Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial

The effects of lifestyle and behavioural interventions on cancer recurrence, overall survival and quality of life in breast cancer survivors: A systematic review and network meta-analysis

Lifestyle/behavioural interventions may improve breast cancer outcomes and quality of life (QoL); however, uncertainty remains about the most effective interventions due to limited evidence. This study aimed to assess and compare the effects of lifestyle/behavioural interventions on cancer recurrence, survival and QoL in breast cancer survivors. Electronic databases including Medline, EMBASE, PsycINFO, CINAHL and EBM Reviews were searched for relevant literature. Randomized controlled trials (RCTs) and quasi-RCTs comparing a lifestyle/behavioural intervention with a control condition in breast cancer survivors were included. Outcomes included cancer recurrence, overall survival and QoL. A network meta-analysis synthesized intervention effect. Studies not included in the analysis were reported narratively. Of 6251 identified articles, 38 studies met the selection criteria. Limited evidence exists on the impacts of lifestyle/behavioural interventions on breast cancer recurrence/survival. Exercise was identified as the most effective intervention in improving overall survival (HR 0.50, 95 % CI 0.36, 0.68). Lifestyle/behavioural interventions may improve QoL; psychosocial interventions (SMD 1.28, 95 % CI 0.80, 1.77) and aerobic-resistance exercise (SMD 0.33, 95 % CI -0.03, 0.69) were the most effective interventions to enhance QoL. This review highlights potential post-breast cancer benefits from lifestyle/behavioural interventions, notably exercise and psychosocial support for QoL and exercise for overall survival. Thus, encouraging active lifestyle, stress management and coping skills programs during and after cancer treatment may enhance physical wellbeing and QoL. However, the findings should be interpreted with caution due to the small number and sample sizes of studies. Future longer-term RCTs are required for conclusive recommendations.

Rural-urban disparities in psychosocial functioning in epithelial ovarian cancer patients

OBJECTIVE

Although rural residence has been related to health disparities in cancer patients, little is known about how rural residence impacts mental health and quality of life (QOL) in ovarian cancer patients over time. This prospective longitudinal study investigated mental health and QOL of ovarian cancer patients in the first-year post-diagnosis.

METHOD

Women with suspected ovarian cancer completed psychosocial surveys pre-surgery, at 6 months and one-year; clinical data were obtained from medical records. Histologically confirmed high grade epithelial ovarian cancer patients were eligible. Rural/urban residence was categorized from patient counties using the USDA Rural-Urban Continuum Codes. Linear mixed effects models examined differences in psychosocial measures over time, adjusting for covariates.

RESULTS

Although disparities were not observed at study entry for any psychosocial variable (all p-values >0.22), urban patients showed greater improvement in total distress over the year following diagnosis than rural patients (p = 0.025) and were significantly less distressed at one year (p = 0.03). Urban patients had a more consistent QOL improvement than their rural counterparts (p = 0.006). There were no differences in the course of depressive symptoms over the year (p = 0.17). Social support of urban patients at 12 months was significantly higher than that of rural patients (p = 0.04).

CONCLUSION

Rural patients reported less improvement in psychological functioning in the year following diagnosis than their urban counterparts. Clinicians should be aware of rurality as a potential risk factor for ongoing distress. Future studies should examine causes of these health disparities and potential long-term inequities and develop interventions to address these issues.

Peri-operative individually tailored psychological intervention in breast cancer patients improves psychological indices and molecular biomarkers of metastasis in excised tumors

Perioperative stress and inflammatory signaling can invigorate pro-metastatic molecular processes in patients' tumors, potentially worsening long-term survival. Yet, it is unknown whether pre-operative psychotherapeutic interventions can attenuate such effects. Herein, three weeks before surgery, forty women diagnosed with stage I-III invasive ductal/lobular breast carcinoma were randomized to a 6-week one-on-one psychological intervention (6 meetings with a medical psychologist and bi-weekly phone calls) versus standard nursing-staff-attention. The intervention protocol was individually tailored based on evaluation of patients' emotional, cognitive, physiological, and behavioral stress response-patterns, and also included psychoeducation regarding medical treatments and recruitment of social support. Resected primary tumors were subjected to whole-genome RNA sequencing and bioinformatic analyses, assessing a priori hypothesized cancer-relevant molecular signatures. Self-report questionnaires (BSI-18, Hope-18, MSPSS, and a stress-scale) were collected three (T1) and one (T2) week before surgery, a day before (T3) and after (T4) surgery, and three weeks (T5) and 3-months (T6) following surgery. The intervention reduced distress (GSI), depression, and somatization scores (BSI-18: p < 0.01, p < 0.05, p < 0.05; T5 vs. T1). Additionally, tumors from treated patients (vs. controls) showed: (i) decreased activity of transcription control pathways involved in adrenergic and glucocorticoid signaling (CREB, GR) (p < 0.001), pro-inflammatory signaling (NFkB) (p < 0.01), and pro-malignant signaling (ETS1, STAT and GATA families) (p < 0.001, p < 0.01, p < 0.005); (ii) increased M1 macrophage polarization (p < 0.05), and CD4+ T cell activity (p < 0.01); and an unexpected increase in epithelial-to-mesenchymal-transition (EMT) signature (p < 0.005). This is the first randomized controlled trial to show beneficial effects of a psychological perioperative intervention on tumor pro-metastatic molecular biomarkers.

Integrative Oncology Approaches to Reduce Recurrence of Disease and Improve Survival

PURPOSE OF REVIEW

After a cancer diagnosis, patients ask what they can do in addition to the recommended treatments to increase their survival. Many turn to integrative medicine modalities and lifestyle changes to improve their chances of survival. Numerous studies have demonstrated that lifestyle changes can significantly improve survival rates for cancer patients. Less support exists for the use of natural products or supplements to improve cancer survival. In this manuscript, we review key findings and evidence in the areas of healthy eating habits, physical activity, stress management and social support, and sleep quality, as well as natural products and supplements as they relate to the cancer recurrence and survival.

RECENT FINDINGS

While more research is needed to fully understand the mechanisms underlying the associations between lifestyle changes and cancer survival, findings suggest that lifestyle modifications in the areas of diet, physical activity, stress management and social support, and sleep quality improve clinical cancer outcomes. This is especially true for programs that modify more than one lifestyle habit. To date, outside of supplementing with vitamin D to maintain adequate levels, conflicting conclusion within the research remain regarding the efficacy of using natural products or supplement to improve cancer recurrence of disease or cancer survival. A call for further research is warranted. Lifestyle screening and counseling should be incorporated into cancer treatment plans to help improve patient outcomes. While the scientific community strives for the pursuit of high-quality research on natural products to enhance cancer survival, transparency, dialogue, and psychological safety between patients and clinicians must continue to be emphasized. Proactive inquiry by clinicians regarding patients' supplement use will allow for an informed discussion of the benefits and risks of natural products and supplements, as well as a re-emphasis of the evidence supporting diet and other lifestyle habits to increase survival.

Machine learning prediction of pathological complete response and overall survival of breast cancer patients in an underserved inner-city population

BACKGROUND

Generalizability of predictive models for pathological complete response (pCR) and overall survival (OS) in breast cancer patients requires diverse datasets. This study employed four machine learning models to predict pCR and OS up to 7.5 years using data from a diverse and underserved inner-city population.

METHODS

Demographics, staging, tumor subtypes, income, insurance status, and data from radiology reports were obtained from 475 breast cancer patients on neoadjuvant chemotherapy in an inner-city health system (01/01/2012 to 12/31/2021). Logistic regression, Neural Network, Random Forest, and Gradient Boosted Regression models were used to predict outcomes (pCR and OS) with fivefold cross validation.

RESULTS

pCR was not associated with age, race, ethnicity, tumor staging, Nottingham grade, income, and insurance status (p > 0.05). ER-/HER2+ showed the highest pCR rate, followed by triple negative, ER+/HER2+, and ER+/HER2- (all p < 0.05), tumor size (p < 0.003) and background parenchymal enhancement (BPE) (p < 0.01). Machine learning models ranked ER+/HER2-, ER-/HER2+, tumor size, and BPE as top predictors of pCR (AUC = 0.74-0.76). OS was associated with race, pCR status, tumor subtype, and insurance status (p < 0.05), but not ethnicity and incomes (p > 0.05). Machine learning models ranked tumor stage, pCR, nodal stage, and triple-negative subtype as top predictors of OS (AUC = 0.83-0.85). When grouping race and ethnicity by tumor subtypes, neither OS nor pCR were different due to race and ethnicity for each tumor subtype (p > 0.05).

CONCLUSION

Tumor subtypes and imaging characteristics were top predictors of pCR in our inner-city population. Insurance status, race, tumor subtypes and pCR were associated with OS. Machine learning models accurately predicted pCR and OS.

Oncology mental health providers' adaptation of an evidence-based intervention: A mixed-methods study

BACKGROUND

Adaptations are intentional modifications maximizing the fit of an evidence-based intervention (EBI) in new context. Little is known about EBI adaptation within psychosocial oncology. Guided by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME), this mixed-methods study describes oncology mental health providers' planned adaptations to a psychosocial oncology EBI and examines the relationship between planned adaptations and longitudinal EBI usage.

METHODS

Providers (N = 128) were social workers (47%) and psychologists (40%) practicing in community settings (44%) or academic medical centers (41%). They attended a 3-day training on a multicomponent psychosocial oncology EBI, the Biobehavioral Intervention (BBI). During training, providers prepared an "adaptation plan" describing necessary adaptations to BBI and rationales for change. Qualitative data from adaptation plans were analyzed using directed content analysis. Linear mixed models examined the relationship between adaptation characteristics (number, similarity to the manualized BBI) and EBI usage across 12 months post-training.

RESULTS

Three sets of qualitative themes reflecting FRAME elements emerged: (1) content modifications (e.g., shortening/condensing, selecting elements, adding/removing elements); (2) contextual changes (e.g., alternative group formats); and (3) reasons for adaptations (e.g., organization/setting, provider, and recipient factors). Neither number of adaptations nor adaptation similarity were associated with BBI usage across 12 months post-training.

CONCLUSIONS

To our knowledge, this study is the first to characterize oncology mental health providers' planned adaptations to a psychosocial oncology EBI. Planned adaptations did not increase usage, but importantly they did not decrease usage. The adaptation process enabled providers to make thoughtful adaptation choices, with implementation successful irrespective of setting constraints.

Predictive Models of Psychological Distress, Quality of Life, and Adherence to Medication in Breast Cancer Patients: A Scoping Review

Purpose

An interplay of clinical and psychosocial variables affects breast cancer patients' experiences and clinical trajectories. Several studies investigated the role of socio-demographic, clinical, and psychosocial factors in predicting relevant outcomes in breast cancer care, thus developing predictive models. Our aim is to summarize predictive models for specific psychological and behavioral outcomes: psychological distress, quality of life, and medication adherence. Specifically, we aim to map the determinants of the outcomes of interest, offering a thorough overview of these models.

Methods

Databases (PubMed, Scopus, Embase) have been searched to identify studies meeting the inclusion criteria: a breast cancer patients' sample, development/validation of a predictive model for selected psychological/behavioral outcomes (ie, psychological distress, quality of life, and medication adherence), and availability of English full-text.

Results

Twenty-one papers describing predictive models for psychological distress, quality of life, and adherence to medication in breast cancer were included. The models were developed using different statistical approaches. It has been shown that treatment-related factors (eg, side-effects, type of surgery or treatment received), socio-demographic (eg, younger age, lower income, and inactive occupational status), clinical (eg, advanced stage of disease, comorbidities, physical symptoms such as fatigue, insomnia, and pain) and psychological variables (eg, anxiety, depression, body image dissatisfaction) might predict poorer outcomes.

Conclusion

Predictive models of distress, quality of life, and adherence, although heterogeneous, showed good predictive values, as indicated by the reported performance measures and metrics. Many of the predictors are easily available in patients' health records, whereas others (eg, coping strategies, perceived social support, illness perceptions) might be introduced in routine assessment practices. The possibility to assess such factors is a relevant resource for clinicians and researchers involved in developing and implementing psychological interventions for breast cancer patients.

Application of Allostatic Load Theory in Cancer Management and Treatment Outcomes

Efforts have been made to improve health outcomes management by identifying the factors associated with survival in patients with cancer. However, different social, nutritional, and management modalities and personal and clinical characteristics may lead to various mortalities and morbidities among patients with cancer. Although stress is known to influence health and well-being in humans, there is still a gap in the studies on how stress plays a significant role in clinical outcomes in patients with cancer. Allostatic load, accumulated physiologic damage because of stressors, differs on the basis of individual perception of stress, coping skills, and other factors. This theory depicts how stress affects and predicts long-term outcomes such as morbidity and mortality. The main goal of this study is to provide potential benefits of using this theory in the cancer field to identify stressors and develop personalized interventions. This study will describe allostatic load theory and explain the relationships between potential stressors and the outcomes through the various levels of dysregulations in cancer. In addition, this study will provide theory implementation in pancreatic cancer.

Application of the National Comprehensive Cancer Network-distress thermometer in pediatric patients during autologous and allogeneic hematopoietic stem cell transplantation and relationship to blood parameters of the stress axis

PURPOSE

Hematopoietic stem cell transplantations (HSCT) are extremely stressful procedures for pediatric patients. The activation of the hypothalamic pituitary adrenocortical axis (HPA) can influence the immune system negatively and therefore the overall outcome. The distress thermometer (DT) is an easy to use tool for the self-assessment of perceived distress.

METHODS

In this prospective study, a DT with an attached problem list was used in 40 pediatric patients undergoing HSCT and in one parent of each patient. The patients were aged 10-18 years. The patients' cortisol, thyroid stimulating hormone, free triiodothyronine and thyroxine levels were measured regularly during the in-patient stay.

RESULTS

After admission to the hospital, the stress levels of the pediatric patients and their parents increased and reached their maximum on the day of HSCT. The overall stress values of the parents were higher than those of their children. There was a significant difference in the parents' stress levels on the day of HSCT, as compared to their stress levels on other days. The mean cortisol values of the pediatric patients also increased after admission, reaching significant elevated levels above the upper normal limit 1 week after HSCT and on discharge day. Although the pediatric patients experienced mainly exhaustion, especially on the day of transplantation, their parents mainly felt worry and anxiety. Interestingly, the rate of worry among children increased in the post-transplant period and reached its maximum on the day of discharge.

CONCLUSIONS

In summary, a significantly increased stress level is shown for both the patients and their parents. This is reflected for the patients both in the DT scores and in the increased cortisol values. For the parents, the focus is primarily on worry and anxiety, for the patients primarily on exhaustion and worry.

Bakar R, Banerji D, Rokicki A, Zhang L, Mulligan CP, Osborne MT, Zarif A, Hammad B, Chan AW, Wirth LJ, Warner ET, Pitman RK, Armstrong KA, Addison D, Neilan TG. Amygdalar activity measured using FDG-PET/CT at head and neck cancer staging independently predicts survival

IMPORTANCE

The mechanisms underlying the association between chronic stress and higher mortality among individuals with cancer remain incompletely understood.

OBJECTIVE

To test the hypotheses that among individuals with active head and neck cancer, that higher stress-associated neural activity (ie. metabolic amygdalar activity [AmygA]) at cancer staging associates with survival.

DESIGN

Retrospective cohort study.

SETTING

Academic Medical Center (Massachusetts General Hospital, Boston).

PARTICIPANTS

240 patients with head and neck cancer (HNCA) who underwent 18F-FDG-PET/CT imaging as part of initial cancer staging.

MEASUREMENTS

18F-FDG uptake in the amygdala was determined by placing circular regions of interest in the right and left amygdalae and measuring the mean tracer accumulation (i.e., standardized uptake value [SUV]) in each region of interest. Amygdalar uptake was corrected for background cerebral activity (mean temporal lobe SUV).

RESULTS

Among individuals with HNCA (age 59±13 years; 30% female), 67 died over a median follow-up period of 3 years (IQR: 1.7-5.1). AmygA associated with heightened bone marrow activity, leukocytosis, and C-reactive protein (P<0.05 each). In adjusted and unadjusted analyses, AmygA associated with subsequent mortality (HR [95% CI]: 1.35, [1.07-1.70], P = 0.009); the association persisted in stratified subset analyses restricted to patients with advanced cancer stage (P<0.001). Individuals within the highest tertile of AmygA experienced a 2-fold higher mortality rate compared to others (P = 0.01). The median progression-free survival was 25 months in patients with higher AmygA (upper tertile) as compared with 36.5 months in other individuals (HR for progression or death [95%CI], 1.83 [1.24-2.68], P = 0.001).

CONCLUSIONS AND RELEVANCE

AmygA, quantified on routine 18F-FDG-PET/CT images obtained at cancer staging, independently and robustly predicts mortality and cancer progression among patients with HNCA. Future studies should test whether strategies that attenuate AmygA (or its downstream biological consequences) may improve cancer survival.

Influence of depression on breast cancer treatment and survival: A Kentucky population-based study

BACKGROUND

Depression is common among breast cancer patients and can affect concordance with guideline-recommended treatment plans. Yet, the impact of depression on cancer treatment and survival is understudied, particularly in relation to the timing of the depression diagnosis.

METHODS

The Kentucky Cancer Registry data was used to identify female patients diagnosed with primary invasive breast cancer who were 20 years of age or older in 2007-2011. Patients were classified as having no depression, depression pre-cancer diagnosis only, depression post- cancer diagnosis only, or persistent depression. The impact of depression on receiving guideline-recommended treatment and survival was examined using multivariable logistic regression and Cox regression, respectively.

RESULTS

Of 6054 eligible patients, 4.1%, 3.7%, and 6.2% patients had persistent depression, depression pre-diagnosis only, and depression post-diagnosis only, respectively. A total of 1770 (29.2%) patients did not receive guideline-recommended cancer treatment. Compared to patients with no depression, the odds of receiving guideline-recommended treatment were decreased in patients with depression pre-diagnosis only (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.54-1.04) but not in patients with post-diagnosis only or persistent depression. Depression post-diagnosis only (hazard ratio, 1.51; 95% CI, 1.24-1.83) and depression pre-diagnosis only (hazard ratio, 1.26; 95% CI, 0.99-1.59) were associated with worse survival. No significant difference in survival was found between patients with persistent depression and patients with no depression (p > .05).

CONCLUSIONS

Neglecting depression management after a breast cancer diagnosis may result in poorer cancer treatment concordance and worse survival. Early detection and consistent management of depression is critical in improving patient survival.

Integrative Oncology and the Clinical Care Network: Challenges and Opportunities

Integrative oncology is a new and growing field of cancer care. Integrative oncology is a patient-centered, evidence-based field of comprehensive cancer care that utilizes integrative therapies such as mind-body practices, acupuncture, massage, music therapy, nutrition, and exercise in collaboration with conventional cancer treatments. Patient interest and utilization has been growing over the past two decades. Clinical research has shown the benefits of these approaches to improving symptom management and quality of life, and is now being incorporated into national guidelines from the National Comprehensive Cancer Network (NCCN) and American Society for Clinical Oncology (ASCO). The availability of these services at cancer centers is growing, although the structure and implementation of integrative oncology remains highly variable. This article discusses the benefits of integrative oncology and provides an overview of the current state of integrative oncology programs nationwide. Current challenges and opportunities for cancer centers to provide integrative services is reviewed in the areas of programmatic structure, clinical service, education, and research.

Effects on long-term survival of psychosocial group intervention in early-stage breast cancer: follow-up of a randomized controlled trial

BACKGROUND

The promise of prolonged survival after psychosocial interventions has long been studied, but not convincingly demonstrated. This study aims to investigate whether a psychosocial group intervention improved long-term survival in women with early-stage breast cancer and investigate differences in baseline characteristics and survival between study participants and non-participants.

METHODS

A total of 201 patients were randomized to two six-hour psychoeducation sessions and eight weekly sessions of group psychotherapy or care as usual. Additionally, 151 eligible patients declined to participate. Eligible patients were diagnosed and treated at Herlev Hospital, Denmark, and followed for vital status up to 18 years after their primary surgical treatment. Cox's proportional hazard regressions were used to estimate hazard ratios (HRs) for survival.

RESULTS

The intervention did not significantly improve survival in the intervention group compared with the control group (HR, 0.68; 95% confidence interval (CI), 0.41-1.14). Participants and non-participants differed significantly in age, cancer stage, adjuvant chemotherapy, and crude survival. When adjusted, no significant survival difference between participants and non-participants remained (HR, 0.77; 95% CI, 0.53-1.11).

CONCLUSIONS

We could not show improved long-term survival after the psychosocial intervention. Participants survived longer than nonparticipants, but clinical and demographic characteristics, rather than study participation, seem accountable for this difference.

Integration of art and technology in personalized radiation oncology care: Experiences, evidence, and perspectives

Cancer diagnoses expose patients to traumatic stress, sudden changes in daily life, changes in the body and autonomy, with even long-term consequences, and in some cases, to come to terms with the end-of-life. Furthermore, rising survival rates underline that the need for interventions for emotional wellbeing is in growing demand by patients and survivors. Cancer patients frequently have compliance problems, difficulties during treatment, stress, or challenges in implementing healthy behaviors. This scenario was highlighted during the COVID-19 emergency. These issues often do not reach the clinical attention of dedicated professionals and could also become a source of stress or burnout for professionals. So, these consequences are evident on individual, interpersonal, and health system levels. Oncology services have increasingly sought to provide value-based health care, considering resources invested, with implications for service delivery and related financing mechanisms. Value-based health care can improve patient outcomes, often revealed by patient outcome measures while seeking balance with economical budgets. The paper aims to show the Gemelli Advanced Radiation Therapy (ART) experience of personalizing the patients' care pathway through interventions based on technologies and art, the personalized approach to cancer patients and their role as "co-stars" in treatment care. The paper describes the vision, experiences, and evidence that have guided clinical choices involving patients and professionals in a co-constructed therapeutic pathway. We will explore this approach by describing: the various initiatives already implemented and prospects, with particular attention to the economic sustainability of the paths proposed to patients; the several pathways of personalized care, both from the patient's and healthcare professional perspective, that put the person's experience at the Gemelli ART Center. The patient's satisfaction with the treatment and economic outcomes have been considered. The experiences and future perspectives described in the manuscript will focus on the value of people's experiences and patient satisfaction indicators, patients, staff, and the healthcare organization.

Stress Management Interventions to Facilitate Psychological and Physiological Adaptation and Optimal Health Outcomes in Cancer Patients and Survivors

Cancer diagnosis and treatment constitute profoundly stressful experiences involving unique and common challenges that generate uncertainty, fear, and emotional distress. Individuals with cancer must cope with multiple stressors, from the point of diagnosis through surgical and adjuvant treatments and into survivorship, that require substantial psychological and physiological adaptation. This can take a toll on quality of life and well-being and may also promote cellular and molecular changes that can exacerbate physical symptoms and facilitate tumor growth and metastasis, thereby contributing to negative long-term health outcomes. Since modifying responses tostressors might improve psychological and physiological adaptation, quality of life, and clinical health outcomes, several randomized controlled trials have tested interventions that aim to facilitate stress management. We review evidence for the effects of stress management interventions on psychological and physiological adaptation and health outcomes in cancer patients and survivors and summarize emerging research in the field to address unanswered questions.

Psychological interventions for women with non-metastatic breast cancer

BACKGROUND

Breast cancer is the most common cancer affecting women worldwide. It is a distressing diagnosis and, as a result, considerable research has examined the psychological sequelae of being diagnosed and treated for breast cancer. Breast cancer is associated with increased rates of depression and anxiety and reduced quality of life. As a consequence, multiple studies have explored the impact of psychological interventions on the psychological distress experienced after a diagnosis of breast cancer. This review is an update of a Cochrane Review first published in 2015.

OBJECTIVES

To assess the effect of psychological interventions on psychological morbidities and quality of life among women with non-metastatic breast cancer.  SEARCH METHODS: We searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov up to 16 March 2021. We also scanned the reference lists of relevant articles.

SELECTION CRITERIA

Randomised controlled trials that assessed the effectiveness of psychological interventions for women with non-metastatic breast cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently appraised, extracted data from eligible trials, and assessed risk of bias and certainty of the evidence using the GRADE approach. Any disagreement was resolved by discussion. Extracted data included information about participants, methods, the intervention and outcomes.

MAIN RESULTS

We included 60 randomised controlled trials comprising 7998 participants. The most frequent reasons for exclusion were non-randomised trials and the inclusion of women with metastatic disease. The updated review included 7998 randomised women; the original review included 3940 women. A wide range of interventions was evaluated. Most interventions were cognitive- or mindfulness-based, supportive-expressive, and educational. The interventions were mainly delivered face-to-face (56 studies) and in groups (50 studies) rather than individually (10 studies). Most intervention sessions were delivered on a weekly basis with an average duration of 14 hours. Follow-up time ranged from two weeks to 24 months.  Pooled standardised mean differences (SMD) from baseline indicated that the intervention may reduce depression (SMD -0.27, 95% confidence interval (CI) -0.52 to -0.02; P = 0.04; 27 studies, 3321 participants, I2 = 91%, low-certainty evidence); anxiety (SMD -0.43, 95% CI -0.68 to -0.17; P = 0.0009; 22 studies, 2702 participants, I2 = 89%, low-certainty evidence); mood disturbance in the intervention group (SMD -0.18, 95% CI -0.31 to -0.04; P = 0.009; 13 studies, 2276 participants, I2 = 56%, low-certainty evidence); and stress (SMD -0.34, 95% (CI) -0.55 to -0.12; P = 0.002; 8 studies, 564 participants, I2 = 31%, low-certainty evidence). The intervention is likely to improve quality of life in the intervention group (SMD 0.78, 95% (CI) 0.32 to 1.24; P = 0.0008; 20 studies, 1747 participants, I2 = 95%, low-certainty evidence). Adverse events were not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Based on the available evidence, psychological intervention may have produced favourable effects on psychological outcomes, in particular depression, anxiety, mood disturbance and stress. There was also an improvement in quality of life in the psychological intervention group compared to control group. Overall, there was substantial variation across the studies in the range of psychological interventions used, control conditions, measures of the same outcome and timing of follow-up.

A detailed description of the distress trajectory from pre- to post-treatment in breast cancer patients receiving neoadjuvant chemotherapy

PURPOSE

To characterize the distress trajectory in patients with newly diagnosed, non-metastatic breast cancer from pre-neoadjuvant chemotherapy until 12 months after onset of treatment and to identify demographic and clinical predictors of distress in these patients.

METHODS

In a retrospective, longitudinal study, chart review data were abstracted for 252 eligible patients treated at a comprehensive cancer care center. The center screens for distress at least monthly with the distress thermometer; the highest distress score per month was included in the analyses. The growth trajectory was established using mixed modeling and predictors were added to the initial growth model in subsequent models.

RESULTS

Distress showed a cubic growth trajectory with highest distress prior to treatment onset followed by a steep decline in the first three months of treatment. A slight increase in distress was apparent over months 6-10. Being Hispanic was associated with a stronger increase in distress in the second half of the year (p = 0.012). NACT was associated with lower distress and surgery with higher distress (both: p < 0.001).

CONCLUSION

Distress is at its peak prior to treatment onset and rapidly decreases once treatment has started. Oncologist should be aware that both completion of NACT and undergoing surgery are associated with increases in distress and Hispanic patients may be more at risk for an increase in distress at these times; this suggests that careful monitoring of distress during the treatment trajectory and in Hispanic patients in particular in order to provide timely support.

The care cascade following a supportive management intervention for patients presenting to a radiation oncology clinic

Patients with cancer have many psychosocial needs, some of which may be addressed by implementation of a screening tool. However, it is unknown what ultimately happens (i.e., the "care cascade") to patients following these interventions. The objective of this study was to evaluate the care cascade for patients following the implementation of a psychosocial needs screening tool. This was a prospective cohort study conducted at a university hospital radiation oncology clinic. Participants who were 18 years or older and presenting for their initial radiation oncology appointment were asked to complete a screening survey. From December 2019 to January 2021, 242 patients completed the survey. 70% of patients were seen for consideration of definitive therapy. 62% of patients checked "yes" to at least one item, most commonly supportive/palliative care (33%), exercise/PT (26%) and advance care planning (26%). Among definitive patients, the most common were supportive/palliative care (33%) and exercise/PT (26%). Among palliative patients, the most common were supportive/palliative care (42%) and advance care planning (32%). Participants were followed for 6 months after taking the survey. 74% of patients with a positive screening survey were contacted by a social worker and/or had a new referral placed with 47% of those patients ultimately attending a new appointment. Screening tools are commonly implemented to quickly identify needs in oncology patients. This study tracked patients following this type of intervention to determine what proportion of patients ultimately received care related to the identified need. Despite the majority of patients being referred to a relevant provider, fewer than half ultimately attended appointments. The combination of a screening tool with social work triage may be an effective way to distribute resources and properly route patients to supportive care providers.

Depression, anxiety and related factors among Syrian breast cancer patients: a cross-sectional study

INTRODUCTION

Breast cancer represents a traumatic experience with a psychological burden. The prevalence of psychological distress (which include depression and anxiety) among breast cancer patients is estimated to be 15 to 54%, but studies have shown that applying some psychological treatments has contributed to decreasing depression and anxiety. So, it is crucial to diagnose and treat patients with the appropriate means. After reviewing the literature, no studies discussed depression and anxiety among Syrian breast cancer patients.

METHODS

A cross-sectional study in Al-Bairouni hospital in Damascus, Syria carried out using face-to-face interviews based on a structured questionnaire. All breast cancer patients were included, except who refused to participate, and responses with missing data were excluded. The questionnaire consisted of 2 sections: the first included Socio-demographic characteristics, and the other evaluated patients' depression using PHQ-2 and GAD-2 scales. Data were gathered using the Kobo toolbox app and then entered into an Excel sheet.

RESULTS

Five hundred patients were interviewed. 35.6% of the patients had a GAD-2 score greater than or equal to 3.00, while 35% had a PHQ-2 score greater than or equal to 3.00. There is a significant negative relationship between the age of the patient and the GAD-2 score and PHQ-2 score, which means the older the patient is, the lower the GAD-2 and PHQ-2 scores are. A multivariable regression model showed that younger (age ≤ 45 years) and being widowed were associated with being positive for further evaluation for generalized anxiety disorder. Similarly, patients younger than 45 are significantly associated with the need for further evaluation for major depressive disorder (MDD). Social status had a stronger association with the need for further assessment for MDD, with divorced women showing the strongest association, followed by widowed and married women compared to single women.

CONCLUSION

This study showed high anxiety and depression among breast cancer patients. The patient's age and social status were significant factors in determining the need for further psychological assessment. In General, Younger patients showed higher levels of depression and anxiety, the size of the tumor did not show significant association with psychological distress.

Biomarker opportunities in the treatment of cancer-related depression

Depression comorbid with cancer is common and associated with a host of negative health outcomes. The inflammatory basis of depression is a growing area of research in cancer, focused on how stressors transduce into inflammation and contribute to the emergence of depression. In this review, we synthesize inflammatory biomarker associations with both depression and the currently available pharmacotherapies and psychotherapies in cancer, underscoring the need for expanding research on anti-inflammatory agents with antidepressant effects. Modulation of inflammatory neuroimmune pathways can slow tumor progression and reduce metastases. Biomarkers associated with depression in cancer may help with diagnosis and treatment monitoring, as well as inform research on novel drug targets to potentially improve cancer survival.

Psychological distress and eustress in cancer and cancer treatment: Advances and perspectives

Facing cancer diagnosis, patients with cancer are prone to psychological stress and consequent psychological disorders. The association between psychological stress and cancer has long been a subject of high interest. To date, preclinical studies have gradually uncovered the promotive effects of psychological distress on tumor hallmarks. In contrast, eustress may exert suppressive effects on tumorigenesis and beneficial effects on tumor treatment, which brings a practicable means and psychosocial perspective to cancer treatment. However, the underlying mechanisms remain incompletely understood. Here, by focusing on the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system, as well as stress-related crucial neurotransmitters and hormones, we highlight the effects of distress and eustress on tumorigenesis, the tumor microenvironment, and tumor treatment. We also discuss the findings of clinical studies on stress management in patients with cancer. Last, we summarize questions that remain to be addressed and provide suggestions for future research directions.

Guided imagery for treatment (GIFT): protocol of a pilot trial of guided imagery versus treatment as usual to address radiotherapy-related distress in head and neck cancer

Background

Cancers of the head and neck region are associated with high symptom burden and elevated levels of psychological distress. Radiotherapy (RT) is a common treatment for patients with head and neck cancer (HNC) that is associated with psychological distress related to the immobilizing nature of the treatment, frequency of treatment delivery, and side effects. Guided imagery is a relaxation technique that is beneficial in reducing psychological distress in patients with other cancer diagnoses but has not been studied in this patient population. The purpose of this study is to evaluate the feasibility and acceptability of a brief guided imagery intervention (guided imagery for treatment, GIFT) to reduce RT-related anxiety and depression in patients with HNC relative to treatment as usual (TAU).

Methods

Patients with HNC planning to receive RT will be recruited to participate in a randomized controlled trial evaluating a brief, two-session guided imagery intervention (GIFT) relative to TAU alone. Primary aims include acceptability and feasibility evaluated through quantitative and qualitative methods. Measures of anxiety and depression, symptom burden, health-related quality of life, and anxiolytic medication use will be collected at baseline, during treatment, and at 1-month follow-up.

Discussion

There are no published interventions of guided imagery for anxiety and depression in patients with HNC despite its efficacy in other populations of patients with cancer. This proposed project evaluates the feasibility and acceptability of an intervention that has the potential to reduce psychological distress in a vulnerable population. Additionally, we will preliminarily examine the impact of behavioral intervention on psychological distress and the use of anxiolytic medication, a novel area of study.

Trial registration

Clinicaltrials.gov NCT03662698; registered on 9/6/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01134-9.

Stressful Life Events and Distress in Breast Cancer: A 5-Years Follow-Up

Background/Objective

Method

Results

Conclusions

Aspects of Psychiatric Comorbidities in Breast Cancer Patients in Tertiary Hospitals Due to COVID-19 Outbreak in South Korea: A Single Center Longitudinal Cohort Study

Background and Objectives: This study aimed to analyze the prevalence of mental disorders in patients with breast cancer at Ajou University Hospital. In addition, the patterns and prevalence of mental disorders according to the occurrence of coronavirus disease (COVID-19) were analyzed. Materials and Methods: From 1 January 2008 to 30 June 2021, psychiatric disorders were identified in 5174 female patients diagnosed with breast cancer at Ajou University Hospital. Based on the time when COVID-19 occurred, the pattern of onset of mental disorders in patients with breast cancer was analyzed. In addition, the prevalence of mental disorders according to the time of breast cancer diagnosis and age was evaluated. Results: A year before the diagnosis of breast cancer, 371 patients were diagnosed with a mental disorder. Of these, 201 patients were diagnosed with stress and adjustment disorders, and 97 patients had anxiety disorders. The overall frequency of psychiatric disorders after breast cancer diagnosis peaked two months later. Among psychiatric disorders reported before the COVID-19 pandemic, the proportion of stress/adaptation disorders was 52%, and among psychiatric disorders reported after the pandemic, it was significantly higher at 94.7%. Anxiety was found to be high in the elderly group aged ≥ 60 years, and the prevalence of stress and adjustment disorders tended to increase in the non-elderly group. Conclusions: Breast cancer patients showed different patterns of psychiatric disorders according to age, time of breast cancer diagnosis, and the occurrence of COVID-19. Owing to the COVID-19 pandemic, delays in treatment and anxiety about infection have increased the rate of stress and adjustment disorders in cancer patients. Mental health management during the pandemic and after cancer diagnosis can improve the quality of life of patients with cancer.

The Effect of Pre-operative Psychological Interventions on Psychological, Physiological, and Immunological Indices in Oncology Patients: A Scoping Review

Introduction

The stressful pre-operative period exerts a profound impact on psychological, physiological and immunological outcomes. Oncological surgeries, in particular, elicit significantly higher stress responses than most other surgeries. Managing these responses through psychological interventions may improve long-term outcomes. The purpose of the current research was to review studies that have explored pre-operative psychological interventions in cancer patients in order to map the types of current interventions and provide an initial assessment of whether these interventions improved psychological, physiological, and/or immunological indices as well as long-term cancer outcomes.

Methods

A systematic literature search for studies that included pre-operative psychological interventions in oncology patients was conducted, using the databases PubMed and Web of Science. Inclusion criteria included studies pertaining to oncological surgery in adults, study designs that included a clearly defined pre-operative psychological intervention and control group.

Results

We found 44 studies, each using one of the following interventions: psychoeducation, cognitive interventions, relaxation techniques, integrated approaches. All the studies reported improved immediate post-operative psychological, physiological, and/or immunological outcomes. Only a few studies addressed long-term cancer outcomes, and only one reported improved survival.

Conclusions

Research on pre-operative interventions with cancer patients is missing systematic methods. Studies provide varying results, which makes it difficult to compare them and reach reliable conclusions. There is considerable heterogeneity in the literature regarding the specific intervention used, the timing of intervention, the characteristics of the patients studied and the outcome measures. In order to improve research in this field, including the measurement of long-term outcomes, we suggest some steps that should be taken in further research.

Contribution of adrenergic mechanisms for the stress-induced breast cancer carcinogenesis

Breast cancer is the most common and deadliest type of cancer in women. Stress exposure has been associated with carcinogenesis and the stress released neurotransmitters, noradrenaline and adrenaline, and their cognate receptors, can participate in the carcinogenesis process, either by regulating tumor microenvironment or by promoting systemic changes. This work intends to provide an overview of the research done in this area and try to unravel the role of adrenergic ligands in the context of breast carcinogenesis. In the initiation phase, adrenergic signaling may favor neoplastic transformation of breast epithelial cells whereas, during cancer progression, may favor the metastatic potential of breast cancer cells. Additionally, adrenergic signaling can alter the function and activity of other cells present in the tumor microenvironment towards a protumor phenotype, namely macrophages, fibroblasts, and by altering adipocyte's function. Adrenergic signaling also promotes angiogenesis and lymphangiogenesis and, systemically, may induce the formation of preneoplastic niches, cancer-associated cachexia and alterations in the immune system which contribute for the loss of quality of life of breast cancer patients and their capacity to fight cancer. Most studies points to a major contribution of β₂ -adrenoceptor activated pathways on these effects. The current knowledge of the mechanistic pathways activated by β₂ -adrenoceptors in physiology and pathophysiology, the availability of selective drugs approved for clinical use and a deeper knowledge of the basic cellular and molecular pathways by which adrenergic stimulation may influence cancer initiation and progression, opens the possibility to use new therapeutic alternatives to improve efficacy of breast cancer treatments.

The lived experience during the peri-diagnostic period of breast cancer: A scoping review

OBJECTIVES

The aim of this scoping review is to provide an overview of the existing research that investigates the lived experience during the peri-diagnostic period of breast cancer.

METHODS

Nine databases were searched for relevant literature between January 2007 and April 2019. Data were extracted and categorized using deductive and inductive approaches.

RESULTS

A majority of the 66 studies included used qualitative methods to retrospectively explore the treatment decision making process of female breast cancer patients. Patients experienced uncertainty, emotional distress, and a need for more information from providers and relied on social support and family guidance during this period.

CONCLUSIONS

The results of this review show that the burdens experienced during the peri-diagnostic period parallel those in later periods of cancer care. However, these burdens are prompted by different circumstances. More research is needed to explore the lived experience during this period through the use of mixed-methods and by recruiting a diverse sample with regards to role in the breast cancer experience, age, gender, race, and ethnicity.

PRACTICE IMPLICATIONS

Interventions positioned at earlier points in the breast cancer experience should provide informational support, which could be delivered through shared decision making models. Additional support could be facilitated by patient navigation programs and health information technology.

Dispositional hope as a potential outcome parameter among patients with advanced malignancy: An analysis of the ENABLE database

BACKGROUND

Hopefulness, whether inherently present (dispositional hope) or augmented (by enhancement techniques), may affect outcomes. This study was performed to determine the association of dispositional hope with survival among patients diagnosed with advanced cancer.

METHODS

Data from ENABLE (Educate, Nurture, Advise, Before Life Ends), a palliative care intervention, were reanalyzed to determine the association of higher dispositional hope and patient survival. This was a secondary analysis of data combined from the ENABLE II and ENABLE III randomized controlled trials (RCTs) with respect to dispositional hope and survival. A dispositional hope index was created from 3 hope items from 2 validated baseline questionnaires. Dispositional hope and survival data were collected during the 2 RCTs. In ENABLE II, participants were randomly assigned to the ENABLE intervention or to usual care. In ENABLE III, participants were randomly assigned to receive the intervention immediately or 12 weeks after enrollment.

RESULTS

In all, 529 persons were included in Cox proportional hazards regression analyses to model the effects of dispositional hope on survival. An initial analysis without covariates yielded a significant effect of hope (Wald statistic, 8.649; hazard ratio, 0.941; confidence interval, 0.904-0.980; P = .003), such that higher dispositional hope was associated with longer survival. In a subsequent analysis that included all covariates, the effect of dispositional hope approached statistical significance (Wald statistic, 2.96; hazard ratio, 0.933; confidence interval, 0.863-1.010; P = .085).

CONCLUSIONS

Higher levels of dispositional hope were associated with longer survival in patients with advanced cancer. Prospective trials are needed to determine the effects of dispositional and augmented hope on the outcomes of patients with advanced cancer.

Biobehavioral Pathways and Cancer Progression: Insights for Improving Well-Being and Cancer Outcomes

The relationship between psychosocial factors and cancer has intrigued people for centuries. In the last several decades there has been an expansion of mechanistic research that has revealed insights regarding how stress activates neuroendocrine stress-response systems to impact cancer progression. Here, we review emerging mechanistic findings on key pathways implicated in the effect of stress on cancer progression, including the cellular immune response, inflammation, angiogenesis, and metastasis, with a primary focus on the mediating role of the sympathetic nervous system. We discuss converging findings from preclinical and clinical cancer research that describe these pathways and research that reveals how these stress pathways may be targeted via pharmacological and mind-body based interventions. While further research is required, the body of work reviewed here highlights the need for and feasibility of an integrated approach to target stress pathways in cancer patients to achieve comprehensive cancer treatment.

Stress and cancer: mechanisms, significance and future directions

The notion that stress and cancer are interlinked has dominated lay discourse for decades. More recent animal studies indicate that stress can substantially facilitate cancer progression through modulating most hallmarks of cancer, and molecular and systemic mechanisms mediating these effects have been elucidated. However, available clinical evidence for such deleterious effects is inconsistent, as epidemiological and stress-reducing clinical interventions have yielded mixed effects on cancer mortality. In this Review, we describe and discuss specific mediating mechanisms identified by preclinical research, and parallel clinical findings. We explain the discrepancy between preclinical and clinical outcomes, through pointing to experimental strengths leveraged by animal studies and through discussing methodological and conceptual obstacles that prevent clinical studies from reflecting the impacts of stress. We suggest approaches to circumvent such obstacles, based on targeting critical phases of cancer progression that are more likely to be stress-sensitive; pharmacologically limiting adrenergic-inflammatory responses triggered by medical procedures; and focusing on more vulnerable populations, employing personalized pharmacological and psychosocial approaches. Recent clinical trials support our hypothesis that psychological and/or pharmacological inhibition of excess adrenergic and/or inflammatory stress signalling, especially alongside cancer treatments, could save lives.

The Risk of Psychological Stress on Cancer Recurrence: A Systematic Review

Cancer recurrence is a significant clinical issue in cancer treatment. Psychological stress has been known to contribute to the incidence and progression of cancer; however, its effect on cancer recurrence remains inconclusive. We conducted a systematic review to examine the current evidence from the Medline (PubMed), Embase and Cochrane Library up to May 2021. Among 35 relevant articles, a total of 6 studies (10 data points) were finally selected, which enrolled 26,329 patients (26,219 breast cancer patients except hepatocellular carcinoma patients in 1 study), 4 cohort studies (8 data points) and 2 RCTs (2 data points). Among the 8 data points in cohort studies, four psychological stress-related factors (two 'anxiety', one 'depression', and one 'hostility') were shown to be moderately related with the risk for cancer recurrence, while 'loss of partner' resulted in opposite outcomes. The 'emotional' and 'mental' health factors showed conflicting results, and an RCT-derived meta-analysis proved the positive efficiency of psychotherapies in reducing the cancer recurrence risk among breast cancer patients (HR = 0.52; 95% CI 0.33-0.84). Despite the limitations, this study produces comprehensive information about the effect of psychological stress on cancer recurrence and provides reference data to clinicians and scientists for further studies.

Heart rate variability and psychosocial symptoms in adolescents and young adults with cancer

Background

Heart Rate Variability (HRV) is a valid, scalable biomarker of stress. We aimed to examine associations between HRV and psychosocial outcomes in adolescents and young adults (AYAs) with cancer.

Methods

This was a secondary analysis of baseline data from a randomized trial testing a resilience intervention in AYAs with cancer. Two widely used HRV metrics, the standard deviation of normal to normal beats (SDNN) and root mean square of successive differences (RMSSD), were derived from electrocardiograms. Patient-reported outcome (PRO) survey measures included quality of life, anxiety, depression, distress, and resilience. Linear regression models were used to test associations between HRV and PRO scores. The Wilcoxon rank sum test was used to test differences in median HRV values among participant subgroups.

Results

Among the n = 76 patients with available electrocardiograms, the mean age was 16 years (SD 3y), 63% were white, and leukemia/lymphoma was the most common diagnosis. Compared to healthy adolescents, AYAs with cancer had lower median HRV (SDNN [Females: 31.9 (12.8–50.7) vs 66.4 (46.0–86.8), p<0.01; Males: 29.9 (11.5–47.9) vs 63.2 (48.4–84.6), p<0.01]; RMSSD [Females: 28.2 (11.1–45.5) vs 69.0 (49.1–99.6), p<0.01; Males: 27.9 (8.6–48.6) vs 58.7 (44.8–88.2), p<0.01]). There was no statistically significant association between PRO measures and SDNN or RMSSD in either an unadjusted or adjusted linear regression models.

Conclusion

In this secondary analysis, we did not find an association between HRV and psychosocial PROs among AYAs with cancer. HRV measures were lower than for healthy adolescents. Larger prospective studies in AYA biopsychosocial research are needed.

Pilot Randomized Controlled Trial in Women With Non-Small Cell Lung Cancer to Assess the Feasibility of Delivering Group-Based Psychosocial Care via Videoconference

Background:

The goal of this pilot randomized controlled trial was to examine the feasibility and acceptability of delivering group-based psychosocial care via videoconference (ie, Zoom) to women with lung cancer undergoing treatment.

Methods:

At baseline, women indicated their typical computer and internet use and were then randomized to a group-based intervention that either focused on mindfulness training or psychoeducation. Participants completed 1 Zoom “practice run” prior to starting the 5 group sessions (1 per week). After the last session, they evaluated their experiences with the intervention and its delivery.

Results:

With a consent rate of 68%, 54 women (mean age = 66 years; 69% non-Hispanic White; 48% with stage IV disease) were equally randomized. Attendance was high in both arms (session mean, mindfulness = 4.38; education = 4.75; 85% attended all sessions). Across arms, all women rated the program as useful; most preferred group-based delivery (67%) and remote delivery (50%) or had no preference. Although the sample’s typical computer use was relatively low (eg, 19% said that they rarely or never use a computer), most women (76%) indicated that Zoom was “very easy” or “easy” to use. After only 0 to 1 attempts, 56% felt comfortable but 26% stated that they never felt comfortable with the technology.

Conclusions:

It seems to be feasible to deliver group-based psychosocial interventions via videoconference in women with lung cancer undergoing treatment. Challenges regarding scheduling the group sessions and familiarizing older rather than infrequent computer users with the technology were encountered but resolved over the course of the trial.

The biology of stress in cancer: Applying the biobehavioral framework to adolescent and young adult oncology research

The stress response influences the development and trajectory of cancer through a host of complex neuroimmune mechanisms. Basic, translational, and clinical research has elucidated these biobehavioral connections and offers a new paradigm for scientific investigation and patient care. Using a biobehavioral approach could offer new diagnostic and therapeutic opportunities in oncology, and this approach will be particularly impactful for adolescent and young adult (AYA) patients with cancer. To date, nearly all biobehavioral oncology research has been done in the adult population. And yet, AYAs have traditionally poorer mental health and cancer-related outcomes, and thus represent a population that could benefit from parallel psychosocial and biomedical intervention. Future biobehavioral work in oncology should focus on the AYA population, integrating new cancer therapies and technology into the next generation of research.

•

Translational research efforts are clarifying the role of stress in cancer biology and patient outcomes.

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AYAs have poorer cancer-related and mental health outcomes, but nearly all biobehavioral oncology studies are in adults.

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Future work in immunotherapy, digital health technology, and interdisciplinary cooperation will advance the field.

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A translational biobehavioral approach brings the paradigm of precision medicine to psychosocial care in cancer.

Recent trends in the management of depression in persons with cancer

PURPOSE OF REVIEW

Depression is a prevalent comorbidity in cancer that significantly increases the risk for numerous negative health outcomes. This review updates the current evidence base for management of depression in cancer, highlighting new research directions based on the inflammatory hypothesis of depression.

RECENT FINDINGS

Research on pharmacotherapy and psychotherapy for depression in cancer has shown mixed efficacy partly because of methodological issues arising from the phenomenology of depression in cancer. After decades of stagnancy, more recent high-quality clinical trials are beginning to provide an evidence base to guide treatment. Inflammatory cytokine-associated depression is a subtype of depression that may have particular relevance in cancer, opening new avenues to explore therapeutic targets and biobehavioral impacts of interventions, which may improve cancer outcomes.

SUMMARY

The continuum of severity in cancer-related depression is important to consider in management approaches. Choice of treatment should be personalized to the patient and their symptom profile as there is currently insufficient evidence to recommend any particular medication or psychotherapy over another. Psychological interventions should be considered first line for mild-to-moderate depression, and pharmacological treatment added for more severe depression, which can be optimally delivered within a collaborative care model.

VIDEO ABSTRACT

http://links.lww.com/YCO/A62.

Addressing distress management challenges: Recommendations from the consensus panel of the American Psychosocial Oncology Society and the Association of Oncology Social Work

Distress management (DM) (screening and response) is an essential component of cancer care across the treatment trajectory. Effective DM has many benefits, including improving patients' quality of life; reducing distress, anxiety, and depression; contributing to medical cost offsets; and reducing emergency department visits and hospitalizations. Unfortunately, many distressed patients do not receive needed services. There are several multilevel barriers that represent key challenges to DM and affect its implementation. The Consolidated Framework for Implementation Research was used as an organizational structure to outline the barriers and facilitators to implementation of DM, including: 1) individual characteristics (individual patient characteristics with a focus on groups who may face unique barriers to distress screening and linkage to services), 2) intervention (unique aspects of DM intervention, including specific challenges in screening and psychosocial intervention, with recommendations for resolving these challenges), 3) processes for implementation of DM (modality and timing of screening, the challenge of triage for urgent needs, and incorporation of patient-reported outcomes and quality measures), 4) organization-inner setting (the context of the clinic, hospital, or health care system); and 5) organization-outer setting (including reimbursement strategies and health-care policy). Specific recommendations for evidence-based strategies and interventions for each of the domains of the Consolidated Framework for Implementation Research are also included to address barriers and challenges.

Dissatisfaction After Post-Mastectomy Breast Reconstruction: A Mixed-Methods Study

BACKGROUND

Breast reconstruction is associated with improved patient well-being after mastectomy; however, factors that contribute to post-surgical dissatisfaction remain poorly characterized.

METHODS

Adult women who underwent post-mastectomy implant-based or autologous breast reconstruction between 2015 and 2019 were recruited to participate in semi-structured interviews regarding their lived experiences with reconstructive care. Participants completed the BREAST-Q, and tabulated scores were used to dichotomize patient-reported outcomes as satisfied or dissatisfied (high or low) for each BREAST-Q domain. A convergent mixed-methods analysis was used to evaluate interviews for content related to satisfaction or dissatisfaction with breast reconstruction.

RESULTS

Overall, we interviewed 21 women and identified 17 subcodes that corresponded with the five BREAST-Q domains. Sources of dissatisfaction were found to be related to the following domains: (a) low breast satisfaction due to asymmetry, cup size, and lack of sensation and physical feeling (n = 8, 38%); (b) poor sexual well-being due to shape, look and feel (n = 7, 78% [of 9 who discussed sexual well-being]); (c) reduced physical well-being of the chest due to persistent pain and weakness (n = 11, 52%); (d) reduced abdominal well-being due to changes in abdominal strength, numbness, and posture (n = 6, 38% [of 16 who underwent abdominally based reconstruction]); and (e) low psychosocial well-being impacted by an unexpected appearance that negatively influenced self-confidence and self-identity (n = 13, 62%).

CONCLUSION

Patients may be unprepared for the physical, sexual, and psychosocial outcomes of breast reconstruction. Targeted strategies to improve preoperative education and shared decision making are needed to mitigate unexpectedness associated with breast reconstruction and related outcomes.

Replicating dissemination and identifying mechanisms of implementation of an empirically supported treatment

OBJECTIVE

Implementation research is needed in cancer control. Replication of the dissemination of empirically supported treatments (ESTs) is important as is the identification of mechanisms by which dissemination leads to implementation. Addressing these gaps, Study 1 (Cohorts 3-6, N = 104) tests for replication of a successful dissemination to community providers (Brothers et al., 2015; Cohorts 1-2; N = 62) and Study 2 (Cohorts 1-6) tests providers' changes on dissemination outcomes as mechanisms of EST usage.

METHOD

The Biobehavioral Intervention (BBI), a psychological EST in cancer control, was disseminated to oncology mental health providers using manual provision, didactics, roleplays, and other strategies. Study 1 tested for pre/post changes in dissemination outcomes (BBI knowledge/skills and attitudes toward and self-efficacy to deliver ESTs/BBI) between cohorts (1-2 vs. 3-6) with repeated measures ANOVAs. In Study 2, the implementation outcome was providers' (N = 166) BBI usage with patients (percent treated). Structural equation models tested dissemination outcome changes as predictors of usage at 2- and 4-months.

RESULTS

Study 1 replicated high dissemination outcomes and significant gains in BBI knowledge (p < .001) in Cohorts 3-6. Unlike Cohorts 1-2, significant gains were observed in self-efficacy (ps < .001) but not attitudes toward ESTs (p = .523) in Cohorts 3-6. In Study 2, gains in providers' self-efficacy (ps < .05) and EST attitudes (p = .008) predicted greater 2-month (58.4% ± 35.5%) and 4-month (66.2% ± 35.0%) usage of the BBI with patients, respectively.

CONCLUSIONS

This is the only replication of a dissemination for a psychological EST in cancer control. Results reliably show disseminations enhancing providers' self-efficacy to use and positive attitudes toward ESTs as mechanisms for EST implementation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Universal social needs assessment in gynecologic oncology: An important step toward more informed and targeted care in the public safety net

BACKGROUND

Social needs are actionable mediators of social determinants of health. Along with distress, they affect quality of life and survival in patients with cancer. The objectives of this study were to identify the most common social needs and distress in a largely immigrant gynecologic oncology patient population at a public safety-net hospital and to evaluate for specific needs associated with distress and poor outcomes.

METHODS

This was a prospective, survey-based cohort study of patients who participated in a performance-improvement initiative offering social needs assessment and distress screening. Patients provided sociodemographic information and completed validated surveys adapted from the Health Leads Social Needs Screening Toolkit, the National Comprehensive Cancer Network Distress Thermometer, and the Emotion Thermometers Tool. Associations between social needs, distress, and treatment outcomes were analyzed.

RESULTS

In total, 135 women were included. Of these, 65.2% had at least 1 unmet social need, and 36.3% screened positive for distress. Help reading hospital materials (30.4%) was the most frequently reported need. Social isolation (odds ratio [OR], 3.65; 95% CI, 1.35-9.9; P = .01) and lack of safety at home (OR, 4.90; 95% CI, 2.23-10.62; P = .0001) were associated with distress. Perceived lack of finances for medical care (OR, 5.69; 95% CI, 1.12-28.9; P = .036) and lack of transportation (OR, 20.5; 95% CI, 2.69-156.7; P = .004) were associated with nonadherence-related treatment interruption, whereas positive distress scores were associated with interruption because of comorbidities or treatment-related toxicities (OR, 20.5; 95% CI, 1.5-268.6; P = .02).

CONCLUSIONS

Systematically identifying social needs and developing interventions aimed at mitigating them may lead to more actionable health care disparities research and affect treatment outcomes.

LAY SUMMARY

Social needs are individual-level social conditions that drive health disparities. In this survey-based study, the objective was to identify common social needs and how these relate to distress and poor health outcomes in a largely immigrant and underserved gynecologic oncology patient population. The authors found that greater than one-third of patients screened positive for distress, nearly two-thirds had at least 1 unmet social need, and these factors were associated with emergency room visits, hospital admissions, and treatment interruptions. These findings suggest that screening for universal social needs allows providers to identify unrecognized needs and implement interventions to mitigate distress and improve health outcomes.

Function of a Psychological Nursing Intervention on Depression, Anxiety, and Quality of Life in Older Adult Patients With Osteoporotic Fracture

BACKGROUND

Osteoporotic fracture is a serious complication of osteoporosis. The long-term therapy process and the heavy restriction to physical activities give rise to a psychological burden on osteoporotic fracture patients, especially older adult patients. Psychological nursing interventions significantly alleviate negative emotional reactions in cancer patients. This research aimed to investigate the function of psychological nursing interventions in the reduction of depression and anxiety and the improvement of quality of life in older adult patients with osteoporotic fracture.

METHODS

Osteoporotic fracture patients (n = 106) were divided into control group (n = 53) or intervention group (n = 53). In the control group, the participants were given conventional nursing care. In the intervention group, the participants were given psychological nursing interventions. Anxiety, depression, and quality of life were evaluated and compared between the two groups.

RESULTS

After 5 weeks of psychological nursing intervention, the anxiety and depression scores significantly decreased in the intervention group. The Mental Function in Quality of Life Questionnaire of the European Foundation for Osteoporosis score also decreased in the intervention group.

LINKING EVIDENCE TO ACTION

Psychological nursing interventions alleviate anxiety and depression in older adult osteoporotic fracture patients and enhance their mental function.

Impact of Race and Health Insurance Status on Response to Neoadjuvant Chemotherapy for Breast Cancer Patients

We evaluated how race, insurance status, and other sociodemographic, tumor, and treatment variables influenced the response to neoadjuvant chemotherapy (NAC) in breast cancer. We performed an IRB-approved retrospective review of 298 breast cancer patients treated with NAC from 2006-2018 at our institution. Univariable and multivariable binary logistic regression analyses were performed to estimate the effects of race, insurance status, and other variables on outcomes. Outcomes of interest included pathologic complete response (pCR), partial response (pPR), and any response (pCR or pPR). Sixty-nine patients (23%) identified as African American. One hundred sixty-eight (57%) patients had private insurance, 71 (24%) had Medicare, 40 (14%) had Medicaid, and 17 (6%) had no insurance. Insurance status was a predictor for any clinical response to NAC in both univariable and multivariable analyses (p<0.01), where odds of pCR or pPR were lower for patients with Medicare compared to private insurance (OR 0.32, 95% CI: 0.15-0.70, p<0.01). Other variables significant for the response to NAC included body mass index, hormone receptor status, clinical group stage, and Ki-67. Race did not influence the response to NAC. Insurance provider, body mass index, hormone receptor status, clinical group stage, and Ki-67 may be useful predictors of treatment outcomes. Future studies that assess the impacts of insurance status and other identified factors on treatment response may help evaluate outcomes in at-risk populations with factors that preclude full benefit from NAC.

Multidisciplinary lifestyle modification program (IM-FIT) for cancer survivors: implementation of a reimbursable model in a cancer hospital

PURPOSE

We examined the initial effects of a real-world application of a multimodal, reimbursable program to improve lifestyle and promote healthy weight loss in cancer survivors as part of their care.

METHODS

The lifestyle program (Integrative Medicine Fitness Program; IM-FIT) focusing on increasing physical activity and strength training, improving nutrition, and facilitating stress management and behavior change was delivered in a group format over 12 weeks. Patients met weekly with a physical therapist, dietitian, and psychologist. Body composition and behavioral data were collected at the start and end of 12 weeks, as well as fitness, nutrition, and psychological data. The first cohort started in September 2017, and the last cohort ended in August 2019.

RESULTS

Twenty-six patients (92% female; mean age = 62.7, SD = 9) completed the program, which was pre-approved and covered as in-network by their health insurance. Patients lost an average of 3.9% of their body weight (SD =  - 2.2). There was a significant reduction in white bread and desserts and increase in legumes and non-dairy milk. Time spent in vigorous exercise (p < .001), strength training (p < .001), and total exercise (p < .001) significantly increased. Patients reported reduction in depression (7.76 to 4.29; p = .01), anxiety (6.14 to 3.29; p < .01), and overall distress (4.70 to 3.40; p < .01).

CONCLUSION

We demonstrated that a multi-disciplinary weight loss program can be tailored to cancer survivors leading to weight reduction and improvements in lifestyle factors and mental health. This program showed successful real-world implementation with insurance reimbursement.

Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: A meta-analysis of 106 randomized controlled trials

BACKGROUND

Hospitals, clinics, and health organizations have provided psychosocial support interventions for medical patients to supplement curative care. Prior reviews of interventions augmenting psychosocial support in medical settings have reported mixed outcomes. This meta-analysis addresses the questions of how effective are psychosocial support interventions in improving patient survival and which potential moderating features are associated with greater effectiveness.

METHODS AND FINDINGS

We evaluated randomized controlled trials (RCTs) of psychosocial support interventions in inpatient and outpatient healthcare settings reporting survival data, including studies reporting disease-related or all-cause mortality. Literature searches included studies reported January 1980 through October 2020 accessed from Embase, Medline, Cochrane Library, CINAHL, Alt HealthWatch, PsycINFO, Social Work Abstracts, and Google Scholar databases. At least 2 reviewers screened studies, extracted data, and assessed study quality, with at least 2 independent reviewers also extracting data and assessing study quality. Odds ratio (OR) and hazard ratio (HR) data were analyzed separately using random effects weighted models. Of 42,054 studies searched, 106 RCTs including 40,280 patients met inclusion criteria. Patient average age was 57.2 years, with 52% females and 48% males; 42% had cardiovascular disease (CVD), 36% had cancer, and 22% had other conditions. Across 87 RCTs reporting data for discrete time periods, the average was OR = 1.20 (95% CI = 1.09 to 1.31, p < 0.001), indicating a 20% increased likelihood of survival among patients receiving psychosocial support compared to control groups receiving standard medical care. Among those studies, psychosocial interventions explicitly promoting health behaviors yielded improved likelihood of survival, whereas interventions without that primary focus did not. Across 22 RCTs reporting survival time, the average was HR = 1.29 (95% CI = 1.12 to 1.49, p < 0.001), indicating a 29% increased probability of survival over time among intervention recipients compared to controls. Among those studies, meta-regressions identified 3 moderating variables: control group type, patient disease severity, and risk of research bias. Studies in which control groups received health information/classes in addition to treatment as usual (TAU) averaged weaker effects than those in which control groups received only TAU. Studies with patients having relatively greater disease severity tended to yield smaller gains in survival time relative to control groups. In one of 3 analyses, studies with higher risk of research bias tended to report better outcomes. The main limitation of the data is that interventions very rarely blinded personnel and participants to study arm, such that expectations for improvement were not controlled.

CONCLUSIONS

In this meta-analysis, OR data indicated that psychosocial behavioral support interventions promoting patient motivation/coping to engage in health behaviors improved patient survival, but interventions focusing primarily on patients' social or emotional outcomes did not prolong life. HR data indicated that psychosocial interventions, predominantly focused on social or emotional outcomes, improved survival but yielded similar effects to health information/classes and were less effective among patients with apparently greater disease severity. Risk of research bias remains a plausible threat to data interpretation.

Achieving oncology mental health providers' usage of an empirically supported treatment: Lessons learned

OBJECTIVE

There is a need for oncology mental health providers to receive training to use empirically supported psychological treatments (ESTs) with their patients. The purpose of this editorial is to describe "lessons learned" from disseminating-conducting EST trainings-and supporting providers' capacity and confidence to use the EST.

METHOD

Processes and outcomes from conducting six, 3-days (18 h) EST training institutes from 2012-2016 are discussed. Institutes trained 166 full time oncology mental health providers from more than 100 different settings. The dissemination was intentionally designed to achieve EST implementation, i.e., therapists' sustained usage of the EST for at least 12 months post training.

RESULTS

Previously published discussion and findings show the effort was successful in achieving positive EST dissemination outcomes and sustained EST implementation by providers. Thus, "lessons learned" include discussions of (1) orientation to design education/training to achieve EST usage using theory based aims and outcomes of training efficacy; (2) multimodal, educational strategies used to achieve therapists' positive attitudes toward and self-efficacy to implement the EST; (3) guidance to therapists for adapting the EST to their practice settings while maintaining fidelity; (4) assistance to therapists to identify and problem solve implementation challenges; and (5) using patient reported outcome measures to determine clinical change.

CONCLUSION

Our discussion of the plan, methods, and goals of EST training contributes to the science of dissemination/implementation by providing support for (1) theory-informed EST dissemination, and (2) mechanisms of EST implementation. For researchers, our experience may guide future EST dissemination/implementation efforts in psycho-oncology. For therapists, lessons learned provide criteria for evaluating future continuing education options.

Screening for distress, related problems and perceived need for psycho-oncological support in head and neck squamous cell carcinoma (HNSCC) patients: a retrospective cohort study

Background

In different cancer entities, several studies have shown the adverse effects of cancer on mental health, psychological well-being and the increased risk of high emotional distress in cancer patients. This study aims to analyze psychosocial distress levels and their relationship between sociodemographic parameters and selected items on the Distress Thermometer (DT) Problem List in head and neck squamous cell carcinoma (HNSCC) patients.

Patients and methods

We assessed a total of 120 HNSCC patients using the Distress Thermometer (DT) Problem List. Distress scores (DTS) of 90 patients were available. A DTS of ≥ 5 on the visual analogue scale represents clinically relevant distress. Data analysis consisted of descriptive statistics, comparison of mean values for different DTS subcategories and correlation between DTS scores and parameters of tumor classification, sociodemographic variables and selected problems.

Results

Distress was present in 57.7% of the sample, with a total of 52 patients with a DTS  ≥ 5. The mean DTS was 4.7 (SD 2.4). Patients with newly diagnosed HNSCC had significantly higher DTS. Distress levels were significantly associated with sadness, general worries, anxiety, nervousness, sleeping disorders, mouth sores and fever. Out of the total sample, 6 patients and out of these 6 individuals, 5 patients with a DTS ≥ 5 requested referrals to psycho-oncological service.

Conclusion

High distress levels were common in HNSCC patients but only few patients desired psycho-oncological care. Addressing patients’ supportive care needs in routine clinical practice is essential to meet unmet needs of HNSCC patients and thus improve cancer care.

Reducing distress and depression in cancer patients during survivorship

OBJECTIVE

Distress and depression are prevalent in cancer patients throughout survivorship and are associated with adverse outcomes. This study examines the association between outpatient psycho-oncology treatment and distress and depression in cancer patients.

METHODS

This is a prospective observational study of adult patients with a primary diagnosis of cancer referred for psycho-oncology services. Patients were seen for two psycho-oncology visits in a single clinical setting with various qualified providers. Patients completed the distress thermometer and problem checklist (DT + PL) and the Patient Health Questionnaire (PHQ-9) at the beginning of their first and second visits and repeated the DT at the end of these visits.

RESULTS

The analysis included 174 patients seen once and 69 patients seen twice. Patients were seen on average 2.5 years after diagnosis. Both visits were associated with significant reductions in distress (5.56 before and 3.85 after for visit 1, p < 0.001; 4.92 before and 3.43 after for visit 2, p < 0.001). There was a significant reduction in distress from baseline to after visit 2 (p < 0.001). Depression scores significantly decreased from the first to second visits (8.79-7.57; p = 0.002).

CONCLUSIONS

Psycho-oncology services were associated with significant reductions in distress and depression, with scores after services no longer meeting criteria for clinically significant distress (DT scores ≥ 4) and depression (PHQ-9 scores ≥ 8) as they did at baseline. Reductions in distress and depression were not significantly associated with provider type, intervention or timing of diagnosis. These findings support the use of psycho-oncology services in cancer patients throughout survivorship.

Chronic Adrenergic Stress Contributes to Metabolic Dysfunction and an Exhausted Phenotype in T Cells in the Tumor Microenvironment

Metabolic dysfunction and exhaustion in tumor-infiltrating T cells have been linked to ineffectual antitumor immunity and the failure of immune checkpoint inhibitor therapy. We report here that chronic stress plays a previously unrecognized role in regulating the state of T cells in the tumor microenvironment (TME). Using two mouse tumor models, we found that blocking chronic adrenergic stress signaling using the pan β-blocker propranolol or by using mice lacking the β2-adrenergic receptor (β2-AR) results in reduced tumor growth rates with significantly fewer tumor-infiltrating T cells that express markers of exhaustion, with a concomitant increase in progenitor exhausted T cells. We also report that blocking β-AR signaling in mice increases glycolysis and oxidative phosphorylation in tumor-infiltrating lymphocytes (TIL), which associated with increased expression of the costimulatory molecule CD28 and increased antitumor effector functions, including increased cytokine production. Using T cells from Nur77-GFP reporter mice to monitor T-cell activation, we observed that stress-induced β-AR signaling suppresses T-cell receptor (TCR) signaling. Together, these data suggest that chronic stress-induced adrenergic receptor signaling serves as a "checkpoint" of immune responses and contributes to immunosuppression in the TME by promoting T-cell metabolic dysfunction and exhaustion. These results also support the possibility that chronic stress, which unfortunately is increased in many patients with cancer following their diagnoses, could be exerting a major negative influence on the outcome of therapies that depend upon the status of TILs and support the use of strategies to reduce stress or β-AR signaling in combination with immunotherapy.