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Psychological distress is a common problem associated with cancer. The main objective of the present study was to test the Hospital Anxiety and Depression Scale (HADS) in a sample of Ethiopian cancer patients and to compare the results with those obtained from a sample in Germany. Data were collected from 256 cancer patients who visited the University of Gondar Hospital between January 2019 and June 2019 using the HADS, the European Organization for Research and Treatment of Cancer Quality of Life questionnaire (EORTC QLQ-C30), and the Multidimensional Fatigue Inventory MFI-20. The reliability of the HADS was good, with Cronbach's α coefficients of 0.86 (anxiety), 0.85 (depression), and 0.91 (total scale). The Ethiopian cancer patients were more anxious (M = 7.9) and more depressed (M = 9.3) than the German patients (M = 6.8 for anxiety and M = 5.5 for depression). Only a weak level of measurement invariance was detected between the Ethiopian and the German sample. In the Ethiopian sample, anxiety and depression were associated with tumor stage (high levels in stage 4) and treatment (high levels for patients not receiving surgery and chemotherapy). Both anxiety and depression were significantly associated with all of the EORTC QLQ-C30 and MFI-20 scales. The HADS proved to be applicable for use with Ethiopian cancer patients. The high level of anxiety and depression present in that group indicates a need for psychosocial care., Competing Interests: The authors have declared that no competing interests exist.

Objective: We aimed to determine whether the Managing Cancer and Living Meaningfully (CALM) therapy is superior to a non-manualized supportive psycho-oncological counselling intervention (SPI)., Methods: Adult patients with advanced cancer and ≥9 points on the PHQ-9 and/or ≥5 points on the DT were randomized to CALM or SPI. We hypothesized that CALM patients would report significantly less depression (primary outcome) on the BDI-II and the PHQ-9 6 months after baseline compared to SPI patients., Results: From 329 eligible patients, 206 participated (61.2% female; age: M = 57.9 [SD = 11.7]; 84.5% UICC IV stage). Of them, 99 were assigned to CALM and 107 to SPI. Intention-to-treat analyses revealed significantly less depressive symptoms at 6 months than at baseline (P < .001 for BDI-II and PHQ-9), but participants in the CALM and SPI group did not differ in depression severity (BDI-II: P = .62, PHQ-9: P = .998). Group differences on secondary outcomes were statistically not significant either., Conclusions: CALM therapy was associated with reduction in depressive symptoms over time but this improvement was not statistically significant different than that obtained within SPI group., (© 2020 John Wiley & Sons Ltd.)

Background: We aimed to analyze preferred and perceived levels of patients' involvement in treatment decision-making in a representative sample of cancer patients. Material and Methods: We conducted a multicenter, epidemiological cross-sectional study with a stratified random sample based on the incidence of cancer diagnoses in Germany. Data were collected between January 2008 and December 2010. Analyses were undertaken between 2017 and 2019. We included 5889 adult cancer patients across all cancer entities and disease stages from 30 acute care hospitals, outpatient facilities, and cancer rehabilitation clinics in five regions in Germany. We used the Control Preferences Scale to assess the preferred level of involvement and the nine-item Shared Decision-Making Questionnaire to assess the perceived level of involvement. Results: About 4020 patients (mean age of 58 years, 51% female) completed the survey. Response rate was 68.3%. About a third each preferred patient-led, shared, or physician-led decision-making. About 50.7% perceived high levels, about a quarter each reported moderate (26.0%) or low (24.3%) levels of shared decision-making. Sex, age, relationship status, education, health care setting, and tumor entity were linked to preferred and/or perceived decision-making. Of those patients who preferred active involvement, about 50% perceived high levels of shared decision-making. Conclusion: The majority of patients with cancer wanted to be involved in medical decisions. Many patients perceived a high level of shared decision-making. However, many patients' level of involvement did not fit their preference. This study provides a solid basis for efforts to improve shared decision-making in German cancer care.

Purpose: Close relationships can be strained by losses related to independence, autonomy, and separation after diagnosis of severe illness. The perceived quality of their close relationships affects individuals' psychological adaptation in this context. We explored the level of perceived relatedness and its impact on demoralization and death acceptance. We further examined a possible protective effect of perceived relatedness on the association between tumor stage and death acceptance., Methods: For this observational study, we consecutively recruited gynecology outpatients and general surgery inpatients at the University Cancer Center Hamburg-Eppendorf and oncological inpatients at the LungenClinic Grosshansdorf, Germany. At baseline, 307 patients (age M = 59.6, 69% female, 69% advanced cancer) participated. At 6- and 12-month (T3) follow-up, 213 and 153 patients responded, respectively. Patients completed self-report questionnaires including a modified version of the Posttraumatic Growth Inventory assessing perceived relatedness, the Life Attitude Profile-Revised assessing death acceptance, the Demoralization Scale, and the Memorial Symptom Assessment Scale assessing symptom burden. We calculated multiple linear regression analyses controlling for demographic and disease-related factors., Results: Participants reported a stronger perceived relatedness at baseline (M = 3.04, SE = 0.03, possible range 0-4) than at T3 (M = 2.93, SE = 0.04; p = 0.02). Perceived relatedness significantly predicted lower demoralization at T3 but did not moderate the relationship between tumor stage and demoralization. Apart from male gender, none of the predictor or moderator variables had a significant impact on death acceptance at T3., Conclusions: The strong impact of perceived relatedness on existential distress emphasizes the importance of strengthening interpersonal relationships within psychosocial interventions.

Objectives: Addressing information and supportive care needs could enhance cancer survivors' ability to cope with the long-term and/or late effects of their disease. The study examines how long-term cancer survivors evaluate information received during the course of cancer and aims to identify supportive care needs., Methods: The data were collected in a cross-sectional cancer registry cohort study including 1002 patients (participation rate 53%, five years post diagnosis n=660 (65.9%), 10 years post diagnosis n=342 (34.1%), mean age 66.7 years, male 52.9%, prostate cancer 25.5%). The survey instruments used included the SCNS-SF34-G, the PHQ-9, GAD-7, the Distress-Thermometer (DT) and a questionnaire measuring comorbidities. Descriptive and inference statistics were applied., Results: Cancer Survivors perceived information on treatment decision-making as most helpful, whereas information about support offers was perceived as least helpful. One in 5 patients (19.6%) expressed a desire for further information. The majority of patients (81.3%) indicated at least one specific unmet supportive care need, on average 11 (SD=7.14) unmet supportive care needs. Most frequent supportive care needs are related to fear of cancer progression or recurrence, physical comorbidities and the wish for one member of the professional health care team with whom they can talk to continuously about medical issues across the treatment period. Higher physical comorbidity and distress are associated with an increased likelihood of further supportive care needs (p<0.001)., Conclusion: There is a need for survivorship care models that take into account medical aspects and psychosocial needs through a multidisciplinary approach., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The use of sum scores of depressive symptoms has been increasingly criticized and may be particularly problematic in oncological settings. Frameworks analyzing individual symptoms and their interrelationships such as network analysis represent an emerging alternative., Methods: We aimed to assess frequencies and interrelationships of 9 DSM-5 symptom criteria of major depression reported in the PHQ-9 questionnaire by 4020 patients with cancer and 4020 controls from the general population. We estimated unregularized Gaussian graphical models for both samples and compared network structures as well as predictability and centrality of individual symptoms., Results: Depressive symptoms were more frequent, but less strongly intercorrelated in patients with cancer than in the general population. The overall network structure differed significantly between samples (correlation of adjacency matrices: rho=0.73, largest between-group difference in any edge weight: 0.20, p < 0.0001). Post-hoc tests showed significant differences in interrelationships for four symptom pairs. The mean variance of symptoms explained by all other symptoms in the same network was lower among cancer patients than in the general population (29% vs. 43%)., Limitations: Cross-sectional data do not allow for temporal or causal inferences about the directions of associations and results from population-based samples may not apply to clinical psychiatric populations., Conclusions: In patients with cancer, both somatic and cognitive/affective depression symptoms are less likely to be explained by other depressive symptoms than in the general population. Rather than assuming a consistent depression construct, future research should study individual depressive symptom patterns and their potential causes in patients with cancer., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to compare the levels of anxiety and depression in cancer patients with those of the general population, to examine age and gender differences in anxiety and depression, to analyse the impact of several socio-demographic and clinical parameters on anxiety and depression, and to test the age and gender measurement invariance of the Hospital Anxiety and Depression Scale (HADS)., Methods: A sample of 3,785 German patients with cancer and a sample of 2,747 people of the German general population were examined using the HADS., Results: Patients with cancer were more anxious but slightly less depressed than age- and gender-matched individuals of the general population. Young patients with cancer were particularly affected by anxiety. Measurement invariance across gender and age could be established. For all analysed clinical variables, including tumour site, tumour stage, metastases, setting and Eastern Cooperative Oncology Group (ECOG) performance status we found no significant interaction effects with gender that exceeded the 5% significance criterion., Conclusion: The HADS provides fair comparisons between age and gender groups. Gender differences in anxiety and depression can be generalised across the cancer sites and clinical subgroups. Young patients with cancer deserve special attention by the healthcare system., (© 2019 John Wiley & Sons Ltd.)

Purpose: Coping with cancer at a young adult age (AYA) is a challenge for many patients and raises support needs. We aim to examine unmet supportive care needs and to investigate predictors of and changes in unmet needs over time., Methods: We surveyed AYAs (18-39 years at time of diagnosis, diagnosis < 4 years) at two time points (t2 = 12 months after t1) using the Supportive Care Needs Survey (SCNS-SF34) among other validated measures. We conducted multiple hierarchical regressions to identify sociodemographic, medical and psychosocial predictors of unmet needs., Results: A total of 514 AYAs (386 women) with a mean age of 29.6 years participated at both times. Psychological needs (M t1  = 35.7; M t2  = 32.09; p = 0.001) and informational needs (M t1  = 32.18; M t2  = 29.04; p = 0.021) were the most often reported unmet needs at both measurements and decreased slightly at t2. All other SCNS domains, except for patient care, remained stable over time. Higher supportive needs were associated with greater levels of effort to cope with the disease at both times in all domains. Older age and female gender were significantly associated with two and one of six domains, respectively, at t1 and t2., Conclusions: AYAs reported primarily unmet psychological and informational needs, which were stable over time and indicated that AYAs do not have sufficient access to the support they need. The degree of effort to cope with cancer plays a key role in terms of unmet support needs., Implications for Cancer Survivors: Regular screening for this variable in acute and especially follow-up care settings could pave the way for clinicians to offer more targeted support.

Purpose: Cancer patients' intimate partners often experience levels of psychological burden that are comparable to or even exceed that of the patients, making it imperative that they too be provided with appropriate psychological support. This review aimed to present the content and the effects of interventions delivered to caregiving partners of cancer patients on both partners and patients. Furthermore, we provide information about the acceptability of the interventions and study quality., Methods: An initial search in Web of Science, PsycINFO, and PubMed databases was conducted. We included RCTs as well as pre-post studies that focused on enhancing partners' wellbeing or diminishing partners' distress. To be included, interventions had to have been offered to partners either only or predominantly. We included studies published until December 2017. The methodological quality of the trials was assessed with the EPHPP assessment tool., Results: Nine studies met the inclusion criteria. Intervention topics included social support, short-term problem solving, the marital relationship quality, role expectations, emotional resilience, and coping strategies. Positive intervention effects were found with regard to social support, emotional distress, improved communication, posttraumatic growth, self-efficacy, and coping. Despite considerably low response rates, the interventions were generally well accepted. Most of the studies suffer limitations because of methodological flaws, the lack of randomization, and small sample sizes., Conclusion: Interventions delivered to partners of cancer patients may have positive effects on both partners and patients. We derive several implications for future research: Intervention programs should be tailored to the specific needs of caregiving partners with regard to the cancer trajectory and gender. Effort has to be made to increase sample sizes as well as to include particularly burdened individuals. Selected measurement instruments should be sensitive to specific intervention effects. Finally, information on both statistical as well as clinical relevance of research findings should be provided., (Copyright © 2019 Elsevier B.V. All rights reserved.)

This cross-sectional German study examined the frequency of health literacy (HL) in adolescents and young adult (AYA) cancer patients and the factors associated with HL. A sample of 206 AYA-aged patients (80.1% female; age 15-39 years) completed measures of HL, health-related quality of life (HRQoL), depression, and sociodemographic characteristics; 28% had a sufficient HL score. Males and patients with higher education levels reported higher HL scores. Regression revealed positive associations between HL and HRQoL and depressive symptoms. Results suggest the need to further examine HL and its predictors in AYAs with cancer to develop interventions for improving HL.

Objective: In order to optimize psycho-oncologic care for patients with severe stressor-related symptomatology, we aimed to provide (a) valid and generalizable prevalence rates of posttraumatic stress disorder (PTSD) in oncological patients and (b) the percentage of PTSD cases elicited by cancer-related events., Methods: This multi-center study was based on a representative sample of patients across cancer types. A diagnostic interview (CIDI-O) was used to assess PTSD according to DSM-IV. We first describe type and frequency of potentially traumatic events (A1-events) and the degree to which they meet the trauma criteria (A2-events). Subsequently, we present adjusted prevalence rates of PTSD and explore the proportion of patients with cancer-related PTSD., Results: Four thousand twenty patients participated (response rate: 68 %), and 2141 completed the diagnostic interview; 1641 patients reported at least one A1-event, of whom 16% (n = 257) reported cancer-related events. Ninety-one percent (n = 232) of theses cancer-related events qualified as A2-events. Across cancer types, the adjusted 4-week prevalence of PTSD was 2.0% (95% CI, 1.5-2.7); 9% (n = 5) of the 4-week PTSD cases were cancer-related., Conclusions: Across cancer types and treatment settings, few cancer patients fulfilled diagnostic criteria for PTSD. Of those, a mere fraction was attributable to cancer-related events. These robust findings should be taken into account in both research and practice to develop and provide adequate care for cancer patients with severe stressor-related symptomatology., (© 2019 John Wiley & Sons, Ltd.)

Background: There are only a few valid instruments measuring couples' communication in patients with cancer for German speaking countries. The Couple Communication Scale (CCS) represents an established instrument to assess couples' communication. However, there is no evidence regarding the psychometric properties of the German version of the CCS until now and the assumed one factor structure of the CCS was not verified for patients with advanced cancer yet., Method: The CCS was validated as a part of the study "Managing cancer and living meaningfully" (CALM) on N=136 patients with advanced cancer (≥18 years, UICC-state III/IV). The psychometric properties of the scale were calculated (factor reliability, item reliability, average variance extracted [DEV]) and a confirmatory factor analysis was conducted (Maximum Likelihood Estimation). The concurrent validity was tested against symptoms of anxiety (GAD-7), depression (BDI-II) and attachment insecurity (ECR-M16)., Results: In the confirmatory factor analysis, the one factor structure showed a low, but acceptable model fit and explained on average 49% of every item's variance (DEV). The CCS has an excellent internal consistency (Cronbachs α=0,91) and was negatively associated with attachment insecurity (ECR-M16: anxiety: r=- 0,55, p<0,01; avoidance: r=- 0,42, p<0,01) as well as with anxiety (GAD-7: r=- 0,20, p<0,05) and depression (BDI-II: r=- 0,27, p<0,01)., Conclusion: The CCS is a reliable and valid instrument measuring couples' communication in patients with advanced cancer., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Quality assurance has become increasingly relevant in the field of outpatient psychosocial cancer counseling. At the same time, no studies are currently available that analyze outpatient psychosocial cancer counseling centers in Germany with respect to standards of service quality. Therefore, this study aimed to determine whether these centers meet selected quality criteria of outpatient psychosocial cancer counseling., Methods: Based on quality standards of outpatient psychosocial cancer counseling previously developed by us in a Delphi study, we surveyed 106 out of 151 German psychosocial outpatient cancer counseling centers registered in a publicly accessible data base of Germany's cancer information service in Heidelberg with respect to the selected quality characteristics. Data analysis used descriptive statistical techniques., Results: The centers of the sample differ in how many of them fulfill the quality standards selected for analysis here. More than 90% provide the services described by the standards as required. In contrast, in the personnel domain, there appears to be room for improvement with respect to the amount of service hours available for psychologists and the number of counselors with advanced training in psycho-oncology. Also, external supervision and case conferences turn out to be quality characteristics with room for improvement in the domain of quality assurance as do distress screening in the domain of diagnostics and using systematic documentation., Conclusion: Referring to recent standards of quality of outpatient psychosocial cancer counseling allowed us to delineate strength and weaknesses that may serve as starting points for quality improvement in the centers providing psychosocial cancer counseling. However, further research is necessary to arrive at a more comprehensive picture of the degree to which outpatient psychosocial cancer counseling centers in Germany comply with current standards of service quality., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Death acceptance may indicate positive adaptation in cancer patients. Little is known about what characterizes patients with different levels of death acceptance or its impact on psychological distress. We aimed to broaden the understanding of death acceptance by exploring associated demographic, medical, and psychological characteristics., Methods: At baseline, we studied 307 mixed cancer patients attending the University Cancer Center Hamburg and a specialized lung cancer center (age M = 59.6, 69% female, 69% advanced cancer). At 1-year follow-up, 153 patients participated. We assessed death acceptance using the validated Life Attitude Profile-Revised. Patients further completed the Memorial Symptom Assessment Scale, the Demoralization Scale, the Patient Health Questionnaire, and the Generalized Anxiety Disorder Questionnaire. Statistical analyses included multinomial and hierarchical regression analyses., Results: At baseline, mean death acceptance was 4.33 (standard deviation [SD] = 1.3, range 1-7). There was no change to follow-up (P = 0.26). When all variables were entered simultaneously, patients who experienced high death acceptance were more likely to be older (odds ratio [OR] = 1.04; 95% confidence interval [CI], 1.01-1.07), male (OR = 3.59; 95% CI, 1.35-9.56), widowed (OR = 3.24; 95% CI, 1.01-10.41), and diagnosed with stage IV (OR = 2.44; 95% CI, 1.27-4.71). They were less likely to be diagnosed with lung cancer (OR = 0.20; 95% CI, 0.07-0.58), and their death acceptance was lower with every month since diagnosis (OR = 0.99; 95% CI, 0.98-0.99). High death acceptance predicted lower demoralization and anxiety at follow-up but not depression., Conclusions: High death acceptance was adaptive. It predicted lower existential distress and anxiety after 1 year. Advanced cancer did not preclude death acceptance, supporting the exploration of death-related concerns in psychosocial interventions., (© 2019 John Wiley & Sons, Ltd.)

Background: Psychosocial care for cancer patients has gained importance in recent years and psycho-oncological counselling centers (POCC's) offer a wide range of services in this area. We investigated the scope and content of a POCC at a university medical center., Methods: The presented data were collected at the POCC at University Medical Center Leipzig in 2014. In total, 469 cancer patients participated (mean age 60 years, 67% female, 36% breast cancer). Psychosocial distress and psychopathology were assessed with the PHQ-9, GAD-7 and the NCCN Distress Thermometer. Descriptive statistics were analyzed., Results: 1 in 4 patients (24%) reported at least moderate levels of depressive symptoms. Patients with hematological malignancies and head and neck tumors showed stronger depressive symptoms. 15% of patients suffered from elevated levels of anxiety. The average number of reported problems on the Distress Thermometer and Problem List was 14 out of 39. Physical and psychosocial problems were most prevalent (e. g. fatigue, problems getting around, anxiety). Supportive care needs were less common than reported problems., Conclusions: We found that a close network of POCS, oncological inpatient and outpatient care can help direct patients toward psychosocial care at an early stage. Psychosocial screening enables psycho-oncologists to identify problem areas and offer tailored counselling services., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Advanced diseases pose a great burden on patients and go hand in hand with existential concerns. Demoralization is considered as a syndrome of existential distress with a perceived inability to cope with loss of meaning in life and feelings of helplessness and hopelessness. Professional health care providers play an important role in providing support for patients and unfavorable conversational styles in their relationship can increase patient's distress. In this study, we examine the association between the patient's perceived relationship to health care providers and demoralization., Methods: We used baseline data of a randomized control trial intervention study for advanced cancer patients (UICC-Stage ≥ III; PHQ ≥ 9 and/or Distress-Thermometer ≥5). We used a subscale of the QUAL-EC-P for assessing doctor-patient relationship, Beck Depression Inventory-II for depressive symptoms, a modified version of the MSAS as physiological symptom checklist, and the Demoralization Scale to assess demoralization. A hierarchical regression analysis was calculated., Results: In our sample of 187 patients with stage III or IV cancer (62% women), demoralization was present in 53.4% (16% moderate demoralization; 37.4% high demoralization) of the patients. Relationship to health care provider was an independent predictor (β = -.33, t(186) = -6.70, P < .001) of demoralization., Conclusions: Our findings underline the importance of the physician-patient relationship in the context of coping with existential challenges in advanced cancer patients. Trainings on how to communicate and build a sustainable relationship with patients and their specific needs may increase the buffering effect of social support by the physicians on patient's existential distress., (© 2018 John Wiley & Sons, Ltd.)

Background: A significant number of oncological patients are heavily burdened by psychosocial stress. Doctors recommending or referring their patients to psycho-oncologists in the course of routine consultations can positively influence psycho-oncological care. The aim of this study was to analyze the frequency and predictors of such recommendations and to examine the use of these services by patients., Methods: 4,020 cancer patients (mean age 58 years; 51% women) were evaluated in a multicenter, cross-sectional study in Germany. Data was gathered about doctors' referral practices, patients' utilization of psycho-oncological care services, and disease-related symptoms. The PHQ-9 depression scale and the GAD-7 anxiety scale were used to measure psychological burden. Descriptive data analysis was conducted on the basis of subgroup comparisons and multivariable analysis was done using binary logistical regression., Results: 21.9% of the respondents reported having been given a recommendation or referral for psycho-oncological care by a doctor within the course of their cancer diagnosis and treatment. This comprises 29.5% of the patients identified by screening as being psychologically burdened. Nearly half of the patients who received a recommendation or referral (49.8%) acted on it. Predictors for seeking out psycho-oncological care included: patient desire (OR = 2.0), previous experience with psycho-oncological care (OR = 1.59), and female gender (OR = 1.57). Multivariable analysis indicated that patients' level of psychological burden (depression, anxiety) had no effect on whether doctors gave them a recommendation or referral., Conclusions: Along with examining the degree to which patients are burdened (e.g. using screening instruments), determining whether or not patients would like to receive psycho-oncological care is an important aspect of improving referral practices and, by extension, will allow important progress in the field of psycho-oncological care to be made., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Our study provides a detailed overview of comorbid conditions and health-related quality of life of long-term cancer survivors and analyses the impact of demographic, disease- and treatment-related characteristics., Methods: We present data obtained from 1000 survivors across mixed tumour entities 5 and 10 years after cancer diagnosis in a cross-sectional study. We analyse the prevalence of physical symptoms and health conditions via self-report and health-related quality of life using the EORTC QLQ-C30 in comparison to gender- and age-matched reference values of the general population., Results: Cancer survivors reported on average 5 comorbidities; 23% had 7 or more comorbid conditions. Cancer survivors reported higher physical symptom burden than the population-especially fatigue, insomnia and pain. Type and prevalence of long-term and late effects differ with disease-related factors (e.g. cancer type, treatment) and characteristics of the patient. Cancer survivors also reported lower quality of life than the population, especially in everyday activities, social life, psychological well-being and financial difficulties. There was a positive association between high quality of life and a low level of morbidity., Conclusions: The specific knowledge about physical long-term consequences for the individual types of cancer could raise awareness in health care professionals for high-risk patients and help to develop adequate prevention and survivorship-programs., Implications for Cancer Survivors: Limitations in the mental health area underlines the importance of psycho-oncological survivorship-care-plans, which go beyond the time of rehabilitation. Special attention should be given to the financial situation of patients in long-term follow-up care.

Purpose: The aim of this study was to compare quality of life (QoL) data from cancer patients in different clinical settings with data from the general population., Methods: A sample of 4020 German cancer patients (1735 inpatients, 1324 outpatients, 961 participants in rehabilitation treatment) was tested with the EORTC QLQ-C30., Results: Compared with the general population, cancer patients reported markedly worse QoL. There were clinically significant differences on all 15 scales of the EORTC QLQ-C30 (except one). For the sum score, averaging across 13 scales, the effect size of the difference between cancer patients and the general population was d = 1.16. Inpatients reported the greatest detriments to QoL, followed by the rehabilitation patients and the outpatients (mean sum scores 68.6, 71.0, and 72.3, respectively, compared with 89.2 in the general population). Mean scores for different groups of cancer sites are given separately for the three settings., Conclusion: The detriments to QoL were stronger than in comparable studies conducted on data from clinical trials. Since these detriments were found in all three settings to a similar degree, health care providers should offer their services not only to inpatients but to outpatients and patients treated in rehabilitation clinics as well. The data can be used for QoL comparisons of assessments from different settings.

Objective: In cancer settings, physician empathy is not always linked to a better patient emotional quality of life quality of life (eQoL). We tested two possible moderators of the inconsistent link: type of consultation (bad news versus follow-up) and patient emotional skills (emoSkills, i.e., the way patients process emotional information)., Methods: In a cross-sectional design, 296 thoracic and digestive tract cancer patients completed validated questionnaires to assess their physician empathy, their emoSkills and eQoL. Moderated multiple regressions were performed., Results: In follow-up consultations, physician empathy was associated with a better eQoL in patients with low or average emotional skills. Those with high emotional skills did not benefit from physician empathy. Their eQoL was nonetheless very good. In bad news consultations, the pattern was reversed: only patients with average or high emotional skills benefited from physician empathy. Those with low emotional skills were not sensitive to it and presented a poor eQoL., Conclusion: Medical empathy is important in all consultations. However, in bad news consultations, patients with low emoSkills are at risk of psychological distress even with an empathetic doctor., Practice Implications: Accordingly, physicians should be trained to detect patients with low emoSkills in order to refer them to supportive care., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: This study provides prevalence data of mental disorders (4-week, 1-year, lifetime) and psychological distress in Adolescent and Young Adult (AYAs) with cancer., Methods: We included an AYA subsample (15 to 39 year olds; diagnosed within the last 5 years) extracted from a larger sample (4.020 cancer patients) who had been recruited for an epidemiological study across all major tumor entities. Participants were assessed with a depression screener (PHQ-9). Following that, 50% of the participants who scored below the cutoff of 9 and all patients who scored above were assessed using the Composite International Diagnostic Interview for Oncology (CIDI-O). Patients also completed an anxiety screener (GAD-7)., Results: A total of 302 AYA (167 completed CIDI-O) were identified. With regard to psychological distress, 29.5% of the AYA had increased depression symptoms (PHQ-9), and 20.8% had increased anxiety symptoms (GAD-7). Gender and age were associated with psychological distress, with women and older AYA being found to have higher distress. The 4-week prevalence of mental disorders of any kind was 46.7% (95%-CI:39%-55%). Anxiety (24.4%; 95%-CI:20%-36%) and adjustment disorders (14.1%; 95%-CI:9%-19%) had the highest prevalence rates. The lowest prevalence rates were reported for alcohol dependence (0.8%; 95%-CI:0%-2%) and somatoform disorders (3.7%; 95%-CI:1%-7%). The 1-year-prevalence was 55.4% (CI:47.36-62.64), and the lifetime-prevalence was 69.5% (CI: 62.29-77.06)., Conclusion: Our findings may sensitize clinicians to the possible presence of mental disorders in AYA. The results indicate that there is a strong need for psycho-oncological interventions designed to improve mental health in AYAs with cancer at all stages of medical care., (Copyright © 2018 John Wiley & Sons, Ltd.)

Objective: Anxiety in cancer patients may represent a normal psychological reaction. To detect patients with pathological levels, appropriate screeners with established cut-offs are needed. Given that previous research is sparse, we investigated the diagnostic accuracy of 2 frequently used screening tools in detecting generalized anxiety disorder (GAD)., Methods: We used data of a multicenter study including 2141 cancer patients. Diagnostic accuracy was investigated for the Generalized Anxiety Disorder Screener (GAD-7) and the anxiety module of the Hospital Anxiety and Depression Scale (HADS-A). GAD, assessed with the Composite International Diagnostic Interview for Oncology, served as a reference standard. Overall accuracy was measured with the area under the receiver operating characteristics curve (AUC). The AUC of the 2 screeners were statistically compared. We also calculated accuracy measures for selected cut-offs., Results: Diagnostic accuracy could be interpreted as adequate for both screeners, with an identical AUC of .81 (95% CI: .79-.82). Consequently, the 2 screeners did not differ in their performance (P = .86). The best balance between sensitivity and specificity was found for cut-offs ≥7 (GAD-7) and ≥8 (HADS-A). The officially recommended thresholds for the GAD-7 (≥ 10) and the HADS-A (≥11) showed low sensitivities of 55% and 48%, respectively., Conclusions: The GAD-7 and HADS-A showed AUC of adequate diagnostic accuracy and hence are applicable for GAD screening in cancer patients. Nevertheless, the choice of optimal cut-offs should be carefully evaluated., (Copyright © 2018 John Wiley & Sons, Ltd.)

ABSTRACTObjective:The prevalence of depression as well as adjustment and anxiety disorders is high in advanced cancer patients, and research exploring intraindividual factors leading to high psychological distress is underrepresented. Cancer patients' feelings about security and trust in their healthcare providers have a significant influence on how they deal with their disease. The perception of social support is affected by patients' attachment styles and influences their reactions to feelings of dependency and loss of control. We therefore aimed to explore attachment and its association with psychological distress in patients with advanced cancer., Method: We obtained data from the baseline measurements of a randomized controlled trial in advanced cancer patients. Patients were sampled from the university medical centers of Hamburg and Leipzig, Germany. The main outcome measures included the Patient Health Questionnaire, the Death and Dying Distress Scale, the Memorial Symptom Assessment Scale, and the Experience in Close Relationships Scale for assessing attachment insecurity., Results: A total of 162 patients were included. We found that 64% of patients were insecurely attached (fearful-avoidant 31%, dismissing 17%, and preoccupied 16%). A dismissing attachment style was associated with more physical symptoms but did not predict psychological distress. A fearful-avoidant attachment style significantly predicted higher death anxiety and depression, whereas preoccupied attachment predicted higher death anxiety only. Overall, insecure attachment contributed to the prediction of depression (10%) and death anxiety (14%)., Significance of Results: The concept of attachment plays a relevant role in advanced cancer patients' mental health. Healthcare providers can benefit from knowledge of advanced cancer patients' attachment styles and how they relate to specific mental distress. Developing a better understanding of patients' reactions to feelings of dependency and distressing emotions can help us to develop individually tailored advanced cancer care programs and psychotherapeutic interventions.

Cancer patients and their relatives suffer from multiple psychological and social problems associated with the illness itself and its treatment. The major challenge for an excellent psychooncological support is the further development and nationwide implementation of effective, patient-centered, quality assured, and affordable concepts of treatment and care., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Context: Quality of life (QoL) is a central focus of care in advanced cancer. Specialized instruments, such as the Quality of Life at the End of Life-Cancer (QUAL-EC), may be useful to assess psychosocial issues associated with QoL unique to this population., Objectives: To evaluate the measurement of the psychosocial dimensions of QoL using the German translation of the QUAL-EC-Psychosocial (QUAL-EC-P) questionnaire, including factor structure and psychometrics., Methods: About 183 patients with advanced cancer from the University Medical Center Hamburg-Eppendorf and University Medical Center Leipzig completed the QUAL-EC-P questionnaire. We conducted exploratory factor analysis as well as item and reliability analysis. We examined convergent validity with correlations between the scale and relevant psychological constructs., Results: The sample was 60% female with mean age of 57.7 (SD = 11.7). We extracted three factors accounting for 44% of the variance aligning with the structure of the instrument. The QUAL-EC-P questionnaire showed good to acceptable internal consistency for the QoL-psychosocial total score (α = 0.77), the Life completion subscale (α = 0.77), and the Relationship with health care provider subscale (α = 0.81). The Preparation for end of life subscale had adequate albeit low internal consistency (α = 0.64) because concerns about family were less associated with financial worry and fear of death than expected. The psychosocial dimensions of QoL correlated negatively with depression (r = -0.27, P ≤ 0.001), anxiety (r = -0.32, P ≤ 0.001), demoralization (r = -0.63, P ≤ 0.001), and attachment insecurity (r = -0.51, P ≤ 0.001) and positively with spiritual well-being (r = 0.63, P ≤ 0.001)., Conclusion: The QUAL-EC-P questionnaire may be used to assess the psychosocial aspects of QoL and promote their clinical discussion in patients with advanced cancer., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Cancer has adverse effects on patient's quality of life. As such, measuring quality of life (QoL) has become an integral part of psycho-oncological health care. Because adolescent and young adult patients have different needs in contrast to children and older cancer patients, instruments for adequately measuring QoL of cancer survivors in this age range are essential. As there is not a corresponding instrument in Germany, we aimed to validate the German version of the Late Adolescence and Young Adulthood Survivorship-Related Quality of Life Measure (LAYA-SRQL), a 30-item questionnaire covering 10 dimensions related to QoL., Methods: The LAYA-SRQL was translated into German following state-of-the-art criteria. We enrolled 234 adolescent and young adult (AYA) cancer patients with different tumour entities aged between 16 and 39 years old. Factorial structure was tested using confirmatory factor analysis. Internal consistency was determined by Cronbach's α. The Short Form Survey quality of life questionnaire (SF-12v2) was used to examine convergent validity., Results: The 10-factor structure of the LAYA-SRQL was confirmed in the German sample, and the model shows high values of fit indicators: χ 2  = 723.32 (df = 360, p < 0.001), CFI = 0.92, TLI = 0.90, SRMR = 0.074, RMSEA = 0.066). Subscales showed acceptable to excellent internal consistencies with Cronbach's α > 0.70 and total Cronbach's α of 0.93. Convergent validity was demonstrated by high positive correlations between the LAYA-SRQL and the physical (r = 0.45) and mental component (r = 0.65) of the SF-12v2., Conclusions: The German version of the LAYA-SRQL showed good psychometric properties. The instrument proved to be a highly reliable and valid instrument that can be recommended for use in the follow-up care of AYAs and for clinical research.

Medical communication is a skill which can be learned and taught and which can substantially improve treatment outcomes, especially if patients' communication preferences are taken into account. Here, we give an overview of communication training research and outline the COMSKIL program as a state-of-the-art communication skills training in oncology. COMSKIL has a solid theoretical foundation and teaches core elements of medical communication in up to ten fully operationalized modules. These address typical situations ranging from breaking bad news to responding to difficult emotions, shared decision-making, and communicating via interpreters.

Since the mid-1970s psycho-oncology and psycho-oncological research have been systematically developed in many industrialized countries and have produced nationally and internationally accepted guidelines. In this article developments and challenges are presented and discussed. From the perspective of various oncological treatment options, different needs for further psycho-oncological research are considered.

Background: Depression screening in patients with cancer is recommended by major clinical guidelines, although the evidence on individual screening tools is limited for this population. Here, the authors assess and compare the diagnostic accuracy of 2 established screening instruments: the depression modules of the 9-item Patient Health Questionnaire (PHQ-9) and the Hospital Anxiety and Depression Scale (HADS-D), in a representative sample of patients with cancer., Methods: This multicenter study was conducted with a proportional, stratified, random sample of 2141 patients with cancer across all major tumor sites and treatment settings. The PHQ-9 and HADS-D were assessed and compared in terms of diagnostic accuracy and receiver operating characteristic (ROC) curves for Diagnostic and Statistical Manual of Mental Disorders, 4th edition diagnosis of major depressive disorder using the Composite International Diagnostic Interview for Oncology as the criterion standard., Results: The diagnostic accuracy of the PHQ-9 and HADS-D was fair for diagnosing major depressive disorder, with areas under the ROC curves of 0.78 (95% confidence interval, 0.76-0.79) and 0.75 (95% confidence interval, 0.74-0.77), respectively. The 2 questionnaires did not differ significantly in their areas under the ROC curves (P = .15). The PHQ-9 with a cutoff score ≥7 had the best screening performance, with a sensitivity of 83% (95% confidence interval, 78%-89%) and a specificity of 61% (95% confidence interval, 59%-63%). The American Society of Clinical Oncology guideline screening algorithm had a sensitivity of 44% (95% confidence interval, 36%-51%) and a specificity of 84% (95% confidence interval, 83%-85%)., Conclusions: In patients with cancer, the screening performance of both the PHQ-9 and the HADS-D was limited compared with a standardized diagnostic interview. Costs and benefits of routinely screening all patients with cancer should be weighed carefully. Cancer 2017;123:4236-4243. © 2017 American Cancer Society., (© 2017 American Cancer Society.)

Context: Due to toxicity and invasiveness, allogeneic hematopoietic stem cell transplantation causes severe and longstanding symptom burden. Longitudinal studies on symptoms and symptom clusters (SC) would be helpful to optimize symptom control but are rare to date., Objectives: The objective of this study was to investigate stability of symptoms, extract time stable SC, and determine their priority in symptom management., Methods: In this multicenter study, patients diagnosed with hematologic cancer were assessed before conditioning (T0) and three months (T1), one year (T2), and five years (T3) after transplantation. Symptoms were assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30). Symptoms were stable when rated as present at three consecutive time points. Applying factor analysis, stable SC were composed of symptoms loading on the same factor across all time points. Priority in symptom management was derived from a combination of severity and predictive power for quality of life (QoL)., Results: Two hundred thirty-nine patients participated at T0, 150 (63%) at T1, 102 (43%) at T2, and 45 (19%) at T3. We identified three stable SC, composed of rest-tired-weak-dyspnea-loss of appetite (exhausted), tense-worried-irritable-depressed (affective), and nausea-vomiting (gastrointestinal). Fatigue was most persistent and also most severe and predictive for QoL, both as symptom and in cluster (exhausted)., Conclusion: Given its high stability, severity, and impact on QoL, fatigue should have priority in symptom management. The treatment of this symptom could be enhanced by also incorporating interventions addressing dyspnea and loss of appetite., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: Attachment insecurity refers to difficulty in trusting and relying on others in times of need. Its underlying factors attachment anxiety and attachment avoidance have been empirically associated with impaired coping in advanced cancer and, therefore, should be considered in individually tailored medical and psychosocial treatment., Objectives: The objective of this study was to evaluate the psychometric properties of the German translation of the Brief Experiences in Close Relationships Scale (ECR-M16-G)., Methods: We recruited 182 advanced cancer patients from outpatient psycho-oncology clinics of the University Medical Center Hamburg-Eppendorf and the University Medical Center Leipzig, local and external cancer care facilities. We performed confirmatory factor analysis to replicate the higher order factor structure reported in previous research. We conducted item and reliability analysis, also correlation analysis, to examine concurrent validity., Results: One hundred fifty-eight patients completed the ECR-M16-G (women 61%, mean age 57.9, SD = 11.1). We replicated the factor structure with the subscales Attachment Anxiety and Attachment Avoidance as second-order factors and Worrying about relationships, Frustration about unavailability, Discomfort with close others, and Turning away from others as first-order factors. An adjusted model that interchanged factor loadings of items 4 and 10 showed good fit (Comparative Fit Index = 0.94, Non-Normed Fit Index = 0.93, root mean square error of approximation = 0.05). Subscales showed acceptable to good internal consistency (anxiety α = .81 and avoidance α = .78). Attachment insecurity (mean = 3.1, SD = 1.0) was positively associated with depression, anxiety, demoralization (P < 0.001), and symptom burden (P = 0.02) and negatively associated with spiritual well-being (P < 0.001)., Conclusion: The ECR-M16-G is a valid and reliable measure of attachment insecurity in patients with advanced cancer and can be recommended as a tool for clinical care and further research., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Aim of the study was to provide information about the prevalence of cancer related fatigue and the association between treatment-related factors and fatigue in cancer patients during the rehabilitation care. In a multicenter study 693 cancer patients (27% breast cancer, 17% prostate cancer etc.) completed the Multidimensional Fatigue Inventory (MFI-20) and sociodemographic and treatment information was noted. 51% of the patients suffer from fatigue (n=356). Fatigue prevalence differed according to tumour localization (p≤0.001). There was a substantial association between fatigue and treatment condition in terms of the combination of surgery and radiation (p≤0.05). Fatigue was high prevalent in patients in the rehabilitation care. Thus, fatigue should be routinely screened and after differentiated diagnostics be considered in rehabilitation care plans., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenskonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Demoralization refers to a state in which there is a perceived inability to cope, that is associated with a sense of disheartenment and a loss of hope and meaning. This study investigated the co-occurrence versus independence of demoralization with mental disorders and suicidal ideation to evaluate its features as a concept of distress in the context of severe illness., Methods: In a cross-sectional sample of 430 mixed cancer patients, we assessed demoralization with the Demoralization Scale (DS); the 4-week prevalence of mood, anxiety, and adjustment disorders and suicidal ideation with the standardized Composite International Diagnostic Interview-Oncology (CIDI-O); and depressive symptoms with the Patient Health Questionnaire-9 (PHQ-9). We compared the relative risk (RR) for mental disorders associated with demoralization to that associated with self-reported depression., Results: Clinically relevant levels of demoralization were present in 21% of the patients. Demoralization co-occurred with a mood/anxiety disorder in 7%; 14% were demoralized in absence of any mood/anxiety disorder. Demoralization and adjustment disorders co-occurred in 2%. The RR for any mood/anxiety disorder was 4.0 in patients with demoralization (95% confidence interval [CI], 2.5-6.2) and 3.0 in those with depression (95% CI, 1.9-4.6). Demoralization, but not depression, was associated with a significantly increased risk for suicidal ideation after controlling for mental disorders (RR, 2.0; 95% CI, 1.1-3.5)., Conclusions: Clinically relevant demoralization frequently occurs independently of a mental disorder in patients with cancer and has a unique contribution to suicidal ideation. Demoralization is a useful concept to identify profiles of psychological distress symptoms amenable to interventions improving psychological well-being in this population. Cancer 2017;123:3394-401. © 2017 American Cancer Society., (© 2017 American Cancer Society.)

Background: In this prospective multicenter study, we investigated cancer-and-treatment-specific distress (CTXD) and its impact on symptoms of posttraumatic stress disorder (PTSD) in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT)., Methods: Patients were consulted before (T0, N = 239), 3 (T1, N = 150), and 12 months (T2, N = 102) after HSCT. Medical (eg, diagnosis and pretreatment) and demographic information, CTXD and PTSD (PCL-C) were assessed., Results: Random intercept models revealed that the sum score of CTXD was highest pre-HSCT (T0), decreased by T1 (γ = -.18, 95% CI [-.26/-.09]), and by T2 (γ = -.10, 95% CI [-.20/-.00]). Uncertainty, family strain, and health burden were rated most distressing during HSCT. Uncertainty and family strain decreased from T0 to T1 (γ = -.30, 95% CI [-.42/-.17]; γ = -.10, 95% CI [-.20/-.00]) and health burden from T1 to T2 (γ = -.21, 95% CI [-.36/.05]). Women were more likely to report uncertainty (γ = .38, 95% CI [.19/.58]), family strain (γ = .38, 95% CI [.19/.58]), and concerns regarding appearance and sexuality (γ = .31, 95% CI [.14/.47]) than men. Uncertainty (γ = .18, 95% CI [.12/.24]), appearance and sexuality (γ = .09, 95% CI [.01/.16]), and health burden (γ = .21, 95% CI [.14/.27]) emerged as predictors of PTSD symptomatology across the 3 assessment points., Conclusions: Our data provide first evidence regarding the course of 6 dimensions of CTXD during HSCT and their impact on PTSD symptomatology. Specifically, results emphasize the major burden of uncertainty pre-HSCT and the impact of uncertainty and concerns regarding appearance and sexuality on PTSD symptomatology., (Copyright © 2016 John Wiley & Sons, Ltd.)

Objectives Breaking bad news can be a very distressing situation for both patients and physicians. Physician communication behavior should therefore match patients' communication preferences. The aim of this study was to characterize the content of bad news from the patients' perspective. Patients' preferences for communication of bad news as well as the fit to communication behavior displayed by physicians were also investigated. Finally, consequences of a mismatch between patients' preferences and physician communication were investigated in relation to psychological distress in patients. Methods The sample consisted of N=270 cancer patients (mean age=56.8 years, 48% female) with various cancer entities and different stages of disease (n=115 patients with early stage of cancer, n=155 patients with advanced cancer). The content of bad news was assessed with a specifically developed list of questions. The Measure of Patients' Preferences Scale (MPP) was used to assess patients' preferences for communication of bad news. Patients further completed the NCCN Distress Thermometer (cancer specific distress), the Hospital Anxiety and Depression Scale (HADS- anxiety and depression) and the Demoralization Scale (DS-Scale) to gain information about psychological distress. Results Patients with early stage breast cancer received bad news M=1.6 times (SD=1.1, range: 1-5), patients with advanced cancers M=2.1 times (SD=1.6, range: 1-12). For 77% of early stage cancer patients and 70% of advanced cancer patients, the subjectively worst consultation was receiving the diagnosis and discussing treatment options. Patients' most important communication preferences were physicians' clinical competence and patient-centered communication, clear and direct communication and asking about patients information preferences. Patients in advanced stages report significantly more (29%) unmet communication needs than patients' in early stages (20%; p<0.01). Breaking bad news without considering patients' preferences was associated with higher psychological distress in patients. Conclusion Physicians should communicate in a patient-centered way to reduce mismatch with patients' preferences and thereby potentially reduce patients' psychological distress., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: Although one-third of cancer patients are perceived to have a need for psychological support based on the percentage of mental disorders, little is known about the actual utilization of psychological care in cancer. We aimed to assess cancer patients' reported use of psychological care and its correlates in a large, representative sample., Methods: In a multicenter, cross-sectional study in Germany, 4020 cancer patients (mean age 58 years, 51% women) were evaluated. We obtained self-reports of use of psychotherapy and psychological counseling. We measured distress with the Distress Thermometer, symptoms of depression with the Patient Health Questionnaire, anxiety with the Generalized Anxiety Disorder Scale, and social support with the Illness-specific Social Support Scale. In a subsample of 2141, we evaluated the presence of a mental disorder using the Composite International Diagnostic Interview., Results: In total, 28.9% (95% confidence interval 27.4%-30.4%) reported having used psychotherapy or psychological counseling or both because of distress due to cancer. Independent correlates of utilization included age (odds ratio [OR] = 0.97 per year], sex (male, OR = 0.55), social support (OR = 0.96), symptoms of depression (OR = 1.04) and anxiety (OR = 1.08), the diagnosis of a mental disorder (OR = 1.68), and a positive attitude toward psychosocial support (OR = 1.27). Less than half of those currently diagnosed with a mental disorder reported having taken up psychological support offers., Conclusion: Special efforts should be made to reach populations that report low utilization of psychological care in spite of having a need for support., (Copyright © 2016 John Wiley & Sons, Ltd.)

Purpose: With increasing age at pregnancy, the likelihood of cancer affecting a family with children under 18 is rising and the issue of parents with cancer is gaining importance. Here, we examined the level of anxiety and depression, social support, and partnership satisfaction of cancer patients with children under 18 years and their partners as well as the dyadic patient-partner relationship concerning psychological distress and predictor variables., Methods: We used a longitudinal survey, recruiting patients with children under legal age and their partners (t1 = post therapy, t2 = 6 months after t1, t3 = 12 months after t1). Patients and partners completed the Hospital Anxiety and Depression Scale (HADS), the Oslo 3-item Social Support Scale (OSS-3), and the Abbreviated Dyadic Adjustment Scale (ADAS). We surveyed 161 cancer patients and 115 partners by mail (t1). Anxiety and depression were compared to German normative data. Dyadic relationships of three variables (social support, partnership satisfaction, and employment) and the psychological distress of 81 patient-partner dyads were analyzed with a structural equation model to estimate the actor-partner interdependence model., Results: After cancer therapy, 28.3 % of the patients and 46.2 % of their partners had moderate to high levels of anxiety and 17.9 % and 23.1 % had moderate to high levels of depression, respectively. Partners' levels of anxiety (p = 0.002) and depression (p = 0.018) had decreased significantly over the 1-year period post therapy. We found no changes in patients' anxiety (p = 0.444) and depression (p = 0.636) over time. Anxiety and depression did not differ on pair level (p = 0.120-0.928). The level of anxiety in patients and partners was significantly higher than that in the general population (p < 0.001-0.006). The analyses of the dyadic relationships showed a positive effect of social support on psychological distress of the patient (beta = -0.206, p < 0.2). Social support (beta = -0.448, p < 0.001), employment (beta = -0.509, p < 0.01), and satisfaction with partnership (beta = -0.448, p < 0.001) showed a positive impact on psychological well-being of the partner., Conclusions: A cancer experience within a family is a large burden for both patients and partners, highlighting the high incidence of anxiety. The results indicate that couples coping with cancer tend to react as an emotional system rather than as individuals. Patients' reintegration in employment is as important as encouraging partners in their working activities. The findings underline the importance of continuing social support for patients and their partners.

Background: Outpatient psychosocial cancer care has gained importance in recent years and psychosocial counselling services (PCS) offer a broad spectrum of counselling interventions. Yet there is no published research on PCS legal counselling services. This study investigated the range of issues addressed by legal counselling and their relationship with characteristics of advice seekers and counsellors., Methods: We analyzed the records of 21 PCS funded by the German Cancer Aid (DKH) including 5203 advice seekers (80 % patients, 20 % others including friends and family; age ∅ 54 years; 24 % male) in 20,947 counselling sessions. We calculated descriptive statistics and binary logistic regression analyses (legal counselling: yes/no)., Results: Fifty-five percent of counselling seekers received legal counselling and 28 % approached the PCS exclusively for legal counselling. The proportion of people seeking legal advice ranged from 15 to 87 % between counselling centers. The most common topics during legal counselling were medical rehabilitation programs (57 %) and disability law (43 %). Counselling occurred in a single session in 68 % of cases and was mostly sought by older and unemployed persons with a recent diagnosis. Legal counselling made up 18 % of counselling time. Legal advice was mostly given by social workers (71 %)., Conclusions: Legal counselling is a major part of psychosocial care services. Our results reveal large differences between counselling centers. Further research on quality of care and efficacy of legal counseling is needed.

Context: Distress and anxiety about issues related to death and dying is commonly experienced in patients with advanced disease and a limited life expectancy., Objectives: To evaluate the psychometric properties of the German version of the Death and Dying Distress Scale (DADDS-G) in advanced cancer patients., Methods: We recruited advanced patients with mixed tumor entities (Union for International Cancer Control [UICC] Stage III/IV) treated in two German University Medical Centers during their outpatient treatment. After testing a preliminary version of the state-of-the-art translated original Death and Dying Distress Scale, we analyzed the psychometric properties of the shortened nine-item adapted DADDS-G using validated instruments measuring distress, anxiety, depression, fear of progression, and quality of life., Results: We obtained complete questionnaires from 77 of 93 patients with advanced cancer (response rate: 83%). Participants were mostly married or cohabiting (75%), well-educated, and both sexes were almost equally represented (52% men; mean age 58 years, SD = 12). The total mean DADDS-G score was 13.3 (SD = 8.5). Patients reported to be most distressed by the feeling of being a burden to others. The exploratory factor analysis led to one factor that accounted for more than 59% of the variance. The DADDS-G's internal consistency was excellent with Cronbach alpha = 0.91. The confirmatory factor analysis demonstrated a very good model fit. Death-related anxiety was significantly associated with distress, depression, anxiety, fear of progression, and lower quality of life (P < 0.001)., Conclusion: Results provide further evidence that the DADDS-G is a valid and reliable instrument of high clinical relevance for use in patients with advanced cancer., (Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Outpatient psychosocial counselling (OPC) centers for those affected by cancer fulfill 2 main purposes: (a) to offer low-threshold psychological, social and legal counselling, and (b) to refer clients to other services. Here we report findings from a user-based assessment of OPC in the state of Saxony, Germany. This study was funded in part by the Saxon State Ministry of Social Affairs and Consumer Protection. We used a paper-based questionnaire to survey 213 clients of OPC in Saxony at 2 points (t1: up to one week after first contact, t2: 4 months after t1). All participants were cancer patients. The survey assessed utilization of services, depressive symptoms (PHQ-9), anxiety (GAD-7), quality of life (SF-8) as well as clients' satisfaction with the counselling service (ZUF-8). The majority of clients (81%) were referred to the OPC from a hospital or rehabilitation center. 46% of patients only had one contact. 78% of counselling sessions treated matters of social law. Patients suffered from 13 problems on average, the most common being fatigue and exhaustion, worries, anxiety, uncertainty about the future, and pain. Half the patients (49%) reported moderate to severe anxiety and 68% showed elevated levels of depressive symptoms. Psychosocial distress did not change significantly over time (GAD-7: p=0.580, PHQ-9: p=0.101). Patients' quality of life was low overall (cut-off<50). At t2, quality of life had particularly increased in physical aspects, but overall quality of life remained lower than in the general population (all subscales: p<0.05). We identified younger age and lower income as risk factors for higher psychosocial distress and lower quality of life. Patients were very satisfied with the counselling they received, 9% reported to be dissatisfied. Our results show that psychosocial distress remains high over a longer period of time at least for some patients. This illustrates the persisting need for long-term support regarding physical, mental and social impairments as a consequence of cancer and its treatments. It also shows the challenging demands which OPC centers are faced with. As a consequence, psychosocial support in the outpatient setting needs to be extended and developed further., (© Georg Thieme Verlag KG Stuttgart · New York.)

Context: Hopelessness is a clinically important construct in patients with advanced illness., Objectives: To evaluate the dimensionality, stability, and validity of the Beck Hopelessness Scale (BHS) in cancer patients receiving either curative or palliative treatment., Methods: Following a longitudinal design, we assessed a sample of cancer patients receiving either curative or palliative treatment (N = 315) at baseline and at follow-up after 12 months (N = 158). In addition to hopelessness, we measured depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder-7), and health-related quality of life (Short-Form Health Survey-8). We analyzed dimensionality, stability, and construct validity of the BHS using confirmatory factor analysis, exploratory factor analysis and correlational analysis., Results: Independent of treatment intention, confirmatory factor analyses resulted in unsatisfactory model fits. Exploratory factor analysis yielded a two-factor solution in both groups receiving curative or palliative treatment. Factor 1 reflected pessimistic/resigned beliefs (Cronbach alpha ≥ 0.85), Factor 2 reflected positive beliefs toward the future (Cronbach alpha = 0.73). Both subscales showed significant associations with anxiety, depression, and decreased health-related quality of life. The factorial structure was partially replicated in patients being reexamined after 12 months (CMIN/DF = 2.130, Standardized Root Mean Square Residual = 0.0716, Comparative Fit Index = 0.904, Tucker-Lewis-Index = 0.883, Root Mean Square Error of Approximation = 0.085). Hopelessness scores were significantly higher in patients reporting suicidal ideation according to the Patient Health Questionnaire-9., Conclusion: Our study demonstrates psychometric limitations of the BHS in patients receiving both curative and palliative treatment, suggesting reduced utility in cancer populations. Given the clinical importance of the construct, a cancer-specific approach to capture the unique meaning of hopelessness in patients with severe medical illness is recommended., (Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate stigmatizing attitudes towards cancer patients in the general population and to examine their association with socio-structural characteristics and perceived causes of disease., Methods: We recruited a representative sample from the German general population (n=2420; mean age: 52 years; 54% women). Stigmatizing attitudes were assessed with a 9-item scale. Predictors of stigmatizing attitudes were identified using a regression analysis., Results: Agreement with stigmatization items ranged from 3.6% (item: work together with a cancer patient) to 18.9% (item: use the same dishes as a cancer patient). Perceived causes of disease with a high levels of personal responsibility showed only weak correlations with stigmatizing attitudes (all r<0.31) and were partially statistical significant (e. g. food intake) or not significant (e. g. alcohol). The strongest predictors of stigmatizing attitudes were lack of cancer-related experiences (Beta=-0,26), age <60 years (Beta=0,1) and the assumption that one cannot protect oneself from cancer (Beta=0,11) (all p<0.001). Further predictors were male gender and living in rural area (p<0.01)., Conclusion: The results demonstrate a need for further research and the development of valid methodological instruments to assess stigmatization towards cancer patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The Patient Health Questionnaire PHQ-9 is a widely used instrument to screen for depression in clinical research. The first aim of this study was to psychometrically test the PHQ-9 in a large sample of cancer patients. The second aim was to calculate unbiased estimates of the depression burden for several cancer groups taking into account age and gender distributions., Methods: A sample of 2,059 cancer patients with varying diagnoses were examined in this study six months after discharge from a rehabilitation clinic. A representative sample of 2,693 people from the general population served as controls. Expected PHQ-9 mean scores of the general population sample, regressed on age and gender, were calculated to enable a fair comparison of different groups of cancer patients., Results: While the reliability (Cronbach's alpha) for the PHQ-9 scale was good (alpha ≥ 0.84), the CFA fit indices of the one-dimensional solution were unsatisfactory in the patients' sample. The factorial analysis confirmed two factors. PHQ-9 mean scores for 15 types of cancer are given, ranging from 4.0 (prostate) to 8.2 (thyroid gland). Differences between expected mean scores (derived from the general population) and raw mean scores of the cancer subsamples are reported that provide a better estimate of the depression burden., Conclusions: The results confirmed that the PHQ-9 performs well in testing depression in cancer patients. Regression coefficients can be used for performing unbiased comparisons among cancer groups, not only for this study. The burden of patients with testis cancer and Hodgkin lymphoma is underestimated when age and gender are not taken into account.

Objective: Although elevated levels of distress are supposed to constitute a need for psychosocial support, the relation between elevated distress and need for support does not appear to be straightforward. We aimed to determine cancer patients' perceived need for psychosocial support, and examine the relation of need to both self-reported emotional distress and the interview-based diagnosis of a mental disorder., Methods: In a multicenter, cross-sectional study in Germany, 4020 cancer patients (mean age 58 years, 51% women) were evaluated. We obtained self-reports of need for psychosocial support. We measured distress with the National Comprehensive Cancer Network (NCCN) Distress Thermometer (DT) and depressive symptoms with the Patient Health Questionnaire (PHQ-9). In a subsample, we evaluated the presence of a mental disorder using the Composite International Diagnostic Interview (CIDI)., Results: 32.1% (95%-CI 30.6 to 33.6) of patients perceived a need for psychosocial support. Younger age, female sex, and higher education were associated with more needs, being married and living with a partner with fewer needs, respectively. While up to 51.2% of patients with elevated distress levels reported a need for psychosocial support, up to 26.1% of those without elevated distress levels perceived such a need. Results were similar across distress assessment methods., Conclusion: Our findings emphasize that the occurrence of mental distress is one important but not an exclusive factor among different motives to report the need for psychosocial support. We should thus consider multifaceted perspectives, facilitators and barriers when planning and implementing patient-centered psychosocial care services., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Information needs in cancer patients are high but often not fulfilled. This study aimed to examine the level of perceived information, information satisfaction, and unmet needs in a large sample of cancer patients. Further, we explored associations with emotional distress and quality of life accounting for gender., Methods: In a multicenter, cross-sectional study in Germany, 4020 cancer patients (mean age 58 years, 51 % women) were evaluated. We obtained self-reports of information level, information satisfaction, and unmet needs, measured depressive symptoms with the Patient Health Questionnaire (PHQ-9), symptoms of anxiety with the Generalized Anxiety Disorder Scale (GAD-7), and health-related quality of life with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30)., Results: Seventy-two to 88 % of participants reported to be well informed regarding various aspects of their disease, except of psychological support (38 %). However, unmet information needs were also prevalent in 36 to 48 %. Gender differences found were generally small. Although men felt less informed about psychological support, they expressed fewer needs for further information regarding this topic. Irrespective of gender, patients who were less satisfied with information received and had more unmet needs reported more anxiety, depression, and lower quality of life. Up to three quarters of those classified as most severely distressed reported unmet needs for information about psychological support., Conclusions: In this largest study to date, we found high levels of both information received and satisfaction with information, but also considerable amounts of unmet needs, particularly regarding psychological support., Implications for Cancer Survivors: Provision of information about psychosocial support seems important to increase utilization of support offers among distressed cancer survivors.

Background: We aimed to investigate type and frequency of stressors, predominant symptom profiles, and predictors of adjustment disorders (AD) in cancer patients across major tumor entities., Methods: In this epidemiological study, we examined 2,141 cancer patients out of 4,020 screened with the Composite International Diagnostic Interview, adaptation for oncology (CIDI-O). AD were operationalized as subthreshold disorders according to DSM-IV criteria., Results: In our sample, 265 out of 2,141 patients (12.4%) met all criteria for AD (unweighted 4-week prevalence). The disclosure of the cancer diagnosis, relapse or metastases, and cancer treatments were most frequently described as stressors associated with depressive or anxious symptoms. With regard to AD symptom profiles, patients showed high prevalence rates of affective symptoms according to the DSM-IV criteria of Major Depression: The highest prevalence rates were found for cognitive disturbances (concentration and memory problems) (88%), sleeping disturbances (86%), and depressive mood (83%). We found sex, education, and metastasis as significant predictors for AD. Higher education was the most influential predictor. Men were half as likely to report symptoms fulfilling the AD criteria as women. Patients with metastasized tumors had a more than 80% higher risk of AD than those without metastasis. However, the explained variance of our model is very small (Nagelkerke's R² = 0.08)., Conclusions: Patients with AD can be identified using a standardized instrument and deserve clinical attention, as they often show severe clinical symptoms and impairments. Improving the clinical conceptualization of AD by the adding-on of potential stress-response-symptoms is necessary to identify severe psychological strain., (© 2015 Wiley Periodicals, Inc.)

Background: Psychological problems are common in cancer patients. For the purpose of planning psycho-oncological interventions and services tailored to the specific needs of different cancer patient populations, it is necessary to know to what extent psychological problems meet the criteria of mental disorders. The purpose of this study was to estimate the 12-month and lifetime prevalence rates of mental disorders in cancer patients., Methods: A representative sample of patients with different tumour entities and tumour stages (n = 2,141) in outpatient, inpatient and rehabilitation settings underwent the standardized computer-assisted Composite International Diagnostic Interview for mental disorders adapted for cancer patients (CIDI-O)., Results: The overall 12-month prevalence for any mental disorder was 39.4% (95% CI: 37.3-41.5), that for anxiety disorders was 15.8% (95% CI: 14.4-17.4), 12.5% (95% CI: 11.3-14.0) for mood disorders, 9.5% (95% CI: 8.3-10.9) for somatoform disorders, 7.3% (95% CI: 6.2-8.5) for nicotine dependence, 3.7% (95% CI: 3.0-4.6) for disorders due to general medical condition, and 1.1% (95% CI: 0.7-1.6) for alcohol abuse or dependence. Lifetime prevalence for any mental disorder was 56.3% (95% CI 54.1-58.6), that for anxiety disorders was 24.1% (95% CI: 22.3-25.9), 20.5% (95% CI: 18.9-22.3) for mood disorders, 19.9% (95% CI: 18.3-21.7) for somatoform disorders, 18.2% (95% CI: 16.6-20.0) for nicotine dependence, 6.4% (95% CI: 5.4-7.6) for alcohol abuse or dependence, 4.6% (95% CI: 3.8-5.6) for disorders due to general medical condition, and 0.2% (95% CI: 0.1-0.6) for eating disorders., Conclusions: Mental disorders are highly prevalent in cancer patients, indicating the need for provision of continuous psycho-oncological support from inpatient to outpatient care, leading to an appropriate allocation of direct personnel and other resources., (© 2016 S. Karger AG, Basel.)

Psychosocial cancer counseling centers represent an increasingly important part of comprehensive psychosocial cancer care. Research on the services provided by those centers is sparse, however, as is research on person-, disease-, and treatment-related characteristics of their clients. Therefore, the present study analyzes the services provided by 26 psychosocial cancer counseling centers temporarily being funded by the German Cancer Aid as well as selected characteristics of their clients. Analyses are based on data collected during 2011 by means of a documentation system specifically designed for the purposes of psychosocial cancer counseling. Testing focuses on whether cancer patients and cancer patients' relatives differ with respect to various characteristics and the services used. The results show that psychosocial and benefit counseling represent a major part of counseling services, followed by giving information and employing relaxation techniques. Clients seek counseling primarily in early phases of disease and treatment. Women with breast cancer are over-represented among clients. Analyses also reveal significant differences between cancer patients and patients' relatives. Psychotherapeutic interventions and grief-counseling are more frequent in counseling relatives, whereas benefit counseling is more frequent in working with patients. The results emphasize the relevance of outpatient psychosocial cancer counseling. They may also help support initiatives aiming at establishing psychosocial cancer counseling targeted to the needs of each individual client., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose and Methods: We investigated the relationship between fear of cancer recurrence (FCR), anxiety, supportive care needs, and utilization of health-care services in a mixed sample of 335 cancer patients. We used validated questionnaires including the Fear of Progression Questionnaire-Short Form (FoP-Q-SF), the General Anxiety Disorder Scale (GAD-7) and the Supportive Care Needs Survey (SCNS-SF34). Health-care services utilization was measured by a self-constructed questionnaire recording the use of 22 health and supportive care offers., Results: In our sample, 3.9% of patients were classified as having high anxiety and 5.1% had high FCR. Patients reported the highest unmet supportive care needs in the domain health system and information followed by psychological needs. Integrated care and complementary support services were the most frequently used (32%) followed by medical (31%), psychological (23%), spiritual and religious (8%) and other support services (9%). Whereas anxiety was related to both unmet psychological and physical/daily living needs (p < 0.01), FCR was associated with unmet supportive care needs in all five domains further including needs with regard to health system and information, patient care, and sexuality (p < 0.01). However, higher levels of anxiety and FCR were not related to higher utilization of health-care services., Conclusion: Our findings show that FCR plays a significant role in unmet supportive care needs in cancer patients but not for health-care service utilization., Implications for Cancer Survivors: We recommend that clinicians monitor supportive care needs in patients struggling with FCR and anxiety.