Abstract
Context
Understanding the healthcare needs of patients with metastatic cancer is necessary for reducing symptom burden and optimizing supportive care interventions. Little is known about the impact of social vulnerability on unmet patient needs and healthcare resources utilization in a healthcare system with universal health coverage.
Objectives
This study aimed to describe the healthcare needs and resource utilization of patients with metastatic cancer in France, while also examining how social vulnerability influences these factors.
Methods
We conducted an observational, multicentric, cross sectional study concerning inpatients and outpatients with incurable metastatic cancer. We assessed quality of life (EORTC-QLQC30), supportive care needs (SCNS-SF34), social vulnerability (EPICES score), and healthcare utilization.
Results
361 patients were included; 67.9% had a good performance status (0 or 1), and 59.4% were undergoing their 1st or 2nd line of systemic treatment. They had numerous moderate to severe symptoms including fatigue (75.9%), sleep disorders (61.2%), dyspnea (56.4%), and pain (54.4%). The most important unmet needs were psychological needs (51.4% of moderate/severe needs). 26.8% of patients had visited the emergency room and 38.5% had been admitted to the hospital in the past three months for a cancer complication. 40.3% of patients were socially vulnerable. In multivariate analysis, patients with high social vulnerability had significantly higher cachexia, less surgical treatment in the past and less recent systemic treatment, and more frequent hospitalization at home.
Conclusion
Even when fit, patients with metastatic cancer had numerous health issues and unmet needs. Despite universal healthcare coverage, socially precarious patients seem to have a later diagnosis and less systemic treatment. Nevertheless they have the same unmet needs and strenghted medical and social care at home. A systematic monitoring of healthcare needs could help to trigger supportive care interventions.
Trial registration
This trial was registered in ClinicalTrial.gov PRS with the ID NCT05339945 on April 21, 2022.
Keywords: Metastatic cancer, Healthcare needs, Early integrated palliative care, Social vulnerability
Introduction
Cancer is a major global public health issue, which affects millions of people around the world every year [1]. Patients with metastatic cancer can suffer from a wide variety of symptoms related to their disease and the side effects of treatment. The critical first step to reducing symptom burden is to identify those patients who have the greatest need for symptom management strategies [2]. Some studies have already analyzed the supportive and palliative care needs of patients with metastatic cancer and their caregivers in different countries [3, 4]. Both patients and caregiver had a wide range of unmet needs, with a significant frequency of physical and psychological needs. However, there is significant variability in the results depending on the population selected, the methodology used, and the local healthcare systems. Demographic, disease-related, physical and psychological variables associated with the unmet needs of patients varied according to the studies, as well as the association between income level and patient unmet needs. These needs have most often not been considered in relation to patient’s use of healthcare resources. Recently, new treatments like immunotherapy and targeted therapy have improved patient quality of life, potentially changing their healthcare needs. Up-to-date data on patient supportive care needs and utilization of care enables healthcare systems worldwide to effectively adapt to these demands.
Social vulnerability has several definitions, depending on the field studied. Applied in medicine, it can be viewed as “the non-health dimensions that keeps individuals incapacitated longer than expected (e.g., in hospital and unable to return home) because of social circumstances close to the individual (e.g., marital status) but also because of social support systems that fail to respond or even perpetuate vulnerability (e.g., lack of affordable housing for people with disabilities)” [5]. In several countries lower levels of social support seem to be associated with higher patient unmet needs in advanced solid cancer [6].The financial burden of cancer was associated with higher unmet needs across all domains for patients with hematologic malignancies [7], suggesting a possible link between social vulnerability and healthcare needs of patients with cancer.
French residents benefit from universal medical coverage. Once diagnosed, cancer patients benefit from equitable and cost-free access to state-of-the-art care, as well as a wide range of supportive care services, free of charge, whether at home or in hospital. The impact of social vulnerability on healthcare needs and resource utilization among patients with metastatic cancer has yet to be assessed in this type of healthcare system.
We conducted an observational, multicentric, cross sectional study with inpatients and outpatients who were followed up in hospital-based oncology wards in France. The primary objective of this study was to obtain a comprehensive assessment of the supportive and palliative care needs and healthcare resource utilization of patients with metastatic cancer. The secondary objective was to explore the association of supportive care needs and healthcare resource utilization with social vulnerability. We aimed to better identify patients’ needs to facilitate targeted supportive and palliative care interventions in a healthcare system characterized by universal coverage.
Methods
Trial design and study population
We conducted an observational, cross-sectioned, multicentric study in eight hospitals in the Ile-de-France region. This trial was registered in ClinicalTrial.gov PRS with the ID APHP210724.
The investigators were members of the palliative care team of each hospital and aimed to include 40 patients per center. The patients were included from consultation, oncology day hospitals, and hospitalization sectors of the oncology ward of each center. The study was held from June 2022 to May 2023. In each study center, patients were screened during a few days in each sector until the completions of the inclusions, spread over a maximum period of three months. On the days dedicated to the study in consultation or day hospital sectors, the investigator screened and informed the patients in order of arrival until saturation of its’ possibilities. On the days dedicated to study in hospitalization sector, he screened and informed all hospitalized patients. All patients over 18 years old with metastatic cancer treated in the investigating center were eligible. The exclusion criteria were the lack of affiliation to a social security system, visual/hearing impairment or aphasia, no understanding of French, inability to give informed non-opposition as judged by the investigators (cognitive impairment due to a preexisting condition or cancer), or a diagnosis of testicular cancer or ovarian choriocarcinoma (curable cancers).
Clinical data and patients related outcome measures
Sociodemographic data were collected with a self or hetero-administered (if patients were unable to read or write) questionnaire: age, place of residence, marital status, existence of a main informal caregiver, level of education according to the International Standard Classification of Education, and EPICES score (a social vulnerability evaluation score validated in French). The EPICES score is a self or hetero-administered questionnaire that explores sociodemographic data, financial outcomes, opportunities for support from relatives, and access to leisure activities. The score is very sensitive, making it possible to detect relative and significant social precariousness [8]. The original study used to develop this score in 1998 was carried out in health centers providing free health check-ups for populations targeted as being at risk of health problems. The threshold used to define social precariousness was initially an EPICES score of 40% [9]. Subsequently, the threshold used to define the presence of social vulnerability was lowered to 30% in 2005 [10], this is the threshold used in our study.
Characteristics of the disease and clinical data were extracted from the medical records regarding primary tumour, time of diagnosis and time of the first metastasis, cancer treatments, performance status, Body Mass Index and cachexia (> 5% weight loss in past 3 months) [11], as well as strong opioid treatments.
The healthcare needs of patients were explored with the EORTC-QLQ C30 questionnaire [12, 13] and the Supportive Care Need Survey short form (SNCS-SF34) [14]. The EORTC QLQC30 assesses quality of life and consists of five multi-item function scales (physical, measuring autonomy and daily activities; role, or the ability to work and engage in leisure activities; emotional; cognitive, such as concentration and memory; and social and family life), a global health status/quality of life scale, and nine symptom scales. The SCNS SF34 measures patients’ own perception of their need for help in dealing with healthcare across five domains: psychological, health system and information (information on cancer, care organization and environment), physical and daily living (physical symptoms and daily activities), patient care and support (choice of hospital and cancer specialist, support by the hospital staff), and sexuality needs.
Finally, we evaluated healthcare service use based on hospital admissions for cancer-related complications, the interventions of professionals either at home or in the hospital, extracted from medical records and a self or hetero-administered questionnaire.
Statistics
This study was essentially descriptive and exploratory. Considering the diversity and the prevalence of healthcare needs described in previous studies [4], assuming a prevalence of healthcare needs of 60%, and 5% of missing values, we calculated that a sample size of 360 patients would allow us to estimate with sufficient accuracy the prevalence of healthcare needs and healthcare resource utilization, for example 60% (IC 95%= [54,8%−65,2%] and 30% [25,1%−34,9%]. Regarding the secondary objective, assuming a proportion of social vulnerability of 30%, this sample size allows us to demonstrate a clinically significant association of supportive care needs with social vulnerability (OR of 2, α = 5%) with a statistical power > 80% (85%).
Descriptive variables are labelled by their number and percentage for categorical variables, and by their mean and standard deviation for continuous variables. For each variable, the number of missing data was specified, and the percentages were calculated on the number of available data.
The responses to the EORTC QLQ-C30 were converted into 0–100 scales according to the scoring manual, and mean scores were calculated [15]. As was done in a previous study, frequencies were designated “no or minor symptom/problem” if the symptom scale score was < 33.3, and “moderate symptom/problems” and “severe symptom/problems” when scores exceeded two thresholds, of 33.3 and 66.7 respectively. It was the opposite for the function scales [16]. The number of moderate or severe symptoms/problems, including both symptom and function scales, were calculated for all scales ranging from 0 to 14.
The SCNS-SF34 data were treated in the same way.
The patients with social vulnerability (assessed using the EPICES score cut-off) were compared to those without one in terms of socio-demographic and clinical features, using a Chi2 or Fisher test for categorical parameters and a Student’s or a Wilcoxon test for continuous parameters.
Social vulnerability was analyzed using multivariate analysis with a logistic regression model. The model included all variables with a p-value < 0.1 in the univariate analysis. Multiple imputations combined with a stepwise model based on the Wald statistic were applied. The number of imputed datasets was set to 50. For each imputed dataset, social vulnerability was analyzed, and a set of variables was retained. The final model included all variables selected in at least 50% of cases [17].
Compliance with Ethical Standards
None of the investigators had conflicts of interest to disclose. The study was conducted in accordance with the Declaration of Helsinki. According to French law regarding non-interventional studies, each patient and caregiver received oral and written information and their non-opposition was recorded by the investigator. This study was approved by the French National Commission for Data Protection and Freedom (Northwest 1 People Protection Committee). This trial was registered in ClinicalTrial.gov PRS with the ID APHP210724.
Results
Sample characteristics
696 patients were identified; 279 were not included due to the saturation of the investigators' inclusion possibilities, and 56 refused to participate. A total of 361 patients were included (26.6% were from consultation, 47.6% from day hospitals, and 25.8% from hospitalizations). The average age was 66 years and 53.2% were women. Most patients lived as a couple (64.9%). 71.4% patients declared having a main caregiver, usually a spouse or a partner (74.4%) (table 1).
Table 1.
Sociodemographic data, according to social vulnerability
| Total (all patients) |
Patients with known social vulnerability status | No social vulnerability | Social vulnerability | p-value | |
|---|---|---|---|---|---|
| Place of inclusion, N(%) | 361 | 303 | 181 | 122 | 0.468 |
| Consultation | 96 (26.6) | 85 (28.1) | 51 (28.2) | 34 (27.9) | |
| Day Hospital | 172 (47.6) | 149 (49.2) | 93 (51.4) | 56 (45.9) | |
| Hospitalization | 93 (25.8) | 69 (22.8) | 37 (20.4) | 32 (26.2) | |
| Age | |||||
| mean(std) | 65.8 (12.5) | 65.4(12.9) | 66.2(12.8) | 64.2(12.9) | 0.192 |
| med[IQ] | 68.0 [58.0; 75.0] | 67.0[57.0;74.5] | 68.0[58.0;75.0] | 66.5[56.0;73.0] | |
| min-max | 24.0–93.0 | 24.0–93.0 | 28.0–93.0 | 24.0–88.0 | |
| Sex, N(%) | 0.047 | ||||
| Women | 192 (53.2) | 159 (52.5) | 86 (47.5) | 73 (59.8) | |
| Men | 169 (46.8) | 144 (47.5) | 95 (52.5) | 49 (40.2) | |
| Marital Status, N(%) | < 0.0001 | ||||
| Married | 198 (58.9) | 175 (58.3) | 132 (73.3) | 43 (35.8) | |
| Divorce or separated | 57 (17.0) | 51 (17.0) | 19 (10.6) | 32 (26.7) | |
| Never married | 54 (16.1) | 49 (16.3) | 19 (10.6) | 30 (25.0) | |
| Widower | 27 (8.0) | 25 (8.3) | 10 (5.6) | 15 (12.5) | |
| Missing | 25 | 3 | 1 | 2 | |
| Living conditions, N(%) | < 0.0001 | ||||
| Live with a spouse or partner | 216 (64.9) | 191 (64.1) | 140 (77.8) | 51 (43.2) | |
| Live with another person | 35 (10.5) | 34 (11.4) | 11 (6.1) | 23 (19.5) | |
| Live alone | 82 (24.6) | 73 (24.5) | 29 (16.1) | 44 (37.3) | |
| Missing | 28 | 5 | 1 | 4 | |
| Presence of a caregiver, N(%) | 0.003 | ||||
| Yes | 242 (71.4) | 214 (71.1) | 140 (77.8) | 74 (61.2) | |
| No | 97 (28.6) | 87 (28.9) | 40 (22.2) | 47 (38.8) | |
| Missing | 22 | 2 | 1 | 1 | |
| If caregiver, live with the patient, N(%) | 0.001 | ||||
| Yes | 38 (18.2) | 158 (83.2) | 111 (90.2) | 47 (70.1) | |
| No | 171 (81.8) | 32 (16.8) | 12 (9.8) | 20 (29.9) | |
| Missing | 33 | 24 | 17 | 7 | |
| Connection to the patient, N(%) | < 0.0001 | ||||
| Spouse or partner | 163 (74.4) | 150 (75.8) | 113 (86.9) | 37 (54.4) | |
| Child | 30 (13.7) | 27 (13.6) | 12 (9.2) | 15 (22.1) | |
| Other family member | 21 (9.6) | 16 (8.1) | 3 (2.3) | 13 (19.1) | |
| Friend/neighbor | 5 (2.3) | 5 (2.5) | 2 (1.5) | 3 (4.4) | |
| Missing | 23 | 16 | 10 | 6 | |
| Educational level, N(%) | < 0.0001 | ||||
| Level 1-2-3 | 121 (37.3) | 43 (14.5) | 27 (15.0) | 16 (13.7) | |
| Level 4 | 45 (13.9) | 112 (37.7) | 52 (28.9) | 60 (51.3) | |
| Level 5–6 | 81 (25.0) | 73 (24.6) | 47 (26.1) | 26 (22.2) | |
| Level 7–8 | 77 (23.8) | 69 (23.2) | 54 (30.0) | 15 (12.8) | |
| Missing | 37 | 6 | 1 | 5 | |
| Social vulnerability (Score EPICES > 30) | |||||
| Yes | 122 (40.3) | ||||
| No | 181 (59.7) | ||||
| Missing | 58 | ||||
For each item, the number of missing data is indicated. Percentages and tests are calculated based on the number of data available. The “total” column present the results for the overall study population. The “patients with known social vulnerability status” column present the results for the population of patients for whom the social status is known (with or without social vulnerability). The statistical tests compare patients with or without social vulnerability
The educational level is defined according to the International Standard Classification of Education: level 1-2-3 correspond to primary/lower secondary/upper secondary education, level 4 correspond to post-secondary non tertiary education, level 5–6 to short-cycle tertiary education and bachelor’s or equivalent, level 7–8 correspond to master’s and doctorate or equivalent
Patients presented a good performance status with 27.5% of patients PS 0 and 40.4% of patients PS 1. The cancers were from various origins, mainly lungs, digestive system, pancreas, and skin. The median time between diagnosis and the first metastasis was 0.6 months. The median time from the first metastasis to the day of inclusion in the study was 13.5 months. Most patients (88.4%) patients had received systemic treatment in the last 30 days (56.2% chemotherapy, 33.8% immunotherapy, 7.5% targeted therapy, 5.8% hormonotherapy). 59.4% were undergoing their first or second line of systemic treatments. 28.3% of patients presented cachexia and 17.2% used strong opioids (table 2).
Table 2.
History of cancer and treatment, according to social vulnerability
| Total (All patients) |
Patients with known social vulnerability status | No social vulnerability | Social vulnerability | p-value | |
|---|---|---|---|---|---|
| Performance Status, N (%) | 0.019 | ||||
| PS 0 | 90 (27.5) | 83 (29.9) | 62 (36.5) | 21 (19.4) | |
| PS1 | 132 (40.4) | 110 (39.6) | 64 (37.6) | 46 (42.6) | |
| PS2 | 81 (24.8) | 66 (23.7) | 33 (19.4) | 33 (30.6) | |
| PS3 | 20 (6.1) | 17 (6.1) | 10 (5.9) | 7 (6.5) | |
| PS4 | 4 (1.2) | 2 (0.7) | 1 (0.6) | 1 (0.9) | |
| Missing | 34 | 25 | 11 | 14 | |
| Type of cancer, N (%) | 350 | 303 | 181 | 122 | 0.419 |
| Gynecological | 26 (7.2) | 24 (7.9) | 15 (8.3) | 9 (7.4) | |
| Liver/biliary tracts | 3 (0.8) | 2 (0.7) | 2 (1.1) | 0 (0.0) | |
| ENT | 7 (1.9) | 6 (2.0) | 1 (0.6) | 5 (4.1) | |
| Pancreas | 46 (12.7) | 29 (9.6) | 16 (8.8) | 13 (10.7) | |
| Skin | 42 (11.6) | 41 (13.5) | 26 (14.4) | 15 (12.3) | |
| Lung | 65 (18) | 60 (19.8) | 37 (20.4) | 23 (18.9) | |
| Prostate | 19 (5.3) | 17 (5.6) | 7 (3.9) | 10 (8.2) | |
| Kidney | 8 (2.2) | 7 (2.3) | 5 (2.8) | 2 (1.6) | |
| Breast | 39 (10.8) | 32 (10.6) | 17 (9.4) | 15 (12.3) | |
| Digestive tract | 65 (18) | 50 (16.5) | 32 (17.7) | 18 (14.8) | |
| Other | 41 (11.4) | 35 (11.6) | 23 (12.7) | 12 (9.8) | |
| Time between diagnosis and the 1 st metastasis (months) | |||||
| Mean (std) | 14.5 (34.6) | 15.8 (36) | 17.5 (32.3) | 13.6 (40.4) | 0.074 |
| Med [IQ] | 0.6 [0.0;14.2] | 0.8 [0.0;16.1] | 1.7 [0.0;18.5] | 0.4 [0.0;10.9] | |
| min-max | 0.0-345.4 | 0.0-345.4 | 0.0-170.7 | 0.0-345.4 | |
| Missing | 104 | 86 | 58 | 28 | |
| Time between 1 st metastasis and day of inclusion (months) | |||||
| Mean (std) | 24.6 (30.4) | 24.6 (30.6) | 25.7 (34.3) | 23.2 (24.9) | 0.854 |
| Med[IQ] | 13.5 [4.4;34.3] | 13.5 [4.6;35.1] | 16.0 [4.6;34.2] | 12.4 [4.6;39.5] | |
| min-max | 0.0-262.6 | 0.0-262.6 | 0.0-262.6 | 0.2-111.1 | |
| Missing | 74 | 64 | 46 | 18 | |
| Treatment received in the past, N (%) | |||||
| Surgery | 201 (55.7) | 172 (56.8) | 112 (61.9) | 60 (49.2) | 0.038 |
| Radiotherapy | 160 (44.3) | 134 (44.2) | 82 (45.3) | 52 (42.6) | 0.732 |
| Systemic treatment | 350 (97.0) | 294 (97.0) | 177 (97.8) | 117 (95.9) | 0.492 |
| Simple monitoring | 6 (1.7) | 5 (1.7) | 2 (1.1) | 3 (2.5) | 0.395 |
| Palliative care only | 1 (0.3) | 1 (0.3) | 1 (0.6) | 0 (0.0) | > 0.99 |
|
Systemic treatment in the last 30 days, N (%) |
319 (88.4) | 267 (88.1) | 165 (91.2) | 102 (83.6) | 0.07 |
|
Number of previous treatment lines, N (%) |
0.973 | ||||
| 0 or 1 | 208 (59.4) | 172 (58.5) | 105 (59.3) | 67 (57.3) | |
| 2 Lines | 66 (18.9) | 59 (20.1) | 35 (19.8) | 24 (20.5) | |
| 3 Lines | 37 (10.6) | 30 (10.2) | 17 (9.6) | 13 (11.1) | |
| More of 4 Lines | 39 (11.1) | 33 (11.2) | 20 (11.3) | 13 (11.1) | |
| Missing | 11 | 9 | 4 | 5 | |
| Type of systemic treatment (in the last 30 days), N (%) | 319 | 267 | |||
| Chemotherapy | 151 (47.3) | 123 (46.1) | 80 (44.2) | 43 (35.2) | 0.151 |
| Immunotherapy | 73 (22.9) | 65 (24.3) | 38 (21.0) | 27 (22.1) | 0.925 |
| Targeted therapy | 23 (7.2) | 21 (7.9) | 14 (7.7) | 7 (5.7) | 0.659 |
| Hormonotherapy | 18 (5.6) | 12 (4.5) | 6 (3.3) | 6 (4.9) | 0.554 |
| Combined systemic therapy | 54 (16.9) | 46 (17.2) | 27 (14.9) | 19 (15.6) | > 0.99 |
|
Cachexia (> 5% weight loss in past 3 months), N (%) |
0.079 | ||||
| Cachexia | 89 (28.3) | 73 (27.4) | 38 (23.3) | 35 (34.0) | |
| Missing | 47 | 37 | 18 | 19 | |
| Need for strong opioids, N (%) | 62 (17.2) | 52 (17.2) | 27 (14.9) | 25 (20.5) | 0.268 |
For each item, the number of missing data is indicated. Percentages and tests are calculated based on the number of data available. The “total” column present the results for the overall study population. The “patients with known social vulnerability status” column present the results for the population of patients for whom the social status is known (with or without social vulnerability). The statistical tests compare patients with or without social vulnerability
Supportive and palliative care needs of patients
Among the functional and symptom scales of the EORTC-QLQC30, the most frequent symptoms were fatigue (51.8%moderate and 24.1% severe), insomnia (48.5% moderate and 12.7% severe), dyspnea (49.1% being moderate and 7.3% severe), and pain (44.7% moderate and 9.7% severe). The global health status showed that 11.9% of patients scored low on quality of life, while 61.1% scored moderately (table 3). 74.8% of patients had a prevalence of problems and symptoms between 3 and 10 (Figure 1). Social functioning was the most impaired scale with 40.8% of moderate problems and 14.5% of severe problems, followed by role functioning, physical functioning, emotional functioning, and cognitive functioning.
Table 3.
Healthcare needs: results of the EORTC-QLQ C30, according to social vulnerability
| Domain | Total (All patients) |
Patients with known social vulnerability status | No social vulnerability | Social vulnerability | p-value | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Physical functioning | No or minor problem (%) | 188 (56.8) | 177 (58.4) | 115 (63.5) | 62 (50.8) | 0.085 | ||||
| Moderate problem (%) | 103 (31.1) | 91 (30.0) | 47 (26.0) | 44 (36.1) | ||||||
| Severe problem (%) | 40 (12.1) | 35 (11.6) | 19 (10.5) | 16 (13.1) | ||||||
| Missing | 30 | 0 | 0 | 0 | ||||||
| Role functioning | No or minor problem (%) | 186 (56.2) | 171 (56.4) | 111 (61.3) | 60 (49.2) | 0.096 | ||||
| Moderate problem (%) | 88 (26.6) | 82 (27.1) | 45 (24.9) | 37 (30.3) | ||||||
| Severe problem (%) | 57 (17.2) | 50 (16.5) | 25 (13.8) | 25 (20.5) | ||||||
| Missing | 30 | 0 | 0 | 0 | ||||||
| Emotional functioning | No or minor problem (%) | 199 (60.3) | 185 (61.5) | 119 (66.1) | 66 (54.5) | 0.061 | ||||
| Moderate problem (%) | 102 (30.9) | 92 (30.6) | 51 (28.3) | 41 (33.9) | ||||||
| Severe problem (%) | 29 (8.8) | 24 (8.0) | 10 (5.6) | 14 (11.6) | ||||||
| Missing | 31 | 2 | 1 | 1 | ||||||
| Cognitive functioning | No or minor problem (%) | 221 (66.8) | 205 (67.9) | 127 (70.6) | 78 (63.9) | 0.478 | ||||
| Moderate problem (%) | 99 (29.9) | 89 (29.5) | 49 (27.2) | 40 (32.8) | ||||||
| Severe problem (%) | 11 (3.3) | 8 (2.6) | 4 (2.2) | 4 (3.3) | ||||||
| Missing | 30 | 1 | 1 | 0 | ||||||
| Social functioning | No or minor problem (%) | 148 (44.7) | 140 (46.4) | 92 (51.1) | 48 (39.3) | 0.063 | ||||
| Moderate problem (%) | 135 (40.8) | 122 (40.4) | 63 (35.0) | 59 (48.4) | ||||||
| Severe problem (%) | 48 (14.5) | 40 (13.2) | 25 (13.9) | 15 (12.3) | ||||||
| Missing | 30 | 1 | 1 | 0 | ||||||
| Fatigue | No or minor problem (%) | 80 (24.1) | 75 (24.8) | 52 (28.7) | 23 (18.9) | 0.148 | ||||
| Moderate problem (%) | 172 (51.8) | 159 (52.5) | 90 (49.7) | 69 (56.6) | ||||||
| Severe problem (%) | 80 (24.1) | 69 (22.8) | 39 (21.5) | 30 (24.6) | ||||||
| Missing | 29 | 0 | 0 | 0 | ||||||
| Nausea and vomiting | No or minor problem (%) | 269 (81.3) | 249 (82.5) | 157 (86.7) | 92 (76.0) | 0.056 | ||||
| Moderate problem (%) | 50 (15.1) | 45 (14.9) | 20 (11.0) | 25 (20.7) | ||||||
| Severe problem (%) | 12 (3.6) | 8 (2.6) | 4 (2.2) | 4 (3.3) | ||||||
| Missing | 30 | 1 | 0 | 1 | ||||||
| Pain | No or minor problem (%) | 151 (45.6) | 138 (45.7) | 89 (49.4) | 49 (40.2) | 0.177 | ||||
| Moderate problem (%) | 148 (44.7) | 134 (44.4) | 72 (40.0) | 62 (50.8) | ||||||
| Severe problem (%) | 32 (9.7) | 30 (9.9) | 19 (10.6) | 11 (9.0) | ||||||
| Missing | 30 | 1 | 1 | 0 | ||||||
| Dyspnea | No or minor problem (%) | 143 (43.6) | 126 (41.9) | 85 (47.2) | 41 (33.9) | 0.029 | ||||
| Moderate problem (%) | 161 (49.1) | 151 (50.2) | 79 (43.9) | 72 (59.5) | ||||||
| Severe problem (%) | 24 (7.3) | 24 (8.0) | 16 (8.9) | 8 (6.6) | ||||||
| Missing | 33 | 2 | 1 | 1 | ||||||
| Insomnia | No or minor problem (%) | 128 (38.8) | 119 (39.5) | 73 (40.6) | 46 (38.0) | 0.823 | ||||
| Moderate problem (%) | 160 (48.5) | 146 (48.5) | 87 (48.3) | 59 (48.8) | ||||||
| Severe problem (%) | 42 (12.7) | 36 (12.0) | 20 (11.1) | 16 (13.2) | ||||||
| Missing | 31 | 2 | 1 | 1 | ||||||
| Appetite loss | No or minor problem (%) | 152 (46.5) | 142 (47.5) | 95 (53.4) | 47 (38.8) | 0.043 | ||||
| Moderate problem (%) | 122 (37.3) | 113 (37.8) | 61 (34.3) | 52 (43.0) | ||||||
| Severe problem (%) | 53 (16.2) | 44 (14.7) | 22 (12.4) | 22 (18.2) | ||||||
| Missing | 34 | 4 | 3 | 1 | ||||||
| Constipation | No or minor problem (%) | 198 (60.0) | 179 (59.5) | 112 (62.2) | 67 (55.4) | 0.138 | ||||
| Moderate problem (%) | 99 (30.0) | 92 (30.6) | 55 (30.6) | 37 (30.6) | ||||||
| Severe problem (%) | 33 (10.0) | 30 (10.0) | 13 (7.2) | 17 (14.0) | ||||||
| Missing | 31 | 2 | 1 | 1 | ||||||
| Diarrhoea | No or minor problem (%) | 214 (64.7) | 197 (65.2) | 119 (66.1) | 78 (63.9) | 0.532 | ||||
| Moderate problem (%) | 97 (29.3) | 86 (28.5) | 52 (28.9) | 34 (27.9) | ||||||
| Severe problem (%) | 20 (6.0) | 19 (6.3) | 9 (5.0) | 10 (8.2) | ||||||
| Missing | 30 | 1 | 1 | 0 | ||||||
| Financial difficulties | No or minor problem (%) | 259 (79.0) | 239 (79.7) | 155 (86.1) | 84 (70.0) | < 0.0001 | ||||
| Moderate problem (%) | 56 (17.1) | 50 (16.7) | 24 (13.3) | 26 (21.7) | ||||||
| Severe problem (%) | 13 (4.0) | 11 (3.7) | 1 (0.6) | 10 (8.3) | ||||||
| Missing | 33 | 3 | 1 | 2 | ||||||
| Global health status/QoL | Low QoL (%) | 39 (11.9) | 32 (10.7) | 20 (11.2) | 12 (9.9) | 0.074 | ||||
| Moderate QoL (%) | 201 (61.1) | 186 (62.0) | 102 (57.0) | 84 (69.4) | ||||||
| High QoL (%) | 89 (27.1) | 82 (27.3) | 57 (31.8) | 25 (20.7) | ||||||
| Missing | 32 | 3 | 2 | 1 | ||||||
| EORTC-QLQ-C30 | Low level (%) | 14 (4.4) | 12 (4.1) | 7 (4.0) | 5 (4.2) | 0.058 | ||||
| Moderate level (%) | 107 (33.5) | 97 (33.0) | 48 (27.6) | 49 (40.8) | ||||||
| High level (%) | 198 (62.1) | 185 (62.9) | 119 (68.4) | 66 (55.0) | ||||||
| Missing | 42 | 9 | 7 | 2 | ||||||
Percentages and tests are calculated based on the number of data available. We defined that a patient had “no or a minor symptom/problem” if the scale score was < 33.3 for the symptom scales or ≥ 66.7 for the function scales, a “moderate symptom/problem” if the scale score was between 33.3 and 66.7 for the symptom scales or the function scales, and a “severe symptom/problem” if the score was at least ≥ 66.7 for the symptom scales or < 33.3 for the function scales. The “total” column present the results for the overall study population. The “patients with known social vulnerability status” column present the results for the population of patients for whom the social status is known (with or without social vulnerability). The statistical tests compare patients with or without social vulnerability
Fig. 1.
Prevalence of the number of moderate or severe symptoms/problems per patient, out of the 14 scales of the EORTC-QLQ C30 self-questionnaire (5 functional scales and 9 symptom scales)
The abscissa represents the number of moderate or severe symptoms/problems on the EORTC questionnaire, and the ordinate the percentage of patients
The most important unmet needs assessed by the SCNS-SF34 were psychological needs (34.9% moderate and 16.5% severe needs), and then physical and daily living needs, health system and information needs, sexuality needs, and finally patient care and support needs. A total of 82.1% of patients reported at least 1 unmet need (table 4).
Table 4.
Unmet needs: SCNS-SF34, according to social vulnerability
| Domain | Total (All patients) |
Patients with known social vulnerability status | No social vulnerability | Social vulnerability | p-value | |
|---|---|---|---|---|---|---|
| Psychological needs | No or minor needs (%) | 159 (48.6) | 151 (50.0) | 97 (53.6) | 54 (44.6) | 0.202 |
| Moderate needs (%) | 114 (34.9) | 105 (34.8) | 61 (33.7) | 44 (36.4) | ||
| Severe needs (%) | 54 (16.5) | 46 (15.2) | 23 (12.7) | 23 (19.0) | ||
| Missing | 34 | 1 | 0 | 1 | ||
| Health system and information needs | No or minor needs (%) | 205 (63.9) | 194 (64.9) | 122 (68.2) | 72 (60.0) | 0.322 |
| Moderate needs (%) | 86 (26.8) | 79 (26.4) | 42 (23.5) | 37 (30.8) | ||
| Severe needs (%) | 30 (9.3) | 26 (8.7) | 15 (8.4) | 11 (9.2) | ||
| Missing | 40 | 4 | 2 | 2 | ||
| Physical and daily living needs | No or minor needs (%) | 184 (56.4) | 176 (58.7) | 121 (66.9) | 55 (46.2) | 0.001 |
| Moderate needs (%) | 95 (29.1) | 84 (28.0) | 39 (21.5) | 45 (37.8) | ||
| Severe needs (%) | 47 (14.4) | 40 (13.3) | 21 (11.6) | 19 (16.0) | ||
| Missing | 35 | 3 | 0 | 3 | ||
| Patient care and support needs | No or minor needs (%) | 248 (77.0) | 232 (77.1) | 141 (78.3) | 91 (75.2) | 0.657 |
| Moderate needs (%) | 59 (18.3) | 55 (18.3) | 30 (16.7) | 25 (20.7) | ||
| Severe needs (%) | 15 (4.7) | 14 (4.7) | 9 (5.0) | 5 (4.1) | ||
| Missing | 39 | 2 | 1 | 1 | ||
| Sexuality needs | No or minor needs (%) | 202 (65.2) | 194 (66.7) | 111 (63.4) | 83 (71.6) | 0.13 |
| Moderate needs (%) | 75 (24.2) | 68 (23.4) | 48 (27.4) | 20 (17.2) | ||
| Severe needs (%) | 33 (10.6) | 29 (10.0) | 16 (9.1) | 13 (11.2) | ||
| Missing | 51 | 12 | 6 | 6 | ||
| Total | No Need- not applicable or satisfied for all items (%) | 59 (17.9) | ||||
| At least 1 non satisfied need (%) | 271 (82.1) | |||||
| Missing | 31 |
For each item, the number of missing data is indicated. Percentages and tests are calculated based on the number of data available. We defined that a patient had “no or minor needs” if the score was < 33.3, “moderate needs” if the score was between 33.3 and 66.7, “severe needs” if the score was at least ≥ 66.7. The “total” column present the results for the overall study population. The “patients with known social vulnerability status” column present the results for the population of patients for whom the social status is known (with or without social vulnerability). The statistical tests compare patients with or without social vulnerability
Healthcare services use
28.6% of patients had met a coordinating hospital nurse. 19.1% were followed by a psychologist in a hospital and 7.6% were in home-based care. 32.2% met a dietitian in a hospital and 6.1% at home. Physiotherapists were involved in the care of 16.2% of patients in a hospital and 20.1% in home-based-care. General practitioners were involved in the care of 47% of the patients. 26.8% of patients had visited the emergency room and 38.5% had been admitted to the hospital in the last three months for a cancer complication (table 5).
Table 5.
Healthcare use, according to social vulnerability
| Total (All patients) |
Patients with known social vulnerability status | No social vulnerability | Social vulnerability | p-value | ||
|---|---|---|---|---|---|---|
| Hospital care in the last 3 months | ||||||
| Consultant | Yes (%) | 137 (41.6) | 127 (42.5) | 83 (46.1) | 44 (37.0) | 0.148 |
| Missing | 32 | 4 | 1 | 3 | ||
| Coordinating nurse | Yes (%) | 94 (28.6) | 87 (29.1) | 53 (29.4) | 34 (28.6) | 0.974 |
| Missing | 32 | 4 | 1 | 3 | ||
| Physiotherapist | Yes (%) | 53 (16.2) | 49 (16.4) | 27 (15.1) | 22 (18.5) | 0.537 |
| Missing | 33 | 5 | 2 | 3 | ||
| Psychologist | Yes (%) | 63 (19.1) | 58 (19.4) | 30 (16.7) | 28 (23.5) | 0.187 |
| Missing | 32 | 4 | 1 | 3 | ||
| Dietitian | Yes (%) | 106 (32.2) | 97 (32.4) | 57 (31.7) | 40 (33.6) | 0.821 |
| Missing | 32 | 4 | 1 | 3 | ||
| Social worker | Yes (%) | 34 (10.3) | 31 (10.4) | 11 (6.1) | 20 (16.8) | 0.006 |
| Missing | 32 | 4 | 1 | 3 | ||
| Toilet help | Yes (%) | 37 (11.2) | 33 (11.0) | 22 (12.2) | 11 (9.2) | 0.538 |
| Missing | 32 | 4 | 1 | 3 | ||
| Home-based care in the last 3 months | ||||||
| General practitioner | Yes (%) | 155 (47.0) | 143 (47.7) | 88 (48.9) | 55 (45.8) | 0.688 |
| Missing | 31 | 3 | 1 | 2 | ||
| Consultant | Yes (%) | 72 (21.9) | 67 (22.4) | 43 (24.0) | 24 (20.0) | 0.499 |
| Missing | 32 | 4 | 2 | 2 | ||
| Hospital-at-home | Yes (%) | 17 (5.2) | 15 (5.0) | 3 (1.7) | 12 (10.0) | 0.003 |
| Missing | 32 | 4 | 2 | 2 | ||
| Liberal nurse | Yes (%) | 146 (44.2) | 134 (44.7) | 85 (47.2) | 49 (40.8) | 0.331 |
| Missing | 31 | 3 | 1 | 2 | ||
| Physiotherapist | Yes (%) | 66 (20.1) | 63 (21.1) | 34 (19.0) | 29 (24.2) | 0.352 |
| Missing | 32 | 4 | 2 | 2 | ||
| Psychologist | Yes (%) | 25 (7.6) | 24 (8.0) | 13 (7.3) | 11 (9.2) | 0.706 |
| Missing | 32 | 4 | 2 | 2 | ||
| Dietitian | Yes (%) | 20 (6.1) | 19 (6.4) | 9 (5.0) | 10 (8.3) | 0.365 |
| Missing | 32 | 4 | 2 | 2 | ||
| Social worker | Yes (%) | 9 (2.7) | 9 (3.0) | 2 (1.1) | 7 (5.8) | 0.033 |
| Missing | 32 | 4 | 2 | 2 | ||
| Toilet help | Yes (%) | 5 (1.5) | 5 (1.7) | 2 (1.1) | 3 (2.5) | 0.394 |
| Missing | 32 | 4 | 2 | 2 | ||
| Life auxiliary | Yes (%) | 6 (1.8) | 6 (2.0) | 2 (1.1) | 4 (3.3) | 0.223 |
| Missing | 32 | 4 | 2 | 2 | ||
| Meal delivery | Yes (%) | 3 (0.9) | 3 (1.0) | 3 (1.7) | 0 (0.0) | > 0.99 |
| Missing | 31 | 3 | 1 | 2 | ||
| Housekeeper | Yes (%) | 28 (8.5) | 27 (9.0) | 16 (8.9) | 11 (9.2) | > 0.99 |
| Missing | 31 | 3 | 1 | 2 | ||
| Unscheduled care | ||||||
| Emergency department consultation in the last 3 months | Yes (%) | 87 (26.8) | 78 (25.8) | 46 (25.4) | 32 (26.4) | 0.947 |
| Missing | 36 | 1 | 0 | 1 | ||
| Hospitalization due to cancer in the last 3 months | Yes (%) | 125 (38.5) | 113 (37.5) | 61 (33.7) | 52 (43.3) | 0.117 |
| Missing | 36 | 2 | 0 | 2 | ||
For each item, the number of missing data is indicated. Percentages and tests are calculated based on the number of data available. The “total” column present the results for the overall study population. The “patients with known social vulnerability status” column present the results for the population of patients for whom the social status is known (with or without social vulnerability). The statistical tests compare patients with or without social vulnerability
Social vulnerability
Social vulnerability (EPICES>30) was present in 40.3% of patients (table 1). Patients with high social vulnerability scores lived alone more often, were less likely to have a primary caregiver, and had a significantly lower level of education compared to those with no social vulnerability (table 1). Their performance status was lower, with a greater proportion of ECOG 2 scores (30.6%) (table 2). The time from diagnosis to first metastasis tended to be shorter (median at 0.4 versus 1.7 months, p=0.074), and they had less history of surgical treatment (p=0.038) (table 2). Patients with high social vulnerability suffered more frequently from cachexia (p=0.079, table 2) and severe appetite loss (p=0.043, table 3). They also had more frequent dyspnea (p=0.029), financial difficulties (p<0.0001), and tended to have a lower quality of life according to the EORTC-QLQ-C30 (p= 0.058, table 3). On the SCNS-SF34, socially precarious patients had greater physical and daily living needs (table 4). Patients with high social vulnerability met more often with social workers, both in home-based care and in hospital settings (respectively 5.8 and 16.8% of these patients). They benefited more often from hospitalization at home (p=0.003).
In multivariate analysis, high social vulnerability was significantly associated with cachexia (OR 2.43, IC 1.16-5.09), being divorced/separated (OR 5.22, IC 2.29-11.87), never married (OR 5.92, IC 2.47-14.18) or widowed (OR 4.27, IC 1.54-11.81), having a low educational level, especially for the lowest educational level (OR between 2.60 and 5.33, p<0.05). They more often benefited from hospitalization at home (OR 4.37, IC 1.04-18.31). Patients with high social vulnerability had received less surgery in the past (OR 0.46, IC 0.25-0.83, p=0.010) and less systemic treatment in the last 30 days (OR 0.34, IC 0.14-0.81, p=0.015) (table 6).
Table 6.
Factors associated with social vulnerability: multivariate analysis
| Characteristics | OR (IC 95%, p-value) |
|---|---|
| Nutritional status : cachexia (> 5% weight loss in past 3 months) | 2.43 (1.16–5.09, p = 0.019)* |
| Sex | |
| Men | 0.63 (0.35–1.15, p = 0.133) |
| Hospital care in the last 3 months : Social worker | 2.16 (0.87–5.37, p = 0.097) |
| Home-based care in the last 3 months : Hospital-at-home | 4.37 (1.04–18.31, p = 0.044)* |
| Systemic treatment in the last 30 days | 0.34 (0.14–0.81, p = 0.015)* |
| Surgical treatment received in the past | 0.46 (0.25–0.83, p = 0.010)* |
| Presence of a caregiver | 0.61 (0.31–1.20, p = 0.148) |
| Level of study | |
| Level 1-2-3 | 5.33 (2.28–12.47, p < 0.001)* |
| Level 4 | 3.27 (1.16–9.22, p = 0.025)* |
| Level 5–6 | 2.60 (1.03–6.54, p = 0.042)* |
| Level 7–8 | - |
| Marital Status | |
| Divorce or separated | 5.22 (2.29–11.87, p < 0.001)* |
| Never married | 5.92 (2.47–14.18, p < 0.001)* |
| Widower | 4.27 (1.54–11.81, p = 0.005)* |
| Married | - |
| Financial difficulties | |
| No or minor problem | 0.09 (0.01–0.75, p = 0.027)* |
| Moderate problem | 0.13 (0.01–1.18, p = 0.070) |
| Severe problem | - |
| Dyspnea | |
| No or minor problem | 0.80 (0.27–2.37, p = 0.684) |
| Moderate problem | 1.74 (0.60–5.01, p = 0.303) |
| Severe problem | - |
Multivariate analysis with a logistic regression model with stepwise selection on imputed data, adjusted for all variables with a p-value < 0.1 in univariate analysis. Significant results are marked with *
Discussion
With this cross-sectional study, we found that patients with metastatic cancer, especially those with good performance status, have many concomitant health issues and unmet needs with a high level of hospital-based care. These patients also frequently expressed their need for help in dealing with daily activities and psychological health. Patients with social vulnerability seemed to have more severe conditions at diagnosis but similar unmet needs during follow-up. Most often, their care pathways included less systemic treatment and more frequent home hospitalization.
The study population was mainly represented by fit patients, as demonstrated by their performance status. The large recruitment from the ambulatory sector, where patients tend to be in better health condition, could explain this result. Nevertheless, those selected had many interrelated healthcare problems represented mainly by physical symptoms like fatigue and psychological frailty. Fatigue is one of the most common and distressing side effects of cancer and its treatment, sometimes leading to treatment discontinuation [18]. Cancer-related fatigue is frequently associated with confounding factors such as depression or anxiety, medication use, pain, nausea, gastrointestinal symptoms, poor nutrition, anemia, infections, and insomnia [19]. Pain, like dyspnea, was one of the more frequent symptoms (44.7% moderate and 9.7% severe), but only 17.2 % of patients were treated by strong opioids, showing a probable underassessment of this problem by professionals [20]. Patients presented multiple symptoms simultaneously. All these interrelated symptoms could explain the significant impact of cancer on social and emotional functioning. Compared to older studies, this population of patients showed a larger range of health concerns [21, 22]. These results could suggest that despite the development of new cancer treatments, and even if these patients were in good general condition, disabling symptoms remained frequent, and were at risk of being underestimated.
Our results showed that patients with metastatic cancer reported significant unmet needs, represented mainly by psychological needs, as it has been shown in precedent studies [4]. The main reasons for referring patients to palliative care are mostly psychological distress followed by physical symptoms [23]. On one hand, the majority of patients in our study expressed psychological needs; on the other, we found a low intervention rate by psychologists. Specialized care provided by a psychologist may not be desired by all patients, even those expressing a high level of psychological distress. Another explanation could be a lack of professional resources. Our study cannot answer these questions and further research is needed to specify patients’ wishes when they express an unmet need. Moreover, some patients expressed they needed moderate to extensive help with their sexuality needs. It has been shown that a large proportion of patients do not receive adequate care on this topic [23]. Discussions between patients and healthcare providers about sex life are absent or infrequent, due to the latter’s insufficient training on the topic [24, 25]. It means that adequate healthcare services for complex needs is a sensitive issue: What are the patient’s wishes? Who should respond to their needs and how? Which are the best organization models for each healthcare system? More research is needed in this field.
Considering the complex and interrelated nature of “hidden” healthcare needs, these patients should be systematically screened using a validated and comprehensive self-assessment tool to provide a good quality level of information. Web-based symptom monitoring showed benefits on the quality of life and survival rates of patients with advanced cancer. It is a promising way to improve clinical practice [26, 27]. The intensity of care could be adjusted depending on the intensity of the problems detected: management by the oncology team alone, or with the joint intervention of a palliative care team in case of severe physical or emotional symptoms [11].
The healthcare services mobilized were mainly hospital-based, with frequent emergency department (ED) visits and hospitalizations due to cancer in the three previous months. In the literature, the percentage of cancer patients with ED visits depended on the origin and stage of the cancer and the time from diagnosis [28]. These ED visits occurred at every stage of cancer management, from initial diagnosis to end of life [29, 30]. Cancer-related ED visits resulted in more frequent hospital admissions compared to other patients [29]. A frequent reason cited for these visits was symptom management [31, 32]. This means that patients in our study presented unstable clinical situations. Integrated early palliative care could reduce the number of unscheduled ED consultations or hospitalizations and be considered preventive medicine [33]. By ensuring a longitudinal monitoring of patients, palliative care aims to avoid the occurrence of crisis situations with uncontrolled symptoms and improve the care pathway by decreasing urgent hospitalizations. Half of the patients had not met their general practitioner (GP) in the last three months, meaning that hospital care tends to replace primary care. Healthcare systems often work in silos, hindering collaborative efforts between primary and secondary sectors [34]. A systematic review showed that primary care providers felt excluded from patients’ care during cancer treatment [35]. From their perspective, patients perceived the role of the GP as unclear and, therefore, favoured specialists to provide follow-up cancer care [36–40].
The large proportion of socially vulnerable patients in our study could be explained by their recruitment in public hospitals where all healthcare costs are covered by health insurance. We cannot rule out the possibility that the EPICES score, developed for the general population, may be too sensitive for a population of cancer patients. Some questions may not be suitable for patients whose access to leisure activities or holidays, for example, might be limited by health condition and not actual social precariousness. Nevertheless, in multivariate analysis, social vulnerability was independently associated with cachexia, living alone, having a lower education level, and not with poor physical condition, suggesting the EPICES score tended to detect true social precariousness and not only less favorable health conditions. In fact, the risk of cachexia can be increased by living alone, without caregiver intervention to stimulate food intake.
Moreover, vulnerable patients seemed to have more severe conditions at diagnosis. The time between diagnosis and the first metastasis tended to be shorter in univariate analysis. In the multivariate analysis the care interventions differ with less history of surgical treatment, less recent systemic treatment and more frequent Hospital-at-home (HaH). These results suggest that the patients could have a late diagnosis, already presenting locally advanced or metastatic cancer. In 2013, a review reported that patients with social disadvantages had more difficulties accessing primary and secondary care and received less aggressive care for their cancer [41]. In our study, patients with social vulnerability had received less recent systemic treatment, perhaps because of cachexia or doctors’ fear that complications would occur in patients who live alone. Further research is needed to explore the reasons for lower access to systemic treatment. However, we found that once the diagnosis was made, there did not seem to be any other difference in access to care. Furthermore, we showed that precarious patients met a social worker more frequently and had more HaH to meet their healthcare needs. HaH in France provides continuous and coordinated health and social care as a substitute for acute hospitalization. In this system, socially vulnerable patients have access to a large range of medical and social services at home funded by the national health insurance.
Our study presents several limitations. First the design of the study did not allow the completely random recruitment of patients. Most patients were recruited in ambulatory settings (day hospitals and consultation) resulting in our study population being mostly made up of patients with good functional status. This result could be explained by asthenia in hospitalized patients, who were not fit enough to fill out a long self-questionnaire. This recruitment bias may have caused an underestimation of patient needs, particularly for those at an advanced phase of cancer. This should be kept in mind when considering which health organizations to involve.
Furthermore, in the embedded clinics involved, the choice of the service where the study was carried out was left to the discretion of the investigators. The investigators may have chosen to carry out the study in departments they were accustomed to work with, where patient needs could be better addressed. In addition, the median time between diagnosis of first metastasis and inclusion was 13.5 months, which seems long considering the prognosis of certain primary cancers like metastatic lung and pancreatic cancer. We observe a probable survival bias and may have included more indolent cancers requiring less healthcare needs.
Finally, considering the number of missing data for certain variables, our study may sometimes have lacked statistical power. Despite these limitations, this is one of the first studies to analyze the overall health status of metastatic cancer patients with good functional status, and in relation to social vulnerability. These results can help us better identify the supportive care needs of patients with metastatic cancer, as well as the healthcare interventions required to meet them.
Conclusion
Our study highlights the frequent and complex entanglement of healthcare needs with a high rate of hospitalisation for patients with metastatic cancer, even with good performance status. Despite universal healthcare coverage, socially precarious patients seem to have a later diagnosis and less systemic treatment. Additionally, they have the same unmet needs but receive more intense medical and social care at home. The early systematic self-screening of complex needs using a comprehensive tool appears necessary for metastatic cancer patients to identify the appropriate health resources required.
Acknowledgements
We thank the Fondation de France and the Ile-de-France regional health agency which financed the study, the staff of the Clinical Research Unit AP-HP Paris Saclay Ouest, Gabriela Lopes who provided English proofreading and the Assistance Publique – Hôpitaux de Paris (Délégation à la Recherche Clinique et à l’Innovation) who was the promoter.
Key message
This observational, multicentric, cross-sectional study showed that patients with metastatic cancer, even with good performance status, had numerous healthcare needs. Despite universal health insurance, socially vulnerable patients seemed to have late diagnosis and less systemic treatment. A systematic screening of supportive care needs would allow targeted care interventions.
Authors’ contributions
All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Marine Sahut d’Izarn, Pascale Vinant, Carole Bouleuc, Ingrid Joffin, Bruno Vincent, Laure Seresse, Aurore Codogno, Florence Behal, Madalina Jacota and Malamine Gassama. The first draft of the manuscript was written by Marine Sahut d’Izarn and Matthieu de Stampa and all authors commented on previous versions of the manuscript. Lucie Ya de Rauglaudre provided English proofreading. All authors read and approved the final manuscript.
Funding
The sponsor was Assistance Publique – Hôpitaux de Paris (Délégation à la Recherche Clinique et à l’Innovation). The study was funded by the Fondation de France and the Ile-de-France regional health agency.
Data availability
all data supporting the findings of this study are available within the paper. Detailed data are available upon reasonable request. The procedures carried out with the French data privacy authority (CNIL, Commission nationale de l’informatique et des libertés) and the european regulation (GDPR) do not provide for the transmission of the database, nor do the information and consent documents signed by the patients. Consultation by the editorial board or interested researchers of individual participant data that underlie the results reported in the article after deidentification may nevertheless be considered, subject to prior determination of the terms and conditions of such consultation and in respect for compliance with the applicable regulations.
Declarations
Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki. This study was approved by a French ethics committee (Northwest 1 People Protection Committee). Non opposition was obtained from all individual participants included in the study, in accordance with the French law on non-interventional studies.
Consent for publication
Not applicable.
Competing interests
The authors have no competing interests to declare that are relevant to the contents of this article.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
all data supporting the findings of this study are available within the paper. Detailed data are available upon reasonable request. The procedures carried out with the French data privacy authority (CNIL, Commission nationale de l’informatique et des libertés) and the european regulation (GDPR) do not provide for the transmission of the database, nor do the information and consent documents signed by the patients. Consultation by the editorial board or interested researchers of individual participant data that underlie the results reported in the article after deidentification may nevertheless be considered, subject to prior determination of the terms and conditions of such consultation and in respect for compliance with the applicable regulations.