Psychological distress and cancer survival: a follow-up 10 years after diagnosis

Serious health-related suffering impairs treatments and survival in older patients with cancer

CONTEXT

More than half of new cancer cases occurred in older adults. Older patients with cancer are particularly at risk of physical, psycho-existential or socio-familial suffering as defined by the concept of Serious Health-related Suffering (SHS).

OBJECTIVES

To assess the direct and indirect effects of physical, psycho-existential and socio-familial dimensions of suffering on cancer treatability, supportive care needs and 12-month mortality in older patients with cancer.

METHODS

We included patients with cancer aged 70 years and over from the Elderly Cancer Patients cohort (ELCAPA, Ile-de-France), referred for geriatric assessment between 2007 and 2019 before cancer treatment. Structural equation modelling examined the direct and indirect relationships between SHS dimensions (latent variables), patients' characteristics (age, sex, tumor location and metastatic status, comorbidity, period of care), and outcomes.

RESULTS

The analysis included 4,824 patients (mean age: 82.2 ± 4 years; women: 56%; main cancer sites: breast [22.3%], colorectal [15.2%], prostate [8.5%], and lung [6.8%]; metastatic cancer: 46%). Physical suffering had direct pejorative effects on cancer treatability, and mortality (standardized coefficient [SC] = 0.12 [P<0.001], SC = 0.27 [P<0.001], respectively). Psycho-existential and socio-familial sufferings had indirect pejorative effects on survival through decreased cancer treatability (SC = 0.08 [P<0.001], SC = 0.03 [P<0.001], respectively). Psycho-existential dimension had the main direct effect size on supportive care needs (SC = 0.35 [P<0.001]) and was interrelated with physical suffering.

CONCLUSION

Physical suffering has direct pejorative effect on survival. All dimensions indirectly decrease survival due to poorer cancer treatability. Our findings support concomitant management of physical and psycho-existential suffering.

Digital Therapeutic (Mika) Targeting Distress in Patients With Cancer: Results From a Nationwide Waitlist Randomized Controlled Trial

BACKGROUND

Distress is highly prevalent among patients with cancer, but supportive care needs often go unmet. Digital therapeutics hold the potential to overcome barriers in cancer care and improve health outcomes.

OBJECTIVE

This study conducted a randomized controlled trial to investigate the efficacy of Mika, an app-based digital therapeutic designed to reduce distress across the cancer trajectory.

METHODS

This nationwide waitlist randomized controlled trial in Germany enrolled patients with cancer across all tumor entities diagnosed within the last 5 years. Participants were randomized into the intervention (Mika plus usual care) and control (usual care alone) groups. The participants completed web-based assessments at baseline and at 2, 6, and 12 weeks. The primary outcome was the change in distress from baseline to week 12, as measured by the National Comprehensive Cancer Network Distress Thermometer. Secondary outcomes included depression, anxiety (Hospital Anxiety and Depression Scale), fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue), and quality of life (Clinical Global Impression-Improvement Scale). Intention-to-treat and per-protocol analyses were performed. Analyses of covariance were used to test for outcome changes over time between the groups, controlling for baseline.

RESULTS

A total of 218 patients (intervention: n=99 and control: n=119) were included in the intention-to-treat analysis. Compared with the control group, the intervention group reported greater reductions in distress (P=.03; ηp²=0.02), depression (P<.001; ηp²=0.07), anxiety (P=.03; ηp²=0.02), and fatigue (P=.04; ηp²=0.02). Per-protocol analyses revealed more pronounced treatment effects, with the exception of fatigue. No group difference was found for quality of life.

CONCLUSIONS

Mika effectively diminished distress in patients with cancer. As a digital therapeutic solution, Mika offers accessible, tailored psychosocial and self-management support to address the unmet needs in cancer care.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00026038; https://drks.de/search/en/trial/DRKS00026038.

Nortriptyline hydrochloride, a potential candidate for drug repurposing, inhibits gastric cancer by inducing oxidative stress by triggering the Keap1-Nrf2 pathway

Effective drugs for the treatment of gastric cancer (GC) are still lacking. Nortriptyline Hydrochloride (NTP), a commonly used antidepressant medication, has been demonstrated by numerous studies to have antitumor effects. This study first validated the ability of NTP to inhibit GC and preliminarily explored its underlying mechanism. To begin with, NTP inhibits the activity of AGS and HGC27 cells (Human-derived GC cells) in a dose-dependent manner, as well as proliferation, cell cycle, and migration. Moreover, NTP induces cell apoptosis by upregulating BAX, BAD, and c-PARP and downregulating PARP and Bcl-2 expression. Furthermore, the mechanism of cell death caused by NTP is closely related to oxidative stress. NTP increases intracellular reactive oxygen species (ROS) and malondialdehyde (MDA) levels, decreasing the mitochondrial membrane potential (MMP) and inducing glucose (GSH) consumption. While the death of GC cells can be partially rescued by ROS inhibitor N-acetylcysteine (NAC). Mechanistically, NTP activates the Kelch-like ECH-associated protein (Keap1)-NF-E2-related factor 2 (Nrf2) pathway, which is an important pathway involved in oxidative stress. RNA sequencing and proteomics analysis further revealed molecular changes at the mRNA and protein levels and provided potential targets and pathways through differential gene expression analysis. In addition, NTP can inhibited tumor growth in nude mouse subcutaneous tumor models constructed respectively using AGS and MFC (mouse-derived GC cells), providing preliminary evidence of its effectiveness in vivo. In conclusion, our study demonstrated that NTP exhibits significant anti-GC activity and is anticipated to be a candidate for drug repurposing.

Depressive symptoms and shorter survival in lung cancer: the role of leukocyte telomere length

OBJECTIVE

To examine the association between depressive symptoms, leukocyte telomere length-a marker of cellular ageing, and survival amongst lung cancer patients.

DESIGN

Patients with non-small cell lung cancer were recruited from a university-affiliated cancer center clinic.

MAIN OUTCOME

Patients (N = 67) reported on depressive symptoms and provided a blood sample for leukocyte telomere length assessment at baseline and at a 3-month follow-up. Survival status was tracked over 3 years.

RESULTS

Age at diagnosis and depressive symptoms, as measured by the CES-D, were associated with shorter leukocyte telomere length (p < .05), although only age at diagnosis contributed statistical significance to the model. Depressive symptoms predicted shorter survival from date of diagnosis (p < .01). Patients who reported experiencing clinically meaningful levels of depressive symptoms (CES-D scores ≥ 16) demonstrated shorter survival than those who reported sub-clinical levels of depressive symptoms (p < .05). Leukocyte telomere length did not emerge as a predictor of shorter survival.

CONCLUSION

Clinically meaningful levels of depressive symptoms are associated with shorter survival amongst lung cancer patients. These findings support the on-going efforts to screen all cancer patients for low mood and to investigate mechanisms linking depressive symptoms and shorter survival in cancer contexts.

The link between psychological distress and survival in solid tumor patients: A systematic review

PURPOSE

Research has demonstrated that solid tumor patients experience high levels of psychological distress at the time of diagnosis. While distress has been associated with many adverse clinical outcomes, little is known about how this symptom may influence the disease trajectory for cancer patients, affecting outcomes such as progression, recurrence, and survival. The purpose of this systematic review was to explore the literature linking distress with survival in solid tumor patients, which may guide future work exploring clinical outcomes as a function of distress.

METHODS

A systematic search of PubMed, Embase, and Web of Science was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with predefined eligibility criteria. Thirteen studies met the inclusion criteria and were selected for review.

RESULTS

Findings from this review demonstrated a weak-to-moderate relationship between cancer patients' experience of distress and overall survival, with most included studies (11/13) finding at least one predictive analysis to be significant when controlling for confounders. However, significant heterogeneity in the literature, particularly with study sample characteristics and varying methodologies, made direct comparisons across studies challenging.

CONCLUSION

Findings from this review suggest that psychological distress may have an impact on disease-related outcomes, including (but not limited to) survival. Future work should consider performing disease-specific analyses controlling for key prognostic factors to better understand the nuanced relationship between distress and clinical outcomes, which may allow further understanding of the biological underpinnings of this relationship and enable the development of targeted interventions for improving distress.

"You start feeling comfortable, you just start sharing:" A qualitative study of patient distress screening in Black and White patients with endometrial cancer

OBJECTIVES

Black patients with endometrial cancer are less likely to express distress and receive referrals for support services compared to White patients. We aim to characterize patient perceptions of the National Comprehensive Cancer Network Distress Thermometer and Problem List (NCCN DT & PL), a common distress screening tool, among Black and White patients with endometrial cancer and determine strategies to improve equity in referral to appropriate support services.

METHODS

We conducted semi-structured interviews with 15 Black and 15 White patients with endometrial cancer who reported varying levels of distress on the NCCN DT & PL. Interviews were audio-recorded, transcribed, evaluated through staged content analysis, and salient themes were compared by patient race.

RESULTS

The NCCN DT & PL was generally considered understandable, however the word "distress" could be alienating to participants who considered their stress to be less "drastic." Black participants mentioned fewer negative emotions such as worry and sadness in describing distress and spoke more often of a positive outlook. Additionally, Black participants emphasized the importance of relationship-building with clinicians for open communication on the NCCN DT & PL and clinical encounter. Finally, participants were divided on whether they would alter the way they completed the NCCN DT & PL given more information on cut off scores for referrals, but generally expressed a desire for more direct offers of support services.

CONCLUSIONS

Relationship-building, open communication around emotion, and longitudinal direct offers of support emerged as avenues to reduce inequities in referral to supportive services for patients with endometrial cancer.

Integrative Approaches to the Treatment of Cancer

A significant proportion of cancer patients use forms of complementary medicine or therapies. An integrative approach to cancer management combines conventional medicine with evidence-based complementary medicines/therapies and lifestyle interventions, for the treatment and prevention of disease and the optimisation of health. Its basis is a holistic one; to treat the whole person, not just the disease. It makes use of adjunct technologies which may assist the clinician in diagnosis of early carcinogenesis and monitoring of treatment effectiveness. Many factors contribute to the development of cancer including some which are largely modifiable by the patient and which oncologists may be in a position to advise on, such as stress, poor nutrition, lack of physical activity, poor sleep, and Vitamin D deficiency. An integrative approach to addressing these factors may contribute to better overall health of the patient and better outcomes. Evidence-based complementary medicine approaches include the use of supplements, herbal medicine, various practices that reduce stress, and physical therapies. Individualised to the patient, these can also help address the symptoms and signs associated with cancer and its orthodox treatment.

Psychedelic/entactogen‐assisted therapy for treatment of anxiety, depression and existential distress in adult palliative care

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the benefits and harms of psychedelic/entactogen‐assisted therapy compared to placebo or active comparators (e.g. antidepressants) for treatment of anxiety, depression, and existential distress in adult palliative care.

The effects of mindfulness-based interventions on symptoms of depression, anxiety, and cancer-related fatigue in oncology patients: A systematic review and meta-analysis

Objective

Mindfulness-based interventions (MBIs) are increasingly being integrated into oncological treatment to mitigate psychological distress and promote emotional and physical well-being. This review aims to provide the most recent evaluation of Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), and Mindfulness-Based Cancer Recovery (MBCR) treatments, in reducing symptoms of depression, anxiety and CRF in oncology populations.

Methods

A search using the following search terms was conducted: (mindful* OR mindfulness* OR mindfulness-based* OR MBI* OR MBCT OR MBSR OR MBCR) AND (Oncol* OR cancer OR neoplasm OR lymphoma OR carcinoma OR sarcoma) to obtain relevant publications from five databases: PsycINFO, PubMed, Embase, and MEDLINE by EC, and ProQuest Dissertations & Theses Global from January 2000 to February 2022. 36 independent studies (n = 1677) were evaluated for their overall effect sizes (using random-effects models), subgroup analyses, and quality appraisals. Evaluations were performed separately for non-randomized (K = 20, n = 784) and randomized controlled trials (K = 16, n = 893).

Results

The results showed that MBIs have significant medium effects in reducing symptoms of depression (Hedges’ g = 0.43), anxiety (Hedges’ g = 0.55) and CRF (Hedges’ g = 0.43), which were maintained at least three months post-intervention. MBIs were also superior in reducing symptoms of anxiety (Hedges’ g = 0.56), depression (Hedges’ g = 0.43), and CRF (Hedges’ g = 0.42) in oncology samples relative to control groups. The superiority of MBIs to control groups was also maintained at least three months post-intervention for anxiety and CRF symptoms, but not for depressive symptoms. The risk of bias of the included studies were low to moderate.

Conclusions

This review found that MBIs reduced symptoms of depression, anxiety and CRF in oncology populations.

Systematic review registration

PROSPERO: International Prospective Register of Systematic Reviews: CRD42020143286.

Distress screening in endometrial cancer leads to disparity in referral to support services

OBJECTIVES

Racial disparities in survival from endometrial cancer (EC) are well known. Cancer distress has also been associated with worse clinical outcomes. We characterized the association between race/ethnicity, patient distress reported on the National Comprehensive Cancer Network Distress Thermometer and Problem List (NCCN DT & PL), referral to support services, time to surgery, and acceptance of adjuvant therapy in patients with EC.

METHODS

We included patients presenting at an academic gynecologic oncology practice from 1/2013-6/2020 who had not received prior EC-directed treatment. Demographics, NCCN DT scores, and treatment details were abstracted from the electronic medical record. Difference in initial DT scores by race/ethnicity and treatment type was tested using general linear modeling. The significance of interaction effects was tested using linear mixed models and logistic regression.

RESULTS

393 non-Hispanic White (NHW) and 134 non-Hispanic Black (NHB) patients were included. Median distress scores were higher in NHW patients compared to NHB patients (4 vs. 2, p < 0.001); 51% of NHW patients qualified for referral to support services compared to 40% of NHB patients (p = 0.03). Distress scores were highest at initial appointment and declined over time in NHW patients regardless of treatment, but were initially low and remained low over time in NHB patients. There was no association of initial distress score with time to surgery or acceptance of adjuvant treatment (p-values >0.25).

CONCLUSIONS

An observed difference in NCCN DT leads to racial disparities in referral to support services. The NCCN DT may not adequately measure distress in NHB women with EC.

Cannabidiol (CBD) in Cancer Management

Simple Summary

Cannabidiol (CBD) is one of the main constituents of the plant Cannabis sativa. Surveys suggest that medicinal cannabis is popular amongst people diagnosed with cancer. CBD is one of the key constituents of cannabis, and does not have the potentially intoxicating effects that tetrahydrocannabinol (THC), the other key phytocannabinoid has. Research indicates the CBD may have potential for the treatment of cancer, including the symptoms and signs associated with cancer and its treatment. Preclinical research suggests CBD may address many of the pathways involved in the pathogenesis of cancers. Preclinical and clinical research also suggests some evidence of efficacy, alone or in some cases in conjunction with tetrahydrocannabinol (THC, the other key phytocannabinoid in cannabis), in treating cancer-associated pain, anxiety and depression, sleep problems, nausea and vomiting, and oral mucositis that are associated with cancer and/or its treatment. Studies also suggest that CBD may enhance orthodox treatments with chemotherapeutic agents and radiation therapy and protect against neural and organ damage. CBD shows promise as part of an integrative approach to the management of cancer.

Abstract

The plant Cannabis sativa has been in use medicinally for several thousand years. It has over 540 metabolites thought to be responsible for its therapeutic effects. Two of the key phytocannabinoids are cannabidiol (CBD) and tetrahydrocannabinol (THC). Unlike THC, CBD does not have potentially intoxicating effects. Preclinical and clinical research indicates that CBD has a wide range of therapeutic effects, and many of them are relevant to the management of cancer. In this article, we explore some of the potential mechanisms of action of CBD in cancer, and evidence of its efficacy in the integrative management of cancer including the side effects associated with its treatment, demonstrating its potential for integration with orthodox cancer care.

Psychosocial distress is dynamic across the spectrum of cancer care and requires longitudinal screening for patient-centered care

PURPOSE

Screening for cancer-related psychosocial distress is recommended for patients with cancer; however, data on the long-term prevalence of distress and its natural history in survivors are scarce, preventing recommendations for screening frequency and duration. We sought to evaluate longitudinal distress in cancer patients.

METHODS

We evaluated longitudinal distress screening data for patients with cancer treated or surveilled at our institution from 2010 to 2018. Anxiety, depression, insurance/financial, family, memory, and strength-related distress were separately assessed and analyzed. Multivariable logistic regression was utilized to evaluate factors associated with distress subtypes.

RESULTS

In 5660 patients, distress was the highest at diagnosis for anxiety, depression, financial, and overall distress. On multivariable analysis, factors independently associated with distress at diagnosis included younger age, female gender, disease site/stage, payor, and income, varying by subtype-specific analyses. Severe distress in at least one subtype persisted in over 30% of survivors surveyed through 10 years after diagnosis. Over half of patients with initially severe distress at diagnosis improved within 12 months; however, distress worsened in 20-30% of patients with moderate, low, and no initial distress, regardless of the distress subtype.

CONCLUSION

Psychosocial distress in cancer survivors is a long-lasting burden with implications for quality of life and oncologic outcomes. Severe distress remains prevalent through 10 years after diagnosis in survivors receiving continued care at cancer centers and results from both persistent and new sources of distress in a variety of psychosocial domains. Longitudinal distress screening is an invaluable tool for providing comprehensive patient-centered cancer care and is recommended to detect new or recurrent distress in cancer survivors.

Association of mental health diagnosis with race and all-cause mortality after a cancer diagnosis: Large-scale analysis of electronic health record data

BACKGROUND

Disparity in mental health care among cancer patients remains understudied.

METHODS

A large, retrospective, single tertiary-care institution cohort study was conducted based on deidentified electronic health record data of 54,852 adult cancer patients without prior mental health diagnosis (MHD) diagnosed at the University of California, San Francisco between January 2012 and September 2019. The exposure of interest was early-onset MHD with or without psychotropic medication (PM) within 12 months of cancer diagnosis and primary outcome was all-cause mortality.

RESULTS

There were 8.2% of patients who received a new MHD at a median of 197 days (interquartile range, 61-553) after incident cancer diagnosis; 31.0% received a PM prescription; and 3.7% a mental health-related visit (MHRV). There were 62.6% of patients who were non-Hispanic White (NHW), 10.8% were Asian, 9.8% were Hispanic, and 3.8% were Black. Compared with NHWs, minority cancer patients had reduced adjusted odds of MHDs, PM prescriptions, and MHRVs, particularly for generalized anxiety (Asian odds ratio [OR], 0.66, 95% CI, 0.55-0.78; Black OR, 0.60, 95% CI, 0.45-0.79; Hispanic OR, 0.72, 95% CI, 0.61-0.85) and selective serotonin-reuptake inhibitors (Asian OR, 0.43, 95% CI, 0.37-0.50; Black OR, 0.51, 95% CI, 0.40-0.61; Hispanic OR, 0.79, 95% CI, 0.70-0.89). New early MHD with PM was associated with elevated all-cause mortality (12-24 months: hazard ratio [HR], 1.43, 95% CI, 1.25-1.64) that waned by 24 to 36 months (HR, 1.18, 95% CI, 0.95-1.45).

CONCLUSIONS

New mental health diagnosis with PM was a marker of early mortality among cancer patients. Minority cancer patients were less likely to receive documentation of MHDs or treatment, which may represent missed opportunities to identify and treat cancer-related mental health conditions.

The Supportive Care Needs of Cancer Patients: a Systematic Review

Cancer, and the complex nature of treatment, has a profound impact on lives of patients and their families. Subsequently, cancer patients have a wide range of needs. This study aims to identify and synthesise cancer patients' views about areas where they need support throughout their care. A systematic  search of the literature from PsycInfo, Embase and Medline databases was conducted, and a narrative. Synthesis of results was carried out using the Corbin & Strauss "3 lines of work" framework. For each line of work, a group of key common needs were identified. For illness-work, the key needs idenitified were; understanding their illness and treatment options, knowing what to expect, communication with healthcare professionals, and staying well. In regards to everyday work, patients wanted to maintain a sense of normalcy and look after their loved ones. For biographical work, patients commonly struggled with the emotion impact of illness and a lack of control over their lives. Spiritual, sexual and financial problems were less universal. For some types of support, demographic factors influenced the level of need reported. While all patients are unique, there are a clear set of issues that are common to a majority of cancer journeys. To improve care, these needs should be prioritised by healthcare practitioners.

Prevalence of distress, its associated factors and referral to support services in people with cancer

AIMS AND OBJECTIVES

To (i) characterise prevalence of distress amongst people diagnosed with cancer, (ii) determine factors associated with increasing distress, (iii) describe reported problems for those with clinically significant distress and (iv) investigate the factors associated with referral to support services.

BACKGROUND

International studies report a high prevalence of clinically significant distress in people with cancer. Australian studies are notably lacking. Additionally, clinicians still do not fully understand the factors associated with cancer-related distress.

DESIGN

Period prevalence study.

METHODS

Distress screening data were analysed for 1,071 people accessing the Cancer Council Western Australia information and support line between 01/01/2016-31/12/2018. These data included people's demographics, cancer diagnoses, level of distress, reported problems and the service to which they were referred. Distress and reported problems were measured using the National Comprehensive Cancer Network Distress Thermometer and Problem List. A partial proportional logistic regression model was constructed to determine which factors were associated with increasing levels of distress. Standard binary logistic regression models were used to investigate factors associated with referral to support services. The STROBE checklist was followed.

RESULTS

Prevalence of clinically significant distress was high. Self-reported depression, sadness, worry and a lack of control over treatment decisions were significantly associated with increasing distress. Emotional problems were the most prevalent problems for people with clinically significant distress. Most people were referred to emotional health services, with depression, fatigue, living regionally and higher socioeconomic status associated with referral.

CONCLUSIONS

Emotional problems such as depression, sadness and worry are associated with increasing levels of distress.

RELEVANCE TO CLINICAL PRACTICE

Not all factors associated with referral to support services were those associated with increasing levels of distress. This suggests that other factors may be more influential to referral decisions.

Severe Reflux and Symptoms of Anxiety and Depression After Esophageal Cancer Surgery

BACKGROUND

Approximately 30% of patients suffer from severe reflux after surgery for esophageal cancer, which may serve as a continuous reminder of the cancer and catalyze fear of recurrence.

OBJECTIVE

The aim of this study was to investigate the association between severe reflux and symptoms of anxiety and depression after esophageal cancer surgery.

METHODS

This was a nationwide prospective cohort study including all Swedish patients who underwent esophageal cancer surgery between 2013 and 2018. Patients reported reflux on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire module for gastroesophageal symptoms and psychological distress on the Hospital Anxiety and Depression Scale at 1 and 2 years after surgery. Repeated-measures logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, body mass index, TNM classification, neoadjuvant therapy, surgery type, postoperative complications, antireflux medication, and elevated headrest at night.

RESULTS

Among 154 included patients, 43 (28%) and 37 (24%) reported severe reflux 1 and 2 years after surgery, respectively. No association between severe reflux and anxiety (OR, 2.1; 95% CI, 0.7-6.3) or depression (OR, 1.2; 95% CI, 0.3-4.6) was found 1 year after surgery. After 2 years, there was still no association between severe reflux and anxiety (OR, 0.9; 95% CI, 0.3-2.8) or depression (OR, 1.2; 95% CI, 0.5-3.3).

CONCLUSIONS

Findings suggest that severe reflux is not associated with anxiety or depression after esophageal cancer surgery.

IMPLICATIONS FOR PRACTICE

For esophageal cancer survivors, other factors than severe reflux may be more important for the psychological recovery.

Self-Care Efficacy-Mediated Associations Between Healthcare Provider-Patient Communication and Psychological Distress Among Patients With Gastrointestinal Cancers

BACKGROUND

Both healthcare provider-patient communication and self-care efficacy affect psychological distress, which is prevalent among patients with gastrointestinal (GI) cancers. It is essential to explore the underlying mechanism among them to relieve psychological distress.

OBJECTIVE

The aim of this study was to examine whether self-care efficacy mediated the association between healthcare provider-patient communication and psychological distress among patients with GI cancers.

METHODS

A cross-sectional study was conducted between March 2018 and May 2019 in China. In total, 219 patients with GI cancers were recruited before discharge from chemotherapy. Healthcare provider-patient communication was assessed by the revised Physician-Patient Communication Scale; patient self-care efficacy was assessed by the Strategies Used by People to Promote Health; and psychological distress was assessed by the Distress Thermometer and the Hospital Anxiety and Depression Scale. Mediation analyses were conducted to examine the mediating effect of self-care efficacy on the association between healthcare provider-patient communication and psychological distress.

RESULTS

A total of 54.34% of patients experienced psychological distress. Patients reported a mean score of 89.93 (SD, 13.81) for healthcare provider-patient communication and 93.91 (SD, 23.39) for self-care efficacy. Self-care efficacy completely mediated the association between healthcare provider-patient communication and psychological distress, and communication outcome was the only domain that significantly influenced self-care efficacy.

CONCLUSION

Psychological distress is prevalent among patients with GI cancers. Healthcare provider-patient communication, especially communication outcome, promoted patients' self-care efficacy to reduce psychological distress.

IMPLICATIONS FOR PRACTICE

Healthcare providers should design interventions to improve communication outcomes and eventually increase self-care efficacy to relieve psychological distress among patients with GI cancers.

Patient-reported distress and age-related stress biomarkers among colorectal cancer patients

OBJECTIVE

Distress among cancer patients has been broadly accepted as an important indicator of well-being but has not been well studied. We investigated patient characteristics associated with high distress levels as well as correlations among measures of patient-reported distress and "objective" stress-related biomarkers among colorectal cancer patients.

METHODS

In total, 238 patients with colon or rectal cancer completed surveys including the Distress Thermometer, Problem List, and the Hospital Anxiety and Depression Scale. We abstracted demographic and clinical information from patient charts and determined salivary cortisol level and imaging-based sarcopenia. We evaluated associations between patient characteristics (demographics, clinical factors, and psychosocial and physical measures) and three outcomes (patient-reported distress, cortisol, and sarcopenia) with Spearman's rank correlations and multivariable linear regression. The potential moderating effect of age was separately investigated by including an interaction term in the regression models.

RESULTS

Patient-reported distress was associated with gender (median: women 5.0, men 3.0, p < 0.001), partnered status (single 5.0, partnered 4.0, p = 0.018), and cancer type (rectal 5.0, colon 4.0, p = 0.026); these effects varied with patient age. Cortisol level was associated with "emotional problems" (ρ = 0.34, p = 0.030), anxiety (ρ = 0.46, p = 0.006), and depression (ρ = 0.54, p = 0.001) among younger patients. We found no significant associations between patient-reported distress, salivary cortisol, and sarcopenia.

CONCLUSIONS

We found that young, single patients reported high levels of distress compared to other patient groups. Salivary cortisol may have limited value as a cancer-related stress biomarker among younger patients, based on association with some psychosocial measures. Stress biomarkers may not be more clinically useful than patient-reported measures in assessing distress among colorectal cancer patients.

Psychiatric problems of anxiety and depression disorder are associated with medical service utilization and survival among patients with cervical cancer

OBJECTIVE

There are few nationwide studies regarding the long-term analysis of cervical cancer patients in Taiwan. Thus, this study aimed to evaluate medical service utilization, and survival among cervical cancer patients initially diagnosed with or without anxiety and/or depressive disorders.

MATERIALS AND METHODS

This was a retrospective longitudinal study using data from the National Health Insurance Research Database from 1996 to 2010. The study subjects were cervical cancer patients identified by ICD-9-CM codes 180.X, while subjects with anxiety and/or depressive disorders were identified using the following codes: 300.0X-300.9X (minus 300.4X) for anxiety disorder, and 296.2X, 296.3X, 300.4, and 311.X for depressive disorder. The cervical patients with anxiety or/and depression disorder were classified as anxiety/depression (AD) group or the non-disorder (ND) group. Propensity score matching (PSM) was used to adjust for differences between the AD and ND groups. T-tests were used to evaluate differences in medical utilization and the Kaplan-Meier method was used to evaluate survival conditions between the two groups. Statistical analyses were performed using SPSS Statistics 20.0.

RESULTS

A total of 3664 patients were identified, with 862 (23.5%) having anxiety, 149 (4.1%) with depression, and 349 (9.5%) having both anxiety and depression. In total, 1360 cervical cancer patients had anxiety/depression disorders. After PSM, the AD group had significantly more outpatient department (OPD) visits than the ND group (p < 0.001) but the survival status was better in the AD group than the ND group (p < 0.001).

CONCLUSIONS

Cervical cancer patients with anxiety/depression disorders visited the OPD more frequently than those without anxiety/depression disorders but had better survival status. Gynecologists should also consider cancer patients' mental status during follow-up, referring patients to psychiatric professionals for appropriate psychiatric care if appropriate.

Impact of employment and insurance status on distress in gynecologic oncology patients

OBJECTIVES

To study associations among employment, insurance status, and distress in gynecologic oncology patients; and to evaluate the impact of being unemployed or having no/Medicaid insurance on different distress problem areas.

METHODS

In this single institution, cross-sectional analysis of gynecologic oncology patients, we screened for distress and problem areas using the National Comprehensive Cancer Network distress thermometer and problem list at outpatient appointments between 6/2017-9/2017. Primary outcome was self-reported high distress (score ≥ 5). The distress problem list included 5 categories-practical, family, emotional, physical, and other. Employment status included employed, unemployed, homemaker, and retired. Logistic regression was used to predict high distress from employment and insurance statuses, adjusting for relevant covariates.

RESULTS

Of 885 women, 101 (11.4%) were unemployed, and 53 (6.0%) uninsured or had Medicaid coverage. One in five patients (n = 191, 21.6%) indicated high distress. Unemployed patients were more likely than employed to endorse high distress [adjusted odds ratio (aOR) = 3.5, 95% confidence interval (CI) 2.2-5.7, p < 0.001]. Compared to employed patients, a greater proportion of unemployed patients endorsed distress related to practical (p < 0.05), emotional (p < 0.001), physical (p < 0.01), and other (p < 0.05) problems. Uninsured/Medicaid patients were more likely to endorse high distress (aOR = 2.8, 95% CI 1.5-5.1, p < 0.001) and report family (p < 0.001), emotional (p < 0.001), and other (p < 0.01) problems than patients who had Medicare/commercial insurance.

CONCLUSIONS

Gynecologic oncology patients who are unemployed or have no/Medicaid insurance face high distress that appears to arise from issues beyond practical problems, including financial and/or insurance insecurities.

Psychological Distress in a Sample of Inpatients With Mixed Cancer-A Cross-Sectional Study of Routine Clinical Data

Background

The diagnosis and treatment of cancer are associated with psychological distress that often leads to a significant reduction in emotional and physical well-being and quality of life. Early detection of psychological distress is therefore important. This study aims to assess the psychological distress of inpatient cancer patients using routine clinical data. Furthermore, variables and problems most strongly associated with psychological distress should be identified.

Materials and Methods

N = 1,869 inpatients were investigated (mean age = 60.89 years; 35.94% female) using the National Comprehensive Cancer Network Distress Thermometer and problem checklist to assess distress as well as multiple possible problem areas. Visceral oncological cancer (31.6%) was the most common tumor diagnosis, followed by skin cancer (26.2%) and urological cancer (21.7%).

Results

65.9% of the sample experienced high levels of distress (Distress Thermometer ≥ 5). Female sex, stage 4 of disease, and visceral and head and neck cancer emerged as risk factors for high distress. A younger age (<65 years) was significantly correlated with higher distress. The most frequently self-reported problems were fears (50.1%), worry (49.9%), and fatigue (49.1%). Patients with all 3 of these problems had 24 times higher risk [odds ratio (OR) = 23.9] for high levels of distress than patients without these problems. Women reported significantly more practical, emotional, and physical problems than men. Younger (<50 years) and middle-aged patients (50-64 years) reported increased levels of practical, family, and emotional problems compared with older patients (≥65 years).

Discussion

Almost two-thirds of the sample reported high levels of distress. The most frequently reported problem areas were emotional and physical problems. These results can help to identify patients with high risk for psychological distress and, therefore, be used to optimize psychosocial and psycho-oncological care for patients with cancer.

Anxiety, Depression, and Colorectal Cancer Survival: Results from Two Prospective Cohorts

Given the unalterable nature of most risk factors for colorectal cancer (CRC) survival (e.g., disease stage), identifying modifiable determinants is critical. We investigated whether anxiety and depression were related to CRC survival using data from the Nurses' Health Study (NHS) and Health Professional Follow-up Study (HPFS). Participants who received a CRC diagnosis and provided information about anxiety (nNHS = 335; nHPFS = 232) and depression (nNHS = 893; nHPFS = 272) within 4 years of diagnosis were included. Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) of overall mortality, while controlling for covariates (sociodemographics, cancer characteristics, and lifestyle factors). Pooled risk estimates were derived from fixed effects meta-analyses of the cohorts. Among 1732 CRC patients, 814 deaths occurred during the 28-year follow-up. Each 1 standard deviation increase in anxiety or depression symptoms was associated with a similar 16% higher mortality risk (anxiety: 95% CI = 1.05-1.29; depression: 95% CI = 1.07-1.26). Comparable results were observed across all sensitivity analyses (introducing a 1-year lag, restricting to CRC-related mortality, considering potential behavioral pathways) and stratified models (cancer stage, sex). Our findings suggest greater anxiety and depression symptoms can not only impede adherence to healthy habits and reduce quality of life in cancer patients but could also be a marker for accelerated CRC progression.

Screening and Stepped Care Targeting Psychological Distress in Patients With Metastatic Colorectal Cancer: The TES Cluster Randomized Trial

BACKGROUND

This study evaluated the effectiveness of a screening and stepped care program (the TES program) in reducing psychological distress compared with care as usual (CAU) in patients with metastatic colorectal cancer starting with first-line systemic palliative treatment.

PATIENTS AND METHODS

In this cluster randomized trial, 16 hospitals were assigned to the TES program or CAU. Patients in the TES arm were screened for psychological distress with the Hospital Anxiety and Depression Scale and the Distress Thermometer/Problem List (at baseline and 10 and 18 weeks). Stepped care was offered to patients with distress or expressed needs, and it consisted of watchful waiting, guided self-help, face-to-face problem-solving therapy, or referral to specialized mental healthcare. The primary outcome was change in psychological distress over time, and secondary outcomes were quality of life, satisfaction with care, and recognition and referral of distressed patients by clinicians. Linear mixed models and effect sizes were used to evaluate differences.

RESULTS

A total of 349 patients were randomized; 184 received the TES program and 165 received CAU. In the TES arm, 60.3% of the patients screened positive for psychological distress, 26.1% of which entered the stepped care program (14.7% used only watchful waiting and 11.4% used at least one of the other treatment steps). The observed low use of the TES program led us to pursue a futility analysis, which showed a small conditional power and therefore resulted in halted recruitment for this study. No difference was seen in change in psychological distress over time between the 2 groups (effect size, -0.16; 95% CI, -0.35 to 0.03; P>.05). The TES group reported higher satisfaction with the received treatment and better cognitive quality of life (all P<.05).

CONCLUSIONS

As a result of the low use of stepped care, a combined screening and treatment program targeting psychological distress in patients with metastatic colorectal cancer did not improve psychological distress. Our results suggest that enhanced evaluation of psychosocial concerns may improve aspects of patient well-being.

Correlation between emotional regulation and peripheral lymphocyte counts in colorectal cancer patients

Background

Colorectal cancer is one of the most common cancers worldwide. Psychological morbidity has an important impact on quality of life and major clinical outcomes. Several data have shown that the immune system may be a key player on the relation between psychological features and cancer outcomes. Natural Killer (NK) cells have been shown to be influenced by psychological factors. The aim of this investigation was to assess the impact of anxiety, depression, and anger state, trait, and expression on the immune response, particularly, their effect on NK cells and CD8⁺ T cells in surgical colorectal cancer patients.

Methods

We studied 54 surgical colorectal cancer patients and assessed patients pre-surgically, post-surgically, and 12 months after surgery (follow-up). We applied the Hospital Anxiety and Depression Scale and the State-Trait Anger Expression Inventory and measured peripheral T cells, CD8⁺ T cells, and NK cells. We did a cross-sectional analysis as well as a longitudinal assessment of the variables during the follow-up period.

Results

Pre-surgical assessment: Trait anger, angry reaction, and anger-out had a significant negative correlation with NK cells. The lymphocytes values were unaffected by the presence of clinical anxiety or depression. Post-surgical assessment: Patients without clinical anxiety had higher levels of T cells. Angry reaction was negatively correlated with NK cells. Lymphocytes values were unaffected by the presence of clinical depression. Follow-up assessment: Patients without clinical depression had higher T cell counts. Trait anger and angry reaction were negatively correlated with the levels of NK cells. The lymphocytes values were unaffected by the presence of clinical anxiety. Longitudinal assessment: Angry-temperament, anger expression, and anger-in reduced significantly from the first to the second assessment. Anxiety, state anger, and trait anger significantly diminished from the pre-surgical to the follow-up assessment. Depression levels did not alter during the follow-up period. The lymphocyte count, and particularly T cells and CD8⁺ T cells, was significantly higher in the follow-up when compared with the pre-surgical assessment.

Conclusion

Our study suggests the existence of a relation between psychological response and immune response in colorectal cancer patients. We identified the importance of emotional regulation as a potential modulator for NK cell counts. Higher values of propensity to experience anger states and express them outwards seem to be associated with lower NK cell counts.

Depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-analysis of cohort studies

The link between depression and anxiety status and cancer outcomes has been well-documented but remains unclear. We comprehensively quantified the association between depression and anxiety defined by symptom scales or clinical diagnosis and the risk of cancer incidence, cancer-specific mortality, and all-cause mortality in cancer patients. Pooled estimates of the relative risks (RRs) for cancer incidence and mortality were performed in a meta-analysis by random effects or fixed effects models as appropriate. Associations were tested in subgroups stratified by different study and participant characteristics. Fifty-one eligible cohort studies involving 2,611,907 participants with a mean follow-up period of 10.3 years were identified. Overall, depression and anxiety were associated with a significantly increased risk of cancer incidence (adjusted RR: 1.13, 95% CI: 1.06-1.19), cancer-specific mortality (1.21, 1.16-1.26), and all-cause mortality in cancer patients (1.24, 1.13-1.35). The estimated absolute risk increases (ARIs) associated with depression and anxiety were 34.3 events/100,000 person years (15.8-50.2) for cancer incidence and 28.2 events/100,000 person years (21.5-34.9) for cancer-specific mortality. Subgroup analyses demonstrated that clinically diagnosed depression and anxiety were related to higher cancer incidence, poorer cancer survival, and higher cancer-specific mortality. Psychological distress (symptoms of depression and anxiety) was related to higher cancer-specific mortality and poorer cancer survival but not to increased cancer incidence. Site-specific analyses indicated that overall, depression and anxiety were associated with an increased incidence risks for cancers of the lung, oral cavity, prostate and skin, a higher cancer-specific mortality risk for cancers of the lung, bladder, breast, colorectum, hematopoietic system, kidney and prostate, and an increased all-cause mortality risk in lung cancer patients. These analyses suggest that depression and anxiety may have an etiologic role and prognostic impact on cancer, although there is potential reverse causality; Furthermore, there was substantial heterogeneity among the included studies, and the results should be interpreted with caution. Early detection and effective intervention of depression and anxiety in cancer patients and the general population have public health and clinical importance.

Economic evaluation of a combined screening and stepped-care treatment program targeting psychological distress in patients with metastatic colorectal cancer: A cluster randomized controlled trial

BACKGROUND

Psychological distress is highly prevalent among patients with metastatic colorectal cancer.

AIMS

To perform an economic evaluation of a combined screening and treatment program targeting psychological distress in patients with metastatic colorectal cancer in comparison with usual care.

DESIGN

Societal costs were collected alongside a cluster randomized controlled trial for 48 weeks. A total of 349 participants were included.

SETTING

Participants were recruited from oncology departments at 16 participating hospitals in the Netherlands.

METHODS

Outcome measures were the Hospital Anxiety and Depression Scale and quality-adjusted life-years. Missing data were imputed using multiple imputation. Uncertainty was estimated using bootstrapping. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated to show uncertainty surrounding the cost-effectiveness estimates. Sensitivity analyses were performed to check robustness of results.

RESULTS

Between treatment arms, no significant differences were found in Hospital Anxiety and Depression Scale score (mean difference: -0.058; 95% confidence interval: -0.13 to 0.011), quality-adjusted life-years (mean difference: 0.042; 95% confidence interval: -0.015 to 0.099), and societal costs (mean difference: -1152; 95% confidence interval: -5058 to 2214). Cost-effectiveness acceptability curves showed that the probability of cost-effectiveness was 0.64 and 0.74 at willingness-to-pay values of €0 and €10,000 per point improvement on the Hospital Anxiety and Depression Scale, respectively. The probability that the intervention was cost-effective compared to usual care for quality-adjusted life-years was 0.64 and 0.79 at willingness-to-pay values of €0 and €20,000 per quality-adjusted life-year, respectively.

CONCLUSION

The intervention is dominant over usual care, primarily due to lower costs in the intervention group. However, there were no statistically significant differences in clinical effects and the uptake of the intervention was quite low. Therefore, widespread implementation cannot be recommended.

Distress evaluation in a veteran affairs oncology clinic

Distress in oncology patients (pts) has a negative impact on quality of life, survival, and healthcare satisfaction. Higher distress leads to lower compliance with treatment and follow-up [1-8]. The 2012 American College of Surgeons Commission on Cancer (CoC) standard of care for oncology pts included an assessment for distress [1]. A screening process for distress allows the healthcare team to address these issues early and refer to appropriate resources [2-9]. This project was initiated to meet National Comprehensive Cancer Network (NCCN) and CoC standard of care, identify distress in veterans with cancer, and address these concerns. Patients who attended the Tuesday oncology clinic at the Dayton VAMC were given the NCCN Distress Thermometer (DT) during triage. The treating physician addressed problems identified. The Wilcoxon signed rank test and the Friedman test were used. DTs were completed by 296 pts from March to December 2016. Mean age was 68, 93% male, 83% white, 55% married, and 93% without PTSD. The distress level was not different from T1 through T3. Number of problems decreased over three time periods. Referrals to nutrition, mental health, and social work services increased over time. Although over time periods we found no decrease in distress scores, there was a decline in number of problems. The mean distress score at all but time 4 was < 4, which is considered mild distress. The mean distress score at T4 was 4.36 (n = 14), suggesting that the few pts who return to clinic more than three times may be experiencing more difficult personal and environmental circumstances. Patient sample ranged from those undergoing intensive cancer treatment (e.g., chemotherapy) to less intensive treatment (e.g., hormone injections) to those who completed treatment.

Quality of Life in Patients With Non-Small Cell Lung Cancer: Structural Equation Modeling

BACKGROUND

Quality of life (QOL) is important for cancer patients, even for survival. However, factors affecting QOL of non-small cell lung cancer (NSCLC) patients have not been studied sufficiently.

OBJECTIVE

The aims of this study were to understand the relationships among social support, resilience, distress, and symptom and to identify predictors of QOL for NSCLC patients.

METHODS

Participants were 212 adult patients who visited an outpatient department at a tertiary hospital located in Seoul, Korea. Data were collected using self-reported questionnaires and clinical records.

RESULTS

Social support, resilience, distress, symptom burden, and QOL explained 99.9% of the variance in QOL. Social support was not a significant predictor of distress and QOL, but a significant predictor of resilience. Resilience was a significant predictor of both distress and QOL. Distress was not a significant predictor of QOL, but a significant predictor of symptom burden. Symptom burden was a significant predictor of QOL and had the largest direct effect on QOL. Resilience also had an important impact on QOL because resilience influenced QOL in various paths.

CONCLUSION

This study suggests that social support, resilience, distress, and symptom burden are predictors of QOL in an NSCLC population. These predictors had direct and indirect effects on each other and on QOL.

IMPLICATIONS FOR PRACTICE

Developing an interventional program to increase resilience and social support as well as to decrease symptom burden and distress may be necessary to improve QOL of NSCLC patients.

What are the optimal measures to identify anxiety and depression in people diagnosed with head and neck cancer (HNC): a systematic review

BACKGROUND

A cancer diagnosis is potentially life-threatening, likely causing distress and uncertainty, which may be psychologically debilitating. Depression and anxiety are commonly underdiagnosed and undertreated in cancer patients. Head and neck cancer (HNC) patients face particular challenges that may contribute to distress. This review aims to: i) identify patient reported outcome measures (PROMs) designed to assess anxiety and depression in HNC; and ii) determine their suitability for use in research and clinical practice to screen patients.

METHODS

We searched five electronic databases between July 2007 to July 2019 for studies assessing anxiety and depression in HNC patients. Searches were limited to this period to account for advances in cancer treatment. Records were screened for eligibility by one reviewer and 10% cross-checked by a second across all stages of the review. In addition to the electronic searches, PROM databases were searched for additional measures of anxiety and depression. All retrieved PROMs were mapped against Diagnostic and Statistical Manual-5 criteria for anxiety and depression to assess content coverage. Then, their psychometric properties appraised against the COSMIN checklist.

RESULTS

Electronic searches identified 98 records, from which five anxiety and eight depression measures were retrieved. PROM database searches retrieved an additional four anxiety and four depression measures; a total of nine anxiety and 12 depression measures were appraised. Content coverage of anxiety measures ranged from 50% to 75% and depression measures from 42% to 100%. Demonstration of psychometric properties against COSMIN criteria ranged from 57% to 71% for anxiety measures (three PROMs > 70%) and from 29% to 86% for depression measures (nine PROMs > 70%). Three anxiety and seven depression measures had established clinical cut-offs in cancer populations.

CONCLUSIONS

The Patient Health Questionnaire-9, Zung Self-rating Depression and Zung Self-rating Anxiety Scales demonstrated good content coverage along with excellent psychometric properties, and thus were considered the most suitable PROMs to assess psychological distress in HNC populations. It is important to have PROMs assessing psychological distress that capture a comprehensive set of subjective symptoms. The identified PROMs will help researchers and health professionals in clinical-decision making, thereby potentially improving quality of life in HNC patients.

Cancer-work management during active treatment: towards a conceptual framework

PURPOSE

Forward progress in cancer treatment has resulted in fewer adverse consequences of cancer during and after treatment, offering employed cancer patients the possibility of continuing to work during treatment, returning to work after treatment, or implementing a combination of strategies to manage the cancer-work interface. Yet, much of the research on cancer and employment examines return to work as the primary outcome, neglecting to consider the circumstances of survivors who maintain employment while engaged in active treatment. We introduce the Cancer-Work Management Framework (CWMF), a conceptual framework for understanding the cancer and job demands survivors who continue to work during active treatment experience and how cancer and job resources and strategies could promote cancer-work fit and ultimately optimize employment and health outcomes.

METHODS

We provide an overview of the research describing the cancer-work management experiences of survivors who maintain employment during active treatment and summarize the theories that informed the CWMF including ecological systems, boundary-spanning, and job demands and resources theories.

RESULTS

The paper presents a description of the components of the CWMF which include cancer demands, cancer care resources and strategies, work demands, and workplace resources. We also describe a process-cancer-work fit-that reflects the interplay between demands and resources influence employment and health outcomes.

CONCLUSIONS

Future research directions for developing knowledge about the cancer-work management process are proposed with suggestions for study of how cancer and job demands influence cancer treatment and employment decisions.

Psychological distress at hospital admission is related to symptoms severity and health status in malignant pleural effusion patients

OBJECTIVE

The incidence and associated healthcare costs of malignant pleural effusion (MPE) are expected to rise, but there is limited evidence about which factors affect patients' prognosis. So, the aim of this study was to determine whether psychological distress at hospital admission is associated with symptom severity and health status in patients with MPE.

METHODS

A longitudinal observational prospective cohort study was carried out in the Pulmonology Service of the Granada University Hospital Complex in Granada, Spain. Patients diagnosed with MPE were included and evaluated at hospital admission, at discharge and at one month after discharge. Outcome measures included symptom severity (i.e. dyspnoea, pain and cough) and health status (functionality and self-perceived health status).

RESULTS

Significant differences were found in symptoms and the health status, with worse results in the group with psychological distress at discharge. One month after discharge, MPE patients with psychological distress exhibited greater symptoms, including more cough and dyspnoea (p < .05). Moreover, these patients showed worse functionality (p < .05) and self-perceived health status (p < .05).

CONCLUSION

Psychological distress is an important factor to take into account in patients with MPE. The presence of psychological distress appears to increase the symptoms and is associated with worse health status after hospitalisation.

Prospective Decision Analysis Study of Clinical Genomic Testing in Metastatic Breast Cancer: Impact on Outcomes and Patient Perceptions

PURPOSE

To evaluate the impact of targeted DNA sequencing on selection of cancer therapy for patients with metastatic breast cancer (MBC).

PATIENTS AND METHODS

In this prospective, single-center, single-arm trial, patients with MBC were enrolled within 10 weeks of starting a new therapy. At enrollment, tumor samples underwent next-generation sequencing for any of 315 cancer-related genes to high depth (> 500×) using FoundationOne CDx. Sequencing results were released to providers at the time of disease progression, and physician treatment recommendations were assessed via questionnaire. We evaluated three prespecified questions to assess patients' perceptions of genomic testing.

RESULTS

In all, 100 patients underwent genomic testing, with a median of five mutations (range, 0 to 13 mutations) detected per patient. Genomic testing revealed one or more potential therapies in 98% of patients (98 of 100), and 60% of patients (60 of 100) had one or more recommended treatments with level I/II evidence for actionability. Among the 94 genomic text reports that were released, there was physician questionnaire data for 87 patients (response rate, 92.6%) and 31.0% of patients (27 of 87) had treatment change recommended by their physician. Of these, 37.0% (10 of 27) received the treatment supported by genomic testing. We did not detect a statistically significant difference in time-to-treatment failure (log-rank P = .87) or overall survival (P = .71) among patients who had treatment change supported by genomic testing versus those who had no treatment change. For patients who completed surveys before and after genomic testing, there was a significant decrease in confidence of treatment success, specifically among patients who did not have treatment change supported by genomic testing (McNemar's test of agreement P = .001).

CONCLUSION

In this prospective study, genomic profiling of tumors in patients with MBC frequently identified potential treatments and resulted in treatment change in a minority of patients. Patients whose therapy was not changed on the basis of genomic testing seemed to have a decrease in confidence of treatment success.

Classical psychedelics for the treatment of depression and anxiety: A systematic review

BACKGROUND

Depression and anxiety are prevalent psychiatric disorders that carry significant morbidity. Pharmacological and psychosocial interventions are used to manage these conditions, but their efficacy is limited. Recent interest into the use of psychedelic-assisted therapy using ayahuasca, psilocybin or lysergic acid diethylamide (LSD) may be a promising alternative for patients unresponsive to traditional treatments. This review aims to determine the efficacy and tolerability of psychedelics in the management of resistant depression.

METHODS

Clinical trials investigating psychedelics in patients with depression and/or anxiety were searched via MEDLINE, EMBASE and PsychINFO. Efficacy was assessed by measuring symptom improvement from baseline, and tolerability was evaluated by noting the incidence and type of adverse effects reported. Risk of bias was assessed.

RESULTS

Seven studies, with 130 patients, were analysed in this review. Three were conducted in patients with depression, two in patients with anxiety and two in patients with both. In a supportive setting, ayahuasca, psilocybin, and LSD consistently produced immediate and significant anti-depressant and anxiolytic effects that were endured for several months. Psychedelics were well-tolerated. The most common adverse effects were transient anxiety, short-lived headaches, nausea and mild increases in heart rate and blood pressure.

LIMITATIONS

At present, the number of studies on this subject is very limited; and the number of participating patients within these is also limited as the treatment under investigations is a relatively novel concept.

CONCLUSIONS

Though further evidence is required, psychedelics appear to be effective in significantly reducing symptoms of depression and anxiety and are well-tolerated.

Patient-Reported Distress in Myelodysplastic Syndromes and Its Association With Clinical Outcomes: A Retrospective Cohort Study

Background: NCCN defines distress as a multifactorial, unpleasant emotional experience of a psychological nature that may interfere with patients' ability to cope with cancer symptoms and treatment. Patients with myelodysplastic syndromes (MDS) are at risk for distress due to the largely incurable nature of this hematopoietic malignancy and its symptom burden, yet associations with clinical outcomes are unknown. Methods: We retrospectively reviewed patient-reported distress data from adult ambulatory patients with MDS visiting a single, tertiary care medical center from July 2013 to September 2015. Demographic, diagnostic, treatment, and comorbidity information were abstracted from records along with NCCN Distress Thermometer (DT) and Problem List (PL) scores. Survival was analyzed using the Kaplan-Meier method and Cox proportional hazards regression. Results: We abstracted 376 DT scores (median, 1; range, 0-10) from 606 visits and 110 patients (median, 2 DT scores/patient; range, 1-16). NCCN Guidelines suggest that patients with DT scores ≥4 should be evaluated for referral to specialty services to address unmet needs. A total of 54 patients (49%) had at least 1 DT score ≥4 and 20 (18%) had 2 or more DT scores ≥4; 98 patients (89.1%) reported 1,379 problems during 23,613 person-days of follow-up (median, 4 problems/patient/visit; range, 1-23). The 5 most frequently reported problems were fatigue (181 times; 78 patients), pain (95 times; 46 patients), worry (80 times; 45 patients), sleep (78 times; 41 patients), and tingling hands/feet (68 times; 33 patients). After adjustment for risk stratification at diagnosis, a single point increase on the DT was associated with an increased risk of death (hazard ratio, 1.18; 95% CI, 1.01-1.36). Conclusions: Patients with MDS experience a high burden of distress, and patient-reported distress is associated with clinical outcomes. Distress should be further studied as a prognostic variable and a marker of unmet needs in MDS.

The Relationships Among Symptom Distress, Posttraumatic Stress Symptoms, and Depression in Patients With Female-specific Cancers

BACKGROUND

Previous studies have demonstrated that posttraumatic stress symptoms (PTSS) affect women with breast cancer. However, few studies have explored the relationships among PTSS, symptom distress, and depression in association with cancers specific to women in Taiwan.

OBJECTIVE

The aim of this study was to explore the relationships among symptom distress, PTSS, and depression in women given a diagnosis of female-specific cancers.

METHODS

A cross-sectional design was used, and 220 women given a diagnosis of female-specific cancer were recruited from a general hospital in southern Taiwan. The outcome measures included the subjects' scores on a symptom distress scale, the Chinese Davidson Trauma Scale, and the Center for Epidemiologic Studies-Depressive Scale; their personal characteristics; and disease-related variables.

RESULTS

There were significant positive relationships among the frequency of PTSS, the severity of PTSS, symptom distress, and depressive symptoms. Logistic regression analysis demonstrated that educational level, symptom distress, and the frequency of PTSS were significant predictors of depression.

CONCLUSIONS

The study demonstrated a high prevalence of depression in women with female-specific cancer, and the results confirm the relationship between PTSS and depression. In addition, educational level and physical distress were also found to be predictors of depression.

IMPLICATIONS FOR PRACTICE

Screening for depressive symptoms should be a component of routine screening in women with female-specific cancer. Oncology nurses should be aware of the distress symptoms experienced by these women and recognize PTSS in patients who are given a diagnosis of female-specific cancer. Awareness will reduce the multiple risks of posttraumatic stress disorder and depression and decrease the depressive symptoms of women after surviving cancer.

Pre-treatment quality of life as a predictor of distant metastasis-free survival and overall survival in patients with head and neck cancer who underwent free flap reconstruction

PURPOSE

This study examined the prognostic associations of pre-treatment quality of life (QoL) with overall survival (OS) and distant metastasis-free survival (DFMS) among patients with head and neck cancer (HNC) who underwent free flap reconstruction.

METHODS

A cohort of 127 HNC patients who received free flap reconstruction between November 2010 and June 2014 at a hospital were recruited. Pre-treatment QoL was measured by the University of Washington Quality of Life Questionnaire, which contains six physical domains, including speech, swallowing, appearance, saliva, taste and chewing, as well as the six social-emotional domains of pain, activity, recreation, shoulder, mood, and anxiety. Cox regression analyses were performed.

RESULTS

Results showed that pre-treatment QoL was predictive of OS and DMFS. Of the domains, swallowing, chewing, speech, taste, saliva, pain and shoulder were demonstrated to be significant predictors of OS. Additionally, swallowing, chewing, speech, pain and activity were demonstrated making significant contributions to DMFS.

CONCLUSION

Our data supported that physical domains of pre-treatment QoL were predictors for OS and DFMS in HNC patients with free-flap reconstruction. Longitudinal studies are warranted to clarify the prognostic abilities of social-emotional domains. Information on pre-treatment QoL should be taken into account to individualize care plan for these patients, and hence prolong their survival.

Self-Management Interventions for Psychological Distress in Adult Cancer Patients: A Systematic Review

Psychological distress is prevalent among cancer patients, who may be vulnerable to distress at times of transition, such as a change in symptom experience, employment, or goal of treatment. Independently, both psychological distress and transitions impair patients' quality of life, and together their adverse impact may be intensified. Self-management allows patients to engage in tasks that influence the disease experience and can include strategies to help mitigate distress associated with transitions. The purpose of this systematic review was to examine research on the relationship between self-management interventions and distress in adult cancer patients receiving active tumor-directed therapy. From a search of seven electronic databases, 5,156 articles were identified; however, nine studies met inclusion criteria. Our review suggested that self-management interventions may help address psychological distress in patients receiving cancer treatment but that the current evidence is not robust enough to support a definitive conclusion.

Addressing the psychosocial needs of cancer patients: a retrospective analysis of a distress screening and management protocol in clinical care

BACKGROUND

A growing recognition of the impact of distress on the quality of life and adherence to treatment of cancer patients has been documented. As a result, national guidelines and standards of care mandate providers to implement distress screening protocols to connect patients with psychosocial services. However, limited literature has examined whether distressed patients are referred to care and their needs addressed. This article assessed differences in rates of referral and psychosocial services by demographic factors, clinical characteristics, and distress severity. Potential predictors of these two outcomes were investigated.

METHODS

A retrospective analysis of patient data abstracted from electronic medical records of a NCI-designated Academic Comprehensive Cancer Center was conducted. Of the 399 cases meeting the inclusion criteria, 302 (75.7%) were screened for distress with the Distress Thermometer. Differences were examined with chi-square, t-tests, and ANOVAs. Predictors were identified with multivariate logistic regressions.

RESULTS

Overall, patients who were identified as distressed were referred to a psychosocial provider (71.4%) and psychosocial services were delivered in approximately 64% of the cases. Referrals and service delivery rates varied by age group, clinic, health insurance coverage, distress severity, and presence of psychosocial issues. Only the distress score predicted the likelihood of being referred, and of a provider intervention to occur. Conclusions and implications for psychosocial providers: Although the protocol appeared to facilitate referral and service delivery to patients scoring above the cutoff for distress, our results suggest that patients were more likely to not have their distress and psychosocial needs addressed if they were older, without insurance coverage, and were seen in clinics where a social worker was not consistently available. Future studies able to monitor patient outcomes in terms of quality of life, satisfaction with care, and service utilization are recommended.

The impact of marital status on survival in patients with surgically treated colon cancer

The aim of this study was to investigate the relationship between marital status and disease outcome in patients with surgically treated colon cancer. Between June 2010 and December 2015, a total of 925 patients with newly diagnosed colon cancer receiving curative resection were enrolled. The effect of marital status on 5-year disease-specific survival (DSS) was calculated using Kaplan-Meier method, and was compared by log-rank tests. A Cox regression model was used to find significant independent variables and determine whether marriage had a survival benefit in patients with colon cancer, using stratified analysis. Among these patients, 749 (80.9%) were married, and 176 (19.1%) were unmarried, including 42 (4.5%) never-married, 42 (4.5%) divorced/separated, and 93 (10.1%) widowed. There was no significant difference between the married and unmarried groups in cancer stage or adjuvant treatment. Married patients had better 5-year DSS compared with unmarried patients (69.1% vs 55.9%, P < .001). Uni- and multivariate analyses also indicated that unmarried patients had worse 5-year DSS after adjusting for various confounders (adjusted HR [aHR], 1.66; 95% CI, 1.24-2.22). Further stratified analysis according to demographic variables revealed that unmarried status was a significant negative factor in patients with the following characteristics: age >65 years, female sex, well/moderately differentiated tumor, and advanced tumor-node-metastasis (TNM) stage disease (III-IV). Thus, marriage has a protective effect, and contributes to better survival in patients with surgically treated colon cancer. Additional social support for unmarried colon cancer patients may lead to improve outcomes.

Screening for psychosocial distress among patients with cancer: implications for clinical practice, healthcare policy, and dissemination to enhance cancer survivorship

Accreditation standards are at the forefront of evolving healthcare systems, setting metrics for high-quality care. Healthcare outcomes (health, experience, cost, provider satisfaction/burn out) are becoming mutual goals of the patient, provider, payer, and healthcare system. Achieving high-quality outcomes in cancer care necessitates collaboration among interdisciplinary teams of clinical providers, administrators, patient advocates, caregivers, and researchers. Dissemination and implementation science provides necessary frameworks to organize the efforts of these implementation teams, inclusive of identifying facilitators and barriers to implementation of accreditation standards. Since 2015, cancer distress screening has been mandated for continued cancer center accreditation by the American College of Surgeon's Commission on Cancer. Cancer centers have thus become real world implementation laboratories. We present the current context of distress screening, highlighting prior research and key areas of future research. We consider multiple levels of cancer care delivery and the use of interdisciplinary teams to help cancer center teams adopt, implement, and maintain efficient distress screening programs. Finally, we present a case study to identify methods for successful implementation of distress screening at one cancer center and then describe efficiencies that can be introduced using elements from human factors engineering, e- and m-health screening platforms, and community partnerships.

Predictors for use of psychosocial services in patients with metastatic colorectal cancer receiving first line systemic treatment

BACKGROUND

Patients with advanced disease experience high levels of psychological distress, yet there is low uptake of psychosocial services offered to patients who screened positive for distress. In this study we aimed to identify predictors for use of psychosocial services in patients with metastatic colorectal cancer (mCRC) receiving first line chemotherapy enrolled in a prospective cluster randomized trial (CRT).

METHODS

Patients completed measures on psychological distress, physical distress, and quality of life at baseline. Demographics, clinical characteristics at baseline and clinical events during treatment (e.g. severe adverse events, clinical benefit) were extracted from patient records. Patients reported psychosocial service utilization in- and outside the hospital after 10, 24 and 48 weeks of treatment. Multivariable logistic regression models were used to identify predictors for the use of psychosocial services.

RESULTS

Out of 349 patients, seventy patients (20.0%) used psychosocial support services during the follow-up period. Use of psychosocial services was associated with younger age, a higher educational level, presence of more pain (at baseline), and the expressed need to talk to a professional (at baseline). In addition, patients without progressive disease within the first ten weeks of treatment were more likely to use psychosocial services .

CONCLUSIONS

One in five patients with mCRC receiving first line palliative treatment used psychosocial services during this prospective longitudinal CRT. Sociodemographic factors (age, education), clinical factors (pain and no progressive disease) and the expressed need to talk to a professional predicted use of psychosocial services. Identification of these predictors may contribute to the understanding of factors that determine the need for psychosocial services.

TRIAL REGISTRATION

Netherlands Trial Register NTR4034 .

Positive and negative affect and well-being in cardiac patients and their spouses: the mediating role of illness representations

OBJECTIVE

The aim of this study was to examine whether illness representations of control and consequences mediate the relation of cardiac patients' affect to well-being. A further aim was to examine this indirect relationship at a dyadic level (i.e. patient and spouse).

DESIGN AND MAIN OUTCOME MEASURES

One hundred and four patients with a cardiovascular disease and their spouses participated in the study. Positive and negative affect was assessed at baseline; illness representations were assessed 2 months later, and physical and psychological well-being 4 months later.

RESULTS

Illness representations generally mediated the impact of patients' and spouses' affect on well-being, while several actor and partner effects were found. However, it was only positive affect that was indirectly related to well-being, while the representations of personal and treatment control chiefly acted as mediators. The effects were stronger for patients than spouses, as well as for physical well-being.

CONCLUSION

The results underline the strong connection between illness-related self-regulation and the overall person/environment interaction as depicted by affect. They also indicate the need to integrate theories on adaptation to illness, with models describing adaptation of couples to stressful conditions, and specific theories about the role of emotion in adaptation to illness.

Standardized Screening and Psycho-oncological Treatment of Orthopedic Cancer Patients

BACKGROUND/AIM

Psycho-oncological distress is a relevant clinical problem. The aim of this study was to administer a standardized psycho-oncological distress screening for early identification and indication-based treatment of highly distressed orthopedic cancer patients as well as the evaluation of distress patterns.

PATIENTS AND METHODS

In total, 35 patients with cancer were psycho-oncologically screened using a cancer-specific expert rating scale (Basic Documentation for Psycho-Oncology Short Form) at three different time points (day of admission, day before discharge, 3 months postoperatively). Psycho-oncological support was offered to all patients whose distress exceeded a defined cut-off value.

RESULTS

Levels of distress in approximately 51% of patients exceeded the cut-off value at the time of admission and these patients received psycho-oncological support. The high distress levels decreased significantly over time. Patients whose distress did not exceed the cut-off value at the first assessment showed low distress levels at all time points.

CONCLUSION

A relevant number of orthopedic tumor patients suffer from psychosocial distress. Standardized screening might help to identify and adequately treat those patients.

Patient-reported distress in Hodgkin lymphoma across the survivorship continuum

Purpose

Hodgkin lymphoma (HL) survivors face long-term, elevated risk of treatment-related sequelae, including psychosocial distress associated with poor health outcomes. The magnitude and sources of distress are not well described in the routine care of HL outside of clinical trials.

Methods

We conducted a retrospective cohort study of patients visiting a tertiary-care center for treatment or long-term follow-up of HL. Patient-reported distress was documented using the National Comprehensive Cancer Network Distress Thermometer (DT) and Problem List. Three survivor groups were compared using descriptive methods: on treatment, surviving < 5 years, and surviving ≥ 5 years since diagnosis.

Results

A total of 1524 DT were abstracted for 304 patients (106 on treatment, 77 surviving < 5 years, and 121 surviving ≥ 5 years). Distress was low overall (median DT = 1, inter-quartile range 0–4) and was similar across survivor groups. However, actionable distress (score ≥ 4) was reported at 29.5% of clinical encounters. Patients on treatment more frequently reported actionable distress (32.5% of visits) compared with patients surviving < 5 years (20.4%) and ≥ 5 years (28.7%) (P = 0.065). Distress was associated primarily with physical and emotional problems, especially fatigue, worry, and sleep. We did not observe any associations between distress and clinical prognostic factors.

Conclusions

Distress burden is low in HL, but survivorship is marked by periods of actionable distress, largely related to physical symptoms and emotional issues. This burden may be higher when on treatment and is unrelated to disease-related prognostic factors. Survivorship research typically focuses on the post-therapy period, but our results support testing the efficacy of interventions to address distress in HL during active treatment as well.

Depressive symptoms in relation to overall survival in people with head and neck cancer: A longitudinal cohort study

OBJECTIVE

The objective of the study is to investigate the relation between pretreatment depressive symptoms (DS) and the course of DS during the first year after cancer diagnosis, and overall survival among people with head and neck cancer (HNC).

METHODS

Data from the Head and Neck 5000 prospective clinical cohort study were used. Depressive symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) pretreatment, at 4 and 12-month follow-up. Also, socio-demographic, clinical, lifestyle, and mortality data were collected. The association between before start of treatment DS (HADS-depression > 7) and course (never DS, recovered from DS, or persistent/recurrent/late DS at 12-month follow-up) and survival was investigated using Cox regression. Unadjusted and adjusted analyses were performed.

RESULTS

In total, 384 of the 2144 persons (18%) reported pretreatment DS. Regarding DS course, 63% never had DS, 16% recovered, and 20% had persistent/recurrent/late DS. People with pretreatment DS had a higher risk of earlier death than people without DS (hazard ratio (HR) = 1.65; 95% confidence interval (CI) 1.33-2.05), but this decreased after correcting for socio-demographic, clinical, and lifestyle-related factors (HR = 1.21; 95% CI 0.97-1.52). Regarding the course of DS, people with persistent/recurrent/late DS had a higher risk of earlier death (HR = 2.04; 95% CI 1.36-3.05), while people who recovered had a comparable risk (HR = 1.12; 95% CI 0.66-1.90) as the reference group who never experienced DS. After correcting for socio-demographic and clinical factors, people with persistent/recurrent/late DS still had a higher risk of earlier death (HR = 1.66; 95% CI 1.09-2.53).

CONCLUSIONS

Pretreatment DS and persistent/recurrent/late DS were associated with worse survival among people with HNC.

Therapeutic use of classic psychedelics to treat cancer-related psychiatric distress

Cancer is highly prevalent and one of the leading causes of global morbidity and mortality. Psychological and existential suffering is common in cancer patients, associated with poor psychiatric and medical outcomes. Promising early-phase clinical research (1960s to early 1970s) suggested a therapeutic signal for serotoninergic psychedelics (e.g. psilocybin, LSD) in treating cancer-related psychiatric distress. After several decades of quiescence, research on psychedelic-assisted therapy to treat psychiatric disorders in cancer patients has resumed within the last 2 decades in the US and Europe. This review article is based on a systematic search of clinical trials from 1960-2018 researching the therapeutic use of psychedelic treatment in patients with serious or terminal illnesses and related psychiatric illness. The search found 10 eligible clinical trials, with a total of 445 participants, with the vast majority of the patients having advanced or terminal cancer diagnoses. Six open label trials, published between 1964 and 1980 (n = 341), suggested that psychedelic therapy (mostly with LSD) may improve cancer-related depression, anxiety, and fear of death. Four RCTs trials were published between 2011 and 2016 (n = 104), mostly with psilocybin treatment (n = 92), and demonstrated that psychedelic-assisted treatment can produce rapid, robust, and sustained improvements in cancer-related psychological and existential distress.