Dropout from exercise trials among cancer survivors-An individual patient data meta-analysis from the POLARIS study

INTRODUCTION

The number of randomized controlled trials (RCTs) investigating the effects of exercise among cancer survivors has increased in recent years; however, participants dropping out of the trials are rarely described. The objective of the present study was to assess which combinations of participant and exercise program characteristics were associated with dropout from the exercise arms of RCTs among cancer survivors.

METHODS

This study used data collected in the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) study, an international database of RCTs investigating the effects of exercise among cancer survivors. Thirty-four exercise trials, with a total of 2467 patients without metastatic disease randomized to an exercise arm were included. Harmonized studies included a pre and a posttest, and participants were classified as dropouts when missing all assessments at the post-intervention test. Subgroups were identified with a conditional inference tree.

RESULTS

Overall, 9.6% of the participants dropped out. Five subgroups were identified in the conditional inference tree based on four significant associations with dropout. Most dropout was observed for participants with BMI >28.4 kg/m2 , performing supervised resistance or unsupervised mixed exercise (19.8% dropout) or had low-medium education and performed aerobic or supervised mixed exercise (13.5%). The lowest dropout was found for participants with BMI >28.4 kg/m2 and high education performing aerobic or supervised mixed exercise (5.1%), and participants with BMI ≤28.4 kg/m2 exercising during (5.2%) or post (9.5%) treatment.

CONCLUSIONS

There are several systematic differences between cancer survivors completing and dropping out from exercise trials, possibly affecting the external validity of exercise effects.

Abstract P6-12-01: Can exercise influence survival following breast cancer? Evidence from randomised, controlled trials

Background: The Exercise for Health (EfH) trials were randomized, controlled trials designed to evaluate an 8-month pragmatic, exercise intervention, commencing 6 weeks post-surgery for women with newly diagnosed breast cancer residing in urban- or rural/regional areas. Outcomes for these exploratory analyses were overall survival (OS), breast cancer-specific survival (BCS) and disease-free survival (DFS). Methods: Consenting urban-residing women (EfH 1, n=194) and rural/regional-residing women (EfH 2, n=143) were randomized to exercise or usual care. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for OS, BCS and DFS (exercise group, n=207, 65% urban women; usual care group, n=130, 46% urban women), with and without adjustment for prognostic factors including trial (urban/rural), age, body mass index, disease stage and presence of comorbidities. Further exploratory subgroup analyses were also conducted to assess whether effect on OS, BCS and DFS differed according to prognostic variables. Results: After a median follow-up of 8.3 years (IQR: 8.0-8.7 years) there were 11 (5.3%) deaths in the exercise group compared with 15 (11.5%) deaths in the usual care group (Table 1).

Table 1 Overall, breast cancer-specific and disease-free survival events by group allocation. All patientsUsual careExercise n=337n = 130n = 207 n (%)n (%)n (%)Breast cancer-related deaths20 (5.9)10 (7.7)10 (4.8)Non-breast cancer-related deaths6 (1.8)5 (3.8)1 (0.5)Overall survival events26 (7.7)15 (11.5)11 (5.3)Recurrence of breast cancer20 (5.9)8 (6.2)12 (5.8)Alive at follow-up9 (2.7)3 (2.3)6 (4.6)Deceased by follow-up11 (3.3)5 (3.1)6 (4.6)New primary breast cancer13 (3.9)5 (3.8)8 (3.9)Alive at follow-up13 (3.9)5 (3.8)8 (6.2)Deceased by follow-up0 (0.0)0 (0.0)0 (0.0)Disease-free survival events*48 (14.2)23 (17.7)25 (12.1)* Disease-free survival events include recurrence of breast cancer, new primary breast cancers, and all-cause deaths. Note that women who had recurrence and died before follow-up only count once towards disease-free survival events.

HRs for the exercise group were: OS: 0.45, 95% CI=0.20-0.96; p=0.04; BCS: 0.61, 95% CI=0.25-1.46, p=0.26; and DFS: 0.66, 95% CI=0.38-1.17; p=0.16 (adjusted analyses yielded similar results). With the exception of BCS for those with a body mass index >30, all HRs for subgroup analyses favored exercise, with effect on OS for women of younger age (<55), those with stage II+ disease, and those with 1+ comorbidity at baseline significant (p<0.05). Effect of exercise on DFS was also significant (p<0.05) for urban women. Conclusion: Findings suggest that an individually-prescribed and monitored exercise program integrated during and beyond treatment for breast cancer, and that was designed to cater for all women, irrespective of place of residence and access to health services, has clear potential to influence survival.

Citation Format: Hayes SC, Steele M, Spence R, Gordon L, Battistutta D, Bashford J, Pyke C, Saunders C, Eakin E. Can exercise influence survival following breast cancer? Evidence from randomised, controlled trials [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-01.

Exercise following breast cancer: exploratory survival analyses of two randomised, controlled trials

PURPOSE

The Exercise for Health trials were randomised, controlled trials designed to evaluate an 8-month pragmatic exercise intervention, commencing 6 weeks post-surgery for women with newly diagnosed breast cancer residing in urban or rural/regional Australia. For these exploratory analyses, the primary and secondary outcomes were overall survival (OS) and disease-free survival (DFS), respectively.

METHODS

Consenting urban- (n = 194) and rural/regional-residing women (n = 143) were randomised to exercise (intervention delivered face-to-face or by telephone) or usual care. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for survival outcomes (exercise group, n = 207, 65% urban women; usual care group, n = 130, 46% urban women).

RESULTS

After a median follow-up of 8.3 years, there were 11 (5.3%) deaths in the exercise group compared with 15 (11.5%) deaths in the usual care group (OS HR for the exercise group: 0.45, 95% CI 0.20-0.96; p = 0.04). DFS events for the exercise versus usual care group were 25 (12.1%) and 23 (17.7%), respectively (HR: 0.66, 95% CI 0.38-1.17; p = 0.16). HRs for OS favoured exercise irrespective of age, body mass index, stage of disease, intervention compliance, and physical activity levels at 12 months post-diagnosis, although were stronger (p < 0.05) for younger women, women with stage II + disease, women with 1 + comorbidity at time of diagnosis, higher intervention compliance and for those who met national physical activity guidelines at 12 months post-diagnosis.

CONCLUSION

An exercise intervention delivered during and beyond treatment for breast cancer, and that was designed to cater for all women irrespective of place of residence and access to health services, has clear potential to benefit survival. Trial numbers: ACT RN: 012606000233527; ACT RN: 12609000809235.

DOES TREATMENT ALLEVIATE LYMPHEDEMA SYMPTOMS? A CROSS-SECTIONAL STUDY EVALUATING PATIENT PERSPECTIVES

Most studies evaluating lymphedema treatment effect focus on objective reductions in limb volume, with little attention given to subjective treatment outcomes. The objective of this work was to describe the range of lymphedema symptoms experienced by patients and the importance of symptom improvement following treatment. The second aim was to explore lymphedema treatment use and the effect of individual treatments on symptoms, from the patient's perspective. Australian adults with lymphedema (n = 421) completed a self-administered questionnaire. Information was collected about patients' symptoms, the importance of symptom improvement following treatment, as well as treatment types used and perceived effectiveness of each treatment. In addition to swelling, the vast majority of participants experienced heaviness and tightness in the affected region. Overall, symptoms of lymphedema varied between individuals but the majority considered subjective symptom improvement to be an important outcome of treatment. The most commonly used treatments were compression garments, self- massage, prescribed exercises, and manual lymph drainage, and the majority (95%) of participants had used multiple treatments to manage their lymphedema. The impact of treatments on subjective symptoms varies widely between treatments. Consequently, in addition to objective measures of swelling, it is important to include patient-reported outcomes in future prospective lymphedema treatment studies.

EFFECTS OF COMPRESSION ON LYMPHEDEMA DURING RESISTANCE EXERCISE IN WOMEN WITH BREAST CANCER-RELATED LYMPHEDEMA: A RANDOMIZED, CROSS-OVER TRIAL

The use of compression garments during exercise is recommended for women with breast cancer-related lymphedema, but the evidence behind this clinical recommendation is unclear. The aim of this randomized, cross-over trial was to compare the acute effects of wearing versus not wearing compression during a single bout of moderate-load resistance exercise on lymphedema status and its associated symptoms in women with breast cancer-related lymphedema (BCRL). Twenty-five women with clinically diagnosed, stable unilateral breast cancer-related lymphedema completed two resistance exercise sessions, one with compression and one without, in a randomized order separated by a minimum 6 day wash-out period. The resistance exercise session consisted of six upper-body exercises, with each exercise performed for three sets at a moderate-load (10-12 repetition maximum). Primary outcome was lymphedema, assessed using bioimpedance spectroscopy (L-Dex score). Secondary outcomes were lymphedema as assessed by arm circumferences (percent inter-limb difference and sum-of-circumferences), and symptom severity for pain, heaviness and tightness, measured using visual analogue scales. Measurements were taken pre-, immediately post- and 24 hours post-exercise. There was no difference in lymphedema status (i.e., L-Dex scores) pre- and post-exercise sessions or between the compression and non-compression condition [Mean (SD) for compression pre-, immediately post- and 24 hours post-exercise: 17.7 (21.5), 12.7 (16.2) and 14.1 (16.7), respectively; no compression: 15.3 (18.3), 15.3 (17.8), and 13.4 (16.1), respectively]. Circumference values and symptom severity were stable across time and treatment condition. An acute bout of moderate-load, upper-body resistance exercise performed in the absence of compression does not exacerbate lymphedema in women with BCRL.

A Monte Carlo study of the effect of coded-aperture material and thickness on neutron imaging

In this paper, a coded-aperture design for a scintillator-based neutron imaging system has been simulated using a series of Monte Carlo simulations. Using Monte Carlo simulations, work to optimise a system making use of the EJ-426 neutron scintillator detector has been conducted. This type of scintillator has a low sensitivity to gamma rays and is therefore particularly useful for neutron detection in a mixed radiation environment. Simulations have been conducted using varying coded-aperture materials and different coded-aperture thicknesses. From this, neutron images have been produced, compared qualitatively and quantitatively for each case to find the best material for the MURA (modified uniformly redundant array) pattern. The neutron images generated also allow observations on how differing thicknesses of coded-aperture impact the system.

Protocol analysis and the "silent dog" method of analyzing the impact of self-generated rules

Within the cognitive literature, verbal protocols of cognitive events are plagued by difficult questions of unconsciousness, completeness, reactivity, and validity. In this paper we argue that these concerns apply with much less force or not at all when protocol analysis is used to determine whether a given instance of behavior is governed by self-generated rules. When adequate controls are used, some patterns of results allow this question to be answered unambiguously and in a manner untouched by the philosophical hurdles encountered within the cognitive literature on protocol analysis. We argue that in at least some circumstances a slightly modified version of protocol analysis allows us to know, in a functional sense, what a person was thinking. Protocol analysis can be very useful to behavior analysts who are interested in determining whether task-relevant behavior is controlled by self-generated rules or is purely contingency shaped.

Theory and technology in behavior analysis

The differences within behaviorism in general and behavior analysis in particular have been described in many ways. Some of the more common distinctions are "basic versus applied", "clinical versus non-clinical", "behavior therapy versus behavior analysis", and "experimental analysis of behavior versus applied behavior analysis". These and other such distinctions do not seem to refer to truely important differences, or refer to important differences in confusing ways. It is suggested that there are two main dimensions which divide behaviorists into meaningful units: the type of paradigm (behavior analysis versus methodological behaviorism) and the level of analysis (technical, methodological, conceptual, or philosophical). By considering these two dimensions a number of issues in the field are recast. In particular, many of the differences within behavior analysis are recast into questions of the relationship between theory and technology.

Acceptance and commitment therapy: Altering the verbal support for experiential avoidance

Acceptance and Commitment Therapy (ACT) is a behavior-analytically-based psychotherapy approach that attempts to undermine emotional avoidance and increase the capacity for behavior change. An overview of this approach is given, followed by several specific examples of the techniques used within ACT. In each instance the behavioral rationale of these techniques is described. A contemporary view of verbal relations provides the basis for new approaches to adult outpatient psychotherapy.

Moral behavior and the development of verbal regulation

The present paper examines the relationship between the development of moral behavior and the development of verbal regulatory processes. Relational frame theory and the distinctions among pliance, tracking, and augmenting forms of rule governance are applied to the domain of moral behavior and its development, in order to identify the specific social and verbal contingencies that are responsible for an evolving moral repertoire. It is argued that moral behavior is controlled by relational and rule-following repertoires, and that these can be arranged into a rough progression: pliance, tracking, augmenting, social concern for pliance, social concern for tracking, and social concern for augmenting. Congruence with data derived from other research traditions is examined, and applied implications are explored.

Mentalism, behavior-behavior relations, and a behavior-analytic view of the purposes of science

In a behavioral view, the purposes of science are primarily prediction and control. To the extent that a scientist embraces both of these as a unified and generally applicable criterion for science, certain philosophical and theoretical practices are counterproductive, including mentalism in both its metaphysical and metatheoretical forms. It is possible and often worthwhile to recast some mentalistic talk into an issue of behavior-behavior relations. When behavior-behavior relations are approached non-mechanistically, however, analysis cannot stop at the level of the relations themselves. Several analytic concepts common in the behavioral community share some of the dangers of mentalism if not employed properly, including such concepts as self-reinforcement, response-produced stimulation, and self-rules.

Why it is crucial to understand thinking and feeling: An analysis and application to drug abuse

Behavior analysis has long accepted the legitimacy of the analysis of private events in a natural science of behavior. However, the topic has languished as a focus of empirical research in either applied or basic arenas. We argue that recent empirical work examining the bidirectional nature of verbal relations may shed light on the role of private events in complex human behavior. Skinner argued that although it would be possible to analyze private events, we need not, because thoughts and feelings were viewed as co-occuring products of the same contingencies that are responsible for changes in overt responses. However, the bidirectional transformation of stimulus function inherent in verbal behavior changes the way that private events participate in complex behavioral episodes for verbal organisms. We examine why we have reached such a conclusion, with special emphasis on the role of self-awareness. Finally, we conclude with an application of our analysis to the problem of substance abuse.

A self-capitalization model for building behavior analysis graduate programs

The development of the Behavior Analysis Program at the University of Nevada through self-capitalization is described. With this model, both doctoral and master's degree programs were established at almost no cost to the university. Some of the problems encountered along the way, including gaining support for the original proposal, attracting and retaining high-quality faculty, engendering support from the Department of Psychology and the university, developing resources, and balancing academic with entrepreneurial demands are discussed, as are the solutions we have found for those problems.

Psychological flexibility and the gains of acceptance-based treatment for post-bariatric surgery: six-month follow-up and a test of the underlying model

Research highlights •  Bariatric surgery is associated with dramatic weight loss. •  Follow-up studies show that many surgery patients continue to struggle with self-stigma, body dissatisfaction and emotional eating. •  To date we are aware of only three published randomized controlled trials evaluating psychological interventions in combination with bariatric surgery. •  Acceptance and Commitment Therapy (ACT) targets psychological flexibility: acceptance to have difficult feelings and thoughts, while at the same time engaging in vital healthy activities. •  The present study shows significant improvements in the ACT group as compared with (TAU) after treatment as usual at a 6-month follow-up and shows that the mechanism of change may be psychological flexibility. •  Results from this study indicate the possibility of optimizing bariatric surgery outcomes by adding interventions targeting psychological flexibility.

SUMMARY

The current article presents and evaluates an Acceptance and Commitment Therapy (ACT) approach for obesity-related psychological struggles post-bariatric surgery. Some patients who have undergone bariatric surgery report loss of control over eating and distress concerning body figure and shape, which can affect other outcomes such as weight loss and quality of life post surgery. A recent randomized trial (n = 39) evaluating a 6-week treatment package of ACT following bariatric surgery found large and significant effects as compared with treatment as usual (TAU) on eating disordered behaviours, body dissatisfaction, psychological flexibility and quality of life. Though effects were found, questions remain regarding maintenance of outcomes and the process changes related to outcomes. The present study examines both the maintenance of behavioural change at a 6-month follow-up for the original study and the processes that may be involved in the outcomes. ACT led to gains in quality of life (es = 0.88) and body dissatisfaction (es = 0.77), as compared with TAU at follow-up. Both groups improved in eating disordered behaviours (ACT; es = 0.86 and TAU; es = 0.55). A series of multiple mediator tests supported the role of enhanced psychological flexibility in the changes seen in body dissatisfaction, eating disordered behaviour and quality of life. This study provides preliminary support for the ACT treatment model in terms of optimizing bariatric surgery outcomes.

UV resonance Raman study of TTR(105-115) structural evolution as a function of temperature

UV resonance Raman spectroscopy was used to probe the temperature dependence of the conformation of TTR(105-115) in solution. Resonance Raman spectra with excitation at 239.5 nm, show an increase in the absolute resonance Raman cross section of Tyr with an increase in temperature. This trend is associated with an increase in the hydrophobicity of the Tyr local environment, suggesting a conformational change at 28 °C. Excitation at ~200 nm is known to enhance scattering due to amide vibrations and provides insights as to the secondary structure of a peptide or protein. UVRR spectra at this excitation suggest that in solution the peptide assumes a disordered conformation with frequent formation of β-turns. Explicit-solvent replica-exchange MD simulations of the isolated peptide in the region 15 to 37 °C suggest that the dominant conformation assumed by the peptide corresponds to a coil with β-turns in the central and C-terminal region. In line with the experiments, an increase in temperature induces structural order in the peptide, reflected by an increase in the probability for the formation of β-turns and hydrophobic side-chain contacts, mainly in the 8-11 moiety, and to a lesser extent in the 4-7 moiety.

Abstract PD08-08: Exercise for Health: A Randomised, Controlled Trial of an Exercise Intervention for Women with Breast Cancer — Effect on Upper-Body Function

Background: Impairments in upper-body function are common during and following breast cancer and may persist into long-term survivorship. An objective of the Exercise for Health program was to assess the effect participation in an 8 month exercise program (initiated 6 weeks after breast cancer surgery) has on upper-body function and associated symptoms.

Methods: Women residing in an Australian metropolitan city and diagnosed with invasive breast cancer were eligible to participate in this randomised, controlled trial. Consenting women were allocated to either a face-to-face delivered exercise group (FG, n=67), a telephone-delivered exercise group (TG, n=67) or a usual-care group (UG, n=60). At 6 weeks (pre-intervention), 6 months (mid-intervention) and 12 months (postintervention) after surgery upper-body function was assessed via self-report using the Disability of the Arm, Shoulder and Hand questionnaire and clinically using an incremental maximal upper-body strength test. The presence and severity of upper-body symptoms such as pain, weakness and numbness were assessed using a 5-point Likert scale, while lymphoedema was measured clinically using bioimpedance spectroscopy.

Results: Women in the exercise intervention groups reported greater improvements (p=0.02) in perceived upper-body function (indicated by negative scores) between 6 weeks and 6 months post-surgery, (FG, mean=-6.3; TG, mean=-11.9) when compared to changes observed in the UG (mean=-4.2) and maintained these improvements by 12-months PS. Similar findings were observed for clinically measured upper-body function (P&lt;0.01). At 12 months post-surgery, those in the UG were 1.5 times more likely to report at least one moderate to severe upper-body function symptom. The number of lymphoedema cases did not differ between the groups at mid-or post-intervention.

Discussion: These results demonstrate that exercise interventions, delivered over the phone or face-to-face, can facilitate improvements in upper-body function during and following breast cancer treatment without adversely increasing risk of developing lymphoedema or other arm-related symptoms. This is particularly important since function is directly associated with a woman's ability to carry out daily tasks and has been shown to predict quality of life.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD08-08.

Abstract P2-14-03: Does the Mode of Delivering an Exercise Intervention Following Breast Cancer Influence Effect on Quality of Life? Results from a Randomized, Controlled Trial

Background: Participating in an exercise intervention during and following breast cancer has been associated with a range of physical and psychosocial benefits that ultimately improve quality of life. However, studies that have demonstrated such effects have largely assessed the effect of clinic-based interventions in well-controlled settings. Questions remain whether a more ‘pragmatic’ exercise intervention could influence quality of life and whether the manner by which the intervention is delivered would influence effect?

Methods: Exercise for Health is a randomized, controlled trial of an eight-month, exercise intervention delivered face-to-face or over the telephone, over 16 sessions with a qualified Exercise Physiologist. Women from urban areas of Queensland diagnosed with unilateral breast cancer in 2006/2007 were eligible to participate and were allocated to either the face-to-face group (FG; n=67), the telephone group (TG; n=67), or the usual-care group (UG; n=60). Quality of life was assessed using the Functional Assessment of Cancer Therapy-Breast questionnaire (FACT-B+4) at six weeks (pre-intervention), six months (mid-intervention) and 12 months (three months post-intervention) post-surgery. Repeated measures analysis of variance was used to assess time and group effects and the potential for an age by group interaction. Differences over time or between groups of at least eight points reflect a clinically meaningful difference and data was analyzed using intention-to-treat principles.

Results: Pre-, mid-and post-intervention, younger (&lt;50 years) breast cancer survivors reported lower QoL when compared with older women (50+ years), however differences were only clinically relevant pre-intervention (mean, 112.6 vs. 120.9). While all women experienced improvements in QoL overtime, only those in the FG and TG experienced improvements of clinical and statistical significance. For younger women, the mode of delivery did not influence effect of the intervention on QoL (mean QoL mid-intervention: 122.3 and 123.2 for FG and TG, respectively; mean QoL post-intervention: 127.9 and 128.9, respectively). However, there was preliminary evidence to suggest that older women responded better to exercise advice delivered over the phone with the TG reporting the highest levels of QoL mid-and post-intervention (128.7 and 130.2, respectively) compared with the FG (118.8 and 124.4, respectively). Discussion: This work demonstrates that an exercise intervention designed to be delivered in the real-world setting can optimize QoL during and following treatment for breast cancer. Results also suggest that the telephone may be an effective medium for delivering exercise counseling. This is particularly important for women living in more rural areas who may have limited access to specialist services and also has potential cost-benefits over face-to-face or clinic-based delivery modes.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-14-03.

Prevalence of upper-body symptoms following breast cancer and its relationship with upper-body function and lymphedema

This investigation describes the prevalence of upper-body symptoms in a population-based sample of women with breast cancer (BC) and examines their relationships with upper-body function (UBF) and lymphedema, as two clinically important sequelae. Australian women (n=287) with unilateral BC were assessed at three-monthly intervals, from six to 18 months post-surgery (PS). Participants reported the presence and intensity of upper-body symptoms on the treated side. Objective and self-reported UBF and lymphedema (bioimpedance spectroscopy) were also assessed. Approximately 50% of women reported at least one moderate-to-extreme symptom at 6- and at 18-months PS. There was a significant relationship between symptoms and function (p < 0.01), whereby perceived and objective function declined with increasing number of symptoms present. Those with lymphedema were more likely to report multiple symptoms, and presence of symptoms at baseline was associated with an increased risk of lymphedema (ORs > 1.3, p = 0.02), although presence of symptoms explained only 5.5% of the variation in the odds for lymphedema. Upper-body symptoms are common and persistent following breast cancer and are associated with clinical ramifications, including reduced UBF and increased risk of developing lymphedema. However, using the presence of symptoms as a diagnostic indicator or prognosticator of lymphedema has its limitations.

Transfer of a conditional ordering response through conditional equivalence classes

Eight adult humans were taught conditional discriminations in a matching-to-sample format that led to the formation of two four-member equivalence classes. When subjects were taught to select one comparison stimulus from each class in a set order, they then ordered all other members of the equivalence classes without explicit training. When the ordering response itself was brought under conditional control, conditional sequencing also transferred to all other members of the two equivalence classes. When the conditional discriminations in the matching-to-sample task were brought under higher order conditional control, the eight stimulus members were arranged into four conditional equivalence classes. Both ordering and conditional ordering transferred to all members of the four conditional equivalence classes; for some subjects this occurred without a typical test for equivalence. One hundred twenty untrained sequences emerged from eight trained sequences for all subjects. Transfer of functions through equivalence classes may contribute to a behavior-analytic approach to semantics and generative grammar.

The marked item technique: a practical procedure for litter control

Unobtrusively marked items of litter were placed among existing trash on the grounds of a federal youth correctional facility. Inmates voluntarily collected trash and deposited it at a central location, where they were given money or special privileges for each piece of marked litter found. A multiple-baseline design with litter counts in three areas revealed successive reductions of 55%, 88%, and 71% after 17, 22, and 36 days of baseline, respectively. A fourth area served as a baseline-only control, and revealed no systematic changes. Advantages of the procedure over previously devised techniques were discussed and applications in other areas of pollution control suggested.

Reducing residential electrical energy use: payments, information, and feedback

Monetary payments, energy information, and daily feedback on consumption were employed to reduce electricity use in four units of a university student housing complex. A combined multiple-baseline and withdrawal design permitted both within- and between-unit comparisons. Payments produced immediate and substantial reductions in consumption in all units, even when the magnitude of the payments was reduced considerably. Feedback also produced reductions, but information about ways to conserve and about the cost of using various appliances did not. It was also found that, in general, payments combined with either information or feedback produced no greater effect than payments alone.

Rule-governed behavior and sensitivity to changing consequences of responding

Humans were presented with a task that required moving a light through a matrix. Button presses could produce light movements according to a multiple fixed-ratio 18/differential-reinforcement-of-low-rate 6-s schedule, with components alternating every 2 min. Moving the light through the maze earned points worth chances on money prizes. In Experiment 1 four conditions were assessed through between-subject comparisons: minimal instructions, instructions to press rapidly, instructions to press slowly, and instructions that sometimes rapid responding would work while at other times a slow rate would work best. Subjects responded in three successive sessions of 32 min each. The results suggested that instructions affected the nature of the contact made with the programmed consequences and thus subsequent performance. In some cases, responding seemed to result from added contingencies introduced by stating rules. In Experiment 2 the relative contribution of these two effects was assessed by presenting and then withdrawing two lights that had been paired with two specific instructions: "Go Fast" or "Go Slow." There were three conditions. In one condition, only the Go Fast light was on; in a second, only the Go Slow light was on; and in a third, the lights alternated each minute. In each condition, half the subjects had all instruction lights turned off after the first session. The results once again showed an effect of instructions on contact with the programmed consequences. However, responding sometimes continued in a manner consistent with added contingencies for rule-following even when the programmed consequences had been contacted and would have controlled a different type of responding in the absence of instructions. The relevance of added contingencies for rule-following in determining the effects of explicitly programmed consequences is emphasized.

Reduction of residential consumption of electricity through simple monthly feedback

Feedback has been widely used in efforts to control the consumption of electricity. Previous efforts, however, have used forms of feedback that seem economically impractical. The present study examined the effects of a feasible program of monthly feedback. Forty matched nonvolunteer participants were randomly divided into two groups: a no-contact control group and a monthly feedback group. In an A-B-A design, the data showed a clear decrease in electricity consumption for the feedback group during the feedback phase. The effect was maintained during a 4-mo intervention period. Withdrawal of the feedback was associated with a return to higher levels of electricity consumption.

Nonhumans have not yet shown stimulus equivalence

Recently, two published articles have reported finding stimulus equivalence in nonhumans. One suggested that equivalence was due to the mediation of names. The procedure used trained all components of all tested relations. Because nothing was derived, the defining characteristics of equivalence were not achieved. In the second study a definition of equivalence was proposed that fails to distinguish functional stimulus classes from equivalence classes. The resulting data are not clearly relevant to stimulus equivalence in Sidman's sense of the term. Stimulus equivalence has not yet been shown in nonhumans.

Instructions, multiple schedules, and extinction: Distinguishing rule-governed from schedule-controlled behavior

Schedule sensitivity has usually been examined either through a multiple schedule or through changes in schedules after steady-state responding has been established. This study compared the effects of these two procedures when various instructions were given. Fifty-five college students responded in two 32-min sessions under a multiple fixed-ratio 18/differential-reinforcement-of-low-rate 6-s schedule, followed by one session of extinction. Some subjects received no instructions regarding the appropriate rates of responding, whereas others received instructions to respond slowly, rapidly, or both. Relative to the schedule in operation, the instructions were minimal, partially inaccurate, or accurate. When there was little schedule sensitivity in the multiple schedule, there was little in extinction. When apparently schedule-sensitive responding occurred in the multiple schedule, however, sensitivity in extinction occurred only if differential responding in the multiple schedule could not be due to rules supplied by the experimenter. This evidence shows that rule-governed behavior that occurs in the form of schedule-sensitive behavior may not in fact become schedule-sensitive even though it makes contact with the scheduled reinforcers.

The transfer of specific and general consequential functions through simple and conditional equivalence relations

The purpose of this study was to examine the transfer of consequential (reinforcement and punishment) functions through equivalence relations. In Experiment 1, 9 subjects acquired three three-member equivalence classes through matching-to-sample training using arbitrary visual forms. Comparison stimuli were then given conditioned reinforcement or punishment functions by pairing them with verbal feedback during a sorting task. For 8 of the 9 subjects, trained consequential functions transferred through their respective equivalence classes without additional training. In Experiment 2, transfer of function was initially tested before equivalence testing per se. Three of 4 subjects showed the transfer without a formal equivalence test. In Experiment 3, 3 subjects were given training that gave rise to six new three-member conditional equivalence classes. For 2 of the subjects, the same stimulus could have either a reinforcement or punishment function on the basis of contextual cues that defined its class membership. Experiment 4 assessed whether equivalence training had established general or specific consequential functions primarily by adding novel stimuli in the transfer test. Subjects treated even novel feedback stimuli in the transfer test as consequences, but the direction of consequential effects depended upon the transfer of specific consequential functions through equivalence relations.

The nature of behavioral assessment: A commentary

This special issue of the Journal of Applied Behavior Analysis provides the reader with a sample of current work in behavioral assessment. The purpose of this paper is to present an overview of behavioral assessment and to place the other articles in context of this developing area.

The technical drift of applied behavior analysis

Four dimensions (applied, analytic, general, conceptual) were selected from Baer, Wolf, and Risley's (1968) seminal article on the nature of applied behavior analysis and were monitored throughout the first 10 volumes of the Journal of Applied Behavior Analysis. Each of the experimental articles in Volumes 1 through 6 and the first half of Volumes 7 through 10 was rated on each of these dimensions. The trends showed that applied behavior analysis is becoming a more purely technical effort, with less interest in conceptual questions. We are using simpler experimental designs and are conducting fewer analogue studies. Although concern for maintenance is increasing, other forms of generality are being measured or analyzed less often. These trends are discussed in terms of a technical drift in applied behavior analysis.

Escape from freedom: Choosing not to choose in pigeons

Preference for the availability of food-reinforcement alternatives was investigated with Rachlin and Green's (1972) concurrent-chains self-control paradigm. The terminal link of one chain made available a choice between immediate access to food for T seconds and delayed access to food for 4 seconds. The terminal link of the other chain provided only delayed access to food. When T was reduced to .25 seconds, pigeons began to select the delayed-access key in both terminal links. Even so, the pigeons strongly preferred constraint over choice. This effect could not be accounted for by differences in the actual amount of food obtained in the terminal links, by avoidance of the immediate-reinforcement key when not presented as part of a choice, or by avoidance of a multi-key terminal link. Rather, constraint was preferred over freedom. Apparently, the preference for choice is determined by the particular type of choice offered.

Stimulus equivalence and rule following

The present study examined the occurrence of a novel behavior pattern with respect to a novel configuration of stimuli enabled by the participation of those stimuli in equivalence classes. In Experiment 1, functional substitutabilities were established via equivalence between two independent sets of musical stimuli. Aspects of stimuli from the two sets were then compounded to produce novel stimulus configurations. Behavioral components enabled by each separate class combined to produce novel musical performances and accurate descriptions of them. In Experiment 2, the impact of experimenter-provided names for equivalence classes on the musical performances was investigated in naive subjects by establishing similar classes without experimenter-provided names. The results indicated few differences in the playing performances under these conditions. These experiments demonstrated a possible method for the analysis of rule following.

Self-reinforcement effects: An artifact of social standard setting?

Two studies were conducted to identify mechanisms responsible for observed "self-reinforcement" effects. In Experiment 1, using a studying task, self-reinforcement procedures did not work when they were private (i.e., when others are not aware of the goals or contingencies), but did work when they were public. Self-delivery of consequences added nothing to the effectiveness of the procedure. The data suggested that public goal setting was the critical element in the procedure's effectiveness. In Experiment 2, an applied extension, goal setting alone was effective in modifying over a long time period studying behaviors of people with significant studying difficulties, but only when the goals were known to others. Overall, the two experiments make more plausible the view that self-reinforcement procedures work by setting a socially available standard against which performance can be evaluated. The procedure itself functions as a discriminative stimulus for stringent or lenient social contingencies. The application of this mechanism to other problems of applied significance is briefly discussed.

Does quality of life among breast cancer survivors one year after diagnosis differ depending on urban and non-urban residence? A comparative study

BACKGROUND

This study examined the quality of life (QOL), measured by the Functional Assessment of Cancer Therapy (FACT) questionnaire, among urban (n = 277) and non-urban (n = 323) breast cancer survivors and women from the general population (n = 1140) in Queensland, Australia.

METHODS

Population-based samples of breast cancer survivors aged < 75 years who were 12 months post-diagnosis and similarly-aged women from the general population were recruited between 2002 and 2007.

RESULTS

Age-adjusted QOL among urban and non-urban breast cancer survivors was similar, although QOL related to breast cancer concerns was the weakest domain and was lower among non-urban survivors than their urban counterparts (36.8 versus 40.4, P < 0.01). Irrespective of residence, breast cancer survivors, on average, reported comparable scores on most QOL scales as their general population peers, although physical well-being was significantly lower among non-urban survivors (versus the general population, P < 0.01). Overall, around 20%-33% of survivors experienced lower QOL than peers without the disease. The odds of reporting QOL below normative levels were increased more than two-fold for those who experienced complications following surgery, reported upper-body problems, had higher perceived stress levels and/or a poor perception of handling stress (P < 0.01 for all).

CONCLUSIONS

Results can be used to identify subgroups of women at risk of low QOL and to inform components of tailored recovery interventions to optimize QOL for these women following cancer treatment.

Mental illness and intellectual disability in Magistrates Courts in New South Wales, Australia

BACKGROUND

Little is known about the prevalence of intellectual disability (ID) and/or cognitive impairment (CI) among accused persons in the Magistrates (Local) Courts, the personal, health and mental health characteristics of this cohort, and their service provision needs in the community. The study aimed to determine the prevalence of dual diagnoses of ID and/or CI and psychiatric disorder in a sample of accused persons appearing before four Magistrates Courts. Accused persons with ID and/or CI may not be identified in the Magistrates Court as having a disability and therefore may be unable to access the legal safeguards which exist for their protection within the criminal justice system and/or may fail to receive appropriate community health and welfare services.

METHOD

The sample was drawn from accused persons aged over 18 years appearing before four Magistrates Courts in metropolitan and urban areas of a large city. Participants were assessed using the Kaufman Brief Intelligence Test, Second Edition (KBIT-2), Vineland Adaptive Behavior Scales, Second Edition (VABS2) and the Psychiatric Assessment Schedules for Adults with Developmental Disabilities Checklist.

RESULTS

On the KBIT-2, 10% of participants achieved a standard score (SS) below 70 (mild ID range) and a further 20% were in the 70-79 (borderline) range. The VABS2 results indicated that 12% of participants had SS below 70 and a further 9% were in the 70-79 (borderline) range. The prevalence of mental illness in the group with intellectual deficits was 46%, compared with a prevalence of 36% for those without intellectual deficits.

CONCLUSIONS

People with ID and/or CI were found to be over-represented in the Magistrates Court. Furthermore, results highlight the unmet mental health needs of this cohort in the criminal justice system. The results of the study have implications for the planning of services and diversionary options to facilitate better management of defendants with ID and/or CI with mental health needs.

Treatment for upper-limb and lower-limb lymphedema by professionals specializing in lymphedema care

Up to 60% of patients with cancer of the vulva, and between 20 and 30% of patients with breast or abdominal cancers may develop lymphedema following treatment. The aims of this study were to assess health professionals' knowledge about treatment, diagnostic procedures, advice and confidence in treatment of patients with either upper-limb (ULL) or lower-limb lymphoedema (LLL), and whether these differed by health professionals' background or for patients with ULL compared with LLL. A cross-sectional telephone interview was undertaken in 2006, of 63 health professionals (response rate 92.6%) known to treat lymphedema. Sixty-three per cent of the health professionals were physiotherapists; the majority were university-trained, with 20 years' experience or more. Ninety-five per cent of health professionals used circumferential measurements to establish lymphedema status, and most health professionals advised avoiding scratches and cuts (100%), insect bites (98.4%), sunburn (98.4%) and excessive exercise (65.1%) on the affected limb. Health professionals reported that compared with patients with LLL, patients with ULL were more likely to present within the first 3 months of being symptomatic (P < 0.01). Patients with LLL were more likely to present with swelling (P = 0.001), heaviness (P = 0.003), tightness (P = 0.007) and skin problems (P < 0.001) compared with patients with ULL. Treatment and advice differed according to health professionals' background, but not location of lymphedema (ULL vs. LLL). Assessment, treatment and advice for lymphedema vary across professional groups. Our results suggest that improvements should be attempted in the early detection of lymphedema, in particular of LLL among cancer patients.

Role of a mixed type, moderate intensity exercise programme after peripheral blood stem cell transplantation

OBJECTIVES

To evaluate the effect of peripheral blood stem cell transplantation on functional capacity, and to determine the role of a mixed type, moderate intensity exercise programme in the recovery of patients after intensive cancer treatment.

METHODS

Peak aerobic capacity and muscular strength (upper body, lower body, and handgrip strength) measures were assessed before (PI) and after (PII) transplant and after a 12 week intervention period (PIII). After PII, 12 patients aged 16-64 years were allotted in equal numbers to a control group or exercise intervention group.

RESULTS

Mean peak aerobic capacity and muscular strength were reduced after the transplant, with significant (p<0.05) decreases for upper body strength. No change was found in aerobic capacity and muscular strength between PII and PIII for the control group. In contrast, participation in the exercise programme led to significant improvements in peak aerobic capacity (p<0.05) and upper and lower body strength (p<0.01). In addition, values recorded after the three month intervention period were significantly higher than before treatment for peak aerobic capacity (litres/min (p<0.05) and ml/kg/min (p<0.01)) and lower body strength (p<0.01).

CONCLUSION

Intensive treatment for cancer can adversely affect aerobic capacity and muscular strength. A mixed type, moderate intensity exercise programme can help patients to regain fitness and strength within three months. No exercise can exacerbate physical losses resulting from treatment.

Assessing task "burden" of daily activities requiring upper body function among women following breast cancer treatment

GOALS OF WORK

To determine which individual or groups of "upper-body" daily tasks are considered most burdensome to women following breast cancer treatment, and to assess whether certain patient or treatment characteristics influence task burden.

PATIENTS AND METHODS

A convenience sample of breast cancer survivors (n =619) completed a self-administered questionnaire regarding 48 daily tasks requiring upper-body function. Women were asked to rate how frequent and physically demanding each task was using a five-point Likert scale, and the product of task frequency and physical demand determined overall task burden. Tasks were ranked to identify the most burdensome individual tasks, while a factor analysis was performed to define independent constructs (groupings) among the tasks. Multiple linear regression models were fitted to consider the independent influences on task groups of various participant characteristics.

MAIN RESULTS

Factor analysis identified seven distinct task groups and the individual tasks considered most burdensome fell in five of these groups, specifically whole body, flexibility, carrying/upper-body strength, hand and weighted flexion tasks. Having lymphoedema or poor fitness was associated with upper-body disability involving all seven task groups, whereas other patient and treatment characteristics were related only to certain types of activities.

CONCLUSIONS

Breast cancer survivors report difficulty with a range of upper-body tasks, particularly if they also have lymphoedema or poor fitness. Using all or some of the tasks within the reported constructs in a questionnaire format, or the functional requirements of the most burdensome tasks to develop more objective and quantitative measures, would provide a solid base for the measurement of upper-body function in women with breast cancer.

Emotion regulation in acceptance and commitment therapy

Acceptance and Commitment Therapy (ACT) offers an alternative to traditional psychotherapies designed to regulate affect. ACT is based on the premise that normal cognitive processes distort and enhance the experience of unpleasant emotion, leading clients to engage in problematic behaviors designed to avoid or attenuate those unpleasant emotions. Such avoidant behavior patterns can hinder and prevent client movement toward valued goals and place the client in harmful situations. Rather than working to change cognitions or decrease levels of emotion, the ACT approach involves the client directly experiencing problematic emotions in a context in which the literal functions of language enhancing the negative implications of those emotions are stripped away. The focus throughout the treatment is facilitating the client's movement toward a more valued and personally fulfilling life, in a context in which previously obstructive unpleasant emotions no longer serve as obstructions. A case study is provided to illustrate some of ACT's core techniques.

Adverse reactions to anthrax immunisation in a military field hospital

OBJECTIVE

To determine the outcome of anthrax immunisation.

METHODS

Adverse reactions (occurrence, nature, severity and incapacity) and immune responses to a voluntary programme of anthrax immunisation at 0, 3, 6, and 24 weeks were monitored by questionnaire and voluntary blood sampling in 129 members, including 24 immunised 7 years previously (immunes), of a military field hospital alerted for possible deployment.

RESULTS

Follow-up was complete in 85%. Ninety-eight (76%) received the first anthrax immunisation. Uptake was greater (p = 0.015) in immunes. Initial prevalence of adverse reaction was 63%. Subsequent uptake and adverse reaction dwindled significantly (p < 0.001). Only 28 (22%) were immunised at 24 weeks. Proportions reporting adverse reactions following the initial immunisation were greater in immunes (p = 0.046) and officers (p = 0.02). There was no significant (p = 0.36) correlation between uptake of immunisation and prevalence of adverse reaction. Antecedent adverse reaction did not reduce the proportion of participants accepting immunisation subsequently. The nature of adverse reactions (47% local, 24% systemic and 27% both) and severity were the same throughout. Forty-five percent of adverse reactions caused incapacity. Seventy-four percent of these had pain in the injected arm (+/- systemic symptoms) which prevented lifting or driving for 48 hours in 63%. Immune responses were greater in immunes.

CONCLUSIONS

It was concluded that anthrax immunisation results in a higher than expected prevalence of adverse reaction with initial incapacity of military significance affecting 18%. Greater immune responses may increase adverse reaction but this does not affect acceptance of anthrax immunisation. Poor completion rates necessitate development of a new anthrax immunisation strategy.

Immunohistochemical analysis of polycyclic aromatic hydrocarbon-DNA adducts in breast tumor tissue

Environmental carcinogens may play a role in the etiology of breast cancer, but the extent of their contribution is not yet defined. The aims of this study were to determine whether polycyclic aromatic hydrocarbon (PAH)-DNA adducts could be detected in stored paraffin blocks of breast tumor tissue (n=147) with an immunoperoxidase technique and whether they correlated with smoking history and/or mutant p53 protein expression. There was no significant difference in mean relative nuclear staining intensity in non-smokers (444+/-90, n=75), ever smokers (435+/-91, n=72), and current smokers (456+/-98, n=35). In either current or ever smokers, PAH-DNA adducts were non-significantly elevated in those with greater compared with lower exposure in relation to age at started smoking, years of smoking, cigarettes per day, and pack years. DNA damage levels were not elevated in tissues with compared with those without mutant p53 protein expression. These data demonstrate that immunohistochemical methods can be used to monitor DNA damage levels in archived breast tissues.

The likely success of functional analysis tied to the DSM

Nelson-Gray and Farmer argue that behavioral assessment and functional analysis may be beneficially applied to personality disorders (PDs). While this is a reasonable response to the largely non-behaviorally derived Diagnostic and Statistical Manual (DSM), it is not yet clear that grafting such theoretically incongruent elements will be viable. In essence, they argue that a syndromal classification system could serve a nomothetic role of guiding a functional, idiographic analysis. This is possible, but it seems unlikely that this process would remain in equilibrium, with no interactive effect of the functional analysis on the syndromes themselves. Yet the DSM system has shown itself to be surprisingly closed to a more functional approach, so the relationship between the DSM and functional analysis is not open in both directions. What is needed is a nomothetic level of analysis that is also functionally derived. The primary benefit of functional over syndromal categories is one of treatment utility, a concept that is itself surprisingly absent from the authors' otherwise comprehensive discussion of behavioral assessment.

Why behavior analysts should study emotion: the example of anxiety

Historically, anxiety has been a dominant subject in mainstream psychology but an incidental or even insignificant one in behavior analysis. We discuss several reasons for this discrepancy. We follow with a behavior-analytic conceptualization of anxiety that could just as easily be applied to emotion in general. Its primary points are (a) that languageable humans have an extraordinary capacity to derive relations between events and that it is a simple matter to show that neutral stimuli can acquire discriminative functions indirectly with no direct training; (b) that private events can readily acquire discriminative functions; (c) that anxiety disorders seem to occur with little apparent direct learning or that the amount of direct learning is extraordinarily out of proportion with the amount of responding; and (d) that the primary function of anxious behavior is experiential avoidance. We conclude that the most interesting aspects of anxiety disorders may occur as a function of derived rather than direct relations between public events and overt and private responses with avoidance functions. Implicit in this conclusion and explicit in the paper is the assertion that anxiety is a suitable subject for behavior-analytic study.