often face decisions whether to proceed with cancer-specific treatment or to switch to best supportive care. In these decisions, patients' preferences should be determining cornerstones. The aim of this survey was to elicit patients' preferences regarding discussions about forgoing treatment and factors influencing their preferences. METHODS: We surveyed 194 patients at the National Center for Tumor Diseases, Germany. Quality of life (FACT-G), cancer-specific distress (QSC-R10), anxiety/depression (PHQ-4/GAD-2), preferences regarding quality/length of life (QQ), patient-physician communication (CARES-SF), and family role (CCAT-P) were assessed. RESULTS: Patients weighting quality of life over lifetime wanted their oncologists to address treatment limitations as early as possible (p = 0.00). Patients striving for a longer lifetime did not want such discussions (p = 0.05). Having discussed treatment limitations was not associated with increased anxiety, depression, or distress. Limiting treatment was discussed only with one-third of the patients with a prognosis of less than 6 months and rather with elderly patients or patients in a worse medical condition. Attributing an important role to family decisions was associated with striving for lifetime (p = 0.01). CONCLUSION: Preferences for either quality or length of life were associated with patients' willingness to discuss forgoing cancer-specific treatment. Timely discussion of realistic treatment goals is one way to avoid overtreatment. Patients striving for lifetime require increased attention and opportunities to address prognosis and risks of treatment.

[Psycho-oncology care in rural areas : Results from a cross-sectional survey on the utilisation of community-based psychosocial support services]. / Psychoonkologische Versorgung im ländlichen Raum : Ergebnisse einer Querschnittsbefragung zur Inanspruchnahme ambulanter Unterstützungsangebote.

BACKGROUND: Clinically relevant distress and unmet psychosocial needs frequently occur in the course of cancer diseases. Particularly for thinly populated rural areas in Germany rates of distressed patients and uptake of community-based psycho-oncology services are unknown. OBJECTIVES: Determination of a) the proportion of cancer patients with psychosocial distress and unmet needs and b) the utilisation of community-based psycho-oncology services in thinly populated rural areas. MATERIALS AND METHODS: Prospective cross-sectional study of 229 cancer patients (colon, breast, prostate cancer) living in thinly populated rural areas. Indicators for clinically relevant distress and utilisation of psychosocial services were assessed by applying screening instruments. We conducted descriptive and multivariate analyses. RESULTS: More than one third of all cancer patients (39.3%) in thinly populated areas exhibited clinically relevant distress. However, only 15.6% of distressed patients consulted community-based psycho-oncology services. Most frequently, medical or psychological psychotherapists were contacted. Information deficits of patients and attending physicians alongside dispositional factors emerged as the main reasons for non-utilisation. DISCUSSION: This study presents first data on psycho-oncology care in rural areas in Germany stratifying the degree of urbanisation in line with the standards of the European Commission. Concerning limitations, we only accounted for structural service coverage, leaving aside other indicators for socio-spatial deprivation.

Online sexual solicitation by adults and peers - Results from a population based German sample.

Prevalence of Internet use among adolescents is high, but little is known about the online sexual activities of German adolescents. This study aimed to describe the 12-month prevalence of German adolescents' online sexual experiences with a focus on Online Sexual Solicitation (OSS, subjectively negative online sexual experiences with a peer or any sexual online experience, positive or negative, with an adult). A sample of male and female adolescents aged 14-17 (N=2238) was recruited using online survey panel. The sample was representative for gender and education. Subjects completed an online survey reporting their online sexual activities (i.e., sexual conversation, exchanging pictures, and cybersex) with peers (14-17y.) and/or adults (≥18y.). Findings illustrated that 51.3% (n=1148) of adolescents had experienced online sexual activity, which mostly involved peers (n=969; 84.4%). In contrast, 23.2% (n=519) of the adolescents experienced OSS with 2.6% (n=57) reporting subjectively negative online sexual interactions with peers and 22.2% (n=490) reporting online sexual interactions with adults, of which 10.4% (n=51) were perceived as negative. The findings suggest that adolescents frequently engage in sexual interactions on the Internet with only a relatively small number perceiving such contacts as exploitative. In addition, females and adolescents with incomplete family situation, foreign nationality, higher education, homo- or bisexual orientation, and those without perceived social support reported OSS significantly more often.

Accessibility, Availability, and Potential Benefits of Psycho-Oncology Services: The Perspective of Community-Based Physicians Providing Cancer Survivorship Care.

BACKGROUND: As persons of trust, community-based physicians providing survivorship care (e.g., general practitioners [GPs]) often serve as the primary contacts for cancer survivors disclosing distress. From the perspective of physicians providing survivorship care for cancer patients, this study explores (a) the accessibility, availability, and potential benefits of psycho-oncology services; (b) whether physicians themselves provide psychosocial support; and (c) predictors for impeded referrals of survivors to services. METHODS: In a cross-sectional survey, all GPs and community-based specialists in a defined region were interviewed. In addition to descriptive analyses, categorical data were investigated by applying chi-square tests. Predictors for impeded referrals were explored through logistic regression. RESULTS: Of 683 responding physicians, the vast majority stated that survivors benefit from psycho-oncology services (96.8%), but the physicians also articulated that insufficient coverage of psycho-oncology services (90.9%) was often accompanied by impeded referrals (77.7%). A substantial proportion (14.9%) of physicians did not offer any psychosocial support. The odds of physicians in rural areas reporting impeded referrals were 1.91 times greater than the odds of physicians in large urban areas making a similar report (95% confidence interval [1.07, 3.40]). CONCLUSION: Most community-based physicians providing survivorship care regard psycho-oncology services as highly beneficial. However, a large number of physicians report tremendous difficulty referring patients. Focusing on those physicians not providing any psychosocial support, health policy approaches should specifically (a) raise awareness of the role of physicians as persons of trust for survivors, (b) highlight the effectiveness of psycho-oncology services, and (c) encourage a proactive attitude toward the assessment of unmet needs and the initiation of comprehensive care. IMPLICATIONS FOR PRACTICE: Community-based physicians providing survivorship care for cancer patients regard psycho-oncology services as a highly reasonable and beneficial addition to medical care. In light of insufficient local coverage with services, difficulties with seamless referrals constitute a major challenge for physicians. Apart from emphasizing the effectiveness of psycho-oncology services and proactive attitudes toward the assessment of unmet needs, future policies should focus on the integration of medical and psychosocial follow-up of cancer survivors, especially in rural areas.

When do we need to care about the caregiver? Supportive care needs, anxiety, and depression among informal caregivers of patients with cancer and cancer survivors.

BACKGROUND: Cancer not only affects patients but also their caregivers. The objective of the current study was to assess the unmet needs of cancer caregivers and to identify possible predictors of their supportive care needs. METHODS: In a cross-sectional survey, 188 dyads of patients diagnosed with lung, urological, or gastrointestinal cancer and their primary caregivers were recruited. Caregivers were asked to complete the Supportive Care Needs Survey self-report questionnaire (for partners and caregivers); patients completed the corresponding questionnaire. Both groups provided information regarding their distress (National Comprehensive Cancer Network Distress Thermometer), anxiety, and depression (Patient Health Questionnaire-4). Clinical characteristics were obtained from medical records. RESULTS: The mean age of the caregivers was 57.8 years. Approximately 72.3% were female. Patients had an average age of 62.5 years, with 33.0% being male. Caregivers were more distressed (P<.01) and exhibited higher anxiety scores (P<.01) compared with patients. Approximately 14.4% of caregivers reported no unmet need and 43.6% had at least 10 needs that were unmet. Main caregiver concerns were regarding health care service and information needs followed by emotional and psychological needs. To some degree, unmet needs in patients and caregivers' anxiety predicted unmet caregiver needs. Sociodemographic and clinical variables were not found to be significant predictors. CONCLUSIONS: A substantial percentage of caregivers have unmet needs for support, mainly with regard to fears concerning the patient's condition, receiving disease-related information, and emotional support for themselves. Prediction of unmet needs in caregivers from other clinical and psychological variables was rather poor. Therefore, by means of the frequency and disparity of caregivers unmet needs, they should be systematically assessed to direct specific offers.

Depression, anxiety and disease-related distress in couples affected by advanced lung cancer.

OBJECTIVES: Lung cancer patients and their partners are prone to high levels of depression and anxiety or severe distress related to the poor prognosis of the illness. However, there remain doubts regarding the extent to which this distress exceeds levels in the general population. This study explored levels of depression and generalized anxiety for comparison with matched data of a representative sample from the general population. Additionally, covariance of distress between the two partners, together with disease-specific components and differences were investigated. MATERIALS AND METHODS: In a cross-sectional survey, 54 pairs of lung cancer patients and their partners (n=108) were assessed for depression and anxiety, cancer-related distress, unmet needs and disclosure in communication. Comparisons between distress levels of participating couples and matched community-comparisons (n=162) were conducted. Additionally, multilevel analysis for estimating intra-dyadic associations of anxiety and depression was computed. Components of distress, needs and aspects of communication were explored via item mean values. RESULTS: Lung cancer patients as well as their partners exhibited significantly higher levels of depression and anxiety when compared to community-based comparison subjects (patients: mean difference of 1.01 for depression with a relative risk (RR) of 4.5 and 0.84 for anxiety with RR=6.1; partners: 1.17 for depression with RR=4.6 and 1.59 for anxiety with RR=7.6). Partial intraclass correlations between patients and partners were weak (PIC=.29 for depression; PIC=.21 for anxiety). Fear of progression emerged as main component of distress for both patients and partners, although differing stressors were described. CONCLUSION: Lung cancer-affected couples exhibit levels of depression and anxiety far exceeding those of the general community. In clinical practice, patients and partners should be assessed separately for distress against the background of weak intra-dyadic associations. In cases of significant depression or anxiety, referral for psychosocial treatment is indicated and has been shown to improve quality of life.

Cancer patients' preferences for quantity or quality of life: German translation and validation of the quality and quantity questionnaire.

BACKGROUND: Decision-making with patients with incurable cancer often requires trade-offs between quality and length of life. The 'Quality and Quantity Questionnaire' (QQ) is an English-language measure of patients' preference for length or quality of life. The aim of this study was to translate and validate this questionnaire. MATERIALS AND METHODS: 1 new item was formulated to improve the 'Quality of life' scale. Construct validity including exploratory factor analysis, convergent and discriminant validity, and reliability was determined in n = 194 patients. RESULTS: The acceptability of the questionnaire among patients was high. The item-non-response rate was very low (2.5-4%). The 2 QQ scales 'Quality of life' (QL) and 'Length of life' (LL) had good and acceptable internal consistency (Cronbach's = 0.71 for LL and 0.59 for QL). Convergent validity was shown by significant correlation of the QL subscale with the CCAT (Cancer Communication Assessment Tool) subscale 'Limitation of treatment' (r = 0.37, p < 0.01) and the LL scale with the CCAT subscale 'Continuing treatment' (r = 0.24, p = 0.00). CONCLUSION: The German version of 'QQ' has satisfactory psychometric properties for measuring patients' preferences for LL or QL. It can be used in all research fields that should be informed by patients' preferences: shared decision-making, palliative care, and health services.

Distress in cancer patients and their caregivers and association with the caregivers' perception of dyadic communication.

BACKGROUND: Discrepancies within cancer-affected couples can disrupt security within the dyadic relationship during cancer treatment. This study investigated the patients' and caregivers' distress and associations between the caregivers' perception of the patients' degree of open communication and their distress. PARTICIPANTS AND METHODS: In a cross-sectional survey, 189 pairs of cancer patients (31% gastrointestinal, 34% lung, 35% urological cancers) and their partners were assessed for distress (QSC-R10), depression and anxiety (PHQ-2/GAD-2). The caregivers also reported their perception of the patients' degree of disclosure regarding cancer-relevant topics (CCAT-F Disclosure subscale), caregiver strain (CSI), and unmet needs (SCNS-P&C). Prevalences of clinically significant distress were calculated. Associations were calculated between the caregivers' and the patients' ratings and between the caregivers' distress and their perception of the patients' degree of disclosure. RESULTS: 33% of the caregivers and 25% of the patients exhibited significant anxiety, with a tendency towards a higher frequency in the caregivers (p = 0.10). The prevalence of depression was lower but equally high in caregivers and patients. The caregivers' perceived non-disclosure by the patients was primarily associated with their anxiety (r = 0.31), disease-specific distress (r = 0.32), and psychological/emotional needs (r = 0.35). CONCLUSION: The identification of caregivers reporting problems in communicating with patients should be pursued in clinical practice as this might indicate that caregivers are particularly burdened.

Assessing patient-caregiver communication in cancer--a psychometric validation of the Cancer Communication Assessment Tool (CCAT-PF) in a German sample.

PURPOSE: The recently introduced Cancer Communication Assessment Tool (CCAT-PF) measures congruence in patient-caregiver communication and was initially validated in lung cancer patients. Contributing to a greater proportion of the variance in the conflict scores, primary caregivers were hypothesized to experience greater stress. For a detailed understanding of conflicting communication patterns of cancer-affected families, our study aimed for psychometric validation of the CCAT-PF in a sample covering heterogeneous tumor entities. METHODS: Subsequent to a cross-sectional survey of 189 pairs of cancer patients (31 % gastrointestinal, 34 % lung, and 35 % urological) and their caregivers' exploratory factor analysis with principal component condensation and varimax rotation was conducted (response rate, 74.2 %). Reliability and construct validity were assessed calculating Cronbach's α and Pearson correlation coefficients for CCAT-P and CCAT-F scales and related constructs, respectively. RESULTS: Cancer-related communication according to the CCAT-PF can be subdivided into four factors including the scales Disclosure, Limitation of treatment, Family involvement in treatment decisions, and Continuing treatment. Reliability ranged from α = .51-.68. The Disclosure scale, describing poor cancer-related communication of the patient, was correlated with patient's distress (QSC-R10: r = .30, p < .0001), unmet needs in several areas (SCNS-SF-34: r = .25-.32, p < .001), and negatively with social/family well-being (FACT: r = -0.31, p < .0001). Higher scores on the scale were significantly associated with considerable decrements in emotional well-being especially for caregivers perceiving patients' disclosure as problematic. CONCLUSIONS: The Disclosure scale originating from the CCAT-PF emerged as a short, valid, and reliable stand-alone instrument for identifying conflicting communication in patient-caregiver-dyads at risk.