The impact of attachment security on death preparation in advanced cancer: The role of couple communication

Fluctuations in core depressive symptoms in colorectal cancer patients. A prospective, population-based PROFILES-registry study

PURPOSE

Research investigating depressive symptoms among cancer patients rarely distinguish between core symptoms of depression (motivational and consummatory anhedonia, and negative affect). This distinction is important as these symptoms may show different trajectories during the course of the illness and require different treatment approaches. The aim of the present study is to investigate fluctuations in core depressive symptoms in patients with colorectal cancer (CRC). It is hypothesized that these core depressive symptoms fluctuate differently during the course of the illness and depend on the phase of the illness (diagnostic, treatment, recovery and palliative phase).

METHOD

This study is based on data from the PROCORE study. PROCORE is a prospective, population-based study aimed to examine the longitudinal impact of CRC and its treatment on patient-reported outcomes. Eligible patients completed self-report questionnaires (i.e. Multifactorial Fatigue Index, Hospital Anxiety and Depression scale, EORTC-C30) after diagnosis, after surgery and at one and two years after diagnosis.

RESULTS

In total, 539 patients participated of whom 68 have died until March 1ste 2021. Core depressive symptoms fluctuated differently during the course of the illness with higher levels of motivational anhedonia during treatment and palliative phase (P<.001), consummatory anhedonia at the palliative phase (p < .001) and negative affect at the diagnostic and palliative phase (P<.001).

CONCLUSION

It is important to distinguish between different core depressive symptoms as they fluctuate differently during the course of an illness like CRC. The various depressive symptoms may require a different treatment approach at specific moments during the illness process.

Clinical evaluation questionnaire in advanced cancer: a psychometric study of a novel measure of healthcare provider interactions

OBJECTIVES

The Clinical Evaluation Questionnaire (CEQ) is a patient-reported experience measure (PREM) that assesses the perceived benefit of therapeutic interactions of patients with advanced cancer with their healthcare providers concerning issues relevant to their illness. It was developed for a randomised controlled trial of Managing Cancer and Living Meaningfully (CALM), a brief supportive-expressive therapy for patients with advanced cancer. The present study evaluates the preliminary psychometric properties of the CEQ.

METHOD

Patients in the CALM and usual care groups completed the CEQ 3 (n=195) and 6 (n=186) months after randomisation. The CEQ's internal consistency, factor structure and concurrent validity were evaluated, and CEQ scores in the treatment groups were compared.

RESULTS

The CEQ demonstrated high internal consistency for both treatment arms (Cronbach's α=0.94 to 0.95), and a single factor was consistently found in exploratory factor analyses. CEQ scores correlated significantly with satisfaction with the relationship with healthcare providers (r=0.23 to 0.61, p≤0.02) and life completion (r=0.24 to 0.37, p≤0.02) in both groups and with spiritual well-being in the CALM group (meaning: r=0.23 to 0.24, p=0.01 to 0.02; faith: r=0.24 to 0.34, p=0.001 to 0.02). The CALM group showed higher CEQ total scores than usual care at 6 months (CALM: 18.19±6.59; usual care: 14.36±7.67, p<0.001).

CONCLUSIONS

The CEQ is a reliable and valid PREM of the benefit perceived by patients with advanced cancer from their interactions with healthcare providers. Further study is needed to establish its value as a measure of perceived intervention benefit across different clinical and research settings.

Association between adult attachment style, communication patterns and caregiver burden in parents of children with solid tumors: A cross-sectional study

PURPOSE

The primary purpose of this cross-sectional study was to delve into the connections among adult attachment styles, communication patterns, and caregiver burden within the sample of parents caring for children diagnosed with solid tumors.

METHODS

A sample of 456 parents responsible for the care of children with solid tumors was conveniently recruited from a pediatric oncology ward at a tertiary hospital from September 2021 to September 2022. The data collection process included a questionnaire on general information, the Caregiver Burden Inventory, the Adult Attachment Questionnaire Short Form, and the Communication Pattern Questionnaire.

RESULTS

The findings demonstrated a strong and positive connection between caregiver burden and attachment avoidance, whereas no considerable association was observed for attachment anxiety. Attachment avoidance exhibited a positive link with communication patterns and caregiver burden, and a noteworthy inverse correlation with attachment anxiety. Additionally, communication patterns were uncovered as a mediator in the association between attachment avoidance and caregiver burden.

CONCLUSIONS

This study underscores the role of communication patterns as mediators between attachment avoidance and caregiver burden among parents of children with solid tumors. These outcomes emphasize the significance of considering attachment styles and communication patterns when comprehending caregiver burden, and can guide the development of targeted interventions to provide support for parents within this challenging context.

Attachment in Couples Coping with Cancer: Associations with Observed Communication and Long-Term Health

Cancer poses a threat to well-being that may activate the attachment system and influence interpersonal dynamics, such as communication. Research indicates that avoidant and anxious attachment, as well as communication, are independently associated with poorer psychosocial well-being, yet studies examining links between attachment, communication, and long-term physical well-being are lacking. We examined (a) associations between patient and partner attachment (measured with the adult attachment scale [AAS-Revised]) and observed communication (across affect [the Relational Affective Topography System (RATS) coding system] and behavior [the Asymmetric Behavior Coding System (ABCS) coding system]) and (b) the extent to which attachment and communication independently predicted long-term physical well-being (measured by the Functional Assessment of Cancer Therapy-General Population [FACT-GP]). Participants were 134 couples [mean age 53.9 (SD = 13.4), 86.2% Caucasian, 66% of patients, 36% of partners female]. Patient participants had either breast, colorectal, or lung cancer. Couples individually completed self-report measures of attachment (baseline) and physical well-being (baseline and 4, 8, and 12 months later). At baseline, couples engaged in a 15 min videorecorded cancer-related conversation coded for communication behavior and affective expression. Patients and partners with higher anxious and avoidant attachment exhibited more negative affect and negative approach behaviors. A greater avoidant attachment was associated with less positive affective expression. Attachment insecurity and affective expression were prospectively linked with physical well-being. Findings indicate that attachment is associated with overt communication behaviors and that insecure attachment and affective expression may be risk factors for poorer health outcomes.

The Italian validation of the Death and Dying Distress Scale

OBJECTIVES

Death anxiety (DA), a condition characterized by fear, angst, or panic related to the awareness of one's own death, is commonly observed in advanced cancer patients. The aim of this study was to examine the psychometric properties of the Italian version of the Death and Dying Distress Scale (DADDS-IT) in a sample of patients with advanced cancer.

METHODS

The sample included 200 Italian advanced cancer patients meeting eligibility criteria to access palliative care. Patients' levels of DA were assessed by using the DADDS-IT, while the levels of depression, anxiety, demoralization, spiritual well-being, and symptom burden were assessed using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the Demoralization Scale, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale, and the Edmonton Symptom Assessment System, respectively; Karnofsky Performance Status was used to measure functional impairment. Confirmatory factor analyses (CFA) of previous structures and exploratory factor analyses (EFA) were conducted.

RESULTS

CFA revealed that none of the previous structures adequately fitted data from our sample. EFA revealed a 4-factor model comprising Finitude (α = 0.91), Regret (α = 0.86), Dying (α = 0.88), and Relational Burden (α = 0.73), accounting for the 77.1% of the variance. Dying subscore was higher in hospice patients than in those recruited in medical wards.

SIGNIFICANCE OF RESULTS

The present study provides further evidence that DA is a condition that deserves attention and that DADDS-IT shows good psychometric properties to support its use in research and clinical settings.

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.

Interventions for interpersonal communication about end of life care between health practitioners and affected people

BACKGROUND

Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes.

OBJECTIVES

To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing.

SELECTION CRITERIA

This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life,  we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes.

DATA COLLECTION AND ANALYSIS

Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies.

MAIN RESULTS

Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials.  Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication.  Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations.  Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions  (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life.  Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear.

AUTHORS' CONCLUSIONS

Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.

Dyadic Experiences and Psychosocial Management of Couples Facing Advanced Cancer: A Systematic Review of the Literature

Background

Cancer diagnosis and treatment represent a real upheaval both for the patient and for his or her life partner. Adjustment to cancer has been widely studied at the individual level, however, there is little in the literature about the experiences of the couple as an entity. This is especially true with regard to a population facing advanced cancer. This systematic review aimed to make an inventory of 1) the current knowledge relating to the experience of the patient-partner dyad when confronted with advanced cancer, and 2) the psychosocial interventions specifically centered on this dyad.

Method

This review was conducted using the Cochrane methodology. The eligibility criteria for the literature review were: one of the members of the dyad being treated for advanced cancer, dyad composed of the patient and his/her life partner. Databases from PubMed, PsycArticle, PsycInfo, Psychology and Behavioral Sciences Collection and Scopus were investigated. A thematic content analysis on the basis of admitted articles made it possible to respond to each of our research objectives.

Results

Three hundred eighty-nine citations were found. Twenty were admitted to the systematic review of the literature. It highlighted the following experiences of the advanced cancer patient-life partner dyad: uncertainty about the future, disjointed time, intrusion into the couple's intimacy, attachment style and caregiving within the couple, couple's adjustment to cancer symptomatology, the couple's supportive care needs, role changes, nature of communication within the couple, anticipation of the coming death, and the meanings and beliefs around death. This review also describes the range of couple therapies used in the context of advanced cancer: emotionally focused-couple therapy, existential therapy, art therapy, support therapy and couple communication and intimacy promotion. These therapies seem to have individual beneficial effects for both the patient and his or her life partner as well as improving marital functioning.

Conclusions

These results clearly highlight that consideration of the couple and communication within the couple during care are fundamental to dyadic adjustment to advanced cancer. Further studies (qualitative and quantitative) are needed to better understand the couple's experience in order to adapt the management of the couple facing advanced cancer.

(Don't) Leave Me Alone: Attachment in Palliative Care

This is the fifth article in the psychological elements of palliative care series. This series focuses on how key concepts from psychotherapy can be used in the context of palliative care to improve communication and fine tune palliative care interventions. In this article, we discuss attachment-the system by which people form bonds in relationships. The different styles that people have in navigating relationships such as clinician-patient relationships develop from early life onward. Attachment styles are not pathological. But they are helpful to understand because they are a relatively stable factor that impacts how people relate to caregivers like clinicians. Our patients all express unique relational needs to us; some of our patients need closeness and reassurance to feel comfortable, others value independence and space. These needs are highly significant to palliative care clinicians; they inflect our patients' goals of care and values, they modulate our patients' psychosocial needs, and they elucidate the ways our patients respond to a range of therapeutic interventions. Understanding attachment gives us a window into these individual care needs and empowers us to tailor the care we provide for a wide range of patients.

Caregiver bereavement outcomes in advanced cancer: associations with quality of death and patient age

Purpose

We investigated relationships between domains of quality of dying and death in patients with advanced cancer and their caregivers’ bereavement outcomes and the moderating effect of patient age at death.

Methods

Bereaved caregivers of deceased patients with advanced cancer who had participated in an early palliative care trial completed measures of grief (Texas Revised Inventory of Grief [TRIG]), complicated grief (Prolonged Grief Inventory [PG-13]), and depression (Center for Epidemiologic Studies-Depression [CESD-10]). They also completed the Quality of Dying and Death measure (QODD), which assesses patients’ symptom control, preparation for death, connectedness with loved ones, and sense of peace with death.

Results

A total of 157 bereaved caregivers completed the study. When patient age × QODD subscale interactions were included, greater death preparation was related to less grief at patient death (past TRIG: β =  − .25, p = .04), less current grief (present TRIG: β =  − .26, p = .03), less complicated grief (PG-13: β =  − .37, p = .001), and less depression (CESD-10: β =  − .35, p = .005). Greater symptom control was related to less current grief (present TRIG: β =  − .27, p = .02), less complicated grief (PG-13: β =  − .24, p = .03), and less depression (CESD-10: β =  − .29, p = .01). Significant patient age × connectedness interaction effects for current grief (present TRIG: β = .30, p = .02) and complicated grief (PG-13: β = .29, p = .007) indicated that, with less connectedness, younger patient age at death was associated with greater caregiver grief.

Conclusion

Better end-of-life death preparation and symptom control for patients with cancer may attenuate later caregiver grief and depression. Less connectedness between younger patients and their families may adversely affect caregiver grief.