The Effects of Cognitive-Behavioral Stress Management for Breast Cancer Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Cognitive-behavioral stress management relieves anxiety, depression, and post-traumatic stress disorder in parents of pediatric acute myeloid leukemia patients: a randomized, controlled study

OBJECTIVES

Cognitive-behavioral stress management (CBSM) is an effective psychological intervention to relieve psychological and symptomatic distress. This study aimed to investigate the effect of CBSM in anxiety, depression, and post-traumatic stress disorder (PTSD) in parents of pediatric acute myeloid leukemia (AML) patients.

METHODS

Totally, 56 pediatric AML patients and 100 parents were randomized into the CBSM group (28 patients and 49 parents) and the normal control (NC) group (28 patients and 51 parents) to receive corresponding interventions for 10 weeks. The questionnaire scores were assessed at month M0, M1, M3, and M6.

RESULTS

In parents of pediatric AML patients, self-rating anxiety scale score at M1 (p = 0.034), M3 (p = 0.010), and M6 (p = 0.003), as well as anxiety at M3 (p = 0.036) and M6 (p = 0.012) were decreased in the CBSM group versus the NC group. Self-rating depression scale score at M3 (p = 0.022) and M6 (p = 0.002), as well as depression at M6 (p = 0.019) were declined in the CBSM group versus the NC group. Symptom checklist-90 (a psychotic status questionnaire) score at M3 (p = 0.031) and M6 (p = 0.019) were declined in the CBSM group versus the NC group. Regarding PTSD, the impact of the events scale-revised score at M3 (p = 0.044) and M6 (p = 0.010) were decreased in the CBSM group versus the NC group. By subgroup analyses CBSM (versus NC) improved all outcomes in parents with anxiety at M0 and depression at M0 (all p < 0.050), but could not affect the outcomes in parents without anxiety or depression at M0 (all p > 0.050).

CONCLUSION

CBSM reduces anxiety, depression, and PTSD in parents of pediatric AML patients.

Cognitive behavioral stress management is an effective intervention to relieve anxiety and depression, improve the quality of life in patients with cervical cancer

BACKGROUND

Cognitive behavioral stress management (CBSM) modifies individuals' maladaptive cognition and improves their ability in managing stress. The present study was to inquire about the utility of CBSM in mental health and quality of life in patients with cervical cancer.

METHODS

Totally, 172 postoperative cervical cancer patients were randomly classified into CBSM (N=86) and normal care group (N=86) to receive 8-week CBSM and normal care, correspondingly. Self-rating anxiety/depression scale (SAS/SDS), EuroQol-5 dimensions (EQ-5D), EuroQol-visual analogue scale (EQ-VAS), and quality of life questionnaire-core 30 (QLQ-C30) scores were evaluated at discharge (M0), 1st month (M1), M3, and M6 after discharge.

RESULTS

SAS scores at M6 (P=0.003), M1 (P=0.042), and M3 (P=0.010), and the proportion of patients with SAS-defined anxiety at M3 (P=0.040) and M6 (P=0.019) were reduced in CBSM group versus normal care group. SDS scores at M3 (P=0.020) and M6 (P=0.016), and the proportion of patients with SDS-defined depression at M6 (P=0.036) was descended in CBSM group versus normal care group. EQ-VAS score at M1 (P=0.044), M3 (P=0.014), and M6 (P=0.002) were increased, while EQ-5D score at M3 (P=0.030) was descended in CBSM group versus normal care group. Meanwhile, QLQ-C30 global health status score at M1 (P=0.046), M3 (P=0.037), and M6 (P=0.007), QLQ-C30 function score at M3 (P=0.033) and M6 (P=0.016) were ascended, but QLQ-C30 symptom score at M3 (P=0.042) was declined in CBSM group versus normal care group.

CONCLUSION

CBSM is an effective intervention for decreasing anxiety and depression, and improving quality of life in patients with cervical cancer.

Cognitive-behavioral stress management program reduces postoperative psychological pressure and improves life quality in prostate cancer patients

OBJECTIVE

Cognitive-behavioral stress management (CBSM) improves mental status and quality of life (QoL) in cancer patients, while its impact on prostate cancer (PC) patients remains unknown. Thus, the study aimed at investigating the potency of CBSM program in ameliorating postoperative anxiety, depression, and QoL in PC patients.

METHODS

Totally, 160 postoperative PC patients were consecutively recruited followed by random assignments to either CBSM (N = 81) or usual care (UC) (N = 79) group as a 1:1 ratio. The patients received the corresponding interventions for 10 weeks then were followed up for 6 months.

RESULTS

CBSM group presented lower Hospital Anxiety and Depression Scale (HADS)-anxiety score and anxiety rate at month (M) 4 and M6 versus UC group (all P < 0.05), but not at M0, M1, and M2. Meanwhile, CBSM group exhibited a lower HADS-depression score versus UC group at M6 (P = 0.036) but no other timepoints; however, CBSM group showed no difference in depression rate versus UC group at any timepoints. Regarding the Quality-of-Life Questionnaire-Core30 (QLQ-C30) evaluation, CBSM group exhibited higher global health status scores at M1 (P = 0.010), M2 (P = 0.001), M4 (P = 0.029), and M6 (P = 0.015), higher functions score at M4 (P = 0.040) and M6 (P = 0.044), but a lower symptom score at M4 (P = 0.034) versus UC group; meanwhile, the above QoL indexes were not different at other timepoints between CBSM and UC groups.

CONCLUSION

CBSM serves as an effective caring program in relieving anxiety and depression as well as improving the QoL in postoperative PC patients.

Peri-operative individually tailored psychological intervention in breast cancer patients improves psychological indices and molecular biomarkers of metastasis in excised tumors

Perioperative stress and inflammatory signaling can invigorate pro-metastatic molecular processes in patients' tumors, potentially worsening long-term survival. Yet, it is unknown whether pre-operative psychotherapeutic interventions can attenuate such effects. Herein, three weeks before surgery, forty women diagnosed with stage I-III invasive ductal/lobular breast carcinoma were randomized to a 6-week one-on-one psychological intervention (6 meetings with a medical psychologist and bi-weekly phone calls) versus standard nursing-staff-attention. The intervention protocol was individually tailored based on evaluation of patients' emotional, cognitive, physiological, and behavioral stress response-patterns, and also included psychoeducation regarding medical treatments and recruitment of social support. Resected primary tumors were subjected to whole-genome RNA sequencing and bioinformatic analyses, assessing a priori hypothesized cancer-relevant molecular signatures. Self-report questionnaires (BSI-18, Hope-18, MSPSS, and a stress-scale) were collected three (T1) and one (T2) week before surgery, a day before (T3) and after (T4) surgery, and three weeks (T5) and 3-months (T6) following surgery. The intervention reduced distress (GSI), depression, and somatization scores (BSI-18: p < 0.01, p < 0.05, p < 0.05; T5 vs. T1). Additionally, tumors from treated patients (vs. controls) showed: (i) decreased activity of transcription control pathways involved in adrenergic and glucocorticoid signaling (CREB, GR) (p < 0.001), pro-inflammatory signaling (NFkB) (p < 0.01), and pro-malignant signaling (ETS1, STAT and GATA families) (p < 0.001, p < 0.01, p < 0.005); (ii) increased M1 macrophage polarization (p < 0.05), and CD4+ T cell activity (p < 0.01); and an unexpected increase in epithelial-to-mesenchymal-transition (EMT) signature (p < 0.005). This is the first randomized controlled trial to show beneficial effects of a psychological perioperative intervention on tumor pro-metastatic molecular biomarkers.

Mindfulness, coping, and optimism as mechanisms of change in the 3RP-NF intervention

INTRODUCTION

Neurofibromatosis (NF) is chronic neurogenetic condition that increases risk for poor quality of life, depression, and anxiety. Given the lack of biomedical treatments, we developed the "Relaxation Response Resiliency for NF" (3RP-NF) program to improve psychosocial outcomes among adults with NF.

OBJECTIVE

To move toward effectiveness testing, we must understand mechanisms that explained treatment effects. We tested whether our hypothesized mechanisms of change-mindfulness, coping, and optimism-mediated improvements in quality of life, depression, and anxiety among adults in the 3RP-NF program (N = 114; ages 18-70; 72.80% female; 81.58% White).

METHODS

We conducted mixed-effects models to assess whether these mechanisms uniquely mediated outcomes.

RESULTS

Improvements in quality of life were most explained by coping, (b = 0.97, SE = 0.28, CI [0.45, 1.56]), followed by mindfulness (b = 0.46, SE = 0.17, CI [0.15, 0.82]) and optimism (b = 0.39, SE = 0.12, CI [0.17, 0.65]). Improvements in depression and anxiety were most explained by mindfulness (b = -1.52, SE = 0.38, CI [-2.32, -0.85], CSIE = -0.26; b = -1.29, SE = 0.35, CI [-2.04, -0.67], CSIE = -0.23), followed by optimism (b = 0.39, SE = 0.12, CI [0.17, 0.65]; b = -0.49, SE = 0.20, CI [-0.91, -0.13]), but were not explained by coping (b = 0.22, SE = 0.43, CI [-0.62, 1.07]; b = 0.06, SE = 0.46, CI [-0.84, 0.97]), respectively.

CONCLUSIONS

Targeting mindfulness, coping, and optimism in psychosocial interventions may be a promising way to improve the lives of adults with NF.

Breast Cancer in the Tissue of the Contralateral Breast Reduction

Breast cancer is the most prevalent malignancy among women worldwide, and the increasing number of survivors is due to advances in early diagnosis and treatment efficacy. Consequently, the risk of developing contralateral breast cancer (CBC) among these survivors has become a concern. While surgical intervention with lumpectomy is a widely used primary approach for breast cancer, post-operative breast asymmetry is a potential concern. Many women opt for symmetrizing reduction procedures to improve aesthetic outcomes and quality of life. However, despite careful radiological screening, there is a chance of accidentally finding CBC. To address this, tissue excised during symmetrizing surgery is examined pathologically. In some cases, CBC or in situ lesions have been incidentally discovered in these specimens, prompting a need for a more thorough examination. Resection in pieces and the absence of surgical marking and pathological inking of the margin have made it challenging to precisely identify tumor location and assess tumor size and margin status, hampering adjuvant treatment decisions. A new protocol introduced in July 2022 aims to enhance the precision of CBC diagnosis, allowing for tailored treatment plans, including re-excision, systemic adjuvant therapy, or radiation therapy.

Depression, Cancer, Inflammation, and Endogenous Opioids: Pathogenic Relationships and Therapeutic Options

Endogenous opioids and their associated receptors form a system that maintains survival by positively reinforcing behaviors that are vital to life. Cancer and cancer treatment side effects capitalize on this system pathogenically, leading to maladaptive biological responses (e.g., inflammation), as well as cognitive and emotional consequences, most notably depression. Psychologists who treat people with cancer frequently find depression to be a primary target for intervention. However, in people with cancer, the etiology of depression is unique and complex. This complexity necessitates that psycho-oncologists have a fundamental working knowledge of the biological substrates that underlie depression/cancer comorbidity. Building on other chapters in this volume pertaining to cancer and endogenous opioids, this chapter focuses on the clinical applications of basic scientific findings.

Advances in the care of breast cancer survivors

Breast cancer survivors may experience significant after effects from diagnoses of breast cancer and cancer directed therapies. This review synthesizes the evidence about optimal management of the sequelae of a diagnosis of breast cancer. It describes the side effects of chemotherapy and endocrine therapy and evidence based strategies for management of such effects, with particular attention to effects of therapies with curative intent. It includes strategies to promote health and wellness among breast cancer survivors, along with data to support the use of integrative oncology strategies. In addition, this review examines models of survivorship care and ways in which digital tools may facilitate communication between clinicians and patients. The strategies outlined in this review are paramount to supporting breast cancer survivors' quality of life.

Psychological Aspects of Breast Cancer

Breast cancer is the most commonly diagnosed cancer in women. Associated psychological symptoms include stress, adjustment difficulties, anxiety, depression, impaired cognitive function, sleep disturbances, altered body image, sexual dysfunction, and diminished overall well-being. Distress screening and assessment identifies women who will benefit from therapeutic interventions. Addressing these symptoms improves compliance with treatment and outcomes including disease-related outcomes, psychological symptoms, and quality of life. The most effective treatments include teaching coping skills such as expressing emotion, along with other structured cognitive behavioral, interpersonal, and mindfulness approaches. Patients should be provided these psychosocial supports throughout their cancer journey.

The impact of a stress management intervention including cultural components on stress biomarker levels and mental health indicators among indigenous women

We examined the effectiveness of a 26-week culture-inclusive intervention on reducing salivary stress biomarker levels, and perceived stress, depressive, and post-traumatic stress disorder (PTSD) symptoms measured using scales in 53 Indigenous women in Ontario, Canada. Statistical analyses compared the average biomarker levels, and the area under the curve (AUC) of biomarkers. Differences in biomarkers and mental health scale scores pre- and post-intervention were compared using mixed models with a random intercept. Interaction terms were included between the intervention and age, education, disability, and HIV status, individually, to test for sub-group differences. Cortisol AUC post-intervention was decreased compared to pre-intervention (β -1.29 µg/dL; 95%CI -2.35, -0.23). There was a slight decrease in perceived stress levels (aOR: -2.80; 95%CI -5.09, -0.50). The associations were stronger among women of younger age, higher education, and no disabilities. These interventions can be effective, but future interventions should target Indigenous population sub-groups to address individual needs.

Predictors of initial engagement with an asynchronous cognitive behavioral stress management website among older women with nonmetastatic breast cancer

PURPOSE

Digital interventions, like websites, offer greater access to psychosocial treatments; however, engagement is often suboptimal. Initial use may be a target to "hook" participants. Few studies examine engagement with cognitive behavioral stress management (CBSM). We tested predictors of engagement in the first week of using a CBSM website among women with breast cancer (BC).

METHODS

Older women (≥ 50 years) with nonmetastatic BC enrolled in an on-going trial (8/2016-4/2022, #NCT03955991) and were randomized to receive 10 synchronous, virtual CBSM group sessions immediately (n = 41) or after a 6-month waitlist (n = 34). All received simultaneous access to an asynchronous website, where supplemental videos and resources were released weekly. Engagement was tracked via breadth (features used) and depth (clicks within content). Multilevel modeling tested predictors of engagement (i.e., time, condition, age, daily stress, depression, race, ethnicity, disease stage).

RESULTS

Breadth decreased over the first week of CBSM (b = -0.93, p < .01), and women with more advanced stage disease engaged with more breadth (b = 0.52, p < .01) and depth (b = 14.06, p < .01) than women with earlier stage disease. Non-Hispanic (b = -0.59, p = .03) and White (b = -0.97, p < .01) women engaged with more features. Cancer stage and intervention timing interacted. Women with more advanced cancer stage who received CBSM later engaged with the most depth (b = -11.73, p = .04). All other characteristics did not predict engagement.

CONCLUSIONS

Disease stage, race, ethnicity, and intervention timing predicted engagement with a CBSM website in older BC patients.

IMPLICATIONS FOR CANCER SURVIVORS

Delivering CBSM later in cancer treatment may mitigate competing demands. Fostering greater engagement in racial/ethnic minorities is needed.

Central Sensitization in Cancer Survivors and Its Clinical Implications: State of the Art

Although the prevalence of cancer pain is 47% after treatment, cancer pain is often underestimated, and many patients are undertreated. The complexity of cancer pain contributes to the lack of its management. Recently, as the mechanism of cancer pain, it has become clear that central sensitization (CS) influences chronic pain conditions and the transition from acute to chronic pain. In this state-of-the-art review, we summarized the association of CS or central sensitivity syndrome with pain and the treatment for pain targeting CS in cancer survivors. The management of patients with CS should not only focus on tissue damage in either the affected body regions or within the central nervous system; rather, it should aim to target the underlying factors that sustain the CS process. Pain neuroscience education (PNE) is gaining popularity for managing chronic musculoskeletal pain and could be effective for pain and CS in breast cancer survivors. However, there is a study that did not demonstrate significant improvements after PNE, so further research is needed. Precision medicine involves the classification of patients into subgroups based on a multifaceted evaluation of disease and the implementation of treatment tailored to the characteristics of each patient, which may play a central role in the treatment of CS.

Anxiety, depression, and quality of life in postoperative non-small cell lung cancer patients under the intervention of cognitive-behavioral stress management

Objective

Cognitive-behavioral stress management (CBSM) is a psychotherapy that helps patients cognize and manage stress to improve mental health and quality of life. This study aimed to explore the influence of CBSM on anxiety, depression, and quality of life in non-small cell lung cancer (NSCLC) patients.

Methods

In total, 172 NSCLC patients who received tumor resection were randomized 1:1 into the usual care (UC) group (N = 86) and CBSM group (N = 86) to receive 10-week UC and CBSM interventions. Moreover, all participants attended a 6-month follow-up.

Results

Hospital Anxiety and Depression Scales (HADS)-anxiety score at 3^rd month (M3) (P = 0.015) and 6^th month (M6) (P = 0.018), HADS-depression score at M3 (P = 0.040) and M6 (P = 0.028), and depression rate at M6 (P = 0.035) were descended in CBSM group compared to UC group. Besides, depression severity was reduced at M6 (P = 0.041) in CBSM group compared to UC group, but anxiety severity only showed a decreased trend (P = 0.051). Additionally, Quality of Life Questionnaire-Core 30 (QLQ-C30) global health status score and QLQ-C30 function score at 1^st month (M1), M3, and M6 were elevated (all P < 0.05), while QLQ-C30 symptoms score was declined at M1 (P = 0.031) and M3 (P = 0.014) in CBSM group compared to UC group. Notably, the efficacy of CBSM was impressive in patients with baseline depression or undergoing adjuvant therapy.

Conclusion

CBSM is a feasible intervention that effectively improves mental health and quality of life in postoperative NSCLC 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.

Effectiveness and implementation of an electronic health record-integrated digital health intervention for managing depressive symptoms in ambulatory oncology: The My Well-Being Guide study rationale and protocol

BACKGROUND

Rates of clinically elevated depressive symptoms among ambulatory oncology patients are higher than in the general population and are associated with poorer health-related quality of life. Furthermore, a reduction in depressive symptoms may be associated with improved cancer survival. Several interventions have demonstrated efficacy in reducing oncologic depressive symptoms, including cognitive-behavioral stress management (CBSM). However, more work is needed to understand how to best implement CBSM into practice, such as through stepped-care approaches and digital health interventions linked to electronic health records (EHR). This manuscript presents the protocol of the My Well-Being Guide study, a pragmatic type 1 effectiveness-implementation hybrid study. This trial will test the effectiveness of My Well-Being Guide, a seven-week structured, CBSM-based digital health intervention designed to reduce depressive symptoms. This trial will also evaluate My Well-Being Guide's implementation across two health systems.

METHODS

The final sample (N = 4561) will be oncology patients at Northwestern Medicine or University of Miami Health System who are ≥18 years of age; have a cancer diagnosis; elevated depressive symptoms on the Patient-Reported Outcomes Measurement Information System Depression; and primary language is English or Spanish. Data collection will occur at baseline, and 2-, 6-, and 12-months post baseline. Outcome domains include depressive symptoms and implementation evaluation.

DISCUSSION

This study may provide valuable data on the effectiveness of our depressive symptom management digital health intervention linked to the EHR and the scalability of digital health interventions in general.

Review of psychological interventions in patients with cancer

OBJECTIVE

Cancer is one of the leading causes of mortality in the world and also causes morbidity and deterioration in the mental health of patients and their caregivers. The most commonly reported psychological symptoms include anxiety, depression, and the fear of recurrence. The purpose of this narrative review is to elaborate and discuss the effectiveness of the different interventions employed and their utilities in clinical practice.

METHODS

Scopus and PubMed databases were searched, with a timeframe from 2020 to 2022, to identify randomised controlled trials, meta-analyses, and reviews and reported using PRISMA guidelines. Articles were searched by the following keywords: "cancer, psychology, anxiety, and depression". An additional search was performed with the keywords "cancer, psychology, anxiety, depression, and [intervention name]". The most popular psychological interventions were included in these search criteria.

RESULTS

A total of 4829 articles were retrieved by the first preliminary search. After reducing duplicates, 2964 articles were assessed for inclusion according to eligibility criteria. After the full-text screening, 25 final articles were chosen. To systematise psychological interventions as described in the literature, the authors have divided them into 3 broad categories, each type targeting a specific domain of mental health: cognitive-behavioural, mindfulness, and relaxation.

CONCLUSION

The most efficient psychological therapies, as well as therapies which require more extensive research, were outlined in this review. The authors discuss the necessity of primary assessment of patients and whether they require the help of a specialist. With the limitations of the potential risk of bias, an overview of different therapies and interventions targeting various psychological symptoms is outlined.

Cognitive behavioral stress management affects different dimensions of benefit finding in breast cancer survivors: a multilevel mediation model

Objective. This study aimed to confirm the multidimensionality of benefit finding (BF), or silver linings within the cancer experience, assess the effects of Cognitive Behavioral Stress Management (CBSM) on those dimensions, and test the mediating role of perceived stress management skills targeted by CBSM.Methods. This secondary analysis used data from 240 women with stage 0-III breast cancer who completed measures of BF (Benefit Finding Scale) and perceived stress management skills (PSMS) at baseline, 6-months, and 12-months post-randomization into CBSM or a psycho-education condition. We tested a six-factor BF model using Confirmatory Factor Analysis and assessed CBSM-related changes in BF and PSMS using Hierarchical Linear Models. We included significantly affected BF dimensions in mediation models.Results. A six-factor model of BF had good fit [χ2(212) = 391.5, p < .001; CFI = 0.94; RMSEA = 0.06; SRMR = 0.04]. CBSM positively affected changes in personal growth (β = 0.06, p = .01), social relations (β = 0.05, p = .05), and worldview (β = 0.05, p = .02) BF. Perceived relaxation skill increases significantly mediated changes in personal growth (β = 0.03, p = .04) and social relations (β = 0.03, p = .04).Conclusion. Some aspects of perceived stress management skills appear to account for specific BF dimensions and should be considered in future efforts to develop interventions to modulate BF.

Stress Management Interventions to Facilitate Psychological and Physiological Adaptation and Optimal Health Outcomes in Cancer Patients and Survivors

Cancer diagnosis and treatment constitute profoundly stressful experiences involving unique and common challenges that generate uncertainty, fear, and emotional distress. Individuals with cancer must cope with multiple stressors, from the point of diagnosis through surgical and adjuvant treatments and into survivorship, that require substantial psychological and physiological adaptation. This can take a toll on quality of life and well-being and may also promote cellular and molecular changes that can exacerbate physical symptoms and facilitate tumor growth and metastasis, thereby contributing to negative long-term health outcomes. Since modifying responses tostressors might improve psychological and physiological adaptation, quality of life, and clinical health outcomes, several randomized controlled trials have tested interventions that aim to facilitate stress management. We review evidence for the effects of stress management interventions on psychological and physiological adaptation and health outcomes in cancer patients and survivors and summarize emerging research in the field to address unanswered questions.

Characteristics of salivary cortisol and alpha-amylase as psychobiological study outcomes in palliative care research

BACKGROUND

Psychosocial interventions are rapidly emerging in palliative care. However, randomized trials often fail to provide evidence for their effectiveness with regard to patient-reported outcomes. Stress biomarkers could complement self-report data, but little is known about their feasibility, acceptance, and interpretability.

METHODS

Therefore, we designed a randomized crossover trial in which 42 patients in a palliative care unit participated in both a brief mindfulness intervention (MI) and a resting state control condition (CC) on two consecutive afternoons. On each day, we collected four saliva samples in 20-min intervals using Salivettes^© to determine salivary cortisol (sCort) and alpha-amylase (sAA) concentration levels. At all measurement points, self-rated well-being and stress as well as cardiovascular markers were assessed. Baseline measurements further included self-rated quality of life and clinician-rated functional status.

RESULTS

78.6% of the patients provided the maximum number of 8 saliva samples and 62.2% reported no subjective difficulties with the sampling procedures. 66.6% (sCort) and 69.6% (sAA) of all possible samples were finally included in the analysis. Xerostomia and nausea were the main reasons for missing data. Higher sCort levels were associated with higher heart rate and lower quality of life, functional status, and heart rate variability. Corticosteroid and sedative medication as well as time since last meal were identified as potential confounders. Regarding reactivity to the MI, we found an overall decrease in sCort levels over time (b = -.03, p = .01), but this effect did not differ significantly between the study conditions (b = .03, p = .21). sAA levels were higher in men than in women. Trajectories over time did not significantly differ between the two conditions (b = -.02, p = .80) and associations with other stress and health-related constructs were weak.

CONCLUSIONS

Findings indicate that sCort might serve as a psychobiological outcome in future palliative care trials. However, future research should refine the exact measurement and conceptualization strategies for sCort in palliative care research. High attrition rates should be expected in patients with xerostomia or nausea.

TRIAL REGISTRATION

Registered at the German Clinical Trials Registry (DRKS00013135) at 04/12/2017.

Effects of Cognitive Behavioral Stress Management Delivered by a Virtual Human, Teletherapy, and an E-Manual on Psychological and Physiological Outcomes in Adult Women: An Experimental Test

Technology may expand the reach of stress management to broader populations. However, issues with engagement can reduce intervention effectiveness. Technologies with highly social interfaces, such as virtual humans (VH), may offer advantages in this space. However, it is unclear how VH compare to telehealth and e-manuals at delivering psychological interventions. This experiment compared the effects of single laboratory session of Cognitive Behavioral Stress Management (CBSM) delivered by a VH (VH-CBSM), human telehealth (T-CBSM), and an e-manual (E-CBSM) on psychological and physiological outcomes in a community sample of stressed adult women. A pilot randomized controlled trial (RCT) with a parallel, mixed design was conducted. Adult women (M age =43.21, SD = 10.70) who self-identified as stressed were randomly allocated to VH-CBSM, T-CBSM, or E-CBSM involving one 90 min session and homework. Perceived stress, stress management skills, negative affect, optimism, relaxation, and physiological stress were measured. Mixed factorial ANOVAs and pairwise comparisons with Bonferroni correction investigated main and interaction effects of time and condition. Participants’ data (N = 38) were analysed (12 = VH-CBSM; 12 = T-CBSM; 14 = E-CBSM). Each condition significantly improved stress, negative affect, optimism, relaxation, and physiological stress over time with large effect sizes. No significant differences were found between conditions on outcomes. Overall, all three technologies showed promise for remotely delivering CBSM in a controlled setting. The findings suggest feasibility of the VH-CBSM delivery approach and support conducting a fully powered RCT to examine its effectiveness when delivering a full 10-week CBSM intervention.

Effects of a randomized-controlled trial of cognitive behavioral stress management: Psychosocial adaptation and immune status in men with early-stage prostate cancer

OBJECTIVE

Targets of intervention in cognitive behavioral stress management (CBSM), such as benefit finding (BF) and perceived stress management skills (PSMS), may counteract stress-related changes that impact the immune system. This study tested whether BF, PSMS, and optimism influence the effects of CBSM on immune status in men with prostate cancer.

METHODS

Men with prostate cancer were randomized to receive CBSM or a psychoeducation (PE) control comparison (NCT05486754). Life Orientation Test-Revised assessed baseline optimism. The Benefit Finding Scale and Measure of Current Status measured BF and PSMS after CBSM. T-cells and T-helper cells captured immune status change at baseline and 6-months post-CBSM. MPlus and SPSS (PROCESS) tested condition effects and moderated mediation, controlling for covariates.

RESULTS

256 primarily middle-aged, White Non-Hispanic or Hispanic men enrolled. PSMS mediated CBSM effects on T-cell and T-helper cell percentage, such that T-cell and T-helper cell percentages were reduced in men in CBSM versus PE via PSMS. Optimism moderated this mediation with the mediating effect of PSMS only observed among men with average optimism versus those with low or high optimism.

CONCLUSION

Baseline psychological characteristics, as well as limited specificity of immune measurement, could explain the conditional effects in this sample.

TRIAL REGISTRATION

NCT05486754.

Study design and protocol for tailored Acceptance and Commitment Therapy (ACT) to optimize quality of life in women living with metastatic breast cancer

Women living with metastatic (stage IV) breast cancer face unique challenges, including arduous treatments, side effects, chronic symptom burden, and emotional distress. Nevertheless, most research has paradoxically focused on optimizing quality of life in women with early-stage, non-metastatic breast cancer. Acceptance and Commitment Therapy (ACT) is an evidence-based, third-wave cognitive behavioral therapy that focuses on creating 'a life worth living' by promoting meaning and purpose and optimizing quality of life. ACT may be particularly well-suited for women with metastatic breast cancer as it addresses salient existential concerns, while allowing for the co-occurrence of feelings of grief and loss that are normal and expected when facing a life-limiting prognosis. This manuscript describes the rationale and study design of a pilot randomized controlled trial to develop and assess the feasibility and acceptability of a tailored ACT intervention for women living with metastatic breast cancer. Participants (N = 30) will be randomized 1:1 to either ACT, cognitive behavioral stress management (CBSM), or a usual care control. Both ACT and CBSM are 8-week, group-based interventions that will be delivered online. Primary outcomes are rates of acceptance, retention, and satisfaction. Preliminary effects on variables of interest, including meaning and purpose, psychological flexibility, and several domains of quality of life, will also be examined. Findings will inform the conduct of a full-scale randomized controlled trial of our tailored ACT intervention in women living with metastatic breast cancer.

Lifestyle and Pain following Cancer: State-of-the-Art and Future Directions

This review discusses chronic pain, multiple modifiable lifestyle factors, such as stress, insomnia, diet, obesity, smoking, alcohol consumption and physical activity, and the relationship between these lifestyle factors and pain after cancer. Chronic pain is known to be a common consequence of cancer treatments, which considerably impacts cancer survivors' quality of life when it remains untreated. Improvements in lifestyle behaviour are known to reduce mortality, comorbid conditions (i.e., cardiovascular diseases, other cancer, and recurrence) and cancer-related side-effects (i.e., fatigue and psychological issues). An inadequate stress response plays an important role in dysregulating the body's autonomic, endocrine, and immune responses, creating a problematic back loop with pain. Next, given the high vulnerability of cancer survivors to insomnia, addressing and treating those sleep problems should be another target in pain management due to its capacity to increase hyperalgesia. Furthermore, adherence to a healthy diet holds great anti-inflammatory potential for relieving pain after cancer. Additionally, a healthy diet might go hand in hand with weight reduction in the case of obesity. Consuming alcohol and smoking have an acute analgesic effect in the short-term, with evidence lacking in the long-term. However, this acute effect is outweighed by other harms on cancer survivors' general health. Last, informing patients about the benefits of an active lifestyle and reducing a sedentary lifestyle after cancer treatment must be emphasised when considering the proven benefits of physical activity in this population. A multimodal approach addressing all relevant lifestyle factors together seems appropriate for managing comorbid conditions, side-effects, and chronic pain after cancer. Further research is needed to evaluate whether modifiable lifestyle factors have a beneficial influence on chronic pain among cancer survivors.

Post-Intensive Care Syndrome in Children: A Concept Analysis

PROBLEM

Post-intensive care syndrome in paediatrics (PICS-p) is a term used to describe newly acquired or worsened impairment in one or more aspects of a child's physical, psychological, cognitive, and social functioning after discharge from the paediatric intensive care unit (PICU). However, consensus, conceptual insights, and assessment guidance are lacking for this syndrome. Therefore, this analysis aimed to define the concept of PICS-p to help practitioners and researchers understand the syndrome in detail using the Walker and Avant approach.

ELIGIBILITY CRITERIA

We reviewed studies retrieved from several databases, namely PubMed, Google Scholar, Web of Science, Ovid, ScienceDirect, and the Springer database, using the following keywords: 'post-intensive care syndrome', 'PICU', 'children', 'PICS-p', and 'concept analysis'. Both quantitative and qualitative studies on PICS-p were included in the search. The articles were limited to those published up to November 21, 2020.

SAMPLE

Of the 762 publications selected, 24 publications met the inclusion criteria.

RESULTS

PICS-p is defined on the basis of the following aspects: (1) Physical dysfunction; (2) Cognitive dysfunction; (3) Psychological dysfunction; and (4) Social dysfunction.

CONCLUSION

With the increasing success rate of PICU treatment, reduced case fatality is no longer the only outcome of critical illness in children. The long-term outcomes in children discharged from hospitals have attracted attention from families, hospitals, and communities.

IMPLICATIONS

A clear definition of PICS-p will help medical staff understand PICS-p in detail and provide a theoretical basis for the diagnosis and treatment of this syndrome.

The mental health impacts of receiving a breast cancer diagnosis: A meta-analysis

BACKGROUND

Receiving a breast cancer diagnosis can be a turning point with negative impacts on mental health, treatment and prognosis. This meta-analysis sought to determine the nature and prevalence of clinically significant psychological distress-related symptoms in the wake of a breast cancer diagnosis.

METHODS

Ten databases were searched between March and August 2020. Thirty-nine quantitative studies were meta-analysed.

RESULTS

The prevalence of clinically significant symptoms was 39% for non-specific distress (n = 13), 34% for anxiety (n = 19), 31% for post-traumatic stress (n = 7) and 20% for depression (n = 25). No studies reporting breast cancer patients' well-being in our specific time frame were found.

CONCLUSION

Mental health can be impacted in at least four domains following a diagnosis of breast cancer and such effects are commonplace. This study outlines a clear need for mitigating the impacts on mental health brought about by breast cancer diagnosis. CRD42020203990.

Current Resources for Evidence-Based Practice, March 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of men's experiences of pregnancy loss and commentaries on reviews focused on the effects of perineal massage on perineal trauma and air pollution and heat exposure on birth outcomes.

Nuevo Amanecer-II: Results of a randomized controlled trial of a community-based participatory, peer-delivered stress management intervention for rural Latina breast cancer survivors

Objective

We report results of a community‐based multisite, randomized controlled trial of Nuevo Amanecer (NA‐II), a 10‐week stress management program for rural, low literacy Latina breast cancer survivors.

Methods

Trained peers delivered NA‐II to Spanish‐speaking Latinas with non‐metastatic breast cancer in three rural communities. Women were randomized to receive the program immediately or wait 6 months. Assessments were conducted at baseline, 3 months, and 6 months. Primary outcomes were breast cancer‐specific quality of life domains; secondary outcomes included general distress symptoms and stress management skills. Intention‐to‐treat analyses using repeated‐measures linear regression models estimated changes in slope between groups.

Results

Of 153 participants (76 randomized to intervention, 77 to control group), 92% were retained at 6 months. Mean age was 54.8 years (SD = 10.5); 80% had less than high school education. There were no statistically significant treatment × time effects on quality of life. Compared to women in the control group, intervention group women reported greater improvements in anxiety at 6 months (−0.20 vs −0.02, P = .049; range 0‐4) as well as three stress management skills: relaxation at 3 months (+0.98 vs −0.07, P < .0001; range 0‐4) and 6 months (+0.82 vs +0.04, P < .001), awareness of tension at 3 months (+0.31 vs −0.19, P < .01; range 0‐4) and 6 months (+0.29 vs −0.11, P < .05), and coping confidence at 3 months (+0.12 vs −0.23, P < .01; range 0‐4).

Conclusions

Stress management programs delivered by trained peers in rural community settings can reduce anxiety and improve stress management skills among Latina breast cancer survivors.

Effectiveness of psychosocial interventions for posttraumatic growth in patients with cancer: A meta-analysis of randomized controlled trials

PURPOSE

To evaluate the effectiveness of psychosocial interventions for posttraumatic growth in patients with cancer.

METHOD

A systematic literature search was performed, and relevant studies published prior to January 8, 2020, were retrieved from MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trails, CINAHL, and PsycINFO. Two reviewers independently assessed the eligibility of each study and extracted the data. The Cochrane risk-of-bias tool was utilized to assess the quality of the studies. Review Manager (Version 5.3) was used to analyse the data. The posttraumatic growth scores were calculated using the standard mean difference (SMD) and 95% confidence intervals (CIs).

RESULTS

Fifteen randomized controlled trials published between 2000 and 2019 were included. Most of the studies had a moderate risk of bias due to low methodological quality. The meta-analysis indicated that the PTG scores in the experimental groups were higher than those in the control groups (SMD = 0.42, 95% CI: 0.26-0.57, P < 0.00001). The most effective and commonly used method was mindfulness-based interventions (SMD = 0.55, 95% CI: 0.15-0.95, P = 0.007). Subgroup analysis showed that the effects of psychosocial interventions on breast cancer patients are greater than the effects on other types of cancer patients (SMD = 0.72, 95% CI: 0.44-0.99, P < 0.00001).

CONCLUSION

Psychosocial interventions for cancer patients are effective in facilitating posttraumatic growth. The most commonly used and effective methods are mindfulness-based interventions. More large well-designed randomized controlled trials are needed to identify the effectiveness of psychosocial interventions for posttraumatic growth in patients with cancer.

Efficacy of stress management program for depressive patients with advanced head and neck cancer: A single-center pilot study

Background/Objective

Patients with head and neck cancer (HNC) have some problems such as dysfunction of breathing, eating, and/or speaking. The aim of this study was to examine efficacy of the stress management program for HNC patients (SMAP-HNC) compared with usual care (UC).

Method

We conducted a pilot study of SMAP-HNC for depressive HNC patients between January 2016 and March 2018. The program contains psychoeducation, stress coping training, and operant reinforcement. The outcome measure was the Hospital Anxiety and Depression Scale (HADS), Functional Assessment of Cancer Therapy (FACT), and Brief Coping Inventory (COPE).

Results

Twenty patients were randomly assigned to SMAP-HNC and UC group. Although a small sample sizes, there was no significant difference of depression score change between SMAP-HNC and UC group (Hedges’d g -0.83; 95% CI -1.80 to 0.13).

Conclusions

It was the first study to conduct stress management program for HNC patients. Unfortunately, our trial designed as a randomized controlled trial is underpowered to make conclusion as to the efficacy of SMAP-HNC. However, there are some valuable suggestions to modify the stress management program in future.