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Kim J, Kim Y, Oh JW, Lee S. Sex differences of the association between handgrip strength and health-related quality of life among patients with cancer. Sci Rep 2024; 14:9876. [PMID: 38684776 PMCID: PMC11059168 DOI: 10.1038/s41598-024-60710-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/26/2024] [Indexed: 05/02/2024] Open
Abstract
The purpose of this study is to investigate the association between handgrip strength (HGS) and health-related quality of life (HRQoL), demonstrating HGS as an effective indicator for evaluating HRQoL of patients with cancer. Analyzing 1657 Korean adult cancer patients (644 males, 1013 females) aged ≥ 20 years from the Korea National Health and Nutrition Examination Survey (2014-2019), HGS was standardized based on body mass index and categorized by sex. HRQoL was assessed using the Euro Quality of Life-5-Dimension 3-Level version (EQ-5D-3L) Index. Lower relative HGS was associated with decreased HRQoL in female patients, while no significant association was found in male patients. The lowest quartile of relative HGS exhibited a 2.5-fold decrease in HRQoL compared to the highest quartile (OR 2.50, 95% CI 1.59-3.95, p < 0.001). Both male and female patients with cancer were affected by age, subjective health perception, and stress recognition regarding HRQoL. This study suggests that HGS may be associated with the HRQoL of female patients with cancer, emphasizing that the HGS measurement can be effectively utilized as a pivotal tool for evaluating HRQoL in female patients with cancer.
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Affiliation(s)
- Jihye Kim
- Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Yujin Kim
- Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
- Department of Social Welfare, Seoul National University, Seoul, Republic of Korea
| | - Jae Won Oh
- Department of Psychology, University of Utah Asia Campus, Incheon, Republic of Korea
| | - San Lee
- Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea.
- Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea.
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Chuan-Yu YANG, CHIANG YC, WU CL, HUNG SK, CHU TL, HSIAO YC. Mediating role of spirituality on the relationships between posttraumatic stress and posttraumatic growth among patients with cancer: A cross-sectional study. Asia Pac J Oncol Nurs 2023; 10:100221. [PMID: 37123032 PMCID: PMC10131104 DOI: 10.1016/j.apjon.2023.100221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
Objective This study explores the impact of posttraumatic stress (PTS) on posttraumatic growth (PTG) and verifies the mediating effect of spirituality among patients with cancer. Methods This study used a cross-sectional correlational design. This study surveyed 141 hospitalized patients over 20 years of age diagnosed with cancer. Participants were recruited by convenience sampling from a regional hospital in Taiwan. Data were collected from January to April 2021. Measurements included sociodemographic and disease-related information and data from the following self-report questionnaires: Posttraumatic Stress Reaction Index-Short Form, Posttraumatic Growth Inventory, and Spiritual Health Scale-Short Form. Structural equation modeling and bootstrapping were used to analyze the mediating effect of spiritual health on PTS and PTG. Results PTS and spirituality were negatively correlated, spirituality, and PTG were positively correlated, and PTS had no correlation with PTG. Spirituality fully presented a mediating role between PTS and PTG. Conclusions Patients' spirituality should be regarded as an important variable that can impact stress appraisal and improve the patient's PTG when a diagnosis of cancer is received. Assessing spiritual health at regular intervals and integrating spiritual care with clinical care could decrease PTS and improve PTG for patients with cancer.
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3
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Walsh EA, Pedreira PB, Moreno PI, Popok PJ, Fox RS, Yanez B, Antoni MH, Penedo FJ. Pain, cancer-related distress, and physical and functional well-being among men with advanced prostate cancer. Support Care Cancer 2022; 31:28. [PMID: 36515785 PMCID: PMC9757851 DOI: 10.1007/s00520-022-07453-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Men with advanced prostate cancer (APC) experience high levels of pain, which contribute to poor psychosocial and functional outcomes. Cancer-related distress explains the relationship between pain severity and interference, yet specificity of distress characteristics (e.g., hyperarousal, intrusive, or avoidant symptoms) in explaining associations between pain experiences and well-being has not been explored within APC. This study examined men with APC entering a clinical trial and tested associations of baseline pain, cancer-related distress, and physical and functional well-being. METHODS One hundred ninety men with APC enrolled in a randomized-controlled trial and were assessed prior to randomization. The McGill Pain Questionnaire assessed pain severity, and the Functional Assessment of Cancer Therapy-General captures physical and functional well-being. The Impact of Events Scale-Revised measured cancer-specific distress symptoms, including hyperarousal, avoidance, and intrusion symptoms. Controlling for age, cancer stage at diagnosis, income, education, and race/ethnicity, mediation models (SPSS PROCESS, model 4) tested whether cancer-specific distress accounted for the associations between pain severity and physical and functional well-being. RESULTS Men were on average 68 years of age, White non-Hispanic, with stage IV cancer. Pain severity was related to poorer physical (p < .001) and functional well-being (p < .001). Associations between pain severity and physical and functional well-being were partially mediated by greater intrusive and hyperarousal symptoms but not avoidant symptoms. CONCLUSION For men with APC, intrusive and hyperarousal symptoms may partially explain the relationship between pain severity and decrements in physical and functional well-being. APC pain management should attend to such distress symptoms, which may contribute to interference if left unaddressed. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03149185.
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Affiliation(s)
- Emily A Walsh
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | | | - Patricia I Moreno
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Paula J Popok
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | - Rina S Fox
- College of Nursing, University of Arizona, Tucson, AZ, USA
| | - Betina Yanez
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael H Antoni
- Department of Psychology, University of Miami, Coral Gables, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Frank J Penedo
- Department of Psychology, University of Miami, Coral Gables, FL, USA.
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA.
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Jung A, Crandell JL, Nielsen ME, Smith SK, Bryant AL, Mayer DK. Relationships among uncertainty, post-traumatic stress disorder symptoms, and quality of life in non-muscle-invasive bladder cancer survivors. Support Care Cancer 2022; 30:6175-6185. [PMID: 35437672 DOI: 10.1007/s00520-022-07034-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 04/03/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE The aim of this study was to examine relationships among uncertainty, PTSD symptoms (PTSS), and quality of life (QOL) in non-muscle-invasive bladder cancer (NMIBC) survivors. METHODS Eligible NMIBC survivors were identified through the North Carolina Central Cancer Registry, and 398 survivors participated in a mailed survey that measured survivor's outcomes (uncertainty, PTSS, and QOL). Structural equation modeling was used to examine the mediating effect of uncertainty and PTSS on the association between personal characteristics and QOL in NMIBC survivors. RESULTS NMIBC survivors experienced cancer-related uncertainty; higher uncertainty was associated with male, lower income, lack of cure, and lower cognition-ability. Uncertainty was significantly and negatively associated with QOL. In addition, PTSS completely mediated the effect of uncertainty on QOL, and higher PTSS had a strong association with poorer QOL. Additionally, comorbidities, cognition-general concerns, uncertainty, and PTSS had strong negative effects on QOL. CONCLUSION This study has identified modifiable psychosocial factors which affect QOL in NMIBC survivors. The study findings can be used in the development of interventions to improve QOL for NMIBC survivors.
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Affiliation(s)
- Ahrang Jung
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,School of Nursing, University of North Carolina at Greensboro, Greensboro, NC, USA.
| | - Jamie L Crandell
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew E Nielsen
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | | | - Ashley Leak Bryant
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Deborah K Mayer
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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5
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Joly F, Rigal O, Guittet L, Lefèvre-Arbogast S, Grellard JM, Binarelli G, Lange M, Rieux C, Fernette M, Tron L, Gernier F, Travers R, Morel A, Richard D, Griffon B, Leconte A, Bastien E, Quilan F, Pépin LF, Jardin F, Leheurteur M, Clarisse B, Lequesne J, Faveyrial A. Post-traumatic stress symptomatology and adjustment of medical oncology practice during the COVID-19 pandemic among adult patients with cancer in a day care hospital. Cancer 2021; 127:4636-4645. [PMID: 34398970 PMCID: PMC8426939 DOI: 10.1002/cncr.33856] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 12/20/2022]
Abstract
Background The COVID‐19 pandemic may induce post‐traumatic stress disorder (PTSD) symptoms among patients with cancer, who also face adaptations to their treatment. The authors assessed the occurrence of PTSD symptoms, investigated pandemic‐induced adjustments in medical oncology practice in patients with cancer, and explored risk factors for PTSD and the association between PTSD symptoms, insomnia, and quality of life (QoL). Methods This prospective French study was conducted in patients with solid/hematologic tumors who were receiving medical treatment in the day care departments of 2 cancer centers during the lockdown. Adjustments to medical oncology practice were collected from medical records. PTSD (measured using the Impact of Event Scale‐Revised), insomnia (measured using the Insomnia Severity Index), QoL (measured using the Functional Assessment of Cancer Therapy‐General instrument), and cognitive complaints (measured using the Functional Assessment of Cancer Therapy–Cognitive Function instrument) were collected through validated questionnaires. Results Clinical data and questionnaires were available for 734 and 576 patients, respectively. The median patient age was 64 years, and 69% of patients were women. Twenty‐one percent of patients had PTSD. Twenty‐seven percent (95% CI, 23%‐30%) had an adjustment in their medical oncology program, including adjournments (29%), treatment interruptions (16%), modified treatment plans (27%), or adapted monitoring (27%). Women and patients experiencing an adjustment in oncology practice had a higher odds of PTSD (odds ratio= 2.10 [95% CI, 1.07‐4.14] and 1.65 [95% CI, 1.03‐2.63]; P < .05). PTSD symptoms were correlated with worse scores for QoL, cognition, and insomnia. Conclusions Twenty‐one percent of patients with cancer experienced PTSD symptoms associated with poor QoL during the first COVID‐19–induced lockdown. Medical oncology practice was adjusted in approximately one‐quarter of patients and was associated with the occurrence of PTSD symptoms. Psychosocial support should be offered in cancer centers to promote emotional resilience and avoid PTSD symptoms in patients. Post‐traumatic stress disorder symptomatology occurred in 21% of patients with cancer during the first lockdown due to COVID‐19, was more frequent among women, and was associated with adjustment in medical oncology treatments. Caregivers should pay special attention to the psychological needs of patients with cancer to prevent or manage post‐traumatic stress disorder symptoms.
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Affiliation(s)
- Florence Joly
- Medical Oncology Department, Francois Baclesse Center, Caen, France.,Anticipe (Interdisciplinary Research Unit for the Prevention and Treatment of Cancer), INSERM Unit 1086, Caen, France.,Clinical Research, Francois Baclesse Center, Caen, France
| | - Olivier Rigal
- Medical Oncology, Henri Becquerel Center, Rouen, France.,Clinical Research, Henri Becquerel Center, Rouen, France
| | - Lydia Guittet
- Anticipe (Interdisciplinary Research Unit for the Prevention and Treatment of Cancer), INSERM Unit 1086, Caen, France
| | - Sophie Lefèvre-Arbogast
- Anticipe (Interdisciplinary Research Unit for the Prevention and Treatment of Cancer), INSERM Unit 1086, Caen, France.,Clinical Research, Francois Baclesse Center, Caen, France
| | | | - Giulia Binarelli
- Anticipe (Interdisciplinary Research Unit for the Prevention and Treatment of Cancer), INSERM Unit 1086, Caen, France.,Clinical Research, Francois Baclesse Center, Caen, France
| | - Marie Lange
- Anticipe (Interdisciplinary Research Unit for the Prevention and Treatment of Cancer), INSERM Unit 1086, Caen, France.,Clinical Research, Francois Baclesse Center, Caen, France
| | - Chantal Rieux
- Clinical Research, Francois Baclesse Center, Caen, France
| | - Marie Fernette
- Clinical Research, Francois Baclesse Center, Caen, France
| | - Laure Tron
- Anticipe (Interdisciplinary Research Unit for the Prevention and Treatment of Cancer), INSERM Unit 1086, Caen, France
| | | | | | - Adeline Morel
- Medical Oncology Department, Francois Baclesse Center, Caen, France
| | | | | | | | - Etienne Bastien
- Medical Oncology Department, Francois Baclesse Center, Caen, France
| | - Florian Quilan
- Medical Oncology Department, Francois Baclesse Center, Caen, France
| | | | - Fabrice Jardin
- Clinical Research, Henri Becquerel Center, Rouen, France.,Hematology, Henri Becquerel Center, Rouen, France
| | | | | | | | - Audrey Faveyrial
- Medical Oncology Department, Francois Baclesse Center, Caen, France
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6
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Effectiveness of different music interventions on managing symptoms in cancer survivors: A meta-analysis. Eur J Oncol Nurs 2021; 52:101968. [PMID: 34020137 DOI: 10.1016/j.ejon.2021.101968] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/07/2021] [Accepted: 04/14/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE Music-based interventions can provide non-pharmacological, low-cost treatment for symptoms. This meta-analysis's purpose is to examine music-based interventions' effectiveness on psychological distress symptoms (anxiety, stress, and depressive symptoms), aspects of positive psychology (benefit-finding and resilience), and quality of life (QoL). METHODS This meta-analysis was conducted according to PRISMA guidelines and meta-analytic methods suggested by Hedges and Olkin (1985). A systematic literature search between 2000 and 2020 was conducted using CINAHL, MEDLINE, PsycINFO, PubMed, and Web of Science databases. Studies and intervention characteristics were independently coded. The Quality Assessment Tool for Quantitative Studies, Cochrane Collaboration's Tool for Assessing Risk of Bias, Begg and Mazumdar's rank correlation, and Egger's regression test evaluated publication bias. RESULTS Twenty-nine of thirty-five eligible studies were included in the statistical analysis. The overall (g = 0.34, SE = 2.27, p < 0.05) and psychological distress symptoms sub-outcome type (g = 0.47, SE = 0.18, p < 0.05) models with moderator analyses were statistically significant. CONCLUSIONS Culturally appropriate music-based interventions conducted in the clinical setting that used passive listening with headphones, occurring ≥ 3-times a week over ≥ 2 months, positively impacted gynecology survivors undergoing chemotherapy and surgical treatments. Specifically, interventions that were ≥ 35-minutes, listening to folk or mixed-music positively impacted psychological distress symptoms, whereas new-age music negatively impacted psychological distress symptoms, positive psychology, and QoL outcomes. Future research should examine positive psychology characteristics (perceived levels of positive adjustment, change, and coping) and include larger cohorts with various cancer populations across all cancer survivorship continuum. Culturally appropriate interventions could lead to greater adherence, compliance, and clinical effectiveness and increase the findings' significance and generalizability.
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7
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Jung A, Crandell JL, Nielsen ME, Mayer DK, Smith SK. Post-traumatic stress disorder symptoms in non-muscle-invasive bladder cancer survivors: A population-based study. Urol Oncol 2020; 39:237.e7-237.e14. [PMID: 33308978 DOI: 10.1016/j.urolonc.2020.11.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/22/2020] [Accepted: 11/21/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This cross-sectional study examined the prevalence of post-traumatic stress disorder (PTSD) and identified the predictive factors associated with PTSD symptoms in a population of non-muscle-invasive bladder cancer (NMIBC) survivors. METHODS A random sample of 2,000 NMIBC survivors, identified through the North Carolina Central Cancer Registry, were sent postal mail survey. PTSD symptoms were measured using the PTSD Checklist for DSM-5 (PCL-5). Descriptive statistics and hierarchical multiple linear regression were used to examine the prevalence of PTSD and to identify the factors associated with PTSD. RESULTS A total of 376 participants were included in the analysis. The average PCL-5 score was 7.1 (standard deviation [SD] = 10.9, range: 0-66), where higher scores represent higher levels of PTSD symptoms. The prevalence of the provisional PTSD diagnosis was 5.3% or 6.9% (after adjusting for nonresponse). In addition, 28.7% of participants met criteria for at least one PTSD symptom cluster. After controlling for other variables, participants who were younger, had active disease or unsure of status, had more comorbidities, had lower social support, and had higher cognitive concerns reported significantly higher PTSD symptoms. CONCLUSION More than one-fourth of NMIBC survivors had PTSD symptoms. Thus, healthcare providers should assess PTSD symptoms and provide supportive care for NMIBC survivors in the survivorship phase of care.
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Affiliation(s)
- Ahrang Jung
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Jamie L Crandell
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew E Nielsen
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC; School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Deborah K Mayer
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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8
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The Effects of Cognitive-Behavioral Stress Management for Breast Cancer Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Cancer Nurs 2020; 43:222-237. [PMID: 32195709 DOI: 10.1097/ncc.0000000000000804] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment for breast cancer can be stressful for patients. Cognitive-behavioral stress management (CBSM) interventions aim to improve patients' skills in coping with stress and buffer against the negative effects of cancer. OBJECTIVES This meta-analysis aimed to demonstrate the impact of CBSM on breast cancer patients. METHODS We searched PubMed, EMBASE, the Cochrane Database, ScienceDirect, MEDLINE, CENTRAL, CINAHL, and PsycNET for randomized controlled trials (RCTs) published up to November 21, 2017. We then performed a meta-analysis of RCTs that compared CBSM for patients with breast cancer with a 1-day psychoeducation seminar, wait-list controls, or standard care. RESULTS Eighteen RCTs with 2564 participants were ultimately included. The results showed that CBSM can increase Measure of Current Status relaxation scores, benefit finding, and positive affect and decrease serum cortisol, anxiety, depression, thought avoidance and intrusion, and negative mood. However, it appears to have no effect on stress or mood disturbance. CONCLUSIONS Cognitive-behavioral stress management appears to be beneficial for breast cancer patients. Further high-quality RCTs are needed to clarify if any other factors are influenced by CBSM intervention. IMPLICATIONS FOR PRACTICE Cognitive-behavioral stress management can help breast cancer patients develop skills to increase relaxation, benefit finding, and positive affect; CBSM may provide a buffer against the negative effects of cancer. Further, CBSM may help breast cancer patients replace negative thoughts, improve their thought processes and behaviors, and maintain social support using cognitive and interpersonal coping skills. Nurses should be aware of the benefits of CBSM in their day-to-day care of breast cancer patients.
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9
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Brown LC, Murphy AR, Lalonde CS, Subhedar PD, Miller AH, Stevens JS. Posttraumatic stress disorder and breast cancer: Risk factors and the role of inflammation and endocrine function. Cancer 2020; 126:3181-3191. [PMID: 32374431 DOI: 10.1002/cncr.32934] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/10/2020] [Accepted: 03/23/2020] [Indexed: 12/20/2022]
Abstract
A breast cancer diagnosis can be a life-changing and stressful experience that can lead to chronic mental health conditions such as posttraumatic stress disorder (PTSD). Greater than one-third of patients initially diagnosed with PTSD after a diagnosis of breast cancer continue to have persistent or worsening PTSD symptoms after 4 years. An emerging body of literature has indicated several key environmental and biological risk factors for PTSD among survivors of breast cancer. Well-recognized risk factors include having a history of childhood trauma, being nonwhite, obesity, younger age at the time of diagnosis, diagnosis with a higher stage of breast cancer, and short time since treatment. Of the emerging risk factors related to fear circuitry in the brain, 2 pathways of particular importance are the stress-driven activation of inflammatory pathways and the long-term effect of antiendocrine therapies. These central and peripheral responses during and after stress exposure are important because increased fear and anxiety can lead to the maintenance of PTSD and worse patient outcomes. Given the poor outcomes associated with PTSD and the high prevalence of breast cancer in women, more research to identify those women at heightened risk of PTSD after breast cancer is warranted to reduce the number of diagnoses and lessen the negative impact of this chronic mental health condition.
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Affiliation(s)
- Lauren C Brown
- Emory University College of Arts and Sciences, Atlanta, Georgia, USA
| | - Amy R Murphy
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Chloe S Lalonde
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Preeti D Subhedar
- Glenn Family Breast Center, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrew H Miller
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.,Glenn Family Breast Center, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jennifer S Stevens
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.,Glenn Family Breast Center, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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10
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Langford DJ, Cooper B, Paul S, Humphreys J, Hammer MJ, Levine J, Conley YP, Wright F, Dunn LB, Miaskowski C. Distinct Stress Profiles Among Oncology Patients Undergoing Chemotherapy. J Pain Symptom Manage 2020; 59:646-657. [PMID: 31711968 DOI: 10.1016/j.jpainsymman.2019.10.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/16/2022]
Abstract
CONTEXT Cancer and its treatment are inherently stressful and stress impacts important patient outcomes. Patients vary considerably in their response to stress. Understanding this variability requires a patient-centered multidimensional approach. OBJECTIVES The objectives of this study were to identify and characterize patient subgroups with distinct multidimensional stress profiles (stress appraisal, exposure, and adaptation) during cancer treatment. METHODS Among 957 patients undergoing chemotherapy for breast, gastrointestinal, gynecological, or lung cancer, latent profile analysis was performed to identify patient subgroups using concurrent evaluations of global (Perceived Stress Scale) and cancer-specific (Impact of Events Scale-Revised) stress, lifetime stress exposure (Life Stressor Checklist-Revised), and resilience (Connor-Davidson Resilience Scale-10). RESULTS Three latent classes were identified: "Normative" (54.3%; intermediate global stress and resilience, lower cancer-related stress, lowest life stress); "Stressed" (39.9%; highest global and cancer-specific stress scores, lowest resilience, most life stress); and "Resilient" (5.7%; lowest global stress, cancer-specific stress comparable to Normative class, highest resilience, intermediate life stress). Characteristics that distinguished the Stressed from the Normative class included the following: younger age, female gender, lower socioeconomic status, unmarried/partnered, living alone, poorer functional status, and higher comorbidity burden. Compared to Stressed patients, Resilient patients were more likely to be partnered, to not live alone, and had a higher functional status. No demographic or clinical characteristics differentiated Normative from Resilient patients. Exposure to specific life stressors differed significantly among the classes. CONCLUSION A subset of patients warrants intensive psychosocial intervention to reduce stress and improve adaptation to cancer. Intervention efforts may be informed by further study of Resilient patients.
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Affiliation(s)
- Dale J Langford
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Bruce Cooper
- School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Steven Paul
- School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | | | | | - Jon Levine
- School of Nursing, University of California, San Francisco, San Francisco, California, USA; School of Dentistry, University of California, San Francisco, San Francisco, California, USA
| | - Yvette P Conley
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Fay Wright
- Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Laura B Dunn
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California, USA.
| | - Christine Miaskowski
- School of Nursing, University of California, San Francisco, San Francisco, California, USA
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11
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Zhang L, Lu Y, Qin Y, Xue J, Chen Y. Post-traumatic growth and related factors among 1221 Chinese cancer survivors. Psychooncology 2019; 29:413-422. [PMID: 31705578 DOI: 10.1002/pon.5279] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 10/21/2019] [Accepted: 10/28/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE There is an increasing number of studies on the post-traumatic growth (PTG) of cancer survivors worldwide. However, few Chinese studies have reported about PTG in cancer survivors because of the underdevelopment of community health services. This study aimed to evaluate the level of PTG in China and explore related factors among a large sample of survivors of more than 12 cancer types. METHODS We recruited 1236 survivors from 14 sites of the Beijing Cancer Rehabilitation Association. Survivors completed standardized questionnaires assessing PTG, social support, coping styles, demographic characteristics, and clinical conditions. Multivariate linear regression was used to evaluate potential predictive factors of PTG. RESULTS A total of 1221 (98.7%) subjects completed the questionnaires. The average PTG score was 61.15 ± 20.26. Seven variables were included in the final regression model: social support, coping style, time after treatment, exercise, BMI, work status, and economic income (P < .05). Survivors who had low levels of social support, had negative coping strategies, had a time after treatment of less than 5 years, exercised irregularly, had an abnormal BMI, were unemployed, or had low economic income had lower PTG levels. CONCLUSIONS PTG levels among Chinese cancer survivors are associated with social support, coping style, time after treatment, exercise, BMI, work status, and economic income. Strategies tailored to Chinese survivors should be developed to promote their PTG and improve their physical and psychological well-being.
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Affiliation(s)
- Liyan Zhang
- The Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of GI Medical Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yuhan Lu
- Nursing Department, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yin Qin
- Beijing Cancer Rehabilitation Association, Beijing, China
| | - Jing Xue
- The Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of GI Medical Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yang Chen
- The Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of GI Medical Oncology, Peking University Cancer Hospital & Institute, Beijing, China
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Li J, Sun L, Wang X, Sun C, Heng S, Hu X, Chen W, Liu F. Are Posttraumatic Stress Symptoms and Avoidant Coping Inhibitory Factors? The Association Between Posttraumatic Growth and Quality of Life Among Low-Grade Gliomas Patients in China. Front Psychol 2019; 10:330. [PMID: 30873074 PMCID: PMC6401985 DOI: 10.3389/fpsyg.2019.00330] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 02/03/2019] [Indexed: 02/05/2023] Open
Abstract
Background: Diagnosing with low-grade gliomas (LGGs) can be a very shocking and stressful experience, a traumatic event potentially leading to the development of posttraumatic stress symptoms (PTSS), and posttraumatic growth (PTG). Understanding how patients cognitively and behaviorally response to their diagnosing is also important to postoperative treatment. Thus, the current study explored the association between PTG and quality of life (QoL) of Chinese patients with LGGs. The moderation effects of coping strategies and PTSS on the relationship between PTG and QoL have been examined as well. Methods: Posttraumatic stress symptoms, Posttraumatic growth, coping strategies, and QoL were measured by using self-report surveys. Three hundred and thirty patients completed surveys approximately 1 month after surgery. We used three multiple regression models and added interaction terms in these models to test the moderation effects of PTSS and coping strategies on the relationship between PTG and QoL. Results: The results of hierarchical multiple regression suggested that PTG significantly predicted QoL, both PTSS and coping strategies moderated the association between PTG and QoL. Specifically, the association between PTG and QoL for patients who have non-significant PTSS is stronger than those who have significant PTSS. Furthermore, as the score of Avoidant Coping increases, the association between PTG and QoL becomes weaker. Conclusion: Posttraumatic growth may help to improve the QoL of LGGs patients, but PTSS and Avoidant Coping impeded the positive effect of PTG on QoL.
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Affiliation(s)
- Junyi Li
- School of Psychology, Sichuan Normal University, Chengdu, China
| | - Lijun Sun
- School of Psychology, Xinxiang Medical University, Xinxiang, China
| | - Xiaoyu Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Cuicui Sun
- School of Psychology, Central China Normal University, Wuhan, China
| | - Shupeng Heng
- School of Psychology, Henan Normal University, Xinxiang, China
| | - Xiangen Hu
- School of Psychology, Central China Normal University, Wuhan, China
| | - Wei Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fujun Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
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Langford DJ, Cooper B, Paul S, Humphreys J, Keagy C, Conley YP, Hammer MJ, Levine JD, Wright F, Melisko M, Miaskowski C, Dunn LB. Evaluation of coping as a mediator of the relationship between stressful life events and cancer-related distress. Health Psychol 2017; 36:1147-1160. [PMID: 28825498 DOI: 10.1037/hea0000524] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Lifetime stressful life events (SLEs) may predispose oncology patients to cancer-related distress (i.e., intrusive thoughts, hyperarousal, avoidance). Coping may influence cancer-related distress by mediating this relationship. This study sought to (a) determine the prevalence and impact of lifetime SLEs among oncology outpatients receiving chemotherapy and (b) examine the relationship between SLEs and cancer-related distress and the mediating role of coping on this relationship. METHOD Patients (n = 957), with breast, gastrointestinal, gynecologic or lung cancer, who were undergoing chemotherapy, completed the Life Stressor Checklist-Revised (LSC-R), a measure of lifetime SLEs. Cancer-related distress was assessed with the Impact of Event Scale-Revised. Coping strategies since beginning chemotherapy were assessed with the Brief COPE; 2 latent variables (engagement and disengagement coping) were identified based on these scores. LSC-R scores (number of SLEs and perceived impact during the prior year) were evaluated in relation to demographic and clinical characteristics. Structural equation modeling was used to evaluate the relationship between LSC-R and Impact of Event Scale-Revised scores and the mediating role of engagement and disengagement coping on this relationship. RESULTS On average, patients reported 6.1 (SD = 4.0; range = 0-23 out of 30) SLEs. Patients who were not married/partnered, had incomes <$30,000/year, or who had lower functional status or greater comorbidity had higher LSC-R scores. The relationship between more SLEs and more severe cancer-related distress was completely mediated by disengagement coping. Engagement coping did not mediate this relationship. CONCLUSIONS Disengagement coping, including behavioral disengagement, avoidance, and denial, should be targeted to mitigate cancer-related distress. (PsycINFO Database Record
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Affiliation(s)
| | - Bruce Cooper
- School of Nursing, University of California, San Francisco
| | - Steven Paul
- School of Nursing, University of California, San Francisco
| | | | | | | | | | - Jon D Levine
- School of Dentistry, University of California, San Francisco
| | | | | | | | - Laura B Dunn
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University
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Swartzman S, Booth JN, Munro A, Sani F. Posttraumatic stress disorder after cancer diagnosis in adults: A meta-analysis. Depress Anxiety 2017; 34:327-339. [PMID: 27466972 DOI: 10.1002/da.22542] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 06/17/2016] [Accepted: 06/17/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Since the introduction of serious illness as a potential traumatic stressor in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), research on the prevalence and predictors of posttraumatic stress disorder (PTSD) after cancer diagnosis has proliferated. Studies have reported widely varying estimates of the number of people with PTSD after cancer. The aim of this review is to synthesize quantitative data from studies reporting the proportion of people with PTSD among groups of cancer survivors. METHODS We undertook a diversified literature search strategy and identified 120 samples from 110 sources reporting a proportion of cancer survivors with PTSD. Of these, 11 studies, containing 12 samples, reported estimates of PTSD in cancer survivors compared to matched controls. RESULTS A random effects meta-analysis estimated the odds ratio as 1.66 (95% confidence interval (CI): 1.09-2.53) for PTSD in cancer survivors compared to controls, although some of this apparent increase may have arisen from publication bias. Factors influencing the reported proportion of a postcancer sample with PTSD included measurement type (clinical interview vs. self-report instrument), type of cancer, type of treatment, geographic region, whether the term "posttraumatic stress" was in the title or abstract, prior trauma, age, and time since diagnosis. CONCLUSIONS PTSD, diagnosed according to DSM-IV criteria, is more common in survivors of cancer than it is in the general population. Estimates of the occurrence of PTSD in patients with a history of cancer depend upon clinical and demographic factors, as well as upon study design.
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Affiliation(s)
| | | | - Alastair Munro
- Tayside Cancer Centre, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Fabio Sani
- School of Social Sciences, University of Dundee, Dundee, UK
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Abstract
The first part of the series of three articles on posttraumatic stress disorder (PTSD) in Court to appear in the journal reviews the history of the construct of PTSD and its presentation in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; American Psychiatric Association, 2013) and the ICD-11 (International Classification of Diseases, 11th Edition; World Health Organization, 2018). There are 20 symptoms of PTSD in the DSM-5. PTSD symptoms are arranged into a four-cluster model, which has received partial support in the literature. Other four-factor models have been found that fit the data even better than that of the DSM-5. There is a five-factor dysphoria model and two six-factor models that have been found to fit better the DSM-5 PTSD symptoms. Finally, research is providing support for a hybrid seven-factor model. An eighth factor on dissociation seems applicable to the minority of people who express the dissociative subtype. At the epidemiological level, individuals can expect trauma exposure to take place about 70% over one's lifetime. Also, traumatic exposure leads to traumatic reactions in about 10% of cases, with PTSD being a primary diagnosis for trauma. Once initiated, PTSD becomes prolonged in about 10% of cases. Polytrauma and comorbidities complicate these prevalence statistics. Moreover, the possibility of malingered PTSD presents confounds. However, the estimate for malingered PTSD varies extensively, from 1 to 50%, so that the estimate is too imprecise for use in court without further research. This first article in the series of three articles appearing in the journal on PTSD in Court concludes with discussion of complications related to comorbidities and heterogeneities, in particular. For example, PTSD and its comorbidities can be expressed in over one quintillion ways. This complexity in its current structure in the DSM-5 speaks to the individual differences involved in its expression.
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Affiliation(s)
- Gerald Young
- Glendon Campus, York University, Toronto, Ontario, Canada.
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Posttraumatic stress symptoms in women with gynaecologic pathology: the role of temperament, self-esteem and mental health. CURRENT ISSUES IN PERSONALITY PSYCHOLOGY 2016. [DOI: 10.5114/cipp.2016.61680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Thekdi SM, Milbury K, Spelman A, Wei Q, Wood C, Matin SF, Tannir N, Jonasch E, Pisters L, Cohen L. Posttraumatic stress and depressive symptoms in renal cell carcinoma: association with quality of life and utility of single-item distress screening. Psychooncology 2015; 24:1477-84. [PMID: 25690556 PMCID: PMC4539280 DOI: 10.1002/pon.3758] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 12/18/2014] [Accepted: 12/23/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The purpose of this study was to examine the prevalence of posttraumatic stress symptoms (PTSS) in patients with renal cell carcinoma (RCC), the associations and co-occurrence between PTSS, depressive, and other cancer-related symptoms and the ability of a single-item distress question to identify patients with PTSS. METHODS Patients with stage I-IV RCC completed assessments of depressive symptoms (Center for Epidemiologic Studies Depression Scale), PTSS (Impact of Event Scale), cancer-related symptoms (MD Anderson Symptom Inventory), fatigue (Brief Fatigue Inventory), and sleep disturbance (Pittsburgh Sleep Quality Index). We used the distress item on the MD Anderson Symptom Inventory as a distress screener and general linear model analyses to test study hypotheses. RESULTS Of the 287 patients (29% stage IV; 42% female; mean age = 58 years), 46% (n = 131) reported psychiatric symptoms with 15% (n = 44) reporting comorbid clinical levels of depressive symptoms and PTSS, 24% (n = 70) PTSS alone, and 6% (n = 17) depressive symptoms alone. Controlling for age, gender, and stage, patients with comorbid depressive symptoms and PTSS reported more cancer-related symptoms (p < 0.0001), fatigue (p < 0.0001), and sleep disturbance (p = 0.0003) than those with PTSS alone and more cancer-related symptoms (p = 0.002) and fatigue (p = 0.09) than those with depressive symptoms alone. Sensitivity analyses revealed that 26.9% of negative cases on the distress item fell within the clinical range of the Impact of Event Scale and 9.3% of negative cases met caseness on the Center for Epidemiologic Studies Depression Scale. CONCLUSIONS Posttraumatic stress symptoms occurred both independently and comorbid with depressive symptoms in patients with RCC. PTSS were correlated with overall cancer symptom burden. Single-item distress screening was less sensitive in detecting PTSS than depressive symptoms. Therefore, additional screening strategies are required in the clinical setting.
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Affiliation(s)
- Seema Malhotra Thekdi
- Department of Psychiatry, The University of Texas MD Anderson Cancer Center, Houston, Texas, US
| | - Kathrin Milbury
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, US
| | - Amy Spelman
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, US
| | - Qi Wei
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, US
| | - Christopher Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Surena F. Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nizar Tannir
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Louis Pisters
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lorenzo Cohen
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, US
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Dobrozsi S, Panepinto J. Patient-reported outcomes in clinical practice. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:501-506. [PMID: 26637765 DOI: 10.1182/asheducation-2015.1.501] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Patient-reported outcome (PRO) measurement plays an increasingly important role in health care and understanding health outcomes. PROs are any report of a patient's health status that comes directly from the patient, and can measure patient symptoms, patient function, and quality-of-life. PROs have been used successfully to assess impairment in a clinical setting. Use of PROs to systematically quantify the patient experience provides valuable data to assist with clinical care; however, initiating use of PROs in clinical practice can be daunting. Here we provide suggestions for implementation of PROs and examples of opportunities to use PROs to tailor individual patient therapy to improve patient outcomes, patient-physician communication, and the quality of care for hematology/oncology patients.
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Affiliation(s)
- Sarah Dobrozsi
- Pediatric Hematology/Oncology, Medical College of Wisconsin/Children's Research Institute of the Children's Hospital of Wisconsin, Milwaukee, WI
| | - Julie Panepinto
- Pediatric Hematology/Oncology, Medical College of Wisconsin/Children's Research Institute of the Children's Hospital of Wisconsin, Milwaukee, WI
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Syrjala KL, Jensen MP, Mendoza ME, Yi JC, Fisher HM, Keefe FJ. Psychological and behavioral approaches to cancer pain management. J Clin Oncol 2014; 32:1703-11. [PMID: 24799497 PMCID: PMC4031190 DOI: 10.1200/jco.2013.54.4825] [Citation(s) in RCA: 195] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
This review examines evidence for psychological factors that affect pain across the cancer continuum from diagnosis through treatment and long-term survivorship or end of life. Evidence is convincing that emotional distress, depression, anxiety, uncertainty, and hopelessness interact with pain. Unrelieved pain can increase a desire for hastened death. Patients with cancer use many strategies to manage pain, with catastrophizing associated with increased pain and self-efficacy associated with lower pain reports. A variety of psychological and cognitive behavioral treatments can reduce pain severity and interference with function, as indicated in multiple meta-analyses and high-quality randomized controlled trials. Effective methods include education (with coping skills training), hypnosis, cognitive behavioral approaches, and relaxation with imagery. Exercise has been tested extensively in patients with cancer and long-term survivors, but few exercise studies have evaluated pain outcomes. In survivors post-treatment, yoga and hypnosis as well as exercise show promise for controlling pain. Although some of these treatments effectively reduce pain for patients with advanced disease, few have been tested in patients at the end of life. Given the clear indicators that psychological factors affect cancer pain and that psychological and behavioral treatments are effective in reducing varying types of pain for patients with active disease, these methods need further testing in cancer survivors post-treatment and in patients with end-stage disease. Multidisciplinary teams are essential in oncology settings to integrate analgesic care and expertise in psychological and behavioral interventions in standard care for symptom management, including pain.
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Affiliation(s)
- Karen L Syrjala
- Karen L. Syrjala and Jean C. Yi, Fred Hutchinson Cancer Research Center; Karen L. Syrjala, Mark P. Jensen, and M. Elena Mendoza, University of Washington, Seattle, WA; and Hannah M. Fisher and Francis J. Keefe, Duke University, Durham, NC.
| | - Mark P Jensen
- Karen L. Syrjala and Jean C. Yi, Fred Hutchinson Cancer Research Center; Karen L. Syrjala, Mark P. Jensen, and M. Elena Mendoza, University of Washington, Seattle, WA; and Hannah M. Fisher and Francis J. Keefe, Duke University, Durham, NC
| | - M Elena Mendoza
- Karen L. Syrjala and Jean C. Yi, Fred Hutchinson Cancer Research Center; Karen L. Syrjala, Mark P. Jensen, and M. Elena Mendoza, University of Washington, Seattle, WA; and Hannah M. Fisher and Francis J. Keefe, Duke University, Durham, NC
| | - Jean C Yi
- Karen L. Syrjala and Jean C. Yi, Fred Hutchinson Cancer Research Center; Karen L. Syrjala, Mark P. Jensen, and M. Elena Mendoza, University of Washington, Seattle, WA; and Hannah M. Fisher and Francis J. Keefe, Duke University, Durham, NC
| | - Hannah M Fisher
- Karen L. Syrjala and Jean C. Yi, Fred Hutchinson Cancer Research Center; Karen L. Syrjala, Mark P. Jensen, and M. Elena Mendoza, University of Washington, Seattle, WA; and Hannah M. Fisher and Francis J. Keefe, Duke University, Durham, NC
| | - Francis J Keefe
- Karen L. Syrjala and Jean C. Yi, Fred Hutchinson Cancer Research Center; Karen L. Syrjala, Mark P. Jensen, and M. Elena Mendoza, University of Washington, Seattle, WA; and Hannah M. Fisher and Francis J. Keefe, Duke University, Durham, NC
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