The denial of cancer interview: development and first assessment of psychometric properties in lung cancer patients

Experiential Avoidance in Advanced Cancer: a Mixed-Methods Systematic Review

BACKGROUND

People with advanced cancer experience psychological distress due to physical symptoms, functional decline, and a limited prognosis. Difficult thoughts, feelings, and emotions may exacerbate distress and lead to avoidance of these experiences which is sometimes referred to as experiential avoidance (EA). Advanced cancer patients may be more likely to engage in EA especially when no obvious solutions to their problems exist. This study aims to examine the terms used to describe EA, the processes that might indicate EA, associations between EA and psychological distress, and to understand why individuals might engage in EA.

METHODS

A mixed-methods review. Literature search of Medline, Embase, Psych INFO, and CINAHL 1980-October 2019.

INCLUSION

adults ≥ 18 years; advanced cancer not amenable to cure.

EXCLUSION

no measures of EA or psychological distress. Risk of bias and study quality assessed. Evidence of statistical techniques collected. Themes coded, grouped, and developed based on meaning.

RESULTS

Nineteen studies identified, 13 quantitative studies and 6 qualitative. The quantitative of which 6 compared early-stage cancers with advanced cancers and examined subscales of EA alongside mood, quality of life, and psychological distress. EA covers a range or terms of which 'avoidant coping' is the commonest. EA is manifest as cognitive, behavioural, and emotional avoidance. A thematic synthesis suggests the function of EA is to protect people from distress, and from confronting or expressing difficult emotions by avoiding communication about cancer, controlling negative information, and maintaining normality and hope and optimism.

CONCLUSIONS

EA may be beneficial in the short term to alleviate distress, but in the longer term, it can impair function and limit engagement in life. Greater clinical awareness of the complexity of EA behaviours is needed. Clinicians and researchers should define EA precisely and be aware of the function it may serve in the short and longer term. Future research studies may consider using specific measures of EA as a primary outcome, to assess the impact of psychological interventions such as ACT.

The influence of socio-demographics and clinical characteristics on coping strategies in cancer patients: a systematic review

OBJECTIVES

Cancer is a frequent illness and a traumatic experience for both patients and their families. This systematic review aims to analyse studies that examine socio-demographic and clinical characteristics that predict the coping strategies in cancer patients.

METHODS

From January 2000 to March 2021, the database searches were conducted in 7 different databases, using relevant keywords. According to PRISMA Statements, full-text, peer-reviewed articles in English which used socio-demographics as independent variables and coping as dependent variables were included.

RESULTS

Of 1101 abstracts and titles, 30 full-text papers were included. Overall results showed a great influence of socio-demographic characteristics (such as women, younger, in a relationship, with high educational level, with active work status, and high income) on positive coping strategies adopted by cancer patients. Regarding clinical characteristics, no-metastatic patients who have recently been diagnosed, especially in the early stage of cancer, and who know the characteristics of their illness and treatments, more frequently used adaptive coping strategies.

CONCLUSIONS

Both socio-demographics and clinical characteristics showed considerable influence on the coping strategies adopted by patients in most of the investigations. These results supported the assessment of basic patients' information (sociodemographic and clinical characteristics) as fundamental to quickly outline an efficient, supportive, and holistic taking-over, before all the essential and in-depth considerations.

TRIAL REGISTRATION

This systematic review was recorded in PROSPERO with the registration number: CRD42021254776.

Development and psychometric properties of a short form of the Illness Denial Questionnaire

BACKGROUND

Coping with chronic illness can be overwhelming for patients and caregivers, and may be inhibited by the denial mechanism, and therefore, denial represents a critical issue for health professionals. Assessing illness denial is far from easy, and brief tools suitable for medical settings are lacking. In this paper, the development of a short form of the Illness Denial Questionnaire (IDQ) for patients and caregivers is presented.

METHODS

In study 1, the IDQ was administered to 118 patients and 83 caregivers to examine the internal structure of denial; then the properties of the items (DIF, fit, and difficulty) were evaluated according to the Rasch model in order to select the best items for the Illness Denial Questionnaire-Short Form (IDQ-SF). Study 2 included 202 participants (113 patients and 89 caregivers). The internal structure of the IDQ-SF was tested via confirmatory factor analysis (CFA). Reliability and concurrent validity were also studied using the Anxiety and Depression Questionnaire-Reduced Form (AD-R).

RESULTS

The CFA showed a two-factor structure encompassing "Denial of negative emotions" and "Resistance to change". Results of the Rasch analyses led to the selection of 4 items for each dimension. The resulting IDQ-SF (8 items) showed a two-factor structure as well as good reliability and concurrent validity with AD-R.

CONCLUSION

The IDQ-SF represents a valid tool for quickly evaluating the core of illness denial in patients and caregivers. This brief and easily administrable questionnaire allows health professionals to outline the presence and severity of illness denial in order to set individually tailored interventions.

Illness denial questionnaire for patients and caregivers

PURPOSE

Interest in assessing denial is still present, despite the criticisms concerning its definition and measurement. We tried to develop a questionnaire (Illness Denial Questionnaire, IDQ) assessing patients' and caregivers' denial in relation to their illness/disturbance.

PATIENTS AND METHODS

After a preliminary study, a final version of 24 dichotomous items (true/false) was selected. We hypothesized a theoretical model with three dimensions: denial of negative emotions, resistance to change, and conscious avoidance, the first two composing the actual Denial and the last representing an independent component of the illness denial behavior. The IDQ was administered to 400 subjects (219 patients and 181 caregivers) together with the Anxiety-Depression Questionnaire - Reduced form (AD-R), in order to assess concurrent validity. Confirmatory factor analysis (CFA), internal consistency indices (Cronbach's α and McDonald's ω), and test-retest analysis were performed.

RESULTS

CFA and internal consistency indices (Cronbach's α: 0.87-0.96) indicated a clear and meaningful three-factor structure of IDQ, for both patients and caregivers. Further analyses showed good concurrent validity, with Denial and its subscale negatively associated with anxiety and depression and avoidance positively associated with anxiety and depression. The IDQ also showed a good stability (r from 0.71 to 0.87).

CONCLUSION

The IDQ demonstrated good psychometric properties. Denial of negative emotions and resistance to change seem to contribute to a real expression of denial, and conscious avoidance seems to constitute a further step in the process of cognitive-affective elaboration of the illness.

The extra burdens patients in denial impose on their family caregivers

Objective:

The purpose of this study was to explore the impact of advanced cancer patients' denial on their family caregivers and how they cope, in order to enable clinicians to better support them and their caregiving.

Method:

As the objective was to obtain clinically useful findings, an interpretive descriptive design was used. Data consisted of prospective semi-structured interviews with 16 family caregivers of advanced cancer patients in denial, field notes, reflexive journals, and memos during the analysis.

Results:

Caregivers experienced extra burdens with the patient's denial. Feeling bound to preserve the denial, which they perceived as immutable, they were prevented from seeking information to manage the patient's care. Additionally, those caring for noncompliant patients felt disenfranchised from their role, resulting in feelings of powerlessness and guilt, and felt burdened by managing medical situations that arose from noncompliance. Caregivers described the ambivalence of feeling frustrated and burdened by the denial while recognizing it as a long-standing coping pattern for the patient. The denial prevented them from acknowledging their own needs to the patients or seeking informal support. They therefore developed solitary coping strategies, sought professional psychosocial support, and/or employed denial themselves.

Significance of results:

Caregivers of patients in denial experience added burdens, which they must bear without most of the usual sources of support. The burden is accentuated when patients are noncompliant with care, placing themselves in dangerous situations. Healthcare providers should identify patients in denial and support their caregivers in meeting both their caregiving and their own needs. Evidence-based strategies to accomplish this should be developed and implemented.

Joint analysis of multiple longitudinal outcomes: application of a latent class model

We address the problem of joint analysis of more than one series of longitudinal measurements. The typical way of approaching this problem is as a joint mixed effects model for the two outcomes. Apart from the large number of parameters needed to specify such a model, perhaps the biggest drawback of this approach is the difficulty in interpreting the results of the model, particularly when the main interest is in the relation between the two longitudinal outcomes. Here we propose an alternative approach to this problem. We use a latent class joint model for the longitudinal outcomes in order to reduce the dimensionality of the problem. We then use a two-stage estimation procedure to estimate the parameters in this model. In the first stage, the latent classes, their probabilities and the mean and covariance structure are estimated based on the longitudinal data of the first outcome. In the second stage, we study the relation between the latent classes and patient characteristics and the other outcome(s). We apply the method to data from 195 consecutive lung cancer patients in two outpatient clinics of lung diseases in The Hague, and we study the relation between denial and longitudinal health measures. Our approach clearly revealed an interesting phenomenon: although no difference between classes could be detected for objective measures of health, patients in classes representing higher levels of denial consistently scored significantly higher in subjective measures of health.