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Studies examining longitudinal associations between socioeconomic factors and quality of life (QoL) in cancer patients are rare. This study investigates changes in QoL over a 6-month period. Four hundred forty-two cancer patients (mean age 64, SD = 11, 70% male) completed standardized questionnaires at the beginning (t1) and end (t2) of their hospital stay and 3 (t3) and 6 months (t4) thereafter. QoL was assessed with the EORTC QLQ-C30 core questionnaire. Mixed effect models were employed to analyze individual changes in QoL in relation to socioeconomic status (education, income, job status) over the four timepoints. Age, sex, cohabitation, disease and treatment factors, and comorbidity were included as covariates in the models. Income was a predictive factor for QoL. Patients with a low income had 8.8 percentage points (PP) lower physical, 4.9 PP lower emotional, and 11.4 PP lower role functioning. They also had 6.6 PP lower global QoL. Lower social functioning (6.2 PP) was found in patients with higher education or university degrees compared with those who were less educated or had not undergone an apprenticeship. Income also influenced trajectories of role functioning. There was no evidence that primary or secondary education and job type were related to QoL. The fact that income is negatively associated with many aspects of quality of life should be considered during and after treatment with a focus on patients with special needs.

Importance Total neoadjuvant therapy has been increasingly adopted for multimodal rectal cancer treatment. The optimal sequence of chemoradiotherapy (CRT) and chemotherapy needs to be established. Objective To report the long-term results of the secondary end points prespecified in the Randomized Phase 2 Trial of Chemoradiotherapy Plus Induction or Consolidation Chemotherapy as Total Neoadjuvant Therapy (CAO/ARO/AIO-12 trial) for Locally Advanced Rectal Cancer. Design, Setting, and Participants This secondary analysis of a randomized clinical trial included 311 patients who were recruited from the accrued CAO/ARO/AIO-12 trial population from June 15, 2015, to January 31, 2018, from 18 centers in Germany. Patients with cT3-4 and/or node-positive rectal adenocarcinoma were included in the analysis. Data were analyzed from June 15, 2015, to January 31, 2018. The follow-up analysis was conducted between January 31, 2018, and November 30, 2020. Interventions Patients were randomly assigned to group A for 3 cycles of fluorouracil, leucovorin, and oxaliplatin before fluorouracil/oxaliplatin CRT (50.4 Gy), or to group B for CRT before chemotherapy. Total mesorectal excision was scheduled on day 123 after the start of total neoadjuvant therapy in both groups. Main Outcomes and Measures The end points assessed in this secondary analysis included long-term oncologic outcomes, chronic toxicity, patient-reported outcome measures for global health status (GHS) and quality of life (QoL), and the Wexner stool incontinence score. Results Of the 311 patients enrolled, 306 were evaluable, including 156 in group A (mean [SD] age, 60 [11] years; 106 men [68%]) and 150 in group B (mean [SD] age, 62 [10] years; 100 men [67%]). After a median follow-up of 43 months (range, 35-60 months), the 3-year disease-free survival was 73% in both groups (hazard ratio, 0.95; 95% CI, 0.63-1.45,P = .82); the 3-year cumulative incidence of locoregional recurrence (6% vs 5%,P = .67) and distant metastases (18% vs 16%,P = .52) were not significantly different. Chronic toxicity grade 3 to 4 occurred in 10 of 85 patients (11.8%) in group A and 8 of 66 patients (9.9%) in group B at 3 years. The GHS/QoL score decreased after total mesorectal excision but returned to pretreatment levels 1 year after randomization with no difference between the groups. Stool incontinence deteriorated 1 year after randomization in both groups and only improved slightly at 3 years, but never reached baseline levels. Conclusions and Relevance This secondary analysis of a randomized clinical trial showed that CRT followed by chemotherapy resulted in higher pathological complete response without compromising disease-free survival, toxicity, QoL, or stool incontinence and is thus proposed as the preferred total neoadjuvant therapy sequence if organ preservation is a priority. Trial Registration ClinicalTrials.gov identifier:NCT02363374

We examined whether multi-disciplinary stepped psycho-social care decreases financial problems and improves return-to-work in cancer patients.In a university hospital, wards were randomly allocated to either stepped or standard care. Stepped care comprised screening for financial problems, consultation between doctor and patient, and the provision of social service. Outcomes were financial problems at the time of discharge and return-to-work in patients 65 years old half a year after baseline. The analysis employed mixed-effect multivariate regression modeling.Thirteen wards were randomized and 1012 patients participated (n = 570 in stepped care and n = 442 in standard care). Those who reported financial problems at baseline were less likely to have financial problems at discharge when they had received stepped care (odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1, 0.7; p = 0.01). There was no evidence for an effect of stepped care on financial problems in patients without such problems at baseline (OR 1.1, CI 0.5, 2.6; p = 0.82). There were 399 patients 65 years old who were not retired at baseline. In this group, there was no evidence for an effect of stepped care on being employed half a year after baseline (OR 0.7, CI 0.3, 2.0; p = 0.52).NCT01859429 CONCLUSIONS: Financial problems can be avoided more effectively with multi-disciplinary stepped psycho-social care than with standard care in patients who have such problems.

Objective Emotional distress in cancer patients often goes unnoticed in daily routine; therefore, distress screening is now recommended in many national guidelines. However, screening alone does not necessarily translate into better well-being. We examined whether stepped psychooncological care improves referral to consultation-liaison (CL) services and improves well-being. Methods In a cluster-randomized trial, wards were randomly allocated to stepped versus standard care. Stepped care comprised screening for distress, consultation between doctor and patient about the patient's need for CL services, and provision of CL service. Primary outcomes were referral to psychosocial services and emotional well-being half a year after baseline, measured with the Hospital Anxiety and Depression Scale. A secondary endpoint was uptake of outpatient health care. Analysis employed mixed-effects multivariate regression modeling. Results Thirteen wards were randomized; 1012 patients participated. With stepped care (N = 570; 7 wards), 22% of the patients were referred to CL services and 3% with standard care (N = 442; 6 wards; odds ratio [OR] 10.0; P

Patients with head and neck cancer experience multiple complaints during treatment which also affect quality of life. The present study assessed predictors of temporal changes in quality of life over a 6-month period among patients treated for head and neck cancer.Patients completed questionnaires at the beginning (t1) and end (t2) of their hospital stay and 3 (t3) and 6 months (t4) thereafter. Quality of life was evaluated using EORTC QLQ-C30 and QLQ-HN35. Descriptive statistics were computed across measurement points for different domains of quality of life; predictors were identified using general linear models.Eighty-three patients (mean age: 58, SD = 11, 20.5% female) participated. Quality of life decreased during treatment and slowly recovered thereafter. From t1 to t4, there were adverse changes that patients consider to be relevant in physical and role functioning, fatigue, dyspnea, insomnia, loss of appetite, financial difficulties, problems with senses and teeth, limited mouth opening, mouth dryness, social eating, coughing, and sticky saliva. Temporal changes in global quality of life between t1 and t2 were predicted by tumor stage (B = - 5.6, p = 0.04) and well-being (B = 0.8, p = 0.04); radiotherapy was a predictor of temporal changes in physical functioning (B = - 12.5, p = 0.03).Quality of life decreases during treatment, half a year after hospital stay there are still restrictions in some areas. A special focus should be given on head and neck cancer patient's quality of life in the aftercare.

Distress impacts the daily life of glioma patients. This study explored its course over time and the usage of psychosocial care. A consecutive sample of glioma patients completed the Hospital Anxiety and Depression Scale to assess distress levels at admission to the hospital (t1), before discharge (t2), after 3 months (t3), and after 6 months (t4). They were interviewed with the Structured Clinical Interview for DSM-IV to ascertain psychiatric disorders at t2. Psycho-oncological care in the hospital was determined with the Hospital Information System, and the use of outpatient treatment was evaluated with the Health Care Usage Questionnaire at t4. We compared the percentages of elevated distress, psychiatric co-morbidity, and care usage between men and women. During the study period, 37 patients were enrolled. Nineteen percent of the patients were diagnosed with a psychiatric disorder. The percentages of patients with elevated distress were 56, 59, 39, and 40% at t1, t2, t3, and t4, respectively. Participants who did not survive the 6 months presented with higher levels of distress. In the hospital, 14% of those with elevated distress were visited by a psycho-oncologist. In the outpatient setting, 43% of those with elevated distress visited a neuro-psychiatrist, and 14% went to a psychotherapist. There was no evidence for an effect of gender on psychiatric co-morbidity, distress, or care use. A significant proportion of glioma patients report elevated distress during the hospital stay and thereafter. Only a fraction of them receive mental health care.

Reasons for the social gradient in cancer survival are not fully understood yet. Previous studies were often only able to determine the socio-economic status of the patients from the area they live in, not from their individual socio-economic characteristics. In a multi-centre cohort study with 1633 cancer patients and 10-year follow-up, individual socio-economic position was measured using the indicators: education, job grade, job type, and equivalence income. The effect on survival was measured for each indicator individually, adjusting for age, gender, and medical characteristics. The mediating effect of health behaviour (alcohol and tobacco consumption) was analysed in separate models. Patients without vocational training were at increased risk of dying (rate ratio (RR) 1.5, 95% confidence interval (CI) 1.1–2.2) compared to patients with the highest vocational training; patients with blue collar jobs were at increased risk (RR 1.2; 95% CI 1.0–1.5) compared to patients with white collar jobs; income had a gradual effect (RR for the lowest income compared to highest was 2.7, 95% CI 1.9–3.8). Adding health behaviour to the models did not change the effect estimates considerably. There was no evidence for an effect of school education and job grade on cancer survival. Patients with higher income, better vocational training, and white collar jobs survived longer, regardless of disease stage at baseline and of tobacco and alcohol consumption.

Summary Background Radiotherapy is the standard care in elderly patients with malignant astrocytoma and the role of primary chemotherapy is poorly defined. We did a randomised trial to compare the efficacy and safety of dose-dense temozolomide alone versus radiotherapy alone in elderly patients with anaplastic astrocytoma or glioblastoma. Methods Between May 15, 2005, and Nov 2, 2009, we enrolled patients with confirmed anaplastic astrocytoma or glioblastoma, age older than 65 years, and a Karnofsky performance score of 60 or higher. Patients were randomly assigned 100 mg/m 2 temozolomide, given on days 1–7 of 1 week on, 1 week off cycles, or radiotherapy of 60·0 Gy, administered over 6–7 weeks in 30 fractions of 1·8–2·0 Gy. The primary endpoint was overall survival. We assessed non-inferiority with a 25% margin, analysed for all patients who received at least one dose of assigned treatment. This trial is registered with ClinicalTrials.gov, number NCT01502241. Findings Of 584 patients screened, we enrolled 412. 373 patients (195 randomly allocated to the temozolomide group and 178 to the radiotherapy group) received at least one dose of treatment and were included in efficacy analyses. Median overall survival was 8·6 months (95% CI 7·3–10·2) in the temozolomide group versus 9·6 months (8·2–10·8) in the radiotherapy group (hazard ratio [HR] 1·09, 95% CI 0·84–1·42, p non-inferiority =0·033). Median event-free survival (EFS) did not differ significantly between the temozolomide and radiotherapy groups (3·3 months [95% CI 3·2–4·1] vs 4·7 [4·2–5·2]; HR 1·15, 95% CI 0·92–1·43, p non-inferiority =0·043). Tumour MGMT promoter methylation was seen in 73 (35%) of 209 patients tested. MGMT promoter methylation was associated with longer overall survival than was unmethylated status (11·9 months [95% CI 9·0 to not reached] vs 8·2 months [7·0–10·0]; HR 0·62, 95% CI 0·42–0·91, p=0·014). EFS was longer in patients with MGMT promoter methylation who received temozolomide than in those who underwent radiotherapy (8·4 months [95e% CI 5·5–11·7] vs 4·6 [4·2–5·0]), whereas the opposite was true for patients with no methylation of the MGMT promoter (3·3 months [3·0–3·5] vs 4·6 months [3·7–6·3]). The most frequent grade 3–4 intervention-related adverse events were neutropenia (16 patients in the temozolomide group vs two in the radiotherapy group), lymphocytopenia (46 vs one), thrombocytopenia (14 vs four), raised liver-enzyme concentrations (30 vs 16), infections (35 vs 23), and thromboembolic events (24 vs eight). Interpretation Temozolomide alone is non-inferior to radiotherapy alone in the treatment of elderly patients with malignant astrocytoma. MGMT promoter methylation seems to be a useful biomarker for outcomes by treatment and could aid decision-making. Funding Merck Sharp & Dohme.

Background Patients with head and neck cancer are known to be more commonly emotionally distressed than patients with other tumors. This study investigates reasons for this difference. Methods Patients in this prospective cohort study included those with head and neck cancer (n = 113) and those with other cancers (n = 1690). The Hospital Anxiety and Depression Scale, measuring emotional distress, along with additional questions regarding emotional support wished and provided were administered. Results Patients with head and neck tumors were 1.5-fold (at the time of admission), 1.2-fold (before discharge), and 2.7-fold (half a year after admission) more frequently distressed than the other patients with cancer. This association was confounded by perceived social support and sociodemographic factors. Patients with head and neck cancer expressed less frequently the wish for and received less support by psycho-oncologists. Conclusions Emotional distress is more common in patients with head and neck tumors; this is largely a result of the psychosocial context the patients live in, especially the amount of social support received. © 2011 Wiley Periodicals, Inc. Head Neck, 2012

We explored the relationship between socio-economic characteristics and cancer stage at presentation. Patients admitted to a university hospital for diagnosis and treatment of cancer provided data on their education, vocational training, income, employment, job, health insurance and postcode. Tumor stage was classified according to the Union International Contre le Cancer (UICC). To analyze disparities in the likelihood of late-stage (UICC III/IV vs. I/II) diagnoses, logistic regression models adjusting for age and gender were used. Out of 1,012 patients, 572 (59%) had late-stage cancer. Separately tested, increased odds of advanced disease were associated with post-compulsory education compared to college degrees, with apprenticeship and no vocational training, with unemployment, disability pension, jobs with a low hierarchy level, blue collar jobs and with low income. Health insurance and community size were not related with late-stage cancer. Jointly modelled, there was evidence for an independent effect of unemployment (odds ratio (OR) 1.7, CI 1.0-2.8), disability pension (OR 1.8, CI 1.0-3.2) and very low income (OR 2.6, CI 1.1-6.1) on the likelihood of advanced disease stage. It is of great concern that these socio-economic gradients occur even in systems with equal access to health care.

The authors investigated whether cancer patients who have comorbid mental health disorders (MD) are at greater risk of early retirement compared with those who do not have MD.Individuals ages 18 to 55 years from a consecutive sample of patients who were admitted for inpatient oncologic treatment were interviewed using structured clinical interviews to ascertain MD. The patients were followed for 15 months, and the date of early retirement was documented. Rates of early retirement per 100 person-years (py) in patients with and without MD were compared using multivariate Poisson regression models.At baseline, 491 patients were interviewed, and 150 of those patients (30.6%) were diagnosed with MD. Forty-one patients began full early retirement during follow-up. In patients with MD, the incidence of early retirement was 9.3 per 100 py compared with 6.1 per 100 py in mentally healthy patients. The crude rate ratio (RR) was 1.5 (95% confidence interval [CI], 0.8-2.8). The effect of MD on early retirement was modified in part by income: in patients with low income, the adjusted RR was 11.7, whereas no effect was observed in higher income groups. Patients with depression were at greater risk of retirement when they had higher income (RR, 3.4; P = .05). The effects of anxiety (RR, 2.4; P = .05), adjustment disorders (RR, 1.7; P = .21), and alcohol dependence (RR, 1.8; P = .40) on early retirement were equal across income groups.Mental health conditions are risk factors for early retirement in cancer patients, although this effect differs according to the type of disorder and the patient's income level.

We investigated the impact of demographic and disease related factors on non-participation and dropout in a cluster-randomised behavioural trial in cancer patients with measurements taken between hospitalisation and 6 months thereafter. The percentages of non-participation and dropout were documented at each time point. Factors considered to be potentially related with non-participation and dropout were as follows: age, sex, marital status, education, income, employment status, tumour site and stage of disease. Of 1,338 eligible patients, 24% declined participation at baseline. Non-participation was higher in older patients (Odds Ratio [OR] 2.1, CI: 0.6-0.9) and those with advanced disease (OR 2.0, CI: 0.1-1.3). Dropout by 6 months was 25%. Dropout was more frequent with increased age (OR 2.8, CI: 0.8-1.2), advanced disease (OR 3.0, CI: 1.0-1.2), being married (OR 2.4, CI 0.7-1.1) and less frequent with university education (OR 0.4, CI -1.3 to -0.8) and middle income (OR 0.4, CI -0.9 to -0.7). When planning clinical trials, it is important to be aware of patient groups at high risk of non-participation or dropout, for example older patients or those with advanced disease. Trial designs should consider their special needs to increase their rate of participation.

Glioblastoma (World Health Organization [WHO] grade IV) is the most common intrinsic brain tumor. The prognosis for patients suffering from this disease remains dismal. Age in particular is a strong negative predictor for survival, resulting in a population-based median survival of elderly patients (ie, >65 y) of 70% of WHO grades II and III gliomas and secondary glioblastomas.13 In primary glioblastomas, IDH mutations are rare. Importantly, IDH mutations are associated with a significantly longer survival time compared with IDH wild-type tumors. Among grades III and IV gliomas pooled, IDH has a stronger prognostic impact than WHO grade. In the same study, the authors also found that in patients age ≥60 years with anaplastic astrocytoma and glioblastoma, IDH1 mutation was found in only 7.5% of the patients (11/146).14 Analysis of the glioblastoma epigenome revealed a distinct hypermethylator phenotype, the glioma cytosine–phosphate–guanine (CpG) island methylator phenotype (G-CIMP), which confers a good prognosis.15 Tumors positive for G-CIMP usually harbor IDH mutations, hence they are common among grades II and III gliomas and rare in primary glioblastomas. Genome- and epigenome-wide analyses of glioblastoma samples further revealed frequent mutations in the histone 3.3 gene (H3F3A) at K27 or G34.16 Just like IDH mutations, both K27M and G34R/V mutations are associated with a distinct epigenetic signature and possibly cell of origin each. In this study, tumors carrying G34 mutations show a favorable clinical course.17 Importantly, H3F3A and IDH mutations are mutually exclusive, suggesting that mutations in either of these genes represent different gliomagenic pathways. While the aforementioned alterations are prognostic, Agnihotri et al18 recently reported on epigenetic inactivation of alkylpurine DNA N-glycosylase (APNG) as a predictive biomarker for benefit from TMZ treatment. APNG is a DNA base excision repair enzyme, which catalyzes removal of N3-methyladenine and N7-methylguanine from DNA, both of which can be caused by TMZ. APNG expression is regulated through promoter methylation, and in patients with an unmethylated MGMT promoter receiving TMZ, the subset of APNG-negative tumors was reported to have a better prognosis. Peroxiredoxin 1 (PRDX1) is another interesting candidate, especially in the group of anaplastic astrocytomas. The PRDX1 promoter was found to be frequently hypermethylated in oligodendroglial tumors and secondary glioblastomas carrying a deletion of 1p/19q, leading to epigenetic downregulation of PRDX1 expression.19 In this study, silencing of PRDX1 in Hs683 glioma cells sensitized these cells both to TMZ and to RT in vitro. The objective of our present study was to determine the prevalence and impact of recently defined biomarkers associated with survival, heretofore established in younger patients, in an elderly collective. We hypothesized that these biomarkers might help to explain the heterogeneity in survival seen in the NOA-08 population. However, as our study revealed that they are virtually absent in elderly patients, we assume that relevant molecular differences exist among malignant gliomas of different age groups, which warrant further studies.

Family caregivers of palliative cancer patients are usually much burdened. In order to avoid the failure of home care, family caregivers need support. The current study evaluates support needs in family caregivers of palliative cancer patients. 53 family caregivers of palliative cancer patients answered the questionnaire. Health-related quality of life was assessed using the EORTC QLQ-C30 questionnaire. Home care burden was assessed using the "Burden Scale for Family Caregivers" (BSFC). Family caregivers suffered of reduced social and emotional function. Female and older caregivers reported a stronger home care burden than male and younger caregivers. For female and older family caregivers of palliative cancer patients, home care is very burdensome. Thus, female caregivers need, above all, psychosocial support, whereas older caregivers need the most support in a physical and social level.

The aim of this study was to compare the precision of two different methods in detecting clinical depression in tumor patients: the use of a screening questionnaire versus the assessment by health care providers (nurses and doctors). During their first days of inpatient cancer treatment, tumor patients were interviewed using the Structured Clinical Interview for DSM (SCID). Their physicians and nurses were asked to assess the mental health of the patients and their need for professional psychosocial support. Additionally, every patient completed the Hospital Anxiety and Depression Scale (HADS). Out of 329 patients, 28 were diagnosed with either a major or a minor depression according to the SCID. Physicians assessed 15 of the depressed patients as being depressed (sensitivity, 0.54; specificity, 0.38). Nurses identified 19 (sensitivity, 0.68; specificity, 0.45) and the HADS 27 (sensitivity, 0.96; specificity, 0.50) of the depressed patients. The HADS performed well in detecting depressed cancer patients in acute oncological care, whereas physicians and nurses often were unable to recognize depressed patients.