| 1. |
- Ax, Anna-Karin, 1980-
(författare)
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Exercise in patients with cancer : Effects on health-related quality of life, costs, and cost-effectiveness during oncological treatment
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Short and long-term side effects of oncological treatment negatively affect daily living and health-related quality of life (HRQoL) in patient with cancer. Exercise during treatment is beneficial for HRQoL, however evidence as to what exercise intensity is most optimal for improving HRQoL and cost-effectiveness is lacking. Cost-effectiveness is important information for decisionmakers when implementing healthcare interventions, such as exercise programmes. The overall aim of this thesis was to study functioning in daily life, HRQoL, costs, and cost-effectiveness of an exercise intervention of different exercise intensities in patients with cancer receiving oncological treatment. Method: Study I was qualitative and explored how individuals with cancer receiving curative treatment and participating in an exercise intervention experienced their functioning in daily life. Semi-structured individual interviews (n =21) were performed and analysed with thematic analysis. Studies II–IV were quantitative and used data from a randomised controlled trial (RCT) of high-intensity (HI) and low-to-moderate-intensity (LMI) exercise of combined resistance and endurance training with or without self-regulatory behaviour change support. The RCT was preceded by a descriptive longitudinal study with usual care (UC). Participants were diagnosed with breast, prostate, or colon cancer and received (neo)adjuvant oncological treatment. Study II evaluated the effects on HRQoL of exercising at HI (n =288) and LMI (n =289) versus UC (n =89) up to 18 months after start of oncological treatment, using the EORTC QLQ-C30 questionnaire. Data were analysed using descriptive and multivariate statistics. Study III evaluated resource utilisation and societal costs of the exercise intervention in the RCT (n =534) versus UC (n =85), and of HI (n =269) versus LMI (n =265) exercise 18 months after start of oncological treatment. Societal costs included costs of healthcare resource utilisation (healthcare visits, hospitalisation, prescribed medication), productivity loss (disability pensions and sick leave), and the exercise intervention. Study IV evaluated the cost-effectiveness of the exercise intensities in the RCT (HI: n =99 and LMI: n =90) at 1-year follow-up post intervention. Cost data were retrieved from Study III and health outcome were collected using the EQ-5D-5L questionnaire and calculated for quality-adjusted life-years. Cost-effectiveness was evaluated as the incremental cost-effectiveness ratio (ICER). Results: Participants experienced impairments from oncological treatment but strove to maintain function in daily life. The exercise programme improved physical and psychological wellbeing during treatment (Study I). There were no significant differences in HRQoL between exercise intensities up to 1 year after the exercise intervention. The exercise groups scored significant better HRQoL compared to UC over time (Study II). There was no significant difference in mean societal costs between the exercise intervention and UC, nor between the exercise intensities (Study III). There was no significant difference in cost or in effect between the exercise intensities. Although the mean ICER indicated that HI was cost-effective compared to LMI, the uncertainty was large (Study IV). Conclusion: Participating in an exercise programme during oncological treatment was a positive and supportive experience that contributed to increase physical and psychological wellbeing. Exercise of HI and LMI during oncological treatment had similar effect on HRQoL and societal costs. In addition, the exercise group had beneficial effects on HRQoL and no significant difference in societal costs compared to UC, meaning the exercise programme did not save or add societal cost. Thus, based on cost-effectiveness we suggest decisionmakers and clinicians implement exercise programmes including both HI and LMI in cancer care and recommend exercise regardless of intensity according to the patient’s preferences to improve or to maintain aspects of HRQoL during oncological treatment.
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| 2. |
- Göransson, Carina, 1967-
(författare)
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Developing and evaluating an interactive app to support self-care among older persons receiving home care
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The proportion of older persons worldwide is growing. With older age, complex health problems may occur and the need for home care increases. To support older persons to maintain health and self-care, innovative ways need to be developed. The aim of the project was to develop and evaluate an interactive app among older persons receiving home care. The project had several phases: i) to define and understand the problem ii) develop the intervention iii) develop and optimise evaluation. Qualitative and quantitative methods were employed. Data were collected through a scoping review, interviews with healthcare experts, older persons and nursing assistants (study I); interviews with older persons (studies II, III); focus groups with homecare nurses (study II). Questionnaires at baseline, end of intervention and 6-month follow-up; with instruments to assess aspects of health, health literacy, self-care, and a study specific question regarding sense of security were used (studies III-IV). Logged data from reported health concerns, alerts, and notes were collected (study IV). Data were analysed using qualitative content analysis (study I), thematic analysis (study II), qualitative content analysis with directed approach (study III) and descriptive and inferential statistics (studies III, IV). Results: Important aspects for health and self-care from the older persons’ perspectives were described as: frame of mind, having relationships and social activities, physical ability and concerns, and maintaining self-care (I). These results were included in the app as questions with self-care advice, graphs and alerts to homecare nurses. The app use was described as an enabler for learning (II). The older persons showed improved communicative and critical health literacy at the 6- month follow-up (IV). They described an increased sense of security (II and III), which decreased at the 6-month follow-up (III). They expressed increased self-confidence (II) and support in self-care, but reported a decrease in self-care ability at the 6-month follow-up (III). App usage was high, with the health concern pain triggering the most alerts (IV). Their aspects of health were unchanged at the three assessments points (IV). In this context using an app may increase older persons’ participation in their care. The results show that for some older persons, an app can be implemented as a tool for support in conventional home care.
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| 3. |
- Henriksson, Anna
(författare)
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Physical activity and exercise during curative oncological treatment : exploring the effects of exercise intensity and behaviour change support, safety, and patients’ and exercise professionals’ experiences
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aims: This thesis aimed to explore the effects of exercise intensity and behaviour change support (BCS), the safety of exercise, and experiences of exercise for both patients and exercise professionals during oncological treatment (e.g. neo/adjuvant chemotherapy, endocrine treatment, radiotherapy). This thesis is based on data from the Phys-Can (Physical training and Cancer) multicentre research program, consisting of a feasibility study, an observation study, and a randomised controlled trial (RCT). Methods: Paper I and II were quantitative studies. Paper I was a RCT with a 2x2 factorial design. Patients newly diagnosed with breast, prostate, or colorectal cancer about to start oncological treatment were randomised to six months of high intensity (HI) or low-moderate intensity (LMI) supervised group based resistance- and home-based endurance training, with or without additional BCS. The primary outcome, cancer related fatigue (CRF), was assessed by the Multidimensional Fatigue Inventory. Multiple linear regression and additional responder analysis for primary outcomes were performed. Paper II was a descriptive and comparative study based on secondary data from the observation study and RCT. Data were presented descriptively, and related factors to adverse events (AEs) were analysed with logistic regressions. Paper III and IV were qualitative studies. Participants were patients with breast, prostate, or colorectal cancer undergoing oncological treatment (Paper III) or coaches supervising exercise for participants in the RCT (Paper IV). Data were collected through semi-structured individual- (Paper III and IV) and focus group interviews (Paper III) and analysed with qualitative content analysis (Paper III) and thematic analysis (Paper IV). Main results and conclusions: The results from this thesis indicate that exercise at HI may not improve CRF in comparison with exercise at LMI in patients undergoing treatment, thus patients can be advised to exercise at either preferred intensity. Also, additional BCS did not improve CRF in relatively motivated patients receiving supervised exercise (Paper I). Furthermore, exercise-related AEs in persons undergoing oncological treatment are minor, of musculoskeletal origin, and with a similar incidence as in healthy populations. However, a higher risk of minor exercise-related AEs was reported in HI groups than in LMI groups. More serious AEs were rare, thus it seems safe to exercise even at HI for these patient groups (Paper II). The results also indicated that patients could experience side effects and concerns regarding the safety of exercising during oncological treatment as barriers to engage in physical activity. Therefore, engaging in physical activity before the onset of side effects from treatment and providing information regarding physical activity to patients could be beneficial (Paper III). Professionals supervising exercise for patients may find it highly rewarding, which is promising for implementation in cancer rehabilitation. However, patients may still receive contradictory information regarding the safety of exercise from health care staff, which can be difficult for exercise professionals to counteract (Paper IV).
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| 4. |
- Fallbjörk, Ulrika, 1967-
(författare)
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I spåren av bröstcancer : att leva med eller utan ett rekonstruerat bröst efter mastektomi
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Bakgrund: I Sverige är bröstcancer den vanligaste formen av kvinnlig cancer och utgör nära en tredjedel av kvinnlig cancer. I behandlingen av bröstcancer har kirurgi en betydande roll. Nära hälften av kvinnorna genomgår mastektomi, men det finns en stor variation inom landet. Att förlora ett bröst efter mastektomi har såväl en kroppslig som psykologisk innebörd. Avhandlingen omfattar fyra delstudier som beskriver detta på olika sätt.Syfte: Det övergripande syftet med avhandlingen är att studera betydelsen av att förlora ett bröst på grund av cancersjukdom samt motiv och beslutsprocess i ställningstagande till att leva med eller utan ett rekonstruerat bröst.Metod: Avhandlingen baseras på två populationer av kvinnor boende i norra Sverige som genomgått mastektomi på grund av bröstcancer: de kvinnor som genomgått mastektomi under 2003 (delstudie I–III) samt de kvinnor som genomgått mastektomi mellan oktober 2006 och september 2007 (delstudie IV). Dessa kvinnor identifierades via det regionala cancerregistret, onkologiskt centrum, Norrlands universitetssjukhus. Statistiska analyser genomfördes i delstudie I och IV och tematisk narrativ analys har tillämpats i delstudie II och III.Resultat: Delstudie I: År 2007 skickades ett nykonstruerat självskattningsformulär ”Life After Mastectomy” (LAM) ut till 149 kvinnor varav 85% (n=126) besvarades. Av dessa kvinnor hade 25% genomgått bröstrekonstruktion. Resultaten av en multipel regressionsanalys visade att bröstrekonstruktion var signifikant relaterat till lägre ålder, känsla av att vara attraktiv och sexuellt intresse. För att få en djupare och mer nyanserad förståelse kring innebörder av att förlora ett bröst efter mastektomi och motiv till att avstå från eller genomgå bröstrekonstruktion gjordes ett strategiskt urval av 15 kvinnor från delstudie I som deltog i en forskningsintervju(delstudie II). I den tematiska narrativa analysen identifierades tre typberättelser. I den första typberättelsen beskrevs mastektomin som ”no big deal” och att genomgå en bröstrekonstruktion var inte ens värt att överväga. I den andra typberättelsen beskrevs mastektomin som ”att förlora sig själv” och en bröstrekonstruktion beskrevs som ett sätt att återställa sig som person, kvinna och sexuell varelse. Den tredje typberättelsen intog en position mellan ”no big deal” och ”att förlora sig själv” och en bröstrekonstruktion beskrevs som ett välkommet erbjudande vilket gjorde det enklare att se och känna sig som kvinna. I delstudie III undersöktes sex kvinnors erfarenheter av att genomgå bröstrekonstruktion. Samtliga kvinnor var oförberedda på den krävande procedur som de genomgick. De beskrev processen som svår och smärtsam med upprepade operationer och en oväntat lång konvalescenstid. Även om kvinnorna var oförberedda på hur tufft det skulle komma att bli både fysiskt och emotionellt beskrevs bröstrekonstruktionen som betydelsefull för dem. Delstudie IV: I denna uppföljningsstudie inkluderades kvinnorna 10 månader efter mastektomin då självskattningsformuläret LAM skickades ut. Datainsamlingen med samma formulär upprepades två år senare (tre år efter mastektomin). Kvinnornas (n=76) känsla av attraktivitet och kvinnlighet hade inte förändrats mellan de två mättillfällena, med undantag för vissa aspekter av sexualitet som hade försämrats. Vid uppföljningen hade 21% av kvinnorna genomgått bröstrekonstruktion och dessa kvinnor var yngre. I övrigt kundeinga signifikanta skillnader ses mellan de kvinnor som genomgått respektiveej genomgått bröstrekonstruktion.Slutsats: Denna avhandling ger en inblick i betydelsen av att förlora ett bröst efter mastektomi. Att förlora ett bröst efter mastektomi kan vara av mindre eller större betydelse. För de kvinnor som upplevde bröstförlusten som en förlust av sig själva, kom en bröstrekonstruktion att betraktas som en livsnödvändighet (delstudie II). De flesta av kvinnorna 75% i delstudie I och 79% i delstudie IV genomgick inte någon bröstrekonstruktion. De kvinnor som genomgick rekonstruktiv kirurgi beskrev proceduren som svår fysiskt och emotionellt, men trots detta sågs den som viktig för dem (delstudie III). Vid uppföljningen i delstudie IV, var kvinnornas upplevelse av attraktivitet och kvinnlighet oförändrade, men upplevelsen av att känna sig bekväm vid sexuell intimitet utvecklades negativt. Detta var oberoende av om kvinnan genomgått bröstrekonstruktion eller inte, vilket kan ses som överraskande. Det är viktigt att som sjukvårdpersonal uppmärksamma hur den enskilda kvinnan själv upplever betydelsen av att ha förlorat ett bröst för att inte låta sig styras av vaga schabloner kring relationen bröst–sexualitet–kvinnlighet.
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| 5. |
- Drott, Jenny, 1976-
(författare)
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Neurotoxic side effects and impact on daily life in patients with colorectal cancer with adjuvant oxaliplatin-based chemotherapy
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Colorectal cancer (CRC) is one of the most common cancers globally. Chemotherapeutic drugs are frequently used in postoperative treatment. The platinum compound oxaliplatin (OXA) is an option for adjuvant treatment of patients with resected CRC, and has been shown to improve survival. OXA-induced neurotoxic side effects are common (e.g. sensitivity to cold, numbness). Neurotoxicity can interfere with the patient’s daily living and affect ability to carry out activities. Because there is no evidence for effective treatment in terms of eliminating neurotoxic side effects, the most successful approaches include early identification, reduction of dose and interruption of treatment. Current research has identified a need for patient-oriented evidence in terms of long-term follow-up of neurotoxicity.Aim: The overall aim of this thesis was to explore OXA-induced neurotoxic side effects in patients with colorectal cancer, and the influence on patients’ daily lives during and post OXA treatment.Methods: The thesis is based on four studies, and includes an analysis of medical records, as well as prospective quantitative and qualitative approaches with longitudinal data collection through a mobile phone-based system. The studies were performed at oncology departments in four hospitals in Sweden. Inclusion criteria were that patients should be at least 18 years of age, and should have been treated with chemotherapy, including OXA (FOLFOX, XELOX), in an adjuvant setting for CRC stages II-III. Study I had a retrospective design, and data involved (n=61) medical records. A structured protocol was used to evaluate the documentation of patients’ neurotoxic side effects. In studies II and III, ten patients were recruited using a strategy of purposeful and consecutive selection according to the inclusion criteria, where OXA-related neurotoxic side effects were assessed. A total of 10 interviews were carried out when neurotoxic side effects appeared (II), and after completed OXA treatment (3, 6 and 12 month’s follow-up) 25 repeated interviews were conducted (III). The prospective longitudinal study IV aimed to identify and assess patient-reported outcomes in terms of neurotoxic side effects, and their impact on patients’ daily activities (n=46). An Oxaliplatin-associated Neurotoxicity Questionnaire (OANQ) was administered in real time to indicate patientreported outcomes. In total, 370 questionnaire responses were available for analysis.Results: The results from the retrospective study (I) showed that a free description of the degree of neurotoxic side effects was given in the patients’ medical records. No formal assessment had been used in the documentation. The findings of the two qualitative studies contribute knowledge about how patients endure neurotoxic side effects early in the treatment phase, and how they learn to live with neurotoxicity in the long-term perspective. Patients coped with their side effects by developing different self-care strategies to restore normality in their daily lives (II-III). Neurotoxic side effects interferes with the patient’s daily activities in a variety of ways. These side effects change in terms of their character and their location in the body over time. The most frequent side effects during treatment were cold-precipitated tingling in the upper extremities and in the mouth/throat. At the end of treatment, neurotoxicity in the lower extremities was considered high and interfered with the patients’ daily activities. The results show significant differences between baseline data, and nine of the patients had not returned to baseline after one year (IV).Conclusion: Neurotoxic side effects affect patients’ daily activities in different ways, with an impact on their physical, psychological, emotional and social life. Patients endured and coped with their side effects in different ways involving self-care strategies to restore normality. The patients’ daily lives were affected by numbness and tingling in the legs and tingling in upper extremity, and they had learned to live with these side effects. The neurotoxic side effects changed character and localisation over time. These results should be taken into account when patients are informed about treatment, and in the dialogue about the benefits and risks.
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