Living with type 2 diabetes: A social cognitive perspective on adherence

OBJECTIVE

This mixed methods study examines the relationship between outcome expectations, self-efficacy, and self-care behaviors in individuals with type 2 diabetes (T2DM). It also explores the personal values motivating these behaviors through in-depth interviews.

METHODS

Adults with T2DM (n = 108, M age = 57 years, 58% female, 48% Black) completed questionnaires and participated in in-depth interviews using a laddering technique.

RESULTS

Ordinary least squares regression models were used to analyze the relationships between self-efficacy, outcome expectations, and four self-care behaviors (physical activity, dietary choices, blood glucose monitoring, and medication usage). The findings indicate that self-efficacy is significantly and positively associated with diet and physical activity. Both outcome expectations for blood glucose testing and self-efficacy are significantly and positively associated with self-reported monitoring. However, neither outcome expectation nor self-efficacy is associated with medication usage. The in-depth interviews revealed three common values related to self-care behaviors: maintaining health and longevity, agentic values of self-control, achievement, and self-esteem, and a sense of belonging.

CONCLUSIONS

This study sheds light on the complexity of diabetes self-management, offering insights into individuals' values, behavioral strategies, and the influence of control perceptions on this relationship, revealing both differences and commonalities in stated values.

PRACTICE IMPLICATIONS

By understanding how personal values drive diabetes self-care behaviors, practitioners can assist patients in establishing meaningful connections between their values and the challenges of living with diabetes.

Processes for identifying caregivers and screening for caregiver and patient distress in community oncology: results from WF-1803CD

BACKGROUND

Despite their vital roles, informal caregivers of adult cancer patients are commonly overlooked in cancer care. This study describes processes for identifying cancer caregivers and processes for distress screening and management among caregivers and patients in the understudied community oncology setting.

METHODS

Supportive care leaders from the National Cancer Institute Community Oncology Research Program practices completed online survey questions regarding caregiver identification, caregiver and patient distress screening, and distress management strategies. We described practice group characteristics and prevalence of study outcomes. Multivariable logistic regression explored associations between practice group characteristics and caregiver identification in the electronic health record (EHR).

RESULTS

Most (64.9%, 72 of 111) supportive care leaders reported routine identification and documentation of informal caregivers; 63.8% record this information in the EHR. Only 16% routinely screen caregivers for distress, though 92.5% screen patients. Distress management strategies for caregivers and patients are widely available, yet only 12.6% are routinely identified and screened and had at least 1 referral strategy for caregivers with distress; 90.6% are routinely screened and had at least 1 referral strategy for patients. Practices with a free-standing outpatient clinic (odds ratio [OR] = 0.29, P = .0106) and academic affiliation (OR = 0.01, P = .04) were less likely to identify and document caregivers in the EHR. However, higher oncologist volume was associated with an increased likelihood of recording caregiver information in the EHR (OR = 1.04, P = .02).

CONCLUSIONS

Despite high levels of patient distress screening and management, few practices provide comprehensive caregiver engagement practices. Existing patient engagement protocols may provide a promising platform to build capacity to better address caregiver needs.

Cultural and linguistic adaptation of a telephone-based cognitive-behavioral therapy (CBT) intervention to treat depression and anxiety in Hispanic cancer survivors

PURPOSE/OBJECTIVES

The purpose of this study was to transcreate a manualized cognitive-behavioral therapy (CBT) intervention to address depression and anxiety among Hispanic cancer survivors.

DESIGN/RESEARCH APPROACH

Stakeholders reviewed the CBT workbook for language, content, and cultural relevance. We designed semi-structured interview guides to elicit intervention feedback.

SAMPLE/PARTICIPANTS

Stakeholder participants were Hispanic cancer survivors (n = 4), bilingual mental health providers (n = 2), and oncology professionals (n = 4).

METHODS

Transcreation was conducted by initial translation of the workbook followed by incorporation of stakeholder feedback. A bilingual (Spanish and English) interviewer conducted stakeholder interviews. The study team discussed themes/suggestions before refining the workbook.

FINDINGS

Stakeholders reported enthusiasm for the intervention. We gathered significant feedback regarding wording, images, and resources for the workbook.

CONCLUSION

Development of culturally appropriate mental health resources for Hispanic cancer survivors is critical.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS OR POLICY

By broadening research on psychosocial care to the Hispanic population, we increase the reach of evidence-based psychological care. Future research should fully evaluate the adapted CBT intervention among Hispanic survivors.

Qualitative results from a randomized pilot study of eHealth Mindful Movement and Breathing to improve gynecologic cancer surgery outcomes

PURPOSE

Improved management of pain and co-morbid symptoms (sleep disturbances, psychological distress) among women undergoing surgery for suspected gynecologic malignancies may reach a population vulnerable to chronic pain.

PARTICIPANTS

Women undergoing surgery for a suspected gynecologic malignancy.

METHOD

We conducted a pilot randomized controlled trial of eHealth Mindful Movement and Breathing (eMMB) compared to an empathic attention control (AC). Semi-structured interviews were conducted by telephone (n = 23), recorded, transcribed, coded, and analyzed using thematic analysis.

FINDINGS

Participants reported overall high acceptability such that all would recommend the study to others. Positive impacts of practicing eMMB included that it relieved tension, facilitated falling asleep, and decreased pain. Participants also reported high adherence to self-directed eMMB and AC writing practices and described facilitators and barriers to practicing.

CONCLUSIONS

This qualitative feedback will inform future research to assess the efficacy of eMMB for reducing pain and use of remotely-delivered interventions more broadly.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03681405.

Reducing Anxiety and Dyspnea via Device-Guided Breathing (RELAX): A Multi-Site Feasibility Study in Post-Treatment Lung Cancer Survivors at Community Cancer Clinics (WF-01213)

INTRODUCTION

Anxiety and dyspnea are 2 common symptoms for lung cancer survivors. Although research suggests decreasing respiration rate can reduce anxiety in several populations, potential benefits of device-guided breathing have not been studied in lung cancer survivors. This feasibility study (WF-01213) provides estimates of accrual, adherence, retention, and preliminary efficacy of 2 doses of a device-guided breathing intervention versus a usual breathing control group for improving self-reported anxiety and dyspnea in post-treatment lung cancer survivors.

METHODS

Stage I-IV lung cancer survivors were recruited through the NCI Community Oncology Research Program (NCORP) and randomized to 12 weeks of a device-guided breathing intervention (high dose vs. low dose) or control device. Self-reported outcomes (anxiety, depression, dyspnea, cancer-related worry, fatigue) were assessed at baseline, mid-intervention (Week-6), and post-intervention (Week-12).

RESULTS

Forty-six participants (ages 41-77, median = 65; 78% White) were randomized to the high-dose intervention (n = 14), low-dose intervention (n = 14), or control (n = 18) groups between July 2015 and September 2019. Study accrual rate was 0.92 per month for 50 months (projected accrual was 6.3/month). Fourteen participants (30%) withdrew early from the study, with almost half of those discontinuing at or immediately following baseline assessment. No participants were adherent with the intervention per protocol specifications. The proportion minimally adherent (using device at least 1x/week) was 43% (6/14), 64% (9/14), and 61% (11/18) for high-dose, low-dose, and control groups, respectively. Anxiety significantly decreased from baseline for all groups at Week 12. Adherence to the intervention was low across all treatment groups.

CONCLUSIONS

This study did not establish feasibility of a community-based randomized trial of 2 doses of device-guided breathing and a control group using an identical-looking device for lung cancer survivors. In both the high-dose and control groups, there were significant improvements from baseline for anxiety and dyspnea. In the low-dose group, there were significant improvements from baseline for anxiety and depression. Ratings and feedback on the intervention were mixed (although leaned in a positive direction). Participants reported liking the feeling of relaxation/calm, helping others, breathing awareness, and music. Participants reporting liking least finding/making time to use the device, frustration with the device, and completing study forms.

TRIAL REGISTRATION: CLINICAL TRIALS ID

NCT02063828, clinicaltrials.gov.

Long-Term Effects of Cognitive-Behavioral Therapy and Yoga for Worried Older Adults

OBJECTIVES

Cognitive-behavioral therapy (CBT) and yoga decrease worry and anxiety. There are no long-term data comparing CBT and yoga for worry, anxiety, and sleep in older adults. The impact of preference and selection on these outcomes is unknown. In this secondary data analysis, we compared long-term effects of CBT by telephone and yoga on worry, anxiety, sleep, depressive symptoms, fatigue, physical function, social participation, and pain; and examined preference and selection effects.

DESIGN

In this randomized preference trial, participants (N = 500) were randomized to a: 1) randomized controlled trial (RCT) of CBT or yoga (n = 250); or 2) preference trial (selected CBT or yoga; n = 250). Outcomes were measured at baseline and Week 37.

SETTING

Community.

PARTICIPANTS

Community-dwelling older adults (age 60+ years).

INTERVENTIONS

CBT (by telephone) and yoga (in-person group classes).

MEASUREMENTS

Penn State Worry Questionnaire - Abbreviated (worry);^1,2 Insomnia Severity Index (sleep);³ PROMIS Anxiety Short Form v1.0 (anxiety);^4,5 Generalized Anxiety Disorder Screener (generalized anxiety);^6,7 and PROMIS-29 (depression, fatigue, physical function, social participation, pain).^8,9 RESULTS: Six months after intervention completion, CBT and yoga RCT participants reported sustained improvements from baseline in worry, anxiety, sleep, depressive symptoms, fatigue, and social participation (no significant between-group differences). Using data combined from the randomized and preference trials, there were no significant preference or selection effects. Long-term intervention effects were observed at clinically meaningful levels for most of the study outcomes.

CONCLUSIONS

CBT and yoga both demonstrated maintained improvements from baseline on multiple outcomes six months after intervention completion in a large sample of older adults.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov Identifier NCT02968238.

Financial burden for caregivers of adolescents and young adults with cancer

OBJECTIVE

Adolescent and young adult (AYA) cancer survivors are vulnerable to cancer-related financial burden, which is likely shared by their caregivers. This study aims to enhance an existing conceptual model of financial burden by conducting concept elicitation interviews with caregivers to generate knowledge that can be translated to inform instrumental and psychosocial support in cancer care.

METHODS

Qualitative concept elicitation interviews were conducted with 24 caregivers of AYA cancer survivors (caregivers of adolescents, n = 12; caregivers of emerging adults, n = 12) recruited from four sites. Constant comparative methods were used to identify themes, and results were interpreted and organized into domains of the conceptual model. We also explored COVID-19 related financial impacts among a subset (n = 12) of caregivers.

RESULTS

Seven themes emerged, which varied by age group and strengthened the conceptualization of the model. Themes centered on: (1) direct and indirect costs of cancer; (2) impact of socioeconomic status on financial burden; (3) caregiver desire to shield AYAs from distress due to financial burden; (4) strategies to manage cancer-related costs; (5) worries about AYAs' financial future; (6) seeking and receiving financial support; and (7) navigating the healthcare system. Findings also revealed that COVID-19 exacerbates financial burden for some caregivers.

CONCLUSIONS

Building upon our prior work, we have adapted the conceptual model of financial burden to reflect perspectives of AYAs, oncology providers, and now, caregivers. An important next step is to develop a reliable and valid self-report measure of financial burden among caregivers of AYA cancer survivors.

A Randomized Preference Trial Comparing Cognitive-Behavioral Therapy and Yoga for the Treatment of Late-Life Worry: Examination of Impact on Depression, Generalized Anxiety, Fatigue, Pain, Social Participation, and Physical Function

Background

Depression, generalized anxiety, fatigue, diminished physical function, reduced social participation, and pain are common for many older adults and negatively impact quality of life. The purpose of the overall trial was to compare the effects of cognitive-behavioral therapy (CBT) and yoga on late-life worry, anxiety, and sleep; and examine preference and selection effects on these outcomes.

Objective

The present analyses compared effects of the 2 interventions on additional outcomes (depressive symptoms, generalized anxiety symptoms, fatigue, pain interference/intensity, physical function, social participation); and examined whether there are preference and selection effects for these treatments.

Methods

A randomized preference trial of CBT and yoga was conducted in adults ≥60 years who scored ≥26 on the Penn State Worry Questionnaire-Abbreviated (PSWQ-A), recruited from outpatient medical clinics, mailings, and advertisements. Cognitive-behavioral therapy consisted of 10 weekly telephone sessions. Yoga consisted of 20 bi-weekly group yoga classes. Participants were randomized to(1): a randomized controlled trial (RCT) of CBT or yoga (n = 250); or (2) a preference trial in which they selected their treatment (CBT or yoga; n = 250). Outcomes were measured at baseline and post-intervention.

Results

Within the RCT, there were significant between-group differences for both pain interference and intensity. The pain interference score improved more for the CBT group compared with the yoga group [intervention effect of (mean (95% CI) = 2.5 (.5, 4.6), P = .02]. For the pain intensity score, the intervention effect also favored CBT over yoga [.7 (.2, 1.3), P < .01]. Depressive symptoms, generalized anxiety, and fatigue showed clinically meaningful within-group changes in both groups. There were no changes in or difference between physical function or social participation for either group. No preference or selection effects were found.

Conclusion

Both CBT and yoga may be useful for older adults for improving psychological symptoms and fatigue. Cognitive-behavioral therapy may offer even greater benefit than yoga for decreasing pain.

Enhancing Access to Yoga for Older Male Veterans After Cancer: Examining Beliefs About Yoga

Background

Yoga is an effective clinical intervention for cancer survivors. Most studies of the positive effects of yoga on cancer patients report on predominantly middle-aged women with breast cancer. Less is known about the use of yoga in older adults, veterans, and those from diverse racial or ethnic backgrounds.

Methods

We examined strategies to enhance access to yoga in older veterans after cancer, focusing on education (study 1) and intervention (study 2). Study 1 included 110 participants with a median (SD) age of 64.9 (9.4) years who were mostly male (99%) cancer survivors who were interviewed 12 months after their cancer diagnosis. Study 2 included 28 participants with a median (SD) age of 69.2 (10.9) years who were mostly male (96%) cancer survivors who participated in a yoga program within 3 years of their cancer diagnosis. Standardized interviews assessed interest in and barriers to yoga while self-reporting assessed health-related quality of life and beliefs about yoga.

Results

In study 1, interest in yoga increased from 5.5 to 31.8% (χ ² = 22.25, P < .001) following education. In open-ended questions 4 themes related to negative beliefs or barriers emerged: lack of knowledge or skepticism, disinterest or dislike, physical health barriers, and logistical barriers. In study 2, beliefs were more positive following intervention for expected benefits (t = 4.44, P < .001), discomfort (t = 4.92, P < .001), and social norms (t = 4.38, P < .001) related to yoga. Physical function improved after participation in a yoga class, especially for those with higher beliefs in yoga prior to class. Age was not associated with beliefs about yoga in either sample.

Conclusions

A portion of older veterans who are cancer survivors were interested in yoga but faced access barriers. Implications for practice and research include increasing knowledge about yoga benefits and addressing physical health and logistical barriers to enhance access to yoga for older veterans.

Stakeholder-informed conceptual framework for financial burden among adolescents and young adults with cancer

BACKGROUND

Cancer and its treatments can result in substantial financial burden that may be especially distressing for adolescents and young adults (AYAs) since they are at a developmental stage focused on completing one's education and establishing independence. The purpose of this study was to develop a conceptual model of financial burden among AYA cancer patients to inform development of a financial burden measure.

METHODS

In-depth concept elicitation interviews were conducted with a purposive-selected stakeholder sample (36 AYAs and 36 AYA oncology health care providers). The constant comparative method was used to identify themes that illustrate AYAs' experience of financial burden by stakeholder groups.

RESULTS

Eleven financial burden themes emerged: (1) impact of socioeconomic status and age; (2) significant cancer costs; (3) indirect cost "ripple effects"; (4) limited awareness of costs (adolescents); (5) emotional impact; (6) feeling overwhelmed navigating the health care system; (7) treatment decision modifications; (8) reducing spending; (9) coping strategies; (10) financial support; and (11) long-lasting impact. The conceptual model highlights the importance of material, psychosocial, and behavioral domains of financial burden with an emphasis on phase along the cancer continuum and developmental stage in the experience of financial burden for AYAs.

CONCLUSIONS

Issues presented in the voice of AYA patients and providers highlight the profound impact of financial burden in this survivor group. The next step in this work will be to develop and test a patient-reported measure of financial burden among AYA cancer survivors.

Predictors of preference for cognitive-behavioral therapy (CBT) and yoga interventions among older adults

The purpose of this study was to examine factors that influence a person's choice of cognitive-behavioral therapy (CBT) or yoga, the stability of these preferences, and the impact of preference on engagement and process measures. We conducted a randomized preference trial of CBT and yoga in 500 adults ≥60 years with symptoms of worry. Participants reported their intervention preference, strength of preference, and factors impacting preference. Engagement in the intervention (session completion and dropout rates) was assessed. Process measures included satisfaction with the intervention, therapeutic alliance, and intervention expectancy. Neither intervention preference (48% and 52% chose CBT and yoga, respectively) nor strength of preference differed significantly between the two preference trial groups. Intervention expectancies at baseline among those in the preference trial were approximately 4.5 units (40-point scale) higher for their preferred intervention (p < .0001 within each group). A principal component analysis of factors influencing preference identified three constructs. Using logistic regression, components focused on attitudes about CBT or yoga were predictive of ultimate preference (odds ratio = 11.5, 95% C.I.6.3-21.0 per 1SD difference in component 1 for choosing CBT; odds ratio = 7.8, 95% CI4.3-13.9 per 1SD difference in component 2 for choosing yoga). There were no significant differences between the randomized and preference trials on intervention adherence, completion of assessments, intervention satisfaction, or working alliance. Receiving a preferred treatment had no significant effects on intervention outcomes through participant engagement or process measures. When options are limited, providers may have confidence in offering the most readily available non-pharmacological treatments.

Systematic review of financial burden assessment in cancer: Evaluation of measures and utility among adolescents and young adults and caregivers

The cost of cancer care is rising and represents a stressor that has significant and lasting effects on quality of life for many patients and caregivers. Adolescents and young adults (AYAs) with cancer are particularly vulnerable. Financial burden measures exist but have varying evidence for their validity and reliability. The goal of this systematic review is to summarize and evaluate measures of financial burden in cancer and describe their potential utility among AYAs and their caregivers. To this end, the authors searched PubMed, Embase, the Cochrane Library, CINAHL, and PsycINFO for concepts involving financial burden, cancer, and self-reported questionnaires and limited the results to the English language. They discarded meeting abstracts, editorials, letters, and case reports. The authors used standard screening and evaluation procedures for selecting and coding studies, including consensus-based standards for documenting measurement properties and study quality. In all, they screened 7250 abstracts and 720 full-text articles to identify relevant articles on financial burden. Eighty-six articles met the inclusion criteria. Data extraction revealed 64 unique measures for assessing financial burden across material, psychosocial, or behavioral domains. One measure was developed specifically for AYAs, and none were developed for their caregivers. The psychometric evidence and study qualities revealed mixed evidence of methodological rigor. In conclusion, several measures assess the financial burden of cancer. Measures were primarily designed and evaluated in adult patient populations with little focus on AYAs or caregivers despite their increased risk of financial burden. These findings highlight opportunities to adapt and test existing measures of financial burden for AYAs and their caregivers.

Ensuring Yoga Intervention Fidelity in a Randomized Preference Trial for the Treatment of Worry in Older Adults

Introduction: Yoga for treatment of worry in older adults is an intervention that is especially likely to translate into real-world practice. Assessing treatment fidelity improves confidence that effective interventions can be consistently applied and allows researchers to explore if any null results for effectiveness are indeed the result of a lack of intervention efficacy or lack of proper intervention implementation. Methods: This study describes treatment fidelity of a yoga intervention in a randomized preference trial that compared cognitive-behavioral therapy (CBT) and yoga for the treatment of worry, anxiety, and sleep in worried older (≥60 years) adults. Established methods for assessing treatment fidelity of CBT guided the procedure for ensuring that the yoga intervention was delivered as intended. The yoga intervention consisted of 20, 75-min, in-person, group, gentle yoga classes held twice weekly. Results: Six female instructors (mean age = 64 years) taught 660 yoga classes that were videotaped. Ten percent of these classes, stratified by instructor, were randomly selected for review. The average adherence score for yoga instructors was 6.84 (range 4-8). The average competency scores were consistently high, with an average score of 7.24 (range 6-8). Teaching content not included in the protocol occurred in 26 (38.1%) sessions and decreased over time. Observed ratings of instructor adherence were significantly related to ratings of competency. Instructor adherence was also significantly associated with lower participant attendance, but not with any of the other process or outcome measures. Conclusions: The larger range found in adherence relative to competence scores demonstrated that teaching a yoga class according to a protocol requires different skills than competently teaching a yoga class in the community, and these skills improved with feedback. These results may foster dialog between the yoga research and practice communities. Clinical Trial Registration No.: NCT02968238.

Comparison of cognitive-behavioral therapy and yoga for the treatment of late-life worry: A randomized preference trial

BACKGROUND

The purpose of this study was to compare the effects of cognitive-behavioral therapy (CBT) and yoga on late-life worry, anxiety, and sleep; and examine preference and selection effects on these outcomes.

METHODS

A randomized preference trial of CBT and yoga was conducted in community-dwelling adults 60 years or older, who scored 26 or above on the Penn State Worry Questionnaire-Abbreviated (PSWQ-A). CBT consisted of 10 weekly telephone sessions. Yoga consisted of 20 biweekly group yoga classes. The primary outcome was worry (PSWQ-A); the secondary outcomes were anxiety (PROMIS-Anxiety) and sleep (Insomnia Severity Index [ISI]). We examined both preference effects (average effect for those who received their preferred intervention [regardless of whether it was CBT or yoga] minus the average for those who did not receive their preferred intervention [regardless of the intervention]) and selection effect (which addresses the question of whether there is a benefit to getting to select one intervention over the other, and measures the effect on outcomes of self-selection to a specific intervention).

RESULTS

Five hundred older adults were randomized to the randomized trial (125 each in CBT and yoga) or the preference trial (120 chose CBT; 130 chose yoga). In the randomized trial, the intervention effect of yoga compared with CBT adjusted for baseline psychotropic medication use, gender, and race was 1.6 (-0.2, 3.3), p = .08 for the PSWQ-A. Similar results were observed with PROMIS-Anxiety (adjusted intervention effect: 0.3 [-1.5, 2.2], p = .71). Participants randomized to CBT experienced a greater reduction in the ISI compared with yoga (adjusted intervention effect: 2.4 [1.2, 3.7], p < .01]). Estimated in the combined data set (N = 500), the preference and selection effects were not significant for the PSWQ-A, PROMIS-Anxiety, and ISI. Of the 52 adverse events, only two were possibly related to the intervention. None of the 26 serious adverse events were related to the study interventions.

CONCLUSIONS

CBT and yoga were both effective at reducing late-life worry and anxiety. However, a greater impact was seen for CBT compared with yoga for improving sleep. Neither preference nor selection effects was found.

Optimizing the measurement of health-related quality of life in adolescents and young adults with cancer

To date, the health‐related quality of life experiences of adolescents and young adults (AYA) with cancer have been inconsistently and incompletely captured by existing patient‐reported outcome (PRO) measures. The National Institutes of Health Patient‐Reported Outcomes Measurement Information System (PROMIS) represents the state of the art for measurement science of PROs and provides an optimal approach for addressing these measurement challenges and catalyzing future patient‐centered research in AYA oncology.

Can Adults with Mild Cognitive Impairment Build Cognitive Reserve and Learn Mindfulness Meditation? Qualitative Theme Analyses from a Small Pilot Study

BACKGROUND/OBJECTIVE

High levels of chronic stress negatively impact the hippocampus and are associated with increased incidence of mild cognitive impairment (MCI) and Alzheimer's disease. While mindfulness meditation may mitigate the effects of chronic stress, it is uncertain if adults with MCI have the capacity to learn mindfulness meditation.

METHODS

14 adults with MCI were randomized 2:1 to Mindfulness Based Stress Reduction (MBSR) or a wait-list control group. We conducted qualitative interviews with those who completed MBSR. Transcribed interviews were: a) coded using an emergent themes inductive approach informed by grounded theory; b) rated 0-10, with higher scores reflecting greater perceived benefit from, and understanding of, mindfulness meditation. Ratings were correlated with daily home practice times and baseline level of cognitive function.

RESULTS

Seven themes emerged from the interviews: positive perceptions of class; development of mindfulness skills, including meta-cognition; importance of the group experience; enhanced well-being; shift in MCI perspective; decreased stress reactivity and increased relaxation; improvement in interpersonal skills. Ratings of perceived benefit and understanding ranged from 2-10 (mean = 7) and of 0-9.5 (mean = 6), respectively. Many participants experienced substantial benefit/understanding, some had moderate, and a few had minimal benefit/understanding. Understanding the key concepts of mindfulness was highly positively correlated with ≥20 minutes/day of home practice (r = 0.90) but not with baseline cognitive function (r = 0.13).

CONCLUSIONS

Most adults with MCI were able to learn mindfulness meditation and had improved MCI acceptance, self-efficacy, and social engagement. Cognitive reserve may be enhanced through a mindfulness meditation program even in patients with MCI.

The National Cancer Institute Clinical Trials Planning Meeting for Prevention and Treatment of Chemotherapy-Induced Peripheral Neuropathy

Although recent scientific advances have improved our understanding of basic biological mechanisms underlying chemotherapy-induced peripheral neuropathy (CIPN), few interventions are available to prevent or treat CIPN. Although some biological targets from preclinical studies show promise in nonhuman animal models, few targets have been translated to successful clinical trials. To address this problem, the National Cancer Institute's Symptom Management and Health-Related Quality of Life Steering Committee convened a meeting of experts in the CIPN and oncology symptom management fields to participate in a Clinical Trials Planning Meeting (CTPM). Investigators presented data from preclinical and translational studies for possible CIPN interventions; these were evaluated for readiness of randomized clinical trial testing by experts, and recommendations were provided. Breakout sessions were convened to discuss and develop future studies. The CTPM experts concluded that there is compelling evidence to move forward with selected pharmacological and nonpharmacological clinical trials for the prevention and treatment of CIPN. Several key feasibility issues need to be addressed, however. These include identification of optimal outcome measures to define the CIPN phenotype, establishment of parameters that guide the evaluation of clinically meaningful effects, and adoption of approaches for inclusion of translational and biomarker and/or genetic measures. The results of the CTPM provide support for conducting clinical trials that include both pharmacological and nonpharmacological approaches, alone or in combination, with biomarkers, genetics, or other measures designed to inform underlying CIPN mechanisms. Several working groups were formed to design rigorous CIPN clinical trials, the results of which are ongoing.

Variability in sleep disturbance, physical activity and quality of life by level of depressive symptoms in women with Type 2 diabetes

AIMS

To examine (1) the prevalence of depressive symptoms in women with Type 2 diabetes, (2) the associations between depressive symptoms and the following dependent variables: sleep disturbance; physical activity; physical health-related; and global quality of life, and (3) the potential moderating effects of antidepressants and optimism on the relationship between depressive symptoms and dependent variables.

METHODS

Participants in the Women's Health Initiative who had Type 2 diabetes and data on depressive symptoms (N=8895) were included in the analyses. In multivariable linear regression models controlling for sociodemographic, medical and psychosocial covariates, we examined the main effect of depressive symptoms, as well as the interactions between depressive symptoms and antidepressant use, and between depressive symptoms and optimism, on sleep disturbance, physical activity, physical health-related quality of life; and global quality of life.

RESULTS

In all, 16% of women with Type 2 diabetes reported elevated depressive symptoms. In multivariable analyses, women with depressive symptoms had greater sleep disturbance (P<0.0001) and lower global quality of life (P<.0001). We found evidence of significant statistical interaction in the models for quality-of-life outcomes: the increased risk of poor physical health-related quality of life associated with antidepressant use was stronger in women without vs with depressive symptoms, and the association between greater optimism and higher global quality of life was stronger in women with vs without depressive symptoms.

CONCLUSIONS

To improve health behaviours and quality of life in women with Type 2 diabetes, sociodemographic and medical characteristics may identify at-risk populations, while psychosocial factors including depression and optimism may be important targets for non-pharmacological intervention.

Development of an Innovative Career Development Program for Early-Career Women Faculty

Objective

Our institutional Women in Medicine & Science Program (formerly the Office of Women in Medicine and Science) developed the Early Career Development Program for Women to promote the careers of women faculty. At 6 monthly sessions, participants learn relevant content (imposter syndrome, strengths, change style, career management, assertive communication, feedback, personal influence, conflict management, negotiation, importance of mentors, resilience, and self-care); exchange ideas; and expand their professional networks. Here, we report changes in participants' career skills/knowledge, confidence, and perceptions of the current environment after attending the program.

Method

Between 2014 and 2017, participants (N = 65) completed pre- and post-program surveys that assessed career knowledge and skills, confidence, and perceptions of the current environment and provided program feedback.

Results

Most skills showed pre-post significant improvement. The greatest increases occurred in knowing paths to promotion, tailoring communication style, ability to manage conflict, and ability to handle personal-professional role balance. Women reported a significant increase for all items measuring confidence. Among these items, establishing networks, understanding institutional culture, providing feedback, motivating others, strategic planning, delegating, and conflict management had the largest increases. Overall, 89.3% of respondents rated the program impact as very strong/profound, 98.5% rated the concepts as essential, 95.2% rated the skills as essential, and 90.8% rated the sense of community with women in their class as very/extremely close.

Conclusions

Work-related skills/knowledge, confidence, and perceptions of the current environment increased significantly among program participants. These early-career women faculty indicated that the program augmented the skills needed to develop their careers in an academic medical center.

Lung Cancer Patient and Caregiver Health Vulnerabilities and Interest in Health Promotion Interventions: An Exploratory Study

Introduction

Lung cancer patients and their caregivers are at risk for negative health behaviors and poor psychosocial functioning, but few interventions exist that target this population. To inform intervention development, we explored potential targets and interest and concordance in health promotion interventions among lung cancer patients and their caregivers.

Methods

Lung cancer patients (n = 18) with a smoking history and their caregivers (n = 15) participated in a cross-sectional, observational survey study (an average of 1 month postdiagnosis) to assess health behaviors, psychosocial functioning, and interest in health promotion interventions. Fisher’s exact and Wilcoxon rank-sum tests examined factors associated with intervention interest. McNemar’s test examined concordance in interest.

Results

Many caregivers (40%) reported providing care at least 4 days per week, and over half (53.3%) reported a smoking history. Patients reported high cancer self-blame (mean = 3.1, standard deviation = 0.9, range = 1–4). Patients (55.6%) and caregivers (60%) reported clinically significant depressive symptoms. There was high interest and concordance in interest in cancer education (patients, 77.8%; caregivers, 86.7%) and diet and exercise (patients, 66.7%; caregivers, 80%) interventions. Significantly more caregivers were interested in stress reduction (patients, 53.3%; caregivers, 73.3%; P = .05) and yoga (patients, 16.7%; caregivers, 50%; P = .03) than patients. Caregivers interested in stress reduction interventions had higher levels of distress than those not interested.

Discussion

Health promotion interventions are needed and of interest to lung cancer patients and caregivers. Shared interests in interventions suggest dyadic interventions may be appropriate, yet interventions should also address distinct patient and caregiver needs.

Yoga for symptom management in oncology: A review of the evidence base and future directions for research

Because yoga is increasingly recognized as a complementary approach to cancer symptom management, patients/survivors and providers need to understand its potential benefits and limitations both during and after treatment. The authors reviewed randomized controlled trials (RCTs) of yoga conducted at these points in the cancer continuum (N = 29; n = 13 during treatment, n = 12 post-treatment, and n = 4 with mixed samples). Findings both during and after treatment demonstrated the efficacy of yoga to improve overall quality of life (QOL), with improvement in subdomains of QOL varying across studies. Fatigue was the most commonly measured outcome, and most RCTs conducted during or after cancer treatment reported improvements in fatigue. Results also suggested that yoga can improve stress/distress during treatment and post-treatment disturbances in sleep and cognition. Several RCTs provided evidence that yoga may improve biomarkers of stress, inflammation, and immune function. Outcomes with limited or mixed findings (eg, anxiety, depression, pain, cancer-specific symptoms, such as lymphedema) and positive psychological outcomes (such as benefit-finding and life satisfaction) warrant further study. Important future directions for yoga research in oncology include: enrolling participants with cancer types other than breast, standardizing self-report assessments, increasing the use of active control groups and objective measures, and addressing the heterogeneity of yoga interventions, which vary in type, key components (movement, meditation, breathing), dose, and delivery mode.

Perspectives of pain in patients with type 2 diabetes

Reducing symptom burden is often secondary to risk factor control in diabetes. Symptom burden with comorbid medical conditions and the need for symptom palliation are not well defined. Although neuropathy is one of the most frequent occurring comorbidities of diabetes, patient experience is inconsistent. Using in-depth interview, we assessed patients' perspectives of pain experienced through neuropathy and the impact on type 2 diabetes management. Areas covered: Participants completed a structured telephone interview during which perspectives on diabetes and its management occurred. Data were analyzed iteratively using content analysis and extracted themes came from reduced data. Interview data were triangulated with clinical data from electronic health records. Expert opinion: During interviews, 41% of patients reported pain interfered with their lives. Three pain-related themes emerged from interviews, augmented by descriptions of how people experience and cope with pain. Themes included: (1) people know what neuropathy is and attribute their pain to it; (2) neuropathic pain seems insurmountable at times; and (3) pain can lead to feeling down or hopeless. Pain, a common comorbidity in diabetes, is a primary driver of patient suffering. Understanding how patients experience pain paves the way for creative interventions to manage it better among those living with diabetes.

The Effects of Yoga on Patients with Mild Cognitive Impairment and Dementia: A Scoping Review

Yoga is an ancient mind body practice. Although yoga has been used as a complementary health approach for enhancing wellness and addressing a variety of health issues, little is known about the impact of yoga on cognitive functioning in adults with mild cognitive impairment (MCI) and dementia. We conducted a literature review to examine the impact of yoga on persons with MCI and dementia. Eight studies were identified that reported on yoga as either the primary intervention or one component of a multi-component intervention in samples of persons with MCI or dementia. Results suggest that yoga may have beneficial effects on cognitive functioning, particularly on attention and verbal memory. Further, yoga may affect cognitive functioning through improved sleep, mood, and neural connectivity. There are a number of limitations of the existing studies, including a lack of intervention details, as well as variability in the frequency/duration and components of the yoga interventions. A further complicating issue is the role of various underlying etiologies of cognitive impairment. Despite these limitations, providers may consider recommending yoga to persons with MCI or dementia as a safe and potentially beneficial complementary health approach.

Feasibility of a Brief Yoga Intervention for Improving Acute Pain and Distress Post Gynecologic Surgery

BACKGROUND

Women undergoing surgical procedures for suspected gynecologic malignancies frequently experience pain and psychological distress related to surgery. Yoga may reduce these negative surgical outcomes. The primary objective of this pilot study was to assess the feasibility of evaluating a perioperative brief Yoga Skills Training (YST) in this population. Secondary objectives were to (1) assess the immediate effects of the YST on pain and psychological distress; and (2) provide preliminary data for future studies.

METHOD

Adult women scheduled to undergo an exploratory laparotomy for a suspected gynecologic malignancy were recruited to this one-arm feasibility study. Each woman received the YST, which consisted of three 15-minute sessions, one before and two after surgery. The following constructs were assessed: feasibility (rates of accrual, intervention adherence, measure completion, retention, and level of satisfaction), immediate effects of the YST (visual analogue scale ratings of pain and distress immediately before and after each session), and descriptive statistics for measures to be used in future studies.

RESULTS

Of the 33 eligible women, 18 were approached and 10 agreed to participate (mean age = 54.7 years; 90% White). Two women discontinued the study prior to starting the YST sessions. Of the eight participants who received the YST, five completed the pre-surgery session (63%) and seven completed (88%) both post-surgical sessions; one woman withdrew after one YST session. Participants reported high satisfaction with the YST. Acute pain and distress decreased from before to immediately after the YST session with moderate to large effects: pain, d's = -0.67 to -0.95; distress, d's = -0.66 to -1.08.

CONCLUSIONS

This study demonstrated reasonable indicators of feasibility. In addition, patients showed short-term reductions in pain and distress. Next steps include attention to improving staff availability and intervention implementation in order to feasibly evaluate the perioperative YST, which shows promise for reducing postoperative pain and distress.

Change in longitudinal trends in sleep quality and duration following breast cancer diagnosis: results from the Women's Health Initiative

Breast cancer survivors frequently report sleep problems, but little research has studied sleep patterns longitudinally. We examined trends in sleep quality and duration up to 15 years before and 20 years after a diagnosis of breast cancer, over time among postmenopausal women participating in the Women's Health Initiative (WHI). We included 12,098 participants who developed invasive breast cancer after study enrollment. A linear mixed-effects model was used to determine whether the time trend in sleep quality, as measured by the WHI Insomnia Rating Scale (WHIIRS), a measure of perceived insomnia symptoms from the past 4 weeks, changed following a cancer diagnosis. To examine sleep duration, we fit a logistic regression model with random effects for both short (<6 h) and long (≥9 h) sleep. In addition, we studied the association between depressive symptoms and changes in WHIIRS and sleep duration. There was a significantly slower increase in the trend of WHIIRS after diagnosis (β = 0.06; p = 0.03), but there were non-significant increases in the trend of the probability of short or long sleep after diagnosis. The probability of depressive symptoms significantly decreased, though the decrease was more pronounced after diagnosis (p < 0.01). Trends in WHIIRS worsened at a relatively slower rate following diagnosis and lower depression rates may explain the slower worsening in WHIIRS. Our findings suggest that over a long period of time, breast cancer diagnosis does not adversely affect sleep quality and duration in postmenopausal women compared to sleep pre-diagnosis, yet both sleep quality and duration continue to worsen over time.

A randomized preference trial of cognitive-behavioral therapy and yoga for the treatment of worry in anxious older adults

Background

Worry is a common problem among older adults. Cognitive-behavioral therapy is the most studied nonpharmacological intervention and it has demonstrated efficacy in reducing late-life worry and anxiety. Although the evidence-base is smaller, yoga has been shown to reduce anxiety and stress. However, little is known about the relative effectiveness of these two nonpharmacological interventions. Further, the impact of patient preference on outcomes is unknown.

Purpose: The purpose to this study is to compare the effectiveness of cognitive-behavioral therapy (CBT) with yoga for improving late-life worry, anxiety, and sleep. We will also examine the effects of preference and selection on outcomes, adherence, and attrition.

Methods

We are conducting a two-stage randomized preference trial comparing CBT and yoga for the reduction of worry in a sample of anxious older adults. Five hundred participants will be randomized to either the preference trial (participants choose the intervention; N = 250) or to the randomized trial (participants are randomized to one of the two interventions; N = 250) with equal probability. CBT consists of 10 telephone-based sessions with an accompanying workbook. Yoga consists of 10 weeks of group yoga classes (twice a week) that is modified for use with older adults.

Conclusions

The study design is based on feedback from anxious older adults who wanted more nonpharmacological options for intervention as well as more input into the intervention they receive. It is the first head-to-head comparison of CBT and yoga for reducing late-life worry and anxiety. It will also provide information about how intervention preference affects outcomes.

Trial registration

ClinicalTrials.gov NCT02968238.

Convenient and Live Movement (CALM) for women undergoing breast cancer treatment: Challenges and recommendations for internet-based yoga research

OBJECTIVE

To conduct a pilot trial of internet-based, cancer-adapted yoga for women receiving breast cancer treatment.

DESIGN

Women undergoing radiation or chemotherapy for breast cancer were recruited for 12, 75-min, biweekly, cancer-adapted yoga classes delivered via internet-based, multipoint videoconferencing. Data were collected on feasibility and acceptability, including qualitative feedback from participants and the yoga instructor.

RESULTS

Among 42 women approached, 13 declined eligibility screening, and 23 were ineligible. All 6 women who were eligible provided consent, but 2 withdrew prior to beginning yoga classes. The remaining 4 participants attended 1-11 of 12 online yoga classes. In post-intervention interviews, participants and the instructor agreed that internet-based yoga classes hold great potential for increasing access and improving psychological outcomes in adults with cancer. Qualitative feedback from participants revealed suggestions for future trials of internet-based, cancer-adapted yoga classes, including: continued use of group format; offering more varied class times to accommodate patients' demanding schedules and fluctuating symptoms; enrolling patients after they have acclimated to or completed cancer treatment; streamlining the technology interface; and careful attention to participant burden when designing surveys/forms. The instructor recommended closed session courses, as opposed to rolling enrollment; teaching the same modified poses for all participants, rather than individual tailoring; and using a large screen to allow closer monitoring of students' class experience.

CONCLUSIONS

Internet delivery may increase patients' access to cancer-adapted yoga classes, but cancer-related and technological barriers remain. This study informs how to optimally design yoga classes, technology, and research procedures to maximize feasibility and acceptability in future trials.

Long-Term Effects of Telephone-Delivered Psychotherapy for Late-Life GAD

OBJECTIVE

To examine the long-term effects of telephone-delivered cognitive-behavioral therapy (CBT-T) compared with nondirective supportive therapy (NST-T) in rural older adults with generalized anxiety disorder (GAD).

METHODS

141 adults aged 60 years and older with a principal/co-principal diagnosis of GAD were randomized to either CBT-T or NST-T. CBT-T consisted of up to 11 sessions (9 were required) focused on recognition of anxiety symptoms, relaxation, cognitive restructuring and use of coping statements, problem-solving, worry control, behavioral activation, exposure therapy, and relapse prevention, with optional chapters on sleep and pain. NST-T consisted of 10 sessions focused on providing a supportive atmosphere in which participants could share and discuss their feelings and did not provide any direct suggestions. Primary outcomes included interviewer-rated anxiety severity and self-report worry severity measured at 9 months and 15 months after randomization. Mood-specific secondary outcomes included self-report GAD symptoms and depressive symptoms.

RESULTS

At 15 months, after adjustment for multiple testing, there was a significantly greater decline in general anxiety symptoms (difference in improvement: 3.31; 95% CI: 0.45-6.17; t = 2.29; df = 136; p = 0.024) and worry (difference in improvement: 3.13; 95% CI: 0.59-5.68; t = 2.43; df = 136; p = 0.016) among participants in CBT-T compared with those in the NST-T group. There were no significant differences between the conditions in terms of depressive symptoms (difference in improvement: 2.88; 95% CI: 0.17-5.60; t = 2.10; df = 136; p = 0.0376) and GAD symptoms (difference in improvement: 1.65; 95% CI: -0.20 to 3.50; t = 1.76; df = 136; p = 0.080).

CONCLUSIONS

CBT-T is superior to NST-T in reducing worry and anxiety symptoms 1 year after completing treatment.

Effect of depression before breast cancer diagnosis on mortality among postmenopausal women

BACKGROUND

Few previous studies investigating depression before the diagnosis of breast cancer and breast cancer-specific mortality have examined depression measured at more than 1 time point. This study investigated the effect of depression (combining depressive symptoms alone with antidepressant use) measured at 2 time points before the diagnosis of breast cancer on all-cause mortality and breast cancer-specific mortality among older postmenopausal women.

METHODS

A large prospective cohort, the Women's Health Initiative, was used. The study included 3095 women with incident breast cancer who had measures of depressive symptoms and antidepressant use before their diagnosis at the baseline and at year 3. Multivariate Cox proportional hazards regression was used to estimate adjusted hazard ratios (HRs) between depression at the baseline, depression at year 3, and combinations of depression at these time points and all-cause mortality and breast cancer-specific mortality.

RESULTS

Depression at year 3 before a breast cancer diagnosis was associated with higher all-cause mortality after adjustments for multiple covariates (HR, 1.35; 95% confidence interval [CI], 1.02-1.78). There was no statistically significant association of baseline depression and all-cause mortality or breast cancer-specific mortality whether or not depression was also present at year 3. In women with late-stage (regional- or distant-stage) breast cancer, newly developed depression at year 3 was significantly associated with both all-cause mortality (HR, 2.00; 95% CI, 1.13-3.56) and breast cancer-specific mortality (HR, 2.42; 95% CI, 1.24-4.70).

CONCLUSIONS

Women with newly developed depression before the diagnosis of breast cancer had a modestly but significantly increased risk for death from any cause and for death from breast cancer at a late stage. Cancer 2017;123:3107-15. © 2017 American Cancer Society.

A brief yoga intervention implemented during chemotherapy: A randomized controlled pilot study

OBJECTIVES

Fatigue and other treatment-related symptoms (e.g., sleep disturbance) are critical targets for improving quality of life in patients undergoing chemotherapy. Yoga may reduce the burden of such symptoms. This study investigated the feasibility of conducting a randomized controlled study of a brief yoga intervention during chemotherapy for colorectal cancer.

DESIGN

We randomized adults with colorectal cancer to a brief Yoga Skills Training (YST) or an attention control (AC; empathic attention and recorded education).

SETTING

The interventions and assessments were implemented individually in the clinic while patients were in the chair receiving chemotherapy.

INTERVENTIONS

Both interventions consisted of three sessions and recommended home practice.

MAIN OUTCOME MEASURES

The primary outcome was feasibility (accrual, retention, adherence, data collection). Self-reported outcomes (i.e., fatigue, sleep disturbance, quality of life) and inflammatory biomarkers were also described to inform future studies.

RESULTS

Of 52 patients initially identified, 28 were approached, and 15 enrolled (age Mean = 57.5 years; 80% White; 60% Male). Reasons for declining participation were: not interested (n = 6), did not perceive a need (n = 2), and other (n = 5). Two participants were lost to follow-up in each group due to treatment changes. Thus, 75% of participants were retained in the YST and 71% in the AC arm. Participants retained in the study adhered to 97% of the in-person intervention sessions and completed all questionnaires.

CONCLUSIONS

This study demonstrated the feasibility of conducting a larger randomized controlled trial to assess YST among patients receiving chemotherapy for colorectal cancer. Data collected and challenges encountered will inform future research.

Randomized trial finds that prostate cancer genetic risk score feedback targets prostate-specific antigen screening among at-risk men

BACKGROUND

Prostate-specific antigen (PSA) screening may reduce death due to prostate cancer but leads to the overdiagnosis of many cases of indolent cancer. Targeted use of PSA screening may reduce overdiagnosis. Multimarker genomic testing shows promise for risk assessment and could be used to target PSA screening.

METHODS

To test whether counseling based on the family history (FH) and counseling based on a genetic risk score (GRS) plus FH would differentially affect subsequent PSA screening at 3 months (primary outcome), a randomized trial of FH versus GRS plus FH was conducted with 700 whites aged 40 to 49 years without prior PSA screening. Secondary outcomes included anxiety, recall, physician discussion at 3 months, and PSA screening at 3 years. Pictographs versus numeric presentations of genetic risk were also evaluated.

RESULTS

At 3 months, no significant differences were observed in the rates of PSA screening between the FH arm (2.1%) and the GRS-FH arm (4.5% with GRS-FH vs. 2.1% with FH: χ2 = 3.13, P = .077); however, PSA screening rates at 3 months significantly increased with given risk in the GRS-FH arm (P = .013). Similar results were observed for discussions with physicians at 3 months and PSA screening at 3 years. Average anxiety levels decreased after the individual cancer risk was provided (P = .0007), with no differences between groups. Visual presentation by pictographs did not significantly alter comprehension or anxiety.

CONCLUSIONS

This is likely the first randomized trial of multimarker genomic testing to report genomic targeting of cancer screening. This study found little evidence of concern about excess anxiety or overuse/underuse of PSA screening when multimarker genetic risks were provided to patients. Cancer 2016;122:3564-3575. © 2016 American Cancer Society.

Effects of Telephone-Delivered Cognitive-Behavioral Therapy and Nondirective Supportive Therapy on Sleep, Health-Related Quality of Life, and Disability

OBJECTIVES

The purpose of this study was to compare the effects of cognitive-behavioral therapy delivered by telephone (CBT-T) and telephone-delivered nondirective supportive therapy (NST-T) on sleep, health-related quality of life, and physical disability in rural older adults with generalized anxiety disorder.

METHODS

This was a secondary analysis of a randomized clinical trial on 141 rural-dwelling adults 60 years and older diagnosed with generalized anxiety disorder. Sleep was assessed with the Insomnia Severity Index. Health-related quality of life was assessed with the 36-item Short-Form Health Survey (SF-36). Physical disability was assessed with the Pepper Center Tool for Disability. Assessments occurred at baseline, 4 months, 9 months, and 15 months.

RESULTS

Insomnia declined in both groups from baseline to 4 months, with a significantly greater improvement among participants who received CBT-T. Similarly, Mental and Physical Component Summaries of the SF-36 declined in both groups, with a differential effect favoring CBT-T. Participants in both interventions reported declines in physical disability, although there were no significant differences between the two interventions. Improvements in insomnia were maintained at the 15-month assessment, whereas between-group differences shrank on the Mental and Physical Component Summaries of the SF-36 by the 15-month assessment.

CONCLUSION

CBT-T was superior to NST-T in reducing insomnia and improving health-related quality of life. The effects of CBT-T on sleep were maintained 1 year after completing the treatment.

Effect of Intensive Chemotherapy on Physical, Cognitive, and Emotional Health of Older Adults with Acute Myeloid Leukemia

OBJECTIVES

To measure short-term changes in physical and cognitive function and emotional well-being of older adults receiving intensive chemotherapy for acute myeloid leukemia (AML).

DESIGN

Prospective observational study.

SETTING

Single academic institution.

PARTICIPANTS

Individuals aged 60 and older with newly diagnosed AML who received induction chemotherapy (N = 49, mean age 70 ± 6.2, 56% male).

MEASUREMENTS

Geriatric assessment (GA) was performed during inpatient examination for AML and within 8 weeks after hospital discharge after induction chemotherapy. Measures were the Pepper Assessment Tool for Disability (activity of daily living, instrumental activity of daily living (IADL), mobility questions), Short Physical Performance Battery (SPPB), grip strength, Modified Mini-Mental State examination, Center for Epidemiologic Studies Depression Scale, and the Distress Thermometer. Changes in GA measures were assessed using paired t-tests. Analysis of variance models were used to evaluate relationships between GA variables and change in function over time.

RESULTS

After chemotherapy, IADL dependence worsened (mean 1.4 baseline vs 2.1 follow-up, P < .001), as did mean SPPB scores (7.5 vs 5.9, P = .02 for total). Grip strength also declined (38.9 ± 7.7 vs 34.2 ± 10.3 kg, P < .001 for men; 24.5 ± 4.8 vs 21.8 ± 4.7 kg, P = .007 for women). No significant changes in cognitive function (mean 84.7 vs 85.1, P = .72) or depressive symptoms (14.0 vs. 11.3, P = .11) were detected, but symptoms of distress declined (5.0 vs 3.2, P < .001). Participants with depressive symptoms at baseline and follow-up had greater declines in SPPB scores those without at both time points.

CONCLUSIONS

Short-term survivors of intensive chemotherapy for AML had clinically meaningful declines in physical function. These data support the importance of interventions to maintain physical function during and after chemotherapy. Depressive symptoms before and during chemotherapy may be linked to potentially modifiable physical function declines.

Prospective data from the Women’s Health Initiative on depressive symptoms, stress, and inflammation

This study examined the longitudinal association of depressive symptoms and stressful life events with inflammation in the Women’s Health Initiative. Women aged 50 years and older ( N = 7477) completed questionnaires assessing depressive symptoms and stressful life events at baseline and 15 years later. Serum measures of C-reactive protein were collected at both assessments. In bivariate analyses, C-reactive protein predicted 15-year depressive symptoms and stressful life events ( ps < .03) and baseline depressive symptoms and stressful life events predicted later C-reactive protein ( ps < .03). These longitudinal relationships were not maintained in multivariate adjusted analyses. Combined with previous research, this suggests the relationship between depression, stressful life events and inflammation attenuates with time.

Positive Psychosocial Functioning in Later Life: Use of Meaning-Based Coping Strategies by Nursing Home Residents

This study examined factors associated with positive psychosocial functioning in 94 cognitively intact nursing home residents reporting poor physical health. It was hypothesized that greater use of meaning-based coping strategies would be associated with higher levels of positive psychosocial functioning. Participants completed an interview containing measures of coping, affect, psychological well-being, depression, and activities of daily living. Findings suggest that meaning-based coping variables (positive reappraisal, perceived uplifts) accounted for significant variance in positive psychosocial variables but not distress variables. In contrast, physical health variables accounted for significant variance in distress but not positive psychosocial variables. Results support the view that the absence of distress does not necessarily imply optimal mental health. Thus, a comprehensive assessment of mental health in older adults requires inclusion of indices of both positive and negative psychological and social functioning.

Physical Functioning among Women 80 Years of Age and Older With and Without a Cancer History

BACKGROUND

Females 80 years and older comprise 22% of the total U.S. survivor population, yet the impact of cancer on the physical well-being of women is this age group has not been well characterized.

METHODS

We compared women, 80 years of age and older in the Women's Health Initiative extension 2, who did (n = 2,270) and did not (n = 20,272) have an adjudicated history of cancer during Women's Health Initiative enrollment; analyses focused on women >2-years postcancer diagnosis. The physical functioning subscale of the RAND-36 was the primary outcome. Demographic, health-status, and psychosocial covariates were drawn from Women's Health Initiative assessments. Analysis of covariance was used to examine the effect of cancer history on physical function, with and without adjustment for covariates.

RESULTS

In adjusted models, women with a history of cancer reported significantly lower mean physical functioning (56.6, standard error [SE] 0.4) than those without a cancer history (58.0, SE 0.1), p = .002. In these models, younger current age, lower body mass index, increased physical activity, higher self-rated health, increased reported happiness, and the absence of noncancer comorbid conditions were all associated with higher physical functioning in both women with and without a history of cancer.

CONCLUSIONS

Women older than 80 years of age with a cancer history have only a moderately lower level of physical function than comparably aged women without a cancer history. Factors associated with higher levels of physical functioning were similar in both groups.

Global Quality of Life Among WHI Women Aged 80 Years and Older

BACKGROUND

The number of older adults living to age 80 and older is increasing rapidly, particularly among women. Correlates of quality of life (QOL) in very advanced ages are not known. We examined the association of demographic, social-psychological, lifestyle, and physical health variables with global QOL in a Women's Health Initiative (WHI) cohort of women aged 80 and older.

METHODS

26,299 WHI participants, who had completed a recent psychosocial and medical update, were included in these analyses. Global QOL was assessed by a single item, asking the women to rate their overall QOL on a scale from 0 to 10. Characteristics of the women were examined by the level of their transformed global QOL scores (≤50, 50-70, ≥70), and multiple regression was used to examine which demographic, social-psychological, lifestyle and health variables were independently associated with higher global QOL.

RESULTS

Social-psychological and current health variables were more strongly associated with global QOL than a history of selected comorbid conditions. In particular, higher self-rated health and fewer depressive symptoms were the most strongly associated with better global QOL in WHI women ≥80 years.

CONCLUSIONS

Interventions to reduce depressive symptoms and improve health may lead to better self-reported health and global QOL among older women. Physical and mental health screenings followed by evidence-based interventions are imperative in geriatric care.

Trajectories of Posttraumatic Growth and Associated Characteristics in Women with Breast Cancer

BACKGROUND

Cancer survivors may experience posttraumatic growth (PTG), positive psychological changes resulting from highly stressful events; however, the longitudinal course of PTG is poorly understood.

PURPOSE

The purpose of the present study was to determine trajectories of PTG in breast cancer survivors and associated characteristics.

METHODS

Women (N = 653) participating in a longitudinal observational study completed questionnaires within 8 months of breast cancer diagnosis and 6, 12, and 18 months later. Group-based modeling identified PTG trajectories. Chi-square tests and ANOVA detected group differences in demographic, medical, and psychosocial variables.

RESULTS

Six trajectory groups emerged. Three were stable at different levels of PTG, two increased modestly, and one increased substantially over time. Trajectory groups differed by age, race, receipt of chemotherapy, illness intrusiveness, depressive symptoms, active-adaptive coping, and social support.

CONCLUSIONS

This first examination of PTG trajectories in US cancer survivors elucidates heterogeneity in longitudinal patterns of PTG. Future research should determine whether other samples exhibit similar trajectories and whether various PTG trajectories predict mental and physical health outcomes.

Barriers to Mental Health Treatment in Rural Older Adults

OBJECTIVES

The purpose of this study was to identify the barriers to seeking mental health treatment experienced by rural older adults. We also examined if barriers differed by age and worry severity.

METHODS

Participants were 478 rural older adults responding to a flyer for a psychotherapy intervention study. Interested participants were screened by telephone, and barriers to mental health treatment were assessed. Participants completed a demographic questionnaire and the Penn State Worry Questionnaire-Abbreviated.

RESULTS

The most commonly reported barrier to treatment was the personal belief that "I should not need help." Other commonly reported barriers included practical barriers (cost, not knowing where to go, distance), mistrust of mental health providers, not thinking treatment would help, stigma, and not wanting to talk with a stranger about private matters. Multivariable analyses indicated that worry severity and younger age were associated with reporting more barriers.

CONCLUSIONS

Multiple barriers interfere with older adults seeking treatment for anxiety and depression. Older age is associated with fewer barriers, suggesting that the oldest old may have found strategies for overcoming these barriers. Young-old adults may benefit from interventions addressing personal beliefs about mental health and alternative methods of service delivery.

A meta-analytic approach to examining the correlation between religion/spirituality and mental health in cancer

Religion and spirituality (R/S) are patient-centered factors and often are resources for managing the emotional sequelae of the cancer experience. Studies investigating the correlation between R/S (eg, beliefs, experiences, coping) and mental health (eg, depression, anxiety, well being) in cancer have used very heterogeneous measures and have produced correspondingly inconsistent results. A meaningful synthesis of these findings has been lacking; thus, the objective of this review was to conduct a meta-analysis of the research on R/S and mental health. Four electronic databases were systematically reviewed, and 2073 abstracts met initial selection criteria. Reviewer pairs applied standardized coding schemes to extract indices of the correlation between R/S and mental health. In total, 617 effect sizes from 148 eligible studies were synthesized using meta-analytic generalized estimating equations, and subgroup analyses were performed to examine moderators of effects. The estimated mean correlation (Fisher z) was 0.19 (95% confidence interval [CI], 0.16-0.23), which varied as a function of R/S dimensions: affective R/S (z = 0.38; 95% CI, 0.33-0.43), behavioral R/S (z = 0.03; 95% CI, -0.02-0.08), cognitive R/S (z = 0.10; 95% CI, 0.06-0.14), and 'other' R/S (z = 0.08; 95% CI, 0.03-0.13). Aggregate, study-level demographic and clinical factors were not predictive of the relation between R/S and mental health. There was little indication of publication or reporting biases. The correlation between R/S and mental health generally was positive. The strength of that correlation was modest and varied as a function of the R/S dimensions and mental health domains assessed. The identification of optimal R/S measures and more sophisticated methodological approaches are needed to advance research.