Long-term effects of cancer
Transcript of Long-term effects of cancer
Long-term effects of cancer:
consequences for supportive and palliative care integrating rehabilitation requirements
Martin Härter
Presentation at the European Cancer Rehabilitation and Survivorship Symposium Kopenhagen, September 17th 2012
Department of Medical Psychology Hubertus Wald Tumor Center University Cancer Center Hamburg (UCCH)
• Introduction
• Distressing symptoms and impairment in cancer patients
• Care approaches and cancer rehabilitation in Germany
• Starting survivorship programs - the UCCH approach
Objectives
Cancer and Survivorship
¹ data presented by Karen Syrjala (Cancer Survivorship Symposium - Hamburg 2011)
Survival rates US ¹
Incidence and Mortality Rates Germany 1980-2006
RKI & GEKID 2008
Cancer Care Trajectory
Recurrence/ second cancer
Cancer-free survival
Managed chronic or
intermittent disease
Treatment with intent to cure
Diagnosis and staging
Palliative treatment
Death
Treatment failure
IOM, 2005
Start here
Survivorship care
2005 26.01.2012
Cancer Survivorship
„Left alone in surviving“
Symptom and emotional distress, and functional impairments
Cancer Survivorship Relevance for Rehabilitation
Chang et al., Cancer 2000
Quality of life
Number of distressing symptoms
The Burden of Symptom Distress Cancer Survivorship
Anxiety
38% of patients report
moderate (> 8) to high
(> 11) anxiety levels
Depression
22% of patients report
moderate (> 8) to high
(> 11) depression levels
Mehnert & Koch, J Psychosom Res 2008
Anxiety and Depression 1083 Breast Cancer Patients (Hamburg Cancer Register) – HADS Scores
18 to 24 months up to 36 months
up to 48 months up to 60 months More than 60 months post
diagnosis
18 to 24 months up to 36 months
up to 48 months up to 60 months More than 60 months post
diagnosis
Fear of Cancer Recurrence
100
90
80
70
60
50
40
30
20
10
0
Pre
vale
nce
(%
)
Sample: n=883 cancer patients (mean=23 months post diagnosis)
Median
Fear of Cancer Recurrence Cancer Survivors
49
50
54
62
35
32
20
Hematological Colon / Rectum Skin Breast Head and Neck Gynecological Lung
100
90
80
70
60
50
40
30
20
10
0
Pre
vale
nce
(%
)
Sample: n=883 cancer patients (mean=23 months post diagnosis)
Fear of Progression Questionnaire - FoP-Q-SF) Mehnert et al. 2012 (in submission)
Median
Mental Comorbidity in Cancer Patients
Meta-analyses (>70 studies) analysed rates of mental disorders (DSM-IV/ICD-10):
– 17.9% affective disorders (12 months) 1
– 19.4% adjustment disorders 2
– 19.3% anxiety disorders (12 months) 1
– 38.2% any mood disorder 2
1 Vehling et al., Psychother Psych Med 2012;62:249–258
2 Mitchell et al., Lancet Oncology 2011;12(2):160-74 Graph: prevalence of depression
+ representative sample for tumor entities and care facilities, cancer incidence-based recruitment strategy
+ sample (N=2.400) > earlier study samples, allows subgroup analyses etc.
+ detection of 4-weeks, 12-months, lifetime prevalence including adjustment/traumatic disorders (CIDI)
Attention deficits („chemo brain“)
Number of impairments in test parameters
Frequ
ency (%
)
About 40% of patients showed impaired attention at each assessment point.
T0: before HSCT
T1: 3 months after HSCT
T2: 12 months after HSCT
Prevalence of Cognitive Impairments 102 Patients with hematological cancers and stem cell transplant
Scherwath et al., Psychooncology online first 2012
• breast cancer patients can expect normal cognitive functioning after 6 mo.
• exception: slight impairments in verbal abilities (word-finding difficulty) and visuospatial abilities (getting lost more easily)
• Efforts needed to develop a core set of neuropsychological tests to be used across studies to facilitate interpretation and meta-analysis
• chemobrain is commonly reported by cancer survivors, research on the topic is relatively new manuscripts that report null results are likely to be of interest (publication bias!)
Published online August 27, 2012
How do we understand or what do we mean with…
• Supportive care?
• Palliative care?
• Rehabilitation?
Long-term Effects of Cancer
= care given to improve the quality of life of patients who have a serious or life-threatening disease. Goal is to prevent or treat as early as possible the symptoms of a disease, side effects caused by treatment of a disease, and psychological, social, and spiritual problems related to a disease or its treatment.
Also called comfort care, palliative care, and symptom management.
Definition of Supportive Care by the NCI
Palliative care is defined as an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and the physical, psychosocial and spiritual problems.
Definition of Palliative Care by the WHO
Early Palliative Care Model
Acute Illness Chronic Illness Advanced
Life-threatening Death
Palliative (Supportive) Care End of life/hospice care
6-months prognosis Diagnosis
Time -------------- ------------------ ------------------ ------------------
Therapies to modify disease
Bereavement care
Last hours of life care (dying)
Last closure (Planning for death)
Am
ou
nt
of
care
Irwin SA & von Gunten CF, in Holland J et al., Psycho-Oncology, 2010
Rehabilitation of people with disabilities is a process aimed at enabling them to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels.
Rehabilitation provides disabled people with the tools they need to attain independence and self-determination.
Definition of Rehabilitation by the WHO
WHO Model of Functioning, Disability and Rehabilitation (ICF)
The (re-)integration of individuals with disabilities, chronic health conditions, diseases
and handicaps into social and work life are important aspects according to the ICF.
Health Condition (disorder or disease)
Participation (Restriction)
Body Functions & Structures (Impairment)
Activities (Limitations)
Environmental Factors Personal Factors
Model of Functioning and Disability, WHO 2001
• Long experience and large knowledge in rehabilitation
• Legal basis that secures the financial basis for the access to rehabilitation services
• Availability of an of specialized service providers
• Comprehensive concept of rehabilitation
• Interdisciplinary rehabilitation teams
• Intensive striving for quality and rehabilitation research
Rehabilitation System in Germany
Cancer
18%
Psychiatry/
Psychosomatics
13%
Cardiology
9%
Addiction
6%
Metabolic diseases
4%
Others
13%
Orthopedics
37%
German Pension Insurance 2012 Rehabilitation Report
Rehabilitation Measures 2010 N=996.154
• > 160.000 cancer rehabilitation measures per year (mainly paid
by pension insurances)
• Traditionally mainly carried out in the inpatient setting,
outpatient rehabilitation programs are rare (< 2% in oncology)
• Conducted in about 100 specialised rehabilitation clinics
• Multidimensional therapeutic approach (medical treatment,
physical therapy, psychotherapy, patient education, sports,
counselling…), up to 6 treatment sessions per day
• Duration of rehabilitation measures: normally 3 weeks
The System of Cancer Rehabilitation in Germany
1.
Admission
2.
Rehab-Assessment
3.
Goal and rehab-planning
4.
Rehab. inter-ventions
5.
Discharge Assessment
6.
Rehab. Aftercare
1) Preparation of admission, patient information via
brochures, internet, flyer
2) Screening and (if necessary) clinical assessment based on the
ICF: medical, functional, social and mental limitations
3) Realistic, concrete, indivi-dualized agreement between
patient and rehab team
5) See 2: ICF-based socio-medical evaluation
and prognosis
4) Use of indication-generic and specific interventions,
coordinated by the (medical) chairperson, process assessment
and program adaptation
6) Specific preparation and information about after care facilities, contact to self-help
groups, self-management programs, e-health aftercare
Cancer Rehabilitation - a systematic Process
Patients‘ Needs for Cancer Rehabilitation
Social impact
Activities of daily living
Emotional/ cognitive impact Quality of life
Leasure/ recreation
Symptoms and side effects
Patient satisfaction treatment/service
Return to work
Interventions in Rehabilitation
Depending on individual functional impairments (initial assessment):
• Medical treatment
• Physiotherapy and physical therapy, sports and exercise therapy
• Occupational therapy / ergotherapy
• Health promotion and patient education
• Psychological diagnostics and counseling
• Relaxation techniques
• Nutritional counseling
• Social, social law and occupational counseling
• Job-related measures
• …
Outcomes of cancer rehabilitation
Bergelt et al. 2009
0
10
20
30
40
50
1 not successful at all 2 3 4 5 very successful
Percent
outpatient rehabilitation (n=380) inpatient rehabilitation (n=450)
Satisfaction with Rehabilitation overall effectiveness
Changes in Anxiety and Depression
Mehnert et al., unpublished
N=883 cancer patients (different tumor sites)
Changes in Quality of Life
Mehnert et al., unpublished
N=883 cancer patients (different tumor sites)
Cancer Patients and Employment
… about 41% of all
cancer patients will
experience the cancer
diagnosis during the
age between 15 and 64
years, when career and
work-related issues
play an important role
in individual and family
lifes.
Cancer incidence in patients between 15-64 years old and between 35-64 years old in comparison to the total cancer incidence (RKI & GEKID, 2008)
Cancer site
(n=568)
Patients (%)
returned to work
Patients (%)
returned immediately after rehabilitation
Mean weeks (SD)
to return to work after rehabilitation
Hematological 94 50 5 ( 7.5)
Colon/Rectum 86 44 10 ( 13.4)
Gynecological 74 47 5 ( 6.8)
Skin 83 79 3 ( 6.0)
Breast 78 49 5 ( 8.0)
Head and Neck 58 36 8 ( 10.3)
Lung 44 10 14 ( 14.2)
Total 76 50 11 ( 11)
P[Chi2] < 0.001,
ρ = 0.18
P[Chi2] < 0.05,
ρ = 0.19
P[MANOVA] < 0.05, eta2 = 0.05
Return to Work - Time to Return
Mehnert & Koch, Scand J Work Environ Health – online first
Work Situation after Rehabilitation
Work after cancer rehabilitation (12 months)
76% of all patients (n=750) returned to work
• 475 (81%) to their former position/work place
• 115 (19%) changed their position/work place within or changed company
• 145 (25%) report mild to severe impairments at their daily work
Predictors: baseline RTW intention (OR 6.2), employer accommodation (OR 1.93), high job requirements
(OR=1.84), cancer recurrence/progression (OR=0.27), baseline sick leave absence (OR=0.26), dificult social
interactions (OR=0.58) R²=0.59
CAVE:
Occupational motivation and skepticism towards RTW should be carefully assessed when planning rehabilitation programs
Mehnert & Koch, Scand J Work Environ Health – online first
Problems of Rehabilitation Services in Germany
• Unsolved questions of needs: under- and overuse
• Strongly developed in-patient rehabilitation and lack of community based services
• Limited provision of outpatient facilities and aftercare
• Problems with the interfaces between financing agencies and different service providers
• Lack of continuity and limited flexibility in supplying services
• Limited evidence-based practice
• Prevention und early detection of new and recurrent cancer
• Prevention und early detection of long term sequelae
- of cancer disease
- of cancer treatment
• Care coordination between specialists and other physicians (GP)
• Cancer treatment history
• Care/survivorship/rehabilitation plan
Institute of Medicine; www.iom.edu
Support Needs of Survivors
UCCH - L.O.T.S.E.
end of therapy in-/outpatient acute care
standardised letter survivorship care plan
patient folder
Guide
Guide
Complemen-tary medicine
Social work
Life style counseling nutrition
sports
Prevention
Psycho-oncology
arts/music therapy
spirituality
Provision of Psycho-oncological Care
Management of Psychosocial Distress
University Cancer Center Hamburg (UCCH) Center for Oncology
Psychosocial Consultation & Liaison and Outpatient Care Services
Psychooncological Outpatient Care Clinic
(Department of Medical Psychology)
Co-operations with
Inpatient Radiotherapy Inpatient Palliative Care Unit
Hematology/Stem cell Transplant. Oncol. Dermatology, Pulmology
Outpatient Radiotherapy Oncological Outpatient/Day Care
Surgery and other clinics and services COSIP
Psychiatry Servives Ambulant Clinics/Care Facilities
Hospice Services Breast Center
▪ Inpatient Care ▪ Outpatient and Day Care
Prostate Center
▪ Inpatient Care ▪ Outpatient Care
6 Psychosocial Health Care Professionals 10 Psychosocial Health Care Professionals
Approaches for effective Rehabilitation Services
• Reinforcing the involvement of patients
• Early/valid evaluation of patients`needs for rehabilitation
• Extension of out-patient services and aftercare
• Manageing the interfaces via integrated care approaches
• Stronger orientation towards return to work
• Emphasis on needs and outcomes by quality management
and rehabilitation research
Communication competencies reform curriculum UKE
Basic skills in communication
+ basic knowledge
Shared decision making
Behavior change counseling - MI
Breaking bad news
Communication in palliative situations
Communication with migrants and difficult
patients
Intra- and interprofessio-
nal commu-nication
Step I
Step II
Step III
Learning cycle modules
Thank you for your attention
Thanks to my colleagues Anja Mehnert, Corinna Bergelt, Frank Schulz-Kindermann, Georgia Schilling and Uwe Koch
Prof. Dr. Dr. Martin Härter Department of Medical Psychology Martinistraße 52, 20246 Hamburg
[email protected] www.uke.de