Demographic development, declining travel costs as well as continuing improvements in supportive and antineoplastic therapies are reasonable predictors of increasing travel activities carried out by patients with former or current malignant diseases in the near future. However, there is only limited scientific exploration of the intersection of malignant diseases and holiday taking, and there is a lack of evidence to guide health care providers and patients (16). We therefore conducted this exploratory study to create and validate a first-in-class comprehensive travel habits questionnaire in order to evaluate travel habits in patients with end-stage malignant diseases.
The overall interest in travel activities of our study cohort was high and 73.2% had already participated in a short or holiday trip after the diagnosis of advanced or metastatic cancer and all but one patient were in the process of planning future travel activities, irrespective of socioeconomic factors. The vast majority of patients attributed positive aspects to prior travelling after the diagnosis, which is in line with a pilot study performed by Hunter-Jones et al in 2003, who interviewed 24 cancer patients about their reflections upon holiday taking (17). In most patients, perceived benefits of travel seem to outweigh travel-related stress and exertion. In addition, we found a trend to improved QOL in patients who already engaged in travelling after the cancer diagnosis and although this association does not prove a causal relationship, previous data and ours suggest a potential impact that needs further scientific addressing. Following these arguments, physicians need to be aware of potential conflicts that might hamper the patient´s travel intentions. In our cohort, overall insecurities as well as medication and disease-related symptoms were among the most frequently named issues that require review by the treating physician. We furthermore identified specific subgroups (e.g. Cluster I) of patients who seemingly require even more support and guidance, especially in terms of planning medical surveillance or providing contact information in case of medical issues or emergency. In general, it is of importance to minimize potential risks by careful planning including professional pre-travel advice. Although concrete pre-travel advices for oncological patients are mostly derived from related non-malignant diseases (e.g. COPD guidelines for patients suffering from lung-cancer), few overarching recommendations exist that should be considered (18), especially when preparing for international travelling.
The main source of information and consultation in our study were family and friends or web-based services. Professional advisors like physicians or a travel agency were involved in less than 50% of all participants, underscoring the need for creating more awareness within professionals. In line with this, Mikati et al. performed a retrospective analysis in patients with a history of cancer and showed that international travel is common among this population, visiting friends and families as well as tourism being the most important purposes for travelling. However, merely ~ 50% of all participants reported seeking pre-travel advice from a health care provider (19). Similar patterns were confirmed in another survey among (autologous and allogeneic) stem cell transplant recipients (20). The high proportion of internet-based consultation in our survey, however, offers the possibility to present relevant information material at exposed websites.
Representative data on travel habits of the German population are annually published by the FUR. Unfortunately, specific subgroups are only explored on cost-intensive request and, more importantly, published results are mainly focused on commercial aspects limiting the scientific value for practical physicians (1). It is one of the strengths of our questionnaire that specific questions were designed in accordance to this large representative survey to perform comparative analyses with the FUR data. However, due to the limited number of cases in our study, we have not included a comparative presentation in this manuscript.
Our study has some limitations. First, the overall number of included patients is too low to derive representative conclusions. However, this study was planned as a multi-step pilot project to gain first insights into this understudied field. Second, albeit a multitude of patients with different cancer entities were included (n = 21, see supplement), epidemiologically important cancer entities such as gynecologic tumors are underrepresented here. An upcoming multi-centric study (Phase IV) aims to generate representative results in the near future. And third, all information provided by the participants are at risk for recall bias and only reflect the current opinion of the patient, which is the main reason why we did not ask for self-reported travel habits prior to the cancer diagnosis. Finally, in light of the recent COVID19 pandemic, travel habits of cancer patients may undergo transformation into yet unknown directions.