Symptom incidence, distress, cancer-related distress, and adherence to chemotherapy among African American women with breast cancer

Availability of Cranial Prostheses for Black Patients at Comprehensive Cancer Centers

PURPOSE

For patients who seek to camouflage cancer-related hair loss, cranial prostheses such as wigs and hair pieces exist. We sought to determine the availability of yaki-textured, type IV curls, and afro wigs at boutiques in Comprehensive Cancer Centers (CCCs).

METHODS

The 56 CCCs in the United States were surveyed to see whether they had an affiliated wig boutique for patients experiencing hair loss. Boutique workers were then asked a series of seven questions regarding cranial prostheses options for patients seeking yaki-textured, type IV curls, and afro wigs. The availability of wigs was compared with US Census data on population size and density of Black residents.

RESULTS

Of the 56 CCCs, 27 (46%) institutions had active affiliated hair boutiques. We were able to reach 19 (70%) of the 27 boutiques, of which 53% (n = 10) offered yaki-textured wigs, 37% (n = 7) offered type IV curls or afro wigs, and 47% (n = 9) offered neither. Two additional boutiques offered in-store catalogs for Black patients who were interested in naturally appearing wigs. Although two institutions offered a wig bank that was free to all patients, neither had yaki-textured or afro wigs in stock. There was no significant relationship between population size or density of Black residents and availability of these wigs.

CONCLUSION

Many Black patients undergoing cancer treatment interested in cranial prosthesis do not have consistent access to wigs with textures comparable with type IV hair at CCCs. With increased inventory of racially inclusive wigs, partnerships with third-party vendors, and support for the previous authorization process, we can better support Black patients experiencing cancer-related hair loss.

Dose delay, dose reduction, and early treatment discontinuation in Black and White women receiving chemotherapy for nonmetastatic breast cancer

BACKGROUND

To describe reasons for deviations from planned chemotherapy treatments in women with nonmetastatic breast cancer that contribute to less-than-planned receipt of chemotherapy.

METHODS

Electronic medical records for patients receiving chemotherapy were reviewed for adverse events and treatment modifications. Log-binomial regression models were used to estimate relative risks (RRs) with 95% CIs to examine associations between chemotherapy modifications, patient characteristics, and treatment modalities.

RESULTS

Delays in chemotherapy initiation (7%) were for surgical complications (58%), personal reasons (16%), and other (26%; port malfunction, infections, and obtaining extra imaging). Delays during chemotherapy (38%) were for infections (20%), neutropenia (13%), and personal reasons (13%). Dose reductions (38%) were for neuropathy (36%), unknown causes (9%), anemia (9%), and neutropenia (8%). Early treatment discontinuations (23%) were for neuropathy (29%). Patients receiving paclitaxel/nab-paclitaxel (RR 2.05; 95% CI, 1.47-2.87) and an anthracycline (RR 1.89; 95% CI, 1.39-2.57) reported more dose delays during chemotherapy. Black race (RR 1.46; 95% CI, 1.07-2.00), stage 3 (RR 1.79; 95% CI, 1.09-2.93), and paclitaxel/nab-paclitaxel receipt (RR 1.39; 95% CI, 1.02-1.90) increased the likelihood of dose reduction. Both Black race (RR 2.06; 95% CI, 1.35-3.15) and receipt of paclitaxel/nab-paclitaxel (RR 1.93; 95% CI, 1.19-3.13) increased the likelihood of early discontinuation. Patients receiving anthracyclines had higher rates of hospitalizations during chemotherapy (RR: 1.79; 95% CI, 1.11-2.89).

CONCLUSION

Toxicities are the most common reason for treatment modifications and need close monitoring in high-risk groups for timely intervention. Dose reductions and early treatment discontinuations occurred more for Black patients and need further study.

Distress, illness perception and coping style among thyroid cancer patients after thyroidectomy: A cross-sectional study

PURPOSE

Thyroid cancer generally has a good prognosis, and thyroidectomy is the main treatment given to thyroid cancer patients. Almost every cancer patient experiences varying degrees of distress, which can reduce their quality of life. This study aims to explore the level of distress and its relationship with illness perception and coping style among Chinese thyroid cancer patients after thyroidectomy and to identify the influencing factors on distress.

METHODS

A cross-sectional study with convenience sampling method was conducted. Totally 184 thyroid cancer patients after thyroidectomy were recruited in a tertiary hospital in Southern China with the response rate being 94.4% . The participants were investigated by a self-designed demographic and disease-related questionnaire, the Distress Management, the Brief Illness Perception Questionnaire, and the Medical Coping Modes Questionnaire. Descriptive statistics, univariate analysis, and multivariate linear regression were applied for data analysis.

RESULTS

In total, 99 (53.8%) thyroid cancer patients after thyroidectomy scored 4 or higher on the DT. Illness perception, emotional problem, body image loss by surgical scars, and acceptance-resignation were the influencing factors of distress and could explain 67.6% of the variance of distress among thyroid cancer patients after thyroidectomy.

CONCLUSIONS

Healthcare professionals should not ignore the distress among thyroid cancer patients after thyroidectomy and should take effective measures to alleviate the distress of thyroid cancer patients after thyroidectomy by enhancing their accurate and positive illness perceptions, decreasing their emotional problems, alleviating their body image loss by surgical scars, and avoiding acceptance-resignation coping style.

A Public Health Emergency: Breast Cancer Among Black Communities in the United States

While Black people have a similar incidence of breast cancer compared to White people, they have a 40% increased death rate. Black people are more likely to be diagnosed with aggressive subtypes such as triple-negative breast cancer. However, despite biological factors, systemic racism and social determinants of health create delays in care and barriers to treatment. While genetic testing holds incredible promise for Black people, uptake remains low and results may be challenging to interpret. There is a need for more robust, multidisciplinary, and antiracist interventions to reverse breast cancer-related racial disparities.

Challenges Experienced by Black Women with Breast Cancer During Active Treatment: Relationship to Treatment Adherence

BACKGROUND

Although rates of death from breast cancer have declined in the USA for both Black and White women since 1990, mortality rates for Black women remain strikingly higher - 40% higher compared to White women (American Cancer Society 1). The barriers and challenges that may be triggering unfavorable treatment-related outcomes and diminished treatment adherence among Black women are not well understood.

METHODS

We recruited 25 Black women with breast cancer who were to receive surgery and chemotherapy and/or radiation therapy. Through weekly electronic surveys, we assessed types and severity of challenges across various life domains. Because the participants rarely missed treatments or appointments, we examined the impact of severity of weekly challenges on thoughts of skipping treatment or appointment with their cancer care team using a mixed-effects location scale model.

RESULTS

Both a higher average severity of challenges and a higher deviation of severity reported across weeks were associated with increased thoughts on skipping treatment or appointment. The correlation between the random location and scale effects was positive; thus, those women that reported more thoughts on skipping a dose of medicine or appointment were also more unpredictable with respect to the severity of challenges reported.

CONCLUSIONS

Black women with breast cancer are impacted by familial, social, work-related, and medical care factors, and these may in turn affect adherence to treatment. Providers are encouraged to actively screen and communicate with patients regarding life challenges and to build networks of support within the medical care team and social community that can help patients successfully complete treatment as planned.

Racial Disparities in Breast Cancer: from Detection to Treatment

PURPOSE OF REVIEW

Update on current racial disparities in the detection and treatment of breast cancer.

RECENT FINDINGS

Breast cancer remains the leading cause of cancer death among Black and Hispanic women. Mammography rates among Black and Hispanic women have surpassed those among White women, with studies now advocating for earlier initiation of breast cancer screening in Black women. Black, Hispanic, Asian, and American Indian and Alaskan Native women continue to experience delays in diagnosis and time to treatment. Further, racial discrepancies in receipt of guideline-concordant care, access to genetic testing and surgical reconstruction persist. Disparities in the initiation, completion, toxicity, and efficacy of chemotherapy, endocrine therapy, and targeted drug therapy remain for racially marginalized women. Efforts to evaluate the impact of race and ethnicity across the breast cancer spectrum are increasing, but knowledge gaps remain and further research is necessary to reduce the disparity gap.

The Effect of Race and Area Deprivation on Symptom Profiles over the Course of Early-Stage Breast Cancer

Purpose

This study compared common symptoms (fatigue, pain), overall physical functioning and changes over time between Black and White women receiving early-stage breast cancer (ESBC) chemotherapy.

Methods

A longitudinal, repeated measures comparative design was employed. Time points of symptom measurement (PROMIS domains) at baseline, mid and end point were adjusted as per patient chemotherapy schedule.

Analyses

Linear mixed models were applied.

Results

There were 147 patients, 36% Black 64% White (54±12 years) recommended to receive early-stage breast cancer chemotherapy with adequate data for symptom analysis.

Pain

Main effect of race was significant (F(1, 390) = 29.43, p<.001) for pain with Black patients experiencing significantly higher pain scores compared to White patients at pretherapy (Mean Difference; MD=3.7, p=.034), midpoint (MD=5.8, p=.002), and endpoint (MD=7.8, p<.001).

Fatigue

Fatigue significantly increased (deteriorated) at endpoint (MDT1-T3= 8.7, p<.001) for Black patients. Among White patients, fatigue significantly increased at midpoint (MDT1-T2= 5.7) and at endpoint (MDT1-T3=10.1, p<.001; MDT2-T3=4.3, p= .017). Physical function: Black patients had significantly lower physical function scores compared to White patients at midpoint (MD=4.0, p=.027). Physical function decreased by endpoint in Black (MDT1-T3=7.8, p<.001), and White patients (MDT1-T3=7.7, p<.001).

Conclusion

Symptom burden significantly increased over the course of chemotherapy for all patients. Scores for pain and physical function were higher overall for Black patients and deteriorated at a greater rate for Black vs. White women over the course of chemotherapy. This assessment holds implication for proactive assessment and mitigation strategies.

A Positive Distress Screen…Now What? An Updated Call for Integrated Psychosocial Care

How can we move collaborative care from evidence-based practice to everyday practice for those living with cancer and distress?

Effects of socioeconomic status and race on survival and treatment in metastatic breast cancer

Race and socioeconomic factors affect outcomes in breast cancer. We aimed to assess the effect of race and neighborhood socioeconomic status (SES) on overall survival and treatment patterns in patients with metastatic breast cancer (MBC). This is a retrospective cohort study involving patients (N = 1246) with distant breast cancer metastases diagnosed at UPMC Magee Women's Breast Cancer Clinic from 2000-2017. Overall survival and treatment patterns were compared between races (Blacks and whites) and SES groups (defined using Area Deprivation Index). Low SES, but not tumor characteristics, was associated with Black race (P < 0.001) in the study population. Low SES (Median [Interquartile Range, IQR] survival 2.3[2.2-2.5] years vs high SES 2.7[2.5-3.1] years, P = 0.01) and Black race (Median [IQR] survival 1.8[1.3-2.3] years, vs white 2.5[2.3-2.7] years P = 0.008) separately were associated with worse overall survival in patients with MBC. In the Cox Proportional Hazard model with SES, race, age, subtype, number of metastases, visceral metastasis, and year of diagnosis as covariates, low SES (Hazard ratio 1.19[1.04-1.35], P = 0.01), but not Black race (Hazard ratio 1.19[0.96-1.49], P = 0.12), independently predicted overall survival in MBC. Moreover, patients from low SES neighborhoods and Black race received fewer lines of chemotherapy than high SES and whites. In conclusion, low neighborhood SES is associated with worse outcomes in patients with MBC. Poor outcomes in Black patients with MBC, at least in part is driven by socioeconomic factors. Future studies should delineate the interplay between neighborhood SES, race, and their effects on tumor biology in MBC.

The Cancer Genomic Integration Model for Symptom Science (CGIMSS): A Biopsychosocial Framework

Current nursing research has characterized symptom clusters and trajectories in individuals with breast cancer. The existing literature describes the relationship between symptoms and biological variables and the potential moderating effects of individual and social factors. The genomic profiling of breast cancer has also been an area of much recent research. Emerging evidence indicates that incorporating cancer genomics into symptom science research can aid in the prognostication of symptoms and elucidate targets for symptom management interventions. The aim of this paper is to outline a model to integrate cancer genomics into symptom science research, illustrated using breast cancer and psychoneurological (PN) symptoms as an example. We present a review of the current literature surrounding breast cancer genomics (specifically cancer genomic instability) and the biological underpinnings of the PN symptom cluster. Advances in both of these areas indicate that inflammation may serve as the bridge between cancer genomics and the PN symptom cluster. We also outline how the integration of cancer genomics into symptom science research synergizes with current research of individual and social factors in relation to symptoms. This model aims to provide a framework to guide future biopsychosocial symptom science research that can elucidate new predictive methods and new targets for intervention.

Racial Differences in Breast Cancer Therapeutic Toxicity: Implications for Practice

Disparities in treatment intensity can contribute to racial disparities in overall breast cancer survival. A natural extension of measuring racial disparities in treatment intensity is consideration of the distribution of treatment toxicities, symptoms, and distress that lead to chemotherapy dose reductions, holds or early termination. There is growing evidence that therapeutic toxicity during early-stage breast cancer treatment may be greater among Black women than White. Important components of symptom management involve the communication of symptoms, the self-care abilities of the patient, the patient's perception of the clinical encounter, and the patient centeredness of the clinical encounter. Racial differences in the symptom reporting, the clinical "reception" and response to symptoms, the prescribed management, and the patient adherence to symptom management requires further investigation. Further research must also consider the structural inequities, as well as institutional and interpersonal racism that contribute to racial differences in cancer symptom burden leading to potential decreases in dose intensity of potentially life-saving early cancer treatment. See related article by Hu et al., p. 167.

Race Differences in Patient-Reported Symptoms during Chemotherapy among Women with Early-Stage Hormone Receptor-Positive Breast Cancer

BACKGROUND

Symptom burden differences may contribute to racial disparities in breast cancer survival. We compared symptom changes from before to during chemotherapy among women with breast cancer.

METHODS

This observational study followed a cohort of Black and White women diagnosed with Stage I-III, hormone receptor-positive breast cancer from a large cancer center in 2007 to 2015, and reported symptoms before and during chemotherapy. We identified patients who experienced a one-standard deviation (SD) increase in symptom burden after starting chemotherapy using four validated composite scores (General Physical Symptoms, Treatment Side Effects, Acute Distress, and Despair). Kitagawa-Blinder-Oaxaca decomposition was used to quantify race differences in symptom changes explained by baseline characteristics (sociodemographic, baseline scores, cancer stage) and first-line chemotherapy regimens.

RESULTS

Among 1,273 patients, Black women (n = 405, 31.8%) were more likely to report one-SD increase in General Physical Symptoms (55.6% vs. 48.2%, P = 0.015), Treatment Side Effects (74.0% vs. 63.4%, P < 0.001), and Acute Distress (27.4% vs. 20.0%, P = 0.010) than White women. Baseline characteristics and first-line chemotherapy regimens explained a large and significant proportion of the difference in Acute Distress changes (93.7%, P = 0.001), but not General Physical Symptoms (25.7%, P = 0.25) or Treatment Side Effects (16.4%, P = 0.28).

CONCLUSIONS

Black women with early-stage breast cancer were more likely to experience significant increases in physical and psychological symptom burden during chemotherapy. Most of the difference in physical symptom changes remained unexplained by baseline characteristics, which suggests inadequate symptom management among Black women.

IMPACT

Future studies should identify strategies to improve symptom management among Black women and reduce differences in symptom burden. See related commentary by Rosenzweig and Mazanec, p. 157.

Black and hispanic women have less support during cancer evaluation and treatment: results from a prospective patient reported outcomes program in gynecologic malignancy

OBJECTIVE

Race remains a significant predictor of poor outcomes in women with gynecologic cancer and minority patients consistently report worse quality of life during cancer treatment. Disparities between patients in strength of social and emotional supports may contribute to these outcomes. This study's objective was to describe the racial differences in patient reported outcomes of women being evaluated or treated for a gynecologic malignancy at a large tertiary cancer hospital.

METHODS

In this prospective cohort study, all patients presenting for care at a tertiary care gynecologic oncology clinic between January 2018 and September 2019 were evaluated for inclusion. All patients were administered validated patient reported outcome measure questionnaires at serial visits. Demographic data was gathered including self-reported race. Patients were characterized as White, Black, Asian, Hispanic/Latino, or Other. Patient reported outcomes were compared between respondents of different races using linear and logistic regression.

RESULTS

Between January 2018 to September 2019, 2022 patients with a known race completed questionnaires. Of these patients, 86.7% were White, 4.3% Black, and 4.9% Hispanic/Latino and 58.7% had a known cancer diagnosis. Non-White patients were significantly less likely to complete questionnaires (p<0.001). Non-White patients reported significantly lower levels of emotional support on all questions (Patient-Reported Outcomes Measurement Information System (PROMIS) emotional support: Q1 p<0.001, Q2 p<0.001, Q3 p=0.013, Q4 p=0.002), and lower overall emotional (p=0.005) and instrumental (p=0.005) support scores when compared with White patients. Hispanic/Latino patients reported the lowest levels of emotional and instrumental support and more cognitive (p=0.043) and financial (p=0.040) difficulties associated with treatment. Black women reported having less support with chores while sick (p=0.014) and being less likely to have someone to talk to (p=0.013).

CONCLUSIONS

Significant differences exist in patient reported outcomes between women of different racial backgrounds. Hispanic/Latino and Black women have less support during gynecologic cancer evaluation and treatment as compared with White women.

A qualitative study of the sources of chronic obstructive pulmonary disease-related emotional distress

OBJECTIVE

The aim of this study is to identify the sources of illness-related emotional distress from the perspective of individuals living with mild to severe chronic obstructive pulmonary disease (COPD).

METHODS

A qualitative study design with purposive sampling was applied at a Swiss University Hospital. Eleven interviews were conducted with individuals who suffered from COPD. To analyze data, framework analysis was used, guided by the recently presented model of illness-related emotional distress.

RESULTS

Six main sources for COPD-related emotional distress were identified: physical symptoms, treatment, restricted mobility, restricted social participation, unpredictability of disease course and COPD as stigmatizing disease. Additionally, life events, multimorbidity and living situation were found to be sources of non-COPD-related distress. Negative emotions ranged from anger, sadness, and frustration to desperation giving rise to the desire to die. Although most patients experience emotional distress regardless of the severity of COPD, the sources of distress appear to have an individual manifestation.

DISCUSSION

There is a need for a careful assessment of emotional distress among patients with COPD at all stages of the disease to provide patient-tailored interventions.

Nurses' comfort care of transarterial chemoembolization patients based on their perceptions around postembolization syndrome and symptom interference

AIM

Post-embolization syndrome is a common adverse event following trans-arterial chemoembolization, which negatively impacts the daily life of the patients involved. This study examined whether perceptions around post-embolization syndrome and symptom interference among nurses affect their comfort care performance toward patients who have undergone this procedure.

DESIGN

A descriptive cross-sectional study.

METHODS

One hundred and fifty registered nurses were surveyed from September to November 2020. Perceived post-embolization syndrome, symptom interference, and comfort care (including physical, psychospiritual, sociocultural, and environmental dimensions) were measured. Data were analyzed using t-tests, analysis of variance, Pearson's correlation, and a multivariate analysis of variance.

RESULTS

There were no individual effects found of perceived post-embolization syndrome or symptom interference on nurses' comfort care performance. However, statistically significant interaction effects were found in terms of their sociocultural and environmental care.

CONCLUSION

Nurses who recognized both high post-embolization syndrome and symptom interference among their patients were found to provide greater sociocultural and environmental care. As such, nurses should improve their early symptom and symptom interference detection protocols based on current care guidelines and provide physical, psychospiritual, sociocultural, and environmental comfort care.

Psychological distress and associated factors among Palestinian advanced cancer patients: A cross-sectional study

OBJECTIVE

There is limited research exploring the experiences of people living with advanced cancer in the Gaza Strip (GS), Palestine. Thus, this study aimed to determine the level of psychological distress, anxiety, and depression among advanced cancer patients in the GS and identify factors associated with a high level of distress.

MATERIALS AND METHODS

A secondary analysis was performed using primary data from a larger study focusing on supportive care needs in advanced cancer patients in GS. Three hundred sixty-one patients agreed to participate and filled out the Distress Thermometer (DT) and the Hospital Anxiety and Depression Scale (HADS). Multivariate logistic regression was conducted to identify factors associated with high distress levels.

RESULTS

Over two-thirds of advanced cancer patients (70.6%) reported a high level of distress. They also reported a significantly higher distress level than patients with early cancer (96.5 vs. 3.5%; p = 0.001). About 92.8% of participants reported depression and anxiety symptoms. Physical, emotional, and practical problems were the primary sources of distress. Breast cancer patients were more likely to have psychological distress than colon and stomach cancer patients. Newly diagnosed patients had a higher level of anxiety, depression, and distress than those who had a cancer diagnosis for an extended period.

CONCLUSION

Patients with advanced cancer in the GS exhibited a significantly higher level of psychological distress, depression and anxiety than patients with advanced cancer elsewhere. Efforts should be made to identify psychological distress as a routine part of oncology practice. Future research should further explore the causes of psychological distress in cancer patients in conflict zones and feasible mitigation strategies.

Reading Wishes from the Lips: Cancer Patients' Need for Psycho-Oncological Support during Inpatient and Outpatient Treatment

Background: Psycho-oncological support (PO) is an effective measure to reduce distress and improve the quality of life in patients with cancer. Currently, there are only a few studies investigating the (expressed) wish for PO. The aim of this study was to evaluate the number of patients who request PO and to identify predictors for the wish for PO. Methods: Data from 3063 cancer patients who had been diagnosed and treated at a Comprehensive Cancer Center between 2011 and 2019 were analyzed retrospectively. Potential predictors for the wish for PO were identified using logistic regression. As a novelty, a Back Propagation Neural Network (BPNN) was applied to establish a prediction model for the wish for PO. Results: In total, 1752 patients (57.19%) had a distress score above the cut-off and 14.59% expressed the wish for PO. Patients’ requests for pastoral care (OR = 13.1) and social services support (OR = 5.4) were the strongest predictors of the wish for PO. Patients of the female sex or who had a current psychiatric diagnosis, opioid treatment and malignant neoplasms of the skin and the hematopoietic system also predicted the wish for PO, while malignant neoplasms of digestive organs and older age negatively predicted the wish for PO. These nine significant predictors were used as input variables for the BPNN model. BPNN computations indicated that a three-layer network with eight neurons in the hidden layer is the most precise prediction model. Discussion: Our results suggest that the identification of predictors for the wish for PO might foster PO referrals and help cancer patients reduce barriers to expressing their wish for PO. Furthermore, the final BPNN prediction model demonstrates a high level of discrimination and might be easily implemented in the hospital information system.

Efficacy and mechanisms of four-week MBSR on psychological distress in lung cancer patients: a single-center, single-blind, longitudinal, randomized controlled trial

Objective

This study aimed to evaluate the efficacy of a 4-week mindfulness-based stress reduction (MBSR) program on psychological distress in patients with lung cancer and elucidate its mechanisms.

Methods

This single-center, single-blinded, longitudinal, randomized controlled trial was conducted on 175 patients with lung cancer randomly allocated to a 4-week MBSR or a waiting-list group. The efficacy and mechanisms of the 4-week MBSR program were evaluated by outcome measures at preintervention (T0), the immediate postintervention (T1), 1 month (T2), and 3 months (T3). We analyzed the collected data using the per-protocol set principle, independent sample t-test, repeated measure analysis of variance, and structural equation modeling.

Results

The 4-week MBSR program significantly alleviated psychological distress (F ​= ​15.05, P ​< ​0.001), decreased perceived stigma (F ​= ​8.260, P ​= ​0.005), improved social support (F ​= ​16.465, P ​< ​0.001), and enhanced mindfulness (F ​= ​17.207, P ​< ​0.001) compared with usual care at T1, T2, and T3. All variables significantly changed over time except for copying style (P ​= ​0.250). The changes in social support, mindfulness, and perceived stigma mediated the efficacy of the 4-week MBSR program on psychological distress (β ​= ​−0.292, P ​= ​0.005; β ​= ​−0.358, P ​= ​0.005).

Conclusions

This study shows the benefits of the MBSR program for psychological distress, social support, mindfulness, and perceived stigma in patients with lung cancer. Also, it elucidates the mechanisms by which the MBSR program alleviates psychological distress by improving social support, enhancing mindfulness, and decreasing perceived stigma. The findings provide insights into applying the MBSR program to reduce psychological distress among patients with lung cancer.

Disparities in Electronic Screening for Cancer-Related Psychosocial Distress May Promote Systemic Barriers to Quality Oncologic Care

BACKGROUND

Screening for cancer-related psychosocial distress is an integral yet laborious component of quality oncologic care. Automated preappointment screening through online patient portals (Portal, MyChart) is efficient compared with paper-based screening, but unstudied. We hypothesized that patient access to and engagement with EHR-based screening would positively correlate with factors associated with digital literacy (eg, age, socioeconomic status).

METHODS

Screening-eligible oncology patients seen at our Comprehensive Cancer Center from 2014 through 2019 were identified. Patients with active Portals were offered distress screening. Portal and screening participation were analyzed via multivariable logistic regression. Household income in US dollars and educational attainment were estimated utilizing zip code and census data.

RESULTS

Of 17,982 patients, 10,279 (57%) had active Portals and were offered distress screening. On multivariable analysis, older age (odds ratio [OR], 0.97/year; P<.001); male gender (OR, 0.89; P<.001); Black (OR, 0.47; P<.001), Hawaiian/Pacific Islander (OR, 1.54; P=.007), and Native American/Alaskan Native race (OR, 0.67; P=.04); Hispanic ethnicity (OR, 0.76; P<.001); and Medicare (OR, 0.59; P<.001), Veteran's Affairs/military (OR, 0.09; P<.01), Medicaid (OR, 0.34; P<.001), or no insurance coverage (OR, 0.57; P<.001) were independently associated with lower odds of being offered distress screening; increasing income (OR, 1.05/$10,000; P<.001) and educational attainment (OR, 1.03/percent likelihood of bachelor's degree or higher; P<.001) were independently associated with higher odds. In patients offered electronic screening, participation rate was 36.6% (n=3,758). Higher educational attainment (OR, 1.01; P=.03) was independently associated with participation, whereas Black race (OR, 0.58; P=.004), Hispanic ethnicity (OR, 0.68; P=.01), non-English primary language (OR, 0.67; P=.03), and Medicaid insurance (OR, 0.78; P<.001) were independently associated with nonparticipation.

CONCLUSIONS

Electronic portal-based screening for cancer-related psychosocial distress leads to underscreening of vulnerable populations. At institutions using electronic distress screening workflows, supplemental screening for patients unable or unwilling to engage with electronic screening is recommended to ensure efficient yet equal-opportunity distress screening.

Pain, depressive symptoms, and self-efficacy for pain management: examination in African-American women with breast cancer

PURPOSE

African-American women with breast cancer face significant disparities, including high levels of pain. Depressive symptoms and self-efficacy for pain management impact how women with breast cancer manage pain, yet little is known about how these variables relate to pain specifically for African-American women with breast cancer.

METHODS

Baseline linear regression analyses were conducted using a sample of women (n = 98) with stage I-III breast cancer identifying as Black or African-American who were part of a larger intervention trial. Linear regressions explored the effect of depressive symptoms on pain (i.e., severity and interference), and the effect of self-efficacy for pain management on pain. Covariates were age (M = 57.22, SD = 10.76), cancer stage (50% = stage 1), and education level (36% = some college).

RESULTS

Participants reported moderate levels of pain severity and interference. Higher depressive symptoms were related to both higher pain severity and interference; (B = 0.06, p < 0.01, 95% CI [0.02,0.09]) and (B = 0.13, p < 0.001, 95% CI [0.09, 0.17]) respectively. Likewise, lower self-efficacy for pain management was also related to both higher pain severity and interference; (B =  - 0.04, p < 0.001, 95% CI [- 0.05, - 0.02]) and (B =  - 0.06, p < 0.001, 95% CI [- 0.08, - 0.04]) respectively. Women reporting less than a high school diploma endorsed significantly higher pain severity and interference than women reporting some college. Age and cancer stage were not significantly related to pain.

CONCLUSION

Pain for African-American women with breast cancer may be influenced by depressive symptoms and self-efficacy for pain management, in addition to other important variables. Attending to better assessment and treatment of depressive symptoms and self-efficacy for pain management may improve outcomes.

Mindfulness Affects the Level of Psychological Distress in Patients With Lung Cancer via Illness Perception and Perceived Stress: A Cross-Sectional Survey Study

Purpose

The aims of the study were first to investigate the association between illness perception and psychological distress and second to determine whether mindfulness affects psychological distress via illness perception and perceived stress in patients with lung cancer.

Methods

Among 300 patients with lung cancer who participated in this cross-sectional study, 295 patients made valid responses to distress thermometer (DT), the Five Facet Mindfulness Questionnaire (FFMQ), the Brief Illness Perception Questionnaire (B-IPQ), and the Perceived Stress Scale (PSS) between January and July 2021. The possible pathways of mindfulness affecting psychological distress were analyzed based on the structural equation modeling analysis.

Results

A total of 24.4% patients with lung cancer had DT > 4. Illness perception (β = 0.17, p = 0.002) and perceived stress (β = 0.23, p < 0.001) had a direct effect on psychological distress. Mindfulness had a direct effect on illness perception (β = -0.16, p = 0.006) and mindfulness indirectly influenced psychological distress (β = -0.04, p = 0.009) through affecting illness perception alone or simultaneously affecting both the illness perception and perceived stress in patients with lung cancer.

Conclusion

Lung cancer suffered from varying levels of psychological distress. Mindfulness may alleviate psychological distress by reducing the level of illness perception and perceived stress. We suggest developing a comprehensive factor model to clarify potential mechanisms of mindfulness on psychological distress due to the very low effect of mindfulness on psychological distress via illness perception and perceived stress.

Integration of Patient-Reported Outcome Measures in the Electronic Health Record: The Veterans Affairs Experience

PURPOSE

There are growing efforts to integrate patient-reported outcome (PRO) data into electronic health records (EHRs) to bring together disparate sources of patient information and improve medical care. PRO measures can be used to assess cancer symptom presence and severity. Integrating PRO tools in EHRs can alert providers to address symptoms, which is an essential component of comprehensive oncology care.

METHODS

We modified a PRO used to measure cancer and end-of-life symptoms, the Edmonton Symptom Assessment System to create the Veteran Symptom Assessment System (VSAS). VSAS was implemented as an integrated PRO as part of the Veterans Administration EHR system and was used at hematology-oncology clinics in Veteran Administration (VA) medical centers in the Southeast.

RESULTS

From 2013 to 2014, VSAS was introduced, underwent usability testing and modifications, and was finally implemented in the EHR. Between 2015 and 2019, VSAS was administered 43,883 times in 9,058 patients. Eighty-nine percent of Veterans were male, 11% were female, 52% identified as non-Hispanic White, and 43% identified as African American. Fatigue, shortness of breath with exertion, and pain were most frequently reported initially (68%, 48%, and 45%, respectively) and were most frequently rated as severe (27%, 16%, and 17%, respectively). In patients diagnosed with stage IV cancer, higher symptom burden was significantly associated with shorter overall survival. The majority of Veterans with longitudinal measurements experienced improvement in symptoms, most frequently in severe symptoms.

CONCLUSION

To our knowledge, this is the first large-scale implementation of a PRO system, integrated in the VA EHR, in ambulatory patients with cancer and blood disorders. The integration of VSAS within the VA EHR is a significant demonstration and a necessary requirement for current and future systemic initiatives in cancer symptom management.

Psychosocial distress is dynamic across the spectrum of cancer care and requires longitudinal screening for patient-centered care

PURPOSE

Screening for cancer-related psychosocial distress is recommended for patients with cancer; however, data on the long-term prevalence of distress and its natural history in survivors are scarce, preventing recommendations for screening frequency and duration. We sought to evaluate longitudinal distress in cancer patients.

METHODS

We evaluated longitudinal distress screening data for patients with cancer treated or surveilled at our institution from 2010 to 2018. Anxiety, depression, insurance/financial, family, memory, and strength-related distress were separately assessed and analyzed. Multivariable logistic regression was utilized to evaluate factors associated with distress subtypes.

RESULTS

In 5660 patients, distress was the highest at diagnosis for anxiety, depression, financial, and overall distress. On multivariable analysis, factors independently associated with distress at diagnosis included younger age, female gender, disease site/stage, payor, and income, varying by subtype-specific analyses. Severe distress in at least one subtype persisted in over 30% of survivors surveyed through 10 years after diagnosis. Over half of patients with initially severe distress at diagnosis improved within 12 months; however, distress worsened in 20-30% of patients with moderate, low, and no initial distress, regardless of the distress subtype.

CONCLUSION

Psychosocial distress in cancer survivors is a long-lasting burden with implications for quality of life and oncologic outcomes. Severe distress remains prevalent through 10 years after diagnosis in survivors receiving continued care at cancer centers and results from both persistent and new sources of distress in a variety of psychosocial domains. Longitudinal distress screening is an invaluable tool for providing comprehensive patient-centered cancer care and is recommended to detect new or recurrent distress in cancer survivors.

Factors associated with symptom distress in women with breast cancer prior to initiation of chemotherapy

BACKGROUND

Symptom distress in women with breast cancer is associated with early discontinuation of chemotherapy and may influence treatment outcomes. Describing racial differences in prechemotherapy symptom distress and examining contextual variables of the symptom experience may inform our understanding of the complex problem of racial disparities in breast cancer.

AIM

To determine if perceived social support, healthcare system distrust, and economic hardship predict symptom distress in women with breast cancer prior to their first chemotherapy treatment.

DESIGN

Descriptive, correlational, cross-sectional.

METHODS

Baseline data (N = 119) was used from a multisite, longitudinal study comparing the symptom experience and ability to receive chemotherapy of Black and White women with breast cancer (R01MD012245; Rosenzweig, PI). Measures included the Symptom Distress Scale, Interpersonal Support Evaluation List, Health Care System Distrust Scale, and Psychological Sense of Economic Hardship scale. The analysis consisted of multiple regression and a t-test.

RESULTS

On average, participants reported five symptoms prior to chemotherapy. Black women reported higher symptoms distress than White women; t(68.34) = 2.15, p = 0.035. The model explained 26% of variance in symptom distress; F(5, 112) = 9.01, p < 0.001. While controlling for age and race, greater perceived economic hardship contributed to higher symptom distress (β = 0.36, p = 0.001, 95% CI: 0.34 to 1.34). Race, health care system distrust and social support did not significantly predict symptom distress.

CONCLUSION

Assessment of perceived financial hardship prior to beginning chemotherapy is critical to identify those patients at risk for greater symptom distress.

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.

Prognostic factors and survival of patients undergoing surgical intervention for breast cancer bone metastases

INTRODUCTION

Bone is the most common distant site of breast cancer metastasis. Skeletal lesions can cause significant morbidity due to pain, pathologic fracture, and electrolyte abnormalities. Current treatment for patients with bone metastases (BoM) from breast cancer is highly personalized and often involves a multidisciplinary approach with chemotherapy, hormone therapy, bone-targeted antiresorptive agents, radiation therapy, and surgery. We have retrospectively collected clinical data from a series of patients with bone metastases to evaluate the clinical characteristics, prognostic factors, and survival patterns of patients with breast cancer BoM receiving standard multimodal therapy.

METHODS

A consecutive series of 167 patients with breast cancer BoM treated at a single institution between August 2013 and March 2020 were identified. Clinical information was obtained from the medical record and survival analyses were performed to evaluate patient outcomes and identify prognostic factors.

RESULTS

Thirty-seven patients (22%) presented with de novo BoM - bone metastases at the time of breast cancer diagnosis - and were 2.6 times more likely to die within the study period than those with asynchronous BoM (HR = 2.62, p = <0.0001). Patients who received bone-targeted medical therapy were 61% less likely to die after BoM diagnosis than those who did not (HR = 0.39, p = 0.001). Operative stabilization of BoM was more frequently employed in patients with lytic (p = 0.02) or mixed (p = 0.02) tumors than it was for those with blastic lesions. Patients treated with surgery had a lower overall bone metastasis survival than those treated without (p < 0.03).

DISCUSSION

These findings reflect the current patterns in metastatic breast cancer treatment and associated outcomes. In a series of 167 consecutive patients, we demonstrate the natural history of breast cancer with BoM being treated with modern multimodal therapy. Understanding these treatment patterns and prognostic factors enhances the provider's ability to counsel patients and direct appropriate treatments.

Investigation of the Spiritual Care Effects on Anxiety, Depression, Psychological Distress and Spiritual Levels of Turkish Muslim Radiotherapy Patients

The aim of this study is to examine the spiritual care support given to Muslim cancer patients undergoing radiotherapy with an experimental study on the spirituality, anxiety, depression and distress levels of these patients. In this study, experimental research design with experimental control group was used. Personal information form designed by researchers, HAD scale, DT scale and Spirituality Scale was used for personal information. In conclusion, it was determined that the support for Islamic spiritual care had positive effects on hospitalized radiotherapy patients. According to the results obtained, it is recommended to examine in larger sample groups in different treatment programs in order to reveal the effect of spiritual care support.

A panel of miRNAs as prognostic markers for African-American patients with triple negative breast cancer

BACKGROUND

To investigate the global expression profile of miRNAs, their impact on cellular signaling pathways, and their association with poor prognostic parameters in African-American (AA) patients with triple negative breast cancer (TNBC).

METHODS

Twenty-five samples of AA TNBC patients were profiled for global miRNA expression and stratified considering three clinical-pathological parameters: tumor size, lymph node (LN), and recurrence (REC) status. Differential miRNA expression analysis was performed for each parameter, and their discriminatory power was determined by Receiver Operating Characteristic (ROC) curve analysis. KMplotter was assessed to determine the association of the miRNAs with survival, and functional enrichment analysis to determine the main affected pathways and miRNA/mRNA target interactions.

RESULTS

A panel of eight, 23 and 27 miRNAs were associated with tumor size, LN, and REC status, respectively. Combined ROC analysis of two (miR-2117, and miR-378c), seven (let-7f-5p, miR-1255b-5p, miR-1268b, miR-200c-3p, miR-520d, miR-527, and miR-518a-5p), and three (miR-1200, miR-1249-3p, and miR-1271-3p) miRNAs showed a robust discriminatory power based on tumor size (AUC = 0.917), LN (AUC = 0.945) and REC (AUC = 0.981) status, respectively. Enrichment pathway analysis revealed their involvement in proteoglycans and glycan and cancer-associated pathways. Eight miRNAs with deregulated expressions in patients with large tumor size, positive LN metastasis, and recurrence were significantly associated with lower survival rates. Finally, the construction of miRNA/mRNA networks based in experimentally validated mRNA targets, revealed nodes of critical cancer genes, such as AKT1, BCL2, CDKN1A, EZR and PTEN.

CONCLUSIONS

Altogether, our data indicate that miRNA deregulated expression is a relevant biological factor that can be associated with the poor prognosis in TNBC of AA patients, by conferring to their TNBC cells aggressive phenotypes that are reflected in the clinical characteristics evaluated in this study.

Optimal communication associated with lower risk of acute traumatic stress after lung cancer diagnosis

PURPOSE

The aim of this study was to assess the role of the patient's background and perceived healthcare-related factors in symptoms of acute stress after lung cancer diagnosis.

METHODS

The study population consisted of 89 individuals referred for diagnostic work-up at Landspitali National University Hospital in Iceland and subsequently diagnosed with lung cancer. Before diagnosis, the patients completed questionnaires on sociodemographic characteristics, pre-diagnostic distress (Hospital Anxiety and Depression Scale), social support, and resilience. At a median of 16 days after diagnosis, the patients reported symptoms of acute stress on the Impact of Event Scale-Revised (IES-R) and experience of communication and support from healthcare professionals and family during the diagnostic period.

RESULTS

Patients were on average 68 years and 52% reported high levels of post-diagnostic acute stress (IES-R > 23) while 24% reported symptoms suggestive of clinical significance (IES-R > 32). Prior history of cancer (β = 6.7, 95% CI: 0.1 to 13.3) and pre-diagnostic distress were associated with higher levels of post-diagnostic acute stress (β = 8.8, 95% CI: 2.7 to 14.9), while high educational level (β = - 7.9, 95% CI: - 14.8 to - 1.1) was associated with lower levels. Controlling for the abovementioned factors, the patients' perception of optimal doctor-patient (β = - 9.1, 95% CI: - 14.9 to - 3.3) and family communication (β = - 8.6, 95% CI: - 14.3 to - 2.9) was inversely associated with levels of post-diagnostic acute stress after lung cancer diagnosis.

CONCLUSIONS

A high proportion of patients with newly diagnosed lung cancer experience high levels of acute traumatic stress of potential clinical significance. Efforts to improve doctor-patient and family communication may mitigate the risk of these adverse symptoms.

Patient-reported symptom burden in routine oncology care: Examining racial and ethnic disparities

Background

Racial and ethnic disparities are well‐documented in cancer outcomes such as disease progression and survival, but less is known regarding potential disparities in symptom burden.

Aims

The goal of this retrospective study was to examine differences in symptom burden by race and ethnicity in a large sample of cancer patients. We hypothesized that racial and ethnic minority patients would report greater symptom burden than non‐Hispanic and White patients.

Methods and results

A total of 5798 cancer patients completed the Edmonton Symptom Assessment Scale—revised (ESAS‐r‐CSS) at least once as part of clinical care. Two indicators of symptom burden were evaluated: (1) total ESAS‐r‐CSS score (i.e., overall symptom burden) and (2) number of severe symptoms (i.e., severe symptomatology). For patients completing the ESAS‐r‐CSS on multiple occasions, the highest score for each indicator was used. Zero‐inflated negative binomial regression analyses were conducted, adjusting for other sociodemographic and clinical characteristics. Symptomology varied across race. Patients who self‐identified as Black reported higher symptom burden (p = .016) and were more likely to report severe symptoms (p < .001) than self‐identified White patients. Patients with “other” race were also more likely to report severe symptoms than White patients (p = .032), but reported similar total symptom burden (p = .315). Asian and Hispanic patients did not differ from White or non‐Hispanic patients on symptom burden (ps > .05).

Conclusion

This study describes racial disparities in patient‐reported symptom burden during routine oncology care, primarily observed in Black patients. Clinic‐based electronic symptom monitoring may be useful to detect high symptom burden, particularly in patients who self‐identify their race as Black or other. Future research is needed to reduce symptom burden in racially diverse cancer populations.

Characterization of Clinical Symptoms by Race Among Women With Early-Stage, Hormone Receptor-Positive Breast Cancer Before Starting Chemotherapy

IMPORTANCE

Race disparities persist in breast cancer mortality rates. One factor associated with these disparities may be differences in symptom burden, which may reduce chemotherapy tolerance and increase early treatment discontinuation.

OBJECTIVES

To compare symptom burden by race among women with early-stage breast cancer before starting chemotherapy and quantify symptom differences explained by baseline characteristics.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of symptom burden differences by race among Black and White women with a diagnosis of stage I to III, hormone receptor-positive breast cancer who had a symptom report collected before chemotherapy initiation in a large cancer center in the southern region of the US from January 1, 2007, through December 31, 2015. Analyses were conducted from November 1, 2019, to March 31, 2021. Blinder-Oaxaca decomposition was used, adjusting for baseline sociodemographic and clinical characteristics.

MAIN OUTCOMES AND MEASURES

Four symptom composite scores with a mean (SD) of 50 (10) were reported before starting chemotherapy (baseline) and were derived from symptom items: general physical symptoms (11 items), treatment adverse effects (8 items), acute distress (4 items), and despair (7 items). Patients rated the severity of each symptom they experienced in the past week on a scale of 0 to 10 (where 0 indicates not a problem and 10 indicates as bad as possible).

RESULTS

A total of 1338 women (mean [SD] age, 54.6 [11.6] years; 420 Black women [31.4%] and 918 White women [68.6%]) were included in the study. Before starting chemotherapy, Black women reported a statistically significantly higher (ie, worse) symptom composite score than White women for adverse effects (44.5 vs 43.8) but a lower acute distress score (48.5 vs 51.0). Decomposition analyses showed that Black patients' characteristics were associated with higher symptom burden across all 4 scores. However, these differences were offset by relatively greater, statistically significant, unexplained physical, distress, and despair symptom reporting by White patients.

CONCLUSIONS AND RELEVANCE

In this study, before starting chemotherapy, Black patients with early-stage breast cancer reported significantly higher burden for symptoms that may be exacerbated with chemotherapy and lower distress symptoms compared with White patients. Future studies should explore how symptoms change before and after treatment and differ by racial/ethnic groups and how they are associated with treatment adherence and mortality disparities.

Predicting the Risk of Psychological Distress among Lung Cancer Patients: Development and Validation of a Predictive Algorithm Based on Sociodemographic and Clinical Factors

Objective

Lung cancer patients reported the highest incidence of psychological distress. It is extremely important to identify which patients at high risk for psychological distress. The study aims to develop and validate a predictive algorithm to identify lung cancer patients at high risk for psychological distress.

Methods

This cross-sectional study identified the risk factors of psychological distress in lung cancer patients. Data on sociodemographic and clinical variables were collected from September 2018 to August 2019. Structural equation model (SEM) was conducted to determine the associations between all factors and psychological distress, and then construct a predictive algorithm. Coincidence rate was also calculated to validate this predictive algorithm.

Results

Total 441 participants sent back validated questionnaires. After performing SEM analysis, educational level (β = 0.151, P = 0.004), residence (β = 0.146, P = 0.016), metastasis (β = 0.136, P = 0.023), pain degree (β = 0.133, P = 0.005), family history (β = -0.107, P = 0.021), and tumor, node, and metastasis stage (β = -0.236, P < 0.001) were independent predictors for psychological distress. The model built with these predictors showed an area under the curve of 0.693. A cutoff of 66 predicted clinically significant psychological distress with a sensitivity, specificity, positive predictive value, and negative predictive value of 65.41%, 66.90%, 28.33%, and 89.67%, respectively. The coincidence rate between predictive algorithm and distress thermometer was 64.63%.

Conclusions

A validated, easy-to-use predictive algorithm was developed in this study, which can be used to identify patients at high risk of psychological distress with moderate accuracy.

The chain mediating role of social support and stigma in the relationship between mindfulness and psychological distress among Chinese lung cancer patients

PURPOSE

Psychological distress greatly impaired the psychological and physical well-being of lung cancer patients. Identification of protective and risk factors is a prerequisite of developing effective psychological treatment protocol. The study aims to determine the relationship of mindfulness and psychological distress and further clarify the mechanism of mindfulness against psychological distress through perceived stigma and social support among Chinese lung cancer patients.

METHOD

A cross-sectional survey study involving 441 valid Chinese lung cancer patients was conducted from September 2018 to August 2019. After all validated questionnaires that measured psychological distress, level of mindfulness, social support, and perceived stigma were returned by patients, we firstly performed correlation analysis to assess the associations between mindfulness, social support, perceived stigma, and psychological distress. Then structural equation modelling analysis was conducted to further clarify the mediating effects of perceived stigma and social support on the relationship between mindfulness and psychological distress.

RESULTS

According to our hypothesis and further modification, our revised model adequately fits to data. Mindfulness (β =  - 0.107, p = 0.008) and social support (β =  - 0.513, p < 0.001) had a direct effect on psychological distress. Meanwhile, mindfulness had a direct effect on perceived stigma (β =  - 0.185, p < 0.001), and perceived stigma had a direct effect on social support (β =  - 0.373, p < 0.001). Furthermore, mindfulness had also the indirect effect on psychological distress through the chain mediating role of stigma and social support among lung cancer patients.

CONCLUSIONS

Mindfulness has direct negative effect on psychological distress and has also indirectly negative psychological distress through impacting social support and perceived stigma.

Pre-treatment assessment for patients with breast cancer undergoing chemotherapy: a best practice implementation project

OBJECTIVES

This project aimed to conduct an audit of pre-treatment assessment for patients with breast cancer undergoing chemotherapy and to assess the impact of these changes in improving the compliance with evidence-based best practice criteria in a large tertiary hospital.

INTRODUCTION

Pre-treatment assessment before cancer chemotherapy is paramount in order for patients to receive effective and safe treatment. Numerous guidelines and consensus-based standards for safe chemotherapy administration have been developed, which state that nurses should conduct and document comprehensive health assessments for patients prior to administration of chemotherapy.

METHODS

The project was conducted in the Breast Surgery Department of a nearly 3000-bed tertiary hospital in China. Evidence-based audit criteria were developed based on a JBI evidence summary. The JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit tool were used to promote changes in practice. Sample sizes of 13 clinical nurses and 30 breast cancer patients undergoing chemotherapy were included in baseline and follow-up audits.

RESULTS

The baseline audit indicated significant deficits in pre-treatment assessment nursing practice in the unit, with eight of the 12 criteria recording 0% compliance and one criterion recording only 3% compliance. Barriers to compliance were identified by the project team, and a series of strategies were adopted to address the barriers. There was improvement in compliance with all the best practice criteria in the follow-up audit compared with the baseline audit, with each one achieving a minimum of 90% compliance.

CONCLUSIONS

The project showed that regular and focused education and ongoing audits on pre-treatment assessment can help to optimize safe and effective chemotherapy treatment. Further strategies are planned to sustain the implementation of evidence.

Protocol for Symptom Experience, Management, Outcomes, and Adherence in Women Receiving Breast Cancer Chemotherapy

BACKGROUND

The 5-year survival for Black women with breast cancer in the United States is lower than White women for stage-matched disease. Our past and ongoing work and that of others suggest that symptom incidence, cancer-related distress, and ineffective communication contribute to racial disparity in dose reduction and early therapy termination. Although race is perhaps the most studied social determinant of health, it is clear that race alone does not account for all disparities.

OBJECTIVES

The aim of the study was to present a study protocol of Black and White women prescribed breast cancer chemotherapy. The aims are to (1) examine and compare chemotherapy received/prescribed over time and in total; (2a) examine and compare symptom incidence, distress, and management and clinical encounter, including patient-centeredness of care and management experience over time and (2b) correlate symptom incidence, distress, and management experience to Aim 1; and (3) explore the effects of social determinants of health, including age, income, education, zip code, and lifetime stress exposure, on Aims 1, 2a, and 2b.

METHODS

A longitudinal, repeated-measures (up to 18 time points), comparative, mixed-methods design is employed with 179 White and 179 Black women from 10 sites in Western Pennsylvania and Northeast Ohio over the course of chemotherapy and for 2 years following completion of therapy.

RESULTS

The study began in January 2018, with estimated complete data collection by late 2023.

DISCUSSION

This study is among the first to explore the mechanistic process for racial disparity in dosage and delay across the breast cancer chemotherapy course. It will be an important contribution to the explanatory model for breast cancer treatment disparity and may advance potential mitigation strategies for racial survival disparity.

Feasibility and effect of a guided self-disclosure intervention designed to facilitate benefit finding in breast cancer patients: A pilot study

PURPOSE

This pilot study aimed to evaluate the feasibility and effect of a guided self-disclosure intervention (GSDI) promoting benefit finding (BF) for breast cancer patients.

METHODS

A total of 40 women with breast cancer were randomized either to a GSDI group, which included a 6-session face-to-face self-disclosure intervention, or to a control group. The Benefit Finding Scale (BFS) was used to measure BF, the Distress Disclosure Index (DDI) was used to measure self-disclosure, and the Impact of Event Scale-Revised (IES-R) was used to measure cognitive reappraisal. The outcomes were evaluated at baseline and the 3rd and 6th months.

RESULTS

The GSDI group had more satisfaction (t = 2.35, P = .02) than the control group and had significant group effects of higher BF (t = 2.214, P = .03) and a lower avoidance of the IES-R (t = -2.353, P = .024) at the 3rd month. There was a significant difference of BF (t = 2.036, P = .049) between the two groups at the 6th month, and other outcomes were not significant (P > .05). Intention-to treat (ITT) analysis showed significant time effects for all outcomes (P < .05); there were slightly significant time × group effects for BF (F = 4.15, P = .052) and disclosure (F = 2.719, P = .090). There were no time × group effects for the other outcomes (all P > .05).

CONCLUSION

This study suggests that the GSDI intervention may be feasible in the clinic and might improve BF for breast cancer patients. However, future research needs to further refine the intervention and expand the sample to carry out a full-scale randomized controlled trial.

Knowledge and Attitudes About Genetic Testing Among Black and White Women with Breast Cancer

Prior to embarking on a large descriptive evaluation of genetic/racial variations in symptom phenotype, we sought foundational information to determine racial differences in (1) feasibility (consent) and acceptability of collecting genomic samples, (2) genetic literacy, and (3) concerns of genomic research during breast cancer (BC) chemotherapy. Women with early-stage BC undergoing chemotherapy were recruited from an academic, urban breast care center. Information was collected for consent to participate, genetic literacy, and concerns about genetic testing in Black and White women with BC. Fifty-six women were eligible, and 48 were consented (24 Black, 24 White). All participants consented to blood testing. This highly educated sample's mean age was 52.5 + 12.05 (years). Education (years) and genetic knowledge were positively correlated (p = .038). Genetic scores were high, and only one question significantly differed by race. On interview, most participants thought conducting genetic research helped to better understand hereditary disease and/or identify genes that cause disease and stated that they participated in the research to help other people. The majority of participants responded that friends/family would participate in genetic research without concerns, though three Black participants cited mistrust as a possible concern. Overall, there were high levels of genetic knowledge, slightly different between Black and White women. There were no high levels of personal concern regarding genetic testing. Black women reported more concern than White women that friends/family would have hesitations about participating in genetic research. There was general acceptability of blood collection for genetic testing among women with early-stage BC without racial difference.

Characteristics of Participation in Patient-Reported Outcomes and Electronic Data Capture Components of NRG Oncology Clinical Trials

PURPOSE

To assess the reasons why patients do not consent to patient-reported outcome (PRO) and electronic PRO data capture components of clinical trials and potential selection bias by having a separate consent.

METHODS AND MATERIALS

Selected NRG Oncology trials were included based on disease site and inclusion of PROs and electronic PRO data capture via VisionTree Optimal Care as separate consent questions. Reasons for not participating were assessed. Pretreatment characteristics between patients who did and did not consent were tested using χ² and t tests for univariate comparisons and logistic regression for multivariable analyses.

RESULTS

Ten trials were selected in head and neck, prostate, gynecologic, breast, lung, and gastrointestinal cancers, with 4 of these trials having electronic PRO data capture. Most patients consented to the PRO component (75.3%) but not electronic PRO data capture (37.8%). More white patients consented to PROs than nonwhite patients across all trials (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.45-0.63; P < .001), and more patients with education after high school consented compared with those with less education (OR, 1.71; 95% CI, 1.46-2.02; P < .001). Patients who are younger (OR, 0.63; 95% CI, 0.47-0.85; P = .002), white (OR, 0.60; 95% CI, 0.44-0.82; P = .001), and a never or former smoker (OR, 0.57; 95% CI, 0.41-0.78; P = .001) are more likely to participate in electronic PRO data capture.

CONCLUSIONS

These results suggest that a patient's race, age, and education can affect whether a patient chooses to consent or is offered to participate in PRO or electronic PRO data capture components. More investigation is needed, but this analysis provides support for making PROs integrated in the trial.

Predictive Model of Psychological Distress in Patients With Lung Cancer: A Cross-sectional Study

BACKGROUND

Patients with lung cancer suffer from significant psychological distress. The underlying theoretical model that may explain what predicts or mediates the degree of psychological distress has not been elucidated.

OBJECTIVES

To describe the incidence of psychological distress in patients with lung cancer and to test a predictive theoretical model of psychological distress based on symptom burden, type D personality, social support, and intrusive thoughts.

METHODS

Three hundred eighty-nine patients with stages I to IV lung cancer were recruited. Participants completed a battery of scales, including measures of psychological distress, symptom burden, type D personality, perceived social support, intrusive thoughts, and demographic and clinical characteristics. The predictive theoretical model was tested using structural equation modeling.

RESULTS

Experiencing clinically significant psychological distress was reported by 63.75% of participants. Consistent with the social cognitive processing model, symptom burden, type D personality, social support, and intrusive thoughts all significantly and directly predicted the level of psychological distress in patients with lung cancer. Moreover, intrusive thoughts mediated the effects of type D personality and symptom burden on psychological distress; social support and symptom burden mediated the effects of type D personality on psychological distress.

CONCLUSIONS

The majority of the participants experienced psychological distress at a clinically significant level. Intrusive thoughts and social support mediated the effects of type D personality and symptom burden on psychological distress.

IMPLICATIONS FOR PRACTICE

Patients with type D personality and symptom burden should be identified. Interventions for targeting social support and intrusive thoughts might ultimately reduce their psychological distress.

Symptom Experience, Management, and Outcomes According to Race and Social Determinants Including Genomics, Epigenomics, and Metabolomics (SEMOARS + GEM): an Explanatory Model for Breast Cancer Treatment Disparity

Even after controlling for stage, comorbidity, age, and insurance status, black women with breast cancer (BC) in the USA have the lowest 5-year survival as compared with all other races for stage-matched disease. One potential cause of this survival difference is the disparity in cancer treatment, evident in many population clinical trials. Specifically, during BC chemotherapy, black women receive less relative dose intensity with more dose reductions and early chemotherapy cessation compared with white women. Symptom incidence, cancer-related distress, and ineffective communication, including the disparity in patient-centeredness of care surrounding patient symptom reporting and clinician assessment, are important factors contributing to racial disparity in dose reduction and early therapy termination. We present an evidence-based overview and an explanatory model for racial disparity in the symptom experience during BC chemotherapy that may lead to a reduction in dose intensity and a subsequent disparity in outcomes. This explanatory model, the Symptom Experience, Management, Outcomes and Adherence according to Race and Social determinants + Genomics Epigenomics and Metabolomics (SEMOARS + GEM), considers essential factors such as social determinants of health, clinician communication, symptoms and symptom management, genomics, epigenomics, and pharmacologic metabolism as contributory factors.

Correlates of Adjuvant Therapy Attitudes in African American Breast Cancer Patients

PURPOSE

Black breast cancer patients delay and underutilize adjuvant breast cancer therapies; yet, very few studies have specifically examined Black women's attitudes toward breast cancer therapy. This study observed the influence of self-reported interpersonal processes of care (e.g. self-efficacy) clinical and sociodemographic factors and sociocultural (e.g. religiosity), related to Black breast cancer patients' attitudes toward radiation and systemic therapies (chemotherapy and adjuvant endocrine therapy - "AET").

METHODS

This was a secondary analysis of data from the Narrowing Gaps in Adjuvant Therapy Study (2006-2011). The analysis included 210 Black women who were newly diagnosed with breast cancer. Bivariate and multiple regression analyses were performed between independent variables (e.g., demographics) and three outcome variables (chemotherapy, AET, and radiation therapy) to asses women's perceptions of therapy type. The lasso method was used to select variables correlated with therapy attitudes.

RESULTS

Most women reported negative attitudes toward AET (56%) and radiation (54%); fewer negative attitudes were observed toward chemotherapy (47%). Higher education and greater perceived susceptibility of a recurrence were associated with more positive attitudes toward chemotherapy. Regarding radiation therapy, women with greater patient satisfaction were more likely to have more positive attitudes.

CONCLUSIONS

Our study findings may aid in the development of behavioral interventions targeted to mitigate Black women breast cancer treatment disparities. We found modifiable factors (e.g. communication, satisfaction ratings) that support opportunities for clinicians to better address Black women's needs regarding adjuvant treatment options. The development of tailored interventions for newly diagnosed Black breast cancer patients on patient related factors in health care are warranted for Black women with lower educational levels.

Higher levels of stress and different coping strategies are associated with greater morning and evening fatigue severity in oncology patients receiving chemotherapy

PURPOSE

A cancer diagnosis and associated treatments are stressful experiences for most patients. Patients' perceptions of stress and their use of coping strategies may influence fatigue severity. This study extends our previous work describing distinct profiles of morning (i.e., Very Low, Low, High, and Very High) and evening (i.e., Low, Moderate, High, and Very High) fatigue in oncology patients by evaluating for differences in stress and coping strategies among these fatigue classes.

METHODS

This longitudinal study evaluated for changes in morning and evening fatigue in oncology patients (n = 1332) over two cycles of chemotherapy (CTX). Patients completed measures of cumulative exposure to stressful life events (SLEs) (i.e., the Life Stressor Checklist-Revised), general stress (i.e., Perceived Stress Scale [PSS]), cancer-specific stress (i.e., Impact of Event Scale-Revised [IES-R]), and coping strategies (i.e., Brief Cope). Differences among the latent classes were evaluated using analyses of variance, Kruskal-Wallis, or chi-square tests.

RESULTS

Patients in both the Very High morning and evening fatigue classes reported higher numbers of and a higher impact from previous SLEs and higher PSS scores than the other fatigue classes. The IES-R scores for the Very High morning fatigue class met the criterion for subsyndromal PTSD. Patients in the Very High evening fatigue class used a higher number of engagement coping strategies compared with the Very High morning fatigue class.

CONCLUSIONS

Our findings suggest that interventions to reduce stress and enhance coping warrant investigation to decrease fatigue in patients undergoing CTX.

The effect of treatment on patient-reported distress after breast cancer diagnosis

BACKGROUND

The National Comprehensive Cancer Network (NCCN) Distress Thermometer (DT) uses a 10-point scale (in which 0 indicates no distress and 10 indicates extreme distress) to measure patient-reported distress. In the current study, the authors sought to examine the relationship between treatment and NCCN DT scores in patients with breast cancer over time.

METHODS

The authors included women aged ≥18 years who were diagnosed with stage 0 to stage IV breast cancer (according to the seventh edition of the American Joint Commission on Cancer staging system) at a 3-hospital health system from January 2014 to July 2016. Linear mixed effects models adjusted for covariates including stage of disease, race/ethnicity, insurance, and treatment sequence (neoadjuvant vs adjuvant) were used to estimate adjusted mean changes in the DT score (MSCs) per week for patients undergoing lumpectomy, mastectomy only, and mastectomy with reconstruction (MR).

RESULTS

The authors analyzed 12,569 encounters for 1029 unique patients (median score, 4; median follow-up, 67 weeks). Patients treated with MR (118 patients) were younger and more likely to be married, white, and privately insured compared with patients undergoing lumpectomy (620 patients) and mastectomy only (291 patients) (all P < .01). After adjusting for covariates, distress scores were found to decline significantly across all 3 surgical cohorts, with patients undergoing MR found to have both the most preoperative distress and the greatest decline in distress prior to surgery (MSC/week: -0.073 for MR vs -0.031 for lumpectomy vs -0.033 for mastectomy only; P = .001). Neoadjuvant therapy was associated with a longitudinal decline in distress for patients treated with lumpectomy (-1.023) and mastectomy only (-0.964). Over time, ductal carcinoma in situ (-0.503) and black race (-1.198) were found to be associated with declining distress among patients treated with lumpectomy and MR, respectively, whereas divorced patients who were treated with mastectomy only (0.948) and single patients treated with lumpectomy (0.476) experienced increased distress (all P < .05).

CONCLUSIONS

When examined longitudinally in consecutive patients, the NCCN DT can provide patient-reported data to inform expectations and guide targeted support for patients with breast cancer.

Introducing a model for emotional distress in respiratory disease: A systematic review and synthesis of symptom management models

AIM

To undertake a theoretical systematic review to develop a conceptual model of illness-related emotional distress in the context of symptom management in chronic respiratory disease.

DESIGN

We performed a systematic search to identify conceptual models.

DATA SOURCES

Electronic databases MEDLINE, CINAHL, EMBASE and PsycINFO were searched and papers included from inception of the search term until June 2017.

REVIEW METHODS

The review was conducted following Pound and Campbell's and Turner's theory synthesis. Conceptual models were appraised using Kaplan's criteria. Models were excluded if they referred to a specific condition and/or lacked clarity.

RESULTS

This synthesis, which includes five models and additional evidence, yielded a new conceptual model describing the processes of regulation and symptom self-management in chronic respiratory disease. Identified sources of illness-related emotional distress are new or increased symptoms, additional treatment, new restrictions in performance of daily life roles and increased unpredictability. People goals and self-efficacy were identified as further drivers of symptom self-management. The regulation process is embedded in contextual factors.

CONCLUSION

Theory synthesis provided transparent guidance in developing a model to understand of the factors driving self-management decisions. Therefore, the model has the potential to guide development of interventions that support symptom self-management in chronic respiratory disease.

IMPACT

This newly presented conceptual model of illness-related emotional distress provides an understanding of the factors that drive self-management decisions when peoples experience new or increased symptoms. Such understanding is critical for nursing practice to developing appropriate interventions, especially in support of people decision-making.

Predictors of Adherence and Treatment Delays among African American Women Recommended to Receive Breast Cancer Chemotherapy

BACKGROUND

Recognition of potential explanations for nonadherence or treatment delays is crucial to improving survival, particularly among African American women, for whom there is limited research assessing patient factors that influence adherence to breast cancer chemotherapy.

OBJECTIVE

This study sought to examine the association of patient factors such as age, income, employment, and partner status with adherence (full dose/on time) to prescribed breast cancer adjuvant chemotherapy and delays in treatment among African American women.

METHODS

This observational, prospective study used baseline data from the Adherence, Communication, Treatment, and Support Intervention Study that included African American women with early stage breast cancer who were recommended to receive chemotherapy. Eleven baseline demographic variables measured by a sociodemographic questionnaire were analyzed against the outcome variables of 85% adherence to chemotherapy, dichotomized as yes or no, and chemotherapy treatment delays measured as number of days.

RESULTS

For the 121 African American women included in this study, only employment status and number of comorbidities were significant predictors for total treatment delays (incidence rate ratio [IRR] = 2.175 [p = .000]; IRR = 1.234 [p = .003]) in the adjusted models.

IMPLICATIONS

Employment status and number of comorbidities are predictors of the ability to receive timely breast cancer chemotherapy among African American women. This knowledge allows identification of patients in need of tailored supportive care to encourage adherence and prevent treatment delays.

Validation of PROMIS emotional distress short form scales for cervical cancer

OBJECTIVES

Cervical cancer patients are at high risk for emotional distress. In this study we evaluate the PROMIS emotional distress-Depression and -Anxiety Short Forms for assessing depression and anxiety in a cervical cancer population.

METHODS

A 15-item questionnaire was used in a cervical cancer biobehavioral randomized clinical trial, testing psychosocial telephone counseling (PTC) against usual care (UC). It was administered to 204 patients prior to randomization, four months post-enrollment, and nine months post-enrollment, together with legacy measures of depression. The short forms were evaluated in patients participating in this study over three time points for internal consistency, convergent validity, and responsiveness to change over time.

RESULTS

Overall, 45% and 47% of patients scored in the moderate to severe range for anxiety and depression, respectively. Internal consistency coefficients were ≥ 0.95 at baseline, 4 months, and 9 months for depression and anxiety. The average inter-item correlation was 0.65 and 0.73 at baseline assessment for depression and anxiety, respectively. The depression short form T-score was correlated with legacy distress scales ranging from 0.44-0.76, and the anxiety short form ranging from 0.45-0.78. The depression short form demonstrated sensitivity to change as patients randomized to the counseling intervention reported greater improvement over time in depression (p = 0.014), and a nonsignificant improvement in anxiety, compared to the patients receiving usual care.

CONCLUSIONS

The PROMIS depression and anxiety short forms reliably and validly assess cervical cancer-specific emotional distress, capture salient features of distress in this population, and perform as well or better than legacy measures.

Exploring Racial Differences in Patient Centeredness of Care (PCC) During Breast Cancer (BC) Chemotherapy Clinical Visits

OBJECTIVES

The communication patterns between clinician and patient, described as the patient centeredness of care (PCC), may be a critically important etiology of breast cancer (BC) racial disparity. The purpose of this prospective, comparative pilot study was to qualitatively explore and code for PCC during the clinical visit of women undergoing BC chemotherapy and compare by race.

METHODS

Age-matched Black and White women were recruited. Audio recordings of clinical visits conducted prior to any cycle (except first) chemotherapy infusion were obtained and transcribed. Transcripts were blindly reviewed by three independent coders assigning PCC scores, ranging from 1 to 5, with lower scores indicating better PCC. Consensus was reached among reviewers via discussion.

RESULTS

Dyads consisted of five Black (mean age 47) and five White (mean age 45) women undergoing BC chemotherapy. Twenty-four recordings were analyzed, 13 White and 11 Black. For all 22 PCC items, the mean scores were worse for Black women with significant differences (compared by chi-square analysis) noted for 6/22 items (27%).

CONCLUSIONS

Qualitatively exploring clinician and patient communication patterns during the chemotherapy clinical visits informs the understanding of racial differences for symptom assessment, reporting, and management. These pilot findings inform future research exploring racial disparity in cancer treatment dose intensity.