COVID-19 or Cancer Stress? Anxiety and Depressive Symptoms in Patients with Advanced Lung Cancer

BACKGROUND

Of all cancer patients, those with lung cancer are among the highest risk for infection, pneumonia, hospitalization, and early death from COVID-19. As cancer stress is ubiquitous, this exploratory study examines patients' COVID-19 stress and cancer stress in relation to their depressive and anxiety symptoms.

METHOD

Newly diagnosed advanced lung cancer patients (N = 76) completed measures of cancer stress, COVID-19 illness perceptions and stress, and depressive and anxiety symptoms at a single monthly follow-up early in the pandemic (May 2020 to July 2020; Clinicaltrials.gov #NCT03199651). Hierarchical linear multiple regression analysis was used to identify the relationship of stressor variables to depressive and anxiety symptoms in this cross-sectional study.

RESULTS

Hierarchical linear models revealed cancer stress was a significant predictor of both depressive symptoms (F(14,30) = 5.327, p < 0.001, R2 = 0.71, adjusted R2 = 0.58) and anxiety symptoms (F(14,30) = 4.513, p < 0.001, R2 = 0.68, adjusted R2 = 0.53) for patients at the start of the COVID-19 pandemic. By contrast, COVID-19 stress was not a significant predictor of depressive (F(13,31) = 1.415 p = .21, R2 = .37, adjusted R2 = .11) or anxiety symptoms (F(13,31) = 1.23, p = .30, R2 = .34, adjusted R2 = - .07).

CONCLUSIONS

Advanced lung cancer patients during the early phase of the COVID-19 pandemic reported cancer stress as more important than COVID-19 stress in relation to their mental health. Empirically supported biobehavioral and cognitive behavioral treatments remain important to reducing psychological symptoms and enhancing patients' quality of life.

Association Between Neighborhood Opportunity, Allostatic Load, and All-Cause Mortality in Patients With Breast Cancer

PURPOSE

Adverse neighborhood contextual factors may affect breast cancer outcomes through environmental, psychosocial, and biological pathways. The objective of this study is to examine the relationship between allostatic load (AL), neighborhood opportunity, and all-cause mortality among patients with breast cancer.

METHODS

Women age 18 years and older with newly diagnosed stage I-III breast cancer who received surgical treatment between January 1, 2012, and December 31, 2020, at a National Cancer Institute Comprehensive Cancer Center were identified. Neighborhood opportunity was operationalized using the 2014-2018 Ohio Opportunity Index (OOI), a composite measure derived from neighborhood level transportation, education, employment, health, housing, crime, and environment. Logistic and Cox regression models tested associations between the OOI, AL, and all-cause mortality.

RESULTS

The study cohort included 4,089 patients. Residence in neighborhoods with low OOI was associated with high AL (adjusted odds ratio, 1.21 [95% CI, 1.05 to 1.40]). On adjusted analysis, low OOI was associated with greater risk of all-cause mortality (adjusted hazard ratio [aHR], 1.45 [95% CI, 1.11 to 1.89]). Relative to the highest (99th percentile) level of opportunity, risk of all-cause mortality steeply increased up to the 70th percentile, at which point the rate of increase plateaued. There was no interaction between the composite OOI and AL on all-cause mortality (P = .12). However, there was a higher mortality risk among patients with high AL residing in lower-opportunity environments (aHR, 1.96), but not in higher-opportunity environments (aHR, 1.02; P interaction = .02).

CONCLUSION

Lower neighborhood opportunity was associated with higher AL and greater risk of all-cause mortality among patients with breast cancer. Additionally, environmental factors and AL interacted to influence all-cause mortality. Future studies should focus on interventions at the neighborhood and individual level to address socioeconomically based disparities in breast cancer.

Racial Disparities in Breast Cancer: from Detection to Treatment

PURPOSE OF REVIEW

Update on current racial disparities in the detection and treatment of breast cancer.

RECENT FINDINGS

Breast cancer remains the leading cause of cancer death among Black and Hispanic women. Mammography rates among Black and Hispanic women have surpassed those among White women, with studies now advocating for earlier initiation of breast cancer screening in Black women. Black, Hispanic, Asian, and American Indian and Alaskan Native women continue to experience delays in diagnosis and time to treatment. Further, racial discrepancies in receipt of guideline-concordant care, access to genetic testing and surgical reconstruction persist. Disparities in the initiation, completion, toxicity, and efficacy of chemotherapy, endocrine therapy, and targeted drug therapy remain for racially marginalized women. Efforts to evaluate the impact of race and ethnicity across the breast cancer spectrum are increasing, but knowledge gaps remain and further research is necessary to reduce the disparity gap.

The Implications of Racialized Economic Segregation and Allostatic Load on Mortality in Patients with Breast Cancer

BACKGROUND

The objective of this study was to examine the association between racialized economic segregation, allostatic load (AL), and all-cause mortality in patients with breast cancer.

PATIENTS AND METHODS

Women aged 18+ years with stage I-III breast cancer diagnosed between 01/01/2012 and 31/12/2020 were identified in the Ohio State University cancer registry. Racialized economic segregation was measured at the census tract level using the index of concentration at the extremes (ICE). AL was calculated with biomarkers from the cardiac, metabolic, immune, and renal systems. High AL was defined as AL greater than the median. Univariable and multivariable regression analyses using restricted cubic splines examined the association between racialized economic segregation, AL, and all-cause mortality.

RESULTS

Among 4296 patients, patients residing in neighborhoods with the highest racialized economic segregation (Q1 versus Q4) were more likely to be Black (25% versus 2.1%, p < 0.001) and have triple-negative breast cancer (18.2% versus 11.6%, p < 0.001). High versus low racialized economic segregation was associated with high AL [adjusted odds ratio (aOR) 1.40, 95% confidence interval (CI) 1.21-1.61] and worse all-cause mortality [adjusted hazard ratio (aHR) 1.41, 95% CI 1.08-1.83]. In dose-response analyses, patients in lower segregated neighborhoods (relative to the 95th percentile) had lower odds of high AL, whereas patients in more segregated neighborhoods had a non-linear increase in the odds of high AL.

DISCUSSION

Racialized economic segregation is associated with high AL and a greater risk of all-cause mortality in patients with breast cancer. Additional studies are needed to elucidate the causal pathways and mechanisms linking AL, neighborhood factors, and patient outcomes.

Oncology mental health providers' adaptation of an evidence-based intervention: A mixed-methods study

BACKGROUND

Adaptations are intentional modifications maximizing the fit of an evidence-based intervention (EBI) in new context. Little is known about EBI adaptation within psychosocial oncology. Guided by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME), this mixed-methods study describes oncology mental health providers' planned adaptations to a psychosocial oncology EBI and examines the relationship between planned adaptations and longitudinal EBI usage.

METHODS

Providers (N = 128) were social workers (47%) and psychologists (40%) practicing in community settings (44%) or academic medical centers (41%). They attended a 3-day training on a multicomponent psychosocial oncology EBI, the Biobehavioral Intervention (BBI). During training, providers prepared an "adaptation plan" describing necessary adaptations to BBI and rationales for change. Qualitative data from adaptation plans were analyzed using directed content analysis. Linear mixed models examined the relationship between adaptation characteristics (number, similarity to the manualized BBI) and EBI usage across 12 months post-training.

RESULTS

Three sets of qualitative themes reflecting FRAME elements emerged: (1) content modifications (e.g., shortening/condensing, selecting elements, adding/removing elements); (2) contextual changes (e.g., alternative group formats); and (3) reasons for adaptations (e.g., organization/setting, provider, and recipient factors). Neither number of adaptations nor adaptation similarity were associated with BBI usage across 12 months post-training.

CONCLUSIONS

To our knowledge, this study is the first to characterize oncology mental health providers' planned adaptations to a psychosocial oncology EBI. Planned adaptations did not increase usage, but importantly they did not decrease usage. The adaptation process enabled providers to make thoughtful adaptation choices, with implementation successful irrespective of setting constraints.

Short-term and long-term financial toxicity from breast cancer treatment: a qualitative study

PURPOSE

The rising cost of breast cancer treatment has increased patients' financial burden, intensifying an already stressful treatment process. Although researchers increasingly recognize the harmful impact of medical and nonmedical costs associated with cancer treatment, understanding patients' perspectives of financial toxicity is limited. We aimed to explore the topic of financial toxicity through the lived experiences of patients with breast cancer from groups at risk of social and economic marginalization.

METHODS

We conducted semi-structured interviews with 50 women with breast cancer from four specific groups: Black women, Medicaid enrollees, rural residents, and women age ≤ 40. We transcribed, coded, and analyzed the data using deductive and inductive approaches.

RESULTS

Two overarching themes captured patients' experiences of financial toxicity: short-term and long-term impacts. Short-term stressors included direct medical (e.g., co-pays, premiums), nonmedical (e.g., transportation, lodging), and indirect (e.g., job loss, reduced work hours) costs. Early in their treatments, patients' focus on survival took precedence over financial concerns. However, as the treatment course progressed, fear of consequences from compounding costs of care and financial distress negatively impacted patients' lifestyles and outlooks for the future.

CONCLUSION

Programs addressing financial toxicity that look beyond early-phase interventions are needed. Specifically, patients struggling with the accumulation of treatment costs and the resultant stress require ongoing support. Long-term support is especially needed for groups vulnerable to financial instability and social marginalization.

Low Hospital Volume Is Associated with Higher All-Cause Mortality in Black Women with Triple Negative Breast Cancer

INTRODUCTION

This study examines the association between hospital volume and all-cause mortality in Black women with triple negative breast cancer (TNBC) who received surgery and chemotherapy.

METHODS

Black women ages 18+ with stage I-III TNBC who received both surgery and chemotherapy were identified in the National Cancer Database (NCDB). Hospital volume was determined using the number of annual breast cancer cases divided by the number of years the hospital participated in the NCDB. Hospital annual volume quartiles ranged from Q1 (lowest) to Q4 (highest). Univariable analysis and multivariable logistic regression modeling with restricted cubic splines examined the effect of hospital volume on all-cause mortality.

RESULTS

Sixteen thousand five hundred fifty-six patients met the study criteria. All-cause mortality incidence was lower at higher volume compared to lower volume hospitals Q1 24.1% (95% CI: 22.8 to 25.4), Q2 21.8% (95% CI: 20.5 to 23.1), Q3 20.9% (95% CI: 19.6 to 22.1), Q4 19.0% (95% CI: 17.7 to 20.1), p<0.001. On multivariable analysis, treatment at the highest hospital volume quartile was associated with a 21% reduction in the odds of death compared to the lowest quartile [Q4 Vs. Q1, OR=0.79 (95% CI: 0.67 to 0.92)]. For every 100-patient increase in annual volume, all-cause mortality was reduced by 4% [OR=0.96 (95% CI: 0.94 to 0.98)]. There was a significant linear dose-dependent relationship between increasing hospital volume and all-cause mortality.

CONCLUSION

Black women treated at high-volume hospitals have lower all-cause mortality than those at low-volume hospitals. Future studies should examine the characteristics of high-volume hospitals associated with improved outcomes.

A cognitive-behavioral model of dyspnea: Qualitative interviews with individuals with advanced lung cancer

OBJECTIVES

Shortness of breath, or dyspnea, is the subjective experience of breathing discomfort and is a common, distressing, and debilitating symptom of lung cancer. There are no efficacious pharmacological treatments, but there is suggestive evidence that cognitive-behavioral treatments could relieve dyspnea. For this, understanding the psychological, behavioral, and social factors that may affect dyspnea severity is critical. To this end, patients with dyspnea were interviewed with questions framed by the cognitive-behavioral model-emphasizing thoughts, emotions, and behaviors as contributors and outcomes of dyspnea.

METHODS

Two trained individuals conducted semi-structured interviews with lung cancer patients (N = 15) reporting current dyspnea. Interviews assessed patients' cognitive-behavioral experiences with dyspnea. Study personnel used a grounded theory approach for qualitative analysis to code the interviews. Inter-rater reliability of codes was high (κ = 0.90).

RESULTS

Thoughts: Most common were patients' catastrophic thoughts about their health and receiving enough oxygen when breathless. Emotions: Anxiety about dyspnea was the most common, followed by anger, sadness, and shame related to dyspnea. Behaviors: Patients rested and took deep breaths to relieve acute episodes of dyspnea. To reduce the likelihood of dyspnea, patients planned their daily activity or reduced their physical activity at the expense of engagement in hobbies and functional activities.

SIGNIFICANCE OF RESULTS

Patients identified cognitive-behavioral factors (thoughts, emotions, and behaviors) that coalesce with dyspnea. The data provide meaningful insights into potential cognitive-behavioral interventions that could target contributors to dyspnea.

Association of Allostatic Load With All-Cause Mortality in Patients With Breast Cancer

Importance

Elevated allostatic load (AL) has been associated with adverse socioenvironmental stressors and tumor characteristics that convey poor prognosis in patients with breast cancer. Currently, the association between AL and all-cause mortality in patients with breast cancer is unknown.

Objective

To examine the association between AL and all-cause mortality in patients with breast cancer.

Design, Setting, and Participants

This cohort study used data from an institutional electronic medical record and cancer registry at the National Cancer Institute Comprehensive Cancer Center. Participants were patients with breast cancer diagnoses (stage I-III) between January 1, 2012, through December 31, 2020. Data were analyzed from April 2022 through November 2022.

Exposure

AL was expressed as a summary score calculated by assigning 1 point for biomarkers in the worst sample quartile. High AL was defined as AL greater than the median.

Main Outcomes and Measures

The main outcome was all-cause mortality. A Cox proportional hazard models with robust variance tested the association between AL and all-cause mortality.

Results

There were 4459 patients (median [IQR] age, 59 [49-67] years) with an ethnoracial distribution of 3 Hispanic Black patients (0.1%), 381 non-Hispanic Black patients (8.5%), 23 Hispanic White patients (0.5%), 3861 non-Hispanic White patients (86.6%), 27 Hispanic patients with other race (0.6%), and 164 non-Hispanic patients with other race (3.7%). The mean (SD) AL was 2.6 (1.7). Black patients (adjusted relative ratio [aRR], those with 1.11; 95% CI, 1.04-1.18), single marital status (aRR, 1.06; 95% CI, 1.00-1.12), and those with government-supplied insured (Medicaid aRR, 1.14; 95% CI, 1.07-1.21; Medicare aRR, 1.11; 95% CI, 1.03-1.19) had a higher adjusted mean AL than those who were White, married/living as married, or privately insured, respectively. Adjusting for sociodemographic, clinical, and treatment factors, high AL was associated with a 46% increase in mortality risk (hazard ratio [HR], 1.46; 95% CI, 1.11-1.93) over low AL. Similarly, compared with patients in the first AL quartile, those in the third quartile (HR, 1.53; 95% CI, 1.07-2.18) and the fourth quartile (HR, 1.79; 95% CI, 1.16-2.75) had significantly increased risks of mortality. There was a significant dose-dependent association between increased AL and a higher risk of all-cause mortality. Furthermore, AL remained significantly associated with higher all-cause mortality after adjusting for the Charlson Comorbidity Index.

Conclusions and Relevance

These findings suggest increased AL is reflective of socioeconomic marginalization and associated with all-cause mortality in patients with breast cancer.

Risk Factors for Immune Checkpoint Inhibitor Immunotherapy Toxicity Among Older Adults with Cancer

OBJECTIVES

Immune checkpoint inhibitor immunotherapy (IO) is revolutionizing cancer care but can lead to significant toxicity. This study seeks to describe potential risk factors for immune-related adverse events (irAEs) specifically among older adults.

MATERIALS AND METHODS

This was a retrospective study at a single academic comprehensive cancer center based on chart review data abstracted by physicians. For patients aged ≥70 years, frequency, type, and grade of irAEs and their association with baseline patient demographics, comorbidities, mobility, and functional status were characterized using bivariate analysis. Based on those results, multivariable logistic regressions were constructed to model the association between these characteristics with any grade and grade 3 or higher irAEs.

RESULTS

Data were analyzed for 238 patients aged ≥70 years who received IO for mostly (≥90%) advanced cancer between 2011 and 2018. Thirty-nine percent of older adults experienced an irAE and 13% experienced one that was grade 3 or higher. In the multivariable analysis, depression was associated with an increased incidence of any grade irAE, while decreased life-space mobility was associated with an increased incidence of grade ≥3 irAEs.

CONCLUSION

Most characteristics of special interest among older adults, include fall risk, weight loss, cognitive limitations, and hearing loss, were not associated with irAEs in our study. However, decreased life-space mobility and depression are potential risk factors for IO toxicity among older adults with advanced cancer. Interventions designed to evaluate and mitigate modifiable risk factors for treatment-related toxicity are needed, and the results of this study may be useful for guiding those efforts.

Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update

PURPOSE

To update the American Society of Clinical Oncology guideline on the management of anxiety and depression in adult cancer survivors.

METHODS

A multidisciplinary expert panel convened to update the guideline. A systematic review of evidence published from 2013-2021 was conducted.

RESULTS

The evidence base consisted of 17 systematic reviews ± meta analyses (nine for psychosocial interventions, four for physical exercise, three for mindfulness-based stress reduction [MBSR], and one for pharmacologic interventions), and an additional 44 randomized controlled trials. Psychological, educational, and psychosocial interventions led to improvements in depression and anxiety. Evidence for pharmacologic management of depression and anxiety in cancer survivors was inconsistent. The lack of inclusion of survivors from minoritized groups was noted and identified as an important consideration to provide high-quality care for ethnic minority populations.

RECOMMENDATIONS

It is recommended to use a stepped-care model, that is, provide the most effective and least resource-intensive intervention based on symptom severity. All oncology patients should be offered education regarding depression and anxiety. For patients with moderate symptoms of depression, clinicians should offer cognitive behavior therapy (CBT), behavioral activation (BA), MBSR, structured physical activity, or empirically supported psychosocial interventions. For patients with moderate symptoms of anxiety, clinicians should offer CBT, BA, structured physical activity, acceptance and commitment therapy, or psychosocial interventions. For patients with severe symptoms of depression or anxiety, clinicians should offer cognitive therapy, BA, CBT, MBSR, or interpersonal therapy. Treating clinicians may offer a pharmacologic regimen for depression or anxiety for patients who do not have access to first-line treatment, prefer pharmacotherapy, have previously responded well to pharmacotherapy, or have not improved following first-line psychological or behavioral management.Additional information is available at www.asco.org/survivorship-guidelines.

Depression in association with neutrophil-to-lymphocyte, platelet-to-lymphocyte, and advanced lung cancer inflammation index biomarkers predicting lung cancer survival

Lung cancer is a product of inflammation and a dysfunctional immune system, and depression has similar dysregulation. Depression disproportionately affects lung cancer patients, having the highest rates of all cancers. Systemic inflammation and depression are both predictive of non-small cell lung cancer (NSCLC) survival, but the existence and extent of any co-occurrence is unknown. Studied is the association between systemic inflammation ratio (SIR) biomarker levels and patients' depressive symptoms, with the hypothesis that depression severity would be significantly associated with prognostically poor inflammation. Newly diagnosed stage-IV non-small cell lung cancer (NSCLC; N = 186) patients were enrolled (ClinicalTrials.gov Identifier: NCT03199651) and blood draws and depression self-reports (Patient Health Questionnaire-9) were obtained. For SIRs, cell counts of neutrophils (N), lymphocytes (L), and platelets (P) were abstracted for ratio (R) calculations for NLR, PLR, and the Advanced Lung cancer Inflammation Index (ALI). Patients were followed and biomarkers were tested as predictors of 2-year overall survival (OS) to confirm their relevance. Next, multivariate linear regressions tested associations of depression with NLR, PLR, and ALI. Overall 2-year mortality was 61% (113/186). Cox model analyses confirmed higher NLR [hazard ratio (HR) = 1.91; p = 0.001] and PLR (HR = 2.08; p<0.001), along with lower ALI (HR = 0.53; p = 0.005), to be predictive of worse OS. Adjusting for covariates, depression was reliably associated with biomarker levels (p ≤ 0.02). Patients with moderate/severe depressive symptoms were 2 to 3 times more likely to have prognostically poor biomarker levels. Novel data show patients' depressive symptoms were reliably associated with lung-relevant systemic inflammation biomarkers, all assessed at diagnosis/pretreatment. The same SIRs were found prognostic for patients' 2-year OS. Intensive study of depression, combined with measures of cell biology and inflammation is needed to extend these findings to discover mechanisms of depression toxicity for NSCLC patients' treatment responses and survival.

Association of Allostatic Load With Overall Mortality Among Patients With Metastatic Non-Small Cell Lung Cancer

Importance

Adverse social determinants of health (SDHs) (eg, poverty) are associated with poor oncologic outcomes among patients with lung cancer. However, no studies have evaluated biological correlates of adverse SDHs, operationalized as allostatic load (AL), with mortality due to lung cancer.

Objective

To examine the association among AL, SDHs, and mortality among patients with metastatic non-small cell lung cancer (NSCLC).

Design, Setting, and Participants

This cross-sectional study of an observational cohort was performed at a National Cancer Institute-designated comprehensive cancer center with data accrued from June 1, 2017, to August 31, 2019. Patients with metastatic (stage IV) NSCLC enrolled at diagnosis into a prospective observational cohort study were included in the present analysis if they had all the biomarkers to calculate an AL score (N = 143). Follow-up was completed on August 31, 2021, and data were analyzed from July 1 to September 30, 2021.

Exposures

Social determinants of health.

Main Outcomes and Measures

Overall mortality and AL.

Results

A total of 143 patients met the study criteria with a median age of 63 (IQR, 55-71) years (89 men [62.2%] and 54 women [37.8%]). In terms of race and ethnicity, 1 patient (0.7%) was Asian, 7 (4.9%) were Black, 117 (81.8%) were White, 17 (11.9%) were of multiple races, and 1 (0.7%) was of other race or ethnicity. The mean (SD) AL was 2.90 (1.37). Elevated AL covaried with lower educational level (r = -0.26; P = .002), male sex (r = 0.19; P = .02), limited mobility (r = 0.19; P = .04), worsening self-care (r = 0.30; P < .001), problems engaging in usual activities (r = 0.21; P = .01), depressive symptoms (r = 0.23; P = .005), and a high number of stressful life events (r = 0.30; P < .001). Multivariable analysis found only increasing difficulty with mobility (r = 0.37 [95% CI, 0.13-0.60]; P = .002) and male sex (r = 0.63 [95% CI, 0.19-1.08]; P = .005) associated with higher AL. On adjusted analysis, elevated AL (hazard ratio, 1.43 [95% CI, 1.16-1.79]; P = .001) and low educational level (hazard ratio, 2.11 [95% CI, 1.03-4.34]; P = .04) were associated with worse overall mortality.

Conclusions and Relevance

The findings of this cross-sectional study suggest that higher AL was associated with adverse SDHs and worse overall mortality among patients with advanced NSCLC. These results provide a framework for replication and further studies of AL as a biological correlate for SDH and future prognostic marker.

Functional Trajectories and Resilience Among Adults With Advanced Lung Cancer

Introduction

To evaluate whether and the degree to which patients with advanced NSCLC (aNSCLC) receiving lung cancer treatments will experience functional disability or have resilience and to identify characteristics associated with functional disability.

Methods

We evaluated longitudinal data of patients with aNSCLC receiving treatment in the Beating Lung Cancer in Ohio prospective cohort study. Disability versus resilience in functional status (usual activities, mobility, and self-care) was measured monthly for 8 months using the EuroQol-5D-5L. Data captured included baseline demographics (Eastern Cooperative Oncology Group performance status), comorbidities, cancer and depressive symptoms (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7 scale), and cancer stress (impact of events). Group-based latent class trajectory modeling was used to determine clinically distinct functional disability trajectories jointly with attrition probability (death or withdrawal) in the study period.

Results

Among 207 participants, the mean age was 63.5 years (range: 34-92 y), 58.9% were male, 6.8% were African American or Black, 73.3% were former smokers, and 35% resided in rural areas. At baseline, participants had adenocarcinoma histological subtype (74.9%), 40.3% had brain metastases, and 46.1% had bone metastases. Participants received chemotherapy plus immunotherapy (46.9%), immunotherapy single agent (21.7%), targeted treatments (18.8%), or no treatment (12.6%). Three distinct functional trajectory groups were identified, as follows: none/mild (n = 79, 38.2%), moderate (n = 99, 47.8%), and severe disability (n = 29, 14.0%). Characteristics associated with severe disability included baseline Eastern Cooperative Oncology Group performance status greater than 1, worse dyspnea and pain, and higher Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 scale scores. At month 8, 95 participants (45.9%) displayed resilience, 11 (5.3%) experienced functional decline, and 69 (33.3%) were deceased.

Conclusions

We identified three distinct functional trajectories among patients with aNSCLC. Risk stratification tools and targeted interventions designed to target these three groups are needed to improve functional resilience and prevent disability.

Characteristics associated with functional resilience versus functional decline among adult patients with advanced non–small cell lung cancer

1538

Background: As more treatment options become available for advanced non-small cell lung cancer (NSCLC), oncologists still have difficulty predicting functional resiliency versus functional disability throughout treatment. Functional resiliency refers to the ability to recover baseline functional status in the face of an intervening health care event. This study aims to identify characteristics associated with resilience among adults with advanced NSCLC. Methods: In a prospective cohort of participants with newly diagnosed stage IV NSCLC, resilience was evaluated based on three functional disability items in the EQ-5D-5L (modified: mEQ-5D-5L) through 12 months of follow-up compared to baseline scores. This included patients treated with chemotherapy, immunotherapy, targeted agents and no treatment. Participants were classified into four groups: functional decline, maintenance, resilient, or variable. Resilience was determined based on improvement in disability scores, with a 1-point increase in functional status score representing a 0.5 standard deviation change on the mEQ-5D-5L. Patient characteristics included demographics, comorbidities, ECOG performance status, presence of brain or bone metastases, mood (GAD-7, PHQ-9), and lung cancer-specific symptoms (QLQ-LC13). Treatment toxicity and toxicity grades were also recorded. Differences between groups were determined through Fisher’s exact test or ANOVA. Results: Among 207 participants, 87 (42.0%) maintained functional status, 78 (37.7%) experienced functional decline, 22 (10.6%) were classified as resilient and 20 (9.7%) were variable. Characteristics associated with higher resilience (p < 0.1) included being employed (p = 0.02) and living in a metro setting (p = 0.10). Characteristics not associated with resilience included age, education level, smoking status, presence of brain metastases, ECOG performance status, or psychological symptoms. Approximately half the participants (n = 105, 50.7%) who received treatment experienced toxicities. One third (33.8%) experienced ≥ grade 3 toxicities. There was no significant association between toxicity grade and resilience grouping. Conclusions: Characteristics associated with functional resilience included employment status and living setting. At least half of adults with advanced NSCLC experience treatment-related toxicities. It is important to determine characteristics of resilience to better understand which patients will tolerate cancer treatments.

Illness perception profiles and psychological and physical symptoms in newly diagnosed advanced non-small cell lung cancer

OBJECTIVE

Of all cancers, advanced nonsmall cell lung cancer (NSCLC) is associated with the highest burden on mental and physical health-related quality of life (HRQoL). Patients' subjective beliefs about their cancer (i.e., illness perceptions) may influence coping responses and treatment decisions and affect health. To identify cognitive and emotional perceptions and their association with patient characteristics and illness circumstances, the relationship between illness perception schemas and psychological and physical responses and symptoms were studied.

METHOD

Patients newly diagnosed with stage IV NSCLC (N = 186) enrolled in a prospective cohort study (NCT03199651) completed measures of illness perceptions; anxiety, depression, and physical symptoms; and health status. Latent profile analysis identified illness perception profiles. Hierarchical linear regressions tested profile assignment as a correlate of responses and symptoms.

RESULTS

A three-profile solution was optimal. Patients with a "struggling" profile (n = 83; 45%) reported the most negative perceptions; patients with a "coping" profile (n = 41; 22%) reported relatively positive perceptions; and patients with a "coping but concerned" profile (n = 62; 33%) endorsed high illness concern but relatively positive perceptions otherwise. Patients with a "struggling" profile reported the highest levels of anxiety and depression symptoms, overall physical symptoms, cough, dyspnea, and pain, and the poorest self-rated health.

CONCLUSIONS

New data add to the clinical portrayal of patients coping with NSCLC since the availability of new therapies and survival improvements. Other disease groups have reported a predominance of positive perceptions, rather than ones of significant cognitive and emotional struggles found here. Illness perception data may provide content-rich resources for intervention tailoring. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The relationship between cognitive schemas activated in sexual context and early maladaptive schemas among married women of childbearing age

Background

Healthy sex can be affected by cognitive schemas activated in the sexual context (CSASCs) and early maladaptive schemas (EMSs). Cognitive schemas are the nuclear structure of the cognitive system which facilitate the interaction between individuals and their environments. CSASCs are emotional and behavioral responses in the sexual context. EMSs are extremely stable, enduring and are developed throughout the life of the individual, beginning in childhood. The present study investigated the relationship between CSASCs and EMSs among married women of childbearing age.

Methods

In a cross-sectional study, 260 married women of childbearing age participated. Using two-stage sampling, ten comprehensive urban health centers were first randomly selected and then 26 individuals from each center were invited to participate. Data collection included demographic variables, the Young Schema Questionnaire-Short Form (YSQ-SF) with 15 EMSs (emotional deprivation, abandonment, mistrust/abuse, social alienation, defectiveness, incompetence, dependency, vulnerability to harm, enmeshment, subjugation of needs, self-sacrifice, emotional inhibition, unrelenting standards, entitlement, and insufficient self-control), and the Cognitive Schema Activation in Sexual Context Questionnaires (CSASCQ) with five subscales (undesirability/rejection, incompetence, self-depreciation, difference/loneliness, and helplessness). Data analysis was performed using a uni-variable and multi-variable linear regression model with a stepwise method at a significance level of 0.05.

Results

The mean age of the participants was 32.48 years and the average duration of their marriage was 10.34 years. The average score of early maladaptive schemas on the YSQ-SF was 151.5 (out of 450). Higher scores indicate more severe maladaptive schemas, although the total score has no defined cutoff point. Scores greater than 15 on each subscale constitute the internalization of that particular maladaptive schema. The highest average subscale scores were the schemas of self-sacrifice and unrelenting standards (M = 16.12, 15.90, respectively), indicating that these two schemas play important roles in the cognition of the participants. The mean score on the CSASCQ was 34.60 (SD ± 12.59; range: 25–125), with the highest mean reported on the loneliness subscale. Hypoactive sexual desire was the most common unpleasant sexual problem (6.9%) and disillusion was the most dominant feeling experienced by participants (33.3%). The results of the multivariable model showed that the following were significant predictors of the CSASC: three subscales of EMS (emotional deprivation [β = 0.28], social isolation [β = 0.31], and emotional inhibition [β = 0.14]) and two demographic variables (job [β = 0.11] and consanguineous marriage [β = 0.20]). In total, the multi-variable model explained 92% of variance of CSASCs.

Conclusions

The present study found a significant and meaningful association between EMSs and CSASCs adjusting for the effect of socio-demographic characteristics. The findings indicate that the study of schemas and schema therapy should be considered in both premarital and marital counseling.

Cancer Treatment During COVID-19: Resilience of Individuals With Advanced Non-Small Cell Lung Cancer Versus Community Controls

BACKGROUND

Among all patients with cancer, those with advanced non-small cell lung cancer (NSCLC) experience the most distress. Although new therapies are improving survival, it is unknown whether receiving immunotherapy or targeted therapy during the COVID-19 pandemic increases patients' psychological vulnerability. To meet clinical needs, knowledge of patients' COVID-19 perceptions and safety behaviors is essential. Thus, this study compared patients' psychological responses at diagnosis and during COVID-19 and compared patients with similar individuals without cancer during the same period.

PATIENTS AND METHODS

Patients with advanced NSCLC enrolled at diagnosis for cohort study participated (ClinicalTrials.gov identifier: NCT03199651). Those with follow-ups from April 28, 2020, through July 14, 2020 (n=76), were assessed again including COVID-19 measures. Simultaneously, community controls with similar sociodemographics and smoking histories were solicited (n=67). Measures were COVID-19 perceptions (Brief Illness Perception Questionnaire), social distancing, and depressive (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) symptoms. First, analyses evaluated differences in the psychological responses of patients with NSCLC at diagnosis and during COVID-19. Second, patients and controls were contrasted on COVID-19 perceptions, social distancing, and psychological symptoms.

RESULTS

The depressive and anxious symptoms of patients with NSCLC were greater at diagnosis (P<.02) than during COVID-19, approximately 1 year later. Patients with NSCLC and controls did not differ in terms of sociodemographics, except those with NSCLC were more racially diverse and older, and had greater smoking history (P<.03). Groups did not differ regarding concern, understanding, or perceived control over COVID-19 (P>.406). Notably, controls anticipated the COVID threat would last longer, practiced more social distancing, were more concerned about family (P<.04), and reported worse psychological symptoms (P<.023). With less depression and anxiety, patients with NSCLC viewed COVID-19 as a shorter-term threat and had fewer COVID-19-related worries than did controls. For controls, COVID-19 was more salient, heightening worries and psychological symptoms.

CONCLUSIONS

Despite multiple health stressors, patients with NSCLC demonstrated resilience when receiving cancer treatment during COVID-19. Nonetheless, this population remains psychologically vulnerable, requiring support at diagnosis and thereafter.

Psychological Symptom Trajectories and Non-Small Cell Lung Cancer Survival: A Joint Model Analysis

OBJECTIVE

Lung cancer remains the number one cause of cancer-related mortality worldwide, but less known is that lung cancer patients are among the most psychologically disabled of all cancer groups. Patients with stage IV non-small cell lung cancer (NSCLC) were studied to test the hypothesis that trajectories of depression and/or anxiety symptoms after diagnosis would show an adverse relationship with survival, beyond relevant controls.

METHODS

Patients with stage IV NSCLC (n = 157) were enrolled (ClinicalTrials.gov Identifier: NCT03199651) at diagnosis and completed validated measures for depressive symptoms (Patient Health Questionnaire-9) and anxiety symptoms (Generalized Anxiety Disorder-7). Patients were reassessed every 1 to 2 months through 24 months (16 assessments; 80% average completion rate) and survival monitored. Joint statistical models provided simultaneous modeling of longitudinal (psychological) and time-to-event (survival) processes. Control variables were age, sex, marital status, education, smoking status, cancer type, and treatment received.

RESULTS

Depression and anxiety symptoms significantly decreased with time since diagnosis. The 2-year trajectory of depressive symptoms was significantly associated with cancer survival after adjustment for covariates (hazard ratio = 1.09 per unit increase in the Patient Health Questionnaire-9, 95% confidence interval = 1.03-1.15, p = .002). Anxiety was marginally significant in the unadjusted (p = .053) but not the adjusted (p = .39) model.

CONCLUSIONS

For the first time, joint model analyses test the interaction of a longitudinal trajectory of psychological symptoms, assessed from diagnosis to 24 months, and cancer survival. New data show the continuation of depressive and anxiety symptoms through treatment and thereafter. Immunotherapy and targeted therapies have dramatically improved survival for patients with advanced NSCLC; however, novel data suggest their benefit may be constrained by depressive symptoms.

Illness representations and psychological outcomes in chronic lymphocytic leukaemia

OBJECTIVES

Chronic lymphocytic leukaemia (CLL) is a lifelong cancer with subtle symptoms. Treatment is not curative and often involves repeated relapses and retreatments. Illness perceptions - cognitive and emotional representations of illness stimuli - were studied in CLL patients to: 1) identify illness perception 'profiles' prior to treatment; and 2) test whether profile membership predicts psychological responses 12 months later as treatment continued.

DESIGN

CLL patients (N = 259), randomized to one of four cancer treatment trials testing targeted therapy, were assessed before starting treatment and at 12 months.

METHODS

The Brief Illness Perception Questionnaire (BIPQ) assessed perceived consequences, timeline, personal/treatment control, identity, comprehension, concern, and emotions toward CLL. Psychological outcomes were depressive symptoms (PHQ-9/BDI-II), negative mood (POMS), and cancer stress (IES-R). Latent profile analysis (LPA) determined number of profiles and differential BIPQ items for each profile. Multilevel models tested profiles as predictors of 12-month psychological outcomes.

RESULTS

LPA selected the three-profile model, with profiles revealing Low (n = 150; 57.9%), Moderate (n = 21; 8.1%), and High-impact (n = 88; 34.0%) illness representations. Profiles were defined by differences in consequences, identity, concern, and emotions. Profile membership predicted all psychological outcomes (ps<.038). Low-impact profile patients endorsed minimal psychological symptoms; High-impact profile patients reported substantial symptoms.

CONCLUSIONS

Results of the first CLL illness representation study provide directions for future clinical efforts. By identifying differences among patients' perceptions of CLL consequences, symptom burden, concerns, and emotional responses, an at-risk patient group might receive tailored psychological treatment. Treatments may address negative perceptions, to reduce psychological risk associated with chronic cancer.

Replicating dissemination and identifying mechanisms of implementation of an empirically supported treatment

OBJECTIVE

Implementation research is needed in cancer control. Replication of the dissemination of empirically supported treatments (ESTs) is important as is the identification of mechanisms by which dissemination leads to implementation. Addressing these gaps, Study 1 (Cohorts 3-6, N = 104) tests for replication of a successful dissemination to community providers (Brothers et al., 2015; Cohorts 1-2; N = 62) and Study 2 (Cohorts 1-6) tests providers' changes on dissemination outcomes as mechanisms of EST usage.

METHOD

The Biobehavioral Intervention (BBI), a psychological EST in cancer control, was disseminated to oncology mental health providers using manual provision, didactics, roleplays, and other strategies. Study 1 tested for pre/post changes in dissemination outcomes (BBI knowledge/skills and attitudes toward and self-efficacy to deliver ESTs/BBI) between cohorts (1-2 vs. 3-6) with repeated measures ANOVAs. In Study 2, the implementation outcome was providers' (N = 166) BBI usage with patients (percent treated). Structural equation models tested dissemination outcome changes as predictors of usage at 2- and 4-months.

RESULTS

Study 1 replicated high dissemination outcomes and significant gains in BBI knowledge (p < .001) in Cohorts 3-6. Unlike Cohorts 1-2, significant gains were observed in self-efficacy (ps < .001) but not attitudes toward ESTs (p = .523) in Cohorts 3-6. In Study 2, gains in providers' self-efficacy (ps < .05) and EST attitudes (p = .008) predicted greater 2-month (58.4% ± 35.5%) and 4-month (66.2% ± 35.0%) usage of the BBI with patients, respectively.

CONCLUSIONS

This is the only replication of a dissemination for a psychological EST in cancer control. Results reliably show disseminations enhancing providers' self-efficacy to use and positive attitudes toward ESTs as mechanisms for EST implementation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sustainability of a biobehavioral intervention implemented by therapists and sustainment in community settings

The ultimate aim of dissemination and implementation of empirically supported treatments (ESTs) in behavioral medicine is (a) sustainability of the therapist/provider's EST usage and (b) sustainment of EST delivery in the setting. Thus far, sustainability has been understudied, and the therapist and setting variables that may be influential are unclear. The purpose of the study was to test the therapists' sustainability of a cancer-specific EST using a prospective longitudinal design and examine its predictors. Oncology mental health therapists (N = 134) from diverse settings (N = 110) completed training in the biobehavioral intervention (BBI) and were provided with 6 months of support for implementation, with no support thereafter. BBI usage (percent of patients treated) was reported at 2, 4, 6, and 12 months. Using a generalized estimating equation with a logistic link function, 12-month sustainability (a nonsignificant change in usage from 6 to 12 months) was studied along with therapist, supervisor, and setting variables as predictors. BBI usage increased through 6 months and, importantly, usage was sustained from 6 (68.4% [95% CI = 62.2%-73.9%]) to 12 months (70.9% [95% CI = 63.6%-77.3%]), with sustainment in 66 settings (60.0%). Predictors of implementation-to-sustainability usage were therapists' early intentions to use the BBI (p < .001) and from the setting, supervisors' positive attitudes toward ESTs (p = .016). Adding to the DI literature, a health psychology intervention was disseminated, implemented, and found sustainable across diverse therapists and settings. Therapists and setting predictors of usage, if modified, might facilitate future sustainability/sustainment of ESTs.

Functional Disability Among Older Versus Younger Adults With Advanced Non-Small-Cell Lung Cancer

PURPOSE

To determine patient and disease characteristics associated with functional disability among adults with advanced non-small-cell lung cancer (NSCLC).

METHODS

In a prospective cohort of participants newly diagnosed with advanced NSCLC and beginning systemic treatment, functional disability in usual activities, mobility, and self-care was measured using the EuroQol-5D-5L at baseline. Demographics, comorbidities, brain metastases, Eastern Cooperative Oncology Group performance status (ECOG PS), and psychologic variables (depression [Patient Health Questionnaire-9] and anxiety [Generalized Anxiety Disorder 7-item scale]) were captured. Patients were classified into two disability groups (none-slight or moderate-severe) on the basis of total functional status scores. Differences between disability groups were determined (chi-square and t tests). Associations between patient characteristics and baseline disability were assessed using logistic regression.

RESULTS

Among 173 participants, mean age was 63.3 years, 56% were male, 83% had ECOG PS 0-1, and 41% had brain metastases. Baseline disability was present in 39% of participants, with patients having moderate to severe disability in usual activities (37.6%), mobility (26.6%), and self-care (5.2%). Depressive and/or anxiety symptoms ranged from none to severe (Patient Health Questionnaire 9-item scale M = 6.5, SD = 5.3). Depressive symptoms were the only characteristic associated with a higher odds of baseline disability (adjusted odds ratio [aOR]: 1.26; 95% CI, 1.15 to 1.38; P < .001). Participants with poorer ECOG PS (aOR: 4.64; 95% CI, 1.84 to 11.68; P = .001) and depressive symptoms (aOR: 1.15; 95% CI, 1.07 to 1.24; P < .001) had higher odds of moderate-severe mobility disability compared with the none-slight disability group.

CONCLUSION

More than one third of all adults with advanced NSCLC have moderate-severe functional disability at baseline. Psychologic symptoms were significantly associated with moderate-severe baseline disability.

Achieving oncology mental health providers' usage of an empirically supported treatment: Lessons learned

OBJECTIVE

There is a need for oncology mental health providers to receive training to use empirically supported psychological treatments (ESTs) with their patients. The purpose of this editorial is to describe "lessons learned" from disseminating-conducting EST trainings-and supporting providers' capacity and confidence to use the EST.

METHOD

Processes and outcomes from conducting six, 3-days (18 h) EST training institutes from 2012-2016 are discussed. Institutes trained 166 full time oncology mental health providers from more than 100 different settings. The dissemination was intentionally designed to achieve EST implementation, i.e., therapists' sustained usage of the EST for at least 12 months post training.

RESULTS

Previously published discussion and findings show the effort was successful in achieving positive EST dissemination outcomes and sustained EST implementation by providers. Thus, "lessons learned" include discussions of (1) orientation to design education/training to achieve EST usage using theory based aims and outcomes of training efficacy; (2) multimodal, educational strategies used to achieve therapists' positive attitudes toward and self-efficacy to implement the EST; (3) guidance to therapists for adapting the EST to their practice settings while maintaining fidelity; (4) assistance to therapists to identify and problem solve implementation challenges; and (5) using patient reported outcome measures to determine clinical change.

CONCLUSION

Our discussion of the plan, methods, and goals of EST training contributes to the science of dissemination/implementation by providing support for (1) theory-informed EST dissemination, and (2) mechanisms of EST implementation. For researchers, our experience may guide future EST dissemination/implementation efforts in psycho-oncology. For therapists, lessons learned provide criteria for evaluating future continuing education options.

Checkpoint inhibitor immunotherapy toxicity and overall survival among older adults with advanced cancer

OBJECTIVES

Despite growing evidence that checkpoint inhibitor immunotherapy (IO) toxicity is associated with improved treatment response, the relationship between immune-related adverse events (irAEs) and overall survival (OS) among older adults [age ≥ 70 years (y)] remains unknown. The study goal was to determine differences in OS based on age and ≥ grade 3 (G3) irAEs.

MATERIALS AND METHODS

This was a retrospective cohort study of 673 patients with advanced cancer. Patients who received ≥1 dose of IO at our institution from 2011 to 2018 were eligible. The primary outcome was OS from the start of first line of IO treatment, compared between four patient groups stratified by age and ≥ G3 irAEs with adjustment for patient characteristics using a Cox proportional hazards model.

RESULTS AND CONCLUSION

Among all 673 patients, 35.4% were ≥ 70y, 39.8% had melanoma, and 45.6% received single-agent nivolumab. Incidence and types of ≥G3 irAEs did not differ by age. Median OS was significantly longer for all patients with ≥G3 irAEs (unadjusted 21.7 vs. 11.9 months, P = 0.007). There was no difference in OS among patients ≥70y with ≥G3 irAEs (HR 0.94, 95% CI 0.61-1.47, P = 0.79) in the multivariable analysis. Patients <70y with ≥G3 irAEs had significantly increased OS (HR 0.33, 95% CI 0.21-0.52, P < 0.001). Younger patients, but not older adults, with high-grade irAEs experience strong survival benefit. This difference may be due to the toll of irAEs themselves or the effects of treatments for irAEs, such as corticosteroids. Factors impacting OS of older adults after irAEs must be determined and optimized.

Cognitive and Behavioral Interventions

Cognitive and behavioral interventions are effective in treating mood and anxiety disorders in patients with cancer. Screening for disorders is more common, but referral (and uptake) of psychosocial services remains low relative to patient need. Efficacious, cognitive behavioral treatments (CBTs) are first-line treatments for adults with major depressive disorder (MDD) and generalized anxiety disorder (GAD), and there is accumulating evidence for CBT effectiveness for individuals with cancer. For those not yet diagnosed but with elevated symptoms, CBT has reduced symptoms and shown physical symptom and health-related quality-of-life improvements. Fewer studies have accrued patients diagnosed with MDD or GAD, but those studies also show CBT to be similarly effective. Thus far, CBT trials with MDD/GAD comorbidity, a common occurrence and negative prognostic factor, have not been conducted. CBT replication and extension trials are needed to confirm CBT as the treatment of choice for patients with psychiatric disorders.

Phase II Study of Combination Obinutuzumab, Ibrutinib, and Venetoclax in Treatment-Naïve and Relapsed or Refractory Chronic Lymphocytic Leukemia

PURPOSE

The development of highly effective targeted agents for chronic lymphocytic leukemia offers the potential for fixed-duration combinations that achieve deep remissions without cytotoxic chemotherapy.

PATIENTS AND METHODS

This phase II study tested a combination regimen of obinutuzumab, ibrutinib, and venetoclax for a total of 14 cycles in both patients with treatment-naïve (n = 25) and relapsed or refractory (n = 25) chronic lymphocytic leukemia to determine the response to therapy and safety.

RESULTS

The primary end point was the rate of complete remission with undetectable minimal residual disease by flow cytometry in both the blood and bone marrow 2 months after completion of treatment, which was 28% in both groups. The overall response rate at that time was 84% in treatment-naïve patients and 88% in relapsed or refractory patients. At that time, 67% of treatment-naïve patients and 50% of relapsed or refractory patients had undetectable minimal residual disease in both the blood and marrow. At a median follow-up of 24.2 months in treatment-naïve patients and 21.5 months in relapsed or refractory patients, the median progression-free and overall survival times were not yet reached, with only 1 patient experiencing progression and 1 death. Neutropenia and thrombocytopenia were the most frequent adverse events, followed by hypertension. Grade 3 or 4 neutropenia was experienced by 66% of patients, with more events in the relapsed or refractory cohort. There was only 1 episode of neutropenic fever. A favorable impact on both perceived and objective cognitive performance during treatment was observed.

CONCLUSION

The combination regimen of obinutuzumab, ibrutinib, and venetoclax offers time-limited treatment that results in deep remissions and is now being studied in phase III cooperative group trials.

Acalabrutinib plus Obinutuzumab in Treatment-Naïve and Relapsed/Refractory Chronic Lymphocytic Leukemia

Acalabrutinib is a selective irreversible Bruton tyrosine kinase (BTK) inhibitor that does not affect IL2-associated tyrosine kinase or antibody-dependent cellular cytotoxicity, making it an attractive candidate for combination therapy with anti-CD20 antibodies. We investigated acalabrutinib plus obinutuzumab in a phase Ib/II study (NCT02296918) of patients with treatment-naïve or relapsed/refractory chronic lymphocytic leukemia (CLL). Nineteen treatment-naïve and 26 relapsed/refractory patients were treated with acalabrutinib (100 mg twice daily) until progression and obinutuzumab (cycle 1: 100 mg day 1, 900 mg day 2, 1000 mg days 8 and 15; cycles 2-6: 1,000 mg day 1). Grade 3/4 adverse events occurred in 71% of patients. Overall response rates were 95% (treatment-naïve) and 92% (relapsed/refractory). Thirty-two percent of treatment-naïve and 8% of relapsed/refractory patients achieved complete remission. At 36 months, 94% (treatment-naïve) and 88% (relapsed/refractory) were progression free. Acalabrutinib plus obinutuzumab was well tolerated, producing high and durable responses in treatment-naïve and relapsed/refractory CLL. SIGNIFICANCE: Rituximab plus the less selective BTK inhibitor ibrutinib has not shown benefit in CLL; however, the selective BTK inhibitor acalabrutinib plus the antibody-dependent cellular cytotoxicity-enhanced antibody obinutuzumab yielded durable responses that deepened over time in treatment-naïve and relapsed/refractory CLL, supporting the evaluation of this approach in larger, comparative studies in CLL.This article is highlighted in the In This Issue feature, p. 327.

Newly diagnosed patients with advanced non-small cell lung cancer: A clinical description of those with moderate to severe depressive symptoms

OBJECTIVES

The aims of this observational study were to 1) accrue newly diagnosed patients with advanced-stage non-small cell lung cancer (NSCLC) awaiting the start of first-line treatment and identify those with moderate to severe depressive symptoms and, 2) provide a clinical description of the multiple, co-occurring psychological and behavioral difficulties and physical symptoms that potentially exacerbate and maintain depressive symptoms.

MATERIALS AND METHODS

Patients with stage IV NSCLC (N = 186) were enrolled in an observational study (ClinicalTrials.gov Identifier: NCT03199651) and completed the American Society of Clinical Oncology-recommended screening measure for depression (Patient Health Questionnaire-9 [PHQ-9]). Individuals with none/mild (n = 119; 64 %), moderate (n = 52; 28 %), and severe (n = 15; 8 %) depressive symptoms were identified. Patients also completed measures of hopelessness, generalized anxiety disorder (GAD) symptoms, stress, illness perceptions, functional status, and symptoms.

RESULTS

Patients with severe depressive symptoms reported concomitant feelings of hopelessness (elevating risk for suicidal behavior), anxiety symptoms suggestive of GAD, and traumatic, cancer-specific stress. They perceived lung cancer as consequential for their lives and not controllable with treatment. Pain and multiple severe symptoms were present along with substantial functional impairment. Patients with moderate depressive symptoms had generally lower levels of disturbance, though still substantial. The most salient differences were low GAD symptom severity and fewer functional impairments for those with moderate symptoms.

CONCLUSIONS

Depressive symptoms of moderate to severe levels co-occur in a matrix of clinical levels of anxiety symptoms, traumatic stress, impaired functional status, and pain and other physical symptoms. All of the latter factors have been shown, individually and collectively, to contribute to the maintenance or exacerbation of depressive symptoms. As life-extending targeted and immunotherapy use expands, prompt identification of patients with moderate to severe depressive symptoms, referral for evaluation, and psychological/behavioral treatment are key to maximizing treatment outcomes and quality of life for individuals with advanced NSCLC.

Cancer-Specific Stress and Trajectories of Psychological and Physical Functioning in Patients With Relapsed/Refractory Chronic Lymphocytic Leukemia

Background

Chronic lymphocytic leukemia is the most prevalent adult leukemia. The disease is incurable with a cycling of treatment and relapse common. Little is known about the psychological and physical functioning of patients with relapsed/refractory chronic lymphocytic leukemia. Cancer-specific stress is an important individual difference variable that predicts psychological and physical outcomes.

Purpose

To examine cancer-specific stress at treatment initiation as a predictor of psychological and physical functioning trajectories in patients with relapsed/refractory chronic lymphocytic leukemia during the first 5 months of treatment.

Methods

Patients with relapsed/refractory chronic lymphocytic leukemia (N = 152) enrolled in a phase II clinical trial completed self-report measures at treatment initiation (baseline), 1, 2, and 5 months of treatment. Cancer-specific stress at baseline was examined as a predictor of psychological (cognitive-affective depressive symptoms, negative mood, mental health quality of life) and physical functioning (fatigue interference, sleep problems, physical health quality of life), controlling for demographic and treatment variables.

Results

Using multilevel modeling, higher baseline cancer-specific stress was related to worse psychological (cognitive-affective depressive symptoms, negative mood, mental health quality of life) and physical functioning (fatigue interference, sleep problems) at baseline and more rapid improvements during the next 5 months. Despite these improvements, higher baseline cancer-specific stress remained associated with poorer 5-month psychological, though not physical, functioning.

Conclusions

Findings suggest cancer-specific stress at treatment initiation may be a risk factor for poorer psychological functioning during treatment for patients with relapsed/refractory chronic lymphocytic leukemia.

Improving biobehavioral outcomes with progressive muscle relaxation in patients with advanced lung cancer

292

Background: Advanced lung cancer involves severe and distressing symptoms, especially anxiety, breathlessness, insomnia, and pain. Progressive muscle relaxation (PMR) is an empirically supported treatment for reducing stress and the emotional, cognitive, and physiological concomitants of anxiety. Methods: A quality improvement effort involved enhancing standard of care (SOC) by offering patients with newly diagnosed lung cancer one brief (20-minute) PMR session during a clinic visit for treatment determination. A static group comparison design was used. The PMR group ( n= 40) received PMR with pre (initial visit) and post (3-4 week follow-up) assessments of anxiety (Generalized Anxiety Disorder-7 Scale), breathlessness (American Thoracic Society for the Division of Lung Diseases Questionnaire), insomnia (Medical Outcomes Study Sleep Scale), and pain (Brief Pain Inventory). The static group ( n= 32) was assessed on one occasion only, during the 3-4 week follow-up visit. Pre/post analyses for the PMR group used paired samples t-tests. Linear regressions compared post data between the two groups. An alpha of .10 determined significance. Results: Analyses showed pre- to post-PMR differences in pain ( p= .036, d= .309) and breathlessness ( p= .084, d= .663), with null effects for anxiety ( p= .149, d= .178) and insomnia ( p= .811, d= .067). Controlling for performance status, smoking history, and toxicities, regression showed that the PMR group reported significantly less pain ( p= .046, b= 2.48). Conclusions: PMR effectively reduced symptoms of breathlessness and pain among patients with advanced lung cancer. Interventions based on the education and training of PMR may provide an improvement to SOC lung cancer treatment.

Predicting implementation of an empirically supported treatment for cancer patients using the theory of planned behavior

BACKGROUND

There is a continuing gap between the availability of cancer control empirically supported treatments (ESTs) to address psychological needs of cancer patients and their dissemination to and implementation by providers in the community. The Theory of Planned Behavior (TPB), with constructs of attitudes, subjective norms, perceived behavioral control, and intentions, is used to understand the pathways to and prediction of providers' behavior, that is, implementation of a cancer control EST and its provision to patients.

PURPOSE

The purpose of the study was to prospectively test the TPB in predicting providers' usage of a cancer-specific EST, the biobehavioral intervention (BBI).

METHOD

Providers (N = 166) were trained. At training's end, providers completed measures of attitudes, perceived behavioral control, and intentions to use the BBI, and their supervisors completed measures of attitudes operationalized as subjective norms. Providers were followed up and 4 months later reported their usage of the BBI with patients in the last 2 months. Regression-based path analyses tested attitudes, perceived behavioral control, subjective norms, and intentions as predictors of BBI usage and for the possible effect of intentions as a mediator.

RESULTS

Provider's BBI usage was high, delivered to 65.6% of patients. Providers' attitudes toward the BBI (b = .006; 95% confidence interval [CI: .002, .010]) and subjective norms (supervisors' attitudes toward providers' EST usage; b = .021; 95% CI [.007, .034]) predicted usage. Intentions predicted usage in univariate analyses but was not a mediator for usage.

CONCLUSIONS

Use of theory in implementation science can test and identify variables key to implementation success. Here the TPB identified providers' and supervisors' attitudes as predictors of EST usage. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Illness Perceptions in Chronic Lymphocytic Leukemia: Testing Leventhal's Self-regulatory Model

BACKGROUND

Leventhal's Self-regulatory Model proposes that somatic characteristics of a health threat (e.g., symptom severity), and prior experience with the threat (e.g., unsuccessful treatment), are determinants of illness perceptions. Chronic lymphocytic leukemia (CLL) is appropriate for test of these postulates, having three phases differing in symptom severity and prior treatment experiences: indolent disease requiring no treatment (active surveillance; AS), symptomatic disease requiring a first treatment (FT), and highly symptomatic disease in those who have relapsed and/or failed to respond to prior treatments (relapsed/refractory; RR).

PURPOSE

To test symptom severity and prior treatment experiences as determinants of illness perceptions, illness perceptions were characterized and contrasted between CLL groups.

METHODS

Three hundred and thirty CLL patients (AS, n = 100; FT, n = 78; RR, n = 152) provided illness perception data on one occasion during a surveillance visit (AS) or prior to beginning treatment (FT, RR).

RESULTS

Analysis of variance with planned comparisons revealed that consequences, identity, and concern were least favorable among RR patients, followed by FT, then AS (ps < .01). AS patients endorsed the lowest levels of coherence (ps < .01), and the most chronic illness timeline (ps < .01). FT patients endorsed the highest levels of personal and treatment control (ps < .01).

CONCLUSIONS

Data provide preliminary empirical support for Self-regulatory Model postulates that symptom severity and prior disease experiences influence illness perceptions. Unique knowledge needs for AS patients and elevated psychological/physical symptoms for later-stage CLL patients may warrant clinical attention.

Is immunotherapy toxicity associated with improved overall survival among older adults with advanced cancer?

6580

Background: There is growing evidence that checkpoint inhibitor immunotherapy (IO) toxicity is associated with improved treatment response. There is a paucity of evidence examining the relationship between toxicity and overall survival (OS) in older adults. Methods: We performed a single institution retrospective cohort study of adults who received IO for advanced cancer from 2011-2017. Baseline clinical characteristics were abstracted from the electronic health record. Immune-related toxicities were graded by physicians based on Common Terminology for Adverse Events criteria, v4.0. Bivariate analysis with chi-squared statistics was used to describe baseline characteristics of patients ≥70 years (y) vs. <70y. Survival outcomes were estimated by the Kaplan-Meier method (time zero = start of first-line IO) and compared using the log-rank test. The association of age and ≥ grade 3 toxicity with OS was tested with a Cox proportional hazards model. Results: Among 676 patients treated with IO, 238 (35.4%) were ≥70y. There was no difference in baseline characteristics of each age group except cancer type (P<0.01). The incidence of ≥ grade 3 toxicity did not differ by age (<70y: 14.5% vs. ≥70y: 13.5%, P=0.71). Median OS was significantly longer for adults <70y (16.4 vs. 13.2 months, P<0.01) or those with ≥ grade 3 toxicity (18.3 vs. 14.7 months, P<0.01). When stratified by age and toxicity, patients <70y with ≥ grade 3 toxicity had longer OS vs. those without ≥ grade 3 toxicity (P<0.01). However, there was no OS difference among adults ≥70y with vs. without ≥ grade 3 toxicity (P=0.78). Adjusted hazard ratios with an interaction term are below. Conclusions: Though the incidence of ≥ grade 3 toxicity did not significantly differ by age, there was no significant OS advantage for older adults with ≥ grade 3 toxicity as compared to younger adults. Caution should be used in considering a toxicity-survival relationship in older adults.[Table: see text]

Factors associated with intentions for breast cancer risk management: Does risk group matter?

OBJECTIVE

National guidelines provide breast cancer (BC) risk management recommendations based on estimated lifetime risk. Despite this specificity, it is unclear if women's risk management intentions are or are not guideline concordant. To address this knowledge gap, women at varying risk levels reported intentions for risk-reducing behaviors. Factors associated with intentions, informed by the Health Beliefs Model, were also studied.

METHODS

Women with elevated BC risk (N = 103) were studied and categorized by risk level: moderate (15%-20%), high (greater than or equal to 20%), or very high (BRCA1/2 positive). Participants self-reported BC susceptibility, self-efficacy, and benefits, barriers, and intentions for risk-reducing mastectomy (RRM), risk-reducing salpingo-oophorectomy (RRSO), chemoprevention, improving diet or physical activity, and reducing alcohol use.

RESULTS

Groups significantly differed in RRSO intentions (P < .01); BRCA1/2 positive women had greater intentions for RRSO. Groups did not differ in intentions for RRM, chemoprevention, or lifestyle changes (Ps > .28). In hierarchical linear regression models examining Health Belief Model (HBM) factors, perceived susceptibility was associated with intentions for RRM (β = .169, P = .08). Perceived benefits was associated with intentions for RRM (β = .237, P = .02) and chemoprevention (β = .388, P < .01). Self-efficacy was associated with intentions for physical activity (β = .286, P < .01).

CONCLUSIONS

Consistent with guidelines, BRCA1/2 positive women reported greater intentions for RRSO, and risk groups did not differ in intentions for lifestyle changes. Notably, women's intentions for RRM and chemoprevention were guideline discordant; groups did not differ in intentions for these behaviors. Accounting for the effects of risk group, modifiable health beliefs were also associated with risk management intentions; these may represent targets for decision support interventions.

Lemons to lemonade: Effects of a biobehavioral intervention for cancer patients on later life changes

OBJECTIVE

The sustainment of gains for cancer patients provided psychosocial interventions is unclear. Furthermore, it is unknown whether interventions also yield long-term positive changes. The present study experimentally tests if an intervention delivered at cancer diagnosis could yield broad, long-term, changes in domains such as relationships, worldview, priorities, and goals. It was hypothesized that the intervention group would report more positive and fewer negative life changes during survivorship versus the control group.

METHOD

Patients with Stage II/III breast cancer were randomized to biobehavioral intervention (BBI) or assessment only. At randomization, patients completed measures of cancer stress (Impact of Events Scale [IES]) and depressive symptoms (Center for Epidemiological Studies Depression scale [CES-D]). At the 24-month follow-up, survivors (N = 160) completed a thought listing task with 7 prompts (e.g., "relationships"). Patients listed thoughts about change since diagnosis and rated each for valence. Groups were compared on the frequency of positive/negative thoughts across prompts. Listed thoughts were content analyzed.

RESULTS

BBI survivors reported significantly more positive changes (p < .05), controlling for IES and CES-D. Groups did not differ on negative changes. Patients with higher IES/CES-D scores reported more negative changes at 24 months (ps < .05). Content analysis revealed a predominance (13/23) of positive thought categories.

CONCLUSIONS

Adding support for efficacy, BBI survivors reported significantly more positive life changes since diagnosis than survivors not receiving BBI. More generally, heightened stress/depressive symptoms at diagnosis foretold survivors' reporting of more negative changes. Thought listing is a strategy to obtain personalized accounts of life changes after breast cancer. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evaluating the effectiveness and implementation of evidence-based treatment: A multisite hybrid design

The gap between treatment development and efficacy testing to scaled up implementations of evidence-based treatment (EBT) is an estimated 20 years, and hybrid research designs aim to reduce the gap. One was used for a multisite study in cancer control, testing coprimary aims: (a) determine the feasibility and utility of a flexible EBT implementation strategy and (b) determine the clinical effectiveness of an EBT as implemented by newly trained providers. Therapists from 15 diverse sites implemented the biobehavioral intervention (BBI) for cancer patients (N = 158) as part of standard care. For implementation, therapists determined treatment format, number of sessions, and so forth and reported session-by-session fidelity. Patients completed fidelity and outcome assessments. Results showed therapists BBI implementation was done with fidelity, for example, session "dose" (59%), core content coverage (60-70%), and others. Patient reported fidelity was favorable and comparable to the BBI efficacy trial. Effectiveness data show the primary outcome, patients' scores on the Profile of Mood States total mood disturbance, significantly improved (R² = 0.06, β = -0.24, p < .01) as did a secondary outcome, physical activity (R² = 0.02, β = 0.13, p < .05). This first use of a hybrid design in health psychology provided support for a novel strategy that allowed providers implementation flexibility. Still, the EBT was delivered with fidelity and in addition, therapists generated novel procedures to enhance setting-specific usage of BBI and its ultimate effectiveness with patients. This research is an example of translational research spanning theory and efficacy tests to dissemination and implementation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cells, cytokines, chemokines, and cancer stress: A biobehavioral study of patients with chronic lymphocytic leukemia

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most prevalent adult leukemia, with profound disease-related cellular, humoral, and innate immune suppression. The objective of this study was to study the correlations between stress and disease-specific, negative prognostic cellular, cytokine, and chemokine markers in patients with CLL.

METHODS

A single-group, observational design was used. Patients with relapsed/refractory CLL (N = 96) who were entering a phase 2 trial of an experimental therapy (ibrutinib) were studied. Before the first dose, a validated self-report measure of stress (the Impact of Event Scale) was completed, and blood was drawn for absolute lymphocyte counts (ALCs) and for cytokine and chemokine enzyme-linked immunosorbent assays. Multiple linear regression models tested stress as a concurrent predictor of ALCs; of cytokines (tumor necrosis factor α [TNFα], a proliferation-inducing ligand [APRIL], B-cell activating factor [BAFF], interleukin 6 [IL-6], IL-10, IL-16, and vascular endothelial growth factor [VEGF]); and of the chemokine (C-C motif) ligand 3 (CCL3).

RESULTS

Controlling for relevant demographic variables, comorbidities, CLL genetic risk (deletion of the short arm of chromosome 17 [del17p]), and correlates of inflammation, stress predicted higher ALCs (P < .05), and higher levels of TNFα (P < .05), IL-16 (P < .01), and CCL3 (P < .05). Stress was not associated with APRIL, BAFF, IL-6, IL-10, or VEGF.

CONCLUSIONS

Novel biobehavioral data from patients with relapsed/refractory CLL demonstrate that stress is related to heightened levels of cellular, cytokine, and chemokine markers associated previously with progressive disease in CLL. The current results indicate that stress is related to immune and inflammatory processes that contribute to cancer cell proliferation and survival. These data provide a first look into these processes. Cancer 2018. © 2018 American Cancer Society.

Implementation of an evidence-based biobehavioral treatment for cancer patients

One aim of dissemination and implementation (DI) research is to study the translation of evidence-based treatments (EBTs) from the research environments of their development and testing to broader communities where they are needed. There are few behavioral medicine DI studies and none in cancer survivorship. A determinant model (Setting, Therapist, Education, imPlementation, and Sustainability (STEPS)) was used to conceptualize DI of mental health treatment and frame a longitudinal study of implementation of a behavioral medicine EBT-a biobehavioral intervention (BBI) for cancer patients. Using effective dissemination strategies, therapists were trained in the BBI and followed to determine if implementation occurred. Participants (N = 108) were psychologists, social workers, and other oncology mental health providers from diverse settings to whom the BBI had been disseminated. BBI trainers then provided 6 months of support for implementation (e.g., monthly conference calls). Therapists reported number of patients treated, with or without the BBI, at 2, 4, and 6 months; use of support strategies was tracked. Generalized linear mixed models show that the proportion of patients treated with BBI ranged from 58 to 68%, with a 2% increase across follow-ups. Therapist and setting characteristics did not predict usage. Implementation of a behavioral medicine EBT provides a "real-world" demonstration of a BBI moved from the research setting to diverse communities. As the first study in cancer, it is an encouraging example of training and supporting mental health providers to deliver evidence-based psychological treatment and finding their success in doing so.

Interventions to Address Sexual Problems in People With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Adaptation of Cancer Care Ontario Guideline

Purpose

The adaptation of the Cancer Care Ontario (CCO) guideline Interventions to Address Sexual Problems in People With Cancer provides recommendations to manage sexual function adverse effects that occur as a result of cancer diagnosis and/or treatment.

Methods

ASCO staff reviewed the guideline for developmental rigor and updated the literature search. An ASCO Expert Panel ( Table A1 ) was assembled to review the guideline content and recommendations.

Results

The ASCO Expert Panel determined that the recommendations from the 2016 CCO guideline are clear, thorough, and based upon the most relevant scientific evidence. ASCO statements and modifications were added to adapt the CCO guideline for a broader audience.

Recommendations

It is recommended that there be a discussion with the patient, initiated by a member of the health care team, regarding sexual health and dysfunction resulting from cancer or its treatment. Psychosocial and/or psychosexual counseling should be offered to all patients with cancer, aiming to improve sexual response, body image, intimacy and relationship issues, and overall sexual functioning and satisfaction. Medical and treatable contributing factors should be identified and addressed first. In women with symptoms of vaginal and/or vulvar atrophy, lubricants in addition to vaginal moisturizers may be tried as a first option. Low-dose vaginal estrogen, lidocaine, and dehydroepiandrosterone may also be considered in some cases. In men, medication such as phosphodiesterase type 5 inhibitors may be beneficial, and surgery remains an option for those with symptoms or treatment complications refractory to medical management. Both women and men experiencing vasomotor symptoms should be offered interventions for symptomatic improvement, including behavioral options such as cognitive behavioral therapy, slow breathing and hypnosis, and medications such as venlafaxine and gabapentin.Additional information is available at: www.asco.org/survivorship-guidelines and www.asco.org/guidelineswiki .

Biobehavioral approaches to cancer progression and survival: Mechanisms and interventions

Over the last decade, there have been groundbreaking strides in our understanding of the multiple biological pathways by which psychosocial and behavioral factors can affect cancer progression. It is now clear that biobehavioral factors not only affect cellular immunity but both directly and indirectly modulate fundamental processes in cancer growth, including inflammation, angiogenesis, invasion, and metastasis. There is also an emerging understanding of how psychological and behavioral factors used in interventions can impact these physiological processes. This review outlines our current understanding of the physiological mechanisms by which psychological, social, and behavioral processes can affect cancer progression. The intervention literature is discussed, along with recommendations for future research to move the field of biobehavioral oncology forward.

Individual differences in physical symptom burden and psychological responses in individuals with chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is an incurable illness, with some patients requiring no treatment until disease progression. Burden from physical symptoms has been associated with depression, anxiety, and stress in cancer patients. Additionally, patient factors, i.e., individual differences, have been associated with worse psychological outcomes. There are few psychological studies of CLL, with no examination of individual differences. A cross-sectional design studied the covariation of symptom burden with depressive and anxiety symptoms and cancer-specific stress, and tested patients' individual differences as predictors and as moderators. CLL patients (N = 112) receiving active surveillance participated. They were Caucasian (100 %) and predominately male (55 %) with a mean age of 61; most (62.5 %) had stage 0 disease. A composite measure of physical symptom burden (CLL symptoms, fatigue, pain, impaired functional status) was tested as a predictor of psychological responses. Individual differences in psychiatric history and social support were tested as moderators. Using multiple linear regression, greater symptom burden covaried with higher levels of depressive and anxiety symptoms and cancer stress (ps < .05). Those with a psychiatric history, low social support, and low relationship satisfaction with one's partner reported greater symptom burden and more psychological symptoms and stress (ps < .05). Findings suggest that CLL patients in surveillance with a psychiatric history and/or low social support are at risk for greater distress when coping with high symptom burden. These new data clarify the experience of CLL surveillance and identify characteristics of patients with heightened risk for symptom burden, stress, and anxiety or depressive symptoms.

Emotions and Emotion Regulation in Breast Cancer Survivorship

Emotional distress in cancer patients is an important outcome; however, emotional experience does not begin and end with emotion generation. Attempts to regulate emotions may lessen their potentially negative effects on physical and psychological well-being. Researchers have called for the study of emotion regulation (ER) in health psychology and psycho-oncology. Thus, this review has three aims. First, we discuss current understandings of emotion and ER across the cancer trajectory, including the principles of ER and methods for its assessment. Second, we present a model for examining the mediating effects of ER on psychosocial outcomes. Third, we “round out” the discussion with an example: new data on the role of ER in recurrent breast cancer. Taken together, these aims illustrate the impact of affective regulatory processes on cancer patients’ long-term outcomes. As survival rates increase, long-term follow-up studies are needed to characterize the dynamic, reciprocal effects of emotion and ER for cancer survivors. Further research on ER may help women with breast cancer better manage the challenges associated with diagnosis and treatment.

Trajectories of Stress, Depressive Symptoms, and Immunity in Cancer Survivors: Diagnosis to 5 Years

PURPOSE

Five-year disease endpoint trajectories are available for every cancer site. In contrast, there are few longitudinal, biobehavioral studies of survivors extending beyond the first or second year following diagnosis. This gap is addressed with stress, depressive symptom, and immunity data from breast cancer patients followed continuously for 5 years.

EXPERIMENTAL DESIGN

Women (N = 113) diagnosed and surgically treated for breast cancer and awaiting adjuvant therapy completed self-report measures of stress and depressive symptoms and provided blood for immune assays [natural killer cell cytotoxicity (NKCC) and T-cell blastogenesis]. Assessments (N = 12) were repeated every 4 to 6 months for 5 years.

RESULTS

Multiphase linear mixed models show phases of change and identified specific time points of change. Cancer stress shows two distinct phases of decline, with the change point being 12 months. In contrast, a steep decline in depressive symptoms occurs by 7 months, with stable, low levels thereafter. NKCC shows a steady upward trajectory through 18 months and upper limit stability thereafter, whereas there was no reliable trajectory for T-cell blastogenesis.

CONCLUSIONS

For the first time, trajectories and specific time points of change in biobehavioral data for breast cancer survivors are provided, traced through 5 years. Following diagnosis, the breast survivor experience is one of a co-occurrence of change (recovery) in psychologic and innate immunity markers from diagnosis to18 months, and a pattern of stability (depression, NKCC) or continued improvement (stress) through year 5. These data provide new directions for survivorship care and detail of the biobehavioral trajectory. Clin Cancer Res; 23(1); 52-61. ©2016 AACR.

The relation of illness perceptions to stress, depression, and fatigue in patients with chronic lymphocytic leukaemia

OBJECTIVE

Chronic lymphocytic leukaemia (CLL) is the most prevalent adult leukaemia and is incurable. The course and treatment of CLL is unique and characterised by repeated cycles of treatment, stable disease and relapse. Utilising a Self-Regulatory Model framework, we examined the relationship between patients' illness perceptions and cancer-specific stress, depressive symptoms and fatigue. Our aim was to test illness perceptions as predictors of these outcomes when variance due to disease and treatment variables was controlled.

DESIGN

Data were collected on 147 patients with relapsed/refractory CLL as they entered a phase II clinical trial of an investigational medication at a university affiliated, National Cancer Institute designated comprehensive cancer center.

MAIN OUTCOME MEASURES

Cancer-specific stress, depressive symptoms and fatigue interference.

RESULT

. Hierarchical multiple regression was used. Consequences and emotional representation were related to all outcomes (ps < .01). Illness concern was related to cancer-specific stress (p < .01), and identity was related to fatigue interference (p < .01). All relationships were observed while controlling for number of previous CLL therapies received.

CONCLUSION

Illness perceptions are related to cancer-specific stress, depressive symptoms and fatigue interference in relapsed/refractory CLL. Interventions targeted at restructuring maladaptive illness perceptions may have clinical benefit in this population.