Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial

Critical research gaps and translational priorities for the successful prevention and treatment of breast cancer

INTRODUCTION

Breast cancer remains a significant scientific, clinical and societal challenge. This gap analysis has reviewed and critically assessed enduring issues and new challenges emerging from recent research, and proposes strategies for translating solutions into practice.

METHODS

More than 100 internationally recognised specialist breast cancer scientists, clinicians and healthcare professionals collaborated to address nine thematic areas: genetics, epigenetics and epidemiology; molecular pathology and cell biology; hormonal influences and endocrine therapy; imaging, detection and screening; current/novel therapies and biomarkers; drug resistance; metastasis, angiogenesis, circulating tumour cells, cancer 'stem' cells; risk and prevention; living with and managing breast cancer and its treatment. The groups developed summary papers through an iterative process which, following further appraisal from experts and patients, were melded into this summary account.

RESULTS

The 10 major gaps identified were: (1) understanding the functions and contextual interactions of genetic and epigenetic changes in normal breast development and during malignant transformation; (2) how to implement sustainable lifestyle changes (diet, exercise and weight) and chemopreventive strategies; (3) the need for tailored screening approaches including clinically actionable tests; (4) enhancing knowledge of molecular drivers behind breast cancer subtypes, progression and metastasis; (5) understanding the molecular mechanisms of tumour heterogeneity, dormancy, de novo or acquired resistance and how to target key nodes in these dynamic processes; (6) developing validated markers for chemosensitivity and radiosensitivity; (7) understanding the optimal duration, sequencing and rational combinations of treatment for improved personalised therapy; (8) validating multimodality imaging biomarkers for minimally invasive diagnosis and monitoring of responses in primary and metastatic disease; (9) developing interventions and support to improve the survivorship experience; (10) a continuing need for clinical material for translational research derived from normal breast, blood, primary, relapsed, metastatic and drug-resistant cancers with expert bioinformatics support to maximise its utility. The proposed infrastructural enablers include enhanced resources to support clinically relevant in vitro and in vivo tumour models; improved access to appropriate, fully annotated clinical samples; extended biomarker discovery, validation and standardisation; and facilitated cross-discipline working.

CONCLUSIONS

With resources to conduct further high-quality targeted research focusing on the gaps identified, increased knowledge translating into improved clinical care should be achievable within five years.

Optimizing expectations to prevent side effects and enhance quality of life in breast cancer patients undergoing endocrine therapy: study protocol of a randomized controlled trial

BACKGROUND

Adjuvant endocrine therapy can improve disease-free survival and time before recurrence in breast cancer patients. However, it is associated with considerable side effects that negatively affect patients' quality of life and cause non-adherence. The recently demonstrated effect of individual expectations on side-effect development (nocebo effect) suggests that psychological factors play a role in the prevention of side effects. The aim of this study is to evaluate cognitive-behavioral side-effect prevention training (SEPT) for breast cancer patients. This article describes the study protocol and applied research methods.

METHODS/DESIGN

In a randomized controlled trial, 184 female breast cancer patients are assigned to receive either SEPT, standard medical care or a manualized supportive therapy at the start of adjuvant endocrine treatment. SEPT consists of three sessions of cognitive-behavioral training including psychoeducation to provide a realistic view of endocrine therapy, imagination-training to integrate positive aspects of medication into daily life, and side-effect management to enhance expectations about coping ability. Side effects three months after the start of endocrine therapy serve as primary outcomes. Secondary outcomes include quality of life, coping ability and patients' medication adherence. Patients' expectations (i.e., expectations about side effects, coping ability, treatment and illness) are analyzed as mediators.

DISCUSSION

The optimization of expectations might be a potential pathway in health care to improve patients' quality of life during long-term medication intake. The results will provide implications for a possible integration of evidence-based prevention training into clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov, (NCT01741883).

'You know I've joined your club… I'm the hot flush boy': a qualitative exploration of hot flushes and night sweats in men undergoing androgen deprivation therapy for prostate cancer

OBJECTIVE

Hot flushes and night sweats are common amongst menopausal women, and psychological interventions for managing these symptoms have recently been developed for women. However, flushes in men with prostate cancer, which commonly occur following androgen deprivation therapy (ADT), remain under-researched. This study is a qualitative exploration of flush-related cognitive appraisals and behavioural reactions reported by a sample of these men.

METHODS

Semi-structured, in-depth interviews were conducted with 19 men who were experiencing flushes after receiving ADT for prostate cancer. Framework analysis was used to generate and categorise emergent themes and explore associations between themes.

RESULTS

Five main cognitive appraisals included the following: changes in oneself, impact on masculinity, embarrassment/social-evaluative concerns, perceived control and acceptance/adjustment. There were men who held beliefs about the impact of flushes on their perceptions of traditional gender roles, who experienced shame and embarrassment due to concerns about the salience of flushes and perceptions by others and who experienced feelings of powerlessness over flushes. Powerlessness was associated with beliefs about the potentially fatal consequences of discontinuing treatment. Two other dominant themes included awareness/knowledge about flushes and management strategies. Experiences of flushes appeared to be influenced by upbringing and general experiences of prostate cancer and ADT.

CONCLUSIONS

The range of men's appraisals of, and reactions to, flushes generated from this qualitative exploration were broadly similar to those of menopausal women but differed in terms of the influence of masculinity beliefs. These findings could be used to inform future research and psychological interventions in this under-researched field.

Effect of cognitive behavioural interventions on the quality of life in Chinese heroin-dependent individuals in detoxification: a randomised controlled trial

AIMS AND OBJECTIVES

To determine whether cognitive behavioural interventions would improve the quality of life in Chinese heroin addicts.

BACKGROUND

Drug dependence is one of the most serious health problems in the world, representing a real menace to mental and somatic health. However, effects of cognitive behavioural interventions on quality of life in Chinese heroin addicts are unclear.

DESIGN

This randomised controlled study was conducted at a Drug-withdrawal Rehabilitation Center in China.

METHODS

Following ethics approval and heroin addicts' consent, 240 heroin addicts were randomly assigned to two groups. The experimental group (n = 120) received a six-month cognitive behavioural intervention comprising education intervention and behavioural intervention developed by the investigators. The control group (n = 120) received the hospital's routine care. The effects of the interventions on patients' quality of life were evaluated at baseline and six months and were compared. A Chinese version of Quality of Life in Drug Addiction Questionnaire was used in this study. Usefulness of the intervention and usual community services was evaluated at six months.

RESULTS

The quality of life of participants with heroin addiction with physical and psychological disorders is poor. The experimental group showed a significant improvement in quality of life after nurse-managed cognitive behavioural intervention.

CONCLUSIONS

The quality of life and the health status of Chinese heroin addicts were improved after they received a nurse-managed cognitive behavioural intervention.

RELEVANCE TO CLINICAL PRACTICE

Appropriate nurse-managed cognitive behavioural intervention for heroin addicts can improve their quality of life and promote their health. It is important for clinical nurses to understand cognitive behavioural therapy, appraisal and coping to apply knowledge in practice when dealing with a client who has heroin addiction.

Premature menopause in young breast cancer: effects on quality of life and treatment interventions

Many young women are at increased risk for premature menopause following adjuvant treatment for breast cancer. These women must deal with consequences of menopause, including loss of fertility and physiologic symptoms such as night sweats, hot flashes, vaginal dryness, and weight gain. These symptoms can be particularly distressing for young women and can adversely affect both health-related and psychosocial quality of life (QOL). While there are a wide range of pharmacologic and non-pharmacologic interventions available to help with these symptoms and in turn, improve QOL, there is little data available about the use and efficacy of these interventions in younger women who become menopausal as a result of their breast cancer treatment. Future studies should focus on this vulnerable population, with the goal of identifying effective strategies to relieve symptoms and improve quality of life in young breast cancer survivors.

Risk factors, pathophysiology, and treatment of hot flashes in cancer

Hot flashes are prevalent and severe symptoms that can interfere with mood, sleep, and quality of life for women and men with cancer. The purpose of this article is to review existing literature on the risk factors, pathophysiology, and treatment of hot flashes in individuals with cancer. Electronic searches were conducted to identify relevant English-language literature published through June 15, 2012. Results indicated that risk factors for hot flashes in cancer include patient-related factors (eg, age, race/ethnicity, educational level, smoking history, cardiovascular risk including body mass index, and genetics) and disease-related factors (eg, cancer diagnosis and dose/type of treatment). In addition, although the pathophysiology of hot flashes has remained elusive, these symptoms are likely attributable to disruptions in thermoregulation and neurochemicals. Therapies that have been offered or tested fall into 4 broad categories: pharmacological, nutraceutical, surgical, and complementary/behavioral strategies. The evidence base for this broad range of therapies varies, with some treatments not yet having been fully tested or showing equivocal results. The evidence base surrounding all therapies is evaluated to enhance hot flash treatment decision-making by clinicians and patients.

Testing a cognitive model of menopausal hot flushes and night sweats

OBJECTIVE

Hot flushes and night sweats (HFNS) are commonly experienced by women during the menopause transition and are particularly problematic for approximately 25% having negative impact on their quality of life. We previously developed a cognitive model of HFNS, which outlines potential predictors of HFNS. This study aims to test the model by investigating the relationships between personality characteristics, perceived stress, mood, HFNS beliefs and subjective and physiological measures of menopausal HFNS.

METHODS

140 women (menopause transition or postmenopausal) who were experiencing at least 10 HFNS per week for at least a month, completed assessment interviews, including questionnaires assessing optimism, somatic amplification, perceived stress, depressed mood, anxiety, HFNS beliefs and HFNS frequency, problem-rating and 24-hour sternal skin conductance monitoring. Structural equation models (SEM) were used to investigate the optimum predictive model for HFNS Frequency and HFNS Problem-Rating.

RESULTS

On average 63 HFNS per week and moderately problematic HFNS were reported. The physiological measure of HFNS frequency was not associated with socio-demographic variables, personality or mood. The final SEM explained 53.2% of the variance in problem rating. Stress, anxiety and somatic amplification predicted HFNS problem rating but only via their impact on HFNS beliefs; HFNS frequency, smoking and alcohol intake also predicted HFNS problem rating.

CONCLUSIONS

Findings support the influence of psychological factors on experience of HFNS at the level of symptom perception and cognitive appraisal of HFNS.

Description of an Audio-Based Paced Respiration Intervention for Vasomotor Symptoms

Millions of women experience menopause-related hot flashes or flushes that may have a negative effect on their quality of life. Hormone therapy is an effective treatment, however, it may be contraindicated or unacceptable for some women based on previous health complications or an undesirable risk-benefit ratio. Side effects and the unacceptability of hormone therapy have created a need for behavioral interventions to reduce hot flashes. A variety of complex, multimodal behavioral, relaxation-based interventions have been studied with women (n = 88) and showed generally favorable results. However, currently extensive resource commitments reduce the translation of these interventions into standard care. Slow, deep breathing is a common component in most interventions and may be the active ingredient leading to reduced hot flashes. This article describes the content of an audio-based program designed to teach paced breathing to reduce hot flashes. Intervention content was based on skills training theory and music entrainment. The audio intervention provides an efficient way to deliver a breathing intervention that may be beneficial to other clinical populations.

Efficacy of Cognitive Behavioral Therapy and Physical Exercise in Alleviating Treatment-Induced Menopausal Symptoms in Patients With Breast Cancer: Results of a Randomized, Controlled, Multicenter Trial

Purpose

The purpose of our study was to evaluate the effect of cognitive behavioral therapy (CBT), physical exercise (PE), and of these two interventions combined (CBT/PE) on menopausal symptoms (primary outcome), body image, sexual functioning, psychological well-being, and health-related quality of life (secondary outcomes) in patients with breast cancer experiencing treatment-induced menopause.

Patients and Methods

Patients with breast cancer reporting treatment-induced menopausal symptoms (N = 422) were randomly assigned to CBT (n = 109), PE (n = 104), CBT/PE (n = 106), or to a waiting list control group (n = 103). Self-report questionnaires were completed at baseline, 12 weeks, and 6 months. Multilevel procedures were used to compare the intervention groups with the control group over time.

Results

Compared with the control group, the intervention groups had a significant decrease in levels of endocrine symptoms (Functional Assessment of Cancer Therapy–Endocrine Symptoms; P < .001; effect size, 0.31-0.52) and urinary symptoms (Bristol Female Lower Urinary Tract Symptoms Questionnaire; P = .002; effect size, 0.29-0.33), and they showed an improvement in physical functioning (36-Item Short Form Health Survey physical functioning subscale; P = .002; effect size, 0.37-0.46). The groups that included CBT also showed a significant decrease in the perceived burden of hot flashes and night sweats (problem rating scale of the Hot Flush Rating Scale; P < .001; effect size, 0.39-0.56) and an increase in sexual activity (Sexual Activity Questionnaire habit subscale; P = .027; effect size, 0.65). Most of these effects were observed at both the 12-week and 6-month follow-ups.

Conclusion

CBT and PE can have salutary effects on endocrine symptoms and, to a lesser degree, on sexuality and physical functioning of patients with breast cancer experiencing treatment-induced menopause. Future work is needed to improve the design and the planning of these interventions to improve program adherence.

Cognitive Behaviour Therapy for Menopausal Hot Flushes and Night Sweats: A Qualitative Analysis of Women's Experiences of Group and Self-Help CBT

Background: There is a growing need for non-medical treatments for women experiencing problematic menopausal symptoms such as hot flushes and night sweats (HF/NS). A recent randomized control trial (RCT) (MENOS2) provides evidence of the effectiveness of Group CBT and Self-Help CBT for HF/NS. Aims: This study examines MENOS 2 participants’ experience of the CBT treatments. Method: Twenty women who had experienced CBT for HF/NS (10 Group CBT and 10 Self-Help CBT) were interviewed at the end of the trial to explore how they experienced the treatment and its effects. The interviews were analysed using interpretative phenomenological analysis. Results: Women experienced both treatment formats as positive and helpful, increasing their ability to cope and their sense of control over HF/NS. Four super-ordinate themes were identified: making sense of symptom change, new ways of coping and regaining control, acknowledging and challenging the menopause taboo, and social interaction and support versus individual learning. Conclusions: These qualitative results are consistent with those of the main trial in that women found both CBT formats helpful in reducing the impact of HF/NS. However, the results also suggest possible mechanisms of change and provide useful information on women's responses to the different treatment components and formats.

Adherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: a systematic review

Adjuvant hormonal therapy significantly improves long-term survival of breast cancer patients with hormone receptor-positive disease. Despite the proven clinical efficacy of tamoxifen and aromatase inhibitors, many breast cancer survivors either fail to take the correct dosage at the prescribed frequency (adherence) or discontinue therapy (persistence). This systematic review aims to: (1) determine the prevalence of adherence and persistence to adjuvant hormonal therapy among breast cancer survivors in clinical practice, and (2) identify correlates of adherence and persistence. We searched Medline, PubMed, PsycINFO, and CINAHL for studies that measured rates and/or correlates of adherence and/or persistence to adjuvant hormonal therapy. Studies were reviewed in a multi-step process: (1) the lead author screened titles and abstracts of all potentially eligible studies; (2) each coauthor reviewed a random 5 % sample of abstracts; and (3) two sets of coauthors each reviewed half of all "maybe" abstracts. Any disagreements were discussed until consensus was reached. Twenty-nine studies met inclusion criteria. Prevalence of adherence ranged from 41 to 72 % and discontinuation (i.e., nonpersistence) ranged from 31 to 73 %, measured at the end of 5 years of treatment. Extremes of age (older or younger), increasing out-of-pocket costs, follow-up care with a general practitioner (vs. oncologist), higher CYP2D6 activity, switching from one form of therapy to another, and treatment side effects were negatively associated with adherence and/or persistence. Taking more medications at baseline, referral to an oncologist, and earlier year at diagnosis were positively associated with adherence and/or persistence. Adherence and persistence to adjuvant hormonal therapy among breast cancer survivors is suboptimal. Many of the correlates of adherence and persistence studied to date are not modifiable. Our review reveals a critical need for further research on modifiable factors associated with adherence to adjuvant hormonal therapy, and the development of behavioral interventions to improve adherence in this population.

A randomised controlled trial of a cognitive behavioural intervention for men who have hot flushes following prostate cancer treatment (MANCAN): trial protocol

BACKGROUND

This randomised controlled trial (RCT) aims to evaluate the effectiveness of a guided self-help cognitive behavioural intervention to alleviate problematic hot flushes (HF) and night sweats (NS) in men who are undergoing prostate cancer treatment. The trial and the self-help materials have been adapted from a previous RCT, which showed that a cognitive behavioural intervention reduced the self-reported problem-rating of hot flushes in women with menopausal symptoms, and in women undergoing breast cancer treatment. We hypothesize that guided self-help will be more effective than usual care in reducing HF/NS problem-rating at post treatment assessment.

METHODS/DESIGN

Seventy men who are undergoing treatment for prostate cancer and who have been experiencing more than ten HF/NS weekly for over a month are recruited into the trial from urology clinics in London. They are randomly allocated to either a four-week self-help cognitive behavioural therapy (CBT) treatment or to their usual care (control group). The treatment includes information and discussion about hot flushes and night sweats in the context of prostate cancer, monitoring and modifying precipitants, relaxation and paced respiration, stress management, cognitive therapy for unhelpful thoughts and beliefs, managing sleep and night sweats, and advice on maintaining these changes. Prior to randomisation, men attend a clinical interview, undergo 24-48-hour sternal skin conductance monitoring, and complete pre-treatment questionnaires (e.g., problem-rating and frequency of hot flushes and night sweats; quality of life; mood; hot flush beliefs and behaviours). Post-treatment measures (sternal skin conductance and the above questionnaires) are collected four-six weeks later, and again at a six-month follow-up.

DISCUSSION

MANCAN is the first randomised controlled trial of cognitive behavioural therapy for HF/NS for men that measures both self-reported and physiologically indexed symptoms. The results will inform future clinical practice by evaluating an evidence-based, non-medical treatment, which can be delivered by trained health professionals.

TRIAL REGISTRATION

UK Clinical Research Network UKCRN10904.

Women's experiences of Group Cognitive Behaviour Therapy for hot flushes and night sweats following breast cancer treatment: an interpretative phenomenological analysis

OBJECTIVES

Many women with breast cancer experience problematic treatment-related menopausal symptoms (HF/NS). This study explores how these women experienced a Group Cognitive Behaviour Therapy (CBT) intervention to help them manage their treatment-related HF/NS. The study was conducted as part of a randomised control trial/RCT (MENOS 1) evaluating the intervention among this target group.

METHODS

In-depth semi-structured interviews were conducted with twenty trial participants to explore how they experienced the intervention and its effects. The interviews were analysed using interpretative phenomenological analysis.

RESULTS

The analysis revealed four superordinate themes: Making sense of symptom change; new ways of coping and regaining control; tailoring the treatment to meet individual needs and resources; and valuing the group context, social support and social comparisons. All the women found Group CBT improved their ability to cope with their HF/NS, while also developing an appreciation of the role of psychological factors in their symptom experience. Through the knowledge and understanding acquired women developed a more accepting stance to their symptoms, as well as gaining a 'sense of control'.

CONCLUSIONS

The results are consistent with the main RCT outcomes which showed that Group CBT led to a clinically significant reduction in 'HF/NS problem rating' relative to 'treatment as usual', as well as improvements in mood and physical and social functioning. The results complement the trial outcomes by illuminating women's experience of different components of the intervention and highlighting possible mechanisms of change.