Treatment beyond treatment: exploring the effects of two complementary interventions on patient reported outcomes of gynaecological cancer

Gynaecological cancers (which include cancers of the ovary, cervix, uterus, vagina, endometrium, vulva and fallopian tube) account for 19% of all female cancers, and there are approximately 942,000 new cases diagnosed per year worldwide. Treatment for gynaecological cancer is often multi modal and consists of surgery, radiotherapy and chemotherapy. Current government policy has highlighted the need to focus on improving patient reported outcomes, including the patient experience of all aspects of cancer (including treatment), and the quality of life (QoL) of patients living with and beyond a cancer diagnosis. This thesis focuses on the effects of two different complementary interventions available to patients who were undergoing active treatment for gynaecological cancer at the Royal Derby Hospital between 2010 and 2012. Patient reported outcomes were explored in terms of the patients’ experience of the interventions and their reported levels of quality of life. The first study in this thesis explores the patient experience of an enhanced recovery programme (ERP) which was implemented for gynaecological cancer patients undergoing surgery at the Royal Derby Hospital in 2010. Previous research has found that ERPs (which complement traditional surgery) can decrease length of hospital stay, and they are now being implemented nationwide. However, there is a paucity of research into the patient experience of ERPs, especially in the field of gynaecological cancer. This study utilised a qualitative methodology to explore the experiences of 14 gynaecological cancer patients who took part in the ERP at Derby. Each patient was interviewed using a semi-structured format and the transcripts were analysed using Interpretative Phenomenological Analysis. The analysis highlighted that patients highly value the programme, and four main themes, fundamental to their experience, emerged from the data: taking part in the programme, the role of home, managing expectations and individual experiences outside of the programme. The second part of this thesis explores whether yoga can improve the quality of life (QoL) of patients undergoing treatment for gynaecological cancer when used as a complementary therapy. Previous research has found that participation in yoga can improve QoL in the breast cancer population, although there have been no similar studies conducted with UK gynaecological cancer patients to date. The study presented here utilised a randomised controlled design; 44 patients receiving treatment for gynaecological cancer were randomly allocated into a control group or a 10 week yoga intervention group. Outcomes were measured using the EORTC QLQ C30 questionnaire pre and post trial alongside visual analogue scales that were incorporated into a weekly diary. The results suggest that there was no significant effect of yoga on QoL, although there was encouraging data from one set of tests within the analysis, which suggested that patients on the yoga arm were seeing more improvement in QoL over time compared to the controls. Methodological improvements to clinical trials investigating complementary interventions are discussed in light of the results of this study. The overall findings of these two studies highlight that the utilisation of mixed methods is efficacious when exploring the effects of complementary interventions on the patient reported outcomes of those with gynaecological cancer. The use of qualitative methods to explore the patient experience of the ERP allowed for an in-depth, unique analysis to take place which was specific to the service delivered at The Royal Derby Hospital. The findings and recommendations from this part of the research have been incorporated into the on-going development of the pathway; it has indicated that more use of qualitative methods is needed in health services research to ensure that the patient experience is being fully explored, in line with the current government policy. Similarly, the second part of the research reported here indicates that further research in the area of yoga and gynaecological cancer is warranted. This requires a narrower focus with regards to both cancer type and point of treatment, to ensure that the number of variables is controlled. In addition, appropriate measurement and analysis techniques need to be considered (such as the generalised additive model used in this research) to preserve the richness of the data as this has not been considered (or utilised) in the many previous pieces of research in the area.