The relation of illness perceptions to stress, depression, and fatigue in patients with chronic lymphocytic leukaemia

OBJECTIVE

Chronic lymphocytic leukaemia (CLL) is the most prevalent adult leukaemia and is incurable. The course and treatment of CLL is unique and characterised by repeated cycles of treatment, stable disease and relapse. Utilising a Self-Regulatory Model framework, we examined the relationship between patients' illness perceptions and cancer-specific stress, depressive symptoms and fatigue. Our aim was to test illness perceptions as predictors of these outcomes when variance due to disease and treatment variables was controlled.

DESIGN

Data were collected on 147 patients with relapsed/refractory CLL as they entered a phase II clinical trial of an investigational medication at a university affiliated, National Cancer Institute designated comprehensive cancer center.

MAIN OUTCOME MEASURES

Cancer-specific stress, depressive symptoms and fatigue interference.

RESULT

. Hierarchical multiple regression was used. Consequences and emotional representation were related to all outcomes (ps < .01). Illness concern was related to cancer-specific stress (p < .01), and identity was related to fatigue interference (p < .01). All relationships were observed while controlling for number of previous CLL therapies received.

CONCLUSION

Illness perceptions are related to cancer-specific stress, depressive symptoms and fatigue interference in relapsed/refractory CLL. Interventions targeted at restructuring maladaptive illness perceptions may have clinical benefit in this population.

Self-Reported Sexual Function Measures Administered to Female Cancer Patients: A Systematic Review, 2008-2014

A systematic review was conducted to identify and characterize self-reported sexual function (SF) measures administered to women with a history of cancer. Using 2009 PRISMA guidelines, we searched electronic bibliographic databases for quantitative studies published January 2008-September 2014 that used a self-reported measure of SF, or a quality of life (QOL) measure that contained at least 1 item pertaining to SF. Of 1,487 articles initially identified, 171 were retained. The studies originated in 36 different countries with 23% from US-based authors. Most studies focused on women treated for breast, gynecologic, or colorectal cancer. About 70% of the articles examined SF as the primary focus; the remaining examined QOL, menopausal symptoms, or compared treatment modalities. We identified 37 measures that assessed at least one domain of SF, eight of which were dedicated SF measures developed with cancer patients. Almost one third of the studies used EORTC QLQ modules to assess SF, and another third used the Female Sexual Function Inventory. There were few commonalities among studies, though nearly all demonstrated worse SF after cancer treatment or compared to healthy controls. QOL measures are better suited to screening while dedicated SF questionnaires provide data for more in depth assessment. This systematic review will assist oncology clinicians and researchers in their selection of measures of SF and encourage integration of this quality of life domain in patient care.

Implementing evidence-based psychological treatments for cancer patients

OBJECTIVE

New regulations and guidelines require implementation of screening and evidence based psychological treatment (EBT) for cancer patients, but little research exists to assist psychosocial care providers with implementation. This study aimed to develop a conceptual framework for community providers to consider as they embark on implementation of EBTs.

METHODS

Full-time psychosocial care providers received dissemination training in delivery of a cancer-specific EBT and then received implementation support. Qualitative data were collected in two phases. In Phase I, after training, trainees (N = 52) participated in six monthly group conference calls with six to eight trainees and EBT trainers. Qualitative data from the calls were analyzed using a grounded theory paradigm. In Phase II, the resultant framework was piloted with additional trainees (N = 73) during EBT training to prompt early planning for implementation at their home institutions.

RESULTS

In Phase I, themes of 'person' (i.e. attitudes, vocalizations, and behaviors of others) and 'environment' factors (i.e. material, monetary, and time resources of organizations) affecting implementation emerged. It appeared that both factors influenced how easily barriers could be addressed, although positive person factors also appeared to positively influence environment factors. In Phase II, trainees found the framework acceptable and considered it when generating solutions for implementation challenges.

CONCLUSIONS

The framework suggests tailoring implementation efforts to consider person and environment factors. As person support is developed, resource limitations of the environment may be more easily addressed.

Women with breast cancer: self-reported distress in early survivorship

PURPOSE/OBJECTIVES

To identify and compare levels of distress and sources of problems among patients with breast cancer in early survivorship.

DESIGN

Descriptive, cross-sectional.

SETTING

A National Cancer Institute-designated comprehensive cancer center.

SAMPLE

100 breast cancer survivors were selected to represent four time points in the cancer trajectory.

METHODS

Distress was self-reported using the Distress Thermometer and its 38-item problem list. Analysis of variance and chi-square analyses were performed as appropriate.

MAIN RESEARCH VARIABLES

Distress scores, problem reports, and time groups.

FINDINGS

Participants scored in range of the cutoff of more than 4 (range = 4.1-5.1) from treatment through three months post-treatment. At six months post-treatment, distress levels were significantly lower. Significant differences were found between groups on the total problem list score (p = 0.007) and emotional (p = 0.01) and physical subscale scores (p = 0.003).

CONCLUSIONS

Comparison of groups at different points in the cancer trajectory found similar elevated levels from diagnosis through three months. Distress remained elevated in early survivorship but significantly decreased at six months post-treatment.

IMPLICATIONS FOR NURSING

Interventions to reduce or prevent distress may improve outcomes in early survivorship.

Evidence-based psychosocial treatment in the community: considerations for dissemination and implementation

BACKGROUND

In psycho-oncology care, steps toward dissemination and implementation of evidence-based treatments (EBTs) have not been made. For this to change, factors associated with real-world dissemination and implementation must be identified. In the community, providers, their organizations, and patients are key stakeholders.

METHOD

A focused review of literatures in continuing education, dissemination, and implementation of mental health services is provided.

RESULTS

Early-career providers are most ready to implement as they have greater openness and more positive attitudes toward EBTs. Current continuing education practices to teach EBTs have limited effectiveness. Instruction using interactive strategies tailored to therapists' clinical needs and the provision of post-education consultation is needed. There is tension between EBT delivery with fidelity and the necessity for adaptation. EBT service provision is the key outcome of implementation, and documenting such is important to patients, providers, and organizations.

CONCLUSION

A multilevel conceptual framework, Setting, Therapist, Education, imPlementation, and Sustainability, is offered and provides directions for dissemination and sustainable implementation. Guidelines from the Commission on Cancer of the American College of Surgeons and the American Society of Clinical Oncology underscore the timeliness of the proposed framework to move EBTs from the research settings where they were developed to the practice settings where they are needed.

Dissemination of an evidence-based treatment for cancer patients: training is the necessary first step

Evidence-based psychological treatments (EBTs) for cancer patients have not been disseminated in part due to lack of available training. The biobehavioral intervention (BBI) is an EBT designed to alleviate cancer stress and enhance coping. The current study evaluates a training program and uses the Theory of Planned Behavior (TpB) to analyze factors related to intentions to implement BBI. Mental health providers (n = 62) attended a training for BBI. Attendees' supervisors (n = 40) were later surveyed. Repeated measure ANOVAs assessed change over time in knowledge gains, attitudes towards EBTs/BBI, and self-efficacy. Linear multiple regression analyses assessed relationships between these factors and implementation intentions. BBI knowledge and attitude scores increased from pre- to post-training (ps < 0.01). Significant predictors in the final model were BBI-specific attitudes and self-efficacy (ps < 0.05). The BBI training program was an effective dissemination vehicle. Intervention-specific attitudes and self-efficacy were key factors in predicting providers' implementation intentions.

Challenges to Standardizing the Care for Adult Cancer Survivors: Highlighting ASCO's Fatigue and Anxiety and Depression Guidelines

There are over 14 million survivors of cancer living in the United States alone and tens of millions more worldwide, with this population expected to nearly double in the next decade. The successes of prevention, early detection, and better therapies have lead to an emerging understanding of the substantial medical and psychosocial issues for this growing population that must be tackled for individuals and from the health care system and societal perspectives.

Test of mindfulness and hope components in a psychological intervention for women with cancer recurrence

OBJECTIVE

Psychological interventions can attenuate distress and enhance coping for those with an initial diagnosis of cancer, but there are few intervention options for individuals with cancer recurrence. To address this gap, we developed and tested a novel treatment combining Mindfulness, Hope Therapy, and biobehavioral components.

METHOD

An uncontrolled, repeated measures design was used. Women (N = 32) with recurrent breast or gynecologic cancers were provided 20 treatment sessions in individual (n = 12) or group (n = 20) formats. On average, participants were middle aged (M = 58) and Caucasian (81%). Independent variables (i.e., hope and mindfulness) and psychological outcomes (i.e., depression, negative mood, worry, and symptoms of generalized anxiety disorder) were assessed pre-treatment and 2, 4, and 7 months later. Session-by-session therapy process (positive and negative affect, quality-of-life) and mechanism (use of intervention-specific skills) measures were also included.

RESULTS

Distress, anxiety, and negative affect decreased, whereas positive affect and mental-health-related quality-of-life increased over the course of treatment, as demonstrated in mixed-effects models with the intent-to-treat sample. Both hope and mindfulness increased, and use of mindfulness skills was related to decreased anxiety.

CONCLUSIONS

This treatment was feasible to deliver and was acceptable to patients. The trial serves as preliminary evidence for a multi-component intervention tailored to treat difficulties specific to recurrent cancer. The blending of the components was novel as well as theoretically and practically consistent. A gap in the literature is addressed, providing directions for testing interventions designed for patients coping with the continuing stressors and challenges of cancer recurrence.

Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation

PURPOSE

A Pan-Canadian Practice Guideline on Screening, Assessment, and Care of Psychosocial Distress (Depression, Anxiety) in Adults With Cancer was identified for adaptation.

METHODS

American Society of Clinical Oncology (ASCO) has a policy and set of procedures for adapting clinical practice guidelines developed by other organizations. The guideline was reviewed for developmental rigor and content applicability.

RESULTS

On the basis of content review of the pan-Canadian guideline, the ASCO panel agreed that, in general, the recommendations were clear, thorough, based on the most relevant scientific evidence, and presented options that will be acceptable to patients. However, for some topics addressed in the pan-Canadian guideline, the ASCO panel formulated a set of adapted recommendations based on local context and practice beliefs of the ad hoc panel members. It is recommended that all patients with cancer be evaluated for symptoms of depression and anxiety at periodic times across the trajectory of care. Assessment should be performed using validated, published measures and procedures. Depending on levels of symptoms and supplementary information, differing treatment pathways are recommended. Failure to identify and treat anxiety and depression increases the risk for poor quality of life and potential disease-related morbidity and mortality. This guideline adaptation is part of a larger survivorship guideline series.

CONCLUSION

Although clinicians may not be able to prevent some of the chronic or late medical effects of cancer, they have a vital role in mitigating the negative emotional and behavioral sequelae. Recognizing and treating effectively those who manifest symptoms of anxiety or depression will reduce the human cost of cancer.

Association of the physiological stress response with depressive symptoms in patients with breast cancer

OBJECTIVE

The literature on the relationship of depressive symptoms and stress hormones after cancer diagnosis has been mixed, with some studies showing a relationship and other studies showing none. Time since diagnosis may explain these contradictory findings. This study examined the relationship of depressive symptoms to stress hormones in patients with breast cancer using 12-month longitudinal data.

METHODS

Patients with Stage II or III breast cancer (n = 227) were assessed every 4 months from diagnosis/surgery to 12 months. They completed the Centers for Epidemiological Studies Depression Scale (CES-D) Iowa Short Form and the Perceived Stress Scale and blood samples were obtained to measure stress hormones (i.e., cortisol, adrenocorticotropin hormone, norepinephrine, and epinephrine).

RESULTS

Depressive symptoms were negatively related to cortisol levels (β= -0.023, p = .002) but were positively related to rate of change in cortisol (β = 0.003, p = .003). Adrenocorticotropin hormone, epinephrine, and norepinephrine did not covary with depressive symptoms (all p values > .05). When the CES-D and Perceived Stress Scale were both used to predict cortisol, only the CES-D was significantly related (β = -0.025, p = .017).

CONCLUSIONS

Depressive symptoms were negatively related to cortisol, but this relationship changed from the time of diagnosis/surgery through 12 months. Cortisol may initially provide a buffering effect against depression during the stress of initial diagnosis and treatment, but this relationship seems to change over time.

Individual counseling is the preferred treatment for depression in breast cancer survivors

A substantial number of cancer patients experience depression. This study investigated treatment preferences for depression. Breast cancer survivors (N = 134) completed an anonymous survey asking preference and interest in three treatments for depression: individual counseling (IC), antidepressant medication (MED), or support groups (SG). Participants were recruited from a surgical oncology office and asked to complete the survey as they waited for their appointment. Preference was compared using Wilcoxon Signed Ranks tests. More than 50% ranked IC as first choice of treatment. Preference for IC was significantly higher than preference for MED and SG. Preference between MED and SG did not differ. Survivors prefered counseling for treatment of depression. Cancer centers should be prepared to provide preferred treatment methods, particulary as screening, and therefore management, of psychosocial distress is to be required.

Informal caregiving for cancer patients

According to the recent worldwide estimation by the GLOBOCAN project, in total, 12.7 million new cancer cases and 7.6 million cancer deaths occurred in 2008. The worldwide number of cancer survivors within 5 years of diagnosis has been estimated at be almost 28.8 million. Informal caregivers, such as family members and close friends, provide essential support to cancer patients. The authors of this report provide an overview of issues in the study of informal caregivers for cancer patients and long-term survivors in the United States and Europe, characterizing the caregivers commonly studied; the resources currently available to them; and their unmet needs, their psychosocial outcomes, and the psychosocial interventions tailored to their special circumstances. A broad overview of the state of research and knowledge, both in Europe and the United States, and observations on the directions for future research are provided.

Emotions and social relationships for breast and gynecologic patients: a qualitative study of coping with recurrence

BACKGROUND

In contrast to the large literature on patients' coping with an initial diagnosis of cancer, there have been few quantitative or qualitative studies of patients coping with recurrence. A qualitative study was undertaken to aid in the development of a tailored intervention for these patients.

METHODS

Individuals (N=35) receiving follow-up care for recurrent breast or gynecologic cancer at a university-affiliated cancer center participated in an individual or a group interview. Transcripts of interviews were analyzed using a coding format with two areas of emphasis. First, we focused on patients' emotions, as there is specificity between emotions and the corresponding ways in which individuals choose to manage them. Secondly, we considered the patients' social environments and relationships, as they too appear key in the adjustment to, and survival from, cancer.

RESULTS

Patients identified notable differences in their responses to an initial diagnosis of cancer and their current ones to recurrence, including the following: (i) depressive symptoms being problematic; (ii) with the passing years and the women's own aging, there is shrinkage in the size of social networks; and (iii) additional losses come from social support erosion, arising from a) intentional distancing by social contacts, b) friends and family not understanding that cancer recurrence is a chronic illness, and/or c) patients stemming their support requests across time.

CONCLUSION

The contribution of these findings to the selection of intervention strategies is discussed.

Supportive care during treatment for breast cancer: resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Breast cancer patients may have unmet supportive care needs during treatment, including symptom management of treatment-related toxicities, and educational, psychosocial, and spiritual needs. Delivery of supportive care is often a low priority in low- and middle-income settings, and is also dependent on resources available. This consensus statement describes twelve key recommendations for supportive care during treatment in low- and middle-income countries, identified by an expert international panel as part of the 5th Breast Health Global Initiative (BHGI) Global Summit for Supportive Care, which was held in October 2012, in Vienna, Austria. Panel recommendations are presented in a 4-tier resource-stratified table to illustrate how health systems can provide supportive care services during treatment to breast cancer patients, starting at a basic level of resource allocation and incrementally adding program resources as they become available. These recommendations include: health professional and patient and family education; management of treatment related toxicities, management of treatment-related symptoms of fatigue, insomnia and non-specific pain, and management of psychosocial and spiritual issues related to breast cancer treatment. Establishing supportive care during breast cancer treatment will help ensure that breast cancer patients receive comprehensive care that can help 1) improve adherence to treatment recommendations, 2) manage treatment-related toxicities and other treatment related symptoms, and 3) address the psychosocial and spiritual aspects of breast cancer and breast cancer treatments.

A national network to advance the field of cancer and female sexuality

INTRODUCTION

Understanding sexual health issues in cancer patients is integral to care for the continuously growing cancer survivor population.

AIM

To create a national network of active clinicians and researchers focusing on the prevention and treatment of sexual problems in women and girls with cancer.

METHODS

Interdisciplinary teams from the University of Chicago and Memorial Sloan-Kettering Cancer Center jointly developed the mission for a national conference to convene clinicians and researchers in the field of cancer and female sexuality. The invitee list was developed by both institutions and further iterated through suggestions from invitees. The conference agenda focused on three high-priority topics under the guidance of a professional facilitator. Breakout groups were led by attendees recognized by collaborators as experts in those topics. Conference costs were shared by both institutions.

MAIN OUTCOME MEASURE

Development of Scientific Working Groups (SWGs).

RESULTS

One hundred two clinicians and researchers were invited to attend the 1st National Conference on Cancer and Female Sexuality. Forty-three individuals from 20 different institutions across 14 states attended, including representation from eight National Cancer Institute (NCI)-funded cancer centers. Attendees included PhD researchers (N = 19), physicians (N = 16), and other healthcare professionals (N = 8). Breakout groups included (i) Defining key life course sexuality issues; (ii) Building a registry; and (iii) Implementing sexual health assessment. Breakout group summaries incorporated group consensus on key points and priorities. These generated six SWGs with volunteer leaders to accelerate future research and discovery: (i) Technology-based interventions; (ii) Basic science; (iii) Clinical trials; (iv) Registries; (v) Measurement; and (vi) Secondary data analysis. Most attendees volunteered for at least one SWG (N = 35), and many volunteered for two (N = 21).

CONCLUSION

This 1st National Conference demonstrated high motivation and broad participation to address research on cancer and female sexuality. Areas of need were identified, and SWGs established to help promote research in this field.

Do survivorship care plans impact patients' evaluations of care? A randomized evaluation with gynecologic oncology patients

OBJECTIVE

Despite recommendations from the Institute of Medicine regarding survivorship care plan (SCP) delivery to cancer patients, there have been few health service outcome evaluations thus far.

METHODS

Gynecologic cancer survivors who were up to one-year post-treatment could participate in an evaluation assessing the health services provided and their perceptions of quality of care. A randomized, nested, cross-sectional design was used in a large group gynecologic oncology practice. Half (n=3) of the physicians were randomized to provide and discuss a SCP to patients during a follow-up visit, and the other half did not. Following their visits, all patients were informed that a health service evaluation of the practice was being conducted. Interested patients completed an anonymous 26-item survey assessing administrative, clinical, and educational health services, helpfulness of written materials, and perceptions of quality of care.

RESULTS

Of the 121 survivors surveyed, 64 received SCPs and 57 were in the no-SCP condition. As a validity check, one question asked about educational materials received during the visit with an expected significant difference noted between conditions (X(2)=5.513, p=.019; more SCP patients reported receiving materials). However, there were no differences between conditions when patients rated health services (Fs>.37) or helpfulness of materials and perceptions of care (Fs>.19).

CONCLUSIONS

Gynecologic oncology patients providing ratings of health services and satisfaction with care provided equivalent evaluations, regardless if they had/had not received a SCP from the physician. Thus, the need remains for further evaluations of SCPs if they are to be vehicles for improving health service outcomes.

Gynecologic care for breast cancer survivors: assisting in the transition to wellness

Currently, there are >2 million survivors of breast cancer in the United States. Two years after cancer treatment, patients may transition to primary care providers and/or gynecologists. Many of these survivors may have difficulties with menopausal symptoms. If they do not know already, some of these women may want or need risk assessment for hereditary- or treatment-induced second cancers. At least 20% will also have significant psychologic, sexual, and/or relationship difficulties that require attention. All of the women will need assistance to learn and follow recommendations for surveillance, detecting recurrence, and promoting wellness. Thus, gynecologists play a critical role in helping these patients in their health care transitions. To assist the gynecologists, we have reviewed the evaluation and management of common sequelae of breast cancer diagnoses and treatments.