Existential distress and meaning-focused interventions in cancer survivorship

Spiritual well-being, faith, meaning in life, peace, and purpose in life for cancer-related fatigue: systematic review with meta-analysis and meta-regressions

BACKGROUND

Cancer-related fatigue is associated with spiritual distress. Spiritual well-being, characterized by the presence of factors such as meaning in life or purpose in life, seems to play an important role in the management of symptoms of cancer. Currently, the number of studies evaluating the association between cancer-related fatigue and spiritual well-being is increasing and no systematic review has been conducted.

AIM

To summarize the association between cancer-related fatigue and spiritual well-being, faith, meaning in life, peace, and purpose in life.

DESIGN

A systematic review with meta-analysis.

DATA SOURCES

The CINAHL, Embase, PsycINFO, and PubMed databases were searched from inception to 9 October 2023. We considered studies evaluating the cross-sectional or longitudinal association between cancer-related fatigue and the spiritual factors above mentioned. The Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies and the Quality in Prognosis Studies tool assessed the methodological quality of cross-sectional and longitudinal studies, respectively. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system rated the certainty of evidence. Meta-analyses, meta-regressions, subgroup meta-analyses, and sensitivity analyses were conducted.

RESULTS

A total of 13 studies were included and no longitudinal findings were found. One meta-analysis showed that cancer-related fatigue may be negatively correlated with spiritual well-being (r =  - 0.37 (95%CI - 0.44 to - 0.28) p < 0.01). In addition, another meta-analysis found the correlation between cancer-related fatigue and faith was not statistically significant (r =  - 0.25 (95%CI - 0.66 to 0.28) p = 0.36).

CONCLUSIONS

Cancer-related fatigue may be correlated with spiritual well-being. However, the certainty of evidence was very low across the meta-analyzed outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

A negative correlation was observed between spiritual well-being and cancer-related fatigue.

From existential uncertainty to a new mindset promoting recovery: Exploring the development of uncertainty experience in women with vulvar neoplasia - A qualitative longitudinal study

BACKGROUND

Women with vulvar neoplasia continue to experience uncertainty up to six months post-surgery. Uncertainty in illness is considered a significant psychosocial stressor, that negatively influences symptom distress, self-management strategies and quality of life. According to the Reconceptualized Uncertainty in Illness Theory, the appraisal of uncertainty changes positively over time in chronic illness. We aimed at exploring whether and how the experience of uncertainty develops in women with vulvar neoplasia.

METHODS

We selected a purposive sample of seven women diagnosed with vulvar neoplasia in four Swiss and one Austrian women's clinic. By means of a qualitative longitudinal study, we conducted 30 individual interviews at five points of time during one year after diagnosis. We applied Saldaña's analytical questions for longitudinal qualitative research.

RESULTS

First, participants experienced uncertainty as an existential threat, then an inherent part of their illness, and finally a certainty. Women initially associated the existential threat with a high risk for suffering from severe health deteriorations. Participants that could reduce their individually assessed risk by adopting health promoting behaviors, accepted the remaining uncertainty. From now on they reframed uncertainty into a certainty. This new mindset was based on a belief of promoting recovery and reducing the risk of recurrence.

CONCLUSIONS

The long-lasting and oscillating nature of uncertainty should receive attention in supportive oncology care. Uncertainty concerning existential issues is of special importance since it can inhibit a positive development of uncertainty experience.

Existential distress among family caregivers of patients with advanced cancer: A systematic review and meta-analysis

OBJECTIVE

Caregiving for a loved one is challenging and requires significant resources. Existential distress in family caregivers may include hopelessness, demoralization, fear of death, pre-loss grief, or a sense of not being emotionally prepared. The aim of this systematic review is to synthesize the quantitative literature on existential distress among family caregivers of patients with advanced cancer, focusing on its prevalence, association with mental disorders, as well as with sociodemographic, disease, and treatment-related factors.

METHODS

We systematically searched electronic databases for quantitative studies of the above-described existential distress concepts in family caregivers of patients with advanced cancer. Two independent reviewers extracted data and evaluated study quality. Data were analyzed using random-effects meta-analysis.

RESULTS

We retrieved 17.587 records, of which 31 studies fulfilled inclusion criteria. 63% of the studies (n = 20) provided sufficient data for meta-analysis for 5558 patients. We found an overall pooled prevalence of 30.6% for existential distress, 95% CI [24.2-37.0]. For existential distress subconcepts, prevalence rates were 57.0%, 95% CI [37.8-76.2], for death anxiety, 13.9%, 95% CI [10.8-17.0], for demoralization, 24.0%, 95% CI [18.0-30.0], for pre-loss grief, 18.4%, 95% CI [4.0-32.7], for hopelessness, 35.2%, 95% CI [28.2-42.2], for loneliness, and 35.6%, 95% CI [13.0-58.3], for emotional unpreparedness.

CONCLUSIONS

Approximately one third of the respondents were affected by high levels of existential distress. The review provides evidence for further development of support services that can reduce existential distress, focused on death anxiety, and improve the quality of life for family caregivers of patients with advanced cancer.

"Is My Brain Ever Going to Work Fully Again?": Challenges and Needs of Cancer Survivors with Persistent Cancer-Related Cognitive Impairment

Many cancer survivors experience cognitive impairments that impact memory, concentration, speed of information processing, and decision making. These impairments, collectively known as cancer-related cognitive impairments (CRCIs), are a key domain of unmet needs and can significantly impact a cancer survivor's identity and quality of life. However, there are no purpose-built, multi-domain, needs assessment tools specifically for CRCI. The development of such tools requires an in-depth understanding of cancer survivors' CRCI-specific challenges and associated needs. This study explored the challenges and associated needs of cancer survivors with persistent CRCI. An in-depth qualitative design using semi-structured interviews with (a) cancer survivors with perceived CRCI (n = 32) and (b) oncology health professionals (n = 19) was utilised. A reflexive thematic analysis of the interviews resulted in five overarching themes: (1) executing regular activities, (2) relational difficulties, (3) occupational functioning, (4) psychological distress, and (5) social functioning, as well as an additional informational needs domain. Ultimately, CRCI was found to directly produce a range of challenges that negatively, and persistently, impact cancer survivors' quality of life. Cancer survivors were also found to have a range of needs associated with these challenges. This research should be used to inform future challenges and needs assessment tools as well as treatment and supportive care priority areas directly relating to CRCI.

The 'Young Adult Taking Action' programme for young adult cancer survivors: A study protocol for a feasibility study

BACKGROUND

Young adult cancer survivors (YACS) aged 18-39 report age-specific multifactorial challenges with self-care, leisure, work and education requiring multicomponent rehabilitation intervention. Therefore, the 'Young Adult Taking Action' (YATAC) programme was developed.

AIMS/OBJECTIVES

To present a protocol for a feasibility study evaluating the acceptability of the YATAC programme and exploring implementation, mechanisms of impact and outcomes.

MATERIAL AND METHODS

A mixed-method feasibility study with a convergent research design will be conducted. The programme is an age-specific, multicomponent, goal-oriented, and peer-based rehabilitation programme delivered by an interdisciplinary staff consisting of nine components: 1) Goal setting, 2) Everyday life, 3) Physical activity, 4) Psychological issues, 5) Work and study, 6) Sexuality and relationship, 7) Rights and finance, 8) Peer-to-peer support and 9) Individual consultation. Quantitative and qualitative data about acceptability, implementation, mechanisms of impact and outcomes will be collected.

RESULTS

The results will provide essential knowledge about the programme's acceptability, implementation, mechanisms of impact and outcomes.

CONCLUSION AND SIGNIFICANCE

The study will inform adjustment of the programme and will provide knowledge of whether and how to deliver age-specific rehabilitation to YACS.

Beyond the treatment: The role of race, sex, and education in health trajectories between cancer survivors and noncancer older adults

INTRODUCTION

The number of older, long-term cancer survivors is increasing. However, little is known about how cancer and aging affect the health trajectories of older adults differently. In addition, the impact of race, sex, and education on the processes of aging and the cancer experience needs further investigation. The current study aims to address this knowledge gap by combining two National Cancer Institute (NIC)-funded longitudinal studies conducted in Cleveland from 1998 to 2010.

MATERIALS AND METHODS

The unique cross-sequential design facilitates a comparison between the health changes in long-term (five years +) older cancer survivors (breast, prostate, and colorectal cancer) and demographically matched older adults without a history of cancer in the same geographic area within the same period. The study also captured comprehensive information on how socioeconomic status interacts with cancer and aging over time. General linear models were employed in the data analysis.

RESULTS

The findings showed that early cancer experience did not affect long-term cancer survivors' health status in later life. Conversely, comorbidities, being an African American, being female, and having education less than a college degree significantly decreased the health trajectory in later life for all older adults. Moreover, compared to other groups, older African American cancer survivors reported a dramatic decrease in self-reported health after controlling for other conditions.

DISCUSSION

Study findings can inform public policy and social services to offer comprehensive treatment plans and help individuals overcome their diseases and lead longer and healthier lives.

Relationship between demoralization and quality of life in end-of-life cancer patients

OBJECTIVE

To examine the relationship between demoralization and health-related quality of life (HRQoL) in a sample of end-of-life cancer patients with a life expectancy of 4 months or less undergoing palliative care, controlling for sociodemographic, clinical, and psychological variables.

METHODS

Sociodemographic, clinical, and psychological data from 170 end-of-life cancer patients were collected using the following scales: Edmonton Symptom Assessment System for palliative care patients' symptoms; Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms; Functional Assessment of Cancer Therapy Scale - General Measure (FACT-G) for HRQoL; Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being for spirituality (FACIT-Sp); Demoralization Scale - Italian Version (DS-IT) for demoralization.

RESULTS

The DS-IT showed that 51.8% of cancer patients were severely demoralized. In addition, 36.5% of the sample had clinically significant depressive symptoms and QoL was severely impaired (FACT-G). The result of regression analysis showed that demoralization (especially "Disheartenment" and "Sense of failure") was the strongest contributor for HRQoL, followed by ESAS_Lack of Well-Being and depression (PHQ-9), with the final model explaining 66% of the variance of the FACT-G.

CONCLUSIONS

The results highlight a very high prevalence of severe demoralization in end-of life cancer patients. Moreover, demoralization was not only associated with patients' HRQoL, but it was also the most important contributing factor. This finding underscores the need to identify preventive or therapeutic psychological interventions that focus on preventing existential distress, and thus improve the QoL of dying patients in their last days of life.

Demoralization during the Italian quarantine due to 2019 coronavirus disease pandemic: prevalence and association with psychological well-being and coping strategies

The aims of the study were to investigate demoralization in a sample of Italian citizens during the Italian quarantine due to COVID-19 pandemic and to explore its associations with psychological well-being, coping strategies, participants' socio-demographic characteristics and COVID-19-related factors. Italian citizens aged over 18 and quarantined in Italy were recruited. A cross-sectional online survey was launched through a snow-ball sampling and 1123 surveys were collected. Participants answered ad hoc questions and completed the Psychological General Well-Being Index, the Demoralization Scale, and the Coping Orientation to Problems Experienced-New Italian Version. Disheartenment, dysphoria, and sense of failure were the subdimensions of demoralization with higher scores. Demoralization was associated with depressed mood, positive well-being, self-control, general health, vitality, problem-solving, and avoidance and religious coping strategies. Individuals who were female, older, without children and not working during quarantine had higher demoralization. Quarantine-related changes can elicit demoralization that is associated to lower psychological well-being. Problem-solving and religious coping can protect against demoralization, while avoidant coping strategies can exacerbate it. Assessing and treating demoralization, especially in the categories of citizens most at risk of developing it, could be useful to provide adequate care against COVID-19-related distress.

Existential distress and meaning making among female breast cancer patients with cancer-related fertility concerns

OBJECTIVES

The current study explored the impact of cancer-related fertility concerns on existential distress and meaning making among female breast cancer (BC) patients of childbearing age and assessed support needs.

METHODS

The current study was embedded within a larger study. A seven-question online survey was administered to female BC participants to explore meaning and identity in their lives. Applied thematic analysis was used to analyze participants' written responses.

RESULTS

A total of 98 participants completed the survey, the majority of whom identified as white, married or partnered, and employed full time and with stage I or II BC. More than 50% of the participants expressed a need for support from a counselor or support group during their cancer experience. Three subthemes emerged related to existential distress and cancer-related fertility concerns: (1) loss of womanhood: treatment-related physical changes impact on gender identity; (2) existential distress due to treatment decisions impacting fertility; and (3) shattered vision: cancer-related infertility impact on meaning and purpose. Four subthemes emerged related to meaning making with fertility-related existential concerns: (1) coping with loss of meaning, (2) re-evaluating priorities in life; (3) resilience to loss, and (4) persistent loss of meaning.

SIGNIFICANCE OF RESULTS

Study results offer valuable insights into the experiences of female BC survivors' cancer-related fertility on existential distress and meaning making. Development of psychological interventions targeted to support this population to cope with existential distress due to cancer-related fertility concerns and meaning making are needed to improve the quality of life of this population.

Prevalence and factors associated with demoralization in palliative care patients: A cross-sectional study from Hong Kong

OBJECTIVES

Although demoralization is common among palliative care patients, it has not yet been examined empirically in the Hong Kong Chinese context. This study aims to examine (1) the prevalence of demoralization among community-dwelling palliative care patients in Hong Kong; (2) the percentage of palliative care patients who are demoralized but not depressed and vice versa; and (3) the association of socio-demographic factors, particularly family support, with demoralization.

METHOD

A cross-sectional study targeting community-living palliative care patients in Hong Kong was conducted. A total of 54 patients were recruited by a local hospice and interviewed for completing a questionnaire which included measures of demoralization, depression, perceived family support, and demographic information.

RESULTS

The prevalence of demoralization was 64.8%. Although there was overlap between demoralization and depression (52.8% meeting the criteria of both), 7.5% of depressed patients were not demoralized, and 13.2% of demoralized patients were not depressed. Participants who were not single and had more depressive symptoms and less family support had a significantly higher demoralization level.

SIGNIFICANCE OF RESULTS

This is the first study which reports the prevalence of demoralization in Hong Kong. Demoralization was found common in community-living palliative care patients receiving medical social work services in Hong Kong. This study provides evidence of the importance of differentiating the constructs between demoralization and depression. It also provides an implication that those who are married, more depressed, and have the least family support could be the most vulnerable group at risk of demoralization. We recommend that early assessment of demoralization among palliative care patients be considered.

Evaluating a couple communication skills training (CCST) intervention for advanced cancer: study protocol for a randomized controlled trial

BACKGROUND

For patients and their intimate partners, advanced cancer poses significant challenges that can negatively impact both individuals and their relationship. Prior studies have found evidence that couple-based communication skills interventions can to be beneficial for patients and partners. However, these studies have been limited by reliance on in-person treatment delivery and have not targeted couples at high risk for poor outcomes. This study tests the efficacy of a Couples Communication Skills Training (CCST) intervention delivered via videoconference for couples reporting high levels of holding back from discussing cancer-related concerns, a variable associated with poorer psychological and relationship functioning.

METHODS

This RCT is designed to evaluate the efficacy of CCST in improving patient and partner relationship functioning (primary outcome). Secondary outcomes include patient and partner psychological functioning and patient symptoms and health care use. We also examine the role of objective and self-reported communication behaviors as mediators of treatment effects. Two hundred thirty patients with advanced lung, gastrointestinal, genitourinary, and breast cancer and their partners will be randomized to CCST or an education control intervention. Participants in both conditions complete self-reported outcome measures at baseline, mid-treatment, post-treatment, and 3 months post-treatment. Objective measures of communication are derived from video-recorded couple conversations collected at baseline and post-treatment. An implementation-related process evaluation (assessing implementation outcomes and potential barriers to/facilitators of implementation) will be conducted to inform future efforts to implement CCST in real-world settings.

DISCUSSION

This trial can yield important new knowledge about effective ways to improve patient and partner adjustment to advanced cancer.

TRIAL REGISTRATION

This study trial is registered at clinicaltrials.gov (Trial # NCT04590885); registration date: October 19, 2020.

Debruyne P. Developing and evaluating a participatory arts programme for cancer patients and their caregivers

OBJECTIVES

Cancer patients, survivors and caregivers often encounter severe distress, having significant consequences to wellbeing, functionality and physical health. This study developed and evaluated a participatory arts programme to determine if such could help to improve the wellbeing of cancer patients and their caregivers.

METHODS

To inform the development of a participatory arts programme, cancer patients and their caregivers at an Organisation of European Cancer Institute (OECI)-designated cancer centre were asked which activities they would wish to engage in (anonymous survey one). A programme was then developed and trialled for 1 year. Following participation, we explored the satisfaction and any benefits of taking part (anonymous survey two).

RESULTS

Survey one had a participation rate of 70%. In this survey, participants indicated they preferred group-based activities (61%) over an individual approachto take place on a monthly basis (46%). The developed programme ran from December 2018 to December 2019, with 435 patients and caregivers taking part. Two hundred and eighteen completed survey two and revealed a positive response to both the structure and content of the programme and its impact on the wellbeing of patients and caregivers. The majority indicated they felt (much) betterfrom participating in the participatory arts programme.

CONCLUSION

This study points out the interest and potential value of a participatory arts programme to the perceived wellbeing. This suggests such programmes could be incorporated into cancer care provision, to serve as psychosocial support. The latter is particularly relevant for improving the lives, wellbeing and health of cancer patients and those supporting them.

How patients with cancer experience dignity: An integrative review

BACKGROUND

A diagnosis of cancer and its treatments can be associated with a prominent issue of loss of dignity or an undermined sense of dignity for patients. Research is increasingly being conducted into how patients with cancer experience dignity, with the aim to build clinical foundations for care that preserves patients' sense of dignity.

AIM

This review summarises and synthesises the available empirical literature on the experience of dignity in patients with cancer regarding both the perception of dignity and associated factors.

METHOD

An integrative review method was used. A literature search was conducted in 11 databases using the search terms 'dignity' OR 'existential' OR 'existentialism' combined with 'cancer'. The Mixed Methods Appraisal Tool (version 2011) was adopted to appraise the methodological quality of the included studies.

RESULTS

Nine qualitative studies and 13 quantitative studies met the selection criteria and were included in the review. The ways that patients with cancer perceived dignity include autonomy/control, respect, self-worth, family connectedness, acceptance, hope/future and God/religious. Factors associated with dignity include demographics, physical and psychosocial distress, experiences of suffering and coping strategies.

CONCLUSION

Dignity-conserving care should respect patients' human autonomy to strengthen their sense of self-worth, acceptance, hope, reinforce family connectedness, and foster coping strategies to control the physical, psychosocial factors and experience of sufferings that threaten their sense of dignity.

Importance of worthwhile life and social health as predictors of suicide ideation among cancer patients

OBJECTIVE

We identify the most associative factors among existential well-being, health-related quality of life, and health behaviors' sub-factors for cancer patients' suicidal ideation (SI) to develop practical intervention tools for general cancer patients in South Korea.

PARTICIPANTS

We surveyed 766 cancer patients from two hospitals in South Korea. The eligibility criteria were as follows: 18 years of age or older, diagnosed with cancer, aware of the stage, and capable of understanding the purpose of the study.

METHODS

We performed a multidimensional multivariate analysis to find the factors that are most associated with SI for cancer patients.

RESULTS

The results showed that life worthwhile (adjusted odds ratio (aOR), 3.946; 95% CI, 1.64-9.48), social functioning (aOR, 2.817; 95% CI, 1.19-6.65), and living with loved ones (aOR, 0.353; 95% CI, 0.15-0.84) were the most predictive factors for SI.

CONCLUSION

To prevent SI in cancer patients, it might be necessary to help them feel that their lives are worthwhile while helping them maintain a high degree of social health.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS OR POLICY

It is important to help cancer patients value their life and lead the high-quality social life to reduce their SI.

Thoughts of death and suicidality among patients with cancer: Examining subtypes and their association with mental disorders

OBJECTIVE

Cancer is associated with an increased risk for completed suicide. We explored subtypes of thoughts of death, death wishes, suicidal ideation and behavior and their association with mental disorders and demographic and disease-related characteristics.

METHODS

We studied 2,141 cancer patients with the standardized Composite International Diagnostic Interview-Oncology (CIDI-O). Assessment included 4-weeks-prevalences of thoughts of death, wish to die, suicidal ideation, suicide plans, and lifetime suicide attempts. We further assessed 4-weeks-prevalences of mood, anxiety, adjustment, somatoform, substance use, and disorders due to general medical condition. We conducted latent class analyses (LCA).

RESULTS

The LCA identified three classes with distinct patterns of suicidality. Class 1 (89.0% of the sample) showed no suicidality. Class 2 (6.9%) was characterized by thoughts of death without suicidal ideation. Class 3 (4.1%) was characterized by thoughts of death, suicidal ideation, and suicide plans. Death wishes occurred in both classes 2 and 3. Classes 2 and 3 were associated with a significantly higher risk for any mental disorder (OR from 4.22, adjustment disorder, to 10.20, mood disorders, p < 0.001) compared to class 1. Patients with mental disorders were equally likely in classes 2 and 3. Patients with incurable cancer were significantly more likely in class 2, and less likely in class 3.

CONCLUSIONS

Cancer patients with suicidal ideation are not distinctly characterized by mental disorders. Further study of concepts that consider problematic adjustment to the cancer stressor such as death anxiety and demoralization may contribute to understand psychological distress underlying subtypes of thoughts of death and suicidality in cancer.

The role of attachment avoidance: A longitudinal mediation model predicting existential distress in patients with advanced cancer

OBJECTIVE

Although a protective effect of reliable interpersonal relationships on existential distress has been established, evidence remains inconclusive for attachment insecurity as an underlying factor of persistent psychological distress. We tested a longitudinal model hypothesizing attachment avoidance as a mediator of high demoralization and anxiety over time.

METHODS

We studied 206 patients with advanced cancer (mean age = 59.6, 61% female) participating in an intervention trial. Patients completed self-report measures for demoralization, anxiety, perceived relatedness, attachment insecurity, and death anxiety. Our mediated path model included perceived relatedness and death anxiety at baseline as predictors, attachment avoidance at baseline as mediator, and demoralization and anxiety at 6-month follow-up (N = 125) as outcomes.

RESULTS

Attachment avoidance partially mediated the relationship between death anxiety and demoralization (β = 0.07, 95% CI 0.02-0.12) and anxiety (β = 0.05, 95% CI 0.001-0.10). Findings for perceived relatedness were less conclusive. Its indirect effects through attachment avoidance were significant for both outcomes (demoralization: β = -0.07, 95% CI -0.13 to -0.02, anxiety: β = -0.05, 95% CI -0.11 to -0.003).

CONCLUSIONS

Due to its trait-like quality, attachment avoidance may play a less central role in explaining the course of existential distress over time than previous research indicated. Addressing change-sensitive relational concerns in psychosocial interventions may be more effective to alleviate existential distress.

The experience of palliative care among older Chinese people in nursing homes: A scoping review

OBJECTIVE

To identify the gaps in understanding the experience of older Chinese people receiving palliative care in nursing homes.

DESIGN

A nine-step scoping review methodology was used to search for relevant literature.

METHODS

Sixteen databases were searched for relevant studies published in English from January 1990 to August 2019. The grey literature was searched for relevant theses pertaining to the topic.

RESULTS

A total of 18 studies from the United States (n = 2), mainland China (n = 1), Hong Kong (n = 13), Taiwan (n = 2) and one thesis from Hong Kong were included in the final analysis. The findings were categorised into four themes: (1) advance care planning preferences; (2) decision-making process related to palliative care; (3) palliative care experiences and barriers; and (4) practice to improve palliative care.

CONCLUSIONS

Given the distinctive experiences of older Chinese residents in nursing homes when faced with death and dying, cultural beliefs strongly influenced their attitudes and behaviours in receiving end-of-life care. As Chinese immigrants have become a major ethnic group in western countries, there is benefit in recognising that older Chinese people living in nursing homes and needing palliative care will face specific challenges. Culturally appropriate interventions to address older Chinese people's existential stress, grief related to loss, communication and dietary requirements, and other barriers should be developed and implemented.

Psychotherapeutic Approach for Advanced Illness: Managing Cancer and Living Meaningfully (CALM) Therapy

With advances in medical treatment and an aging population, there is an increasing global burden of advanced and life-limiting illnesses. Individuals living with these conditions may experience substantial distress related to disease progression, changes in important roles and life goals, loss of meaning, and uncertainty about the future, but there has been limited evidence to inform their psychotherapeutic care. Managing cancer and living meaningfully (CALM) therapy is a brief, evidence-based, semistructured intervention that provides a framework to address practical issues, such as navigating the health care system and treatment decisions, and existential issues, including finding meaning and hope in the face of mortality. CALM has been shown to alleviate and prevent depression and to facilitate preparation for the end of life among patients with advanced cancer. It is being adapted to other life-threatening illnesses and different cultural contexts and health care settings. Advocacy is needed to support such approaches for individuals living with advanced and life-threatening illness.

Neurobiology of Cancer: the Role of β-Adrenergic Receptor Signaling in Various Tumor Environments

The development and progression of cancer depends on both tumor micro- and macroenvironments. In addition, psychosocial and spiritual “environments” might also affect cancer. It has been found that the nervous system, via neural and humoral pathways, significantly modulates processes related to cancer at the level of the tumor micro- and macroenvironments. The nervous system also mediates the effects of psychosocial and noetic factors on cancer. Importantly, data accumulated in the last two decades have clearly shown that effects of the nervous system on cancer initiation, progression, and the development of metastases are mediated by the sympathoadrenal system mainly via β-adrenergic receptor signaling. Here, we provide a new complex view of the role of β-adrenergic receptor signaling within the tumor micro- and macroenvironments as well as in mediating the effects of the psychosocial and spiritual environments. In addition, we describe potential preventive and therapeutic implications.

Strategies for living well with hormone-responsive advanced prostate cancer-a qualitative exploration

PURPOSE

Due to recent treatment advances, men are increasingly living longer with advanced prostate cancer (PCa). This study sought to understand men's experiences of living with and adjusting to advanced hormone-responsive PCa and how this influenced their quality of life (QoL), in order to highlight how support could be optimized.

METHODS

Participants were recruited through a UK wide survey-the 'Life After Prostate Cancer Diagnosis' study. In-depth telephone interviews were conducted with 24 men (aged 46-77 years) with advanced (stage IV) hormone-responsive PCa diagnosed 18-42 months previously. Thematic analysis was undertaken using a framework approach.

RESULTS

Most participants perceived their QoL to be relatively good, which was influenced by the following factors (enablers to 'living well' with PCa): a sense of connectedness to others, engagement in meaningful activities, resources (social, cognitive, financial), ability to manage uncertainty, utilization of adjustment strategies and support, communication and information from health professionals. Barriers to 'living well' with PCa were often the converse of these factors. These also included more troublesome PCa-related symptoms and stronger perceptions of loss and restriction.

CONCLUSIONS

In our study, men living with advanced hormone-responsive PCa often reported a good QoL. Exploring the influences on QoL in men with advanced PCa indicates how future interventions might improve the QoL of men who are struggling. Further research is required to develop and test interventions that enhance QoL for these men.

Meaning in life and quality of life: palliative care patients versus the general population

BACKGROUND AND OBJECTIVES

Meaning in life (MIL) represent a key topic in palliative care. The aims of this study were to explore (1) the differences in perceived MIL and in the meaning-relevant life areas between a representative sample of the Swiss population and palliative care patients, and (2) to what extent MIL can be considered as a significant predictor of quality of life (QOL).

METHODS

A cross-sectional study was conducted separately for the patients (face-to-face interviews) and the general population (telephone survey). MIL was measured with the Schedule for Meaning in Life Evaluation (SMILE) and QOL with a single-item visual analogue scale (0-10). Sociodemographic variables were controlled for in the analyses.

RESULTS

206 patients and 1015 participants from the Swiss population completed the protocol. Results indicated high MIL scores in both populations even if the difference was significant (patients 81.9 vs general population 87, p<0.001). Patients were more likely to cite 'family' (OR=1.78), 'social relations' (OR=1.9), 'spirituality and religion' (OR=3.93), 'social commitment' (OR=1.94) and 'growth' (OR=2.07), and less likely to cite 'finances' (OR=0.15) and 'health' (OR=0.21) as MIL-relevant areas. The SMILE scores and MIL areas explained 21.8% of the QOL variance for the patients and 15.1% for the representative sample.

CONCLUSIONS

Our data emphasise the importance of MIL as a contributor to QOL in both populations. It highlights the importance of the life areas contributing to MIL, especially social interactions for both populations, and spirituality and areas related to growth in palliative care patients.

Rationale and design of a randomised controlled trial investigating the effect of multidisciplinary nutritional rehabilitation for patients treated for head and neck cancer (the NUTRI-HAB trial)

Background

Eating problems frequently affect quality of life and physical, psychological and social function in patients treated for head and neck cancer (HNC). Residential rehabilitation programmes may ameliorate these adverse effects but are not indicated for all individuals. Systematic assessment of rehabilitation needs may optimise the use of resources while ensuring referral to rehabilitation for those in need. Yet, evidence lacks on which nutrition screening and assessment tools to use. The trial objectives are: 1) To test the effect of a multidisciplinary residential nutritional rehabilitation programme compared to standard care on the primary outcome body weight and secondary outcomes health-related quality of life, physical function and symptoms of anxiety and depression in patients curatively treated for HNC and 2) To test for correlations between participants’ development in outcome scores during their participation in the programme and their baseline scores in Nutritional Risk Screening 2002 (NRS 2002), the Scored Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), and M. D. Anderson Dysphagia Inventory (MDADI) and to assess sensitivity, specificity and predictive values of the three tools in relation to a clinically relevant improvement in outcome scores.

Methods

In a randomised controlled trial, 72 patients treated for HNC recruited through a nationwide survey will be randomised to a multidisciplinary residential nutritional rehabilitation programme or to a wait-list control group. Data are collected at baseline, three and six months. Primary outcome is change in body weight, and secondary outcomes include changes in quality of life, physical function and symptoms of anxiety and depression. Potential correlations between intervention effect and baseline scores in NRS 2002, PG-SGA-SF and MDADI will be tested, and sensitivity, specificity and predictive values of the three tools in relation to a clinically relevant improvement in outcome scores will be assessed.

Discussion

This is the first randomised controlled trial to test the effect of a multidisciplinary residential nutritional rehabilitation programme in patients treated for HNC. Recruitment through a nationwide survey gives a unique possibility to describe the trial population and to identify potential selection bias. As the trial will explore the potential of different nutrition screening and assessment tools in the assessment of rehabilitation needs in patients treated for HNC, the trial will create knowledge about how selection and prioritisation of nutritional rehabilitation aimed at patients treated for HNC should be offered. The results may contribute to a better organisation and use of existing resources in benefit of patients treated for HNC.

Trial registration

The trial is registered by The Danish Data Protection Agency (registration 2012-58-0018, approval number 18/14847) and the Regional Committees on Health Research Ethics for Southern Denmark (journal number 20182000–165). ClinicalTrials.gov Identifier: NCT03909256. Registered April 9, 2019.

Comparing the efficacy of integrative body-mind-spirit intervention with cognitive behavioral therapy in patient-caregiver parallel groups for lung cancer patients using a randomized controlled trial

Purposes/objectives: This paper reports the comparative efficacies of integrative body-mind-spirit intervention (I-BMS) and cognitive behavioral therapy (CBT) in patient-caregiver parallel groups for Chinese patients with lung cancer.Design: Randomized controlled trial (RCT).Methods: One hundred and fifty-seven patient-caregiver dyads with no marked functional impairment were randomized into one of the two interventions with eight weekly patient-caregiver parallel groups. Assessments were conducted at baseline, within one, eight- and sixteen-weeks post-intervention. Effects of treatment group across time were analyzed by multilevel modeling.Findings: CBT led to greater reduction in emotional vulnerability than I-BMS. I-BMS resulted in greater increase in overall QoL and spiritual self-care, and more reduction in depression than CBT. Patients in both interventions experienced improvement in physical, emotional and spiritual, except social, domains of QoL.Conclusion: I-BMS was more efficacious for diverse domains of QoL, and CBT was more effective for emotional well-being, despite the relatively small between-group effect sizes.Implications for psychosocial providers/policy: (1) With the expanding repertoire of psychosocial interventions for families facing lung cancer, it has become imperative to investigate the comparative efficacies of empirically supported and culturally adapted interventions. (2) Our findings show that I-BMS was more effective for diverse domains of QoL, while CBT was more efficacious with emotional well-being, although both interventions led to significant improvements in physical, emotional and spiritual domains of patient QoL. (3) Patient-caregiver parallel groups have been shown to be effective for enhancing QoL of Chinese lung cancer patients. (4) Care professionals are encouraged to dispense interventions based on the idiosyncratic needs and preferences of the patients to maximize the treatment effects.

Cancer patients' interest in participating in cancer rehabilitation

Introduction: Rehabilitation for cancer patients aims at preventing and reducing the physical, mental, social and existential consequences of a cancer disease and its treatment. The aim of this study is to describe the patients' self-perceived interest in participating in cancer rehabilitation (CR).Material and methods: A total of 1179 cancer patients, diagnosed with 28 different cancer diagnoses, from November 2015 to October 2016, were identified via the national cancer quality registers. A questionnaire was developed for the purpose of this study, the Cancer Rehabilitation Interest. The questionnaire comprises 16 different rehabilitation activities. This study describes what activities the patients are interested to participate in.Results: The response rate was 62% and the final sample comprised 728 patients. The rehabilitation activities wanted by the cancer patients were Psychoeducational support group together with others with the same cancer diagnosis, Open lectures on cancer, Individual weight training with a physiotherapist and Personal support from a social worker. Most interested in cancer rehabilitation were women, younger patients, university educated patients and those who had received their diagnosis ≥12 months prior. Patients with a mandatory educational level had the lowest interest in all suggested activities compared with those having medium or high education.Conclusions: The interest of cancer rehabilitation of all approached patients in this study were 21%. Most interested were women, young patients, university educated and those who received their diagnosis ≥12 months earlier. About 30% of the participating cancer patients reported an interest of information and supportive groups, physical training and support from a hospital social worker. Patients with low level of education reported a low interest in CR. There are limitations in rehabilitation accessibility and that might affect a person's motivation to participate in this study.

Effects of psychosocial interventions on meaning and purpose in adults with cancer: A systematic review and meta-analysis

Meaning and purpose in life are associated with the mental and physical health of patients with cancer and survivors and also constitute highly valued outcomes in themselves. Because meaning and purpose are often threatened by a cancer diagnosis and treatment, interventions have been developed to promote meaning and purpose. The present meta-analysis of randomized controlled trials (RCTs) evaluated effects of psychosocial interventions on meaning/purpose in adults with cancer and tested potential moderators of intervention effects. Six literature databases were systematically searched to identify RCTs of psychosocial interventions in which meaning or purpose was an outcome. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, rater pairs extracted and evaluated data for quality. Findings were synthesized across studies with standard meta-analytic methods, including meta-regression with robust variance estimation and risk-of-bias sensitivity analysis. Twenty-nine RCTs were identified, and they encompassed 82 treatment effects among 2305 patients/survivors. Psychosocial interventions were associated with significant improvements in meaning/purpose (g = 0.37; 95% CI, 0.22-0.52; P < .0001). Interventions designed to enhance meaning/purpose (g = 0.42; 95% CI, 0.24-0.60) demonstrated significantly higher effect sizes than those targeting other primary outcomes (g = 0.18; 95% CI, 0.09-0.27; P = .009). Few other intervention, clinical, or demographic characteristics tested were significant moderators. In conclusion, the results suggest that psychosocial interventions are associated with small to medium effects in enhancing meaning/purpose among patients with cancer, and the benefits are comparable to those of interventions designed to reduce depression, pain, and fatigue in patients with cancer. Methodological concerns include small samples and ambiguity regarding allocation concealment. Future research should focus on explicitly meaning-centered interventions and identify optimal treatment or survivorship phases for implementation.

Symptom Burden and Unmet Existential Needs in Adults With Cystic Fibrosis

Although patients with cystic fibrosis (CF) experience many symptoms and impaired quality of life, little is known about existential distress. This multivariable logistic regression evaluated the relationship between symptom burden and five existential needs representing existential distress in 164 adults with CF. Eleven percent of participants reported no symptom burden, 61% mild burden, and 28% moderate/severe burden. The most prevalent existential needs were fears about CF worsening (50%) and uncertainty about the future (39%). Participants with moderate/severe symptom burden were likelier to report needing support with all five needs than participants with no or mild burden. For each six-point increase in burden, there was an increased odds of reporting need for support with learning to feel in control, feelings about death and dying, fears about CF worsening, uncertainty about the future, and concerns about worries of others. CF-specific palliative care support based on these prevalent unmet existential needs should be developed and provided.

Psychological support for patients with cancer: evidence review and suggestions for future directions

PURPOSE OF REVIEW

Psychological distress and mental health comorbidity are common in cancer. Various therapeutic frameworks have been used for interventions to improve psychological wellbeing and quality of life in cancer patients with mixed results. This article reviews contributions to that literature published since January 2017.

RECENT FINDINGS

The majority of new psychological intervention research in cancer has used cognitive behavioural therapy (CBT) or mindfulness-based interventions. CBT has been considered a gold-standard intervention and recent evidence justifies continuation of this. Recent reviews call into question the validity of evidence for mindfulness-based interventions. A smaller number of trials using acceptance and commitment therapy, meta-cognitive therapy, dignity therapy and coaching have emerged, and whereas findings are promising, additional fully powered trials are required. Weaker evidence exists for counselling, support-based and narrative therapy interventions.

SUMMARY

Efficacious, timely and acceptable psychological interventions are a necessary component of comprehensive cancer care. There is some way to go before the evidence conclusively points towards which interventions work for which cancer groups and for which specific outcomes. Methodological limitations must be addressed in future trials; at the forefront remains the need for fully powered, head-to-head comparison trials.

Exploring demoralization in end-of-life cancer patients: Prevalence, latent dimensions, and associations with other psychosocial variables

Objective

Demoralization is an existential distress syndrome that consists of an incapacity of coping, helplessness, hopelessness, loss of meaning and purpose, and impaired self-esteem. It can affect cancer patients, and the Demoralization Scale is a valid instrument to assess it. The present study aimed to investigate the prevalence of demoralization in end-of-life cancer patients and its associations with the medical and psychosocial variables. In addition, the latent dimensions of demoralization emerging in this distinctive population were explored.

Method

The study is cross-sectional. The sample consisted of 235 end-of-life cancer patients with a Karnofsky performance status (KPS) lower than 50 and a life expectancy of a few weeks. For each patient, personal and medical data was gathered by a palliative physician and a set of validated rating scales, assessing demoralization, anxiety, depression, physical symptoms, pain, spiritual well-being, and dignity, was administered by a psychologist during the first consultation.

Result

Sixty-four participants (27.2%) had low demoralization, 50.2% (n = 118) had medium demoralization, and 22.6% (n = 53) had high demoralization. Factor analysis evidenced a five-factor solution that identified the following demoralization factors: Emotional Distress and Inability to Cope, Loss of Purpose and Meaning, Worthlessness, Sense of Failure, and Dysphoria. All the considered variables were associated with demoralization, except for pain, nausea, breathing problems, and sociodemographic and clinical variables.

Significance of results

End-of-life cancer patients showed higher levels of demoralization than has been reported in other studies with advanced cancer. These data could suggest that demoralization could increase in proximity to death and with impaired clinical condition. In particular, the five demoralization dimensions that emerged could represent the typical concerns around which the syndrome evolves in end-of-life cancer patients. Finally, spiritual well-being could play a protective role with respect to demoralization.

The Effect of Positive Psychotherapy on the Meaning of Life in Patients with Cancer: A Randomized Clinical Trial

Background and Aim:

Cancer, as a social phenomenon, disrupts the daily functions and social activities of a person and changes his ability to perform roles and responsibilities and reach the meaning of life. The purpose of this study was to investigate the effect of positive psychotherapy on understanding the meaning of life in patients with cancer.

Materials and Methods:

This was a randomized clinical trial study. Sixty-one patients with cancer were selected by convenience sampling method and were assigned randomly into two positive psychotherapeutic (n = 30) and control (n = 31) groups. Positive psychotherapy included eight 90-min sessions held weekly in group form. The life attitude profile-Gary Reker was completed before and after the intervention.

Results:

The results showed that there was no significant difference between the mean scores of meaning of life and all its dimensions (purposes, existential vacuum, death acceptance, goal seeking, coherence and responsibility choice) before intervention, but there was a significant difference between the two groups after intervention (P < 0.05). Also in the control group, the mean score was reduced after the intervention.

Conclusion:

The positive psychotherapy is effective in increasing the level of meaningful life, enjoyable and committed life of people with cancer. Therefore, based on the results of this study, health-care managers can plan to train and increase the empowerment of nurses in providing these interventions to patients in need.

Depressive Symptom Profiles and Survival in Older Patients with Cancer: Latent Class Analysis of the ELCAPA Cohort Study

BACKGROUND

The expression of depressive symptoms in older people with cancer is heterogeneous because of specific features of age or cancer comorbidity. We aimed to identify depressive symptom profiles in this population and describe the associated features including survival.

MATERIALS AND METHODS

Patients ≥70 years who were referred to geriatric oncology clinics were prospectively included in the ELCAPA study. In this subanalysis, depressive symptoms were used as indicators in a latent class analysis. Multinomial multivariable logistic regression and Cox models examined the association of each class with baseline characteristics and mortality.

RESULTS

For the 847 complete-case patients included (median age, 79 years; interquartile range, 76-84; women, 47.9%), we identified five depressive symptom classes: "no depression/somatic only" (38.8%), "no depression/pauci-symptomatic" (26.4%), "severe depression" (20%), "mild depression" (11.8%), and "demoralization" (3%). Compared with the no depression/pauci-symptomatic class, the no depression/somatic only and severe depression classes were characterized by more frequent comorbidities with poorer functional status and higher levels of inflammation. "Severe" and "mild" depression classes also featured poorer nutritional status, more medications, and more frequent falls. Severe depression was associated with poor social support, inpatient status, and increased risk of mortality at 1 year (adjusted hazard ratio, 1.62, 95% confidence interval, 1.06-2.48) and 3 years (adjusted hazard ratio, 1.49; 95% confidence interval, 1.06-2.10).

CONCLUSION

A data-driven approach based on depressive symptoms identified five different depressive symptom profiles, including demoralization, in older patients with cancer. Severe depression was independently and substantially associated with poor survival.

IMPLICATIONS FOR PRACTICE

Older patients with cancer present with distinct profiles of depressive symptomatology, including different severity levels of depression and the demoralization syndrome. Clinicians should use a systematic assessment of depressive symptoms to adequately highlight these distinct profiles. Geriatric and oncological features are differently associated with these profiles. For instance, severe depression was associated with more frequent comorbidities with poorer functional, poor nutritional status, polypharmacy, frequent falls, inpatient status and poor social support. Also, severe depression was independently and substantially associated with poor survival so that the identification and management of depression should be considered a high priority in this population.

Psychological interventions in palliative care

PURPOSE OF REVIEW

To provide an update on recent studies about psychological interventions in palliative (mainly cancer) care with a focus on physical, psychological, spiritual, and social aspects.

RECENT FINDINGS

Some promising psychological interventions for physical challenges, such as fatigue, pain, dyspnea, and insomnia do exist, but further research is needed. Regarding psychological aspects, current reviews showed small to large effects in the reduction of depression and anxiety symptoms through cognitive behavioral-based interventions, mindfulness-based interventions, and meaning-based interventions. Meaning-based or dignity-based approaches were also used for targeting spiritual aspects or existential distress. Social aspects that play a crucial role in palliative care are addressed by social support interventions, end-of-life discussions, and advanced careplanning. All of these psychological interventions must meet the specific requirements of palliative care, namely abbreviated session time and flexibility concerning locality of interventions, a minimized questionnaire burden and a high attrition rate caused by patients' poor physical conditions or deaths.

SUMMARY

There is substantial research on psychological interventions in palliative care that shows promising results, but sample sizes were often small. Due to its high relevance for this growing patient group, there is a strong need for ongoing/further research.