Anxiety profiles are associated with stress, resilience and symptom severity in outpatients receiving chemotherapy

Symptom Patterning Across the Cancer Care Trajectory for Patients Receiving Chemoradiation for Head and Neck Cancer: A Retrospective Longitudinal Study Using Latent Transition Analysis

BACKGROUND

Patients with head and neck cancer (HNC) experience a multitude of symptoms because of the tumor and its treatment.

OBJECTIVE

To identify the symptom patterns present in cancer treatment and survivorship periods for patients with HNC using latent class analysis.

METHODS

A retrospective longitudinal chart review was conducted to examine symptoms reported by patients who received concurrent chemoradiation for HNC in a regional Northeastern United States cancer institute. Latent class analysis was performed to identify the latent classes present across multiple timepoints during treatment and survivorship for the most commonly reported symptoms.

RESULTS

In 275 patients with HNC, the latent transition analysis revealed 3 latent classes for both treatment and survivorship periods: (1) mild, (2) moderate, and (3) severe symptoms. Patients were more likely to report a greater number of symptoms in a more severe latent class. During treatment, moderate and severe classes had representation of all most common symptoms: pain, mucositis, taste alterations, xerostomia, dysphagia, and fatigue. Different symptom patterns emerged for survivorship, with prominence of taste alterations and xerostomia across all classes, and all symptoms present in the severe class. The probability of symptom expression varied more in the survivorship period compared with the treatment period.

CONCLUSIONS

Patients reported numerous symptoms during active treatment persisting into survivorship. Patients tended to transition to more severe symptomatology as treatment progressed and to more moderate symptomatology as survivorship evolved.

IMPLICATIONS FOR PRACTICE

Examining the trend of persistent moderate symptomatology into survivorship is useful to optimize symptom management.

The association of resilience and positive mental health in systemic sclerosis: A Scleroderma Patient-centered Intervention Network (SPIN) cohort cross-sectional study

OBJECTIVE

A previous study using Scleroderma Patient-centered Intervention Network (SPIN) Cohort data identified five classes of people with systemic sclerosis (also known as scleroderma) based on patient-reported somatic (fatigue, pain, sleep) and mental health (anxiety, depression) symptoms and compared indicators of disease severity between classes. Across four classes ("low", "normal", "high", "very high"), there were progressively worse somatic and mental health outcomes and greater disease severity. The fifth ("high/low") class, however, was characterized by high disease severity, fatigue, pain, and sleep but low mental health symptoms. We evaluated resilience across classes and compared resilience between classes.

METHODS

Cross-sectional study. SPIN Cohort participants completed the 10-item Connor-Davidson-Resilience Scale (CD-RISC) and PROMIS v2.0 domains between August 2022 and January 2023. We used latent profile modeling to identify five classes as in the previous study and multiple linear regression to compare resilience levels across classes, controlling for sociodemographic and disease variables.

RESULTS

Mean CD-RISC score (N = 1054 participants) was 27.7 (standard deviation = 7.3). Resilience decreased progressively across "low" to "normal" to "high" to "very high" classes (mean 4.7 points per step). Based on multiple regression, the "high/low" class exhibited higher resilience scores than the "high" class (6.0 points, 95% confidence interval [CI] 4.9 to 7.1 points; standardized mean difference = 0.83, 95% CI 0.67 to 0.98).

CONCLUSIONS

People with worse disease severity and patient-reported outcomes reported substantially lower resilience, except a class of people with high disease severity, fatigue, pain, and sleep disturbance but positive mental health and high resilience.

Increases in stress and adverse childhood experiences are associated with the co-occurrence of anxiety and depression in oncology patients

PURPOSE

Identify subgroups of patients with distinct joint anxiety AND depression profiles and evaluate for differences in demographic and clinical characteristics, as well as stress, resilience, and coping.

DESIGN

Longitudinal study.

PARTICIPANTS

Patients (n = 1328) receiving chemotherapy.

METHODS

Measures of state anxiety and depression were done six times over two cycles of chemotherapy. All of the other measures were completed prior to second or third cycle of chemotherapy. Latent profile analysis was used to identify the distinct joint anxiety and depression profiles.

FINDINGS

Three classes were identified (i.e. Low Anxiety and Low Depression (57.5%); Moderate Anxiety and Moderate Depression (33.7%), High Anxiety and High Depression (8.8%)). For all of the stress measures, a dose response effect was seen among the profiles. Two worst profiles reported higher occurrence rates for a number of adverse childhood experiences.

IMPLICATIONS FOR PROVIDERS

Patients need referrals for stress reduction techniques and mental health and social services.

Higher Levels of Multiple Types of Stress Are Associated With Worse State Anxiety and Morning Fatigue Profiles in Patients Receiving Chemotherapy

BACKGROUND

Anxiety and fatigue are common problems in patients receiving chemotherapy. Unrelieved stress is a potential cause for the co-occurrence of these symptoms.

OBJECTIVES

The aims of this study were to identify subgroups of patients with distinct state anxiety and morning fatigue profiles and evaluate for differences among these subgroups in demographic and clinical characteristics, as well as measures of global, cancer-specific, and cumulative life stress and resilience and coping.

METHODS

Patients (n = 1335) completed measures of state anxiety and morning fatigue 6 times over 2 cycles of chemotherapy. All of the other measures were completed prior to the second or third cycle of chemotherapy. Latent profile analysis was used to identify the state anxiety and morning fatigue profiles.

RESULTS

Three distinct joint profiles were identified: Low Anxiety and Low Morning Fatigue (59%), Moderate Anxiety and Moderate Morning Fatigue (33.4%), and High Anxiety and High Morning Fatigue (7.6%). Patients in the 2 highest classes were younger, were less likely to be married/partnered, and had a higher comorbidity burden. All of the stress scores demonstrated a dose-response effect (ie, as anxiety and morning fatigue profiles worsened, stress increased). Patients in the 2 highest classes reported higher rates of emotional abuse, physical neglect, physical abuse, and sexual harassment.

CONCLUSIONS

More than 40% of these patients experienced moderate to high levels of both anxiety and morning fatigue. Higher levels of all 3 types of stress were associated with the 2 highest profiles.

IMPLICATIONS FOR PRACTICE

Clinicians need to perform comprehensive evaluations of patients' levels of stress and recommend referrals to psychosocial services.

Adverse Childhood Experiences and Higher Levels of Stress Are Associated With the Co-occurrence of Cancer-Related Cognitive Impairment and Anxiety

OBJECTIVES

We sought to identify subgroups of patients with distinct joint cancer-related cognitive impairment (CRCI) AND anxiety profiles and evaluate for differences in demographic and clinical characteristics, as well as levels of global stress, cancer-specific stress, cumulative life stress, and resilience.

DATA SOURCES

Patients (n = 1332) completed the Attentional Function Index and the Spielberger State Anxiety Inventory six times over two cycles of chemotherapy. Global, cancer-specific, and cumulative life stress and resilience were evaluated using Perceived Stress Scale, Impact of Event Scale-Revised, Life Stressor Checklist-Revised, and Connor-Davidson Resilience Scale, respectively. Latent profile analysis was used to identify subgroups of patients with distinct joint CRCI AND anxiety profiles. Differences were evaluated using parametric and nonparametric tests.

RESULTS

Three classes were identified (ie, No CRCI and Low Anxiety [57.3%], Moderate CRCI and Moderate Anxiety [34.5%], and High CRCI and High Anxiety [8.2%]). All of the stress measures showed a dose-response effect (ie, as the CRCI AND anxiety profile worsened, scores for all three types of stress increased). The two highest symptom classes reported higher occurrence rates for six specific stressors (eg, emotional abuse, physical abuse, sexual harassment).

CONCLUSIONS

Findings suggest that higher levels of co-occurring CRCI AND anxiety are associated with some common risk factors, as well as higher levels of stress and lower levels of resilience. Increased knowledge of modifiable risk factors and sources of stress associated with the co-occurrence of these two symptoms will assist clinicians to identify high-risk patients and implement individualized interventions.

Anxiety in oncology outpatients is associated with perturbations in pathways identified in anxiety focused network pharmacology research

PURPOSE

Evaluate for perturbed signaling pathways associated with subgroups of patients with low versus high levels of state anxiety. These pathways were compared to the pathways identified across eight network pharmacology studies of the anxiolytic effect(s) of a variety of compounds.

METHODS

Adult outpatients had a diagnosis of breast, gastrointestinal, gynecological, or lung cancer; had received chemotherapy within the preceding four weeks; and were scheduled to receive at least two additional cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct anxiety profiles based on Spielberger State Anxiety Inventory scores that were obtained six times over two cycles of chemotherapy. Blood samples were processed using RNA sequencing (i.e., RNA-seq sample, n = 244) and microarray (i.e., microarray sample; n = 256) technologies. Pathway perturbations were assessed using pathway impact analysis. Fisher's combined probability method was used to combine test results using a false discovery rate of 0.01.

RESULTS

In the RNA-seq sample, 62.3% and 37.7% of the patients were in the low- and high-anxiety classes, respectively. In the microarray sample, 61.3% and 38.7% were in the low and high-anxiety classes, respectively. Forty-one perturbed signaling pathways were identified. Eight of these pathways were common to those identified in the network pharmacology studies.

CONCLUSIONS

Findings increase our knowledge of the molecular mechanisms that underlie anxiety in patients receiving chemotherapy. This study provides initial insights into how anxiety in patients with cancer may share common mechanisms with anxiety in patients with other clinical conditions.

Oncology Outpatients With Worse Anxiety and Sleep Disturbance Profiles Are at Increased Risk for a Higher Symptom Burden and Poorer Quality of Life

BACKGROUND

Anxiety and sleep disturbance are frequent symptoms during chemotherapy.

OBJECTIVES

Purposes were to identify subgroups of oncology outpatients with distinct joint anxiety and sleep disturbance profiles, as well as evaluate for differences in demographic and clinical characteristics, sleep disturbance characteristics, severity of common symptoms, and quality-of-life outcomes among these subgroups.

METHODS

Oncology outpatients (n = 1331) completed self-report measures of anxiety and sleep disturbance 6 times over 2 chemotherapy cycles. Latent profile analysis was done to identify subgroups of patients with distinct joint anxiety and sleep disturbance profiles.

RESULTS

Three profiles were identified (ie, no anxiety and low sleep disturbance (59.7%), moderate anxiety and high sleep disturbance (32.5%), high anxiety and very high sleep disturbance (7.8%)). Compared with the no anxiety and low sleep disturbance class, the other 2 classes were younger; less likely to be married; had a lower annual household income; and had childcare responsibilities. Patients in the 2 worse profiles had problems with both sleep initiation and maintenance. These patients reported higher levels of depressive symptoms, trait and state anxiety, and evening fatigue, as well as lower levels of morning and evening energy, cognitive function, and poorer quality of life.

CONCLUSIONS

More than 40% of patients had moderate or high levels of anxiety and high or very high levels of sleep disturbance. Modifiable risk factors associated with these profiles may be used to develop targeted interventions for 1 or both symptoms.

IMPLICATIONS FOR PRACTICE

Clinicians need to assess for the co-occurrence of anxiety and sleep disturbance.

The relationship between uncertainty and acute procedure anxiety among surgical patients in Chinese mainland: the mediating role of resilience

BACKGROUND

Surgery, as one of the main diagnostic and treatment methods, is a routine work in medical settings. Patients undergoing surgery often experience acute procedure anxiety due to uncertainty. There is ample evidence showing that uncertainty is a risk factor for the acute procedure anxiety in surgical patients. However, little is known about the psychological processes mediating this relationship. Therefore, this study aims to evaluate resilience as a mediator of the association between uncertainty and anxiety.

METHODS

A population-based cross-sectional survey with a convenience sampling method was conducted, involving 243 surgical patients in Jiaxing, Zhejiang province of China was carried out. Relevant data were collected by self-reporting questionnaires, including demographic characteristics questionnaire, Amsterdam Preoperative Anxiety and Information Scale (APAIS-C), Mishel's Illness Uncertainty Scale (MUIS), Connor-Davidson Resilience Scale (CD-RISC). Pearson correlation analysis was employed to examine correlations between various variables. A path model was used to assess the mediation effect of resilience with respect to uncertainty and acute procedure anxiety.

RESULTS

In the path model, uncertainty have an indirect effect on acute procedure anxiety through resilience. The results suggest that resilience has a mediating role in uncertainty and acute procedure anxiety among surgical patients.

CONCLUSIONS

These findings call for the development of interventions targeting the role of resilience in effectively predicting and preventing acute procedure anxiety and uncertainty among surgical patients.

Mind-body-medicine in oncology-from patient needs to tailored programs and interventions: a cross-sectional study

Introduction

National and international guidelines recommend early integration of evidence-based multimodal interventions and programs, especially with a focus on relaxation techniques and other Mind-Body-based methods to maintain the quality of life of oncology patients, improve treatment tolerability, and promote healthy lifestyle behaviors. Consequently, we aim to understand what drives patients and how they navigate integrative medicine to best advise them. This study aimed to detect possible topics of particular interest to patients and identify the patient groups that could benefit most from further programs. Furthermore, we aimed to investigate if patients are open-minded toward integrative oncology concepts and learn about their motivational level to maintain or change behavior.

Methods

Between August 2019 and October 2020 we surveyed patients undergoing oncological therapy in a university oncological outpatient center using a custom-developed questionnaire based on established Mind-Body Medicine concepts.

Results

We included 294 patients with various cancers. More than half reported problems sleeping through (61%) and 42% felt stressed frequently, invariably rating this as detrimental to their health. Moreover, a slight majority (52%) felt physically limited due to their disease and only 30% performed defined exercise programs. Women were significantly more likely to feel stressed and reported with alarming frequency that they often feel "everything was up to them." The 40-65-year-olds reported significantly less restful sleep, more stress and were more dissatisfied with their situation. However, this group already used natural remedies most frequently and was most often motivated to use relaxation techniques in the next 6 months. The lower the perceived individual energy level (EL), the less frequently patients did sport, the more frequently they felt their disease impaired their activity, mostly feeling stressed and tense. We also found significant associations between negative emotions/thoughts and the variables "sleep," "use of relaxation techniques," "personal stress perception," and "successful lifestyle modification."

Conclusion

Mind-Body programs that focus on patient's individual resources, with tools to explore impairing patterns of self-perception and cognitive biases, can be a valuable resource for oncology patients and should therefore be part of an integrative medical treatment concept.

Sleep disturbance and decrements in morning energy contribute to a higher symptom burden in oncology patients

OBJECTIVE/BACKGROUND

An emerging area of research is the relationship between sleep disturbance and decrements in energy. Given the paucity of research on the co-occurrence of these two symptoms, study purposes were to identify subgroups of oncology patients with distinct joint sleep disturbance AND morning energy profiles and evaluate for differences among the subgroups in demographic, clinical, and sleep disturbance characteristics, as well as the severity of other common symptoms and QOL outcomes.

PATIENTS/METHODS

Patients (n = 1336) completed measures of sleep disturbance and energy 6 times over two cycles of chemotherapy. All of the other measures were completed at enrollment. Latent profile analysis was used to identify the distinct joint sleep disturbance and morning energy profiles.

RESULTS

Three distinct profiles were identified (i.e., Low Sleep Disturbance and High Morning Energy (Normal, 20.6%), Moderate Sleep Disturbance and Low Morning Energy (Moderately Severe, 52.1%), Very High Sleep Disturbance and Very Low Morning Energy (Very Severe, 27.3%). Compared to Normal class, other two classes were more likely to be female, less likely to be employed, and had higher comorbidity burden and poorer functional status. Symptom scores and QOL outcomes exhibited a dose response effect (i.e., as the profile worsened, symptom scores increased and QOL scores decreased).

CONCLUSIONS

Given the associations between sleep disturbance and decrements in energy and a higher symptom burden, poorer QOL outcomes, and increased mortality, assessment of these two symptoms needs to be a high priority for clinicians and appropriate interventions initiated.

Neuroendocrine mechanisms in oxaliplatin-induced hyperalgesic priming

ABSTRACT

Stress plays a major role in the symptom burden of oncology patients and can exacerbate cancer chemotherapy-induced peripheral neuropathy (CIPN), a major adverse effect of many classes of chemotherapy. We explored the role of stress in the persistent phase of the pain induced by oxaliplatin. Oxaliplatin induced hyperalgesic priming, a model of the transition to chronic pain, as indicated by prolongation of hyperalgesia produced by prostaglandin E 2 , in male rats, which was markedly attenuated in adrenalectomized rats. A neonatal handling protocol that induces stress resilience in adult rats prevented oxaliplatin-induced hyperalgesic priming. To elucidate the role of the hypothalamic-pituitary-adrenal and sympathoadrenal neuroendocrine stress axes in oxaliplatin CIPN, we used intrathecally administered antisense oligodeoxynucleotides (ODNs) directed against mRNA for receptors mediating the effects of catecholamines and glucocorticoids, and their second messengers, to reduce their expression in nociceptors. Although oxaliplatin-induced hyperalgesic priming was attenuated by intrathecal administration of β 2 -adrenergic and glucocorticoid receptor antisense ODNs, oxaliplatin-induced hyperalgesia was only attenuated by β 2 -adrenergic receptor antisense. Administration of pertussis toxin, a nonselective inhibitor of Gα i/o proteins, attenuated hyperalgesic priming. Antisense ODNs for Gα i 1 and Gα o also attenuated hyperalgesic priming. Furthermore, antisense for protein kinase C epsilon, a second messenger involved in type I hyperalgesic priming, also attenuated oxaliplatin-induced hyperalgesic priming. Inhibitors of second messengers involved in the maintenance of type I (cordycepin) and type II (SSU6656 and U0126) hyperalgesic priming both attenuated hyperalgesic priming. These experiments support a role for neuroendocrine stress axes in hyperalgesic priming, in male rats with oxaliplatin CIPN.

Co-occurring Fatigue and Lymphatic Pain Incrementally Aggravate Their Negative Effects on Activities of Daily Living, Emotional Distress, and Overall Health of Breast Cancer Patients

BACKGROUND

Fatigue and lymphatic pain are the most common and debilitating long-term adverse effects of breast cancer treatment. Fatigue and pain independently have negative effects on quality of life, physical functions, and cancer recurrence-free survival. The interactions between fatigue and pain may aggravate their negative effects.

OBJECTIVES

Examine the effects of co-occurring fatigue and lymphatic pain on activities of daily living (ADLs), emotional distress, and overall health of breast cancer patients.

METHODS

A cross-sectional and observational design was used to enroll 354 breast cancer patients. Valid and reliable instruments were used to assess fatigue, lymphatic pain, ADLs, emotional distress, and overall health. Descriptive statistics and multivariable regression models were used for data analysis.

RESULTS

After controlling for demographic and clinical factors, patients with co-occurring fatigue and lymphatic pain had higher odds of having impaired ADLs (OR = 24.43, CI = [5.44-109.67], P < .001) and emotional distress (OR = 26.52, CI = [9.64-72.90], P < .001) compared to patients with only fatigue and only lymphatic pain. Patients with co-occurring fatigue and lymphatic pain had 179% increase in impaired ADL scores (B = 8.06, CI = [5.54-10.59]) and 211% increase in emotional distress scores (B = 9.17, CI = [5.52-12.83]) compared to those without co-occurring fatigue and lymphatic pain. Patients with co-occurring fatigue and lymphatic pain had a 34% decrease (B = -26.29, CI = [-31.90 to -20.69]) and patients with only fatigue had a 33% decrease in overall health scores (B = -25.74, 95% CI = [-34.14 to -17.33]), indicating poor overall health.

CONCLUSIONS

Fatigue and lymphatic pain affected 66.4% of breast cancer patients. Findings from this study suggest that co-occurring fatigue and lymphatic pain have negative effects on breast cancer patients' ADLs, emotional distress, and overall health. The synergistic interactions between fatigue and lymphatic pain incrementally aggravated their negative effects on ADLs and emotional distress. Findings of the study highlight the need to evaluate the underlying mechanisms for co-occurring fatigue and lymphatic pain and develop interventions that target both fatigue and lymphatic pain to improve breast cancer patients' the quality of life.