Publications by authors named "Annette J Berendsen"

40 Publications

Home-based Physical Activity to Alleviate Fatigue in Cancer Survivors: A Systematic Review and Meta-analysis.

Med Sci Sports Exerc 2021 Dec;53(12):2661-2674

Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, THE NETHERLANDS.

Purpose: Physical activity (PA) affects fatigue and mental health in cancer survivors favorably, but participation in PA interventions tends to be low. More participants may be reached by home-based PA owing to greater accessibility and self-monitoring. This systematic review therefore evaluated the effects of home-based PA of low to moderate intensity on symptoms of fatigue, depression, and anxiety among cancer survivors.

Methods: PubMed, CINAHL, PsycINFO, and Web of Science were systematically searched for randomized controlled trials. We included investigations of home-based PA interventions in adults treated curatively for cancer and evaluating fatigue, depression, or anxiety as outcomes. We performed a random-effect meta-analysis for the effects of PA interventions on fatigue in the short and long terms. Subgroup analyses were performed for the frequency of counseling. Standardized mean differences (SMD) and 95% confidence intervals are reported.

Results: Eleven articles comprising 1066 participants were included: 77% had a history of breast cancer; 14%, ovarian cancer; 4%, colorectal cancer; 4%, prostate cancer; and 1%, "other" cancer (not specified). Concerning the outcomes, nine articles reported on fatigue and two reported on depression or anxiety. Meta-analyses showed a significant effect of home-based PA on fatigue immediately after the intervention (SMD = 0.22 [0.06-0.37]), at 3 months' follow-up (SMD = 0.27 [0.04-0.51]), and at 6-9 months' follow-up (SMD = 0.31 [0.08-0.55]). PA interventions that used frequent counseling were associated with larger improvements in fatigue than those using no or infrequent counseling.

Conclusions: Home-based PA interventions can reduce fatigue among adult cancer survivors for up to 9 months, and frequent counseling may improve the benefits of these interventions.
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http://dx.doi.org/10.1249/MSS.0000000000002735DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8594505PMC
December 2021

Fatigue among Long-Term Breast Cancer Survivors: A Controlled Cross-Sectional Study.

Cancers (Basel) 2021 Mar 15;13(6). Epub 2021 Mar 15.

Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, PO Box 196, 9700 AD Groningen, The Netherlands.

Background: Fatigue is the most common and persistent symptom among women in the first five years after a breast cancer diagnosis. However, long-term prevalence of fatigue, among breast cancer survivors, needs further investigation.

Aim: To compare fatigue experienced by long-term breast cancer survivors with that in a reference population and to evaluate the determinants of that fatigue.

Design And Setting: A cross-sectional cohort study of 350 breast cancer survivors ≥5 years after diagnosis and a reference population of 350 women matched by age and general practitioner.

Method: Fatigue was measured using the Multidimensional Fatigue Inventory (MFI-20), and a sum score of >60 (multidimensional fatigue) was the primary outcome. Logistic regression was applied to compare the prevalence of multidimensional fatigue between the survivor and reference populations, adjusted for body mass index (BMI) and for cardiovascular and psychological variables. Odds ratios (ORs) and 95% confidence intervals (95%CIs) were estimated. Logistic regression was applied to evaluate the determinants of multidimensional fatigue among the survivors.

Results: Breast cancer survivors (median 10 years after diagnosis), more often experienced multidimensional fatigue than the reference population (26.6% versus 15.4%; OR, 2.0 [95%CI, 1.4-2.9]), even after adjusting for confounders. The odds of multidimensional fatigue were also higher among survivors with symptoms of depression (32.2% versus 2.7%; OR, 17.0 [95%CI, 7.1-40.5]) or anxiety (41.9% versus 10.1%; OR, 6.4 [95%CI, 3.6-11.4]).

Conclusion: One in four breast cancer survivors experience multidimensional fatigue and fatigue occurs more frequently than in women of the same age and general practitioner. This fatigue appears to be associated with symptoms of depression and anxiety.
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http://dx.doi.org/10.3390/cancers13061301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8001130PMC
March 2021

Diagnostic accuracy of follow-up tests for detecting colorectal cancer recurrences in primary care: A systematic review and meta-analysis.

Eur J Cancer Care (Engl) 2021 Sep 11;30(5):e13432. Epub 2021 Mar 11.

Department of General Practice & Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

Introduction: Traditionally, follow-up of colorectal cancer (CRC) is performed in secondary care. In new models of care, the screening part care could be replaced to primary care. We aimed to synthesise evidence on the diagnostic accuracy of commonly used screeners in CRC follow-up applicable in primary care: carcinoembryonic antigen (CEA), ultrasound and physical examination.

Methods: Medline, EMBASE, Cochrane Trial Register and Web of Science databases were systematically searched. Studies were included if they provided sufficient data for a 2 × 2 contingency tables. QUADAS-2 was used to assess methodological quality. We performed bivariate random effects meta-analysis, generated a hypothetical cohort, and reported sensitivity and specificity.

Results: We included 12 studies (n = 3223, median recurrence rate 19.6%). Pooled estimates showed a sensitivity for CEA (≤ 5 μg/l) of 59% [47%-70%] and a specificity of 89% [80%-95%]. Only few studies reported sensitivities and specificities for ultrasound (36-70% and 97-100%, respectively) and clinical examination (23% and 27%, respectively).

Conclusion: In practice, GPs could perform CEA screening. Radiological examination in a hospital setting should remain part of the surveillance strategy. Personalised algorithms accounting for recurrence risk and changes of CEA-values over time might add to the diagnostic value of CEA in primary care.
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http://dx.doi.org/10.1111/ecc.13432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8518902PMC
September 2021

Adherence and Concordance between Serious Illness Care Planning Conversations and Oncology Clinician Documentation among Patients with Advanced Cancer.

J Palliat Med 2021 01 22;24(1):53-62. Epub 2020 Jun 22.

Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Serious illness conversations are part of advance care planning (ACP) and focus on prognosis, values, and goals in patients who are seriously ill. To be maximally effective, such conversations must be documented accurately and be easily accessible. The two coprimary objectives of the study were to assess concordance between written documentation and recorded audiotaped conversations, and to evaluate adherence to the Serious Illness Conversation Guide questions. Data were obtained as part of a trial in patients with advanced cancer. Clinicians were trained to use a guide to conduct and document serious illness conversations. Conversations were audiotaped. Two researchers independently compared audiorecordings with the corresponding documentation in an electronic health record (EHR) template and free-text progress notes, and rated the degree of concordance and adherence. We reviewed a total of 25 audiorecordings. Clinicians addressed 87% of the conversation guide elements. Prognosis was discussed least frequently, only in 55% of the patients who wanted that information. Documentation was fully concordant with the conversation 43% of the time. Concordance was best when documenting family matters and goals, and least frequently concordant when documenting prognostic communication. Most conversations (64%) were documented in the template, a minority (28%) only in progress notes and two conversations (8%) were not documented. Concordance was better when the template was used (62% vs. 28%). Clinicians adhered well to the conversation guide. However, key information elicited was documented and fully concordant less than half the time. Greater concordance was observed when clinicians used a prespecified template. The combined use of a guide and EHR template holds promise for ACP conversations.
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http://dx.doi.org/10.1089/jpm.2019.0615DOI Listing
January 2021

Prioritisation of treatment goals among older patients with non-curable cancer: the OPTion randomised controlled trial in Dutch primary care.

Br J Gen Pract 2020 07 25;70(696):e450-e456. Epub 2020 Jun 25.

Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.

Background: Older patients with cancer often find it difficult to take part in shared decision making.

Aim: To assess the utility of the Outcome Prioritisation Tool (OPT), designed to aid discussion with a patient in regards to their treatment goals, to empower patients with cancer through structured conversations about generic treatment goals with GPs.

Design And Setting: A randomised controlled trial of 114 Dutch participants recruited between November 2015 and January 2019, aged ≥60 years with non-curable cancer who had to make a treatment decision with an oncologist. The intervention group used the OPT while the control group received care as usual.

Method: The primary outcome was patient empowerment using the score on the decision self-efficacy (DSE) scale. Secondary outcomes were symptoms measures of fatigue, anxiety, and depression. The experiences of participants were also explored.

Results: No effect was found on patient empowerment between the OPT group ( = 48; DSE 86.8; standard deviation [SD] = 18.2) and the control group ( = 58; DSE 84.2; SD = 17.6; = 0.47). In the OPT group, although statistically non-significant, fewer patients had low empowerment (18.8%, = 9 versus 24.1%, = 14; P = 0.50), but they did have statistically significant lower mean anxiety scores (6.0, SD = 4.6 versus 7.6, SD = 4.4; P<0.05) and less mild fatigue (58.8%, = 30 versus 77.2%, = 44; = 0.05). Overall, 44.8% ( = 13) of patients indicated that the OPT-facilitated conversation helped them make a treatment decision, and 31.1% ( = 14) of the GPs reported that they gained new insights from the conversation.

Conclusion: An OPT-facilitated conversation about generic treatment goals between patients and their GPs is associated with less anxiety and fatigue, but did not show statistically significant improvements in patient empowerment. Adding the OPT to routine care might ensure more patient-tailored care.
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http://dx.doi.org/10.3399/bjgp20X710405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274544PMC
July 2020

Long-term survivors of early breast cancer treated with chemotherapy are characterized by a pro-inflammatory biomarker profile compared to matched controls.

Eur J Heart Fail 2020 07 20;22(7):1239-1246. Epub 2020 Feb 20.

Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

Background: Chemo- and radiotherapy for breast cancer (BC) can lead to cardiotoxicity even years after the initial treatment. The pathophysiology behind these late cardiac effects is poorly understood. Therefore, we studied a large panel of biomarkers from different pathophysiological domains in long-term BC survivors, and compared these to matched controls.

Methods And Results: In total 91 biomarkers were measured in 688 subjects: 342 BC survivors stratified either to treatment with chemotherapy ± radiotherapy (n = 170) or radiotherapy alone (n = 172) and matched controls. Mean age was 59 ± 9 years and 65 ± 8 years for women treated with chemotherapy ± radiotherapy and radiotherapy alone, respectively, with a mean time since treatment of 11 ± 5.5 years. No biomarkers were differentially expressed in survivors treated with radiotherapy alone vs. controls (P for all >0.1). In sharp contrast, a total of 19 biomarkers were elevated, relative to controls, in BC survivors treated with chemotherapy ± radiotherapy after correction for multiple comparisons (P <0.05 for all). Network analysis revealed upregulation of pathways relating to collagen degradation and activation of matrix metalloproteinases. Furthermore, several inflammatory biomarkers including growth differentiation factor 15, monocyte chemoattractant protein 1, chemokine (C-X-C motif) ligand 16, tumour necrosis factor super family member 13b and proprotein convertase subtilisin/kexin type 9, elevated in survivors treated with chemotherapy, showed an independent association with lower left ventricular ejection fraction.

Conclusion: Breast cancer survivors treated with chemotherapy ± radiotherapy show a distinct biomarker profile associated with mild cardiac dysfunction even 10 years after treatment. These results suggest that an ongoing pro-inflammatory state and activation of matrix metalloproteinases following initial treatment with chemotherapy might play a role in the observed cardiac dysfunction in late BC survivors.
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http://dx.doi.org/10.1002/ejhf.1758DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540448PMC
July 2020

Using the Outcome Prioritization Tool (OPT) to assess the preferences of older patients in clinical decision-making: A review.

Maturitas 2019 Oct 30;128:49-52. Epub 2019 Jul 30.

University of Groningen, University Medical Center Groningen, Department of General Practice and Elderly Care Medicine, the Netherlands.

Shared decision making can guide patients facing difficult treatment decisions, with a trade-off between risks and benefits, taking patient goals and preferences into account. The Outcome Prioritization Tool (OPT) was developed to facilitate the discussion of goals and preferences with older patients in an encompassing, non-disease-specific way. The OPT is used in both primary and secondary healthcare for several treatment decisions, but data regarding the tool are limited. A concise review yielded two developmental articles, four articles describing three studies using the OPT, and one study protocol. All studies were performed among older patients. In those studies, the majority of patients ranked maintaining independence as most important. The tool has been shown to be feasible for both patients and healthcare providers.
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http://dx.doi.org/10.1016/j.maturitas.2019.07.022DOI Listing
October 2019

[Correspondence between primary and secondary healthcare providers about patients with cancer; how can it be improved?]

Ned Tijdschr Geneeskd 2019 05 31;163. Epub 2019 May 31.

Rijksuniversiteit Groningen-Universitair Medisch Centrum Groningen, afd. Huisartsgeneeskunde, Groningen.

Objective: To explore the correspondence between primary and secondary healthcare providers about patients with lung, breast or colorectal cancer.

Design: Qualitative research.

Method: We collected the medical files of 50 patients with lung, breast or colorectal cancer by purposive sampling and selected the correspondence-related items from them. These concerned referral letters from primary to secondary caregivers and letters from specialists. A qualitative content analysis of these documents was performed. In addition, 4 general practitioners, 4 oncologists and 1 nurse specialist were interviewed.

Results: We analysed 50 referral letters and 369 letters from specialists. Content could be divided into 6 main themes in the referral letters, and it was noticeable that highly relevant information regarding the past medical history was often mixed with less relevant information. The same was true for the medication list and case history to a certain extent. We could distinguish 9 themes in the letters from specialists. All the letters from specialists did include information about the current treatment, but information about treatment intent (curative or palliative) or alternative treatment options was rarely available. Interviews with the healthcare providers confirmed these findings.

Conclusion: The study findings indicate that referral letters and specialist correspondence are not sufficiently tailored to the needs of the recipient.
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May 2019

Cardiac Function After Radiation Therapy for Breast Cancer.

Int J Radiat Oncol Biol Phys 2019 06 11;104(2):392-400. Epub 2019 Feb 11.

Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. Electronic address:

Purpose: The main purpose of this study was to test the hypothesis that incidental cardiac irradiation is associated with changes in cardiac function in breast cancer (BC) survivors treated with radiation therapy (RT).

Methods And Materials: We conducted a cross-sectional study consisting of 109 BC survivors treated with RT between 2005 and 2011. The endpoint was cardiac function, assessed by echocardiography. Systolic function was assessed with the left ventricular ejection fraction (LVEF) (n = 107) and the global longitudinal strain (GLS) of the left ventricle (LV) (n = 52). LV diastolic dysfunction (n = 109) was defined by e' at the lateral and septal region, which represents the relaxation velocity of the myocardium. The individual calculated RT dose parameters of the LV and coronary arteries were collected from 3-dimensional computed tomography-based planning data. Univariable and multivariable analysis using forward selection was performed to identify the best predictors of cardiac function. Robustness of selection was assessed using bootstrapping. The resulting multivariable linear regression model was presented for the endpoints of systolic and diastolic function.

Results: The median time between BC diagnosis and echocardiography was 7 years. No relation between RT dose parameters and LVEF was found. In the multivariable analysis for the endpoint GLS of the LV, the maximum dose to the left main coronary artery was most often selected across bootstrap samples. For decreased diastolic function, the most often selected model across bootstrap samples included age at time of BC diagnosis and hypertension at baseline. Cardiac dose-volume histogram parameters were less frequently selected for this endpoint.

Conclusions: This study shows an association between individual cardiac dose distributions and GLS of the LV after RT for BC. No relation between RT dose parameters and LVEF was found. Diastolic function was most associated with age and hypertension at time of BC diagnosis. Further research is needed to make definitive conclusions.
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http://dx.doi.org/10.1016/j.ijrobp.2019.02.003DOI Listing
June 2019

A Qualitative Study of Serious Illness Conversations in Patients with Advanced Cancer.

J Palliat Med 2019 07 6;22(7):773-781. Epub 2019 Feb 6.

1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Conversations with seriously ill patients about their values and goals have been associated with reduced distress, a better quality of life, and goal-concordant care near the end of life. Yet, little is known about how such conversations are conducted. To characterize the content of serious illness conversations and identify opportunities for improvement. Qualitative analysis of audio-recorded, serious illness conversations using an evidence-based guide and obtained through a cluster randomized controlled trial in an outpatient oncology setting. Clinicians assigned to the intervention arm received training to use the "Serious Illness Conversation Guide" to have a serious illness conversation about values and goals with advanced cancer patients. Conversations were de-identified, transcribed verbatim, and independently coded by two researchers. Key themes were analyzed. A total of 25 conversations conducted by 16 clinicians were evaluated. The median conversation duration was 14 minutes (range 4-37), with clinicians speaking half of the time. Thematic analyses demonstrated five key themes: (1) supportive dialogue between patients and clinicians; (2) patients' openness to discuss emotionally challenging topics; (3) patients' willingness to articulate preferences regarding life-sustaining treatments; (4) clinicians' difficulty in responding to emotional or ambiguous patient statements; and (5) challenges in discussing prognosis. Data from this exploratory study suggest that seriously ill patients are open to discussing values and goals with their clinician. Yet, clinicians may struggle when disclosing a time-based prognosis and in responding to patients' emotions. Such skills should be a focus for additional training for clinicians caring for seriously ill patients.
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http://dx.doi.org/10.1089/jpm.2018.0487DOI Listing
July 2019

Cancer survivorship and palliative care: Shared progress, challenges, and opportunities.

Cancer 2018 12 11;124(23):4435-4441. Epub 2018 Sep 11.

Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1002/cncr.31723DOI Listing
December 2018

Effects of Shared Decision Making on Distress and Health Care Utilization Among Patients With Lung Cancer: A Systematic Review.

J Pain Symptom Manage 2018 12 24;56(6):975-987.e5. Epub 2018 Aug 24.

Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

Context: Lung cancer is associated with significant distress, poor quality of life, and a median prognosis of less than one year. Benefits of shared decision making (SDM) have been described for multiple diseases, either by the use of decisions aids or as part of supportive care interventions.

Objectives: The objective of this study was to summarize the effects of interventions facilitating SDM on distress and health care utilization among patients with lung cancer.

Methods: We performed a systematic literature search in the CINAHL, Cochrane, EMBASE, MEDLINE, and PsychINFO databases. Studies were eligible when conducted in a population of patients with lung cancer, evaluated the effects of an intervention that facilitated SDM, and measured distress and/or health care utilization as outcomes.

Results: A total of 12 studies, detailed in 13 publications, were included: nine randomized trials and three retrospective cohort studies. All studies reported on a supportive care intervention facilitating SDM as part of their intervention. Eight studies described effects on distress, and eight studies measured effects on health care utilization. No effect was found in studies measuring generic distress. Positive effects, in favor of the intervention groups, were observed in studies using anxiety-specific measures (n = 1) or depression-specific measures (n = 3). Evidence for reductions in health care utilization was found in five studies.

Conclusion: Although not supported by all studies, our findings suggest that facilitating SDM in the context of lung cancer may lead to improved emotional outcomes and less aggressive therapies. Future studies, explicitly studying the effects of SDM by using decision aids, are needed to better elucidate potential benefits.
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http://dx.doi.org/10.1016/j.jpainsymman.2018.08.011DOI Listing
December 2018

Correspondence between primary and secondary care about patients with cancer: A qualitative mixed-methods analysis.

Eur J Cancer Care (Engl) 2019 Jan 23;28(1):e12903. Epub 2018 Aug 23.

University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands.

Cancer care is complex and involves many different healthcare providers, especially during diagnosis and initial treatment, and it has been reported that both general practitioners and oncology specialists experience difficulties with interdisciplinary communication. The aim of this qualitative study was to explore information sharing between primary and secondary care for patients with lung, breast or colorectal cancer. A qualitative content analysis of 50 medical files (419 documents) was performed, which identified 70 correspondence-related items. Six main topics were identified in most referral letters from primary to secondary care, but it was particularly notable that highly relevant information regarding the past medical history was often mixed with less relevant information. To lesser extents, the same held true for the medication list and presenting history. In the letters from specialists, nine topics were identified in most letters. Although information about actual treatment was always present, only limited detail, if any, was given about the intent of the treatment (curative or palliative) or the treatment alternatives. Interviews with nine healthcare providers confirmed these issues. These findings indicate that neither the initial referral nor the specialist correspondence is tailored to the needs of the recipient.
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http://dx.doi.org/10.1111/ecc.12903DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6588262PMC
January 2019

Possible missed opportunities for diagnosing colorectal cancer in Dutch primary care: a multimethods approach.

Br J Gen Pract 2018 01 4;68(666):e54-e62. Epub 2017 Dec 4.

Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.

Background: Early detection of colorectal cancer (CRC) is important to achieve better survival. Discriminating symptoms suggestive of CRC from benign conditions is a challenge for GPs because most known 'alarm symptoms' have low predictive values.

Aim: To further understand the diagnostic process of CRC in general practice in terms of healthcare use and by analysing factors related to diagnostic intervals.

Design And Setting: A multimethod approach comprising a historical, prospective registry study and qualitative content analysis.

Method: Healthcare use in the year before referral for colonoscopy was compared between patients diagnosed with CRC and an age-, sex,- and GP-matched control population. Qualitative content analysis was performed on free texts in electronic patient records from a purposive sample of patients with CRC.

Results: Patients with CRC ( = 287) had 41% (25-59%) more face-to-face contacts and 21% (7-37%) more medication prescriptions than controls ( = 828). Forty-six per cent of patients with CRC had two or more contacts for digestive reasons, compared with 12.2% of controls, more often for symptoms than diagnoses. From qualitative analysis two themes emerged: 'possible missed diagnostic opportunities' and 'improvements in diagnostic process unlikely'. Possible missed diagnostic opportunities were related to patients waiting before presenting symptoms, doctors attributing symptoms to comorbid conditions or medication use, or doctors sticking to an initial diagnosis.

Conclusion: Fewer missed diagnostic opportunities might occur if GPs are aware of pitfalls in diagnosing CRC: the assumption that symptoms are caused by comorbid conditions or medication, or relating complaints to pre-existing medical conditions. GPs also need to be aware that repeated digestive complaints warrant rethinking an earlier diagnosis.
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http://dx.doi.org/10.3399/bjgp17X693905DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5737320PMC
January 2018

Long-term outcome of cardiac function in a population-based cohort of breast cancer survivors: A cross-sectional study.

Eur J Cancer 2017 08 8;81:56-65. Epub 2017 Jun 8.

University of Groningen, Department of General Practice, P.O. Box 196, 9700 AD Groningen, The Netherlands. Electronic address:

Background: Chemotherapy and radiotherapy for breast cancer may lead to cardiac dysfunction, but the prevalence of long-term echocardiographic evidence of cardiac dysfunction is unknown among survivors.

Methods: In a cross-sectional study in primary care, we included 350 women who survived breast cancer for at least 5 years after diagnosis (treated with chemotherapy and/or radiotherapy) and 350 matched women (age and primary care physician). The primary outcome was cardiac dysfunction, defined as a left ventricular ejection fraction (LVEF) < 54% and an age-corrected decreased left ventricular (LV) diastolic function. Secondary outcomes included serum N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, newly diagnosed cardiovascular diseases and cardiovascular medication.

Results: The median age at diagnosis was 63 (interquartile range (IQR) 57-68) years for the breast cancer survivors. Median follow-up after diagnosis was 10 (IQR 7-14) years. LVEF < 54% was present in 52 (15.3%) survivors and 24 (7%) controls (OR 2.4, 95%CI 1.4-4.0), but there was no significant increased prevalence of either LVEF < 50% or LV diastolic dysfunction. Serum NT-proBNP levels were increased, cardiovascular disease was more frequently diagnosed and cardiovascular medication use was more frequent among survivors compared with controls. These associations remained after adjustment for relevant covariates at diagnosis and at follow-up.

Conclusions: In the long term, breast cancer survivors are at increased risk of mild LV systolic dysfunction, increased NT-proBNP levels, and cardiovascular disease compared with matched controls, even after adjustment for cardiovascular risk factors. Previous breast cancer treatment with chemotherapy, radiotherapy or both should be considered when assessing a patient's cardiovascular risk profile.
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http://dx.doi.org/10.1016/j.ejca.2017.05.013DOI Listing
August 2017

Patients' views on general practitioners' role during treatment and follow-up of colorectal cancer: a qualitative study.

Fam Pract 2017 04;34(2):234-238

Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

Purpose: To clarify experiences and preferences of patients regarding the current and future role of GPs during treatment and follow-up care of colorectal cancer (CRC).

Methods: Qualitative semi-structured, audio-recorded, face-to-face interviews in patients' homes in the north of the Netherlands were performed. Patients were sampled purposively on age, gender, time since diagnoses and primary health care use. Data were transcribed verbatim and analysed thematically by two independent researchers until saturation was reached.

Results: Twenty-two patients were interviewed. GPs played a significant and highly valued role directly after surgery by proactively contacting their patients and offered support in clarification of medical issues, lifestyle advice and care for treatment-related side effects. During follow-up, GPs provided psychosocial support for patients and family members, besides routine health care. Concerning the organization of future follow-up care, most patients expressed a preference for specialist-led services; some said that primary care-led care would be more accessible and less expensive.

Conclusion: Although at present patients perceived their GP is involved in CRC care, they would prefer their follow-up care in a hospital setting. If, in line with recent insights, future follow-up care might become more relying on testing for markers instead of imaging, there may be scope for incorporating this care in current GP routines.
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http://dx.doi.org/10.1093/fampra/cmw124DOI Listing
April 2017

Patients' beliefs about the aims of breast cancer follow-up: A qualitative study.

Maturitas 2016 Sep 23;91:140-4. Epub 2016 Jun 23.

Department of Epidemiology, University of Groningen, University Medical Center Groningen, The Netherlands.

Objective: To explore patients' beliefs about the aims of breast cancer follow-up, and to compare these with the current literature on best practice for survivor care.

Study Design: We reviewed the literature on breast cancer and interviewed 61 women with a history of early-stage breast cancer. By means of descriptive content analysis with qualitative and quantitative elements, the patients' verbatim responses were thematically and independently analysed by two researchers. Results were compared with current literature and breast cancer guidelines.

Results: When patients were asked to comment on what they thought the aims of breast cancer follow-up were, they most frequently mentioned 'detection of recurrence' and 'receiving reassurance', followed by 'receiving psychological support', and 'collecting data to evaluate care'. Some patients explicitly mentioned 'surveillance for metastatic disease' as an aim of follow-up. However, some patients believed that breast cancer could not recur after 2-5 years of follow-up, and that recurrences could not develop directly after or between follow-up appointments. In relation to follow-up appointments, some patients experienced anxiety, while others felt it made them confront their breast cancer history.

Conclusions: Patients' beliefs are often not in line with guidelines. Educating patients about the aims of follow-up, and the evidence underlying it, might be important, in part to make patients' expectations more realistic.
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http://dx.doi.org/10.1016/j.maturitas.2016.06.014DOI Listing
September 2016

Knowledge and preferences regarding cardiopulmonary resuscitation: A survey among older patients.

Patient Educ Couns 2016 Jan 26;99(1):160-3. Epub 2015 Jul 26.

Department of General Practice, University of Groningen, University Medical Center Gro-ningen, Groningen, The Netherlands. Electronic address:

Objective: Survival rates following cardiopulmonary resuscitation (CPR) are low for older people, and are associated with a high risk of neurological damage. This study investigated the relationship between the preferences, knowledge of survival chances, and characteristics among older people regarding CPR.

Methods: A cross-sectional, self-administrated survey was distributed by researchers to 600 patients aged at least 50 years. The 14-question survey tool was used to collect basic demographic data, knowledge about CPR, and preference for CPR. We performed binary logistic regression analysis to predict whether patients wanted to receive CPR or not.

Results: The response rate was 48%. Most respondents (84%) predicted the estimated survival rate to be higher than the actual rate. Patients were significantly less likely to want to receive CPR if they correctly estimated the survival rate, had ever contemplated CPR, were older, or female. Discussing CPR with a doctor had no influence on patient preference for CPR.

Conclusion: Older patients choose to receive CPR based on incorrect knowledge.

Practice Implications: Doctors should be aware of the impact of knowing the true chances of survival on patient preference for CPR. Knowledge and skills need to be updated to provide this information to patients.
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http://dx.doi.org/10.1016/j.pec.2015.07.025DOI Listing
January 2016

Physician-assisted death is less frequently performed among women with a lower education: a survey among general practitioners.

Palliat Med 2014 Oct;28(9):1161-2

Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

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http://dx.doi.org/10.1177/0269216314535828DOI Listing
October 2014

Increased primary health care use in the first year after colorectal cancer diagnosis.

Scand J Prim Health Care 2014 Jun 15;32(2):55-61. Epub 2014 Jun 15.

Department of General Practice, University Medical Center Groningen, University of Groningen , Groningen , The Netherlands.

Objective: The view that the general practitioner (GP) should be more involved during the curative treatment of cancer is gaining support. This study aimed to assess the current role of the GP during treatment of patients with colorectal cancer (CRC).

Design: Historical prospective study, using primary care data from two cohorts.

Setting: Registration Network Groningen (RNG) consisting of 18 GPs in three group practices with a dynamic population of about 30,000 patients.

Subjects: Patients who underwent curative treatment for CRC (n = 124) and matched primary care patients without CRC (reference population; n = 358).

Main Outcome Measures: Primary healthcare use in the period 1998-2009.

Findings: Patients with CRC had higher primary healthcare use in the year after diagnosis compared with the reference population. After correction for age, gender, and consultation behaviour, CRC patients had 54% (range 23-92%) more face-to-face contacts, 68% (range 36-108%) more drug prescriptions, and 35% (range -4-90%) more referrals compared with reference patients. Patients consulted their GP more often for reasons related to anaemia, abdominal pain, constipation, skin problems, and urinary infections. GPs also prescribed more acid reflux drugs, laxatives, anti-anaemic preparations, analgesics, and psycholeptics for CRC patients.

Conclusions: The GP plays a significant role in the year after CRC diagnosis. This role may be associated with treatment-related side effects and psychological problems. Formal guidelines on the involvement of the GP during CRC treatment might ensure more effective allocation and communication of care between primary and secondary healthcare services.
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http://dx.doi.org/10.3109/02813432.2014.929811DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075017PMC
June 2014

Patients' preferences for post-treatment breast cancer follow-up in primary care vs. secondary care: a qualitative study.

Health Expect 2015 Dec 25;18(6):2192-201. Epub 2014 Mar 25.

Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

Objective: To explore patients' preferences for follow-up in primary care vs. secondary care.

Methods: A cross-sectional design was employed, involving semi-structured interviews with 70 female patients with a history of early-stage breast cancer. Using descriptive content analysis, interview transcripts were analysed independently and thematically by two researchers.

Findings: Patients expressed the strongest preference for annual visits (31/68), a schedule with a decreasing frequency over time (27/68), and follow-up > 10 years, including lifelong follow-up (20/64). The majority (56/61) preferred to receive follow-up care from the same care provider over time, for reasons related to a personal doctor-patient relationship and the physician's knowledge of the patient's history. About 75% (43/56) preferred specialist follow-up to other follow-up models. However, primary care-based follow-up would be accepted by 57% (39/68) provided that there is good communication between GPs and specialists, and sufficient knowledge among GPs about follow-up. Perceived benefits of primary care-based follow-up referred to the personal nature of the GP-patient relationship and the easy access to primary care. Perceived barriers included limited oncology knowledge and skills, time available, motivation among GPs to provide follow-up care and patients' confidence with the present specialist follow-up.

Conclusions: More than half of the patients were open to primary care-based follow-up. Patients' confidence with this follow-up model may increase by using survivorship care plans to facilitate communication across the primary/secondary interface and with patients. Training GPs to improve their oncology knowledge and skills might also increase patients' confidence.
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http://dx.doi.org/10.1111/hex.12189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810665PMC
December 2015

[Adjusting medication: elderly patient's preference counts].

Ned Tijdschr Geneeskd 2013 ;157(47):A6491

Universitair Medisch Centrum Groningen, afd. Huisartsgeneeskunde, Groningen.

Elderly patients with multimorbidity treated in accordance with disease-specific guidelines use a large number of drugs. As this approach may harm the patient's wellbeing, our care should evolve from disease-oriented to patient-oriented. A simple tool has been introduced to facilitate this type of consultation. On a visual analogue scale (VAS; 0-100) four generic treatment goals are presented to the patient: extending life, maintaining independence, pain relief and relief of other symptoms. The patient is invited to weigh the importance of these outcomes using the 'trade-off' principle, and asked to rank these goals in such a way that the score reflects the patient's preference profile. With the help of this decision aid, the medication of two female patients aged 85 and 94 was reviewed. Embedding this tool in the first step of the medication review process may help to shift the focus from the disease to the patient.
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July 2014

Easy navigating through the forest of survivorship care.

J Clin Oncol 2014 Jan 18;32(1):61-2. Epub 2013 Nov 18.

University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.

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http://dx.doi.org/10.1200/JCO.2013.52.9933DOI Listing
January 2014

[Discharge from hospital: left in limbo].

Ned Tijdschr Geneeskd 2013 ;157(32):A6394

Universitair Medisch Centrum, afd. Huisartsgeneeskunde, Groningen, the Netherlands.

An article pertaining to a large European qualitative study into the discharge of patients from hospital was published in the Dutch Journal of Medicine (Nederlands Tijdschrift voor Geneeskunde). Earlier qualitative and quantitative research in the Netherlands had resulted in the same findings: patients wish to receive more information upon discharge. Improvements have been realised, but not at every hospital or department. There is considerable variation as to how much information is desired by individual patients. Healthcare providers should take these differences into account and provide personalised information. For some patients, too much information increases their anxiety. We agree with the recommendations of the authors of the article. It is very important that nurses and doctors communicate with patients who are to be discharged. The elderly and patients who live alone need extra attention. GPs and specialists should discuss amongst themselves how to best compose a format for the specialist's report, including what type of information the GPs need to inform their patients adequately. As performance indicators, the telephone accessibility of GPs and the time it takes to receive the specialist's report could be considered as options.
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April 2014

Do patient and practice characteristics confound age-group differences in preferences for general practice care? A quantitative study.

BMC Fam Pract 2013 Jun 25;14:90. Epub 2013 Jun 25.

Background: Previous research showed inconsistent results regarding the relationship between the age of patients and preference statements regarding GP care. This study investigates whether elderly patients have different preference scores and ranking orders concerning 58 preference statements for GP care than younger patients. Moreover, this study examines whether patient characteristics and practice location may confound the relationship between age and the categorisation of a preference score as very important.

Methods: Data of the Consumer Quality Index GP Care were used, which were collected in 32 general practices in The Netherlands. The rank order and preference score were calculated for 58 preference statements for four age groups (0-30, 31-50, 51-74, 75 years and older). Using chi-square tests and logistic regression analyses, it was investigated whether a significant relationship between age and preference score was confounded by patient characteristics and practice location.

Results: Elderly patients did not have a significant different ranking order for the preference statements than the other three age groups (r = 0.0193; p = 0.41). However, in 53% of the statements significant differences were found in preference score between the four age groups. Elderly patients categorized significantly less preference statements as 'very important'. In most cases, the significant relationships were not confounded by gender, education, perceived health, the number of GP contacts and location of the GP practice.

Conclusion: The preferences of elderly patients for GP care concern the same items as younger patients. However, their preferences are less strong, which cannot be ascribed to gender, education, perceived health, the number of GP contacts and practice location.
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http://dx.doi.org/10.1186/1471-2296-14-90DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699367PMC
June 2013

Discharge of breast cancer patients to primary care at the end of hospital follow-up: a cross-sectional survey.

Eur J Cancer 2013 May 28;49(8):1836-44. Epub 2013 Feb 28.

Department of General Practice, University of Groningen, University Medical Center Groningen, P.O. Box 196, 9700 AD Groningen, The Netherlands.

Aim: The present study explored (a) the discharge of breast cancer patients to primary care by specialists, at the end of hospital follow-up and (b) the experiences and views of general practitioners (GPs) regarding transfer of follow-up to the primary care setting.

Methods: A cross-sectional survey was performed by sending a self-administered questionnaire to 960 GPs working in the three northern provinces of the Netherlands. Data were analysed using descriptive statistics.

Results: Of 949 eligible questionnaires, 502 were returned, providing an adjusted response rate of 53%. In the year before the survey took place, one or more patients aged >60 years, and 5 years after breast-conserving therapy, were discharged to 22% of GPs (n=112) for follow-up. According to 56% of these GPs, transfer of follow-up was communicated by the hospital. The initiative to arrange follow-up visits and mammography appointments was mainly taken by patients. In this survey, 40% of GPs (n=200) were willing to accept exclusive responsibility for follow-up earlier than 5 years after completion of active treatment. Perceived barriers in current and future primary care-based follow-up included: communication with breast cancer specialists, patients' preference for specialist follow-up, GPs' oncology knowledge and skills and the organisation of follow-up in general practice.

Conclusions: Primary care-based follow-up might be improved if breast cancer specialists discharge patients more actively to their GPs. Survivorship care plans are needed to facilitate communication across the primary/secondary interface and with patients. Training of GPs and developing administrative tools may be helpful in arranging follow-up care and using guidelines in general practice.
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http://dx.doi.org/10.1016/j.ejca.2013.01.016DOI Listing
May 2013

[Skin tumours underexposed in general practice].

Ned Tijdschr Geneeskd 2012 ;156(44):A5279

Universitair Medisch Centrum Groningen, afd. Huisartsgeneeskunde, Groningen, the Netherlands.

General practitioners (GPs) in the Netherlands frequently assess skin tumours such as moles. However, the training of medical students, GP trainees and postgraduate training of GPs in evaluating these skin lesions is limited. Furthermore, literature is scarce and no guidelines are available. It is still unclear when histopathological evaluation of an excised skin lesion should be performed. Additional research in primary care populations and the development of a guideline would promote a more unambiguous approach. More (postgraduate) education is needed on this topic. Dermatoscopy and teledermatology might also play a role in improving care.
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December 2012

Increased primary healthcare utilisation among women with a history of breast cancer.

Support Care Cancer 2013 Apr 4;21(4):941-9. Epub 2012 Oct 4.

Department of General Practice, University of Groningen, University Medical Center Groningen, P.O. Box 196, 9700 AD, Groningen, The Netherlands.

Purpose: Little is known about the current role of the general practitioner (GP) in breast cancer follow-up care. This study explores primary healthcare use in the period after completion of primary breast cancer treatment.

Methods: A total of 336 women with a history of early-stage breast cancer treated with curative intent were identified in the primary care database of the Registration Network Groningen (RNG) (1998-2007) and matched with a reference population of 983 women without breast cancer on birth year and GP.

Results: Over the entire follow-up period (starting 1 year post-diagnosis), the median numbers of face-to-face contacts, drug prescriptions, and referrals in the patient group were significantly higher than those in the reference group: 4.0 vs. 3.2/year, 12.3 vs. 8.4/year, and 0.4 vs. 0.3/year, Mann-Whitney (M-W) test p < 0.001 for all differences. At least one annual face-to-face contact was observed for 96.7 % of patients and 92.9 % of women from the reference population (Chi-square test p = 0.011). More patients than women from the reference population had face-to-face contacts for reasons related to breast cancer or were prescribed hormone antagonists and aromatase inhibitors to treat breast cancer. The main predictor of higher rates of face-to-face contacts and drug prescriptions was a higher age at diagnosis.

Conclusions: This study shows increased primary healthcare utilisation among women with a history of breast cancer, especially among the elderly. When follow-up is transferred to the primary care setting, new responsibilities of GPs might be incorporated into existing primary healthcare delivery.
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http://dx.doi.org/10.1007/s00520-012-1609-2DOI Listing
April 2013

COPD exacerbations in general practice: variability in oral prednisolone courses.

BMC Fam Pract 2012 Jan 12;13. Epub 2012 Jan 12.

Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, FA 20, 9700 AD Groningen, the Netherlands.

Background: The use of oral corticosteroids as treatment of COPD exacerbations in primary care is well established and evidence-based. However, the most appropriate dosage regimen has not been determined and remains controversial. Corticosteroid therapy is associated with a number of undesirable side effects, including hyperglycaemias, so differences in prescribing might be relevant. This study examines the differences between GPs in dosage and duration of prednisolone treatment in patients with a COPD exacerbation. It also investigates the number of general practitioners (GPs) who adjust their treatment according to the presence of diabetic co-morbidity.

Methods: Cross-sectional study among 219 GPs and 25 GPs in training, located in the Northern part of the Netherlands.

Results: The response rate was 69%. Nearly every GP prescribed a continuous dose of prednisolone 30 mg per day. Among GPs there were substantial differences in treatment duration. GPs prescribed courses of five, seven, ten, or fourteen days. A course of seven days was most common. The duration of treatment depended on exacerbation and disease severity. A course of five days was especially prescribed in case of a less severe exacerbation. In a more severe exacerbation duration of seven to fourteen days was more common. Hardly any GP adjusted treatment to the presence of diabetic co-morbidity.

Conclusion: Under normal conditions GPs prescribe prednisolone quite uniformly, within the range of the current Dutch guidelines. There is insufficient guidance regarding how to adjust corticosteroid treatment to exacerbation severity, disease severity and the presence of diabetic co-morbidity. Under these circumstances, there is a substantial variation in treatment duration.
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http://dx.doi.org/10.1186/1471-2296-13-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3323421PMC
January 2012
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