Screening, resilience, patient navigation and information needs - key areas in cancer control

I hope our readers have enjoyed the festive season, and are ready to meet the challenges of a new year. We have a range of interesting articles from across the cancer spectrum to kick things off in 2016, and I hope you find them enjoyable. There has never been a more challenging time for cancer services in western countries – our populations are ageing; cancer patients and their health care providers face more complex challenges, in the context of increasing co-morbidities. At the same time expenditure on health is under unprecedented strain – meaning that services for cancer patients attract even greater scrutiny. This issue includes some common themes in cancer control, such as screening and early diagnosis, assessment of patients’ information needs, co-ordination and integration of care and resilience. Most authors propose new and novel strategies for improving patient experiences and outcomes, and inevitably such proposals require scrutiny – can we afford them, and will they be cost-effective? Early detection and screening can potentially reduce the burden from common cancers, yet programmes sometimes struggle to achieve uptake rates sufficient to achieve mortality benefits. In the case of colorectal screening, involvement of primary care can lead to significantly improved uptake. Attitudes of GPs and practices are also of critical importance – GPs generally have positive attitudes although they do identify significant barriers to screening (Damery et al. 2010). In an interesting paper, Aubin-Auger et al. (2016) have demonstrated, in a cluster randomised controlled trial, that improving communication skills among French GPs can improve rates of screening. While the paper reflects some of the unique characteristics of the French programme, it underlines the importance of communication and information provision in successful screening programmes. Despite the existence of bowel screening programmes, the majority of patients are diagnosed through ‘symptomatic’ routes; Oberoi et al. (2016) examine experiences of men diagnosed with colorectal cancer – their paper focuses particularly on delay and barriers to seeking timely medical advice. Their qualitative study highlights factors including misinterpretation of symptoms, fear of cancer diagnosis and reticence to discuss symptoms or consulting GPs – again reflecting similar findings in the international literature. Berens et al. (2016) examine determinants of breast screening among Turkish women in Germany. Their findings highlight common themes in the screening literature – language skills, insufficient knowledge about breast cancer and a range of attitudinal factors. It is vital in strategies to promote mammography uptake and informed choice that factors such as these are taken in to account. In screening it is also important also to examine potential adverse effects of ‘downstream’ investigations – we too often focus exclusively on the screening test itself. Kola-Palmer et al. (2016) emphasise the need for preparatory information to reduce anxiety, pain and distress associated with colposcopy investigations following cervical screening. Lastly among our screening and prevention papers, Marek et al. (2016) explore, in a Hungarian study, some of the complex determinants of cervical cancer preventive behaviours, focusing on adolescent risk-taking behaviour. Turning to post-diagnosis topics, individuals with colorectal cancer experience a range of physical, psychological and social factors in adjusting to everyday life – evidence suggests that they employ a arrange of techniques to make appropriate adjustments, such as goal setting, and the adoption of strategies for physical and emotional recovery (Appleton et al. 2013). We need better methods for assessing the needs of CRC patients; Ngune et al. (2016) have undertaken important work in developing a self-assessment tool which should be a valuable resource for researchers in this field. It is difficult to draw clear and consistent conclusions about the relative merits of different settings for chemotherapy provision – although qualitative studies suggest that the patient time and energy required for outpatient chemotherapy reduces quality of life (Corbett et al. 2015). In this issue, Coolbrandt et al. (2016) examine a range of issues faced by patients receiving chemotherapy at home, highlighting many of the benefits, and challenges, associated with this approach to chemotherapy provision. It is not always practical, or cost-effective, to deliver chemotherapy treatments in major oncology centres, and a range of approaches have emerged to deal more effectively with patient needs and preferences. For example, tele-oncology models are emerging as an important mechanism for delivering oncology care in rural and remote settings (Chan et al. 2015). Jhaveri et al. (2016) explore the complex issues around remote monitoring of chemotherapy, from the perspective of providers; their paper provides a helpful summary of the important considerations when designing these innovative services for cancer patients. It is well known that support and advice around fertility can alleviate anxiety in cancer patients and contribute to improved quality of life after a cancer diagnosis (Letourneau et al. 2012). It is interesting, however, to examine in more detail the motivation for having children after cancer treatment – Schmidt et al. (2016) have addressed this issue in their systematic review. They identify important practical barriers to post-cancer parenthood and describe motivations for parenthood, including ‘achievement of normality’ and a desire to focus on the positive. By way of contrast, Ussher et al. (2016) describes a broad range of health professional perspectives on fertility in the context of cancer – clearly there is a need for all professionals involved in this sensitive aspect of cancer care to provide advice which is both evidence based and supportive. Resilience has emerged as a key concept in cancer survivorship – it is vital that we understand the factors underpinning resilience and how resilience can be enhanced (Rowland & Baker 2005). Two papers in the journal this issue explore the concept of resilience in greater detail; Çuhadar et al. (2016) examine psychological resilience in the context of hematopoietic stem cell transplants and suggests that patients and their families should be evaluated for psychiatric symptoms – along with attempts to improve levels of resilience by helping patients to improve their coping and problem solving skills. Similarly Engeli et al. (2016) examine resilience in melanoma patients and emphasise the importance of the concept of ‘situation manageability’, with associated mechanisms to reinforce coping skills. Patient navigation has attracted a great deal of interest, particularly in the North American literature, yet its place in management of common cancers such as breast cancer is still emerging (Robinson-White et al. 2010). Cancer patients often face complex choices during the course of their treatment and follow-up, and ‘patient navigators’ can potentially help patients through this difficult process. Gotlib Conn et al. (2016) identify some key benefits for patients, including ‘demystifying the system’, ensuring comprehension, managing expectations and delivering patient-centred care. They emphasise that navigators can provide individualised and extended family support, and address emotional and psychological needs. Patient navigation is a concept we should continue to explore, as it has significant potential to promote better integrated care – and potentially reduce health care costs. Our journal features regular papers on information needs of cancer patients; these have been found to vary among patient groups, and across the continuum of care (Squiers et al. 2005). Coyne et al. (2016) examine this issue in the context of children with cancer – their papers paints a rich picture of the dynamics of information exchange between health care professionals, children with cancer and their parents. Patients with head and neck cancer are another group with significant information needs – difficulties arise from receiving insufficient, confusing and often untimely information (Parker et al. 2014). Head and neck cancer is often associated with persistent and traumatic experiences which challenge patients’ physical, mental and emotional coping capacity. Threader and McCormack (2016) explore these experiences in some depth, and identify significant cancer-related trauma and stigma associated with this group of cancers – they emphasise the importance of developing more accepting and empathic constructs to support patients. So, an interesting potpourri of papers as we head into a new year. Keep watching this space – we have themed issues coming up in areas including cancer in indigenous populations, palliative care and global cancer control. Thanks for your support in 2015, and all the very best for the year ahead.