Documenting stress in caregivers of transplantation patients: initial evidence of HPA dysregulation

Hematopoietic Stem-Cell Transplantation: Exploring the Latest Advances and Gaps in Disparities, Psychosocial and Symptom Management Interventions, and Chronic Graft-Versus-Host Disease Care

Although allogeneic hematopoietic cell transplantation (HCT) offers a potential for cure for many patients with advanced hematologic malignancies and bone marrow failure or immunodeficiency syndromes, it is an intensive treatment and accompanied by short- and long-term physical and psychological symptoms requiring specialized care. With substantial advances in therapeutic approaches for HCT and supportive care, HCT survivors experience less morbidity and mortality. However, disparities in both HCT access and outcomes persist, and HCT survivors and their caregivers often lack access to much-needed psychosocial care. Additionally, more medical and psychosocial resources are needed to holistically care for HCT survivors with chronic graft-versus-host disease (GVHD). Hence, this chapter focuses on three areas pertaining to advances and gaps in HCT care: disparities in access to and outcomes of HCT, psychosocial and physical symptom management with supportive care interventions, and GVHD prevention and management.

A Positive Psychology Intervention for Caregivers of Hematopoietic Stem Cell Transplantation Survivors (PATH-C): Initial Testing and Single-Arm Pilot Trial

Caregivers of patients with hematologic malignancies undergoing allogeneic hematopoietic stem cell transplantation (HSCT) play a crucial role in supporting their loved ones through physical, emotional, and practical challenges. This role has been associated with high levels of psychological distress and low levels of positive psychological well-being (PPWB). Positive psychology interventions for caregivers in other disease groups (eg, breast cancer) have been associated with improved outcomes. However, positive psychology interventions that specifically address HSCT caregivers' psychological needs are currently lacking. The goal of this single-arm open-pilot trial was to determine the feasibility and acceptability of the Positive Affect in the Transplantation of Hematopoietic Stem Cells (PATH) intervention for HSCT Caregivers to identify caregiver preferences to tailor PATH for HSCT caregivers. Adult caregivers of HSCT recipients were eligible for PATH during the HSCT recipient's first 100 d post-transplant. We defined, a priori, feasibility as >60% of participants who start the intervention completing ≥6/9 intervention sessions and acceptability as weekly ratings of ease and utility of the PP exercises ≥7/10 on a 10-point Likert Scale (0 = very difficult/not helpful; 10 = very easy/very helpful). We conducted semistructured qualitative exit interviews (n = 15) to explore HSCT caregivers' perception of PATH's content, benefits of PATH, as well as facilitators and barriers to engaging with the intervention. Transcribed interviews were analyzed using framework-guided rapid analysis by 2 coders. The intervention was feasible with 83% (15/18) of caregivers who started the intervention completing ≥6/9 intervention sessions. Among caregivers who completed ≥6/9 intervention sessions, ratings of ease (mean = 8.1; 95% CI: 7.4, 8.7) and utility (mean = 8.3; 95% CI: 7.8, 8.9) also exceeded our a priori threshold of ≥7/10. Caregivers identified benefits of PATH, including identifying and responding to emotions, dedicating time to self-care, and cultivating important relationships. Sociodemographic factors (eg, being retired) and the manualized structure of PATH were cited as facilitators to intervention engagement. Barriers to PATH engagement included lack of time and competing caregiving responsibilities. Caregivers preferred remote intervention delivery within the first 100 d post HSCT. This is the first study to show a 9-wk, phone-delivered positive psychology intervention is feasible in caregivers of allogeneic HSCT recipients. Our findings also underscore the specific preferences of this population for positive psychology interventions. Larger studies are warranted to establish the efficacy of these interventions in addressing persistent unmet psychological needs for HSCT caregivers.

A Mixed-Methods Feasibility Study: Eliciting ICU Experiences and Measuring Outcomes of Family Caregivers of Patients Who Have Undergone Hematopoietic Stem Cell Transplantation

The impact of an intensive care unit (ICU) admission on family caregivers of patients who have undergone hematopoietic stem cell transplantation (HSCT) has not been well described. Aims of this study were to determine the feasibility of conducting research with family caregivers of HSCT patients during an ICU admission and generate preliminary data about their experiences and engagement in care. Using a mixed-methods, repeated measures design, we collected data from family caregivers after 48 hr in the ICU (T1) and at 48 hr after transferring out of ICU (T2). Enrolling HSCT caregivers in research while in the ICU was feasible (10/13 consented; 9/10 completed data collection at T1); however, data collection at T2 was not possible for most caregivers. Caregiver distress levels were high, and engagement in care was moderate. The three themes that emerged from interviews (n = 5) highlighted that although HSCT family caregivers faced many challenges and received limited support during their ICU experience, they were able to access their own personal resources and demonstrated resilience.

Coping in caregivers of patients with hematologic malignancies undergoing hematopoietic stem cell transplantation

Caregivers of patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) must cope with substantial caregiving burden, high rates of psychological distress, and diminished quality of life (QOL). However, data describing coping strategies before HSCT and the association between coping, QOL, and psychological outcomes in this population are lacking. We conducted a secondary analysis of data collected during a multisite randomized clinical trial of a supportive care intervention in HSCT recipients and their caregivers. Caregivers completed the Brief COPE, Hospital Anxiety and Depression Scale, and the Caregiver Oncology Quality of Life Questionnaire to measure coping strategies, psychological distress, and QOL, respectively. We grouped coping into 2 higher-order domains: approach-oriented (ie, emotional support and active coping) and avoidant (ie, self-blame and denial). We used the median split method to describe the distribution of coping and multivariate linear regression models to assess the relationship between coping and caregiver outcomes. We enrolled 170 caregivers, with a median (range) age of 53 (47-64) years. Most were White (87%), non-Hispanic (96%), and female (77%). Approach-oriented coping was associated with less anxiety (β = -0.210, P = .003), depression symptoms (β = -0.160, P = .009), and better QOL (β = 0.526, P = .002). In contrast, avoidant coping was associated with more anxiety (β = 0.687, P<.001), depression symptoms (β = 0.579, P < .001), and worse QOL (β = -1.631, P < .001). Our findings suggest that coping is related to distress and QOL among caregivers of HSCT recipients even before transplant. Hence, caregivers of patients with hematologic malignancies undergoing HSCT may benefit from resources that facilitate adaptive coping with the demands of caregiving.

How Caregivers Cope and Adapt When a Family Member Is Diagnosed With a Hematologic Malignancy: Informing Supportive Care Needs

BACKGROUND

Informal family caregivers (FCs) of adults with various diseases including hematologic malignancy (HM) experience low quality of life and psychological well-being. Although HMs are life-threatening cancers associated with high mortality, numerous symptoms, and lengthy hospitalizations and are therefore likely to be challenging for FCs to cope with, there is scant research exploring FC experiences.

OBJECTIVE

The aim of this study was to describe the coping and adaptation of FCs of patients during diagnosis and treatment of HM.

METHODS

This study used a qualitative descriptive design to analyze semi-structured interview responses from FCs (N = 28) within 3 months of the patients' HM diagnosis. A content analysis was conducted to generate common themes.

RESULTS

Family caregivers endorsed adaptive and maladaptive coping. Adaptive strategies included taking one day at a time, spirituality, engaging in pastimes, and utilizing emotional and instrumental family and community support. Maladaptive coping included wishful thinking, harmful habits, avoidance, and lacking or being unable to accept family and community support.

CONCLUSIONS

Findings highlight the complexities of caregiver burden as they support their loved ones with HM.

IMPLICATIONS FOR PRACTICE

Family caregivers would benefit from receiving an interdisciplinary family-centered approach as their HM person is initiating treatment. Nurses should consider assessing the FCs' psychosocial needs to help facilitate appropriate services, such as palliative care consultations, social work referrals, support groups, and/or counseling.

Biobehavioral Implications of Covid-19 for Transplantation and Cellular Therapy Recipients

A growing body of literature has emphasized the importance of biobehavioral processes - defined as the interaction of behavior, psychology, socioenvironmental factors, and biological processes - for clinical outcomes among transplantation and cellular therapy (TCT) patients. TCT recipients are especially vulnerable to distress associated with pandemic conditions and represent a notably immunocompromised group at greater risk for SARS-CoV-2 infection with substantially worse outcomes. The summation of both the immunologic and psychologic vulnerability of TCT patients renders them particularly susceptible to adverse biobehavioral sequelae associated with the Covid-19 pandemic. Stress and adverse psychosocial factors alter neural and endocrine pathways through sympathetic nervous system and hypothalamic-pituitary-adrenal axis signaling that ultimately affect gene regulation in immune cells. Reciprocally, global inflammation and immune dysregulation related to TCT contribute to dysregulation of neuroendocrine and central nervous system function, resulting in the symptom profile of depression, fatigue, sleep disturbance, and cognitive dysfunction. In this article, we draw upon literature on immunology, psychology, neuroscience, hematology and oncology, Covid-19 pathophysiology, and TCT processes to discuss how they may intersect to influence TCT outcomes, with the goal of providing an overview of the significance of biobehavioral factors in understanding the relationship between Covid-19 and TCT, now and for the future. We discuss the roles of depression, anxiety, fatigue, sleep, social isolation and loneliness, and neurocognitive impairment, as well as specific implications for sub-populations of interest, including pediatrics, caregivers, and TCT donors. Finally, we address protective psychological processes that may optimize biobehavioral outcomes affected by Covid-19.

Risk of somatic hospitalization in parents after cancer in a child, a nationwide cohort study

OBJECTIVE

The diagnosis of cancer in a child is a profoundly stressful experience. The impact on parents' somatic health, including lifestyle-related diseases, however, is unresolved.

METHODS

We conducted a nationwide population- and register-based study with parents of all children under age 20 diagnosed with cancer in Denmark between 1998 - 2013 and parents of cancer-free children, matched (1:10) on child's age and family type. We estimated hazard ratios (HR) with 95% confidence intervals (CI) in Cox proportional hazard models for thirteen major International Classification of Diseases-10 disease-groups, selected stress- and lifestyle-related disease-groups and investigated moderation by time since diagnosis, parental sex, and cancer type.

RESULTS

Among n=7797 parents of children with cancer compared with n=74,388 parents of cancer-free children (51% mothers, mean age 42), we found no overall pattern of increased risk for 13 broad disease-groups. We found increases in digestive system diseases (HR1.06, 95% CI1.01-1.12), genitourinary system diseases (HR 1.08, 95% CI 1.02-1.14), and neoplasms (HR 1.20, 95% CI 1.13-1.27), the latter attributable mostly to increased rates of tobacco-related cancers and mothers' diet-related cancers.

CONCLUSIONS

This is the first attempt to document the impact of childhood cancer on parents' somatic health. With the exception of increased risk for neoplasms, likely due to shared genetic or lifestyle factors, our findings offer the reassuring message, that the burden of caring for a child with cancer does not in general increase parents' risk for somatic diseases. This article is protected by copyright. All rights reserved.

Association of cancer caregiver stress and negative attribution style with depressive symptoms and cortisol: a cross-sectional study

PURPOSE

We examined the effect of informal cancer caregiver stress and negative attribution style (NAS) on depressive symptoms and salivary cortisol.

METHOD

The sample came from a hospital bone marrow unit and caregiver support organizations and included 60 informal cancer caregivers (51.7% partners) of individuals with cancer (provided care for a median of 27.5 h per week for 12 months) and 46 non-caregiver participants. In this cross-sectional study, participants completed questionnaires assessing NAS and depressive symptoms and provided saliva samples to measure cortisol.

RESULTS

Linear regressions demonstrated that cancer caregiver stress (p = 0.001) and the cancer caregiver stress by NAS interaction (p = 0.017), but not NAS alone (p = 0.152), predicted depressive symptoms. Caregivers independent of their NAS and non-caregivers high in NAS reported high depression while non-caregivers low in NAS reported low depression. Neither cancer caregiver stress (p = 0.920) nor NAS alone (p = 0.114), but their interaction, predicted cortisol (p = 0.036). Higher NAS was associated with a higher cortisol in both groups while non-caregivers had higher cortisol than caregivers.

CONCLUSIONS

If the findings can be replicated, consideration of NAS in existing interventions to support informal cancer caregivers in managing chronic stress appears warranted.

The Lived Experiences of Caregivers of Lung Transplant Recipients

INTRODUCTION

Lung transplantation is a treatment crucial for the survival of patients with end-stage lung diseases. An identified caregiver is obligatory for a patient to be eligible for a lung transplant and plays an essential role in the transplant recipient's care. Most caregiver research, however, has been on caregivers of persons with Alzheimer's disease or the elderly, with limited research on caregivers' experiences caring for transplant recipients. This study examined the experiences of caregivers of recipient's pre- and post-lung transplantation.

METHODS/APPROACH

Caregivers of lung transplant recipients were recruited using purposeful sampling. Audiotaped semi-structured open ended interviews were conducted until data saturation. Each interview was transcribed verbatim, and conventional content analysis performed to extract significant themes and subthemes.

FINDINGS

Four main themes and 12 sub-themes were identified. The former included (1) establishing the diagnosis, (2) caregiver roles, (3) caregiver psychological and psychosocial issues, and (4) support. Caregivers lacked basic knowledge related to lung transplantation. The caregivers' roles necessitated rearranging priorities, lifestyle changes, and redirecting emotional and physical energy. Support played an important role in caregiving experiences.

DISCUSSION

Each caregiver shared their unique caregiving experiences. Caregivers lack knowledge about transplantation, experience dramatic changes in their family life, social activities, employment, and often financial status. Healthcare providers can use the findings of this study in developing informational, and psychological interventions to alleviate caregivers' stress and anxiety.

Association between inflammatory cytokines and caregiving distress in family caregivers of cancer patients

PURPOSE

Caregivers of cancer patients experience distress that can manifest as caregiving burden, burnout, depression, and fatigue. Caregiving distress affects physical health in various ways such as causing the dysregulation of inflammatory functions. We examined the relationships between psychological distress experienced by and inflammatory cytokine levels of family caregivers of cancer patients.

METHODS

A descriptive, cross-sectional study involving 93 family caregivers of cancer patients was conducted. Self-report questionnaires were used to measure the distress variables, which included the caregiving burden, burnout, depression, and fatigue, and peripheral blood samples were collected to measure the IL-6, IL-10, and TNF-α levels. Multiple linear regression analyses were conducted to evaluate the impact of caregivers' distress on their inflammatory cytokine levels.

RESULTS

Inflammatory cytokine levels were negatively correlated with caregiving distress. High fatigue levels (B =  - 0.047, p = 0.026) and additional days of care provided per week (B =  - 0.048, p = 0.009) was associated with low IL-6 levels. High depression levels (B =  - 0.250, p = 0.007), high fatigue levels (B =  - 0.054, p = 0.027), and more days of care provided per week (B =  - 0.048, p = 0.033) were associated with low TNF-α levels. The age of the caregiver (B =  - 0.011, p = 0.020) and days of care provided per week (B =  - 0.138, p = 0.031) were associated factors for IL-10 levels.

CONCLUSION

The inflammatory responses were associated with the distress in family caregiving for cancer patients. Thus, interventions are needed to support caregivers and manage their caregiving distress.

The moderated associations of self-compassion with physiological and psychological stress responses: Comparisons between cancer caregivers and non-caregivers

Self-compassion has been shown to be protective against stress. Whether its stress buffering effect differs between cancer caregivers and non-caregivers is unknown. This study examined the moderating effect of self-compassion among cancer caregivers relative to non-caregivers by recruiting cancer caregivers from the hospital and a community sample matching on sex and age. Participants completed a questionnaire which comprised the self-reported anxiety (STAI-6) and self-compassion (SCS-SF) measures, and administered cortisol sample collections with Salivette tubes at home. Whereas caregivers experienced higher diurnal cortisol level, the differential protective effects of self-compassion were only present against anxiety symptoms but not physiological stress.

Can volunteer medical visit companions support older adults in the United States?

BACKGROUND

Older adults are encouraged to use Medical Visit Companions (MVCs) for routine medical encounters; however, many vulnerable older adults attend alone or fail to attend. In the absence of available family or friends, community volunteers could potentially fill this gap. We aimed to understand the role and acceptability of volunteer MVCs accompanying older adults to medical visits and explore potential barriers and facilitators of increasing MVC availability and expanding roles beyond transportation.

METHODS

Two moderators conducted 4 focus groups with 29 volunteers grouped by whether they provided (n = 15) or received (n = 14) rides to medical visits. All were members of Partners In Care (PIC), a community organization in Maryland, United States which offers a range of programs and services that support the independence of older adults including the provision of volunteer MVCs. Participants were asked to discuss why they were involved with PIC, and to describe their experiences with providing or receiving companionship during medical visits. Inductive thematic analysis was used to explore the views and experiences of participants, particularly around the roles played by MVCs and the feasibility of expanding these roles.

RESULTS

All participants reported benefits from their role whether that was giving or receiving rides. Many accompanied participants reported missing medical appointments prior to joining PIC and being able to avail of the services of a MVC. Volunteer roles varied and ranged from transportation only, help with care coordination and in some cases accompanying the person into their medical visit. A subgroup of volunteers expressed a willingness to take on additional roles during the physician visit following additional training and isolated older adults welcomed the prospect of their assistance.

CONCLUSION

Our qualitative data indicate that non-family, volunteer MVCs are willing and able to assist older people going to a medical visit. With appropriate training and support, volunteer companions could do much to improve the healthcare experience for those who otherwise would attend alone or would not attend medical visits.

Assessing How a Transplant Hospitality House for Patients and Families Can Promote Wellbeing

Patients and caregivers face increasingly complex and unique challenges when they travel to distant hospitals for transplant care. They can find themselves in a strange city managing hospital stays and outpatient appointments, requiring lodging, food, transportation, financial assistance, and emotional support. Those unable to overcome these logistical challenges may lose access to lifesaving treatment. Transplant specific hospitality houses have emerged to support patients who travel long distances from home to seek care, though little is known about the impact of such programs. Can a transplant hospitality house impact opportunities for family-centered care, perceptions of physiological and physical security, and perceptions of belonging and esteem? Can their contributions also be linked to perceived positive health outcomes and what aspects of a transplant hospitality house are most significant for a patient's and caregiver's health journey? One transplant hospitality house investigated these questions with 71 participating in focus groups or key stakeholder interviews: transplant patients and caregivers, transplant hospital social workers, volunteers, financial contributors, board members, and staff. The findings suggest that while patients and caregivers were dependent and deeply grateful for the lodging and amenities that met their basic needs, it was the contact and support from other patients and caregivers at the transplant hospitality house that had the most profound positive impact on patient and family attitudes, outlooks, and perceived well-being.

Check your sleep before you start: A secondary analysis of a stress management intervention for caregivers of stem cell transplant patients

OBJECTIVE

Caregiving for hematopoietic stem cell transplant (HSCT) patients is associated with significant physical and psychological sequelae. While psychosocial interventions may reduce caregiver burden, knowledge regarding which caregivers may benefit the most from such interventions is limited. The purpose of this secondary analysis was to examine whether HSCT caregivers' peritransplant sleep moderated the effect of a psychosocial intervention on depression and anxiety posttransplant.

METHODS

Participants included 135 caregivers (mean age = 54.23) who participated in randomized controlled trial and were assigned to receive either 8 weeks of Psychoeducation, Paced Respiration, and Relaxation (PEPRR) or treatment as usual (TAU). Sleep, depression, and anxiety were assessed using the Pittsburg Sleep Quality Index, the Center for Epidemiologic Studies Depression Scale, and the State-Trait Anxiety Inventory, respectively. Caregiver symptoms were assessed at baseline (e.g., peritransplant period) and 6-month posttransplant.

RESULTS

Baseline sleep quality (∆R²  = 0.04, p = 0.002), sleep efficiency (∆R²  = 0.03, p = 0.02), and sleep onset latency (∆R²  = 0.07, p < 0.001) independently moderated the effect of group assignment on depression outcomes at the 6-month follow-up. Specifically, caregivers with poor sleep at baseline who received PEPRR reported significantly lower depression scores at follow-up compared to caregivers with poor sleep who received TAU. By contrast, only sleep quality (∆R²  = 0.02, p = 0.01) and sleep onset latency (∆R²  = 0.02, p = 0.005) moderated the effect of the group assignment on anxiety.

CONCLUSIONS

Psychosocial interventions for HSCT caregivers may buffer against psychological morbidity, particularly among caregivers with poor sleep quality.

A pilot study of mobilized intervention to help caregivers of oncology patients manage distress

OBJECTIVE

Caregivers of patients with advanced cancer experience significant anxiety, depression, and distress. Caregivers have barriers to accessing in-person treatment to manage stress. Technology allows for the dissemination of evidence-based interventions in a convenient way. This study examined usage rates of Pep-Pal (an evidence-based mobilized intervention to help caregivers of patients with advanced cancer manage distress) and estimates of efficacy on anxiety, depression, stress, and sexual dysfunction.

METHODS

Fifty-six primary caregivers of patients with advanced cancer were recruited through oncology clinics and randomized to either Pep-Pal (a mobilized psychoeducation and skills-based intervention for caregivers, n = 26) or treatment as usual (TAU; n = 30). All were screened for moderate anxiety on the Hospital Anxiety and Depression Scale-Anxiety screening assessment (A ≥ 8) at baseline.

RESULTS

Participants randomized to Pep-Pal experienced greater reductions in perceived stress (PSS; F = 3.91, p = .05), greater increases in ability to learn and use stress management skills (F = 6.16, p = 0.01), and greater increases in sexual function (women only; F = 5.07, p = 0.03) compared to participants in TAU. Of Pep-Pal participants, only 10 (38.5%) watched at least 7/9 full-length sessions. The a priori hypothesis and criterion that participants would watch at least 75% full-length sessions were not met.

CONCLUSIONS

A brief, easily disseminated mobile intervention showed poor adherence, but had limited estimates of efficacy for secondary outcomes; perceived stress, learning stress management skills, and sexual functioning (women only). Future directions are discussed.

A Qualitative Study to Explore the Needs of Lung Transplant Caregivers

INTRODUCTION

Providing support throughout the lung transplant process is an intensive task, which requires a dedicated caregiver. The needs of caregivers who must relocate with their loved one receiving the transplant are currently unknown. The objective of this study is to explore experiences and perceptions of lung transplant caregivers identified from a satellite clinic to inform the development of educational resources.

METHODS

A qualitative study with a phenomenology approach was undertaken with individuals who have taken on the role of a caregiver for lung transplant candidates or recipients and must travel to the specialized transplant center. Semistructured interviews were conducted with 12 caregivers. Interviews conducted by phone were audio-recorded and then transcribed verbatim. NVivo software was used to code the data and identify emerging themes.

RESULTS

Ideas were classified into the following 4 themes: (1) the stress of being a caregiver, (2) caregivers undertake a variety of roles, (3) caregivers require support, and (4) satisfaction with health care providers. Even though the caregivers lived an average of 7.1 (standard deviation 2) hours from the surgical transplant center, all expressed satisfaction with the level of care that they received. Caregivers identified several stressors during the transplant process and described various strategies for coping.

CONCLUSION

Caregivers shared their experiences on the transplant process. It was evident that being a caregiver was a stressful and supports were necessary for those undertaking this role. These insights will help inform the development of a new educational resource for patients and caregivers.

Strain specific stress-modulating effects of candidate probiotics: A systematic screening in a mouse model of chronic restraint stress

BACKGROUND

Changes in the gut microbiota have been implicated in mood and cognition. In rodents, supplementation with certain bacteria have been shown to alleviate adverse effects of stress on gut microbiota composition and behaviour, but little is known of how the performance of different strains compare to each other. We took a systematic approach to test the efficacy of twelve candidate probiotic strains from ten species/sub-species of Bifidobacterium and Lactobacillus on behaviours and neuroendocrine responses of chronically stressed mice.

METHODS

The strains were tested in four screening experiments with non-stressed and chronically stressed vehicle groups. The three most efficacious strains were re-tested to validate the results. Mice were administered a daily oral gavage containing either 1 × 10⁹ colony forming units (CFU) of selected candidate probiotic or saline solution for one week prior to and for three weeks during daily chronic restraint stress. Behavioural tests including the elevated plus maze, open field, novel object recognition, and forced swim test were applied during week five. Corticosterone and adrenocorticotropic hormone (ACTH) were analysed to measure the neuroendocrine response to stress. Plasma and tissue samples were collected for biomarker analyses.

RESULTS

Of the twelve candidate probiotics, Lactobacillus paracasei Lpc-37, Lactobacillus plantarum LP12407, Lactobacillus plantarum LP12418 and Lactobacillus plantarum LP12151 prevented stress-associated anxiety and depression-related behaviours from developing compared with chronically stressed vehicle mice. In addition, Lpc-37 improved cognition.

CONCLUSION

This systematic screening indicates species- and strain-dependent effects on behavioural outcomes related to stress and further suggests that strains differ from each other in their effects on potential mechanistic outcomes.

Repetitive Negative Thinking, Depressive Symptoms, and Cortisol in Cancer Caregivers and Noncaregivers

OBJECTIVES

To examine the effect of informal cancer caregiving and repetitive negative thinking (RNT) on depressive symptoms and salivary cortisol levels.

SAMPLE & SETTING

The sample was recruited from a hospital bone marrow unit and caregiver support organizations. It included 60 informal cancer caregivers (52% partners) of individuals with cancer who provided care for a median of 27.5 hours per week for 12 months, and 46 noncaregiver participants.

METHODS & VARIABLES

In this cross-sectional study, participants completed questionnaires assessing RNT and depressive symptoms and provided saliva samples to measure cortisol levels.

RESULTS

Cancer caregiving and RNT, but not the interaction, were associated with more depressive symptoms. RNT, but not cancer caregiving, was associated with salivary cortisol. A disordinal interaction effect suggests that cancer caregiving was associated with lower cortisol levels, and RNT in noncaregivers was associated with higher cortisol levels.

IMPLICATIONS FOR NURSING

Given that RNT is related to depressive symptoms and cortisol, connecting cancer caregivers who experience RNT to resources and the development and evaluation of brief nurse-led interventions to reduce RNT in informal cancer caregivers seems warranted.

Is Family Caregiving Associated With Inflammation or Compromised Immunity? A Meta-Analysis

BACKGROUND AND OBJECTIVES

Family caregiving stress has been widely reported to have negative effects on circulating biomarkers of immune system function and inflammation. Our goals were to systematically review this literature and conduct a meta-analysis on the extracted effects.

RESEARCH DESIGN AND METHODS

A systematic search of published studies comparing caregivers and noncaregivers on biomarkers measured from blood samples was conducted in the PubMed, Embase, and Cochrane databases. This search identified 2,582 articles and abstracts. After removing duplicative papers and studies not meeting inclusion criteria, 30 articles were identified that reported analyses on 86 relevant biomarkers from 1,848 caregivers and 3,640 noncaregivers.

RESULTS

Random-effects models revealed an overall effect size across all biomarkers of 0.164 SD units (d). A slightly larger overall effect (d = 0.188) was found for dementia caregivers only. Immune system comparisons yielded somewhat larger differences than inflammation comparisons. Most studies used small convenience samples, and effect sizes were larger for studies with moderate or high bias ratings than for studies with low bias ratings. No significant associations were found in studies that used population-based samples.

DISCUSSION AND IMPLICATIONS

Caregivers had small but significantly reduced immune system functioning and greater inflammation than noncaregivers, but associations were generally weak and of questionable clinical significance. The absence of clear associations from low bias studies and population-based studies underscores concerns with possible selection biases in many of the convenience samples. Population-based studies that assess biomarkers before and after the onset of caregiving might add much clarity to this literature.

Quality of Life of Caregivers of Hematopoietic Cell Transplant Recipients

Caregivers are critical to recipient recovery after hematopoietic cell transplant (HCT); however, little is known about their long-term health and quality of life (QoL). In this study we surveyed 4446 caregiver-recipient pairs in the post-HCT period to describe their QoL and its determinants. In total, 849 caregiver-recipient pairs at a median of 6 years after autologous or allogeneic HCT responded. Among 849 responding caregivers at a median of 6 years post-HCT, 67% of caregivers were women and 68% indicated they were still providing care to the recipient. Mean and median QoL measures of caregivers were at or above general population norms; however, approximately 20% of caregivers reported poor QoL relative to general population norms. Multivariate analysis revealed that caregiver characteristics, including age, gender, and educational attainment, were important determinants of caregiver QoL. Additional determinants of caregiver QoL included recipient QoL, relapse after autologous HCT, and ongoing use of immunosuppression after allogeneic HCT. Additionally, the prevalence of depression and sleep disorders appear to be higher in caregivers than in the general population. We have identified a population of caregivers who may benefit from interventions aimed at improving QoL and health outcomes. HCT clinical practice should also consider caregiver well-being.

The Role of Biomarkers in Research on Caregivers for Cancer Patients: A Scoping Review

BACKGROUND

Biomarkers can be used as prognostic, predictive, or monitoring indicators of an associated outcome. The purpose of this review was to provide a comprehensive summary of the research examining the use of biomarkers as surrogate end points for clinical outcomes in family caregivers for cancer patients, identify gaps, and make recommendations for future research.

METHODS

A scoping review, a process of mapping the existing literature, was conducted. Studies comparing biomarkers across caregivers and controls and/or examining relationships between biomarkers and psychological health were reviewed.

RESULTS

The studies ( N = 18) of caregivers for cancer patients who were identified used biomarkers to predict outcomes ( n = 13) and to monitor the efficacy of interventions ( n = 6). Biomarkers were divided into two categories based on physiological systems involved: (1) neuroendocrine function (sympathetic-adrenal-medullary axis activity, hypothalamic-pituitary-adrenal axis activity) and (2) immune function. Predictive biomarkers were sensitive to differences between caregivers and controls. The biomarkers were used to evaluate outcomes frequently associated with stress, depression, and anxiety. Cortisol was the biomarker most commonly measured to monitor the efficacy of interventions.

DISCUSSION

Biomarkers are most commonly incorporated into caregiver studies to predict group membership and psychological health. Neuroendocrine biomarkers, specifically cortisol, are most frequently assessed. Future research should include biomarkers of other physiologic functions (e.g., cardiovascular function, cognitive dysfunction, and cell aging) and those that serve as multisystem indicators. Expanding the scientific study of biomarkers will contribute to our understanding of the mechanisms through which stress may influence caregiver health.

Cardiometabolic risk factors and health behaviors in family caregivers

The purpose of this study was to compare components of cardiometabolic risk and health behaviors of 20 family caregivers of allogeneic hematopoietic stem cell transplant patients to those of age, gender, and race/ethnicity-matched controls. A prospective, repeated measures design was used to compare cardiometabolic risk and health behaviors in caregivers and controls at three time-points: pre-transplantation, discharge, and six weeks post-discharge. Measures included components of metabolic syndrome, Reynolds Risk Score, NMR serum lipoprotein particle analyses, and the Health-Promoting Lifestyle Profile II (HPLP-II). Mixed-model repeated measure analyses were used. There were no between or within group differences in LDL cholesterol, HDL cholesterol, and triglycerides. There was a significant interaction effect between time and role in large VLDL concentration (VLDL-P) (F (2, 76) = 4.36, p = .016), with the trajectory of large VLDL-P increasing over time in caregivers while remaining stable in controls. Within caregivers, VLDL particle size (VLDL-Z) was significantly larger at time-point three compared to time-points one (p = .015) and two (p = .048), and VLDL-Z was significantly larger in caregivers than in controls at time point three (p = .012). HPLP-II scores were lower in caregivers than controls at all time-points (p < .01). These findings suggest that caregiving may have a bigger impact on triglycerides than on other lipids, and it is through this pathway that caregivers may be at increased cardiometabolic risk. More sensitive measurement methods, such as NMR lipoprotein particle analyses, may be able to detect early changes in cardiometabolic risk.

National Institutes of Health Hematopoietic Cell Transplantation Late Effects Initiative: The Patient-Centered Outcomes Working Group Report

In 2015, the National Institutes of Health convened six working groups to address the research needs and best practices for late effects of hematopoietic stem cell transplantation survivors. The Patient-Centered Outcomes Working Group, charged with summarizing the HRQOL evidence base, used a scoping review approach to efficiently survey the large body of literature in adult and pediatric HCT survivors over 1 year after transplantation. The goals of this paper are to (1) summarize the current literature describing patient-centered outcomes in survivors, including the various dimensions of health-related quality of life affected by HCT, and describe interventions tested to improve these outcomes; (2) highlight areas with sufficient evidence allowing for integration into standard practice; (3) address methodological issues that restrict progress in this field; (4) identify major gaps to guide future research; and (5) specify priority research recommendations. Patient-centered outcomes were summarized within physical, psychological, social, and environmental domains, as well as for adherence to treatment, and health behaviors. Interventions to improve outcomes were evaluated for evidence of efficacy, although few interventions have been tested in long-term HCT survivors. Methodologic issues defined included lack of consistency in the selection of patient-centered outcome measures, along with the absence of a standard for timing, frequency, and mode of administration. Recommendations for HCT survivorship care included integration of annual screening of patient-centered outcomes, use of evidence-based practice guidelines, and provision of treatment summaries and survivorship care plans after HCT. Three priority research recommendations included the following: (1) design and test risk-targeted interventions with dose-intensity modulation matching the needs of HCT survivors with priority domains, including sexual dysfunction, fatigue, sleep disruption, nonadherence to medications and recommended health care, health behaviors including physical inactivity and healthy eating, and psychological dysfunction, with particular consideration of novel technologies to reach HCT survivors distant from their transplantation centers; (2) design a consensus-based methodologic framework for outcomes evaluation; and (3) evaluate and compare existing practices for integrating patient-centered outcome screening and interventions across HCT survivorship programs.

An evidence-based stress management intervention for allogeneic hematopoietic stem cell transplant caregivers: development, feasibility and acceptability

PURPOSE

Caregivers of cancer patients face challenges impacting their physical, psychological and social well-being that need attention in the form of well-designed and tested interventions. We created an eight-session individual stress management intervention for caregivers of allogeneic hematopoietic stem cell transplant (Allo-HSCT) recipients. This intervention, tested by randomized control trial, proved effective in decreasing distress. Herein, we describe the intervention including theoretical framework, development, and elements of fidelity. Implementation challenges along with recommendations for refinement in future studies are discussed with the goal of replication and dissemination.

METHODS

Seventy-four of 148 caregivers received stress management training following randomization. The intervention occurred during the 100-day post-transplant period when caregivers are required. The training provided integrated cognitive behavioral strategies, psychoeducation, and problem-solving skills building as well as use of a biofeedback device.

RESULTS

Seventy percent of caregivers completed all eight sessions indicating good acceptability for the in-person intervention; however, most caregivers did not reliably use the biofeedback device. The most common reason for drop-out was their patient becoming gravely ill or patient death. Few caregivers dropped out because of study demands. The need for flexibility in providing intervention sessions was key to retention.

CONCLUSION

Our evidence-based stress management intervention for Allo-HSCT caregivers was feasible. Variability in acceptability and challenges in implementation are discussed and suggestions for refinement of the intervention are outlined. Dissemination efforts could improve by using alternative methods for providing caregiver support such as telephone or video chat to accommodate caregivers who are unable to attend in-person sessions.