Supportive Care Needs Trajectories in Patients With Advanced Non-Small-Cell Lung Cancer Receiving Chemotherapy: A Longitudinal Study

Introduction

Lung cancer is the leading cause of cancer death worldwide, followed by colorectal and female breast cancer (Sung et al., 2021). Non-small-cell lung cancer (NSCLC) is the most common lung cancer, accounting for 80%–85% of all lung cancer cases (American Cancer Society, 2019). The National Comprehensive Cancer Network Clinical Practice Guidelines for Oncology—Non-Small Cell Lung Cancer (Version 2) recommend platinum-based agents (cisplatin or carboplatin) be applied in combination with another chemical drug as a first-line, doublet chemotherapy treatment for patients with advanced NSCLC without gene mutation. The optimal number of treatment cycles of platinum-based chemotherapy for advanced NSCLC is four for any NSCLC histology (Rossi & Maio, 2016). After evaluation of the treatment effect after the end of the fourth cycle, if the treatment effect fails to progress, different chemical drugs should be considered for application in continued treatments (National Comprehensive Cancer Network, 2021). For patients with lung cancer who experience the effects of their disease diagnosis and complex treatment, follow-up should be accompanied by physical, emotional, social, psychological, informational, and practical supportive care needs (Mazor et al., 2022). Unmet supportive care needs have been associated with poorer quality of life in patients with lung cancer (Cochrane et al., 2022), whereas providing individualized care interventions based on patient needs has been shown to improve cancer care quality (Reiser et al., 2019).

The supportive care needs of patients with lung cancer cross multiple domains. Patients with NSCLC receiving chemotherapy or immunotherapy have reported unmet supportive care needs (McLouth et al., 2021). Moreover, patients with lung cancer have various supportive care needs after discharge (Ni et al., 2022). Whereas information is the most prominent supportive care needs domain for patients with lung cancer in Taiwan and China (Kao et al., 2013; Zhang et al., 2019), psychological and physical and daily living requirements are the most prominent supportive care needs domains for patients with lung cancer in Singapore, Canada, and Mexico (Doubova & Pérez-Cuevas, 2020; Giuliani et al., 2016; Huang et al., 2020). Patients in the United States with metastatic NSCLC receiving target therapy were identified with prominent needs in the information and psychosocial support domains (Petrillo et al., 2021), whereas, in Norway, patients with primary lung cancer after lung cancer surgery reported prominent needs in the information and supportive care categories (Kyte et al., 2019). Preliminary findings from the literature suggest that culture is a factor of influence on the supportive care needs domains of patients with lung cancer.

In a systematic review, patients with cancer were reported to have higher supportive care needs during treatment than during either diagnosis or follow-up and higher supportive care needs in the advanced stages of cancer and during poor health than in the early stages of cancer (Harrison et al., 2009). Studies on factors related to the supportive care needs of patients with lung cancer have found diverse results; no consistency currently exists in the literature regarding associations among sociodemographic characteristics (e.g., age, gender, educational level, primary caregiver, function of daily activities), disease characteristics (e.g., cancer cell type, treatment modality, cancer stage, comorbidities), and supportive care needs in patients with lung cancer (Doubova & Pérez-Cuevas, 2020; Huang et al., 2020; Zhang et al., 2019). It has only been found that patients with lung cancer receiving chemotherapy have higher supportive care needs than those not receiving chemotherapy (Doubova & Pérez-Cuevas, 2020).

Most of the previous cross-sectional studies on supportive care needs in patients with lung cancer have not focused exclusively on patients with advanced lung cancer (Doubova & Pérez-Cuevas, 2020; Giuliani et al., 2016; Zhang et al., 2019). Moreover, the small number of studies on patients with advanced lung cancer did not focus specifically on patients treated with chemotherapy and did not clearly indicate that the measurement time was equal to the treatment period (Huang et al., 2020). In recent years, several longitudinal studies have been conducted on the supportive care needs of patients with breast and colorectal cancers, with results showing that these needs exhibit different classes of trajectories, for example, low stable care needs and high-decline needs, before and after surgery or treatment (Lam et al., 2014, 2016; Pérez-Fortis et al., 2018). However, the supportive care needs trajectories in patients with advanced NSCLC during chemotherapy and the related factors have yet to be determined.

To provide continuous and individualized care, the supportive care needs of patients with cancer should be investigated longitudinally to elicit the trajectories associated with these needs during chemotherapy. During extended chemotherapy courses (over at least four cycles) in patients with advanced NSCLC, healthcare providers should attempt to understand the correlation between classes of supportive care needs trajectories during chemotherapy and patient characteristics to enhance their sensitivity toward these trajectories. Accordingly, the purpose of this study was to understand the classes of supportive care needs trajectories and the association between sociodemographic and disease characteristics of patients with advanced NSCLC over four cycles of chemotherapy. The two hypotheses investigated in this study were as follows: (a) The overall supportive care needs and their related domains of patients with advanced NSCLC are all associated with different trajectory classes over the four cycles of chemotherapy, and (b) the classes of overall supportive care needs and the subdomains of supportive care needs trajectories are related to sociodemographic and disease characteristics.

Methods Design

An observational, longitudinal approach was adopted in this study, and a structured questionnaire was used to collect data.

Participants and Setting

From September 5, 2018, to July 10, 2021, potential participants were screened and recruited using a convenience sampling method in a medical center in southern Taiwan. Physician-diagnosed adult patients with advanced (Stages IIIB, IIIC, or IV) NSCLC who were expected to receive first-line chemotherapy during hospitalization were invited to participate. Patients in the intensive care unit, those who were confused or unaware of their disease, and those receiving other treatments in addition to first-line chemotherapy were excluded. To detect between subgroups in a chi-square test with 80% power, at a significance level of 5%, at an assumed effect size of .4, and at a degree of freedom of 2, the estimated minimum total sample size needed was 61. Presuming an attrition rate of 35% over the four courses of chemotherapy, a sample size of 94 patients was recruited. Ninety-five persons meeting the inclusion criteria were screened by the investigators, and after the study was explained, 94 agreed to participate.

Measurements Participant characteristics

Patient sociodemographics included age, gender, education, marital status, primary caregiver, and function of daily activities. Disease characteristics included lung cancer cell type, the presence or absence of metastasis, and the presence or absence of comorbidities.

Supportive care needs

The Needs Evaluation Questionnaire–Chinese version (NEQ-C; Kao et al., 2013) covers five domains of care needs, including information needs (Items 1–8 and 13), needs related to assistance/care needs (Items 9–12), relational needs (Items 20–23), needs for a psychoemotional support (Items 17–19), and material needs (Items 14–16). This self-administered instrument with 23 dichotomous items have a total possible score range of 0–23 based on the number of “yes” answers given. Higher scores indicate a higher number of unmet supportive care needs. No cutoff point for overall supportive care needs (NEQ-C) was recommended in the original study (Kao et al., 2013), and scores ranging from 8 to 15 (the middle tertile) were defined in this study as “moderate” needs. The NEQ has been found to measure supportive care needs effectively in both inpatient and outpatient patients with cancer (Bonacchi et al., 2016). The Cronbach's alpha of the NEQ-C was .85 in the original study (Kao et al., 2013) and .92 in this study.

Data Collection

The researchers collected basic and supportive care needs information during face-to-face questionnaire interviews 1 day before the first, second, third, and fourth cycles of chemotherapy. Patients were admitted into the hospital to receive gemcitabine and carboplatin for 2–3 days during the first week. After discharge, the patients were administered gemcitabine in the outpatient clinic during the second and third weeks. No chemotherapy was administered on the fourth week to give patients a chance to rest and recuperate. Generally, one cycle of chemotherapy lasts for 4 consecutive weeks; the subsequent cycle commenced immediately after. On the seventh day after the end of the first, second, and third cycles, supportive care needs information was collected by telephone follow-up. On the day of the first return to the outpatient clinic after the end of the fourth cycle of chemotherapy (7–10 days after the end), this information was collected using face-to-face questionnaire interviews, with each interview lasting 20–30 minutes.

Ethical Considerations

The study protocol for this observational longitudinal study was approved by the institutional review board of Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUHIRB-E[I]-20180254). Data were collected after the participants provided signed informed consent. The participants were informed that they could withdraw from the study or refuse to answer questionnaire questions at any time without affecting their treatment or care.

Statistical Analysis

Descriptive analysis of the participants' sociodemographic data and the eight assessments of their supportive care needs were analyzed by frequency distribution and percentage, mean, and standard deviation. The PROC TRAJ application of SAS software Version 9.4 (SAS Institute, Inc., Cary, NC, USA) applied group-based trajectory modeling analysis to identify the change in trends and classifications of the eight supportive care needs (precycle and postcycle) assessments (https://www.andrew.cmu.edu/user/bjones/download.htm). The principles for determining the number of category groups and the most appropriate model included (a) selecting the model with the smallest negative number of the Bayesian information criterion and (b) determining the shape of the pattern of change for each group over time, for example, constant, linear, or quadratic pattern (Jones et al., 2001). The chi-square test was used to identify significant differences between different classes of supportive care needs trajectories and, respectively, sociodemographic characteristics and disease characteristics. When over 20% of the cells were found to have an expected frequency below 5, the Freeman–Halton extension of Fisher's exact test was used to compute the two-tailed probability of obtaining a distribution of values in a 2 × 3 contingency table (http://vassarstats.net/fisher2x3.html).

Results Characteristics and Supportive Care Needs of Participants

Of the 94 initial participants, nine, 10, and four patients withdrew because of various reasons during the first, second, and third cycles, respectively, leaving 71 participants who received all eight follow-up data interviews over the four cycles (Figure 1; attrition rate = 24.4%). The mean age of the 71 participants was 60.7 (SD = 8.5, range: 41–79) years. Most were < 64 years old, male, educated to the high school level or below, married/partnered, cared for by a nonspouse caregiver, and able to perform daily activities completely independently. Most had adenocarcinoma, with those having distant metastases (Stages IVA and IVB) with other comorbidities accounting for most adenocarcinoma diagnoses. The overall supportive care needs scores for the participants before and after the four cycles of chemotherapy ranged from 14.4 ± 5.8 to 14.6 ± 5.0 (Table 1).

F1Figure 1.:

Flowchart of Patient Follow-Up

Table 1. - Participant Characteristics and Mean Scores of Supportive Care Needs at the Eight Time Points Over Four Cycles (N = 94) Variable Cycle 1 (n = 9) Cycle 2 (n = 10) Cycle 3 (n = 4) Cycle 4 (n = 71) t/F/χ2 p n % n % n % n % Age (years; mean and SD) 61.9 13.3 61.8 13.1 62.8 6.2 60.7 8.5 0.120 .948 Age (years) 1.107 .775  41–64 5 55.6 5 50.0 3 75.0 45 63.4  65 and above 4 44.6 5 50.0 1 25.0 26 36.6 Gender a 2.830 .419  Male 4 44.4 8 80.0 2 50.0 40 56.3  Female 5 55.6 2 20.0 2 50.0 31 43.7 Educational level 0.927 .819 a  Senior high school or below 6 66.7 8 80.0 3 75.0 57 80.3  College or above 3 33.3 2 20.0 1 25.0 14 19.7 Marital status 1.057 .787 a  Married/cohabiting 7 77.8 7 70.0 2 50.0 47 66.2  Single/divorced/separated/widowed 2 22.2 3 30.0 2 50.0 24 33.8 Primary caregiver a 4.292 .232  Spouse 4 44.4 6 60.0 0 0 32 45.1  Not spouse 5 55.6 4 40.0 4 100 39 54.9 Activities of daily living (mean and SD) 90.0 19.4 92.5 14.6 98.8 2.5 94.3 14.6 0.397 .756 Activities of daily living a 2.994 .393  100 points 5 55.6 6 60.0 3 75.0 55 77.5  Under 100 points 4 44.4 4 40.0 1 25.0 16 22.5 Cancer cell subtype 3.747 .290 a  Adenocarcinoma 5 55.6 6 60.0 4 100 53 74.6  Not adenocarcinoma 4 44.4 4 40.0 0 0 18 25.4 Metastasis a 2.139 .544  Yes 8 88.9 7 70.0 4 100 58 81.7  No 1 11.1 3 30.0 0 0 13 18.3 Comorbidity a 0.864 .834  Yes 7 77.8 9 90.0 3 75.0 55 77.5  No 2 22.2 1 10.0 1 25.0 16 22.5 Supportive care needs (mean and SD)  Pre-first-cycle treatment 11.1 6.2 17.2 2.2 8.8 8.1 14.4 5.8 3.09 .031  Post-first-cycle treatment 11.1 7.0 16.6 3.7 11.0 5.7 14.5 5.6 2.09 .107  Pre-second-cycle treatment b 17.2 2.2 8.8 8.1 14.4 5.8 3.26 .043  Post-second-cycle treatment 16.6 3.7 11.0 5.7 14.5 5.6 1.58 .212  Pre-third-cycle treatment 8.8 8.1 14.4 5.8 −1.87 .065  Post-third-cycle treatment 11.0 5.7 14.5 5.6 −1.20 .233  Pre-fourth-cycle treatment 14.5 5.1  Post-fourth-cycle treatment 14.6 5.0
Supportive Care Needs Trajectory Classes

After grouping the trajectory pattern analysis and selecting the most suitable modeling approach, the overall supportive care needs trajectories were divided into three classes, namely, low-unstable group (19.7%), moderate-stable group (43.7%), and high-stable group (36.6%). Information needs trajectories were divided into three classes, namely, low-unstable group (13.2%), moderate-stable group (37.1%), and high-stable group (49.7%); psychoemotional support needs trajectories were divided into three classes, namely, nonstable group (52.2%), moderate-decline group (43.6%), and high-increase group (4.2%); assistance/care needs trajectories were divided into three classes, namely, low-increase group (22.6%), moderate-stable (57.7%), and high-stable group (19.7%); relational needs trajectories were divided into three classes, namely, low-stable group (43.4%), moderate-increase group (27.1%), and high-stable group (29.5%); and material needs trajectories were divided into three classes, namely, low-decline group (23.4%), moderate-stable group (59.7%), and high-stable group (16.9%; Figure 2).

F2Figure 2.:

Supportive Care Needs Trajectories

Factors Related to Supportive Care Needs Trajectories

The classes of overall supportive care needs trajectories were found to relate to marital status (p = .014), with those who were married/cohabiting more likely to be in the high-stable supportive care needs trajectory group than their single/divorced/separated/widowed peers (84.6% vs. 15.4%; Table 2). The classes of assistance/care needs trajectories were found to relate to marital status (p = .019), with those who were married/cohabiting more likely to be in the high-stable supportive care needs trajectory group than their single/divorced/separated/widowed peers (92.9% vs. 7.1%). The classes of information needs trajectories were found to relate to spouse as primary caregiver (p = .004), with those who had their spouse as a primary caregiver more likely to be in the high-stable information needs trajectory group than their peers without a spouse as their primary caregiver (58.3% vs. 41.7%). The classes of material needs trajectories were found to relate to spouse as primary caregiver, with those who had their spouse as their primary caregiver more likely to be in the high-stable material needs trajectory group than their peers without a spouse as their primary caregiver (75.0% vs. 25%). The classes of psychoemotional support needs trajectories were found to relate to educational level (p = .028), with those educated to the college level or above more likely to be in the high-increase psychoemotional support needs trajectory group than their peers educated to the senior high school level or below (66.7% vs. 33.3%). No association was found between the relational needs trajectory classes and either sociodemographic or disease characteristics (p > .05).

Table 2. - Factors Related to the Overall and Domains of Supportive Care Needs Trajectory Classes (N = 71) Trajectory Class Related Factor Class I Class II Class III χ2 p Overall supportive care needs Marital status 8.51 .014  Married/cohabiting 10 71.4 15 48.4 22 84.6  Single/divorced/separated/widowed 4 28.6 16 51.6 4 15.4 Assistance/care needs Marital status 7.88

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