ORIGINAL ARTICLE

A qualitative assessment of the supportive care and resourceneeds of patients undergoing craniotomy for benign braintumours

Janice Wong & Daniel Mendelsohn &

Joyce Nyhof-Young & Mark Bernstein

Received: 2 June 2010 /Accepted: 11 October 2010 /Published online: 27 October 2010# Springer-Verlag 2010

AbstractPurpose As past literature has focused on support needs ofpatients with malignant brain tumours, the support needs ofpatients with benign brain tumours have largely beenoverlooked. The purpose of this study was to evaluate thesupportive care and resource needs of patients undergoingcraniotomy for benign brain tumours.Methods Individual, semi-structured interviews were con-ducted with patients who had undergone craniotomy for abenign brain tumour within the past 2 years. Interviewswere audio-recorded, transcribed, anonymized and sub-jected to descriptive thematic analysis by multiple inves-tigators in the grounded theory tradition.Results Twenty-nine patients (20 women, 20–88 years ofage) with World Health Organization grade I brain tumours(25 meningioma) were interviewed. Five overarchingthemes emerged: (1) need for formal support fromdiagnosis onwards; (2) complexity of supportive needsduring postoperative recovery; (3) importance of regular

long-term monitoring by physicians; (4) influence ofpsychosocial factors on supportive needs; and (5) existenceof barriers to equal access to available supports.Conclusions Patients’ supportive care needs are temporallydependent on disease course and treatment, and modifiableby demographic and psychosocial factors. Findings of thisstudy show that patients with benign tumours lacked butneeded many supportive care resources currently availableto cancer patients. Many of the potential solutions to thiscurrent gap in supportive care involve extending supportresources already available for cancer patients to patientswith benign brain tumours. We thus suggest recommenda-tions to improve service gaps and reduce disparities insupportive care for patients with benign brain tumours.

Keywords Brain tumour . Surgery . Supportive care . Unmetneed . Qualitative research

Introduction

Supportive care literature has largely overlooked thesupportive needs of patients with benign brain tumours.Past studies focused on patients with malignant braintumours [1–7]. Unfortunately, an estimated 186,678 non-malignant brain or central nervous system tumours arenewly diagnosed worldwide each year [8–10]. Non-malignant meningioma is the most frequently reportedbrain or central nervous system tumour pathology at 33%[8, 9]. Patients with meningiomas appear to have higherlevels of anxiety and depression than those with other typesof intracranial neoplasms, but these levels decreased moreafter surgery [11], suggesting that benign brain tumoursimpact patients’ lives and that assessment of their needsmust account for the surgical experience.

J. Wong :D. Mendelsohn :M. Bernstein (*)Division of Neurosurgery, Toronto Western Hospital,University of Toronto,4West Wing, 399 Bathurst Street,Toronto, ON, Canada M5T 2S8e-mail: mark.bernstein@uhn.on.ca

J. Nyhof-YoungDepartment of Radiation Oncology, University of Toronto,Toronto, ON, Canada

J. Nyhof-YoungCancer Survivorship Program, Princess Margaret Hospital/University Health Network Helliwell Medical Education,Toronto General Hospital,200 Elizabeth Street,Toronto, ON, Canada M5G 2C4

Support Care Cancer (2011) 19:1841–1848DOI 10.1007/s00520-010-1027-2

Whilst not all patients with benign brain tumours requireintervention, candidates for craniotomy include patientswith tumours that may be life-threatening if tumour growthprogresses [9]. These patients’ experiences with craniotomycan be subdivided into several time periods around theirsurgery: (1) the preoperative phase between diagnosis andsurgery, (2) the immediate postoperative recovery phaseand (3) the long-term phase afterward. Similarly, cancerpatients’ experiences can generally be described in terms ofan acute period between diagnosis and intervention, anextended period when patients recover from treatment and along-term recovery period [12]. In contrast to malignantbrain tumours, benign brain tumours have lower recurrencerates and are often treatable by surgery without additionalchemotherapy or radiotherapy [9]. Thus, it is important tounderstand the unique experiences of patients with benignbrain tumours.

This study qualitatively assesses the supportive needsand resources of patients with benign (World HealthOrganization grade I) brain tumours who have undergonecraniotomy. A previous study evaluated the informationneeds of craniotomy patients with benign brain lesions [13],but to our knowledge, this is the first study comprehen-sively investigating the multifactorial support needs ofthese patients. As race and ethnicity appear associated withdisparities in treatment or survival for patients withmalignant brain tumours in the USA [14–16], this studyinvestigates the influence of ethnicity and religion onpatients’ supportive care resources. The primary objectiveof this study was to assess current supportive care andresource needs of patients with benign brain tumours inorder to provide recommendations to improve care andreduce disparities in quality of care.

Methods

This study was approved by the University Health NetworkResearch Ethics Board and performed in accordance withethical standards laid down in the 1964 Declaration ofHelsinki. Given limited information in the literature,qualitative methods allow for the exploration of unantici-pated ideas [17]. Study respondents were a conveniencesample of the senior author’s (MB) patients. A patient waseligible for the study if he or she (1) was diagnosed with abenign brain tumour, (2) underwent craniotomy for thetumour within the past 2 years, (3) could communicateadequately in English or had a translator available and (4)was sufficiently cognitively intact.

Semi-structured, face-to-face interviews were conductedby one interviewer in a private setting at the Division ofNeurosurgery at Toronto Western Hospital after informedconsent was obtained. A semi-structured interview guide

allowed relevant topics introduced by respondents to befreely explored (Appendix). Interview questions focused onpatients’ concerns, changes in daily activities, access tosupports, and satisfaction with supports throughout theirexperience with disease, surgery and recovery.

Interviews were audio-recorded, transcribed and anony-mized. Transcripts were independently read and subjectedto descriptive thematic analysis by three investigators,which enhanced the internal reliability of results [17].Themes were inductively generated in the tradition ofgrounded theory [13, 17]. In the analysis of the transcripts,special codes were attached to text fragments with a certainidea or concept [17]. These codes were grouped into largercategories and, ultimately, themes by each investigator [17].Investigators then compared and reanalysed themes, re-solved coding disagreements by consensus and generatedmajor themes that encompassed the data [17]. Respondentswere recruited until data “saturation” was reached, with nonew themes emerging from the interviews [17, 18].

Results

Of 30 eligible patients, 29 consented to participate. Writteninformed consent was obtained from all respondents prior tothe interview. Demographic and clinical characteristics ofrespondents are summarized in Table 1. Five overarchingthemes emerged about supportive care and resource needs ofpatients undergoing craniotomy for benign brain tumours.

Need for formal support from diagnosis onwards

Most respondents reported no access to formal supportsystems, such as support groups or counselling services.Although recognizing that benign brain tumours have muchbetter prognoses than cancer, respondents neverthelesswould have liked to access these supports.

I still think there needs to be just more support ingeneral, you know, for people who have this type ofsurgery.…It’s not like cancer, where you get thefollow-up and you get the ongoing care.…It would benice to have more supports available, at least to accessif people choose to access them. (Respondent 16,female)

Whilst many patients reported using fact-based Internetresources for information about their brain tumour and theirneurosurgeon, they had mixed opinions about onlinediscussion boards: “…there were some real horror storieson that website, and some of that made me anxious to somedegree” (respondent 1, female).

Respondents expressed interest in formal support sys-tems from the moment of their diagnosis. Preoperatively,

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some patients had physical symptoms such as fatigue orneurological deficits, but the majority expressed a need forpsychological or emotional support. Many respondents feltthat they would have benefited from support groups. Somepatients did not have time between diagnosis and surgery toseek additional supports. For those who did, contact withother patients could have helped alleviate preoperativeanxiety and information needs: “It would have been helpfulto have something in the community, maybe like a group,to tell you what’s going on, tell you how to cope, tell youwhat to expect” (respondent 12, female).

Interestingly, one respondent had been previously diag-nosed with an unrelated cancer. This diagnosis enabled himto access support services at a large teaching hospitalspecializing in oncology. He took advantage of theseservices to meet his support needs with respect to hisbenign brain tumour: “I found social services at the[hospital], and they were fantastic.…It was very supportive

and very soothing to me just to be able to speak about whatwas going on” (respondent 2, male). This respondent’sexperience contrasts the easy availability of resourcesavailable to patients with cancer to the limited support forpatients with benign tumours.

Complexity of supportive needs during postoperativerecovery

Respondents reported the most complex supportive needsin the weeks or months after surgery. It was important topatients that the neurosurgeon honestly explained whatsymptoms meant and what activities the patients couldundertake post-operation: “…It wasn’t the surgery thatbothered me. It was what was going to happen afterwards,and that was the biggest concern that I had” (respondent 23,male). Common postoperative symptoms included pain,fatigue, weakness and decreased ability to concentrate or doactivities. Many patients would have liked to speak toothers about what to expect postoperatively: “There were afew concerns that nobody ever told me that I would knowor face.…For the first couple of months [post-surgery], Iwould have loved to talk to somebody about it…”(respondent 21, female).

During the recovery period, respondents suggested thatsupport groups could have enhanced their physical andmental recovery. Many patients sought to live healthierlifestyles after surgery, and support systems could promoteself-help activities.

But I’ll tell you one thing that would have beenhelpful—would be that if after the surgery, they hadsome kind of therapy, maybe a group therapy, to tellyou what to expect from this brain surgery and to giveyou maybe exercises to build up your strength, tobuild up your morale… (respondent 12, female)

Respondents also expressed a need for practical supportpostoperatively as many had difficulty performing activitiesof daily living. Respondents discussed using services ofpersonal support workers or nurses from community careorganizations, but some found the available practicalsupport inadequate: “I would have liked somebody in thehouse to have been able to give me a shower, help dress,just be there for moral support, to be in the house. Therewas nobody. It was difficult” (respondent 29, female).

Importance of regular long-term monitoring by physicians

Respondents wanted regular, long-term monitoring byphysicians, including their neurosurgeon and family physi-cian. Monitoring was seen as necessary and largelysufficient in addressing one of the most significantpostoperative concerns of patients—tumour recurrence:

Table 1 Demographic and clinical characteristics of respondents

Total number of participants 29

Sex

Female 20

Male 9

Age

Age range 20–88

Average age 60.4±14.2

Tumour histology (WHO grade I)

Meningioma 25 (3 with recurrence)

Other 4

Marital status

Married or common-law 22

Single or separated 7

Education

High school 11

Post-secondary education 18

Country of origin

Canada 17

Outside Canada 12

Translation required

Yes 3

No 26

Self-reported ethnicity

Caucasian-Canadian 14

Italian 4

Chinese 2

Other 9

Religion

Christianity 19

Judaism 6

Other or none 4

Support Care Cancer (2011) 19:1841–1848 1843

“It’s nice to know that I’m going to be followed up verythoroughly” (respondent 26, male). For one patient, regularlong-term monitoring was crucial for detecting recurringtumours, but not sufficient for alleviating his anxiety: “I’vehad lulls in the past when things have been fine, and all of asudden a tumour comes again and I’m not prepared for it”(respondent 2, male). In contrast, some patients found thediagnosis of non-malignancy sufficiently reassuring: “Butthe fact that they say benign, well, then it’s not as much toworry, right, as it would have been if it wasn’t” (respondent25, female). Aside from regular monitoring, most respond-ents anticipated few future needs or focused on the present:“I’m thinking that I’m going to be fantastic in 2 moreweeks and that’s as far as I see” (respondent 14, female).

Influence of psychosocial factors on supportive needs

The amount of family or social support was an importantdeterminant of patients’ support needs, whilst factors likeethnicity and religion strengthened existing supports. Socialsupport from family and friends was one of the mostimportant factors influencing support needs. If patients hadadequate support from their family, they sought feweradditional supports: “I think everybody depends on theirfamily and friends, and if then they don’t have that, thenyou’ve got to go out to the community. I didn’t have to, thankgoodness” (respondent 14, female). One respondent actuallyfound family members unsupportive because they wereanxious themselves: “I have an adult child, but it was prettytraumatic for her to find out about it” (respondent 16, female).As a result, this respondent reported a more difficultpostoperative experience: “It was challenging for me becauseI was so exhausted all the time” (respondent 16, female).

Most respondents felt that their ethnicity did not influencetheir support needs or the types of supports they used. But forsome, their ethnicity was a key strength of their social supportsystem. For example, one patient who lived alone and did nothave an immediate family received extensive support fromhis ethnic community. Other patients had family supportstrengthened by ethnicity: “I think [people with my ethnicbackground] have always been notorious for being close knit,so that’s been good.…That’s very good for recoverytherapy…” (respondent 28, male).

When asked how their ethnicity influenced their supportneeds, many respondents offered that it was their religion,including prayer, that helped them through the surgery:“Before I went in, I just put myself in my creator’s handsand that’s truth” (respondent 26, male). They found comfortin their personal faith, as well as moral support from othersin their religious community: “…my minister and my friendcame down and talked with me and had a prayer with me,and from then on I was, no doubt, I was in their prayers…”(respondent 23, male). Religion also influenced how these

patients viewed life postoperatively, positively contributingto their recovery and rehabilitation. In turn, for somepatients, their experience with surgery enhanced their faith:“God has been good to me, it’s a miracle. So I’ve beenmaking the best of the beauty of the world. I am gratefulevery day” (respondent 5, female).

Existence of barriers to equal access to available supports

Whilst the majority of respondents did not feel that there wereany particular barriers preventing access to existing supports,a few respondents discussed access barriers in terms oflocation, English as a second language and level of education.

Notably, these respondents discussed the greater access tosocial supports in large urban centres compared to rural areas.Other patients were not able to access health services such asoccupational therapy because of long waiting lists in theirregion: “…anyone who lives in a central, large city area wouldhave lots of supports to go and use, whereas somebody in arural area such as myself, no” (respondent 3, female).

Multiple respondents pointed out that language was apotential barrier to care: “I think maybe other people whodon’t have English as a first language might find thingsmore difficult” (respondent 4, female). However, none ofthe three respondents requiring translators found thatlanguage barriers negatively impacted their health careexperience. Translators were readily available at this largeurban institution.

One English-speaking respondent who had not complet-ed high school was frustrated by lack of easily understand-able information about his surgery: “I wish they’d beenmore informative so I could understand what was going on”(respondent 26, male).

Discussion

The experiences of patients with benign brain tumours areunique compared to existing models of cancer survivorship[19]. Compared to patients with malignant tumours,patients with benign tumours may have similar needsbefore and shortly after operation. They may havecomplications from the intervention that last indefinitely,but generally do not experience the progressive and oftenpalliative course experienced by patients with malignantbrain tumours [9]. Instead, they have support needs thatbegin with diagnosis, peak in a relatively short postopera-tive recovery and decrease significantly in the long term.

Preoperative support needs

Respondents’ reasons for wanting support groups andresources varied with time. Before surgery, support groups

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were important sources of information. Respondents hadmixed feelings about Internet information. Similarly, onestudy reported that over 80% of brain tumour patients usedInternet resources, but over 50% felt that they lackedinformation [20]. Self-help informational resources shouldnot aim to replace support groups or health care profes-sionals who can give personal guidance.

Postoperative support needs

The largest perceived gap between existing resources andpatient needs occurs during postoperative recovery. Cur-rently, no formal support systems exist for patients withbenign tumours, but many respondents would have likedsupport groups or peer support. Previous studies on cancerpatients’ supports reported that women were more likely toaccess support groups [21] and Internet-based cancersupport groups [22]. Likewise, whilst both men and womenin this study used Internet resources and had similar supportneeds, women more often articulated a desire to accessformal support groups. The higher number of responses bywomen about support groups likely reflects the high ratio ofwomen to men in this study, which, in turn, is concordantwith the higher prevalence of meningiomas in women [9].Support groups for brain tumour patients serve as safetherapeutic forums that promote morale and provideindividualized information [23]. Aside from information,respondents in this study suggested that support groupscould have helped build morale and teach physicalexercises. A previous study also found that brain tumourpatients would like to have support services to managestress and improve physical activity [7]. Thus, respondentswanted both information and practical support duringrecovery.

Janda et al. [6] correspondingly reported that patientsupport needs included information and practical support.However, they also found that brain tumour patients wantedsupport to deal with long-term care, social isolation, respitecare, reduced life expectancy and stigma [6], issues that didnot concern respondents in this study. In the long term, thepresent patients valued regular visits with their neurosur-geon to monitor tumour recurrence. Patients’ concernsabout tumour recurrence were valid as WHO grade Imeningiomas had a 10-year recurrence rate of 7.5% and a20-year rate of 9.3% [24].

Ethnicity and religion

Throughout the illness experience, the level of supportrequired by patients was influenced by psychosocial ordemographic factors. Whilst ethnicity did not directlyinfluence patients’ support needs, ethnicity could impactthe strength of social supports. In this study, no disparities

in the quality of supportive care were detectable among avariety of self-reported ethnicities, which suggests thatethnicity did not influence the quality of medical care.Language barriers were not major issues due to the readyavailability of translators in this large urban teachinghospital.

Religion emerged as a major supportive factor forpatients going through their course of disease, surgery andrecovery. Although a robust methodology for measuringreligious coping has not been well established [25],religious frameworks appeared to help many respondentsin this study cope as well as provide additional socialsupport through religious organizations. Spirituality andreligion differ, but patients’ experiences often involveelements of both. As personal faith and prayer wereimportant for many respondents in this study, furtherinvestigations could explore the role of spirituality incoping and quality of life of these patients using validatedscales for spirituality [26]. A previous study found thatpatient spirituality was positively associated with copingduring cancer treatment [27], and spirituality is a majordomain of quality of life in a model of cancer survivorship[19].

Social support theory

Supportive relationships consist of social and professionalsupport [28]. Social supports can be further divided intoembedded social networks like family, friends or co-workers, and created social networks like support groupsor peer support [28]. This study confirms that patientsundergoing craniotomy for benign brain tumours valueeach of these types of support. Moreover, an interactionwas found between embedded and created social networksas the level of embedded social networks available to apatient determined the level of created social networksrequired or desired by the patient. Created social networksof peer support involve provision of information, emotionaland affirmative support [28], and respondents in this studywere interested in formal support systems incorporating allof these components of support.

Recommendations

This study aimed to produce recommendations toimprove supportive care for patients who undergocraniotomy for benign brain tumours (Table 2). Concernsraised by patients offer opportunities for further resourcedevelopment: First, the health care team should strive tobe aware of factors that modify patient support needs andaccordingly suggest additional community support resour-ces. Translation for patients who do not speak Englishshould continue to be offered. Easily understood informa-

Support Care Cancer (2011) 19:1841–1848 1845

tion resources should be available in print and online forbroader access (e.g. on www.caringvoices.ca). There areno easy solutions for providing additional resources tounderserviced regions, but health care professionals couldprovide more information resources to patients who livefar from urban centres.

Addressing the practical needs of patients who lackadequate home support requires a multidisciplinary ap-proach. Future research can also explore optimizingcoordination of support for patients with multiple diagnosesand understanding family members’ needs. Whilst mostpatients with benign brain tumours do not require long-termsupport from family members, family members’ needs inthe short term appear significant.

Formal support (Table 2) should be made available topatients with benign brain tumours. Patients with benignbrain tumours may not require the long-term, complexsupportive care offered to cancer patients, but manypatients with benign tumours can benefit from short-termsupportive care systems. Patients with recurring benignbrain tumours may have experiences that are more similarto cancer patients’ experiences and require higher levels oflong-term support. Table 2 summarizes possible solutionsto the gap between desired and existing support resources,with Internet-based support groups as a first recommendedstep. Many of these solutions involve the cost-effectiveapproach of extending support resources and expertisealready available for cancer patients to patients with benignbrain tumours.

Limitations

First, approximately half of the patients were interviewed inthe presence of a family member or friend. Whilstrespondents were often more comfortable with this arrange-ment, respondents could have downplayed deficiencies insupport, introducing bias in the study. Secondly, generaliz-ability of the study results may be limited because the studytook place with one patient population in one neuro-surgeon’s practice in a large urban teaching hospital in

Canada [17]. Nevertheless, study results reassuringlymatched the limited available literature. A survey of a largepopulation of patients from different clinics would haveprovided results that are more generalizable, but lack thedepth found from qualitative methods, so a mixed methodsapproach would have strengthened this study. Thirdly, thisstudy only included patients who underwent surgery withinthe past 2 years. Whilst respondents could better recall theirperioperative experiences, their needs could not be assessedpast this 2-year time frame. Finally, whilst no disparities inaccess to supportive resources were reported, the majorityof respondents were Caucasian, so additional ethnic-baseddisparities may not have been detectable.

Conclusions

This study provides insight into the support needs ofpatients who undergo craniotomy for benign tumours,revealing current gaps in care and confirming the need toimprove supportive resources for these patients. Specificresources such as support groups, contact with otherpatients and practical support are especially critical in theperioperative period. Feasible solutions exist to improvethe experiences of these patients, including the cost-effective integration of patients with benign braintumours into the presently available support systems forcancer patients.

Acknowledgements JW received academic credit for this study inthe undergraduate medical course, Determinants of Community HealthII at the University of Toronto, Faculty of Medicine. The authorswould like to thank the patients and family members who participatedin this study for their time and insights. JW would also like to thankRaageen Kanjee for his insights during conceptualization of this work.

Conflict of interest statement The authors do not have any sourcesof funding to disclose and have no conflicts of interest to declare forthe submission entitled “A qualitative assessment of the supportivecare and resource needs of patients undergoing craniotomy for benignbrain tumours”. The authors have full control of all primary data andagree to allow the journal to review their data if requested.

Table 2 Recommendations to improve supportive care for patients undergoing craniotomy for benign brain tumours

Internet-based support groups: Develop an online discussion board for patients with benign brain tumours moderated by health care professionals,which can be modelled on discussion boards for cancer patients.

Support groups: Create face-to-face support groups for patients with benign brain tumours.

Individual peer support: Connect new patients who have questions or concerns to past patients so that they can share their experiences.

Counselling services: Extend counselling resources for cancer patients to include patients with benign brain tumours.

Information resources: Provide easily read, multilingual print and online resources for patients with benign brain tumours that explain what toexpect from the course of disease, surgery and recovery.

Practical support: Coordinate with the multidisciplinary health care team (including nurses, occupational therapists, physical therapists, personalsupport workers, social workers) to ensure that patients lacking adequate home support can access community services.

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Appendix: interview guide

1. How did you first find out about your diagnosis?2. Before your brain surgery, what concerns did you have?

(prompt: What were you most worried about whenyou found out about your diagnosis? What were yourconcerns with regard to the surgery?)

(a) What support did you receive for your concerns?(prompt: Did you get help from any of the

following: family, friends, an organization, supportgroup or community services?)

3. After your diagnosis but before your surgery, werethere any changes in what you could do on a dailybasis?

(prompt: Did you require assistance for any of thefollowing activities: eating, moving around, or self-care?Did you require assistance for any of the followingactivities: preparing meals, shopping, driving, takingmedications, paying bills, or managing other chores?)

(a) What assistance did you receive?(prompt: Did you get help from any of the

following: family, friends, an organization, supportgroup or community services? For how long didyou use this assistance?)

4. How was your experience at the hospital?5. How did you feel leaving the hospital?6. What was life like after your operation?

(prompt: Did you have any complications aftersurgery? How was adjusting to life at home?)

7. What types of community support did you expect orhope to have after your surgery?

(prompt: Did you expect to have access to supportgroups? Did you expect to have any particular communityservices?)

8. After your brain surgery, what concerns did you have?

(a) What support did you receive for your concerns?(Prompt: Did you get help from any of the

following: family, friends, an organization, supportgroups or community services?)

9. After your surgery, were there any changes in what youcould do on a daily basis?

(Prompt: Did you require assistance for any of thefollowing activities: eating, moving around, or self-careactivities such as dressing, bathing and using the toilet?Did you require assistance for any of the followingactivities: preparing meals, shopping, driving, takingmedications, paying bills, or managing other chores?)

(a) What assistance did you receive?(Prompt: Did you get help from any of the

following: family, friends, an organization, support

groups or community services? For how long didyou use this support?)

10. Have any of your needs after your surgery not beenmet?

11. Now that you are in the recovery stage after surgery,have any of your long-term goals changed since yoursurgery?

(prompt: What are some of your long term plans?What are some of your hopes or dreams?)

12. What are some of the needs that you think you mighthave in the long-term future, and associated supportsyou might need?

13. Could you tell me more about your ethnic or culturalbackground?

(prompt: What is your ethnicity? What is yourcountry of origin?)

14. How much does your ethnic or cultural backgroundinfluence your attitude towards surgery?

(prompt: Does your background influence yourattitudes towards major life events? Did your back-ground influence your experience with surgery?)

15. How do you think your ethnic, cultural or religiousbackground influenced the types of supports that youused?

(prompt: Do you think that brain surgery patientswith your ethnic, cultural or religious backgroundhave any particular needs? Do you think that brainsurgery patients with your ethnic, cultural or religiousbackground have preferences for any particular typesof supports?)

16. Is there anything that you would like to add?

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