Identification of distinct depressive symptom trajectories in women following surgery for breast cancer

The trajectories of psychosocial adjustment among young to middle-aged women with breast cancer: A prospective longitudinal study

PURPOSE

This study aims to explore heterogeneous trajectories of psychosocial adjustment among young to middle-aged women with breast cancer and determine the predictive factors influencing these trajectories.

METHODS

This study was conducted from October 2019 to October 2022 across two hospitals in Guangzhou. Demographic and disease characteristics, psychosocial adjustment, self-efficacy, social support, and coping modes were collected at baseline. Follow-up evaluations of psychosocial adjustment occurred at 1, 3, and 6 months post-surgery. Latent class growth modeling identified distinct patterns of psychosocial adjustment trajectories. Logistic regression analysis determined the predictive factors.

RESULTS

A total of 377 young to middle-aged women with breast cancer participated in this study, with 289 participants completing the 6-month follow-up. Three distinct trajectories of psychosocial adjustment were identified including a "sustained severe maladjustment" trajectory, comprising 22.5% of participants, a "sustained moderate maladjustment" trajectory, comprising 50.4% of participants, and a "well-adjusted class" trajectory, comprising 27.1% of participants. Predictors of psychosocial adjustment trajectories included affected side, surgical type, chemotherapy, self-efficacy, social support, and coping modes.

CONCLUSIONS

This study revealed three distinct trajectories of psychosocial adjustment among young to middle-aged women with breast cancer. Those with right-sided breast cancer, undergoing total mastectomy, receiving chemotherapy, low self-efficacy, limited social support, and relying on confrontation or avoidance coping modes may experience sustained maladjustment.

Chronic Decrements in Energy in Women with Breast Cancer are Associated with Cytokine Gene Polymorphisms

OBJECTIVES

Decrements in energy were found in 67% of women who underwent breast cancer surgery. However, no information is available on chronic decrements in energy and associations with inflammation. Purposes were to identify latent classes of patients with distinct average energy profiles from prior to through 12 months after breast cancer surgery; evaluate for differences in demographic and clinical characteristics between the two extreme average energy classes; and evaluate for polymorphisms for cytokine genes associated with membership in the Low energy class.

METHODS

Women (n = 397) completed assessments of energy prior to and for 12 months following breast cancer surgery. Growth mixture modeling was used to identify classes of patients with distinct average energy profiles. Eighty-two single nucleotide polymorphisms (SNPs) among 15 cytokine genes were evaluated.

RESULTS

Three distinct energy profiles were identified (ie, Low [27.0%], Moderate [54.4%], Changing [18.6%]). Data from patients in the Low and Moderate energy classes were used in the candidate gene analyses. Five SNPs and one haplotype in six different genes remained significant in logistic regression analyses (ie, interleukin [IL]-1β rs1143623, IL1 receptor 1 rs3917332 IL4 rs2243263, IL6 HapA1 [that consisted of rs1800795, rs2069830, rs2069840, rs1554606, rs2069845, rs2069849, and rs2069861], nuclear factor kappa beta subunit 1 rs170731, tumor necrosis factor rs1799964). For several SNPs for IL6, expression quantitative trait locis were identified in subcutaneous and visceral adipose tissue and thyroid tissue. In addition, skeletal muscle was identified as an expression quantitative trait loci for nuclear factor kappa beta subunit 1.

CONCLUSIONS

Findings suggest that cytokine genes are involved in the mechanisms that underlie chronic decrements in energy in women following breast cancer surgery. Given the roles of subcutaneous and visceral adipose and thyroid tissues in metabolism and energy balance, the findings related to IL6 suggest that these polymorphisms may have a functional role in the development and maintenance of chronic decrements in energy.

Depressive symptom trajectories in older breast cancer survivors: the Thinking and Living with Cancer Study

PURPOSE

To identify trajectories of depressive symptoms in older breast cancer survivors and demographic, psychosocial, physical health, and cancer-related predictors of these trajectories.

METHODS

Recently diagnosed nonmetastatic breast cancer survivors (n = 272), ages 60-98 years, were evaluated for depressive symptoms (Center for Epidemiological Studies Depression Scale, CES-D; scores ≥16 suggestive of clinically significant depressive symptoms). CES-D scores were analyzed in growth-mixture models to determine depression trajectories from baseline (post-surgery, pre-systemic therapy) through 3-year annual follow-up. Multivariable, multinomial logistic regression was used to identify baseline predictors of depression trajectories.

RESULTS

Survivors had three distinct trajectories: stable (84.6%), emerging depressive symptoms (10.3%), and recovery from high depressive symptoms at baseline that improved slowly over time (5.1%). Compared to stable survivors, those in the emerging (OR = 1.16; 95% CI = 1.08-1.23) or recovery (OR = 1.26; 95% CI = 1.15-1.38) groups reported greater baseline anxiety. Greater baseline deficit accumulation (frailty composite measure) was associated with emerging depressive symptoms (OR = 3.71; 95% CI = 1.90-7.26). Less social support at baseline (OR = 0.38; 95% CI = 0.15-0.99), but greater improvement in emotional (F = 4.13; p = 0.0006) and tangible (F = 2.86; p = 0.01) social support over time, was associated with recovery from depressive symptoms.

CONCLUSIONS

Fifteen percent of older breast cancer survivors experienced emerging or recovery depressive symptom trajectories. Baseline anxiety, deficit accumulation, and lower social support were associated with worse outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

Our results emphasize the importance of depression screening throughout the course of cancer care to facilitate early intervention. Factors associated with depressive symptoms, including lower levels of social support proximal to diagnosis, could serve as intervention levers.

Well-being trajectories in breast cancer and their predictors: A machine-learning approach

OBJECTIVE

This study aimed to describe distinct trajectories of anxiety/depression symptoms and overall health status/quality of life over a period of 18 months following a breast cancer diagnosis, and identify the medical, socio-demographic, lifestyle, and psychological factors that predict these trajectories.

METHODS

474 females (mean age = 55.79 years) were enrolled in the first weeks after surgery or biopsy. Data from seven assessment points over 18 months, at 3-month intervals, were used. The two outcomes were assessed at all points. Potential predictors were assessed at baseline and the first follow-up. Machine-Learning techniques were used to detect latent patterns of change and identify the most important predictors.

RESULTS

Five trajectories were identified for each outcome: stably high, high with fluctuations, recovery, deteriorating/delayed response, and stably poor well-being (chronic distress). Psychological factors (i.e., negative affect, coping, sense of control, social support), age, and a few medical variables (e.g., symptoms, immune-related inflammation) predicted patients' participation in the delayed response and the chronic distress trajectories versus all other trajectories.

CONCLUSIONS

There is a strong possibility that resilience does not always reflect a stable response pattern, as there might be some interim fluctuations. The use of machine-learning techniques provides a unique opportunity for the identification of illness trajectories and a shortlist of major bio/behavioral predictors. This will facilitate the development of early interventions to prevent a significant deterioration in patient well-being.

Distinct Cognitive Function Profiles Are Associated With a Higher Presurgery Symptom Burden in Patients With Breast Cancer

BACKGROUND

Cancer-related cognitive impairment (CRCI) is a common symptom in patients with breast cancer. In our previous study of 397 women with breast cancer, we identified 3 groups of patients with distinct CRCI profiles (ie, high, moderate, and low-moderate attentional function). Compared with the other 2 classes, the low-moderate class was younger, had more comorbidities, and with lower functional status.

OBJECTIVES

In this study, we expand on this work and evaluate for differences among these latent classes in the severity of psychological (depression and anxiety) and physical (fatigue, decrements in energy, sleep disturbance, and pain) symptoms before surgery.

METHODS

Cancer-related cognitive impairment was assessed using the Attentional Functional Index from before through 6 months after surgery. Lower Attentional Functional Index scores indicate higher levels of CRCI. Psychological and physical symptoms were assessed with valid instruments. Parametric and nonparametric tests were used to evaluate for differences in symptom severity scores among the latent classes.

RESULTS

Approximately 60% of patients experienced CRCI (ie, moderate and low-moderate classes). Significant differences were found among the 3 classes in the severity of trait and state anxiety, depressive symptoms, fatigue, and sleep disturbance (ie, high < moderate < low-moderate). In addition, compared with the other 2 classes, the low-moderate class reported higher pain interference scores.

CONCLUSIONS

These findings suggest that women with clinically meaningful levels of persistent CRCI have a relatively high symptom burden before surgery.

IMPLICATIONS FOR PRACTICE

Clinicians need to routinely perform preoperative assessments of CRCI and associated symptoms and initiate therapeutic interventions.

Denis-Katz H, Webb C, Temple-Oberle C. Breast Reconstruction Perceptions and Access in First Nations Women are Influenced by Colonization

Purpose: This qualitative study explored First Nations (FN) women's perceptions about breast reconstruction (BR) after breast cancer surgery. Method: Participants were recruited through purposive and snowball sampling via Aboriginal health and community organizations, breast and plastic surgeons, an Aboriginal health liaison and an FN elder. Semistructured one-on-one interviews and an FN sharing circle were conducted, transcribed, and analyzed using thematic content analysis. Results: Nine women participated in the interviews. Three (33%) had been offered and had pursued BR, while 6 (67%) were either not offered or had not pursued breast reconstruction. Two of these 6 stated that they were not interested in BR. Four women participated in the sharing circle; 2 had been interviewed prior and 2 were new participants who shared similar themes and experiences to other participants also interviewed. Four key themes were identified: identity, information gaps, financial and transportation barriers, and consequences of colonization. Reasons cited to pursue BR were consistent with non-FN women such as improving self-image, concepts of femininity, and sense of normalcy. All participants reported that accessible, appropriate, and timely and culturally sensitive BR information was lacking. Living on reserve and the attendant expenses related to attending medical appointments was another barrier experienced by women in our study. The devastating impacts of colonization also deeply impacted several women in our study. Conclusion: When offered, FN women were receptive to pursuing BR. FN women have a particular set of obstacles related to consequences of colonization. Culturally sensitive and relevant oral communications grounded in first-hand experiences are desired. The 4 themes identified did influence the rate of BR uptake in the FN women who participated in our study and provided significant and unique obstacles to FN women.

Trajectories of neuropsychological symptom burden in postmenopausal women prescribed anastrozole for early-stage breast cancer

PURPOSE

Aromatase inhibitors (AIs) prolong survival for postmenopausal women with hormone receptor-positive breast cancer (HR + BC) but also burden patients with symptoms, a major reason for suboptimal AI adherence. This study characterizes inter-relationships among symptom measures; describes neuropsychological symptom burden trajectories; and identifies trajectory group membership predictors for postmenopausal women prescribed anastrozole for HR + BC.

METHODS

This study utilized prospectively collected data from a cohort study. Relationships among various self-reported symptom measures were examined followed by a factor analysis to reduce data redundancy before trajectory analysis. Four neuropsychological scales/subscales were rescaled (range 0-100) and averaged into a neuropsychological symptom burden (NSB) score, where higher scores indicated greater symptom burden. Group-based trajectory modeling characterized NSB trajectories. Trajectory group membership predictors were identified using multinomial logistic regression.

RESULTS

Women (N = 360) averaged 61 years old, were mostly White, and diagnosed with stage I HR + BC. Several measures were correlated temporally but four neuropsychological measures had strong correlations and dimensional loadings. These four measures, combined for the composite NSB, averaged (mean ± standard deviation) 17.4 ± 12.9, 18.0 ± 12.7, 19.5 ± 12.8, and 19.8 ± 13.0 at pre-anastrozole, 6, 12, and 18 months post-initiation, respectively. However, the analysis revealed five NSB trajectories-low-stable, low-increasing, moderate-stable, high-stable, and high-increasing. Younger age and baseline medication categories (pre-anastrozole), including anti-depressants, analgesics, anti-anxiety, and no calcium/vitamin D, predicted the higher NSB trajectories.

CONCLUSION

This study found relationships among neuropsychological symptom measures and distinct trajectories of self-reported NSB with pre-anastrozole predictors. Identifying symptom trajectories and their predictors at pre-anastrozole may inform supportive care strategies via symptom management interventions to optimize adherence for women with HR + BC.

Stressful life events and trajectories of depression symptoms in a U.S. military cohort

Depression is a common mental disorder that may comprise distinct, underlying symptom patterns over time. Associations between stressful life events throughout the civilian lifecourse-including during childhood-and adult depression have been documented in many populations, but are less commonly assessed in military samples. We identified different trajectories of depression symptoms across four years in a military cohort using latent class growth analysis, and investigated the relationship between these trajectories and two domains of civilian life experiences: childhood adversity (e.g., being mistreated during childhood) and more proximal stressful experiences (e.g., divorce). A four-group depression model was identified, including a symptom-free group (62%), an increasing symptom group (13%), a decreasing symptom group (16%), and a "chronic" symptom group (9%). Compared to the symptom-free group, soldiers with childhood adversity were more likely to be in the chronic depression, decreasing, and increasing symptom groups. Time-varying adult stressors had the largest effect on depression symptoms for the increasing symptom group compared to other groups, particularly in the last two years of follow-up. This study indicates the importance of considering events from throughout the lifecourse-not only those from deployment-when studying the mental health of servicemembers.

Characterization of Depressive Symptoms Trajectories After Breast Cancer Diagnosis in Women in France

Importance

Breast cancer (BC) diagnosis and treatment expose patients to a 5-fold higher risk of depression compared with the general population, with an estimated prevalence of 10% to 25%. A depressive episode in patients with BC has implications for the tolerance of and adherence to treatment, impairing quality of life and reducing life expectancy.

Objective

To identify and characterize distinct longitudinal patterns of depressive symptoms in patients with BC from diagnosis to 3 years after treatment.

Design, Settings, and Participants

The CANTO-DEePRESS (Deeper in the Understanding and Prevention of Depression in Breast Cancer Patients) cohort study included women in the French multicenter CANTO (CANcer TOxicities) cohort study (conducted between March 20, 2012 and December 11, 2018), who were 18 years or older with invasive stage I to III BC and no previous BC treatment. The study aimed to characterize toxicities over a 5-year period following stage I to III primary BC treatment. Assessments of depressive symptoms were performed on a subset of patients with available data at diagnosis and at least 2 other time points. All data were extracted from the CANTO database on October 1, 2020.

Main Outcomes and Measures

The primary outcome was the level of depressive symptoms at each assessment time point measured with the Hospital Anxiety and Depression Scale and depression subscale at BC diagnosis and at 3 to 6, 12, and 36 months after the end of treatment. The group-based trajectory modeling was used to identify trajectory groups, and multinomial logistic regression models were used to characterize the following factors associated with trajectory group affiliation: demographic, socioeconomic, clinical, lifestyle, and quality-of-life data.

Results

A total of 4803 women (mean [SD] age, 56.2 [11.2] years; 2441 patients [50.8%] with stage I BC) were included in the study. Six trajectory groups that described the heterogeneity in the expression of depressive symptoms were identified: noncases with no expression of symptoms (n = 2634 [54.8%]), intermediate worsening (1076 [22.4%]), intermediate improvement (480 [10.0%]), remission (261 [5.4%]), delayed occurrence (200 [4.2%]), and stable depression (152 [3.2%]). HADS-D scores at diagnosis were consistently associated with the 5 depressive trajectory group affiliations, with an estimated higher probability per point increase of experiencing subthreshold or clinically significant depressive symptoms between diagnosis and the 3 years after the end of BC treatment. The higher probabilities ranged from 1.49 (95% CI, 1.43-1.54) for the intermediate worsening group to 10.53 (95% CI, 8.84-12.55) for the stable depression group. Trajectory groups with depressive symptoms differed from the noncases group without symptoms by demographic and clinical factors, such as having dependent children, lower household income, cancer stage, family history of BC, previous psychiatric hospitalizations, obesity, smoking status, higher levels of fatigue, and depression at diagnosis.

Conclusions and Relevance

In this cohort study, nearly a third of patients with BC experienced temporary or lasting significant depressive symptoms during and after treatment. Improving early identification of women at risk of developing long-term or delayed depression is therefore critical to increase quality of life and overall survival. Subjected to validation, this study is an important first step toward personalized care of patients with BC at risk of depression.

Trajectories of Anxiety and Depression Symptoms over Five Years since Breast Cancer Diagnosis: Results of the NEON-BC Prospective Study

Anxiety and depression symptoms are frequent among patients with breast cancer (BCa) and may last after initial treatments. We aimed to identify five-year trajectories of anxiety and depression symptoms among women with BCa. Neuro-oncological complications of BCa (NEON-BC) cohort included 506 patients admitted at the Portuguese Institute of Oncology of Porto in 2012, who were evaluated with the Hospital Anxiety and Depression Scale before cancer treatment and after one, three, and five years (7.9% attrition rate). Mixed-effect models were used to model anxiety and depression scores over time and model-based clustering to identify the different trajectories. Three trajectories of anxiety symptoms were identified: (1) high scores at baseline and increasing over time (21.7%); (2) consistently low scores over time (63.6%); (3) mid-range scores at baseline, decreasing over time (14.6%). Three trajectories were identified for depression symptoms: (1) high scores at baseline and increasing over time (21.1%); (2) mid-range scores at baseline, which decreased afterward (58.7%); (3) consistently low levels over time (20.2%). Age, education, baseline, and one-year anxiety/depression status predicted the worst five-year trajectories. These results show that assessing anxiety and depression symptoms before treatment and after one year may contribute to identifying the patients who could benefit the most from psychological support.

Symptom trajectories in patients with breast cancer: An integrative review

Objective

This study aimed to synthesize the available knowledge of symptom trajectories in patients with breast cancer and identify predictors associated with these trajectories.

Methods

Whittemore and Knafl’s integrative review method was employed to guide a systematic search for literature in four databases (PubMed, Embase, Web of Science, and CINAHL). The retrieved articles’ publication time was limited to 2010 to 2020, and only peer-reviewed English articles were included.

Results

Twenty-seven articles were included. The findings of the relevant studies were analyzed using thematic analysis. They were grouped into two themes: symptom trajectories of patients with breast cancer (symptom trajectories in patients with breast cancer, in patients who underwent surgery, and in patients who received cancer-related treatment) and associated factors (socioeconomic factors, health characteristics, cancer-related treatment characteristics). Newly diagnosed patients tended to report high trajectories of depression and persistent sleep disturbance. Most patients who underwent surgery reported significant sleep disturbance and anxiety shortly after surgery. For patients who received cancer-related treatment, only a small proportion had a high level of physical activity after cancer-related therapy over time. A high body mass index, a low relationship quality, parental responsibilities, insufficient social support, a low educational background, and an unhealthy lifestyle may increase the risk of negative symptom trajectories in patients with breast cancer. Additionally, old patients were more likely to report cognitive impairment after chemotherapy, while young patients tended to report trajectories of persistent sexual dysfunction. Concurring symptoms and poor health status also contributed to adverse symptom trajectories.

Conclusion

The findings of this review add to the body of knowledge of the interindividual variability of symptom trajectories in patients with breast cancer. Despite the overall similarity in appraisal at baseline, the patients reported varied symptom trajectories over time. It is recommended that nurses consider sociodemographic, clinical and cancer-related treatment characteristics and perform targeted early preventive interventions for patients with breast cancer.

Symptom trajectories in breast cancer survivors: growth mixture analysis of patient-reported pain, fatigue, insomnia, breast and arm symptoms

BACKGROUND

Variations in symptom development among breast cancer (BC) survivors are understudied. We examined: (Q1) Symptom trajectories of pain, fatigue, insomnia, breast, and arm symptoms in BC survivors, (Q2) possible patterns or cluster-like associations between trajectory classification of different symptoms, and (Q3) characteristics of survivors assigned to high-burden symptom trajectories.

MATERIAL AND METHODS

Participants were 968 women (mean age = 59.6 years) treated for early-stage BC and followed across a three-year postoperative period. As part of routine follow-up procedures, patients reported symptom burden and functioning levels at each hospital visit using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and the BC-specific module (QLQ-BR-23). Growth mixture modeling (GMM) analysis was used to differentiate potential subgroups of individuals with similar longitudinal symptom patterns, i.e., symptom trajectories (Q1). With this approach, groups experiencing persistent, highly distressing cancer- and treatment-related late effects (LEs) may be identified. Latent class analysis (LCA) was used for Q2 and logistic regression analysis for Q3.

RESULTS

GMM identified two relatively parallel trajectories across the tested symptoms: The majority of the sample exhibited a low-burden symptom trajectory (74.4-89.2%) and a minority by a high-burden symptom trajectory (10.8-25.6%). LCA revealed that approximately one in five women (18.8%) were likely to be members of the high-burden symptom trajectory across all tested symptoms. In addition to a high probability of being burdened over time across multiple symptoms, these women were also characterized by poorer self-reported physical and social functioning.

CONCLUSION

A substantial minority followed a high-burden symptom trajectory for several years following BC treatment. Associations were found in trajectory classification across symptoms, indicating that cancer-related LEs appear in clusters of multiple concurrent symptoms.

The trajectories of depression symptoms and comorbidity in knee osteoarthritis subjects

BACKGROUND

Previous cross-sectional studies have demonstrated the high prevalence of depression and comorbidity in knee osteoarthritis (KOA), and KOA or its impact on lifestyle was seen as a potential trigger factor of depression and comorbidity. However, the exact onset and progression pattern of depression and comorbidity in KOA was still unknown.

METHODS

Group-based trajectory modeling (GBTM) analysis was conducted in the 2833 subjects selected from the osteoarthritis initiative (OAI) database. Eight-year trajectories were determined and described. Baseline characteristics were investigated in multi-variable regression to detect the risk factors of the unfavored trajectory.

RESULTS

Stable trajectory (70.4%) and worsening trajectory (29.6%) were identified in comorbidity. The risk factors for the worsening trajectory membership were the obesity (OR = 1.47 CI = [1.20, 1.79], P < 0.001), older age (OR = 1.74, CI = [1.41, 2.16], P < 0.001), and smoke (OR = 1.30, CI = [1.08, 1.57], P < 0.01) at baseline. Stable trajectory (52.0%), slow-worsening trajectory (40.5%), and fast-worsening trajectory (7.5%) were identified in depression symptoms. The risk factors for the fast-worsening trajectory membership were female (OR = 1.51 CI = [1.03, 2.20], P < 0.05), lower income (OR = 1.52, CI = [1.01, 2.27], P < 0.05), and smoke (OR = 1.30, CI = [1.08, 1.57], P < 0.01) at baseline.

CONCLUSION

A significant amount of KOA subjects tends to develop depression symptoms and comorbidity. Managing related risk factors, like weight loss or smoking cessation, might have considerable significance in preventing or delaying depression symptoms and comorbidity in KOA. Key Points • The first study investigating the trajectory of comorbidity progression in KOA. • Approximately 7.5% of KOA patients tend to develop depression symptoms quite rapidly, and 30% of KOA patients tend to develop comorbidity • Risk factors of worsening trajectories were identified: obesity, older age, smoking, female, and lower income.

Tumor-to-Gland Volume Ratio versus Tumor-to-Breast Ratio as Measured on CBBCT: Possible Predictors of Breast-Conserving Surgery

Background

Breast-conserving surgery plus postoperative radiotherapy is the standard surgical treatment mode for early breast cancer. Currently, there are no clear predictive indicators to determine whether a patient can choose breast-conserving surgery, which mainly depends on the surgeon’s clinical experience and subjective judgment. Cone-beam breast computed tomography (CBBCT) reconstructs the breast 3D image from three mutually perpendicular angles, helping surgeons to locate and accurately measure the volume of the tumor, mammary gland, and breast. We used CBBCT to retrospectively measure the tumor-to-gland volume ratio and tumor-to-breast volume ratio in breast cancer cases. Then, we analyzed the correlation between the surgical methods and ratios in breast cancer patients.

Methods

We collected 100 patients undergoing breast-conserving surgery as the study group, and 100 patients undergoing mastectomy as the control group. All patients chose the surgical approach after comprehensive consideration of examination results and assessment of patient condition. Patients underwent CBBCT examination before surgery. We retrospectively measured the volume of tumor, mammary glands and breast, then calculated tumor-to-gland and tumor-to-breast volume ratios.

Results

Tumor volume and the ratios of the two groups statistically differed (P < 0.001), while the mammary gland and breast volume did not (P > 0.05). The average tumor-to-gland volume ratio was 4.32% in the study group and 10.74% in the control group, and the average tumor-to-breast volume ratio was 0.74% in the study group and 1.36% in the control group. In breast-conserving surgery, the 95% reference range of tumor-to-gland ratio is (0, 12.90%), and the 95% reference range of tumor-to-breast ratio is (0, 2.17%).

Conclusion

The tumor-to-gland volume ratio and tumor-to-breast volume ratio measured using CBBCT are correlated with the choice of surgical methods (breast-conserving surgery or mastectomy) for breast cancer patients. This can be used as possible predictor of breast-conserving surgery to help surgeons.

Psychological Symptoms and Stress Are Associated With Decrements in Attentional Function in Cancer Patients Undergoing Chemotherapy

BACKGROUND

Decrements in attentional function-perceived effectiveness in everyday functioning related to cognitive dysfunction-are frequently reported by cancer patients during treatment. However, patients vary widely in their experiences of changes in attentional function.

OBJECTIVE

The aim of this study was to understand differences in attentional function among cancer patients during chemotherapy.

METHODS

Patients (n = 1329) undergoing chemotherapy were assessed at 6 time points during 2 rounds of chemotherapy. Latent profile analysis was used to identify subgroups of patients based on patterns in changes on the Attentional Function Index. Differences among the subgroups in demographic and clinical characteristics, psychological symptoms, and stress were evaluated.

RESULTS

Three latent classes (ie, high, moderate, and low attentional function) were identified. Patients in the low and moderate classes were younger, more likely to be female, and less likely to be employed compared with those in the high class. Patients in the low class had higher levels of depressive and anxiety symptoms, cancer-related distress, and perceived stress compared with those in the moderate class, who, in turn, reported higher levels of these symptoms compared with those in the high class.

CONCLUSIONS

Different experiences of changes in self-perceived attentional function are associated with psychological symptoms in cancer patients.

IMPLICATIONS FOR PRACTICE

Relationships between changes in attentional function and psychological symptoms and stress suggest that clinicians should attend to the potential that patients' cognitive and psychological experiences may be closely linked and may need to be addressed as related phenomena. Clinical trials are needed that evaluate treatments for both attentional and psychological symptoms.

Social support and psychosocial functioning in women after mastectomy

OBJECTIVE

Social support has been reported as beneficial for the psychological functioning of people coping with a disease. The objective of this study was to verify whether levels of perceived social support are associated with psychosocial functioning in women who have had a mastectomy and whether specific types of social support are linked to specific indices of functioning.

METHOD

Seventy women with a history of mastectomy completed questionnaires measuring their psychosocial functioning as related to their health status: Disease-Related Appraisal Scale, Acceptance of Life with the Disease Scale and Beck Depression Inventory. All participants also completed a measure of perceived social support (Disease-Related Social Support Scale).

RESULTS

Women who reported higher levels of perceived social support revealed statistically significantly lower levels of depressive symptoms, higher appraisals of their disease in terms of challenge and value, and lower appraisals of their disease in terms of obstacle/loss. Women with greater social support also revealed higher levels of acceptance of life with the disease compared to those with less social support. Regression analyses showed that spiritual support was the type of support that significantly accounted for the variance in the majority of functioning indices. Some indices of functioning were also significantly accounted for by emotional and instrumental support.

SIGNIFICANCE OF THE RESULTS

The process of psychological adjustment to a life-threatening disease such as breast cancer depends on multiple variables; however, social support, including spiritual support, seems to be one significant contributor to this process.

The Double-Edged Sword of Reflective Pondering: The Role of State and Trait Reflective Pondering in Predicting Depressive Symptoms Among Women With Breast Cancer

BACKGROUND AND PURPOSE

Prior research has debated whether reflective pondering is a more constructive form of rumination than brooding, which is generally considered maladaptive. This study sought to investigate whether reflective pondering predicts depressive symptoms and whether reflective pondering is adaptive under certain conditions. We predicted that the effectiveness of reflective pondering could depend on concurrent coping strategies and the trait-state distinction.

METHOD

Women with breast cancer (N = 309; M age = 47.5) were assessed at four waves over 2 years. A time-lagged design was applied, with rumination (i.e., brooding and reflective pondering) and coping (i.e., engagement and disengagement) measured from T1 to T3, predicting depressive symptoms assessed from T2 to T4. These variables were measured by the Ruminative Response Scale, the Brief COPE, and the Hospital Anxiety and Depression Scale.

RESULTS

Using hierarchical linear modeling, brooding, but not reflective pondering, predicted elevated depressive symptoms at both between- and within-person levels. The relationship between reflective pondering and depression was moderated by the coping strategies. Individual differences in reflective pondering predicted worse depressive symptoms, but higher use of engagement coping mitigated the detrimental effect. Within individuals, the co-occurrence of reflective pondering and disengagement coping predicted a subsequent decrease in depressive symptoms.

CONCLUSIONS

The emerging role of reflective pondering in the face of breast cancer-related stress appears to be a double-edged sword. Its impact on depression may depend on concurrent coping strategies and whether reflective pondering is assessed at state and trait levels.

Longitudinal Symptom Burden Trajectories in a Population-Based Cohort of Women with Metastatic Breast Cancer: A Group-Based Trajectory Modeling Analysis

Understanding the symptom burden trajectory for metastatic breast cancer patients can enable the provision of appropriate supportive care for symptom management. The aim of this study was to describe the longitudinal trajectories of symptom burden for metastatic breast cancer patients at the population-level. A cohort of 995 metastatic breast cancer patients with 16,146 Edmonton Symptom Assessment System (ESAS) assessments was constructed using linked population-level health administrative databases. The patient-reported ESAS total symptom distress score (TSDS) was studied over time using group-based trajectory modeling, and covariate influences on trajectory patterns were examined. Cohort patients experienced symptom burden that could be divided into six distinct trajectories. Patients experiencing a higher baseline TSDS were likely to be classified into trajectory groups with high, uncontrolled TSDS within the study follow-up period (χ2 (1, N = 995) = 136.25, p < 0.001). Compared to patients classified in the group trajectory with the highest relative TSDS (Group 6), patients classified in the lowest relative TSDS trajectory group (Group 1) were more likely to not have comorbidities (97.34% (for Groups 1-3) vs. 91.82% (for Group 6); p < 0.05), more likely to receive chemotherapy (86.52% vs. 80.50%; p < 0.05), and less likely to receive palliative care (52.81% vs. 79.25%; p < 0.0001). Receiving radiotherapy was a significant predictor of how symptom burden was experienced in all identified groups. Overall, metastatic breast cancer patients follow heterogeneous symptom burden trajectories over time, with some experiencing a higher, uncontrolled symptom burden. Understanding trajectories can assist in establishing risk-stratified care pathways for patients.

Impact of Time to Initiation of Treatment on the Quality of Life of Women with Breast Cancer

Introduction: Breast cancer is the most common malignancy in women. Due to the large number of women living with breast cancer and the increasing incidence of this cancer, it is very important to understand the factors determining the quality of life (QOL) of patients. The aim of the study. The aim of the study was to determine the impact of time to initiation of treatment on the quality of life of women with breast cancer. Materials and methods. The study involved 324 women with breast cancer, treated at the Podkarpackie Oncology Centre in Brzozów, Poland. The study was conducted using a diagnostic survey, using a standardised questionnaire to measure the quality of life of women treated for breast cancer, i.e., the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC) QLQ-C30 and the QLQ-BR23 module, as well as a proprietary survey questionnaire. Statistical analysis was performed using the Statistica 10.0 software (StatSoft Inc., 2011). A p value of <0.05 was considered statistically significant. Results: The examined women had a reduced overall quality of life and health (M = 53.88). The quality of life was higher in women who consulted a doctor the earliest after noticing initial symptoms of the disease, i.e., up to one week (M = 57.58), compared to patients who delayed the decision (over four weeks; M = 47.8) (p = 0.002). The quality of life was also considered higher by women who received treatment within two weeks of diagnosis (M = 56.79) and was lower for patients who waited for treatment for more than two months (M = 43.68). Statistically significant relationships were demonstrated for functional scales and disease intensity. Conclusions: Women diagnosed with breast cancer had a considerably lower overall quality of life. A relatively higher quality of life was experienced by patients who consulted a doctor the earliest after discovering symptoms of the disease and those whose waiting time for treatment was shorter. In a systematic manner, the individual stages of diagnosis should be maximally reduced and breast cancer treatment initiated without delay.

Understanding the Public's Emotions about Cancer: Analysis of Social Media Data

Cancer survivors suffer from emotional distress, which varies depending on several factors. However, existing emotion management programs are insufficient and do not take into consideration all of the factors. Social media provides a platform for understanding the emotions of the public. The aim of this study was to explore the relationship between the public's emotions about cancer and factors affecting emotions using social media data. We used 321,339 posts on cancer and emotions relating to cancer extracted from 22 social media channels between 1 January 2014, and 30 June 2017. The factors affecting emotions were analyzed using association rule mining and social network analysis. Hope/gratitude was the most frequently mentioned emotion group on social media followed by fear/anxiety/overwhelmed, sadness/depression/loneliness/guilt, and anger/denial. Acute survival stage, treatment method, and breast cancer were associated with hope/gratitude. Early stage, gastrointestinal problems, fatigue/pain/fever, and pancreatic cancer were associated with fear/anxiety/overwhelmed. Surgery, hair loss/skin problems, and fatigue/pain/fever were associated with sadness/depression/loneliness/guilt. Acute survival stage and hair loss/skin problems were associated with anger/denial. We found that emotions concerning cancer differed depending on the cancer type, cancer stage, survival stage, treatment, and symptoms. These findings could guide the development of tailored emotional management programs for cancer survivors that meet the public's needs more effectively.

Breast reconstruction after therapeutic or prophylactic mastectomy for breast cancer: A comparison of guideline recommendations

BACKGROUND

The purpose of this article is to illuminate differences in published clinical practice guideline recommendations for breast reconstruction after prophylactic and therapeutic mastectomy.

METHODS

Ten guidelines were identified through a systematic search of websites and databases of reputable oncology guideline developers, and key differences and gaps in recommendations were noted. Quality assessment of the guidelines was conducted by three reviewers using the AGREE II tool, focusing on breast reconstruction specific documents rather than the general breast cancer guidelines.

RESULTS

The most comprehensive guidelines were published by Alberta Health Services, Cancer Care Ontario, the American Society of Plastic Surgeons, and the Association of Breast Surgery/British Association of Plastic Reconstructive and Aesthetic Surgeons. AGREE II scores in the domains of "Scope and Purpose" and "Clarity and Presentation" were ranked relatively high for all four guidelines while "Applicability" and "Editorial Independence" were ranked relatively low. The Alberta and Ontario guidelines were the overall highest ranked guidelines across all domains.

CONCLUSION

Overall, these guidelines provide consistent recommendations on who should receive breast reconstruction education, who is a candidate for postmastectomy breast reconstruction, and the appropriate timing of reconstruction and extent of mastectomy. Future updates from all should focus on expanding to include alloplastic and autologous forms of reconstruction and should include a broad scope of relevant questions.

Psychological Response to a False Positive Ovarian Cancer Screening Test Result: Distinct Distress Trajectories and Their Associated Characteristics

Routine screening for ovarian cancer (OC) can yield an abnormal result later deemed benign. Such false positive (FP) results have been shown to trigger distress, which generally resolves over time. However, women might differ in the trajectory of the distress experience. Women participating in a routine OC screening program (n = 373) who received an abnormal screening result completed a baseline assessment prior to a follow-up screening test to clarify the nature of their abnormal result. All women were subsequently informed that no malignancy was present, and follow-up assessments were completed one and four months post-baseline. Demographic, clinical, dispositional (optimism, monitoring), and social environmental (social constraint, social support) variables were assessed at baseline. OC-specific distress was assessed at all three assessments. Trajectory analyses identified three distress trajectories differing in the baseline level of distress. A high decreasing trajectory, representing about 25% of women, was characterized by high levels of distress at baseline with distress declining over time, but still elevated at four-month follow-up. In contrast, a no distress trajectory group, representing about 30% of women, was characterized by essentially no distress at any time point. Principal risk factors for membership in the high decreasing trajectory group included a family history of OC, lower dispositional optimism, and greater social constraint. These risk factors could be used to target resources efficiently towards managing women at risk for potentially clinically-significant distress after receipt of an FP OC screening test.

Identifying subgroups of renal function trajectories

Background

Renal function in patients with chronic kidney disease (CKD) may follow different trajectory profiles. The aim of this study was to evaluate and illustrate the ability of the latent class linear mixed model (LCMM) to identify clinically relevant subgroups of renal function trajectories within a multicenter hospital-based cohort of CKD patients.

Methods

We analysed data from the NephroTest cohort including 1967 patients with all-stage CKD at baseline who had glomerular filtration rate (GFR) both measured by 51 Cr-EDTA renal clearance (mGFR) and estimated by the CKD-EPI equation (eGFR); 1103 patients had at least two measurements. The LCMM was used to identify subgroups of GFR trajectories, and patients' characteristics at baseline were compared between the subgroups identified.

Results

Five classes of mGFR trajectories were identified. Three had a slow linear decline of mGFR over time at different levels. In the two others, patients had a high level of mGFR at baseline with either a strong nonlinear decline over time ( n  = 11) or a nonlinear improvement ( n  = 94) of mGFR. Higher levels of proteinuria and blood pressure at baseline were observed in classes with either severely decreased mGFR or strong mGFR decline over time. Using eGFR provided similar findings.

Conclusion

The LCMM allowed us to identify in our cohort five clinically relevant subgroups of renal function trajectories. It could be used in other CKD cohorts to better characterize their different profiles of disease progression, as well as to investigate specific risk factors associated with each profile.

Predicting trajectories of recovery in prostate cancer patients undergone Robot-Assisted Radical Prostatectomy (RARP)

OBJECTIVE

To identify trends of patients' urinary and sexual dysfunctions from a clinical and psychological perspective and understand whether sociodemographic and medical predictors could differentiate among patients following different one-year longitudinal trajectories.

METHODS

An Italian sample of 478 prostate cancer patients undergone Robot-Assisted Radical Prostatectomy completed the EPIC-26 survey between July 2015 and July 2016 at the pre-hospitalization (T0), 45 days (T1) and 3 (T2), 6 (T3), 9 (T4), and 12 months (T5) after surgery. Sociodemographic and clinical characteristics (age, BMI, diabetes, nerve-sparing procedure) were also collected. Latent Class Growth Analysis was conducted separately for sexual dysfunction and urinary incontinence EPIC-26 subscales. The association between membership in the two longitudinal trajectories of urinary and sexual dysfunctions was assessed by considering Chi-square test and its related contingency table.

RESULTS

People who have a high level of urinary incontinence at T1 are likely to have a worse recovery. Age, BMI and pre-surgical continence may affect the level of incontinence at T1 and the recovery trajectories. Patients with low and moderate sexual problems at T1 can face a moderate linear recovery, while people with high level of impotence immediately after surgery may take a longer period to solve sexual dysfunctions. Age and the pre-surgical sexual condition may impact the recovery. Finally, a great proportion of patients reported both steady problems in sexual function and constant high levels of urinary incontinence over time.

CONCLUSIONS

This study highlights different categories of patients at risk who may be important to know in order to develop personalized medical pathways and predictive models in a value-based healthcare.

Symptom Trajectories Are Associated With Co-occurring Symptoms During Chemotherapy for Breast Cancer

CONTEXT

Symptoms are reported to co-occur during treatment for breast cancer. We previously identified three patterns of fatigue and two patterns of disturbed sleep, depressed mood, and anxiety in women undergoing chemotherapy for breast cancer using a Latent Growth Mixture Model.

OBJECTIVES

The purpose of this study was to explore whether membership in symptom classes of fatigue, disturbed sleep, depressed mood, and anxiety is associated with other symptoms at moderate-to-severe levels.

METHODS

Using data from three longitudinal studies, Wilcoxon rank-sum tests and Jonckheere-Terpstra tests for trend were used to distinguish between classes of women on co-occurring symptoms. Summative scores were calculated, including the number of days subjects reported moderate-to-severe levels (4 or higher on a 0-10 scale) of seven symptoms during two cycles of chemotherapy and compared to class membership.

RESULTS

Participants (n = 166) in the higher fatigue severity class reported more days with moderate-to-severe disturbed sleep, depressed mood, anxiety, nausea, and trouble thinking. Women in the higher severity disturbed sleep class reported more days with moderate-to-severe fatigue, depressed mood, anxiety, and trouble thinking. Women in the higher depressed mood severity class reported more days with moderate-to-severe fatigue, disturbed sleep, anxiety, and nausea. Women in the higher anxiety severity class reported more days with moderate-to-severe fatigue, disturbed sleep, and depressed mood.

CONCLUSION

Moderate-to-severe symptoms co-occur during cancer treatment for breast cancer. The dynamic process of multiple symptoms may be altered by future identification of a shared etiology.

A Systematic Review of Utility Score Assessments in the Breast Surgery Cost-Analysis Literature

BACKGROUND

Surgery for breast cancer can have significant impact on patient quality-of-life. Cost-utility analysis provides a way to analyze the economic impact of a surgical procedure with the change in a patient's quality of life. Utility scores are used in these analyses to quantify the impact on quality of life. We undertook a systematic review of the literature on breast cancer surgical procedures to compile a repository of utility scores and to assess gaps in the current literature.

METHODS

Following PRISMA guidelines, a systematic review was performed for studies reporting utility scores for breast surgery and breast reconstruction. The health states and utility scores were extracted and grouped into seven procedural categories based on oncologic and reconstructive methods. Mean utility score and ranges were calculated and reported for each procedural category.

RESULTS

Nineteen articles met the inclusion criteria assessing 118 health states. Most utility scores were obtained from healthcare professionals. Breast-conserving therapy yielded the highest mean utility score at 0.79, whereas mastectomy yielded a mean utility score of 0.75. Among reconstruction health states, implant reconstruction had a lower score than autologous reconstruction (0.64 implant vs. latissimus dorsi 0.69 and TRAM/DIEP 0.71). No utility scores were found associated with oncoplasty or nipple-sparing mastectomy procedures.

CONCLUSIONS

A reliable body of utility scores is important in enabling future cost-utility and value-based analysis comparisons for breast surgical oncology. Additional work is needed to obtain health state assessments from the patient perspective, as well as assessment of more modern surgical and reconstructive approaches.

Examining cancer survivorship trajectories: Exploring the intersection between qualitative illness narratives and quantitative screening instruments

OBJECTIVE

This article examines the associations of quantitatively refined trajectories of adjustment to cancer survivorship determined by previously published qualitative narrative analysis.

METHOD

Patients completed measures of cancer-related worry (Cancer Related Worries Scale), depression (Patient Health Questionnaire-9), posttraumatic growth (Benefit Finding Scale), and open-ended survey questions 6, 12, and 18 months postdiagnosis of head and neck, esophageal, gastric, or colorectal cancer. Previously published narrative analysis revealed five distinct survivorship "paths," which were combined into four paths in the present article: Moving On, Seeing the World Differently, Taking One Day at a Time, and Never the Same. To determine the association of qualitatively determined paths with quantitatively assessed adjustment (i.e., Cancer Related Worries Scale, Patient Health Questionnaire-9, Benefit Finding Scale), we used linear multilevel modeling to regress the adjustment variables on time, path, the time-by-path interaction, and relevant covariates (age, stage, cancer site, ethnicity, and Deyo score).

RESULTS

There was a significant main effect of path on cancer worry, depression, and posttraumatic growth (p < 0.02 for all). Patients in the Moving On group reported consistently low worry, depression, and growth compared to the other groups. Patients in the Seeing the World Differently and Taking One Day at a Time paths both reported moderate worry and depression; but those in the Seeing the World Differently path reported the highest posttraumatic growth, whereas patients in the Taking One Day at a Time path reported little growth. Finally, patients in the Never the Same path reported the highest worry and depression but lowest posttraumatic growth.Significance of resultsThis longitudinal study reinforces the notion that cancer survivorship is not a one-size-fits-all experience nor a dichotomized experience of "distress" or "no distress." Additionally, this hypothesis-generating study suggests future directions for potential self-report measures to help clinicians identify cancer survivors' trajectory to develop a more patient-centered survivorship care plan.

Identifying and predicting distinct distress trajectories following a breast cancer diagnosis - from treatment into early survival

OBJECTIVE

Most longitudinal studies on distress in breast cancer (BC) patients reported a continuous decrease after diagnosis, however masking individual variations in patterns of adjustment. We sought to identify distinct trajectories of distress during primary treatment into survivorship and to identify variables that are determinants of which patient follows which type of adjustment trajectory.

METHODS

Psychological distress was measured at four significant time points (after surgery/biopsy, at treatment completion, two and six months thereafter) among 181 newly diagnosed BC patients. A latent growth mixture modeling approach was used to identify distinct distress trajectories.

RESULTS

Four distress trajectories were identified: a 'resilient' pattern (73.1%), a 'high-remitting' (7.7%) trajectory, a 'delayed' increase in distress (7.9%), and a constantly high 'chronic' distress (11.3%) pattern. High perceived burden from physical symptoms at treatment completion encompassed a higher chance for the 'high-remitting' and 'chronic' distress trajectory. High self-efficacy at baseline increased chances for the 'high-remitting' pattern. Neither type of treatment, demographic or medical characteristics, nor baseline distress reliably predicted distress trajectories.

CONCLUSION

The majority of BC patients adjust well through a demanding treatment period. High patient-perceived burden from physical symptoms, and high coping self-efficacy is suggesting a transient, self-limiting distress trajectory, while patients experiencing constant 'chronic' distress, and those developing distress following treatment completion only cannot be identified by a single, initial assessment. Only systematic tracking with repeated measurement extending into survivorship can eliminate this problem. Interventions should aim at reducing the impact of symptom burden on women's every-day life and on strengthening coping-self efficacy.

Characteristics of psychological resilience and body image in women in the early and late periods after mastectomy

Background

European statistics confirm a rise in breast cancer among women. Those suffering from breast cancer and undergoing mastectomy are undoubtedly experiencing a range of negative and/or positive emotions, thoughts and behaviours that depend on many factors such as psychological resilience. The study reported here aimed to identify factors that protect body image resilience in women suffering from breast cancer after mastectomy.

Participants and procedure

The research group comprised 120 women after either a short (up to 2 years) or a long (over 2 years) time since mastectomy. Three scales were applied, namely the Resilience Measurement Scale (SPP-25) developed by Juczyński and Ogińska-Bulik to measure the variability of psychological resilience, the Body Attitude Test (BAT) developed by Probst, and others (Polish version by Brytek-Matera), and Probst’s Body Self Questionnaire developed by Mirucka for the measurement of the body image.

Results

Post-mastectomy patients proved to have a significantly poorer self-assessment of the body, more restrictive eating behaviours and weight control employed with the aim to improve their appearance. Women just after mastectomy, seemed more focused on mobilising their resources necessary to adapt to new conditions and to restore balance after the difficult experience compared to women who had undergone mastectomy over 2 years before the study. The former are characterised by a higher degree of psychological resilience, higher perseverance and determination in action. They also better cope with experienced failure and negative emotions, which indicates that they have a greater capacity to detach from difficult situations.

Conclusions

The greater mobilisation of resources necessary to adapt to new conditions and to restore balance after a difficult experience require consideration and application of psychological support from the very beginning of treatment. For this reason, psychological counselling and work on strengthening resilience among women after mastectomy are indicated.

Fatigue after breast cancer treatment: Biobehavioral predictors of fatigue trajectories

OBJECTIVE

Fatigue is a common side effect of cancer treatment, but there is considerable variability in fatigue severity and persistence among survivors. This study aimed to characterize longitudinal trajectories of fatigue after breast cancer treatment and to identify predictors of varying fatigue trajectories.

METHODS

Women (N = 191) from the Mind-Body Study completed assessments after primary treatment for early stage breast cancer and at regular follow-ups that occurred up to 6 years after treatment (M = 4.3 years). Growth mixture models were used to characterize fatigue trajectories, and demographic, medical, and biobehavioral risk factors were examined as predictors of trajectory group.

RESULTS

Five trajectories were identified, characterized as High, Recovery, Late, Low, and Very Low fatigue. The High and Recovery groups (40% of sample) evidenced elevated fatigue at posttreatment that declined in Recovery but persisted in the High group. In bivariate analyses, trajectory groups differed significantly on depressive symptoms, sleep disturbance, childhood adversity, body mass index, and the inflammatory marker soluble TNF receptor type II, which were higher in the High and/or Recovery groups. In multivariate models, depressive symptoms and childhood adversity distinguished High and Recovery from other groups. Rates of chemotherapy were higher in the Recovery than in the High or Late group, whereas rates of endocrine therapy were higher in the High than in the Recovery group.

CONCLUSIONS

There are distinct longitudinal trajectories of fatigue after breast cancer treatment. Psychological factors are strongly associated with adverse fatigue trajectories, and together with treatment exposures may increase risk for cancer-related fatigue. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Classes of depression symptom trajectories in patients with major depression receiving a collaborative care intervention

PURPOSE

Collaborative care is effective in improving symptoms of patients with depression. The aims of this study were to characterize symptom trajectories in patients with major depression during one year of collaborative care and to explore associations between baseline characteristics and symptom trajectories.

METHODS

We conducted a cluster-randomized controlled trial in primary care. The collaborative care intervention comprised case management and behavioral activation. We used the Patient Health Questionnaire-9 (PHQ-9) to assess symptom severity as the primary outcome. Statistical analyses comprised latent growth mixture modeling and a hierarchical binary logistic regression model.

RESULTS

We included 74 practices and 626 patients (310 intervention and 316 control recipients) at baseline. Based on a minimum of 12 measurement points for each intervention recipient, we identified two latent trajectories, which we labeled 'fast improvers' (60.5%) and 'slow improvers' (39.5%). At all measurements after baseline, 'fast improvers' presented higher PHQ mean values than 'slow improvers'. At baseline, 'fast improvers' presented fewer physical conditions, higher health-related quality of life, and had made fewer suicide attempts in their history.

CONCLUSIONS

A notable proportion of 39.5% of patients improved only 'slowly' and probably needed more intense treatment. The third follow-up in month two could well be a sensible time to adjust treatment to support 'slow improvers'.

Depression and cancer were independently associated with quality of life in Brazilian older people

OBJECTIVE

To analyse the factors associated with low health-related quality of life (HRQoL) in older people living in Brazil.

METHODS

In this cross-sectional study of the Jewish community residing in Sao Paulo, Brazil, we extensively evaluated the characteristics - including clinical, functional and sociodemographic - of 496 older people. Quality of life was assessed using the World Health Organization Quality of Life-BREF (WHOQOL-BREF), while the Geriatric Depression Scale (GDS) was used to measure depressive symptoms.

RESULTS

After adjusting for potential confounders, we found that GDS score (β = -0.07; P = 0.04) and cancer (β = -0.47; P = 0.05) were associated with a low WHOQOL-BREF score.

CONCLUSION

Depressive symptoms and cancer were independently associated with low HRQoL among older people living in Brazil.

Distinct attentional function profiles in older adults receiving cancer chemotherapy

PURPOSE

While attentional function is an extremely important patient outcome for older adults, research on changes in function in this group is extremely limited. The purposes of this study were to: identify subgroups of older patients (i.e., latent growth classes) based on changes in their level of self-reported attentional function; determine which demographic and clinical characteristics were associated with subgroup membership; and determine if these subgroups differed on quality of life (QOL) outcomes.

METHODS

Older oncology outpatients (n = 365) who were assessed for changes in attention and working memory using the Attentional Function Index a total of six times over two cycles of chemotherapy (CTX). QOL was assessed using the Medical Outcomes Study-Short Form 12 and the QOL-Patient Version Scale. Latent profile analysis (LPA) was used to identify subgroups of older adults with distinct attentional function profiles.

RESULTS

Three distinct attentional functional profiles were identified (i.e., low, moderate, and high attentional function). Compared to the high class, older adults in the low and moderate attentional function classes had lower functional status scores, a worse comorbidity profile and were more likely to be diagnosed with depression. In addition, QOL scores followed an expected pattern (low class < moderate class < high attentional function class).

CONCLUSIONS

Three distinct attentional function profiles were identified among a relatively large sample of older adults undergoing CTX. The phenotypic characteristics associated with membership in the low and moderate latent classes can be used by clinicians to identify high risk patients.

Distress Among Locally Advanced Breast Cancer Patients from Diagnosis to Follow-Up: A Critical Review of Literature

OBJECTIVE

This critical review used a systematic approach to explore the prevalence of distress among locally advanced breast cancer (LABC) patients along their treatment journey. This review explored the domains of distress (psychosocial, physical and/or practical) that are significant to this patient population and determined indications for psychosocial support throughout the patients' treatment.

METHODS

Electronic databases including CINAHL, EmBase, Medline PsycInfo, and gray literature were searched from the year 2000 to 2016, to produce relevant literature. A critical review was conducted on 73 articles meeting the inclusion and exclusion criteria. A narrative synopsis was used to summarize the findings under key themes.

RESULTS

The results indicate that 16/73 studies assessed for distress in all three domains of distress throughout the treatment course. A meta-analysis was not possible due to the methodological heterogeneity of the articles, the variation of assessment tools used, timing in which the assessments were done, and the different treatment modalities. Distress was prevalent from the time of diagnosis, through treatment, and into survivorship. Sexuality, body image, age, financial difficulty, family/social support, and informational needs were common themes that emerged among the LABC population in these studies.

CONCLUSIONS

Comprehensive assessments incorporating all three domains of distress with the appropriate tools will assist health care professionals throughout the complicated treatment trajectory of LABC patients in taking a more proactive approach in assisting patients' concerns and preventing undue or increase in psychological distress during or after active treatment. This will encourage effective patient-centered communication and supportive care referrals for a better patient experience.

Psychological Resilience as a Protective Factor for the Body Image in Post-Mastectomy Women with Breast Cancer

European statistics confirm a rise in breast cancer among contemporary women. Those suffering from cancer and undergoing a surgery (mastectomy) are undoubtedly considered to be in difficult situations. The range of the numerous negative and/or positive emotions, thoughts, and behaviours depend on many psychological factors such as psychological resilience. The authors are currently drawing a report on their own studies where they are trying to determine factors that protect body image resilience in women suffering from breast cancer after mastectomies. The research group consisted of 120 women after a short (up to 2 years) or a long (over 2 years) duration having elapsed since their mastectomy. The results of the research groups show that psychological resilience is a significant protecting factor for the body image that prevents the excessive development of negative self-esteem in post-mastectomy women. Female patients ought to be provided aid in the short time immediately after the procedure and afterwards, when they are less capable of tolerating negative emotions. In order to significantly improve the general body image resilience to emotional and cognitive distortions in post-mastectomy women who experienced breast cancer, it is recommended that psychological interventions (from psychoeducation to psychological assistance and specialist psychotherapy) are conducted systematically throughout the course of treatment.

An open trial of individualized face-to-face cognitive behavior therapy for psychological distress in parents of children after end of treatment for childhood cancer including a cognitive behavioral conceptualization

OBJECTIVE

A subgroup of parents of children who have been treated for childhood cancer report high levels of psychological distress. To date there is no empirically supported psychological treatment targeting cancer-related psychological distress in this population. The aim of the current study was to test the feasibility and preliminarily evaluate the effect of individualized face-to-face cognitive behavior therapy (CBT) for parents of children after the end of treatment for childhood cancer. A secondary aim was to present a cognitive behavioral conceptualization of cancer-related distress for these parents.

METHODS

An open trial was conducted where 15 parents of children who had completed successful treatment for cancer three months to five years earlier and who reported psychological distress related to a child's previous cancer disease were provided CBT at a maximum of 15 sessions. Participants were assessed at baseline, post-intervention, and three-month follow-up using self-reported psychological distress (including posttraumatic stress symptoms (PTSS), depression, and anxiety) and the diagnostic Mini-International Neuropsychiatric Interview. Feasibility outcomes relating to recruitment, data collection, and delivery of the treatment were also examined. Individual case formulations for each participant guided the intervention and these were aggregated and presented in a conceptualization detailing core symptoms and their suggested maintenance mechanisms.

RESULTS

A total of 93% of the participants completed the treatment and all of them completed the follow-up assessment. From baseline to post-assessment, parents reported significant improvements in PTSS, depression, and anxiety with medium to large effect sizes (Cohen's d = 0.65-0.92). Results were maintained or improved at a three-month follow-up. At baseline, seven (47%) participants fulfilled the diagnostic criteria for major depressive disorder and four (29%) fulfilled the criteria for posttraumatic stress disorder, compared to none at a post-assessment and a follow-up assessment. The resulting cognitive behavioral conceptualization suggests traumatic stress and depression as the core features of distress, and avoidance and inactivity is suggested as the core maintenance mechanisms.

CONCLUSION

The treatment was feasible and acceptable to the participants. Significant improvements in distress were observed during the study. Overall, results suggest that the psychological treatment for parents of children after end of treatment for childhood cancer used in the current study is promising and should be tested and evaluated in future studies.

Cytokine Gene Polymorphisms Associated With Various Domains of Quality of Life in Women With Breast Cancer

CONTEXT

Little is known about the phenotypic and molecular characteristics associated with various domains of quality of life (QOL) in women after breast cancer surgery.

OBJECTIVES

In a sample of women with breast cancer (n = 398), purposes were as follows: to identify latent classes with distinct trajectories of QOL from before surgery through six months after surgery and to evaluate for differences in demographic and clinical characteristics, as well as for polymorphisms in cytokine genes, between these latent classes.

METHODS

Latent class analyses were done to identify subgroups of patients with distinct QOL outcomes. Candidate gene analyses were done to identify cytokine gene polymorphisms associated with various domains of QOL (i.e., physical, psychological, spiritual, social).

RESULTS

One latent class was identified for the psychological and spiritual domains. Two latent classes were identified for the social domain and overall QOL scores. Three latent classes were identified for the physical domain. For the physical and social domains, as well as for the overall QOL scores, distinct phenotypic characteristics (i.e., younger age, poorer functional status, higher body mass index, and receipt of adjuvant chemotherapy) and a number of cytokine gene polymorphisms (CXCL8, NFKB2, TNFSF, IL1B, IL13, and NFKB1) were associated with membership in the lower QOL classes.

CONCLUSIONS

Findings suggest that women experience distinctly different physical well-being, social well-being, and total QOL outcomes during and after breast cancer surgery. The genetic associations identified suggest that cytokine dysregulation influences QOL outcomes. However, specific QOL domains may be impacted by different cytokines.

Stability of Symptom Clusters in Patients With Breast Cancer Receiving Chemotherapy

CONTEXT

Patients with breast cancer who undergo chemotherapy (CTX) experience between 10 and 32 concurrent symptoms. An evaluation of how these symptoms cluster together and how these symptom clusters change over time may provide insights into how to treat these multiple co-occurring symptoms.

OBJECTIVES

The purposes of this study were to determine the occurrence rates and severity ratings for 38 common symptoms, evaluate for differences in the number and types of symptom clusters, and evaluate for changes over time in these symptom clusters (i.e., before CTX, the week after CTX, and two weeks after CTX).

METHODS

At each of the assessments, a modified version of the Memorial Symptom Assessment Scale was used to assess the occurrence and severity of the 38 symptoms. Exploratory factor analyses were used to extract the symptom clusters.

RESULTS

Although across the two symptom dimensions (i.e., occurrence and severity) and the three assessments, eight distinct symptom clusters were identified, only five were relatively stable across both dimensions and across time (i.e., psychological, hormonal, nutritional, gastrointestinal, and epithelial). Two of the additional clusters varied by time but not by symptom dimension (i.e., sickness behavior and weight change). The CTX neuropathy cluster was identified only at the assessment performed in the week after CTX.

CONCLUSION

These findings provide insights into the most common symptom clusters in patients undergoing CTX for breast cancer. In addition, the most common symptoms within each cluster appear to be relatively stable across the two dimensions, as well as across time.

Strength through adversity: Moderate lifetime stress exposure is associated with psychological resilience in breast cancer survivors

Stress research typically emphasizes the toxic effects of stress, but recent evidence has suggested that stress exposure, in moderation, can facilitate resilience. To test whether moderate stress exposure promotes psychological resilience to cancer, we examined the relationship between lifetime stress exposure prior to cancer diagnosis and postdiagnosis psychological functioning among 122 breast cancer survivors. Lifetime acute and chronic stress was assessed using an interview-based measure, and psychological functioning was assessed using measures of cancer-related intrusive thoughts and positive and negative affect. Results indicated that acute stress exposure was associated with cancer-related intrusive thoughts in a quadratic fashion (p = .016), such that participants with moderate acute stress reported fewer intrusive thoughts compared to those with low or high acute stress. Similarly, a quadratic relationship emerged between acute stress exposure and positive affect (p = .009), such that individuals with moderate acute stress reported the highest levels of positive affect. In contrast, acute and chronic stress were related to negative affect in a positive, linear fashion (ps < .05). In conclusion, moderate stress exposure was associated with indicators of psychological resilience among breast cancer survivors, supporting stress exposure as a key factor influencing adjustment to breast cancer and providing evidence for stress-induced resilience in a novel population.

Distinct Trajectories of Fatigue and Sleep Disturbance in Women Receiving Chemotherapy for Breast Cancer

PURPOSE/OBJECTIVES

To examine self-reported severity of fatigue and disturbed sleep experienced daily by women with breast cancer during multiple cycles of chemotherapy, exploring potential classes of women experiencing similar symptom trajectories.
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DESIGN

In a secondary analysis, classes of women experiencing similar patterns of fatigue and disturbed sleep were identified.
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SETTING

Oncology clinics in the United States.
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SAMPLE

166 women with breast cancer receiving chemotherapy. 
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METHODS

Severity scores were self-reported daily using an automated system. Classes of fatigue and disturbed sleep severity were identified using latent growth mixture modeling.
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MAIN RESEARCH VARIABLES

Fatigue, disturbed sleep, age, stage of disease, education, employment, marital status, chemotherapy regimen, hours lying down, and missed work.
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FINDINGS

Three fatigue classes were identified.

CONCLUSIONS

Patterns of symptom trajectories for fatigue and disturbed sleep were distinguished by baseline symptom severity.
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IMPLICATIONS FOR NURSING

Identification of women at risk for fatigue and disturbed sleep may allow clinicians to intensify symptom management.

Association of Personality Profiles with Depressive, Anxiety, and Cancer-related Symptoms in Patients Undergoing Chemotherapy

Background

This study identified latent classes of cancer patients based on Big Five personality dimensions and evaluated for differences in demographic and clinical characteristics, depression, anxiety, and cancer-related symptoms.

Methods

Patients (n=1248) with breast, gastrointestinal, gynecological, or lung cancer completed the Center for Epidemiological Studies-Depression scale, Spielberger State-Trait Anxiety Inventories, NEO-Five Factor Inventory (NEO-FFI), and Memorial Symptom Assessment Scale (MSAS). Latent class profile analysis of NEO-FFI scores was used to identify patient subgroups.

Results

Three latent classes were identified. The "Distressed" class (14.3%) scored highest on neuroticism and lowest on extraversion, agreeableness, and conscientiousness. The "Resilient" class (31.9%) scored lowest on neuroticism and highest on extraversion, agreeableness, and conscientiousness. The "Normative" class (53.8%) was intermediate on all dimensions except openness. Compared to the Resilient class, patients in the Distressed class were younger, less educated, more likely to care for another adult, had more comorbidities, and exercised less. The three classes differed by performance status, marital and employment status, and income, but not by gender, time since diagnosis, or type of prior cancer treatment. The classes differed (Distressed > Normative > Resilient) in depression, anxiety, and cancer symptoms.

Conclusions

Personality is associated with psychological and physical symptoms in cancer patients.

Predictors of the multidimensional symptom experience of lung cancer patients receiving chemotherapy

PURPOSE

Few studies have examined interindividual variability in the symptom experience of lung cancer patients. We aimed to identify the most prevalent, severe, and distressing symptoms, and risk factors associated with increased symptom burden.

METHODS

Lung cancer patients (n = 145) reported occurrence, severity, and distress for 38 symptoms on the Memorial Symptom Assessment Scale 1 week after chemotherapy. Using multidimensional subscales, risk factors for higher global distress, physical, and psychological symptoms were evaluated using simultaneous linear regression.

RESULTS

Mean age was 64.0 years and 56.6% were female. Mean Karnofsky Performance Status score was 79.1 (SD 14.6) and mean Self-Administered Comorbidity Questionnaire score was 7.3 (SD 3.9). The most distressing and prevalent symptom was fatigue. Problems with sexual interest/activity had the highest mean severity rating. Patients with lower functional status (p = 0.001) and higher comorbidity (p = 0.02) reported higher global distress. Similarly, lower functional status (p = 0.003) and higher comorbidity (p = 0.04) were associated with a higher physical symptom burden along with lower body mass index (p = 0.02). Higher psychology symptom burden was associated with lower functional status (p = 0.01), younger age (p = 0.02), non-metastatic disease (p = 0.03), higher number of prior treatments (p = 0.04), and income (p = 0.03).

CONCLUSIONS

Fatigue was the most distressing and prevalent symptom among lung cancer patients receiving chemotherapy. Lower functional status was associated with a higher burden of global distress, physical, and psychological symptoms. Younger age and non-metastatic disease were additional risk factors for increased psychological symptoms. Together, these risk factors can help clinicians identify lung cancer patients at increased need for aggressive symptom management.

Differences in symptom clusters identified using symptom occurrence rates versus severity ratings in patients with breast cancer undergoing chemotherapy

PURPOSE

One of the unanswered questions in symptom clusters research is whether the number and types of symptom clusters vary based on the dimension of the symptom experience used to create the clusters. Given that patients with breast cancer receiving chemotherapy (CTX), report between 10 and 32 concurrent symptoms and studies of symptom clusters in these patients are limited, the purpose of this study, in breast cancer patients undergoing CTX (n = 515), was to identify whether the number and types of symptom clusters differed based on whether symptom occurrence rates or symptom severity ratings were used to create the clusters.

METHODS

A modified version of the Memorial Symptom Assessment Scale was used to assess for the occurrence and severity of 38 symptoms, one week after the administration of CTX. Exploratory factor analysis was used to extract the symptom clusters.

RESULTS

Both the number and types of symptom clusters were similar using symptom occurrence rates or symptom severity ratings. Five symptom clusters were identified using symptom occurrence rates (i.e., psychological, hormonal, nutritional, gastrointestinal, epithelial). Six symptom clusters (i.e., psychological, hormonal, nutritional, gastrointestinal, epithelial, chemotherapy neuropathy) were identified using symptom severity ratings. Across the two dimensions, the specific symptoms within each of the symptom clusters were similar.

CONCLUSIONS

Identification of symptom clusters in patients with breast cancer may be useful in guiding symptom management interventions. Future studies are warranted to determine if symptom clusters remain stable over a cycle of CTX in patients with breast cancer.

Personality, coping, and social support as predictors of long-term quality-of-life trajectories in older breast cancer survivors: CALGB protocol 369901 (Alliance)

BACKGROUND

To determine long-term quality-of-life (QOL) trajectories among breast cancer survivors aged 65+ (older) evaluating the effects of personality and social support.

METHODS

Older women (N = 1280) newly examined with invasive, nonmetastatic breast cancer completed baseline assessments. Follow-up data were collected 6 and 12 months later and then annually for up to 7 years (median 4.5 years). Quality of life was assessed using EORTC-QLQ-C30 emotional, physical, and cognitive scales. Optimism (Life Orientation Test), Coping (Brief COPE), and social support (Medical Outcomes Study) were assessed at baseline. Group-based trajectory modeling identified QOL trajectories; multinomial regression evaluated effects of predictors on trajectory groups. Age, education, systemic therapy, comorbidity, and reported precancer function (SF-12) were considered as controlling variables.

RESULTS

Three trajectories were identified for each QOL domain: "maintained high," "phase shift" (lower but parallel scores to "maintained high" group), and "accelerated decline" (lowest baseline scores and steepest decline). Accelerated decline in emotional, physical, and cognitive function was seen in 6.9%, 31.8%, and 7.6% of older survivors, respectively. Maladaptive coping and lower social support increased adjusted odds of being in the accelerated decline group for all QOL domains; lower optimism was only related to decline in emotional function. Chemotherapy was related to physical and cognitive but not emotional function trajectories.

CONCLUSIONS

Personality and social resources affect the course of long-term emotional well-being of older breast cancer survivors; treatment is more important for physical and cognitive than emotional function. Early identification of those vulnerable to deterioration could facilitate clinical and psychological support.

Construction of longitudinal prediction targets using semisupervised learning

In establishing prognostic models, often aided by machine learning methods, much effort is concentrated in identifying good predictors. However, the same level of rigor is often absent in improving the outcome side of the models. In this study, we focus on this rather neglected aspect of model development. We are particularly interested in the use of longitudinal information as a way of improving the outcome side of prognostic models. This involves optimally characterizing individuals' outcome status, classifying them, and validating the formulated prediction targets. None of these tasks are straightforward, which may explain why longitudinal prediction targets are not commonly used in practice despite their compelling benefits. As a way of improving this situation, we explore the joint use of empirical model fitting, clinical insights, and cross-validation based on how well formulated targets are predicted by clinically relevant baseline characteristics (antecedent validators). The idea here is that all these methods are imperfect but can be used together to triangulate valid prediction targets. The proposed approach is illustrated using data from the longitudinal assessment of manic symptoms study.

Targeted use of growth mixture modeling: a learning perspective

From the statistical learning perspective, this paper shows a new direction for the use of growth mixture modeling (GMM), a method of identifying latent subpopulations that manifest heterogeneous outcome trajectories. In the proposed approach, we utilize the benefits of the conventional use of GMM for the purpose of generating potential candidate models based on empirical model fitting, which can be viewed as unsupervised learning. We then evaluate candidate GMM models on the basis of a direct measure of success; how well the trajectory types are predicted by clinically and demographically relevant baseline features, which can be viewed as supervised learning. We examine the proposed approach focusing on a particular utility of latent trajectory classes, as outcomes that can be used as valid prediction targets in clinical prognostic models. Our approach is illustrated using data from the Longitudinal Assessment of Manic Symptoms study. Copyright © 2016 John Wiley & Sons, Ltd.

Polymorphisms in Cytokine Genes Are Associated With Higher Levels of Fatigue and Lower Levels of Energy in Women After Breast Cancer Surgery

CONTEXT

Little is known about the phenotypic and molecular characteristics associated with changes over time in fatigue and lack of energy in patients with breast cancer.

OBJECTIVES

The aim of this study was to identify subgroups (i.e., latent classes) of women with distinct fatigue and energy trajectories; evaluate for differences in phenotypic characteristics between the latent classes for fatigue and energy; and evaluate for associations between polymorphisms in genes for pro- and anti-inflammatory cytokines, their receptors, and their transcriptional regulators and latent class membership.

METHODS

Patients were enrolled before and followed for six months after breast cancer surgery. Latent class analyses were done to identify subgroups of patients with distinct fatigue and energy trajectories. Candidate gene analyses were done to identify cytokine genes associated with these two symptoms.

RESULTS

For both fatigue and lack of energy, two distinct latent classes were identified. Phenotypic characteristics associated with the higher fatigue class were younger age, higher education, lower Karnofsky Performance Status score, higher comorbidity, higher number of lymph nodes removed, and receipt of chemotherapy (CTX). Polymorphisms in interleukin (IL) 1β and IL10 were associated with membership in the higher fatigue class. Phenotypic characteristics associated with the lower energy class included: a lower Karnofsky Performance Status score and a higher comorbidity score. A polymorphism in IL1R1 was associated with membership in the lower energy class.

CONCLUSION

Within each latent class, the severity of fatigue and decrements in energy were relatively stable over the first six months after breast cancer surgery. Distinct phenotypic characteristics and genetic polymorphisms were associated with membership in the higher fatigue and lower energy classes.