"Moving Forward": Older Adult Motivations for Group-Based Physical Activity After Cancer Treatment

Background

Engagement in physical activity (PA) post-treatment can improve health outcomes and quality of life among cancer survivors. The purpose of this study is to explore United States (US) older adult cancer survivors’ (OACS) reasons for engaging in group-based PA classes, to identify themes supporting exercise motivations in the context of cancer recovery.

Methods

OACS participating in a fitness program at a large US comprehensive cancer center completed semi-structured interviews. Transcripts were analyzed using modified grounded theory, and demographic data were analyzed descriptively.

Results

Modified grounded theory analysis (n = 25; age M = 70.92, SD = 10.82; 9 cancer types) identified individual rationales for exercise grounded in collective experience. Participants’ internal motivations for PA are shaped by the desire for control over an uncertain future and post-treatment body, obtained by literally “moving forward” post-cancer; this is supported by external motivations for social connections that present a positive model of survivorship, within a setting that instills confidence and safety.

Conclusions

Exercise can be a way for older adults to tap into internal and external motivations that support cancer survivorship. Interventions that make explicit connections between exercise and cancer recovery, facilitate interpersonal interaction, and promote a sense of safety may be the most effective. The concepts identified in this study can inform the development of future interventions to improve long-term behavior change among OACS and evaluate existing PA programs.

Genetic Predictors of Response to Acupuncture or Cognitive Behavioral Therapy for Insomnia in Cancer Survivors: An Exploratory Analysis

CONTEXT

Insomnia is a common problem affecting cancer survivors. While effective nonpharmacological treatments are available, it is unknown whether individual genetic characteristics influence treatment response.

OBJECTIVES

We conducted an exploratory analysis of genetic associations with insomnia treatment response in a randomized trial of cognitive behavioral therapy for insomnia (CBT-I) vs. acupuncture in a heterogeneous group of cancer survivors.

METHODS

We successfully genotyped 136 participants for 11 genetic variants. Successful treatment response was defined as a reduction in Insomnia Severity Index score of at least eight points from baseline to week 8. We used Fisher exact tests to evaluate associations between genotype and treatment success for each treatment arm, for an alpha level of 0.05 with unadjusted and Holm-Bonferroni-adjusted P-values.

RESULTS

We found that more carriers of COMT rs4680-A alleles responded to acupuncture compared to the GG carriers (63.6% vs. 27.8%, P = 0.013). More carriers of the NFKB2 rs1056890 CC genotype also responded to acupuncture compared to TT or CT carriers (72.2% vs. 38.9%, P = 0.009). There were no significant differences found between any of the tested gene variants and CBT-I response. None of the results remained statistically significant after adjustment for multiple testing.

CONCLUSION

In cancer survivors, specific variants in the COMT and NFKB2 genes are potentially associated with response to acupuncture but not to CBT-I. Confirming these preliminary results will help inform precision insomnia management for cancer survivors.

ChemoPalRx-A Mobile App That Enhances Chemotherapy Prescription Accuracy: A Cross-Sectional Study

PURPOSE

ChemoPalRx is a novel provider order entry mobile application for chemotherapy. This study aims to evaluate the accuracy of prescribing chemotherapy using ChemoPalRx versus handwritten orders at a safety-net hospital in Los Angeles.

METHODS

In a cross-sectional study from October 2019 to December 2019, we evaluated all outpatient chemotherapy orders for accuracy. Our primary predictor was type of prescription, dichotomized as handwritten or ChemoPalRx. Primary outcome was accuracy, dichotomized as accurate if no error was made on an order and as inaccurate if any error was made. Preplanned subgroup analyses were performed with covariates including provider experience, complexity of order, and day of order submission. We characterized error type and analyzed our data using univariate and multivariate logistic regression models.

RESULTS

Among 288 orders (78.5% handwritten; 21.5% ChemoPalRx), prescription accuracy was higher among ChemoPalRx (93.5%) compared with handwritten orders (81.4%; P = .012). In multivariate analysis, prescription accuracy remained superior for ChemoPalRx after adjusting for provider experience, complexity of order, and day of order submission (adjusted odds ratio, 1.82; P = .012). Compared with handwritten orders, ChemoPalRx orders had less missing or incorrect information (1.6% v 13.7%; P = .0016). ChemoPalRx orders were also more accurate on prescriptions that contained two or fewer medications (92.2% v 80.2%; P = .032), submitted on the highest patient-volume clinic day of the week (96.7% v 83.2%; P = .035), and generated by a senior fellow or an attending (97.3% v 76.9%; P = .001).

CONCLUSION

ChemoPalRx is associated with improved chemotherapy prescription accuracy over handwritten orders in the safety-net hospital setting and may serve as an alternative prescribing tool for oncology practices.

A Systematic Review of CheeZheng Pain Relieving Plaster for Musculoskeletal Pain: Implications for Oncology Research and Practice

BACKGROUND

Musculoskeletal pain is a common and debilitating condition for cancer patients. Existing therapies for these pain conditions have substantial limitations. To identify an integrative approach to pain management, we conducted a systematic review to evaluate the safety and efficacy of a Tibetan herbal-based topical agent, CheeZheng Pain Relieving Plaster (PRP), for the treatment of osteoarthritis (OA) pain.

METHODS

We extracted citations from PubMed and Chinese databases (CNKI, WanFang Data, and CQVIP). We included randomized clinical trials evaluating the effectiveness and safety of CheeZheng PRP compared to conventional OA pain treatments.

RESULTS

Twenty-two randomized clinical trials (n = 2556 participants) compared CheeZheng PRP against nonsteroidal anti-inflammatory drugs (11), glucosamine (2), intraarticular corticosteroid (2), hyaluronic acid injections (6), and acetaminophen (1). Ten studies found a statistically greater effectiveness (assessed by ≥30% reduction in symptom severity) of CheeZheng PRP in improving OA pain (measured by the Visual Analogue Scale), stiffness, and function compared to control. Ten studies reported that 4.8% of participants experienced application site skin irritation that resolved after discontinuing the plaster. Randomization was not sufficiently described in most studies, and no placebo-controlled trials were identified.

CONCLUSIONS

There is promising evidence for the safety and clinical effectiveness of CheeZheng PRP to treat OA; however, lack of placebo control and unclear descriptions of randomization increase the potential risk for bias. Future randomized, placebo-controlled trials are needed to establish the safety and efficacy of CheeZheng PRP for pain management in oncology settings.

Availability of Integrative Medicine Therapies at National Cancer Institute-Designated Comprehensive Cancer Centers and Community Hospitals

Introduction: The authors compared the availability of integrative medicine therapies in National Cancer Institute-Designated Comprehensive Cancer Centers and community hospitals. Methods: The authors reviewed 51 Comprehensive Cancer Center and 100 community hospital websites and collected race and median household income data for community hospital populations. Results: Availability of acupuncture (56% vs. 76.5%, p = 0.01), meditation (63% vs. 82.4%, p = 0.02), and music therapy (55% vs. 74.5%, p = 0.02) was significantly lower at community hospitals compared with Comprehensive Cancer Centers. Integrative medicine availability was also significantly lower in community hospitals serving lower-income populations. Conclusion: Equitable access to evidence-based integrative medicine in community hospitals is needed.

Patient Perspectives on Active vs. Passive Music Therapy for Cancer in the Inpatient Setting: A Qualitative Analysis

CONTEXT

Music therapy (MT) is a nonpharmacologic therapy where licensed therapists provide active (e.g., singing, playing songs) or passive (e.g., listening) music-based interventions. Both active and passive MT are effective techniques for treating cancer-related symptoms. However, the influence of active vs. passive MT techniques on patient-reported perceptions and experiences of care have yet to be explored.

OBJECTIVES

To understand how active and passive MT is perceived and experienced by patients with cancer.

METHODS

We conducted a retrospective analysis of semistructured interviews collected as part of a quality improvement study (n = 20) with patients in the inpatient setting who had received active or passive MT within the past 24 hours. Transcripts were analyzed using thematic content analysis.

RESULTS

Four themes emerged: 1) Different articulations of benefit for recipients of active vs. passive MT; 2) patient choice as a form of empowerment; 3) changed perception of hospital experience; and 4) differing recommendations for future MT. Recipients of active MT emphasized the session's interactive elements, finding the sessions stimulating by providing opportunities for joyous social interaction not centered on their diagnosis. Passive MT recipients focused on the calming therapeutic effect of the session, easing anxieties through focus and reflection on the music itself.

CONCLUSION

This analysis builds on current MT literature by providing insights specifically from oncology patients treated in the inpatient setting. Patients experience active and passive MT in different ways and perceived unique benefits for coping with cancer from each technique. Our findings can inform development of specific MT for symptom control in hospital settings.

Herbal Topical Analgesic for Pain Management: Perspectives from Cancer Patients

OBJECTIVE

Herbs and natural products are increasingly used by cancer patients for pain management, but few studies have examined their integration within conventional cancer care. This study describes the characteristics, experiences, and perspectives of cancer patients who were prescribed an herbal topical analgesic for pain management.

DESIGN AND SETTING

Program evaluation of a pilot herbal dispensary at a National Cancer Institute-designated comprehensive cancer center.

SUBJECTS

Cancer patients who were prescribed the Tibetree Pain-Relieving Plaster (PRP) by an integrative medicine physician.

METHODS

Sociodemographic and clinical characteristics of patients were abstracted from medical records. Semistructured phone interviews were conducted 1-2 weeks after PRP prescription to evaluate patient experiences with using PRP for pain. Interviews were analyzed through thematic content analysis.

RESULTS

From February 2019 to February 2020, 50 patients were prescribed PRP. Median age (range) was 63 years (21-86), 37 patients (74%) were female, 14 (28%) were non-White, and 38 (76%) were using oral analgesics. During interviews, the majority of patients reported that the PRP improved pain and health-related outcomes, was convenient to use, and addressed pain management needs that were not fulfilled by oral analgesics. However, a few patients described adverse experiences with PRP, including skin irritation.

CONCLUSIONS

Understanding patient experiences and perspectives is a critical step toward evidence-based integration of herbs and natural products into cancer pain management. Findings from this program evaluation will inform the design of a randomized clinical trial on the efficacy and safety of PRP for pain in patients with cancer.

Patient Reported Traditional Chinese Medicine Spleen Deficiency Syndrome (TCM-SDS) Scale for Colorectal Cancer: Development and Validation in China

Introduction:

Spleen Deficiency Syndrome (SDS) is recognized as one of the most common Traditional Chinse Medicine (TCM) syndromes in patients with colorectal cancer (CRC). However so far there is no existing patient-reported outcome (PRO) to evaluate SDS. Our study aimed to develop and validate a PRO TCM-SDS scale for CRC in China.

Methods:

We developed an initial 8-item TCM-SDS scale for CRC based on literature review and consultation with experts. We then pilot tested the scale (n = 40) and performed item revision. We conducted a survey study among CRC patients from oncology clinics at a TCM Hospital to further determine the reliability and validity of the scale.

Results:

Among 100 patients finally enrolled and analyzed in the survey study, 46% were female with median age of 60 years old, 77% had left side tumors and 23% had stage IV disease. Factor loading indicated that there were three domains within TCM-SDS scale. The final TCM-SDS scale involves 5 items including “I feel loss of appetite,” “I feel abdomen fullness,” “I feel my arms and legs lack strength,” “I feel short of breath when talking,” and “My stool is formless” (Cronbach’s alpha coefficient 0.76). We calculated the total score of the scale by summing the 5 individual items and normalizing them to a value maximum of 10, with higher scores indicating greater burden of spleen deficiency syndrome. The average spleen deficiency score for all patients was 3.55 ± 1.54. Among them, those who had stage IV disease had higher scores than stage I-III patients (4.30 vs 3.38, P = .015). Test-retest reliability after 2 weeks showed Pearson coefficient of 0.67 and all items were highly related (P < .001). Compared with healthy controls, CRC patients had significantly higher spleen deficiency scores (3.55 vs 3.23, P = .045).

Conclusion:

The patient-reported TCM-SDS scale for CRC showed adequate initial reliability and validity. The development of the scale provided an outcome measurement tool, which could facilitate future studies to better evaluate the role of TCM in treating CRC.

Quality of life in long-term survivors of advanced melanoma treated with checkpoint inhibitors

Background

Immune checkpoint inhibitors (CIs) have revolutionized treatment of advanced melanoma, leading to an emerging population of long-term survivors. Survivors’ quality of life (QOL) and symptom burden are poorly understood. We set out to evaluate symptom burden and QOL in patients with advanced melanoma alive more than 1 year after initiating CI therapy.

Methods

Cross-sectional surveys, accompanied by chart review of patients with advanced melanoma treated with CIs at Memorial Sloan Kettering Cancer Center, completed therapy, and were alive >1 year after treatment initiation. Surveys were administered between February and August 2018. Surveys included: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, EuroQOL, items from Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events and Fatigue Severity Scale.

Results

We included 90 patients. The most common CI regimens were ipilimumab plus nivolumab (53%) and pembrolizumab (41%); most patients (71%) were not treated in clinical trials. Median time from CI therapy initiation was 40 months and from last dose was 28 months. Fatigue was reported by 28%, with higher fatigue scores in women than men; 12% reported difficulty sleeping. Aching joints (17%) and muscles (12%) were fairly common. Level of functioning was generally high. Overall QOL was excellent though 40% reported ‘some or moderate’ problems with anxiety/depression and 31% with pain/discomfort.

Conclusions

After CI therapy, long-surviving advanced melanoma patients commonly report fatigue but otherwise have moderate symptom burden and good QOL. Ensuring appropriate symptom management will optimize clinical outcomes for these patients.

Virtual Mind-Body Programming for Patients With Cancer During the COVID-19 Pandemic: Qualitative Study

BACKGROUND

Patients with cancer are particularly vulnerable to stress and anxiety during the COVID-19 pandemic. Social distancing is critical for patients with cancer; however, it can also reduce their access to psychosocial coping resources.

OBJECTIVE

The aim of this study was to explore patient experiences to generate a model of how virtual mind-body programs can support the psychosocial well-being of patients with cancer.

METHODS

We conducted a qualitative study among patients (aged ≥18 years) who participated in a virtual mind-body program offered by a National Cancer Institute-designated Comprehensive Cancer Center during the COVID-19 pandemic. The program consisted of mind-body group therapy sessions of fitness, yoga, tai chi, dance therapy, music therapy, and meditation. Live integrative medicine clinicians held each session via Zoom videoconferencing for 30-45 minutes. In semistructured phone interviews (n=30), patients were asked about their overall impressions and perceptions of the benefits of the sessions, including impacts on stress and anxiety. Interviews were analyzed using grounded theory.

RESULTS

Among the 30 participants (average age 64.5 years, SD 9.36, range 40-80, 29 female), three major themes were identified relating to experiences in the virtual mind-body program: (1) the sessions helped the patients maintain structured routines and motivated them to adhere to healthy behaviors; (2) the sessions enhanced coping with COVID-19-related-stressors, allowing patients to "refocus" and "re-energize"; and (3) the sessions allowed patients to connect, fostering social relationships during a time of isolation. These themes informed the constructs of a novel behavioral-psychological-social coping model for patients with cancer.

CONCLUSIONS

Virtual mind-body programming supported patients with cancer during the COVID-19 pandemic through a behavioral-psychological-social coping model by enhancing psychological coping for external stressors, supporting adherence to motivation and health behaviors, and increasing social connection and camaraderie. These programs have potential to address the behavioral, psychological, and social challenges faced by patients with cancer during and beyond the COVID-19 pandemic. The constructs of the conceptual model proposed in this study can inform future interventions to support isolated patients with cancer. Further clinical trials are needed to confirm the specific benefits of virtual mind-body programming for the psychosocial well-being and healthy behaviors of patients with cancer.

Tibetan herbal pain-relieving plaster for low back pain: A systematic review and meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Tibetan traditional medicine CheeZheng Pain-Relieving Plaster (CZPRP) is frequently used as an over-the-counter external analgesic for musculoskeletal pain; however, its evidence for low back pain (LBP) has not been evaluated.

AIM OF THE STUDY

This study aims to assess the efficacy and safety of CZPRP for both acute, subacute and chronic LBP through a systematic review and meta-analysis of clinical trials.

MATERIALS AND METHODS

PubMed, CENTRAL, CNKI, CQVIP, and Wanfang databases were searched through April 20, 2020 for randomized controlled trials of CZPRP for LBP. Eligible comparators were placebo, active treatment, or usual care. Clinical outcomes included pain severity, lower back function score, pain-free rate, and adverse events (AEs). Qualitative evaluations were conducted using the Cochrane risk of bias assessment tools. Quantitative analyses were conducted using a random-effects model.

RESULTS

This study includes 1674 LBP patients from nine clinical studies. Pooled analyses among subjects with acute LBP show 1) significant pain reductions (mean difference -0.84, 95% confidence interval[CI] -1.31, -0.37) in CZPRP plus diclofenac versus diclofenac, 2) significant improvements in lower back function (standard mean difference -1.50, 95% CI -2.16, -0.85) in CZPRP versus diclofenac, and 3) a higher pain-free rate in CZPRP alone (risk ratio 1.48, 95% CI 1.16, 1.89; I² = 61%) or CZPRP plus nonsteroidal anti-inflammatory drugs (NSAIDs) (risk ratio 1.66, 95% CI 1.14, 2.40; I² = 0%) versus NSAIDs. However, in a heterogeneous population with mixed LBP subtypes, there was no significant difference in pain outcomes between CZPRP and diclofenac. Additionally, CZPRP use did not increase AEs compared with no CZPRP (p = 0.40). All nine studies are associated with moderate to high risk of bias.

CONCLUSIONS

The use of CZPRP is associated with improved acute LBP outcomes compared to diclofenac. However, due to the moderate to high risk of bias of the studies, future rigorous randomized controlled trials are needed to evaluate the effects of CZPRP for acute and chronic LBP.

Effectiveness of Electroacupuncture or Auricular Acupuncture vs Usual Care for Chronic Musculoskeletal Pain Among Cancer Survivors: The PEACE Randomized Clinical Trial

Importance

The opioid crisis creates challenges for cancer pain management. Acupuncture confers clinical benefits for chronic nonmalignant pain, but its effectiveness in cancer survivors remains uncertain.

Objective

To determine the effectiveness of electroacupuncture or auricular acupuncture for chronic musculoskeletal pain in cancer survivors.

Design, Setting, and Participants

The Personalized Electroacupuncture vs Auricular Acupuncture Comparative Effectiveness (PEACE) trial is a randomized clinical trial that was conducted from March 2017 to October 2019 (follow-up completed April 2020) across an urban academic cancer center and 5 suburban sites in New York and New Jersey. Study statisticians were blinded to treatment assignments. The 360 adults included in the study had a prior cancer diagnosis but no current evidence of disease, reported musculoskeletal pain for at least 3 months, and self-reported pain intensity on the Brief Pain Inventory (BPI) ranging from 0 (no pain) to 10 (worst pain imaginable).

Interventions

Patients were randomized 2:2:1 to electroacupuncture (n = 145), auricular acupuncture (n = 143), or usual care (n = 72). Intervention groups received 10 weekly sessions of electroacupuncture or auricular acupuncture. Ten acupuncture sessions were offered to the usual care group from weeks 12 through 24.

Main Outcomes and Measures

The primary outcome was change in average pain severity score on the BPI from baseline to week 12. Using a gatekeeping multiple-comparison procedure, electroacupuncture and auricular acupuncture were compared with usual care using a linear mixed model. Noninferiority of auricular acupuncture to electroacupuncture was tested if both interventions were superior to usual care.

Results

Among 360 cancer survivors (mean [SD] age, 62.1 [12.7] years; mean [SD] baseline BPI score, 5.2 [1.7] points; 251 [69.7%] women; and 88 [24.4%] non-White), 340 (94.4%) completed the primary end point. Compared with usual care, electroacupuncture reduced pain severity by 1.9 points (97.5% CI, 1.4-2.4 points; P < .001) and auricular acupuncture reduced by 1.6 points (97.5% CI, 1.0-2.1 points; P < .001) from baseline to week 12. Noninferiority of auricular acupuncture to electroacupuncture was not demonstrated. Adverse events were mild; 15 of 143 (10.5%) patients receiving auricular acupuncture and 1 of 145 (0.7%) patients receiving electroacupuncture discontinued treatments due to adverse events (P < .001).

Conclusions and Relevance

In this randomized clinical trial among cancer survivors with chronic musculoskeletal pain, electroacupuncture and auricular acupuncture produced greater pain reduction than usual care. However, auricular acupuncture did not demonstrate noninferiority to electroacupuncture, and patients receiving it had more adverse events.

Trial Registration

ClinicalTrials.gov Identifier: NCT02979574.

Effects of acupuncture versus cognitive behavioral therapy on brain-derived neurotrophic factor in cancer survivors with insomnia: an exploratory analysis

INTRODUCTION

Decreased brain-derived neurotrophic factor (BDNF) is associated with poor sleep. This study examined the effects of acupuncture versus cognitive behavioral therapy for insomnia (CBT-I) on serum BDNF and sleep outcomes in cancer survivors with insomnia.

METHODS

This was an exploratory analysis of a randomized clinical trial (n = 160) comparing acupuncture versus CBT-I for cancer survivors with insomnia. Interventions were delivered over 8 weeks. Outcomes were assessed at baseline and week 8. Serum BDNF was evaluated with enzyme-linked immunosorbent assay (ELISA). Sleep was evaluated with the insomnia severity index and consensus sleep diary. Pearson correlations between BDNF and sleep outcomes were calculated. Data analysis was limited to 87 survivors who provided serum samples.

RESULTS

Among 87 survivors, the mean age was 61.9 (SD: 11.4) years, 51.7% were women, and 24.1% were non-White. Mean serum BDNF did not significantly increase in acupuncture (n = 50) or CBT-I (n = 37) groups. When analysis was restricted to patients with low baseline BDNF (i.e. levels below the sample median of 47.1 ng/mL), the acupuncture group (n = 22) demonstrated a significant 7.2 ng/mL increase in mean serum BDNF (P = 0.03), whereas the CBT-I group (n = 21) demonstrated a non-significant 2.9 ng/mL increase (P = 0.28). Serum BDNF was not significantly correlated with sleep outcomes (all P > 0.05).

CONCLUSION

Among cancer survivors with insomnia and low baseline BDNF, acupuncture significantly increased serum BDNF levels; however, the clinical significance of this finding requires further investigation.Trial registration no. NCT02356575 (ClinicalTrials.gov).

Understanding interest, barriers, and preferences related to yoga practice among cancer survivors

PURPOSE

Despite growing evidence supporting the benefits of yoga for cancer-related symptom management, yoga usage among cancer survivors is low. To translate the evidence of yoga benefits into community practice, it is critical to understand interest in yoga as well as barriers and preferences that influence yoga usage among cancer survivors.

METHOD

We conducted a cross-sectional survey study among cancer survivors, 18 years or older, with a primary diagnosis of cancer, and receiving treatment or follow-up care at outpatient clinics at five regional academic cancer center sites. We collected data and performed bivariate and multivariable analyses on self-reported yoga usage and interest in and barriers to practicing yoga, as well as preferred location and time for yoga practice.

RESULTS

Of 857 participants, 70.0% had never practiced yoga and 52.3% were interested in practicing yoga. Among those interested, 52.5% had never practiced yoga. Lower interest was independently associated with being male (odds ratio [OR] = 0.30, 95% confidence interval [CI] = 0.20-0.44, p < 0.001), unemployed (OR = 0.60, 95% CI = 0.39-0.91, p = 0.016), and white (OR = 0.42, 95% CI = 0.23-0.78, p = 0.005). Commonly cited barriers among those who were interested but had never practiced were not aware of yoga benefits (36.3%), difficulty motivating (28.7%), experiencing symptoms (22.9%), and not enough time (22.0%). Participants indicated "on-site and at a studio near home" (41.5%) as preferred location and evenings (3-8 pm, 34.0%) as preferred time for yoga practice.

CONCLUSION

Although more than 50% of patients indicated interest in practicing yoga, use of yoga is low among cancer survivors. Barriers and patient preferences for yoga practice need to be addressed to design effective yoga programs for this population.

Hyperarousal and Insomnia in Survivors of Cancer

BACKGROUND

Cancer survivors are prone to insomnia due to the physical and psychological sequelae of cancer and treatment. Individuals with insomnia may present symptoms of hyperarousal. Cancer survivors with insomnia and trait hyperarousal may require different clinical treatments than patients with insomnia without trait hyperarousal. To our knowledge, no study has examined these factors previously. This study examined the relation between insomnia and trait hyperarousal in cancer survivors.

METHODS

The sample included 160 individuals with previous cancer diagnoses who met DSM-5 criteria for insomnia disorder. Measures were collected with cross-sectional batteries of questionnaires, including the Insomnia Severity Index (ISI) and Hyperarousal Scale (HAS). This study is based on baseline data collected in a randomized clinical trial comparing CBT-I to acupuncture for cancer survivors with insomnia (Garland, Gehrman, Barg, Xie, & Mao, 2016).

RESULTS

Hyperarousal was positively associated with insomnia (ISI total score) in bivariate correlations (r = .350, p < .01) and linear regressions (F = 22.06, p < .001). In bivariate correlations, hyperarousal was related to perceptions about the consequences of disturbed sleep rather than reported sleep patterns. For example, hyperarousal was positively related to reported satisfaction (r = .159, p < .05) and worry about sleep (r = .415, p < .01), but not to falling asleep, staying asleep, or awakening too early. In regressions, younger age, insomnia duration, and worry about sleep were uniquely associated with hyperarousal when adjusting for insomnia (B = 0.200, B = 0.177, B = -0.182, p < .05).

CONCLUSIONS

Hyperarousal is associated with psychological appraisal of insomnia rather than reported sleep pattern. Younger age and longer duration of insomnia are associated with trait hyperarousal. These findings suggest targeting trait hyperarousal with amplified psychological treatment may lead to more personalized, effective treatment for insomnia.

Multi-stakeholder perspectives on managing insomnia in cancer survivors: recommendations to reduce barriers and translate patient-centered research into practice

PURPOSE

Insomnia is a debilitating symptom experienced by nearly 60% of cancer survivors. Building on our prior research showing the clinical benefit of cognitive behavioral therapy for insomnia (CBT-I) and acupuncture, we organized a workshop of patient advocates and clinician stakeholders to understand the barriers and develop recommendations for the dissemination and implementation of these interventions.

METHODS

Participants completed a pre-workshop survey assessing their experiences with insomnia and barriers to insomnia treatment and participated in a workshop facilitated by professionals and patient experts. Responses from the survey were tabulated and the discussions from the workshop were content-analyzed to extract relevant factors that may influence dissemination and implementation.

RESULTS

Multidisciplinary and stakeholder workshop participants (N = 51) identified barriers and proposed solutions and future recommendations for dissemination and implementation of evidence-based interventions to improve sleep health in cancer survivors. Barriers were identified in four categories: patient (e.g., knowledge, time, cost), clinician (e.g., education, time, capacity), institutional (e.g., space, insurance reimbursement, referrals), and societal (e.g., lack of prioritization for sleep issues). Based on these categories, we made six recommendations for dissemination and implementation of research findings to improve clinical sleep management in oncology.

CONCLUSION

Dissemination and implementation efforts are necessary to translate research into clinical practice to improve patient care.

IMPLICATIONS FOR CANCER SURVIVORS

Sleep needs to be prioritized in cancer care, but patient, provider, and institutional/societal barriers remain. Dedicated effort and resources at each of these levels are needed to help millions of people affected by cancer manage their insomnia and improve their quality of life.

Herbal formula MaZiRenWan (Hemp Seed Pill) for constipation: A systematic review with meta-analysis

BACKGROUND

There is growing interest in using herbal supplements to treat constipation; however, little evidence exists for their use.

PURPOSE

This study evaluates the efficacy and safety of herbal formula MaZiRenWan (Hemp Seed Pill, HSP) in patients with functional or non-functional constipation.

STUDY DESIGN

Systematic review and meta-analysis METHODS: PubMed, CENTRAL, Embase, CNKI, and Wanfang were searched through April 20, 2020 for randomized trials of HSP versus placebo or medications for all types of constipation. The primary outcomes were complete response rate, complete spontaneous bowel movement (CSBM), patient-reported satisfactory treatment rate (prSTR), and adverse events (AEs). Clinical data were analyzed using a random-effects model, and the quality of evidence was evaluated with the GRADE system.

RESULTS

This review includes 1681 constipation patients from 17 moderate-to-high risk of bias trials that were conducted in east Asia. Two high-quality trials showed that HSP compared with placebo significantly increased weekly CSBM (mean difference, 0.95; 95% CI: 0.56, 1.35) and had a higher complete response rate (risk ratio [RR], 1.43; 95% CI: 1.20, 1.71) in patients with functional constipation. Low-quality evidence showed significant improvement in prSTR in HSP compared with conventional medications (RR, 1.79; 95% CI: 1.42, 2.25). Additionally, HSP use did not increase AEs compared with no HSP (p = 0.99).

CONCLUSIONS

This study found that HSP was effective among Asian patients with functional constipation. Rigorous trials need to be conducted in clinical populations outside of east Asia and in those with non-functional constipation to increase the generalizability of the evidence.

Reduction of Opioid Use by Acupuncture in Patients Undergoing Hematopoietic Stem Cell Transplantation: Secondary Analysis of a Randomized, Sham-Controlled Trial

OBJECTIVE

To evaluate acupuncture as a nonpharmacologic intervention for pain management in patients undergoing hematopoietic stem cell transplantation (HSCT).

METHODS

Adult patients with multiple myeloma undergoing high-dose melphalan chemotherapy and autologous peripheral blood HSCT were randomized to receive either true (TA) or sham acupuncture (SA) once daily for five days starting on the day after chemotherapy. Use of pain medications and pain scores were assessed at baseline and at days 5, 15, and 30 after transplantation.

RESULTS

Among 60 evaluable subjects, the SA group (vs TA) had greater than five times odds of increasing pain medication use from baseline. Among patients who were opioid nonusers at baseline, all 15 patients in the TA group remained free from opioid use at the end of the study. In contrast, 20% of those in the SA group (four of the 20 patients) started to use opioids after chemotherapy and stem cell infusion (day 5) and 40% (eight of the 20) had become opioid users by day 30 after HSCT (Fisher exact test P = 0.006). Among patients who were taking opioids at baseline, 14% in the TA group vs 10% in the SA group increased opioid intake at day 5, and 21% (TA) vs 30% (SA) at day 30 (P = 0.86).

CONCLUSIONS

Acupuncture appears to significantly reduce the need for pain medications during HSCT and the number of post-HSCT opioid users among baseline opioid nonusers. It warrants further studies as an opioid-sparing intervention for pain in HSCT patients.

Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis

Question

Is the use of acupuncture and acupressure associated with improved cancer pain management compared with sham intervention and/or analgesic therapy alone?

Findings

In this systematic review of 17 randomized clinical trials and meta-analysis of 14 trials in the current English-language and Chinese-language literature, a significant association was found between real (compared with sham) acupuncture and reduced pain, and acupuncture combined with analgesic therapy was associated with decreased analgesic use. However, heterogeneity lowered the level of certainty of the evidence.

Meaning

This study found a moderate level of evidence that acupuncture and/or acupressure was significantly associated with lower pain intensity in patients with cancer compared with a sham control, which suggests a potential for a combination of acupuncture and acupressure to help reduce opioid doses in patients with cancer.

Importance

Research into acupuncture and acupressure and their application for cancer pain has been growing, but the findings have been inconsistent.

Objective

To evaluate the existing randomized clinical trials (RCTs) for evidence of the association of acupuncture and acupressure with reduction in cancer pain.

Data Sources

Three English-language databases (PubMed, Embase, and CINAHL) and 4 Chinese-language biomedical databases (Chinese Biomedical Literature Database, VIP Database for Chinese Technical Periodicals, China National Knowledge Infrastructure, and Wanfang) were searched for RCTs published from database inception through March 31, 2019.

Study Selection

Randomized clinical trials that compared acupuncture and acupressure with a sham control, analgesic therapy, or usual care for managing cancer pain were included.

Data Extraction and Synthesis

Data were screened and extracted independently using predesigned forms. The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. Random-effects modeling was used to calculate the effect sizes of included RCTs. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation approach.

Main Outcomes and Measures

The primary outcome was pain intensity measured by the Brief Pain Inventory, Numerical Rating Scale, Visual Analog Scale, or Verbal Rating Scale.

Results

A total of 17 RCTs (with 1111 patients) were included in the systematic review, and data from 14 RCTs (with 920 patients) were used in the meta-analysis. Seven sham-controlled RCTs (35%) were notable for their high quality, being judged to have a low risk of bias for all of their domains, and showed that real (compared with sham) acupuncture was associated with reduced pain intensity (mean difference [MD], −1.38 points; 95% CI, −2.13 to −0.64 points; I² = 81%). A favorable association was also seen when acupuncture and acupressure were combined with analgesic therapy in 6 RCTs for reducing pain intensity (MD, −1.44 points; 95% CI, −1.98 to −0.89; I² = 92%) and in 2 RCTs for reducing opioid dose (MD, −30.00 mg morphine equivalent daily dose; 95% CI, −37.5 mg to −22.5 mg). The evidence grade was moderate because of the substantial heterogeneity among studies.

Conclusions and Relevance

This systematic review and meta-analysis found that acupuncture and/or acupressure was significantly associated with reduced cancer pain and decreased use of analgesics, although the evidence level was moderate. This finding suggests that more rigorous trials are needed to identify the association of acupuncture and acupressure with specific types of cancer pain and to integrate such evidence into clinical care to reduce opioid use.

Symptom burden and willingness to participate: implications for herbal clinical trials in lung cancer

Background:

People with lung cancer are interested in using herbs for symptom management. However, well-designed clinical trials are lacking. We aimed to quantify symptom burden and willingness to participate in herbal clinical trials among this population.

Methods:

We conducted a cross-sectional analysis using data collected from people with lung cancer at an oncology clinic at an academic cancer center. The primary outcome was self-reported willingness to participate in herbal research. We measured symptoms using the MD Anderson Symptom Inventory (MDASI). Multivariate logistic regression was performed to explore the relationship between demographic/clinical factors, symptom burden, and willingness to participate in herbal studies.

Results:

Among 288 participants, 55% were female, 42% were >65 years, 54% had stage IV cancer, and 86% had non-small cell lung cancer (NSCLC). Nearly half (46%) indicated willingness to participate in an herbal clinical trial. The most commonly reported moderate to severe symptoms (≥4 on the MDASI scale) were fatigue (57%), drowsiness (44%), disturbed sleep (43%), distress (42%), and dyspnea (36%). In multivariate analyses, higher education was significantly associated with willingness to participate in herbal studies (adjusted odds ratio 1.87, 95% confidence interval, 1.12–3.10, P=0.016), while symptom burden was not.

Conclusions:

People with lung cancer experience high rates of symptom burden. Nearly half of our participants expressed willingness to participate in an herbal clinical trial, particularly those with higher education. These findings can inform the design of future herbal clinical trials targeting common symptoms in lung cancer populations.

Oncology Acupuncture: Precision Medicine Meets Patient-Centered Care

The Precision Medicine Initiative of 2015, together with a growing focus on patient-centered care, has challenged the U.S. health care system to provide the correct treatment to the correct individual patient rather than to a collective population. This demonstrates that acupuncture-with its history as an individualized therapy and with growing evidence-based clinical findings-is the ideal model for personalized medicine within oncology care. The current author and colleagues used previously conducted oncology acupuncture trials for pain, hot flashes, and insomnia to demonstrate that precise delivery of acupuncture might depend on a patient's genetics. Individual preferences and perceived evidence surrounding treatments might also factor into patient treatment choices. Further effectiveness evidence comparing acupuncture to drugs or cognitive-behavioral therapy provides insight on the relative benefit or harm of each treatment, which, in turn, can help clinicians and patients to choose the best treatment plans centered on patients' goals. To advance precision oncology acupuncture research, appropriate biomarkers and psychologic attributes should be incorporated into adequately powered and well-designed clinical trials to evaluate how acupuncture can be delivered to the correct patients.

Rapid deployment of virtual mind-body interventions during the COVID-19 outbreak: feasibility, acceptability, and implications for future care

INTRODUCTION

COVID-19 increased stress levels while reducing access to mind-body services in patients with cancer. We describe the rapid deployment of remotely delivered mind-body services to people with cancer during COVID-19, rates of participation, and acceptability from patients' perspectives.

METHODS

Eligible participants were patients with cancer age ≥ 18 years enrolled in a single academic cancer center's online patient portal. Interventions included mind-body group therapy sessions in fitness, meditation, yoga, dance, tai chi, and music delivered using Zoom video conferencing. Sessions were 30-45 min and led by an integrative medicine clinician. Following each session, participants were asked to complete a three-item questionnaire assessing (1) satisfaction with the class session, (2) reduction in stress/anxiety, and (3) likelihood of recommending the class to others. Patients could also provide comments in real-time using the Zoom chat function.

RESULTS

Among 5948 unique visits, the most frequently attended classes were fitness (n = 2513, 42.2%) followed by meditation (n = 1176, 19.8%) and yoga (n = 909, 15.3%). Of these visits, 3902 (65.6%) had an associated completed questionnaire. Across class types, a large majority of participants reported being extremely satisfied (n = 3733, 95.7%), experiencing extreme reductions in anxiety/stress (n = 3268, 83.8%), and being extremely likely to recommend the class to others (n = 3605, 92.4%). Fitness had the highest endorsement among class types (all p values < 0.001). Themes from the chat responses included gratitude, expressions of helpfulness, and feelings of connection.

CONCLUSION

High utilization of and satisfaction with these virtual mind-body services demonstrate the significant potential of remote delivery to facilitate patient access to services.