Preliminary testing of "roadmap to parenthood" decision aid and planning tool for family building after cancer: Results of a single-arm pilot study

OBJECTIVE

Many young adult female cancer survivors need to use reproductive medicine, surrogacy, or adoption to have a child. This study pilot tested Roadmap to Parenthood, a web-based, self-guided decision aid and planning tool for family building after cancer (disease agnostic).

METHODS

A single-arm pilot study tested feasibility, acceptability, and obtained effect size estimates of the Roadmap tool. Participants, recruited via hospital-based and social media strategies, completed a baseline survey (T1), accessed the Roadmap tool (website), then completed surveys at one- and 3-months (T2 and T3, respectively). Feasibility and acceptability were evaluated with rates of eligibility, enrollment, and survey completion, and feedback. Pairwise t-tests and repeated measures ANOVA evaluated usage effects. Effect size estimates were calculated.

RESULTS

Participants (N = 98) averaged 31 years old (SD = 5.61); 71% were nulliparous. Enrollment rate was 73%, T1-T2 completion rate was 80%, and 93% accessed the website. From T1-T2, participants reported improvements in decisional conflict (p < 0.001; Cohen's d = 0.85), unmet information needs (p < 0.001; Cohen's d = 0.70), self-efficacy (p = 0.003; Cohen's d = 0.40), and self-efficacy for managing negative emotions (p = 0.03; Cohen's d = 0.29); effects were sustained at T3. There was no change in reproductive distress (p = 0.22). By T3, 94% reported increased consideration of preparatory actions and 20%-61% completed such actions.

CONCLUSIONS

The Roadmap intervention was feasible to conduct, acceptable to users, and led to improvements in key psychosocial outcomes. Future directions will test intervention efficacy in a randomized controlled trial with a larger sample and over a longer period. A web-based tool may help women make decisions about family building after cancer and prepare for potential challenges.

Tranceformation: Digital dissemination of hypnosis

Hypnosis is an underutilized tool despite evidence of efficacy from randomized clinical trials. In this NeuroView, I discuss potential mechanisms in the context of brain networks and propose the use of app-based instruction in self-hypnosis.

The Neural Separability of Emotion Reactivity and Regulation

One foundational distinction in affective science is between emotion reactivity and regulation. This conceptual distinction has long been assumed to be instantiated in spatially separable brain systems (a typical example: amygdala/insula for reactivity and frontoparietal areas for regulation). In this research, we begin by reviewing previous findings that support and contradict the neural separability hypothesis concerning emotional reactivity and regulation. Further, we conduct a direct test of this hypothesis with empirical data. In five studies involving healthy and clinical samples (total n = 336), we assessed neural responses using fMRI while participants were asked to either react naturally or regulate their emotions (using reappraisal) while viewing emotionally evocative stimuli. Across five studies, we failed to find support for the neural separability hypothesis. In univariate analyses, both presumptive "reactivity" and "regulation" brain regions demonstrated equal or greater activation for the reactivity contrast than for the regulation contrast. In multivariate pattern analyses (MVPA), classifiers decoded reactivity (vs. neutral) trials more accurately than regulation (vs. reactivity) trials using multivoxel data in both presumptive "reactivity" and "regulation" regions. These findings suggest that emotion reactivity and regulation-as measured via fMRI-may not be as spatially separable in the brain as previously assumed. Our secondary whole-brain analyses revealed largely consistent results. We discuss the two theoretical possibilities regarding the neural separability hypothesis and offer thoughts for future research.

Supplementary Information

The online version contains supplementary material available at 10.1007/s42761-023-00227-9.

Toxicity and Efficacy of Hypofractionated Regional Nodal Irradiation

PURPOSE/OBJECTIVE(S)

Hypofractionated whole-breast irradiation (HF-WBI) has been widely adopted. However, there are still limited data on whether hypofractionated regional nodal irradiation (HF-RNI) is safe and effective. We report toxicity and cancer outcomes with our HF-RNI approach.

MATERIALS/METHODS

This retrospective study included 154 patients with node-positive or high-risk node-negative breast cancer treated with HF-RNI with curative intent at a single academic institution from 2008-2020. Median dose to the breast or chest wall/reconstructed breast was 40 Gy in 16 fractions (interquartile range [IQR], 40-45 Gy in 16-18 fractions). Median dose to the regional nodes was 40 Gy in 16 fractions (IQR, 40-40 Gy in 16-16 fractions). The primary end-point was the rate of chronic toxicity. Secondary endpoints were local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), disease-free survival (DFS), and overall survival (OS). Toxicities were scored using the Common Terminology Criteria for Adverse Events v5.0 and Radiation Therapy Oncology Group scale where appropriate. This study was approved by the Institutional Review Board.

RESULTS

Median follow-up was 46 months (IQR 33-63 mo). Median age at diagnosis was 58 years. Sentinel lymph node biopsy (SLNB) was performed in 49% of patients, 16% underwent both SLNB and axillary lymph node dissection (ALND), 32% underwent ALND alone, and 3% had no axillary surgery; 79% had partial mastectomy and 21% had total mastectomy with or without reconstruction. The nodal target included the supraclavicular and axillary Level 1-3 nodes in 66% of patients and supraclavicular and Level 3 nodes in 34%. The crude incidence of grade 1 chronic brachial plexopathy was 2%, grade 1 chronic limited range of motion (LROM) of the upper extremity was 3%, and chronic upper extremity lymphedema was 8% (11 patients with grade 1 toxicity and 1 patient with grade 2 toxicity). The only grade 3+ chronic toxicity was hyperpigmentation (1%). The median time to the development of the highest-grade toxicity was 10 months for brachial plexopathy, 10 months for LROM, and 11 months for lymphedema, respectively. Five-year actuarial rates of LRFS, RRFS, DFS, and OS were 98%, 99%, 90%, and 88%, respectively.

CONCLUSION

HF-RNI resulted in low rates of chronic toxicities and excellent disease control in this study. Results of randomized trials of HF-RNI are needed for definitive evidence, but these retrospective data support wider adoption of HF-RNI.

Circadian, hormonal, and sleep rhythms: effects on cancer progression implications for treatment

Circadian, hormonal, and sleep rhythm disruptions are commonly experienced concerns among cancer patients throughout the cancer care continuum. This review aims to summarize the existing literature on circadian, hormonal, and sleep rhythms in the oncological population, focusing on circadian disruption and physiological and psychological abnormalities, disease progression, and chronomodulated treatment approaches. The findings demonstrate that subjectively and objectively measured circadian rhythm disruption is associated with adverse mental health and disease outcomes in patients with cancer. Chronomodulated chemotherapy, light therapy, cognitive behavioral therapy for insomnia, and physical activity have shown evidence of effectiveness in improving sleep, and occasionally, disease outcomes.

Changing cancer mindsets: A randomized controlled feasibility and efficacy trial

OBJECTIVE

A cancer diagnosis and subsequent treatment can disrupt the full spectrum of physical, social, emotional, and functional quality of life. But existing psychological treatments are focused primarily on specific psychological symptoms as opposed to improving the overall patient experience. We studied the feasibility and efficacy of a novel digital intervention targeting patient mindsets-core assumptions about the nature and meaning of illness-designed to improve overall health-related quality of life (HRQoL) in newly diagnosed cancer patients undergoing treatment with curative intent.

METHODS

Recently diagnosed (≤150 days) adult patients with non-metastatic cancers undergoing systemic treatment (N = 361) were recruited from across the United States to participate in this decentralized clinical trial. Patients were randomized 1:1 to receive the Cancer Mindset Intervention (CMI) or Treatment as Usual (TAU). Participants in the CMI group completed seven online modules over 10 weeks (2.5 h total) targeting mindsets about cancer and the body. The primary outcome was overall HRQoL, and secondary outcomes were coping behaviors and symptom distress.

RESULTS

Patients in the CMI group reported significant (p < 0.001) improvements in adaptive mindsets about cancer and the body over time. Compared with the TAU condition, the CMI group reported significant improvements in overall HRQoL (B = 0.60; 95% CI 0.34-0.85; p < 0.001), increased engagement in adaptive coping behaviors (B = 0.03; 95% CI 0.02-0.04; p < 0.001), and reduced distress from physical symptoms (B = -0.29; 95% CI -0.44 to -0.14; p < 0.01). Effect sizes of these changes ranged from d = 0.42-d = 0.54.

CONCLUSION

A brief mindset-focused digital intervention was effective at improving physical, social, emotional, and functional HRQoL, increasing adaptive coping behaviors, and reducing physical symptom distress in newly diagnosed cancer patients.

Real-Time Semi-Automated and Automated Voxel Placement using fMRI Targets for Repeated Acquisition Magnetic Resonance Spectroscopy

BACKGROUND

Currently, magnetic resonance spectroscopy (MRS) is dependent on the investigative team to manually prescribe, or demarcate, the desired tissue volume-of-interest. The need for a new method to automate precise voxel placements is warranted to improve the utility and interpretability of MRS data.

NEW METHOD

We propose and validate robust and real-time methods to automate MRS voxel placement using functionally defined coordinates within the prefrontal cortex. Data were collected and analyzed using two independent prospective studies: 1) two independent imaging days with each consisting of a multi-session sandwich design (MRS data only collected on one of the days determined based on scan time) and 2) a longitudinal design. Participants with fibromyalgia syndrome (N = 50) and major depressive disorder (N = 35) underwent neuroimaging. MRS acquisitions were acquired at 3-tesla. Evaluation of the reproducibility of spatial location and tissue segmentation was assessed for: 1) manual, 2) semi-automated, and 3) automated voxel prescription approaches RESULTS: Variability of voxel grey and white matter tissue composition was reduced using automated placement protocols. Spatially, post- to pre-voxel center-of-gravity distance was reduced and voxel overlap increased significantly across datasets using automated compared to manual procedures COMPARISON WITH EXISTING METHODS: Manual prescription, the current standard in the field, can produce inconsistent data across repeated acquisitions. Using automated voxel placement, we found reduced variability and more consistent voxel placement across multiple acquisitions CONCLUSIONS: These results demonstrate the within subject reliability and reproducibility of a method for reducing variability introduced by spatial inconsistencies during MRS acquisitions. The proposed method is a meaningful advance toward improved consistency of MRS data in neuroscience and can be utilized for multi-session and longitudinal studies.

Emotion regulation and choice of bilateral mastectomy for the treatment of unilateral breast cancer

BACKGROUND

There has been steadily increasing use of bilateral mastectomy (BMX) in the treatment of primary breast cancer (BC). In this study, we utilized functional magnetic resonance imaging (fMRI) to examine the influence of emotion regulation on the decision of newly diagnosed BC patients to choose BMX rather than non-BMX treatments.

METHODS

We recruited 123 women with unilateral BC, 61 of whom received BMX and 62 of whom received non-BMX treatments, and 39 healthy controls. While participants were in the fMRI scanner, we showed them BC-related and non-BC-negative images. In one condition, they were instructed to watch the images naturally. In another, they were instructed to regulate their negative emotion. We compared the fMRI signal during these conditions throughout the brain.

RESULTS

With non-BC-negative images as the baseline, BC patients showed greater self-reported reactivity and neural reactivity to BC-related images in brain regions associated with self-reflection than did controls. Among the BC patients, the BMX group showed weaker activation in prefrontal emotion regulation brain regions during emotion regulation than did the non-BMX group.

CONCLUSIONS

BC patients are understandably emotionally hyper-reactive to BC-related stimuli and those who ultimately received BMX experience more difficulty in regulating BC-related negative emotion than non-BMX BC patients. These findings offer neuropsychological evidence that difficulty in managing anxiety related to the possibility of cancer recurrence is a factor in surgical treatment decision-making and may be an intervention target with the goal of strengthening the management of cancer-related anxiety by nonsurgical means.

TRIAL REGISTRATION

NCT03050463.

Point-of-Care Testing of Enzyme Polymorphisms for Predicting Hypnotizability and Postoperative Pain

Hypnotizability is a stable trait that moderates the benefit of hypnosis for treating pain, but limited availability of hypnotizability testing deters widespread use of hypnosis. Inexpensive genotyping of four single-nucleotide polymorphisms in the catechol-o-methyltransferase (COMT) gene was performed using giant magnetoresistive biosensors to determine if hypnotizable individuals can be identified for targeted hypnosis referrals. For individuals with the proposed optimal COMT diplotypes, 89.5% score highly on the Hypnotic Induction Profile (odds ratio, 6.12; 95% CI, 1.26-28.75), which identified 40.5% of the treatable population. Mean hypnotizability scores of the optimal group were significantly higher than the total population (P = 0.015; effect size = 0.60), an effect that was present in women (P = 0.0015; effect size = 0.83), but not in men (P = 0.28). In an exploratory cohort, optimal individuals also reported significantly higher postoperative pain scores (P = 0.00030; effect size = 1.93), indicating a greater need for treatment.

Brief structured respiration practices enhance mood and reduce physiological arousal

Controlled breathwork practices have emerged as potential tools for stress management and well-being. Here, we report a remote, randomized, controlled study (NCT05304000) of three different daily 5-min breathwork exercises compared with an equivalent period of mindfulness meditation over 1 month. The breathing conditions are (1) cyclic sighing, which emphasizes prolonged exhalations; (2) box breathing, which is equal duration of inhalations, breath retentions, and exhalations; and (3) cyclic hyperventilation with retention, with longer inhalations and shorter exhalations. The primary endpoints are improvement in mood and anxiety as well as reduced physiological arousal (respiratory rate, heart rate, and heart rate variability). Using a mixed-effects model, we show that breathwork, especially the exhale-focused cyclic sighing, produces greater improvement in mood (p < 0.05) and reduction in respiratory rate (p < 0.05) compared with mindfulness meditation. Daily 5-min cyclic sighing has promise as an effective stress management exercise.

Marital status and survival in cancer patients: A systematic review and meta-analysis

BACKGROUND

In recent years, authors have repeatedly reported on the significance of social support in cancer survival. Although overall the studies appear to be convincing, little is known about which types of social support promote better survival rates, and which subgroups of cancer patients are more susceptible to the benefits of it. The aim of this study was to identify, organize, and examine studies reporting on the significance of social support in cancer survival.

METHODS

The PubMed, CINAHL and EBSCO databases were searched using the keywords social support/marital status, cancer, and survival/mortality. Where possible we used a meta-analytical approach, specifically a random effect model, in order to combine the results of the hazard ratios in studies from which this information could be obtained. When interpreting clinical relevance, we used the number needed to treat (NNT).

RESULTS

Better survival was observed in married patients when compared to unmarried (single, never-married, divorced/separated, and widowed) in overall and cancer-specific survival. Gender group differences showed that the association was statistically significant only in cancer-specific survival when comparing divorced/separated male and female cancer patients (p < 0.001), thus confirming results from the previous meta-analysis.

CONCLUSIONS

Being unmarried is associated with significantly worse overall and cancer-specific survival. The most vulnerable group found in our study were divorced/separated men. The results of this review can motivate physicians, oncologists, and other healthcare professionals to be aware of the importance of patients' social support, especially in the identified sub-group.

Effects of hypnosis versus enhanced standard of care on postoperative opioid use after total knee arthroplasty: the HYPNO-TKA randomized clinical trial

BACKGROUND

Hypnosis decreases perioperative pain and has opioid-sparing potential but has not been rigorously studied in knee arthroplasty. This trial investigates the impact of perioperative hypnosis on inpatient opioid use following total knee arthroplasty.

METHODS

This prospective randomized controlled trial was conducted at a single academic medical center. The hypnosis arm underwent a scripted 10 min hypnosis session prior to surgery and had access to the recorded script. The control arm received hypnosis education only. The primary outcome was opioid use in milligram oral morphine equivalents per 24 hours during hospital admission. A secondary analysis was performed for patients taking opioids preoperatively.

RESULTS

64 primary knee arthroplasty patients were randomized 1:1 to hypnosis (n=31) versus control (n=33) and included in the intent-to-treat analysis. The mean (SD) postoperative opioid use in oral morphine equivalents per 24 hours was 70.5 (48.4) in the hypnosis versus 90.7 (74.4) in the control arm, a difference that was not statistically significant (difference -20.1; 95% CI -51.8 to 11.4; p=0.20). In the subgroup analysis of the opioid-experienced patients, there was a 54% daily reduction in opioid use in the hypnosis group (82.4 (56.2) vs 179.1 (74.5) difference of -96.7; 95% CI -164.4 to -29.0; p=<0.01), equivalent to sparing 65 mg of oxycodone per day.

CONCLUSION

Perioperative hypnosis significantly reduced inpatient opioid use among opioid-experienced patients only. A larger study examining these findings is warranted.

TRIAL REGISTRATION NUMBER

NCT03308071.

The longitudinal effects of chronotype on chemotherapy-induced nausea and vomiting in patients with breast cancer receiving neoadjuvant chemotherapy

OBJECTIVE

The object of this longitudinal cohort study was to investigate whether chronotype affects the incidence of chemotherapy-induced nausea and vomiting (CINV) among patients with breast cancer.

METHODS

The study included a total of 203 breast cancer patients who received neoadjuvant chemotherapy using a regimen of doxorubicin and cyclophosphamide with high emetogenicity. Patients received four cycles of chemotherapy in approximately three months. Patients completed questionnaires including the Munich Chronotype Questionnaire (MCTQ) before the first chemotherapy and the Multinational Association of Supportive Care in Cancer Antiemesis Tool (MAT) after each of the four chemotherapy sessions. To confirm the effect of chronotype on CINV during the four cycles, we performed statistical analyses using a generalized estimating equation (GEE).

RESULTS

CINV occurred in 108 (53.2%), 112 (55.2%), 102 (50.3%), and 62 (30.5%) patients during four cycles of treatment. In the GEE approach, late and early chronotypes (vs. intermediate chronotype) were associated with an increased risk of CINV (late chronotype: odds ratio [OR], 2.06; 95% confidence interval [CI], 1.41-2.99; p < 0.001, early chronotype: OR, 1.84; CI, 1.25-2.73; p = 0.002), which remained significant even after adjusting for age, BMI, antiemetic treatment, history of nausea and vomiting, anxiety, and sleep quality.

CONCLUSION

Chronotype affected CINV across the four cycles of neoadjuvant chemotherapy in patients with breast cancer, suggesting the need to consider chronotype in predicting and managing CINV.

Development of a Web-Based Decision Aid and Planning Tool for Family Building After Cancer (Roadmap to Parenthood): Usability Testing

Background

Owing to gonadotoxic cancer treatments, young adult female survivors often report uncertainty about their fertility, reproductive potential, and family-building options after treatment. Roadmap to Parenthood is a web-based decision aid and planning tool for family building after cancer.

Objective

As part of a patient-centered development process, this study evaluated the usability of the decision aid website to inform design modifications and improve user experience.

Methods

In total, 2 rounds of usability testing were conducted with the target population of young adult female cancer survivors. During the testing sessions, participants viewed the website twice; first, as a think-aloud exercise, and second, while a researcher interrupted at key points to obtain user feedback. Quantitative and qualitative data were collected to assess website usability. Quantitative measures included the System Usability Scale, WebQual, and eHealth Impact Questionnaire. An exit interview with open-ended questions gathered feedback on likes and dislikes and suggestions for improvement.

Results

Participants (N=10) were young adult women, with average age of 30.9 (SD 4.51) years, and average time since treatment was 4.44 (SD 3.56) years. Website usability scores improved on the System Usability Scale from “acceptable” in round 1 to “excellent” in round 2 after making design changes based on user feedback (scores of 68 and 89.4, respectively). WebQual scores showed similar improvement from round 1 to round 2 of testing (mean 5.6 to 6.25; range 1-7). On the eHealth Impact Questionnaire, the information and presentation of the website was perceived as comprehensive, easy to understand, and trustworthy. Participants also reported improved confidence to discuss and manage fertility and family-building issues and felt encouraged to play a more active role in managing their fertility. In all, 3 usability themes were identified from the qualitative feedback: ease of use, visibility and navigation, and informational content and usefulness. Overall feedback was positive, and participants reported intentions to use the decision aid website in the future. In total, 10% (1/10) of the participants reported negative emotions when learning about infertility risks and potential family-building challenges.

Conclusions

Website usability improved after design changes were made in response to user feedback. Young adult female survivors reported positive views about the website and indicated that the decision aid would be useful in decision-making about family building after cancer. Future studies will include further design modifications to consider the emotional experiences of users and any additional navigational features or content to optimize the ease of use and support provided by the tool.

Identification With the Aggressor and Inward and Outward Aggression in Abuse Survivors

Childhood abuse survivors may display both inward and outward aggression manifested in self-injurious behavior (SIB) and violent acts toward others. Scrutinizing the literature reveals that the relational dynamics between victims and their perpetrators might be involved in these phenomena. Yet, research on this subject matter has been sparse. Filling this gap, this study investigated the contribution of the singular bonds between victims and their perpetrators, known as identification with the aggressor, in explaining survivors' aggression. The study was conducted among 306 Israeli college/university students who reported a history of childhood abuse. Results revealed that levels of adopting the perpetrator's experience, identifying with the perpetrator's aggression, and replacing one's agency with that of the perpetrator were significantly associated with survivors' inward and outward aggression. Moreover, profile type-that is, having high versus low levels of identification with the aggressor-was implicated in participants' SIBs, urge to harm others, and violent acts toward others, above and beyond the effects of gender and posttraumatic stress disorder (PTSD) symptoms. The present findings suggest that identification with the aggressor might make survivors prone to the re-enactment of past abusive dynamics, which, in turn, could eventuate in aggression toward themselves and others.

Morning Chronotype Decreases the Risk of Chemotherapy-Induced Peripheral Neuropathy in Women With Breast Cancer

BACKGROUND

The purpose of this longitudinal prospective cohort study was to investigate the role of chronotype in the incidence of chemotherapy-induced peripheral neuropathy (CIPN) among women with breast cancer.

METHODS

We recruited women with breast cancer awaiting adjuvant chemotherapy, including four cycles of docetaxel. Participants reported peripheral neuropathy symptoms of numbness/tingling at the baseline, and at 4weeks after completion of chemotherapy. Candidate psychiatric factors associated with CIPN were assessed at the baseline, using the Composite Scale of Morningness, the Pittsburgh Sleep Quality Index, and the Hospital Anxiety and Depression Scale. To examine the association between chronotype and CIPN, we built logistic regression models, adjusting for demographic, clinical, and other psychiatric variables.

RESULTS

Among 48 participants, 29 participants developed CIPN. The morning chronotype was inversely associated with CIPN (odds ratio, 0.06; confidence interval, 0.01-0.74; P = 0.028) after adjusting for age, BMI, education, type of operation, alcohol use, smoking, sleep quality, depression, and anxiety.

CONCLUSION

Our results suggest that the morning chronotype is a protective factor against the development of CIPN in patients with breast cancer who were treated with docetaxel.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01887925.

Impact of assessment frequency of patient-reported outcomes: an observational study using an eHealth platform in cancer patients

BACKGROUND AND AIM

The evaluation of patient-reported outcomes (PRO) in cancer has proven relevant positive clinical impact on patients' communication with healthcare professionals, decision-making for management, well-being, and overall survival. However, the optimal frequency of PRO assessment has yet to be defined. Based on the assumption that more frequent sampling would enhance accuracy, we aimed at identifying the optimal sampling frequency that does not miss clinically relevant insight.

METHODS

We used pilot data from 31 advanced cancer patients who completed once daily the 19-item MD Anderson Symptom Inventory at home. The resulting dataset allowed us to compare different PRO assessment frequencies to daily sampling, i.e., alternate days (q2d), every third day (q3d), or once a week (q1w). We evaluated the sampling frequencies for two main outcomes: average symptom intensity and identification of severe symptoms.

RESULTS

The majority of the differences between corresponding averages of daily data and those for q2d, q3d, and q1w datasets were close to 0, yet the extremes exceeded 5. Clinically meaningful differences, i.e., > 1, were observed in 0.76% of patient items for q2d, in 2.72% for q3d, and in 11.93% for q1w. Moreover, median values of missed instances of a severe symptom (i.e., > 6) were 14.6% for q2d, 27.8% for q3d, and 55.6% for q1w.

CONCLUSIONS

Our analysis suggests that in patients receiving chemotherapy for advanced cancer, increasing the density of PRO collection enhances the accuracy of PRO assessment to a clinically meaningful extent. This is valid for both computations of averages symptom burden and for the recognition of episodes of severe symptom intensity.

352 Feasibility of Hypnosis as Adjunctive Treatment for Subjective Sleep Disturbance: A Pilot Study and Proof of Concept

Introduction

Hypnosis-based interventions have been shown to have a positive impact on several dimensions of sleep health. However, current evidence is limited as only a paucity of studies included populations with sleep complaints. Here we present a pilot data set to demonstrate the feasibility of developing a hypnosis-based adjunctive treatment for subjective sleep complaints.

Methods

Eleven adults (42% female; mean age 45±16.87 years) who sought treatment at the Stanford Sleep Medicine Center or Center for Integrative Medicine for subjective sleep complaints received hypnosis as adjunctive treatment. Self-report questionnaires were used to assess the weekly frequency of subjective sleep disturbances experienced before and after treatment, as well as 5-point Likert scale ratings of perceived qualitative improvement in symptom severity and overall sleep quality.

Results

Five participants (45%) reported a reduction in symptom frequency and severity after hypnosis treatment. All five participants attributed at least some of the improvement to hypnosis treatment. Most participants (63%) observed post-treatment improvements in their overall sleep quality. No participants reported adverse effects of hypnosis.

Conclusion

Results suggest hypnosis-based adjunctive treatment may be effective for alleviating subjective sleep disturbances. The findings serve as preliminary support for further randomly controlled trials in larger samples.

Support (if any):

The Variability of Pelvic Obliquity Measurements in Patients with Neuromuscular Scoliosis

Pelvic obliquity (PO), or pelvic alignment in the coronal plane, is an important radiographic parameter to indicate fusion levels and judge success of scoliosis correction in patients with neuromuscular scoliosis. There are multiple commonly used techniques to measure PO that have good to excellent interrater and intrarater reliability, but these different methods yield inconsistent values when used on the same radiograph. This study evaluates the inconsistency in the magnitude of PO measurements for patients with neuromuscular scoliosis among 5 common measurement techniques.

Shared cognitive mechanisms of hypnotizability with executive functioning and information salience

In recent years, evidence linked hypnotizability to the executive control and information salience networks, brain structures that play a role in cognitive conflict resolution and perseveration (insisting on applying a previously learned logical rule on a new set). Despite the growing body of neuroimaging evidence, the cognitive phenotype of hypnotizability is not well understood. We hypothesized that higher hypnotizability would correspond to lower perseveration and set-shifting. Seventy-two healthy adults were tested for hypnotizability and executive functions (perseveration and set-shifting). Multiple regression analyses were performed to test the relationship between hypnotizability and perseveration and set-shifting. Higher hypnotizability was associated with lower perseveration after accounting for age and education. Hypnotizability significantly predicted perseveration but not set-shifting. Our results indicate an inverse relationship between trait hypnotizability and perseveration, an executive function that utilizes regions of both the executive control and the salience systems. This suggests that hypnotizability may share a common cognitive mechanism with error evaluation and implementation of logical rules.

Classically activated mouse macrophages produce methylglyoxal that induces a TLR4- and RAGE-independent proinflammatory response

The highly reactive compound methylglyoxal (MG) can cause direct damage to cells and tissues by reacting with cellular macromolecules. MG has been identified as a biomarker associated with increased sepsis-induced mortality. Patients undergoing septic shock have significantly elevated circulating MG levels compared to postoperative patients and healthy controls. Furthermore, MG has been implicated in the development of type II diabetes mellitus and Alzheimer's disease. Because MG is generated during glycolysis, we hypothesized that MG may be produced by classically activated (M1) macrophages, possibly contributing to the inflammatory response. LPS and IFN-γ-treated macrophages acquired an M1 phenotype (as evidenced by M1 markers and enhanced glycolysis) and formed MG adducts, MG-H1, MG-H2, and MG-H3, which were detected using antibodies specific for MG-modified proteins (methylglyoxal 5-hydro-5-methylimidazolones). MG adducts were also increased in the lungs of LPS-treated mice. Macrophages treated with LPS and IFN-γ also exhibited decreased expression of glyoxalase 1 (Glo1), an enzyme that metabolizes MG. Concentrations of exogenous, purified MG > 0.5 mM were toxic to macrophages; however, a nontoxic dose of 0.3 mM induced TNF-α and IL-1β, albeit to a lesser extent than LPS stimulation. Despite prior evidence that MG adducts may signal through "receptor for advanced glycation endproducts" (RAGE), MG-mediated cell death and cytokine induction by exogenous MG was RAGE-independent in primary macrophages. Finally, RAGE-deficient mice did not exhibit a significant survival advantage following lethal LPS injection. Overall, our evidence suggests that MG may be produced by M1 macrophages during sepsis, following IFN-γ-dependent down-regulation of Glo1, contributing to over-exuberant inflammation.

Posthypnotic Amnesia in Hypnotizability Assessment: Validation of a New Scoring System for the Hypnotic Induction Profile

The Hypnotic Induction Profile (HIP) is a standardized assessment of hypnotizability featuring a validated 0-10 scoring system, that does not factor in posthypnotic amnesia. Using confirmatory factor analyses (CFA), we compared the 10-point scoring system with a new 12-point system that includes the posthypnotic amnesia item in independent samples of individuals with fibromyalgia (n = 98) and healthy adults (n = 97). Additionally, we explored associations of the two scoring systems with measures of hypnotic phenomena. CFA results indicate that the 12-point scoring system is a good fit for the 1-factor model of hypnotizability. Posthypnotic amnesia loaded highly on the model in the fibromyalgia sample, and moderately on the model in healthy adults. Furthermore, the 12-point scoring system correlated significantly with measures of hypnotic phenomena. We conclude that the 12-point scoring system is psychometrically equivalent yet conceptually more comprehensive than the 10-point scoring system.

Testing Hypnotizability by Phone: Development and Validation of the Remote Hypnotic Induction Profile (rHIP)

Standard hypnotizability scales require physical contact or direct observation by tester and participant. The authors addressed this limitation by developing and testing the remote Hypnotic Induction Profile (rHIP), a hypnotizability test derived from the Hypnotic Induction Profile that is completed by telephone. To assess the validity of the rHIP, 56 volunteers naïve to hypnotizability testing completed both the HIP and the rHIP, with order of testing randomized. Results indicate a strong correlation between HIP and rHIP scores, r _s =.71(0.53-0.84), p <.0001, and good concordance, difference =.03(-0.53, 0.59), p =.91, independent of testing order. The rHIP had few complications. Possible advantages of using the rHIP include improving patient expectancy prior to scheduling a hypnosis session, increasing access to hypnotizability testing for remote interventions, and obviating resource-intensive in-person hypnotizability screening for trials that exclude subjects with certain scores.

The Hypnotic Induction Profile (HIP) in Clinical Practice and Research

The Hypnotic Induction Profile (HIP) was developed as a brief, yet thorough, assessment of a person's level of trait hypnotizability and their potential to experience a hypnotic state. The HIP quantitatively and qualitatively measures hynotizability by evaluating biological and sensorimotor experiences designed to assess 3 fundamental observable and measurable components of hypnosis: absorption, dissociation, and suggestibility through a guided assessment that takes 5 to 10 minutes. From conception, the HIP has been utilized in clinical settings to assess appropriateness for the use of hypnosis in treatment planning and research protocols to stratify research participants. The brevity, accessibility, and reliability of the HIP have allowed it to adapt, not only across settings but through media platforms as technology and remote delivery become increasingly incorporated in the field of hypnosis.

International Prevalence and Correlates of Psychological Stress during the Global COVID-19 Pandemic

This study reports perceived stress and associated sociodemographic factors from an international sample of adults, during the COVID-19 pandemic. The Perceived Stress Scale (PSS-10) along with socio-demographic questions were conducted between 8 April 2020 and 11 May 2020. The survey was translated from English into five languages. Recruitment was conducted worldwide using social media. A total of 1685 survey responses were collected across 57 countries with eleven countries (≥30 responses/country) included in the sub-analyses. Overall, the mean PSS-10 score was 19.08 (SD = 7.17), reflecting moderate stress compared to previously reported norms. Female gender was associated with a higher PSS score (3.03, p < 0.05) as well as four-year degree holders (3.29, p < 0.05), while adults over 75 years (-7.46, p < 0.05) had lower PSS scores. Personal care composite score (including hours of sleep, exercise, and meditation) was associated with lower PSS scores (-0.39, p < 0.01). Increases in personal care and changes in work expectations were associated with lower PSS scores (-1.30 (p < 0.05) and -0.38 (p < 0.01), respectively). Lower total PSS scores were reported in Germany (-4.82, p < 0.01) compared to the global response sample mean. This information, collected during the initial period of global mitigation orders, provides insight into potential mental health risks and protective factors during crises.

Evening salivary cortisol as a single stress marker in women with metastatic breast cancer

BACKGROUND

Flattened diurnal salivary cortisol patterns predict shorter subsequent survival with breast, lung, and renal cell carcinomas. The underlying cause of this flattened slope is undetermined, though it has been hypothesized to be secondary to a deficit in the amplitude of the circadian clock. To gain greater insight into the portions of the diurnal salivary curve that are associated with cancer survival, we examined (1) which points in the diurnal curve are predictive of the slope of the curve and (2) whether elevated evening cortisol levels alone are associated with reduced HPA-axis feedback inhibition (i.e., decreased sensitivity to the dexamethasone suppression test).

METHOD

We examined study hypotheses on adult women with advanced breast cancer (age = 54.3 ± 9.58 years; n = 99) using non-parametric Wilcoxon's rank-sum tests, Spearman correlation coefficients and an accuracy formula based on a confusion matrix. Cortisol was sampled five times per day for three consecutive days, with dexamethasone administered late on the second day.

RESULTS

Salivary cortisol concentrations did not vary between those with flat and steep slopes during the morning (p's > .05), but did vary in the evening (p's < 0.05). Furthermore, the concentration of the 2100h alone was 86% accurate in discriminating between individuals classified as having "flat" or "steep" slopes. Dexamethasone suppression was only associated with diurnal salivary cortisol slope (p = .0042).

CONCLUSIONS

Evening cortisol levels are a sensitive indicator flattened diurnal cortisol slope, suggesting evening cortisol may also be a useful predictor of breast cancer survival. Future research should focus on determining the causes of abnormally increased evening cortisol.

Use of CART cells to selectively target autoantigen-specific T cells for the treatment of autoimmune diabetes

Previous clinical trials using biologics-based broad-spectrum T cell- and B cell-depleting molecules for the treatment of autoimmune diabetes have shown promising, yet mixed, results. Their varied extent of success may be due to their non-specific action and failure to permanently and completely remove the pathogenic subpopulations. As CD8+ T cells, the most dominant cell type in human insulitis, are thought to be the primary mediator of β-cells damage, we thus designed a strategy by adapting chimeric antigen receptor engineered T (CART) technology to directly target these pathogenic T cells.

The newly generated CAR construct maintains original transmembrane and intracellular components, while the extracellular scFv antigen-binding domain was replaced with HLA-A2/β2-microglobulin (B2M) complex that is linked with either diabetes-associated immunodominant peptide zinc transporter 8(ZnT8)186–194 or negative control peptide HIV Gag77–85. We have shown that HLA-A2/B2M complexes were correctly folded and presenting right peptide epitopes on CART cells. The CAR signaling was also sustained, as the expression levels of CD25 and CD69 were significantly elevated only on CAR-transduced Jurkat cells presenting ZnT8186–194 peptide co-cultured with a T-cell line that expresses TCRs recognizing the same peptide. To determine the killing ability of CART cells, we further engineered primary human T cells to express our CAR construct and demonstrated that CART cells can selectively deplete human antigen-specific CD8+ T cells in vitro. Therefore, our results have provided proof-of-principle for the development of a novel immunotherapy for disease treatment.

Brain and Physiological Markers of Autonomic Function Are Associated With Treatment-Related Improvements in Self-Reported Autonomic Dysfunction in Veterans With Gulf War Illness: An Exploratory Pilot Study

BACKGROUND

Gulf War Illness (GWI) is a poorly understood condition characterized by a constellation of mood, cognitive, and physical symptoms. A growing body of evidence demonstrates autonomic nervous system (ANS) dysfunction. Few published treatment studies exist for GWI.

METHOD

We recently completed a randomized controlled trial comparing a 10-week group yoga intervention to 10-week group cognitive behavioral therapy (CBT) for veterans with GWI. Here, we present exploratory data on ANS biomarkers of treatment response from a small pilot exploratory neurophysiological add-on study (n = 13) within that larger study.

RESULTS

Findings suggest that veterans with GWI receiving either yoga or CBT for pain improved following treatment and that changes in biological ANS-especially for the yoga group-moved in the direction of healthy profiles: lower heart rate, higher square root of the mean squared differences between successive R-R intervals (RMSSD), greater parasympathetic activation/dominance (increased high-frequency heart rate variability [HF-HRV], decreased low-frequency/high-frequency [LF/HF] ratio), reduced right amygdala volume, and stronger amygdala-default mode/amygdala-salience network connectivity, both immediately posttreatment and at 6-month follow-up. Biological mechanisms of CBT appeared to underlie improvements in more psychologically loaded symptoms such as self-reported fatigue and energy. Higher tonic arousal and/or more sympathetic dominance (higher skin conductance, lower RMSSD, lower HF-HRV, higher LF/HF ratio) pretreatment predicted greater treatment-related improvements in self-reported ANS for both the yoga and CBT group.

CONCLUSION

These exploratory pilot data provide preliminary support for the suggestion that treatment (yoga, CBT) is associated with improvements in both biological and self-reported ANS dysfunctions in GWI. The major limitation for these findings is the small sample size. Larger and more controlled studies are needed to replicate these findings and directly compare biomarkers of yoga versus CBT.

Association between Anterior Cingulate Neurochemical Concentration and Individual Differences in Hypnotizability

Hypnosis is the oldest form of Western psychotherapy and a powerful evidence-based treatment for numerous disorders. Hypnotizability is variable between individuals; however, it is a stable trait throughout adulthood, suggesting that neurophysiological factors may underlie hypnotic responsiveness. One brain region of particular interest in functional neuroimaging studies of hypnotizability is the anterior cingulate cortex (ACC). Here, we examined the relationships between the neurochemicals, GABA, and glutamate, in the ACC and hypnotizability in healthy individuals. Participants underwent a magnetic resonance imaging (MRI) session, whereby T1-weighted anatomical and MEGA-PRESS spectroscopy scans were acquired. Voxel placement over the ACC was guided by a quantitative meta-analysis of functional neuroimaging studies of hypnosis. Hypnotizability was assessed using the Hypnotic Induction Profile (HIP), and self-report questionnaires to assess absorption (TAS), dissociation (DES), and negative affect were completed. ACC GABA concentration was positively associated with HIP scores such that the higher the GABA concentration, the more hypnotizable an individual. An exploratory analysis of questionnaire subscales revealed a negative relationship between glutamate and the absorption and imaginative involvement subscale of the DES. These results provide a putative neurobiological basis for individual differences in hypnotizability and can inform our understanding of treatment response to this growing psychotherapeutic tool.

Wrangling with p-values versus effect sizes to improve medical decision-making: A tutorial

The most pervasive and damaging myth in clinical research is that the smaller the p-value, the stronger the hypothesis. In reality, the p-value primarily reflects the quality of research design decisions. The most common proposal to avoid misleading conclusions from clinical research requires the appropriate use of effect sizes, but which effect size, used when and how, is an open question. A solution is proposed for perhaps the most common problem in clinical research, the comparison between two populations, for example, comparison of two treatments in a randomized clinical trial or comparison of high risk versus low risk individuals in an epidemiological study: the success rate difference or equivalently the number needed to treat/take (NNT).

Post-Traumatic Growth, Dissociation, and Sexual Revictimization in Female Childhood Sexual Abuse Survivors

BACKGROUND

Childhood sexual abuse (CSA) survivors are at high risk of sexual revictimization. At the same time, some survivors report positive transformations resulting from the traumatic experience, a phenomenon known as post-traumatic growth (PTG). Although one might expect PTG to be related to reduced risk of revictimization, the link between PTG and revictimization has not been investigated. Furthermore, mixed findings regarding the associations between PTG and distress imply that the effects of PTG are multifaceted. One potential explanation may be that dissociation shapes the implications of PTG, making it more like denial than adaptive processing of traumatic experience. This longitudinal study explores (a) the associations between PTG and sexual revictimization and (b) the moderating role of dissociation within the associations between PTG and revictimization.

METHOD

Participants were 111 female CSA survivors who participated in a 6-month efficacy trial evaluating the effectiveness of group psychotherapy for CSA survivors with HIV risk factors.

RESULTS

Dissociation moderated the associations between PTG and revictimization: Whereas PTG had nonsignificant effects on revictimization in participants with low dissociation, it predicted elevated levels of revictimization in participants with high dissociation.

CONCLUSIONS

Reports of PTG among some CSA survivors might mirror dissociative beliefs that increase their risk of revictimization.

A proof-of-principle study of the short-term effects of 3,4-methylenedioxymethamphetamine (MDMA) on tinnitus and neural connectivity

Background: This study was conducted to investigate the short-term behavioural and neurophysiological effects of 3,4-methylenedioxymethamphetamine (MDMA) on tinnitus perception.Methods: A double-blind randomized controlled cross-over design. Part 1. Behavioural measures of tinnitus following 30 mg MDMA or placebo administration (N = 5 participants) and Part 2. Behavioural measures of tinnitus and correlations between pairs of apriori regions of interest (ROI) using resting-state functional magnetic resonance imaging (rs-fMRI) before and after 70 mg of MDMA or placebo (N = 8 participants).Results: The results to MDMA were similar to placebo. For the 70 mg dose, there was a significant reduction after 4 h in annoyance and ignore ratings. RsMRI showed decreased connectivity compared with placebo administration between the left hippocampal, right hippocampal, left amygdala and right amygdala regions, and between the right posterior parahippocampal cortex and the left amygdala after two hours of 70 mg MDMA administration. Increased connectivity compared to placebo administration was found post MDMA between the right post-central gyrus and right posterior and superior temporal gyrus, and between the thalamus and frontoparietal network.Conclusions: Following 70 mg of MDMA two tinnitus rating scales significantly improved. There was, however, a placebo effect. Compared with placebo the rsMRI following the MDMA showed reductions in connectivity between the amygdala, hippocampus and parahippocampal gyrus. There is sufficient proof of concept to support future investigation of MDMA as a treatment for tinnitus.

Family-building decision aid and planning tool for young adult women after cancer treatment: protocol for preliminary testing of a web-based decision support intervention in a single-arm pilot study

INTRODUCTION

Many young adult female (YA-F) cancer survivors who received gonadotoxic therapy will experience fertility problems. After cancer, having a child will often require assisted reproductive technology (ART), surrogacy or adoption. However, there are significant informational, psychosocial, financial and logistical barriers to pursuing these options. Survivors report high rates of decision uncertainty and distress related to family-building decisions. The aim of this study is to pilot test a web-based decision aid and planning tool for family-building after cancer.

METHODS AND ANALYSIS

The pilot study will use a single-arm trial design to test the feasibility and acceptability (aim 1) and obtain effect size estimates of the decision support intervention (aim 2). The target sample size is 100. Participants will include YA-F survivors (aged 18-45 years) who are post-treatment and have not completed desired family-building. A longitudinal prepost design will be conducted. Participants will complete three psychosocial assessment surveys over a 3-month time period to track decisional conflict (primary outcome) and cognitive, emotional, and behavioural functioning (secondary outcomes). After completing the baseline survey (T1; pre-intervention), participants will have access to the decision aid website. Postintervention surveys will be administered at 1-month (T2) and 3-month (T3) follow-up time points. Feasibility and acceptability metrics will be analysed. Pairwise t-tests will test mean scores of outcome variables from T1 to T2. Effect size estimates (Cohen's d) will be calculated. Google analytics will evaluate user engagement with the website over the study period. Baseline and follow-up data will examine measures of feasibility, acceptability and intervention effect size.

ETHICS AND DISSEMINATION

This will be the first test of a supportive intervention to guide YA-F cancer survivors in family-building decisions and early planning. Study findings will inform intervention development. Future directions will include a randomised controlled trial to test intervention efficacy over a longer time period.

TRIAL REGISTRATION NUMBER

NCT04059237; Pre-results.

The Dissociative Subtype of PTSD Interview (DSP-I): Development and Psychometric Properties

The inclusion of the dissociative subtype of post-traumatic stress disorder (PTSD-DS) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reflects the importance of assessing PTSD-DS. We developed the Dissociative Subtype of PTSD Interview (DSP-I). This clinician-administered instrument assesses the presence and severity of PTSD-DS (i.e., symptoms of depersonalization or derealization) and contains a supplementary checklist that enables assessment and differentiation of other trauma-related dissociative symptoms (i.e., blanking out, emotional numbing, alterations in sensory perception, amnesia, and identity confusion). The psychometric properties were tested in 131 treatment-seeking individuals with PTSD and histories of multiple trauma, 17.6 % of whom met criteria for PTSD-DS in accordance with the DSP-I. The checklist was tested in 275 treatment-seeking individuals. Results showed the DSP-I to have high internal consistency, good convergent validity with PTSD-DS items of the CAPS-5, and good divergent validity with scales of somatization, anxiety and depression. The depersonalization and derealization scales were highly associated. Moreover, the DSP-I accounted for an additional variance in PTSD severity scores of 8% over and above the CAPS-5 and number of traumatic experiences. The dissociative experiences of the checklist were more strongly associated with scales of overall distress, somatization, depression, and anxiety than scales of depersonalization and derealization. In conclusion, the DSP-I appears to be a clinically relevant and psychometrically sound instrument that is valuable for use in clinical and research settings.

Trends in Cancer Survival by Health Insurance Status in California From 1997 to 2014

Importance

There have been substantial improvements in the early detection, treatment, and survival from cancer in the United States, but it is not clear to what extent patients with different types of health insurance have benefitted from these advancements.

Objective

To examine trends in cancer survival by health insurance status from January 1997 to December 2014.

Design, Setting, and Participants

California Cancer Registry (a statewide cancer surveillance system) data were used to estimate population-based survival by health insurance status in 3 calendar periods: January 1997 to December 2002, January 2003 to December 2008, and January 2009 to December 2014 with follow-up through 2014. Overall, 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma in California were included in the study.

Main Outcomes and Measures

Five-year all-cause and cancer-specific survival probabilities by insurance category and calendar period for each cancer site and sex; hazard ratios (HRs) and 95% CIs for each insurance category (none, Medicare, other public) compared with private insurance in each calendar period.

Results

According to data from 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma gathered from the California Cancer Registry, improvements in survival were almost exclusively limited to patients with private or Medicare insurance. For patients with other public or no insurance, survival was largely unchanged or declined. Relative to privately insured patients, cancer-specific mortality was higher in uninsured patients for all cancers except prostate, and disparities were largest from 2009 to 2014 for breast (HR, 1.72; 95% CI, 1.45-2.03), lung (men: HR, 1.18; 95% CI, 1.06-1.31 and women: HR, 1.32; 95% CI, 1.15-1.50), and colorectal cancer (women: HR, 1.30; 95% CI, 1.05-1.62). Mortality was also higher for patients with other public insurance for all cancers except lung, and disparities were largest from 2009 to 2014 for breast (HR, 1.25; 95% CI, 1.17-1.34), prostate (HR, 1.17; 95% CI, 1.04-1.31), and colorectal cancer (men: HR, 1.16; 95% CI, 1.08-1.23 and women: HR, 1.11; 95% CI, 1.03-1.20).

Conclusions and Relevance

After accounting for patient and clinical characteristics, survival disparities for men with prostate cancer and women with lung or colorectal cancer increased significantly over time, reflecting a lack of improvement in survival for patients with other public or no insurance. To mitigate these growing disparities, all patients with cancer need access to health insurance that covers all the necessary elements of health care, from prevention and early detection to timely treatment according to clinical guidelines.

Quantitative Sensory Testing (QST) Estimation of Regional Cutaneous Thermal Sensitivity During Waking State, Neutral Hypnosis, and Temperature Specific Suggestions

This study aimed to determine the effects of neutral hypnosis and hypnotic temperature suggestions in thermal and pain thresholds compared to resting state. Sixteen healthy medium or high hypnotizable volunteers were enrolled. Hypnotizability was assessed with the Hypnotic Induction Profile (HIP); QST was checked in resting state, in neutral hypnosis, after suggestions of heat and cold, and after deinduction. A significant increase in heat threshold was recorded during hypnosis with both cold and heat suggestions compared to neutral hypnosis. HIP induction score showed a linear correlation with changes of temperature thresholds after heat and cold suggestions. Thermal suggestions may result in a significant increase of heat perception thresholds with respect to neutral hypnosis. HIP score is related to thermal threshold changes. QST is a valuable and manageable tool to measure temperature threshold change during hypnosis.

Morning chronotype is a protective factor against chemotherapy-induced hot flashes in premenopausal women with breast cancer

PURPOSE

Adjuvant chemotherapy in patients with breast cancer often causes hot flashes, impairing quality of life. However, the chronobiological or psychiatric factors associated with the development of chemotherapy-induced hot flashes (CIHFs) remain undetermined. The purpose of this study was to investigate whether chronotype was associated with the incidence of CIHFs.

METHODS

A total of 119 premenopausal women with non-metastatic breast cancer awaiting adjuvant chemotherapy after surgery without hot flashes were included. The presence of CIHF was defined as having moderate to severe hot flashes, as measured by the subscale of hot flashes in the Menopause Rating Scale, at 4 weeks after the completion of chemotherapy. Chronotype (Morning/Intermediate/Evening) was assessed with the Composite Scale of Morningness before adjuvant chemotherapy. To examine the association between chronotype and CIHF, we built logistic regression models, adjusting for age, body mass index, sleep quality, and radiation therapy.

RESULTS

CIHF occurred in 50.4% of participants. Morning type was inversely associated with CIHF (reference: Intermediate type, odds ratio [OR], 0.37; 95% confidence interval [CI], 0.16-0.94; p = 0.040) in the univariate model, and the association remained significant (OR, 0.37; CI, 0.13-0.96; p = 0.045) after adjusting for age, body mass index, sleep quality, and radiation therapy.

CONCLUSIONS

Morning chronotype is a protective factor against the development of CIHF in patients with breast cancer. Chronotypes should be assessed and considered in the prediction and management of CIHF.

Reenacting Past Abuse - Identification with the Aggressor and Sexual Revictimization

Childhood sexual abuse (CSA) poses a risk for sexual revictimization. Additionally, according to theory CSA may lead to identification with the aggressor, expressed by adopting the perpetrator's experience concerning the abuse; identifying with the perpetrator's aggression; replacing one's agency with that of the perpetrator; and becoming hyper-sensitive to the perpetrator. Although clinical impressions suggest that identification with the aggressor underlies reenactment of trauma, this linkage between identification with the aggressor and sexual revictimization remains largely uninvestigated. This study assessed (a) the relationship between identification with the aggressor (total score and four subscales) and sexual revictimization; (b) the unique associations between identification with the aggressor (total score and four subscales) and sexual revictimization, above and beyond chronicity of abuse and PTSD symptoms. Participants were Israeli women students who reported a history of CSA (n = 174). Analyses indicated significant correlations between two subscales of identification with the aggressor - replacing one's agency with that of the perpetrator and becoming hyper-sensitive to the perpetrator - and sexual revictimization. These subscales of identification with the aggressor were associated with sexual revictimization, above and beyond the effects of chronicity of the abuse and PTSD symptoms. Nevertheless, these associations were in opposite directions - while replacing one's agency with that of the perpetrator was related with higher occurrence of sexual revictimization, becoming hyper-sensitive to the perpetrator was related with lower levels of revictimization. These results imply that identification with the aggressor may serve as a multifaceted phenomenon in the context of sexual revictimization, comprised of both adaptive and maladaptive aspects.

"Not just another meta-analysis": Sources of heterogeneity in psychosocial treatment effect on cancer survival

Background

Currently, there are eight meta‐analyses that address the question whether psychosocial intervention can prolong survival with widely disparate conclusions. One reason for inconsistent findings may be the methods by which previous meta‐analyses were conducted.

Methods

Databases were searched to identify valid randomized controlled trials that compared psychosocial intervention with usual care. Hazard ratios (HRs) and their confidence intervals were pooled to estimate the strength of the treatment effect on survival time, and z‐tests were performed to assess possible heterogeneity of effect sizes associated with different patient and treatment characteristics.

Results

Twelve trials involving 2439 cancer patients that met screening criteria were included. The overall effect favored the treatment group with a HR of 0.71 (95% Cl 0.58‐0.88; P = 0.002). An effect size favoring treatment group was observed in studies sampling lower vs higher percentage of married patients’ (NNT = 4.3 vs NNT = 15.4), when Cognitive‐Behavioral Therapy was applied at early vs late cancer stage (NNT = 2.3 vs NNT = −28.6), and among patients’ older vs younger than 50 (NNT = 4.2 vs NNT = −20.5).

Conclusions

Psychosocial interventions may have an important effect on survival. Reviewed interventions appear to be more effective in unmarried patients, patients who are older, and those with an early cancer stage who attend CBT. Limitations of previous meta‐analysis are discussed.

Circadian rest-activity rhythm as an objective biomarker of patient-reported outcomes in patients with advanced cancer

BACKGROUND

Psychosocial symptoms often cluster together, are refractory to treatment, and impair health-related quality of life (HR-QoL) in cancer patients. The contribution of circadian rhythm alterations to systemic symptoms has been overlooked in cancer, despite a causal link shown under jet lag and shift work conditions. We investigated whether the circadian rest-activity rhythm provides a reliable and objective estimate of the most frequent patient-reported outcome measures (PROMs).

METHODS

Two datasets were used, each involving concomitant 3-day time series of wrist actigraphy and HR-QoL questionnaires: EORTC QLQ-C30 was completed once by 237 patients with metastatic colorectal cancer; MD Anderson Symptom Inventory (MDASI) was completed daily by 31 patients with advanced cancer on continuous actigraphy monitoring, providing 1015 paired data points. Circadian function was assessed using the clinically validated dichotomy index I < O. Nonparametric tests compared PROMs and I < O. Effect sizes were computed. Sensitivity subgroup and temporal dynamics analyses were also performed.

RESULTS

I < O values were significantly lower with increasing symptom severity and worsening HR-QoL domains. Fatigue and anorexia were worse in patients with circadian disruption. The differences were both statistically and clinically significant (P < 0.001; d ≥ 0.33). Physical and social functioning, and global quality/enjoyment of life were significantly better in patients with robust circadian rhythm (P < 0.001; d ≥ 0.26). Sensitivity analyses validated these findings.

CONCLUSION

Objectively determined circadian disruption was consistently and robustly associated with clinically meaningfully severe fatigue, anorexia, and interference with physical and social functioning. This supports an important role of the circadian system in the determination of cancer patients' HR-QoL and symptoms that deserves therapeutic exploitation.

Brain Activity and Functional Connectivity Associated with Hypnosis

Hypnosis has proven clinical utility, yet changes in brain activity underlying the hypnotic state have not yet been fully identified. Previous research suggests that hypnosis is associated with decreased default mode network (DMN) activity and that high hypnotizability is associated with greater functional connectivity between the executive control network (ECN) and the salience network (SN). We used functional magnetic resonance imaging to investigate activity and functional connectivity among these three networks in hypnosis. We selected 57 of 545 healthy subjects with very high or low hypnotizability using two hypnotizability scales. All subjects underwent four conditions in the scanner: rest, memory retrieval, and two different hypnosis experiences guided by standard pre-recorded instructions in counterbalanced order. Seeds for the ECN, SN, and DMN were left and right dorsolateral prefrontal cortex, dorsal anterior cingulate cortex (dACC), and posterior cingulate cortex (PCC), respectively. During hypnosis there was reduced activity in the dACC, increased functional connectivity between the dorsolateral prefrontal cortex (DLPFC;ECN) and the insula in the SN, and reduced connectivity between the ECN (DLPFC) and the DMN (PCC). These changes in neural activity underlie the focused attention, enhanced somatic and emotional control, and lack of self-consciousness that characterizes hypnosis.

Racial and Ethnic Disparities in Cancer Survival: The Contribution of Tumor, Sociodemographic, Institutional, and Neighborhood Characteristics

Purpose Racial/ethnic disparities in cancer survival in the United States are well documented, but the underlying causes are not well understood. We quantified the contribution of tumor, treatment, hospital, sociodemographic, and neighborhood factors to racial/ethnic survival disparities in California. Materials and Methods California Cancer Registry data were used to estimate population-based cancer-specific survival for patients diagnosed with breast, prostate, colorectal, or lung cancer between 2000 and 2013 for each racial/ethnic group (non-Hispanic black, Hispanic, Asian American and Pacific Islander, and separately each for Chinese, Japanese, and Filipino) compared with non-Hispanic whites. The percentage contribution of factors to overall racial/ethnic survival disparities was estimated from a sequence of multivariable Cox proportional hazards models. Results In baseline models, black patients had the lowest survival for all cancer sites, and Asian American and Pacific Islander patients had the highest, compared with whites. Mediation analyses suggested that stage at diagnosis had the greatest influence on overall racial/ethnic survival disparities accounting for 24% of disparities in breast cancer, 24% in prostate cancer, and 16% to 30% in colorectal cancer. Neighborhood socioeconomic status was an important factor in all cancers, but only for black and Hispanic patients. The influence of marital status on racial/ethnic disparities was stronger in men than in women. Adjustment for all covariables explained approximately half of the overall survival disparities in breast, prostate, and colorectal cancer, but it explained only 15% to 40% of disparities in lung cancer. Conclusion Overall reductions in racial/ethnic survival disparities were driven largely by reductions for black compared with white patients. Stage at diagnosis had the largest effect on racial/ethnic survival disparities, but earlier detection would not entirely eliminate them. The influences of neighborhood socioeconomic status and marital status suggest that social determinants, support mechanisms, and access to health care are important contributing factors.

Advancing psychosocial care in cancer patients

Cancer is a devastating disease causing significant psychological problems among patients and their families. In the past few decades, there have been growing implementation and dissemination of screening methods for the psychological consequences of cancer, including distress, depression, anxiety, post-traumatic stress, and demoralisation. Also, guidelines for the management of psychological distress have been developed and endorsed by a number of scientific cancer associations. This review examines some of the most significant related issues, also focusing on recent advances in psychosocial and psychopharmacological interventions as a part of a mandatory, integrated, and comprehensive approach to cancer care.