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

ABSTRACT Background The supportive care needs trajectories in patients with advanced non-small-cell lung cancer (NSCLC) during chemotherapy and the related factors have yet to be explored or addressed in the literature. Purpose This study was designed to investigate supportive care needs trajectories in patients with advanced NSCLC receiving chemotherapy and the association between the sociodemographic and disease characteristics of these patients over the four cycles of chemotherapy. Methods For this longitudinal study, 95 patients with advanced NSCLC were recruited using convenience sampling at a medical center in Taiwan. The supportive care needs of the participants were assessed in each of the four chemotherapy cycles using the Needs Evaluation Questionnaire–Chinese version (NEQ-C) with 23 dichotomous items on the day before and the seventh day after the end of each cycle. Group-based trajectory modeling was applied to identify the classes of supportive care needs trajectories, whereas chi-square tests were used to examine the factors related to these classes. Results Seventy-one participants completed all eight questionnaire sessions across the four cycles. The mean NEQ-C scores for these participants ranged between 14.4 and 14.6. Three classes of supportive care needs trajectories (low, moderate, and high) were identified for the entire NEQ-C and for each domain. Marital status was found to be associated with the classes of trajectories related to supportive care and assistance/care needs, spouse as the primary caregiver was found to be associated with the classes of trajectories related to information needs, and educational level was found to be associated with the classes of trajectories related to psychoemotional support needs. Conclusions The results of this study indicate that marital status and spouse as primary caregiver relate significantly to supportive care needs trajectories in patients with advanced NSCLC during chemotherapy. Healthcare professionals should provide continuous, tailored supportive care interventions that address the needs of patients and their spouses/partners.


Introduction
in continued treatments (National Comprehensive Cancer Network, 2021). For patients with lung cancer who experience the effects of their disease diagnosis and complex treatment, follow-up should be accompanied by physical, emotional, social, psychological, informational, and practical supportive care needs (Mazor et al., 2022). Unmet supportive care needs have been associated with poorer quality of life in patients with lung cancer (Cochrane et al., 2022), whereas providing individualized care interventions based on patient needs has been shown to improve cancer care quality (Reiser et al., 2019).
The supportive care needs of patients with lung cancer cross multiple domains. Patients with NSCLC receiving chemotherapy or immunotherapy have reported unmet supportive care needs (McLouth et al., 2021). Moreover, patients with lung cancer have various supportive care needs after discharge (Ni et al., 2022). Whereas information is the most prominent supportive care needs domain for patients with lung cancer in Taiwan and China (Kao et al., 2013;Zhang et al., 2019), psychological and physical and daily living requirements are the most prominent supportive care needs domains for patients with lung cancer in Singapore, Canada, and Mexico (Doubova & Pérez-Cuevas, 2020;Giuliani et al., 2016;Huang et al., 2020). Patients in the United States with metastatic NSCLC receiving target therapy were identified with prominent needs in the information and psychosocial support domains (Petrillo et al., 2021), whereas, in Norway, patients with primary lung cancer after lung cancer surgery reported prominent needs in the information and supportive care categories (Kyte et al., 2019). Preliminary findings from the literature suggest that culture is a factor of influence on the supportive care needs domains of patients with lung cancer.
In a systematic review, patients with cancer were reported to have higher supportive care needs during treatment than during either diagnosis or follow-up and higher supportive care needs in the advanced stages of cancer and during poor health than in the early stages of cancer (Harrison et al., 2009). Studies on factors related to the supportive care needs of patients with lung cancer have found diverse results; no consistency currently exists in the literature regarding associations among sociodemographic characteristics (e.g., age, gender, educational level, primary caregiver, function of daily activities), disease characteristics (e.g., cancer cell type, treatment modality, cancer stage, comorbidities), and supportive care needs in patients with lung cancer (Doubova & Pérez-Cuevas, 2020;Huang et al., 2020;Zhang et al., 2019). It has only been found that patients with lung cancer receiving chemotherapy have higher supportive care needs than those not receiving chemotherapy (Doubova & Pérez-Cuevas, 2020).
Most of the previous cross-sectional studies on supportive care needs in patients with lung cancer have not focused exclusively on patients with advanced lung cancer (Doubova & Pérez-Cuevas, 2020;Giuliani et al., 2016;Zhang et al., 2019). Moreover, the small number of studies on patients with advanced lung cancer did not focus specifically on pa-tients treated with chemotherapy and did not clearly indicate that the measurement time was equal to the treatment period (Huang et al., 2020). In recent years, several longitudinal studies have been conducted on the supportive care needs of patients with breast and colorectal cancers, with results showing that these needs exhibit different classes of trajectories, for example, low stable care needs and high-decline needs, before and after surgery or treatment (Lam et al., 2014(Lam et al., , 2016Pérez-Fortis et al., 2018). However, the supportive care needs trajectories in patients with advanced NSCLC during chemotherapy and the related factors have yet to be determined.
To provide continuous and individualized care, the supportive care needs of patients with cancer should be investigated longitudinally to elicit the trajectories associated with these needs during chemotherapy. During extended chemotherapy courses (over at least four cycles) in patients with advanced NSCLC, healthcare providers should attempt to understand the correlation between classes of supportive care needs trajectories during chemotherapy and patient characteristics to enhance their sensitivity toward these trajectories. Accordingly, the purpose of this study was to understand the classes of supportive care needs trajectories and the association between sociodemographic and disease characteristics of patients with advanced NSCLC over four cycles of chemotherapy. The two hypotheses investigated in this study were as follows: (a) The overall supportive care needs and their related domains of patients with advanced NSCLC are all associated with different trajectory classes over the four cycles of chemotherapy, and (b) the classes of overall supportive care needs and the subdomains of supportive care needs trajectories are related to sociodemographic and disease characteristics.

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

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

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

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

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

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

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

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

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

Discussion
The results of this study show that patients with advanced NSCLC may be distinguished into three trajectories groups (relatively mild, moderate, and high needs) in terms of overall supportive care needs and each supportive care needs subdomain over the four chemotherapy cycles. The trajectory types and distributions for overall supportive care needs and information needs were similar. Most of the participants showed moderate-stable or high-stable overall supportive care needs and information needs trajectories over the chemotherapy cycles. In a previous study conducted in Hong Kong, most of the patients with colorectal cancer and patients diagnosed with advanced breast cancer followed for 12 months were assessed as belonging to either the lowdecline or low-stable health system and information needs trajectories group (Lam et al., 2014(Lam et al., , 2016. In addition, the results of an intervention study indicate that a care needs support intervention led and coordinated by nurses improves the postoperative information needs of patients with breast and colorectal cancer (Sussman et al., 2018). Therefore, follow-up studies should be conducted to further explore in detail the information needs of patients with advanced NSCLC during chemotherapy to develop standardized, in-person supportive-care, interventions for patients with advanced  NSCLC during chemotherapy and then use these interventions to explore their effectiveness in improving patients' supportive care needs.
More than half of the patients with advanced NSCLC in this study exhibited no psychoemotional support needs during chemotherapy, and only a very small percentage exhibited persistently high levels of psychoemotional support needs. The participants with a college education or higher were found to be more likely to belong to the high and persistently increasing psychoemotional support needs trajectory. This result is similar to that of a previous study conducted in China that found the psychological needs of college-educated patients to be higher than those of patients with a high school or lower level of education (Zhang et al., 2019). With regard to the findings of previous cross-sectional surveys on the supportive care needs of patients with lung cancer, patients in Supportive Care Needs Trajectories VOL. 31, NO. 3, JUNE 2023 Taiwan and China both had information needs as their main unmet care needs, whereas patients in Canada and Mexico had psychological needs as their main unmet care needs (Doubova & Pérez-Cuevas, 2020;Giuliani et al., 2016;Lee et al., 2021;Zhang et al., 2019). Thus, follow-up studies may further explore the influence of cultural background on supportive care needs trajectories in patients with cancer at the same cancer stage, using the same treatment method, and in the same treatment period. Factors associated with classes of supportive care needs trajectories during chemotherapy in patients with advanced NSCLC were found to relate to marital status and spouse as primary caregiver. However, few studies have explored the relationship between the supportive care needs of patients with lung cancer and having a spouse as the primary caregiver. One Taiwanese study indicated that patients with lung cancer who were married had higher overall care needs than their unmarried peers after the first cycle of chemotherapy (Chiu et al., 2016). In addition, a longitudinal study of changes in health-related quality of life in patients with breast cancer and melanoma found living with a partner to be associated with worsening health-related quality of life (Toscano et al., 2020). Therefore, qualitative research should be conducted to further explore the experiences, feelings, and care needs of patients with advanced lung cancer who are cared for by their spouse/partner during chemotherapy to further understand how to provide individual supportive care interventions that take into appropriate consideration the spouse/partner. This study was limited to patients admitted to chemotherapy for the first time in the chest medicine ward of one hospital. Because of the short survival rate of patients with advanced NSCLC and the relatively limited number of patients who received chemotherapy only and completed all four chemotherapy cycles, the sample set available was relatively small despite the 2-year study period. Therefore, this report may not be fully representative of all patients.
To the best of our knowledge, this longitudinal study was the first to evaluate the supportive care needs trajectories of patients with advanced NSCLC receiving chemotherapy. Future studies should follow up on the supportive care needs trajectories in patients with advanced NSCLC receiving targeted therapy or immunotherapy and related factors.

Conclusions
The findings of this study support that patients with advanced NSCLC exhibit three classes of trajectories with regard to the overall and various domains of supportive care needs over the four cycles of chemotherapy. The factors found to relate significantly to the overall and various domains of supportive care needs trajectories included marital status, spouse as primary caregiver, and educational level. In addition to understanding the supportive care needs characteristics of patients with lung cancer during chemotherapy, healthcare providers should also pay attention to the support and influence of patient family members, spouses, and primary caregivers to increase care sensitivity and provide a continuum of care interventions that better meet patient needs. Meeting the supportive care needs of patients with lung cancer in each cycle of chemotherapy may be expected to increase patient confidence in chemotherapy, enabling them to better finish their treatment with higher levels of satisfaction.