Management of Distress in Patients with Cancer-Are We Doing the Right Thing?

Perceived discrimination and quality of life for African American and Caucasian American cancer patients: a coping mediation analysis of subtle and overt microaggressions

OBJECTIVE

Perceived discrimination (PD; e.g. racism, agism, sexism, etc.) negatively impacts quality of life (QOL) among cancer patients. Prior research has established that for African American Cancer Patients (AACPs) only disengagement/denial coping mediated the PD-QOL relationship. In contrast, for Caucasian American Cancer Patients (CACPs), both agentic and disengagement/denial coping were mediators of the PD-QOL relationship. However, according to social constraint theory there may be a difference between subtle and overt PD in terms of the utility of certain coping mechanisms in relation to QOL, especially for AACPs.

METHOD

217 AACPs and 121 CACPs completed measures of PD, coping (agentic, disengagement/denial, adaptive disengagement) and QOL. PD items were classified as subtle or overt microaggressions. PD was mainly attributed to race/ethnicity by AACPs and to income, age, and physical appearance for CACPs.

RESULTS

: In both subtle and overt microaggression models with CACPs, agentic coping and disengagement/denial coping were significant mediators of PD-QOL. Like CACPs, for AACPs, agentic and disengagement/denial coping were significant in the context of subtle microaggressions. In contrast, for overt microaggression only disengagement/denial coping was a significant mediator of the PD-QOL relationship for AACPs. Adaptive disengagement was related to QOL only for AACPs.

CONCLUSIONS

: Whereas more research is needed, it appears that overt microaggressions for AACPs, that consist mainly of racial and ethnic maltreatment, constitute a class of social contexts that may raise above the threshold for serious threat and harm, and, as a result, disengagement/constraint may reduce negative consequences. This additional burden for AACPs contributes to disparities in QOL. Future research is needed on the utility of adaptive disengagement for AACPs in relation to PD.

Pairing automated exercise coaching with patient-reported symptom monitoring: A way to nudge exercise uptake during cancer treatment?

INTRODUCTION

Symptoms during cancer treatment cause burden, diminished physical functioning, and poor quality of life. Exercise is recommended during treatment to mitigate symptoms; however, interventions are difficult to translate into clinical care due to the lack of patient uptake and clinical implementation barriers. We evaluated the uptake, acceptability, and impact of an automated ePRO exercise module triggered by three patient-reported symptoms: nausea/vomiting, fatigue, and anxiety, during chemotherapy.

METHODS

We conducted a secondary analysis of an exercise module intervention imbedded in the cancer symptom monitoring and management platform, Symptom Care at Home (SCH). Utilizing behavioral economics principles, the exercise module was triggered when any of the three symptoms were reported. Once triggered, participants were coached on exercise benefits for symptom reduction and then offered the opportunity to set weekly exercise goals plus tracking of the goal outcomes and receive further encouragement. We examined uptake, exercise goal setting and attainment, and symptom impact.

RESULTS

Of 180 SCH participants receiving the SCH intervention, 170 (94.4%) triggered the exercise module and 102 of the 170 (60%) accepted the module, setting goals on average for 6.3 weeks. Of 102 participants, 82 (80.4%) achieved one or more exercise goals, exercising on average 79.8 min/week. Participants who achieved a higher proportion of goals had statistically significant lower overall symptom severity and lower severity of the triggered symptom.

CONCLUSION

An automated mHealth exercise coaching intervention, aimed to nudge those receiving chemotherapy to initiate an exercise routine had significant uptake, is acceptable and may reduce symptom severity.

TRIAL REGISTRATION

NCT01973946.

Negotiating cancer alone: A qualitative study exploring care experiences of racially and ethnically diverse women diagnosed with breast cancer during COVID-19

COVID-19 has critically impacted cancer care services including reduced screenings, diagnoses, and surgeries; particularly among Black and Latina/x women who already suffer worse outcomes. This qualitative study explored the care experiences of a diverse sample of breast cancer survivors (N = 21; 7 Black, 4 Hispanic, 10 White) undergoing treatment during the pandemic via online semi-structured interviews. Grounded theory analysis yielded the core category "negotiating cancer alone," that included: (1) psychological distress, negotiating the cancer trajectory in isolation; (2) provider/healthcare system diagnostic and treatment delays; (3) heightened anxiety about treatment delays causing cancer progression; (4) supportive care limitations; and (5) disparate experiences of cancer care disruptions. Black and Latina/x women described greater delays in care, financial challenges, treatment complications, and insurance limitations than White women. The study identifies cancer patients' pandemic-related psychological, healthcare system, and health equity challenges and suggests recommendations to support their increased psychological needs during oncologic care disruptions.

Toward an improved conceptualization of emotions in patients with cancer

Cancer and its associated treatment is a major stressor, leading to emotions such as anxiety or depressive mood. Human emotions have developed through the course of evolution because they facilitate adaptation to important events, such as cancer and its associated treatment. On the other hand, emotions can be maladaptive and interfere with adaptation to cancer. Emotions are maladaptive if they are disproportionally severe or persistent, and if they interfere with functioning. We aim to expand the conceptualization of adaptive and maladaptive emotions in patients with cancer. We draw on major theories in the field of mental disorder and mental health, and apply these theories to conceptualize adaptive and maladaptive emotions in patients with cancer. (i) Maladaptive emotions have two essential features: mental dysfunction and patient harm. Maladaptive emotions are characterized by a network of strongly associated emotional symptoms, which may include cancer-related somatic symptoms. The dysfunctional symptom network is hypothesized to be the result of disturbance of life goal pursuit caused by cancer. (ii) Adaptive emotions have two essential features: ability to deal with cancer and functioning well. The ability to use emotions in an adaptive way depends on skills to recognize, express, and regulate emotions in a flexible manner. A secure attachment style facilitates adaptive emotional responses to cancer. The present conceptualization of adaptive and maladaptive emotions is expected to contribute to better understanding and management of emotions in patients with cancer.

Implementing a nurse-led screening clinic for symptom distress with community-based referral for cancer survivors: A feasibility study

INTRODUCTION

This prospective, single-arm, pragmatic implementation study evaluated the feasibility of a nurse-led symptom-screening program embedded in routine oncology post-treatment outpatient clinics by assessing (1) the acceptance rate for symptom distress screening (SDS), (2) the prevalence of SDS cases, (3) the acceptance rate for community-based psychosocial support services, and (4) the effect of referred psychosocial support services on reducing symptom distress.

METHODS

Using the modified Edmonton Symptom Assessment System (ESAS-r), we screened patients who recently completed cancer treatment. Patients screening positive for moderate-to-severe symptom distress were referred to a nurse-led community-based symptom-management program involving stepped-care symptom/psychosocial management interventions using a pre-defined triage system. Reassessments were conducted at 3-months and 9-months thereafter. The primary outcomes included SDS acceptance rate, SDS case prevalence, intervention acceptance rate, and ESAS-r score change over time.

RESULTS

Overall, 2988/3742(80%) eligible patients consented to SDS, with 970(32%) reporting ≥1 ESAS-r symptom as moderate-to-severe (caseness). All cases received psychoeducational material, 673/970(69%) accepted psychosocial support service referrals. Among 328 patients completing both reassessments, ESAS-r scores improved significantly over time (p < 0.0001); 101(30.8%) of patients remained ESAS cases throughout the study, 112(34.1%) recovered at 3-month post-baseline, an additional 72(22%) recovered at 9-month post-baseline, while 43(12.2%) had resumed ESAS caseness at 9-month post-baseline.

CONCLUSION

Nurse-led SDS programs with well-structured referral pathways to community-based services and continued monitoring are feasible and acceptable in cancer patients and may help in reducing symptom distress. We intend next to develop optimal strategies for SDS implementation and referral within routine cancer care services.

Falling off the screening grid-Predictors for postponed utilization of psycho-oncological support in cancer patients and its implications for distress assessment and management

OBJECTIVE

Distress assessment of cancer patients is considered state-of-the-art. In addition to distress scores, individual care needs are an important factor for the initiation of psycho-oncological interventions. In a mono-centric, observational study, we aimed for characterization of patients indicating a subjective need but declining to utilize support services immediately to facilitate implementation of adapted screenings.

METHODS

This study analyzed retrospective data from routine distress screening and associated data from hospital records. Descriptive, variance and regression analyses were used to assess characteristics of postponed support utilization in patients with mixed cancer diagnoses in different treatment settings.

RESULTS

Of the total sample (N = 1863), 13% indicated a subjective need but postponed support utilization. This subgroup presented as being as burdened by symptoms of depression (p < 0.001), anxiety (p < 0.001) and distress (p < 0.001) as subjectively distressed patients with intent to directly utilize support. Time periods since diagnosis were shorter (p = 0.007) and patients were more often inpatients (p = 0.045).

CONCLUSIONS

Despite high heterogeneity among the subgroups, this study identified distress-related factors and time since diagnosis as possible predictors for postponed utilization of psycho-oncological interventions. Results suggest the necessity for time-individualized support which may improve utilization by distressed patients.

Incremental Health Care Costs of Anxiety and Depression Among Medicare Beneficiaries With Cancer

PURPOSE

Mental health comorbidities are commonplace among patients with cancer and have been associated with adverse health outcomes and elevated health care costs. Given the rapidly evolving cancer care landscape, an updated understanding of the prevalence and costs of mental health conditions among patients with cancer is needed. This study assessed the incremental costs of anxiety and depression among Medicare beneficiaries with cancer.

METHODS

This retrospective cohort study used the SEER-Medicare database. Patients diagnosed with melanoma, breast, lung, prostate, or colorectal cancer between July 2013 and December 2017 were followed for at least 12 months and up to 36 months after cancer diagnosis. Patients were categorized on the basis of anxiety/depression (AD) diagnosis: (1) predating cancer, (2) onset after cancer, or (3) no AD. Multivariable regression was used to estimate differences in all-cause incremental costs (before v after cancer) between the three groups.

RESULTS

Of 230,626 patients, 10% had AD before their cancer diagnosis and 22% were diagnosed after cancer. In the first year after cancer diagnosis, average monthly health care costs were $5,750 in US dollars (USD) for patients with newly onset, $5,208 (USD) for patients with preexisting, and $3,919 (USD) for patients without a diagnosis of AD. The incremental cost of cancer was the greatest among patients with newly onset AD-$1,458 (USD) per month greater than those with no AD. Similar patterns were observed across cancer types and stages.

CONCLUSION

One in three Medicare beneficiaries with cancer in this study had a diagnosis of anxiety or depression. Newly onset AD is associated with an increase in health care costs of $17,496 (USD) per year. Screening and management of mental health conditions for patients with cancer should be part of coordinated oncology care.

Early Impact of the COVID-19 Pandemic on Psycho-Oncological Support: A Latent Class Analysis

INTRODUCTION

Research suggests a global shortfall of psycho-oncological assessment and care during the COVID-19 pandemic in addition to delayed diagnosis of cancer. The present study is the first to explore the effect of the pandemic on the provision of psycho-oncological care, stage of cancer at first diagnosis, and duration of hospitalizations.

METHOD

Retrospective latent class analysis of 4,639 electronic patient files with all types, treatment types, and stages of cancer, 370 of which were treated during the pandemic prior to availability of vaccinations.

DISCUSSION

Latent class analysis identified four subgroups based on differences in screening for distress, provision of psycho-oncological support (consultation with a psychiatrist or clinical psychologist), administration of psychotropic medication, use of 1:1 observation, stage of cancer at first diagnosis, and duration of hospitalizations. Yet, the pandemic had no effect on subgrouping. Thus, the COVID-19 pandemic had no effect on the provision of psycho-oncological support.

CONCLUSION

Results are contrary to prior research. The efficiency and quality of procedures implemented to provide psycho-oncological support during and prior to the pandemic are critically reflected.

Music Therapy as a Form of Nonpharmacologic Pain Modulation in Patients with Cancer: A Systematic Review of the Current Literature

Simple Summary

Cancer is a condition that affects millions of people worldwide each year. Treatments include pharmacologic and surgical interventions that can pose great risks to the physical and mental health of patients. The objective of this systematic review is to consolidate the literature surrounding the use of music therapy as a low-risk and effective pain management adjunct to traditional cancer therapy. This analysis reveals that the use of music therapy thus far has provided a nearly unanimous positive effect on cancer patients, with the potential to provide both physical and psychosocial benefits. The apparent adverse effects appear to be negligible, and music therapy should be considered when creating a cancer care plan.

Abstract

Aims and Objectives: To consolidate and summarize the current literature surrounding the use of music therapy as an effective noninvasive adjunct to conventional cancer therapy, especially as a low-risk alternative for pain management and anesthetic use in cancer patients. Background: Current studies have proposed that music therapy may be effective as a noninvasive adjunct to conventional cancer therapy in managing numerous outcomes in cancer patients. However, the findings of these investigations have not been consolidated and analyzed on a large scale. Therefore, focusing a systematic review on the effects of music therapy as an adjunct to conventional cancer therapy would give a better understanding of which intervention approaches are associated with better clinical outcomes for cancer patients. Design: A systematic review. Methods: A review of randomized controlled trials to evaluate the effectiveness of music therapy in physical, cognitive, and psychosocial outcomes for cancer patients alone or in conjunction with standard therapy was implemented. We conducted searches using the PubMed/MEDLINE, CINAHL, and Cochrane Library databases for all articles meeting the search criteria up until the time of article extraction in May, 2022. Only studies published in English were included. Two reviewers independently extracted data on participant and intervention characteristics. The main outcome variables included pain, anxiety, quality of life, mood, sleep disorders, fatigue, heart rate, blood pressure, respiratory rate, and oxygen saturation. Results: Of the 202 initially identified articles, 25 randomized controlled trials met the inclusion criteria for evaluation. Of the 25 studies, 23 (92.0%) reported statistically and clinically significant improvements across the outcome variables. Two of the studies (8.00%) found no significant positive effect from music therapy in any of the aforementioned outcomes variables. Conclusion: Music therapy, both as a standalone treatment and when used in conjunction with other pharmacologic and nonpharmacologic modalities, has a generally beneficial effect across several physiologic and psychosocial aspects of cancer.

Clinical Decision Support for Symptom Management in Lung Cancer Patients: A Group RCT

CONTEXT

Clinical guidelines are available to enhance symptom management during cancer treatment but often are not used in the practice setting. Clinical decision support can facilitate the implementation and adherence to clinical guidelines. and improve the quality of cancer care.

OBJECTIVES

Clinical decision support offers an innovative approach to integrate guideline-based symptom management into oncology care. This study evaluated the effect of clinical decision support-based recommendations on clinical management of symptoms and health-related quality of life (HR-QOL) among outpatients with lung cancer.

METHODS

Twenty providers and 179 patients were allotted in group randomization to attention control (AC) or Symptom Assessment and Management Intervention (SAMI) arms. SAMI entailed patient-report of symptoms and delivery of recommendations to manage pain, fatigue, dyspnea, depression, and anxiety; AC entailed symptom reporting prior to the visit. Outcomes were collected at baseline, two, four and six-months. Adherence to recommendations was assessed through masked chart review. HR-QOL was measured by the Functional Assessment of Cancer Therapy-Lung questionnaire. Descriptive statistics with linear and logistic regression accounting for the clustering structure of the design and a modified chi-square test were used for analyses.

RESULTS

Median age of patients was 63 years, 58% female, 88% white, and 32% ≤high school education. Significant differences in clinical management were evident in SAMI vs. AC for all target symptoms that passed threshold. Patients in SAMI were more likely to receive sustained-release opioids for constant pain, adjuvant medications for neuropathic pain, opioids for dyspnea, stimulants for fatigue and mental health referrals for anxiety. However, there were no statistically significant differences in HR-QOL at any time point.

CONCLUSION

SAMI improved clinical management for all target symptoms but did not improve patient outcomes. A larger study is warranted to evaluate effectiveness.

'Patients with Cancer are Distressed!' Indian Healthcare Provider Perspectives on Distress Screening and Referrals to Psycho-oncology Services - A Mixed Methods Study

Objectives:

Routine screening for distress is a guideline prescribed by the National Comprehensive Cancer Network (NCCN) to adequately assess distress in a cancer setting. Our centre conducted routine screening but failed to utilize psycho-oncology services. Our aim was to assess the extent of self-reported distress, referrals to psycho-oncology services and healthcare provider perspectives about the existing distress management system and psycho-oncology services.

Materials and Methods:

We conducted a record review of adult patients (n=372) who reported to the Out-patient department of the tertiary cancer centre. Semi-structured interviews were conducted with fourteen healthcare providers. We used a concurrent mixed methods study design. Adult patients were screened for distress using NCCN-Distress Thermometer and problem checklist. Healthcare providers from different oncology specialties were interviewed and the data was analysed using descriptive thematic analysis.

Results:

Patients screened for distress were found to report moderate to extreme levels of distress (53.5%). The total referrals to psycho-oncology support services were low (8.6%). Interviews with healthcare providers revealed three major themes: Enablers, barriers and solutions for utilization of distress management system and psycho-oncology services.

Conclusions:

Moderate to extreme distress was found among patients routinely screened for distress, although there was poor utilization of distress management system and psycho-oncology support services due to time constraints, patient’s negative attitudes towards mental health referrals, generic screening tools and use of own clinical judgement to make referrals by healthcare providers. Future research warrants implementation of strategies to integrate psycho-oncology services into routine cancer care by focusing on improving visibility of services.

Clinical judgment of the need for professional mental health care in patients with cancer: a qualitative study among oncologists and nurses

PURPOSE

In daily practice, oncologists and nurses frequently need to decide whether or not to refer a patient for professional mental health care. We explored the indicators oncologists and nurses use to judge the need for professional mental health care in patients with cancer.

METHODS

In a qualitative study, oncologists (n = 8) and nurses (n = 6) were each asked to select patients who were or were not referred for professional mental health care (total n = 75). During a semi-structured interview, they reflected on their decision concerning the possible referral of the patient. Thematic analysis was used to analyze the data.

RESULTS

Respondents reported using a strategy when judging whether professional mental health care was needed. They allowed patients time to adjust, while monitoring patients' psychological well-being, especially if patients exhibited specific risk factors. Risk and protective factors for emotional problems included personal, social, and disease- and treatment-related factors. Respondents considered referral for professional mental health care when they noted specific indicators of emotional problems. These indicators included lingering or increasing emotions, a disproportionate intensity of emotions, and emotions with a negative impact on a patient's daily life or treatment.

CONCLUSIONS

This study identified the strategy, risk and protective factors, and the indicators of emotional problems used by oncologists and nurses when judging the need for professional mental health care in patients with cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Oncologists and nurses can play an important role in the identification of patients in need of professional mental health care.