Documenting patients’ and providers’ preferences when proposing a randomized controlled trial: a qualitative exploration

Background

With advances in cancer diagnosis and treatment, women with early-stage breast cancer (ESBC) are living longer, increasing the number of patients receiving post-treatment follow-up care. Best-practice survivorship models recommend transitioning ESBC patients from oncology-provider (OP) care to community-based care. While developing materials for a future randomized controlled trial (RCT) to test the feasibility of a nurse-led Telephone Survivorship Clinic (TSC) for a smooth transition of ESBC survivors to follow-up care, we explored patients’ and OPs’ reactions to several of our proposed methods.

Methods

We used a qualitative study design with thematic analysis and a two-pronged approach. We interviewed OPs, seeking feedback on ways to recruit their ESBC patients for the trial, and ESBC patients, seeking input on a questionnaire package assessing outcomes and processes in the trial.

Results

OPs identified facilitators and barriers and offered suggestions for study design and recruitment process improvement. Facilitators included the novelty and utility of the study and simplicity of methods; barriers included lack of coordination between treating and discharging clinicians, time constraints, language barriers, motivation, and using a paper-based referral letter. OPs suggested using a combination of electronic and paper referral letters and supporting clinicians to help with recruitment. Patient advisors reported satisfaction with the content and length of the assessment package. However, they questioned the relevance of some questions (childhood trauma) while adding questions about trust in physicians and proximity to primary-care providers.

Conclusions

OPs and patient advisors rated our methods for the proposed trial highly for their simplicity and relevance then suggested changes. These findings document processes that could be effective for cancer-patient recruitment in survivorship clinical trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01549-1.

Correction to: Machine Learning for Identifying Emotional Expression in Text: Improving the Accuracy of Established Methods

[This corrects the article PMC7467127.].

Narrative-Informed, Emotion-Focused Psychotherapy in Synchronous, Online Chat Groups for Adolescents and Young Adults with Cancer: A Proof-of-Concept Study

Few, scalable, evidence-based psychosocial interventions exist for adolescent and young adult cancer survivors (AYAs, 18–39 years old). Using an existing, facilitated, online synchronous chat group-plus-education model (OSG+E), we replaced their educational workbook with an AYA-created film to stimulate an age-specific, emotion-focused group discussion (OSG+V). This randomized proof-of-concept trial compared the two models' content suitability, group processes, and feasibility over 9 months in 34 male and female AYAs with a range of cancers. AYAs rated the OSG + V model more suitable, cohesive, and as having higher levels of important group processes than the OSG+E. A larger randomized trial is feasible for this AYA-appropriate, emotion-focused OSG + V model.

A comparison of two models of follow-up care for adult survivors of childhood cancer

PURPOSE

Few studies have compared follow-up-care models for adult survivors of childhood cancer (ASCCs), though choice of model could impact medical test adherence, and health-related quality of life (QOL). This study compared two follow-up-care models, cancer-center-based versus community-based, for ASCCs in Alberta, Canada, to determine which model would demonstrate greater ASCC adherence to guideline-recommended medical screening tests for late effects, QOL, physical symptoms, and adherence to yearly follow-up.

METHODS

ASCC discharged to a community model (over 15 years) and those with comparable birth years (1973-1993) currently followed in a cancer center model were recruited via direct contact or multimedia campaign. Chart review identified chemotherapeutic and radiation exposures, and required medical late effect screening tests. ASCCs also completed questionnaires assessing QOL, physical symptoms, and follow-up behavior.

RESULTS

One hundred fifty-six survivors participated (community (n = 86); cancer center (n = 70)). Primary analysis indicated that cancer center ASCCs guideline-recommended total test adherence percentage (Mdn = 85.4%) was significantly higher than the community model (Mdn = 29.2%, U = 3996.50, p < 0.0001). There was no significant difference in QOL for cancer center ASCCs (M = 83.85, SD = 20.55 versus M = 77.50, SD = 23.94; t (154) = 1.77, p = 0.078) compared to community-based ASCCs. Cancer center-based ASCCs endorsed from 0.4-7.1% fewer physical symptom clusters, and higher adherence to follow-up behavior in comparisons using effect sizes without p values.

CONCLUSION

This study highlights the cancer center model's superiority for adherence to exposure-based medical late effect screening guidelines, cancer-specific follow-up behaviors, and the reporting of fewer physical complaints in ASCCs.

IMPLICATIONS FOR CANCER SURVIVORS

ASCCs followed in a cancer center model likely benefit from earlier late-effects detection and opportunities for early intervention.

Alberta CancerBridges development of a care plan evaluation measure

Background

No standardized measures specifically assess cancer survivors' and healthcare providers' experience of Survivor Care Plans (scps). We sought to develop two care plan evaluation (cpe) measures, one for survivors (cpe-s) and one for healthcare providers (cpe-p), examine initial psychometric qualities in Alberta, and assess generalizability in Manitoba, Canada.

Methods

We developed the initial measures using convenience samples of breast (n = 35) and head and neck (n = 18) survivors who received scps at the end of active cancer-centre treatment. After assessing Alberta's scp concordance with Institute of Medicine (iom) recommendations using a published coding scheme, we examined psychometric qualities for the cpe-s and cpe-p. We examined generalizability in Manitoba, Canada, with colorectal survivors discharged to primary care providers for follow-up (n = 75).

Results

We demonstrated acceptable internal consistency for the cpe-s and cpe-p subscales and total score after eliminating one item per subscale for cpe-s, two for cpe-p, resulting in revised scales with four 7-item and 6-item subscales, respectively. Subscale scores correlated highly indicating that for each measure the total score may be the most reliable and valid. We provide initial cpe-s discriminant, convergent, and predictive validity using the total score. Using the Manitoba sample, initial psychometrics similarly indicated good generalizability across differences in tumour groups, scp, and location.

Conclusions

We recommend the revised cpe-s and cpe-p for further use and development. Studies documenting the creation and standardization of scp evaluations are few, and we recommend further development of patient experience measures to improve both clinical practice and the specificity of research questions.

Depressive symptoms predict head and neck cancer survival: Examining plausible behavioral and biological pathways

BACKGROUND

Head and neck cancers are associated with high rates of depression, which may increase the risk for poorer immediate and long-term outcomes. Here it was hypothesized that greater depressive symptoms would predict earlier mortality, and behavioral (treatment interruption) and biological (treatment response) mediators were examined.

METHODS

Patients (n = 134) reported depressive symptomatology at treatment planning. Clinical data were reviewed at the 2-year follow-up.

RESULTS

Greater depressive symptoms were associated with significantly shorter survival (hazard ratio, 0.868; 95% confidence interval [CI], 0.819-0.921; P < .001), higher rates of chemoradiation interruption (odds ratio, 0.865; 95% CI, 0.774-0.966; P = .010), and poorer treatment response (odds ratio, 0.879; 95% CI, 0.803-0.963; P = .005). The poorer treatment response partially explained the depression-survival relation. Other known prognostic indicators did not challenge these results.

CONCLUSIONS

Depressive symptoms at the time of treatment planning predict overall 2-year mortality. Effects are partly influenced by the treatment response. Depression screening and intervention may be beneficial. Future studies should examine parallel biological pathways linking depression to cancer survival, including endocrine disruption and inflammation. Cancer 2018;124:1053-60. © 2018 American Cancer Society.

Protocol for the MATCH study (Mindfulness and Tai Chi for cancer health): A preference-based multi-site randomized comparative effectiveness trial (CET) of Mindfulness-Based Cancer Recovery (MBCR) vs. Tai Chi/Qigong (TCQ) for cancer survivors

PURPOSE

A growing number of cancer survivors suffer high levels of distress, depression and stress, as well as sleep disturbance, pain and fatigue. Two different mind-body interventions helpful for treating these problems are Mindfulness-Based Cancer Recovery (MBCR) and Tai Chi/Qigong (TCQ). However, while both interventions show efficacy compared to usual care, they have never been evaluated in the same study or directly compared. This study will be the first to incorporate innovative design features including patient choice while evaluating two interventions to treat distressed cancer survivors. It will also allow for secondary analyses of which program best targets specific symptoms in particular groups of survivors, based on preferences and baseline characteristics.

METHODS AND SIGNIFICANCE

The design is a preference-based multi-site randomized comparative effectiveness trial. Participants (N=600) with a preference for either MBCR or TCQ will receive their preferred intervention; while those without a preference will be randomized into either intervention. Further, within the preference and non-preference groups, participants will be randomized into immediate intervention or wait-list control. Total mood disturbance on the Profile of mood states (POMS) post-intervention is the primary outcome. Other measures taken pre- and post-intervention and at 6-month follow-up include quality of life, psychological functioning, cancer-related symptoms and physical functioning. Exploratory analyses investigate biomarkers (cortisol, cytokines, blood pressure/Heart Rate Variability, telomere length, gene expression), which may uncover potentially important effects on key biological regulatory and antineoplastic functions. Health economic measures will determine potential savings to the health system.

Machine Learning for Identifying Emotional Expression in Text: Improving the Accuracy of Established Methods

Expression of emotion has been linked to numerous critical and beneficial aspects of human functioning. Accurately capturing emotional expression in text grows in relevance as people continue to spend more time in an online environment. The Linguistic Inquiry and Word Count (LIWC) is a commonly used program for the identification of many constructs, including emotional expression. In an earlier study (Bantum & Owen, 2009) LIWC was demonstrated to have good sensitivity yet poor positive predictive value. The goal of the current study was to create an automated machine learning technique to mimic manual coding. The sample included online support groups, cancer discussion boards, and transcripts from an expressive writing study, which resulted in 39,367 sentence-level coding decisions. In examining the entire sample the machine learning approach outperformed LIWC, in all categories outside of Sensitivity for negative emotion (LIWC Sensitivity = .85; Machine Learning Sensitivity = .41), although LIWC does not take into consideration prosocial emotion, such as affection, interest, and validation. LIWC performed significantly better than the machine learning approach when removing the prosocial emotions (p = <.0001). The sample over-represented examples of emotion that fit into the overarching category of positive emotion. Remaining work is needed to create more effective machine learning features for codes that are thought to be important emotionally but were not well represented in the sample (e.g., frustration, contempt, and belligerence), and Machine Learning could be a fruitful method for continued exploration.

Barriers to care in two differing models of follow-up for long-term childhood cancer survivors

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Background: Long-term childhood cancer survivors (CCSs) require lifetime medical follow-up to screen for and treat adverse health outcomes related to cancer and its treatment. In Alberta, primary-care providers (PCPs) are involved in this follow-up care, though differently so in Northern and Southern regions of the province. Our aim was to identify potential province-wide and region-specific preferences and care barriers that may impact medical and quality-of-life outcomes for patients. Methods: Forty-four PCPs following CCSs completed surveys about knowledge gaps, communication, and health-system barriers. Knowledge gaps were assessed using a hypothetical case vignette followed by three multiple-choice questions regarding appropriate follow-up, based on available guidelines. Communication barriers were measured using a 6-item 5-point scale. Health-system barriers were measured using a 12-item 5-point scale. Results: PCPs were 54.54% female, age 31-72 ( m=51.36) with 1-50 years of practice ( m=22.49). These preliminary results suggest PCPs across Alberta are experiencing moderate communication barriers (scale: 0-24, m=10.85, SD=6.59) but fewer health-system barriers (scale: 0-48, m=14.58, SD=5.11). Scores on the case vignette were markedly low province-wide (scale: 0-3, m=0.65, SD=0.65), indicating considerable knowledge gaps regarding long-term oncology-related care follow-up. No statistically significant differences were observed between regions. Conclusions: Albertan PCPs are experiencing barriers to care and knowledge gaps when following ASCCs. This is of primary concern for PCPs in Southern Alberta, currently tasked with the sole responsibility of providing oncology-related follow-up care. These data will be linked with data collected from their patients to explore the relationship between PCPs’ barriers and knowledge, and the symptoms, quality of life, and unmet needs of their patients.

The Age Conundrum: A Scoping Review of Younger Age or Adolescent and Young Adult as a Risk Factor for Clinical Distress, Depression, or Anxiety in Cancer

This scoping review was conducted to understand the extent, range, and nature of current research on adolescents and young adults (AYA) with cancer and distress, depression, and anxiety (DDA). This information is necessary to find and aggregate valuable data on the AYA population embedded in generalized studies of DDA. Keyword searches of six relevant electronic databases identified 2156 articles, with 316 selected for abstract review and 40 for full text review. Full-text reviews and data extraction resulted in 34 studies being included, which ranged widely in design, sample size, age-range categorization, analysis methods, DDA measurement tool, overall study rigor, and quality of evidence. Studies very seldom reported using theory to guide their age categorization, with only four studies giving any rationale for their age-group definitions. All 34 studies found a significant association between at least one DDA construct and the younger age group relative to the older age groups at some point along the cancer trajectory. However, age as an independent risk factor for DDA is still unclear, as the relationship could be confounded by other age-related factors. Despite the wide range of definitions and effect sizes in the studies included in this review, one thing is clear: adolescents and young adults, however defined, are a distinct group within the cancer population with an elevated risk of DDA. Widespread adoption of a standard AYA age-range definition will be essential to any future meta-analytical psycho-oncology research in this population.

Illustrating the Multi-Faceted Dimensions of Group Therapy and Support for Cancer Patients

In cancer support groups, choice of therapy model, leadership style, and format can impact patients’ experiences and outcomes. Methodologies that illustrate the complexity of patients’ group experiences might aid in choosing group style, or testing therapeutic mechanisms. We used this naturalistic study as a beginning step to explore methods for comparing cancer group contexts by first modifying a group-experience survey to be cancer-specific (Group Experience Questionnaire (GEQ)). Hypothesizing that therapist-led (TL) would differ from non-therapist-led (NTL), we explored the GEQ’s multiple dimensions. A total of 292 patients attending three types of groups completed it: 2 TL groups differing in therapy style ((1) Supportive-Expressive (SET); (2) The Wellness Community (TWC/CSC)); (3) a NTL group. Participants rated the importance of “Expressing True Feelings” and “Discussing Sexual Concerns” higher in TL than NTL groups and “Discussing Sexual Concerns” higher in SET than other groups. They rated “Developing a New Attitude” higher in TWC/CSC compared to NTL. In addition, we depict the constellation of group qualities using radar-charts to assist visualization. These charts facilitate a quick look at a therapy model’s strengths and weaknesses. Using a measure like the GEQ and this visualization technique could enable health-service decision making about choice of therapy model to offer.

Discharge to Primary Care for Survivorship Follow-Up: How Are Patients With Early-Stage Breast Cancer Faring?

PURPOSE

Oncology centers in public health systems often transfer routine follow-up of patients with early-stage breast cancer (BC) to primary care physicians because of the increasing numbers of survivors and evidence supporting the safety of this practice. After transfer of care, it is unknown how BC survivors fare with treatment and surveillance goals, and whether they have unmet needs for access to specialist care. This study conducted in a sample of women in Alberta, Canada, examined adherence with follow-up guidelines, symptoms, and need for a telephone-based survivorship clinic.

METHODS

Through the Alberta Cancer Registry, we randomly invited women with stage I-III invasive BC (N=960) to participate. Of those, 272 responded, and 240 consented to a structured telephone interview and chart review.

RESULTS

Women adhered well to follow-up guidelines for mammogram, but less so for clinical examination and endocrine therapy (ET). However, most patients reported ongoing bothersome symptoms, which tended to be higher in those not on ET. More than one-third of patients reported ongoing needs (managing weight, side effects, exercise adherence, and psychosocial health). Younger, fatigued or depressed, nonurban women not on ET reported the most need for a telephone clinic.

CONCLUSIONS

Adherence with follow-up goals (examination, mammography, ET) was better than expected. Despite this, interest in a telephone survivorship clinic was high. Perceived needs included symptom management plus support for lifestyle behavior change. Medical follow-up needs might be well-met by discharge to primary care. However, high levels of ongoing symptoms and psychosocial needs would suggest that telephone-based survivorship clinics, psychosocial and exercise interventions, or transition programs might benefit the survivorship experience of patients with BC.

Patient-reported outcomes, body composition, and nutrition status in patients with head and neck cancer: Results from an exploratory randomized controlled exercise trial

BACKGROUND

Patients with head and neck cancer experience loss of weight and muscle mass, decreased functioning, malnutrition, depression, and declines in quality of life during and after treatment. The purpose of this exploratory randomized study was to determine the optimal timing for the initiation of a lifestyle and progressive resistance exercise training intervention (during or after radiation therapy), as determined by intervention adherence and by comparing between-group outcomes across 24 weeks.

METHODS

Sixty patients with head and neck cancer were randomized to engage in a 12-week lifestyle intervention and progressive resistance-training program either during radiation treatment or immediately after completion. The primary outcome of body composition--specifically, lean body mass, body mass index, and body fat--as well as secondary outcomes of fitness, quality of life, depression, and nutrition status were evaluated.

RESULTS

The progressive resistance-training intervention carried out during treatment did not significantly influence the primary outcome of body composition, despite a significant increase in weekly physical activity reported by the intervention group. A small-to-medium intervention effect was noted for some secondary outcomes, including fitness, quality of life, and nutrition status. Regardless of whether patients received the immediate or delayed progressive resistance-training intervention, the analysis revealed a main effect of time on body composition, fitness, quality of life, depression, and nutritional scores.

CONCLUSIONS

Although the intervention during treatment did not reduce the loss of lean body mass, delaying the exercise program until after treatment completion was associated with improved intervention adherence, a finding with important clinical implications.

Mindfulness-based cancer recovery and supportive-expressive therapy maintain telomere length relative to controls in distressed breast cancer survivors

BACKGROUND

Group psychosocial interventions including mindfulness-based cancer recovery (MBCR) and supportive-expressive group therapy (SET) can help breast cancer survivors decrease distress and influence cortisol levels. Although telomere length (TL) has been associated with breast cancer prognosis, the impact of these two interventions on TL has not been studied to date.

METHODS

The objective of the current study was to compare the effects of MBCR and SET with a minimal intervention control condition (a 1-day stress management seminar) on TL in distressed breast cancer survivors in a randomized controlled trial. MBCR focused on training in mindfulness meditation and gentle Hatha yoga whereas SET focused on emotional expression and group support. The primary outcome measure was relative TL, the telomere/single-copy gene ratio, assessed before and after each intervention. Secondary outcomes were self-reported mood and stress symptoms.

RESULTS

Eighty-eight distressed breast cancer survivors with a diagnosis of stage I to III cancer (using the American Joint Committee on Cancer (AJCC) TNM staging system) who had completed treatment at least 3 months prior participated. Using analyses of covariance on a per-protocol sample, there were no differences noted between the MBCR and SET groups with regard to the telomere/single-copy gene ratio, but a trend effect was observed between the combined intervention group and controls (F [1,84], 3.82; P = .054; η(2)  = .043); TL in the intervention group was maintained whereas it was found to decrease for control participants. There were no associations noted between changes in TL and changes in mood or stress scores over time.

CONCLUSIONS

Psychosocial interventions providing stress reduction and emotional support resulted in trends toward TL maintenance in distressed breast cancer survivors, compared with decreases in usual care.

Shame, guilt, and communication in lung cancer patients and their partners

Lung cancer patients report the highest distress levels of all cancer groups. In addition to poor prognosis, the self-blame and stigma associated with smoking might partially account for that distress and prevent patients from requesting help and communicating with their partners. The present study used innovative methods to investigate potential links of shame and guilt in lung cancer recovery with distress and marital adjustment. A specific emphasis was an examination of the impact of shame on partner communication. Lung cancer patients (n = 8) and their partners (n = 8) completed questionnaires and interviews that were videotaped. We report descriptive statistics and Spearman correlations between shame and guilt, relationship talk, marital satisfaction, distress, and smoking status. We coded the interviews for nonverbal expressions of shame. Greater self-reported shame was associated with decreased relationship-talk frequency and marital satisfaction, and with increased depression and smoking behaviour. Nonverbal shame behaviour also correlated with higher depression and increased smoking behaviour. Guilt results were more mixed. More recent smoking behaviour also correlated with higher depression. At a time when lung cancer patients often do not request help for distress, possibly because of shame, our preliminary study suggests that shame can also disrupt important partner relationships and might prevent patients from disclosing to physicians their need for psychosocial intervention and might increase their social isolation. Even if patients cannot verbally disclose their distress, nonverbal cues could potentially give clinicians an opportunity to intervene.

Deconstructing therapeutic mechanisms in cancer support groups: do we express more emotion when we tell stories or talk directly to each other?

Studies indicate that story-telling and emotional expression may be important therapeutic mechanisms. This study examined how they work together over 1 year of supportive-expressive group therapy (SET). Participants were 41 women randomized to SET. We coded emotional expression and story types (story vs. non-story) at the initial session, 4, 8, and 12 months. Women engaged in more storytelling in their initial than later sessions. In later sessions, women expressed significantly more emotion, specifically compassion and high-arousal positive affect. Direct communication (non-story) allowed more positive but also more defensive expression as women supported and challenged each other. Greater hostility in non-story and greater constrained anger during story were associated with increasing depression. Greater high-arousal positive affect in non-story and greater primary negative affect in story were associated with increasing social network size. These results inform clinicians about cues they might use to improve the effectiveness of cancer support groups.

Actigraphy-measured sleep disruption as a predictor of survival among women with advanced breast cancer

BACKGROUND

Poor sleep, prevalent among cancer survivors, is associated with disrupted hormonal circadian rhythms and poor quality of life. Using a prospective research design, this study aimed to clarify the relationship between objective measures of sleep efficiency and sleep disruption with survival among women with advanced breast cancer.

METHOD

We examined sleep quality and duration via wrist-worn actigraphy and sleep diaries for 3 days among 97 women in whom advanced breast cancer was diagnosed (age = 54.6 ± 9.8 years). Sleep efficiency was operationalized using actigraphy as the ratio of total sleep time to total sleep time plus wake after sleep onset.

RESULTS

As hypothesized, better sleep efficiency was found to predict a significant reduction in overall mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94-0.98; P < 0.001) at median 6 y follow-up. This relationship remained significant (HR, 0.94; 95% CI, 0.91-0.97; P < 0.001) even after adjusting for other known prognostic factors (age, estrogen receptor status, cancer treatment, metastatic spread, cortisol levels, and depression). Secondary hypotheses were also supported (after adjusting for baseline prognostic factors) showing that less wake after sleep onset (HR, 0.41; 95% CI, 0.25-0.67; P < 0.001), fewer wake episodes, (HR, 0.93; 95% CI, 0.88-0.98; P = 0.007); and shorter wake episode duration (HR, 0.29; 95% CI, 0.14-0.58; P < 0.001) also contributed to reductions in overall mortality.

CONCLUSIONS

These findings show that better sleep efficiency and less sleep disruption are significant independent prognostic factors in women with advanced breast cancer. Further research is needed to determine whether treating sleep disruption with cognitive behavioral and/or pharmacologic therapy could improve survival in women with advanced breast cancer.

Qualitative evaluation of care plans for Canadian breast and head-and-neck cancer survivors

BACKGROUND

Survivorship care plans (scps) have been recommended as a way to ease the transition from active cancer treatment to follow-up care, to reduce uncertainty for survivors in the management of their ongoing health, and to improve continuity of care. The objective of the demonstration project reported here was to assess the value of scps for cancer survivors in western Canada.

METHODS

The Alberta CancerBridges team developed, implemented, and evaluated scps for 36 breast and 21 head-and-neck cancer survivors. For the evaluation, we interviewed 12 of the survivors, 9 nurses who delivered the scps, and 3 family physicians who received the scps (n = 24 in total). We asked about satisfaction, usefulness, emotional impact, and communication value. We collected written feedback from the three groups about positive aspects of the scps and possible improvements (n = 85). We analyzed the combined data using qualitative thematic analysis.

RESULTS

Survivors, nurses, and family physicians agreed that scps could ease the transition to survivorship partly by enhancing communication between survivors and care providers. Survivors appreciated the individualized attention and the comprehensiveness of the plans. They described positive emotional impacts, but wanted a way to ensure that their physicians received the scps. Nurses and physicians responded positively, but expressed concern about the time required to implement the plans. Suggestions for streamlining the process included providing survivors with scp templates in advance, auto-populating the templates for the nurses, and creating summary pages for physicians.

CONCLUSIONS

The results suggest ways in which scps could help to improve the transition to cancer survivorship and provide starting points for larger feasibility studies.

Assessing the need for a nurse-led breast cancer telephone follow-up clinic in Alberta, Canada

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Background: Routine follow-up of breast cancer (BC) patients is largely transferred to primary care due to limited tertiary care resources and evidence supporting the acceptability and safety of this approach. It is unknown how BC survivors are faring in the community with treatment and surveillance goals, and if there is an unmet need for access to specialist care. Objectives of this cross-sectional study of BC survivors were to examine: concordance with endocrine therapy and follow-up recommendations; perceived need for help with achieving these recommendations; and, perceived need for a telephone follow-up clinic. Methods: Eligible participants were women with stage I-III BC diagnosed June 2006-September 2009 who had been seen in consultation at a tertiary cancer centre (TCC) in Alberta, Canada. 960 potentially eligible women were invited to participate via mail-out from the Alberta Cancer Registry. Consenting participants completed a structured telephone interview. Further patient, disease, endocrine therapy and surveillance data were obtained from the electronic chart and pharmacy databases. Results: 240 participants completed the telephone interview. 68.8% had been discharged from a TCC. 87.1% reported having had a clinical breast examination, and 97.1% with remaining breast tissue reported having had a surveillance mammogram within the past year. Concordance with endocrine therapy varied between pharmacy dispensing records (95.4%) versus self-report (82.0%). Top participant-identified gaps in post-treatment services were: side effect management, achieving body weight and physical activity goals, psychosocial health, and sexual health. 71.7% of participants reported that they would have used a telephone follow-up clinic. Factors associated with telephone follow-up clinic use included younger age, no endocrine therapy, fatigue, and non-urban residence. Conclusions: Concordance with measurable follow-up goals (exam, mammography, endocrine therapy) was better than expected. Despite this, interest in a nurse-led BC telephone follow-up clinic was high. Perceived needs included management of symptoms plus support for life-style behavior change.

Reflective research: supporting researchers engaged in analyzing end-of-life communication

OBJECTIVES

The objectives of this commentary are to: (1) identify unique aspects of communication at end-of-life as compared to more commonly studied healthcare encounters; (2) outline challenges and opportunities research team members may encounter in coding and analyzing end-of-life communication; and (3) offer recommendations for quantitative communication research teams. This commentary is based on ours and others' experiences in studying the communication among patients with terminal illnesses, their families and their providers. Provider-patient/caregiver communication at end-of-life has some differences as compared to other forms of healthcare communication and, thus, has implications for researcher response. Challenges and opportunities for research team members include gaining new knowledge, developing feelings of attachment to study participants, burn-out, and emotional and existential impact on personal life. Practical and psychological considerations for conducting end-of-life communication research are discussed.

CONCLUSIONS

Researchers engaged in the study of end-of-life interactions may experience unique challenges, potentially compromising the validity of the research results and interpretation of communication processes. A balance between likely coder emotions and objectivity must be achieved.

IMPLICATIONS

Anticipating and facilitating the research teams' reactions to end-of-life interactions while still maintaining scientific standards may be achieved by using a reflective, mindful approach.

Trait mindfulness, repression, suppression, and self-reported mood and stress symptoms among women with breast cancer

OBJECTIVE

This study sought to identify relationships between trait mindfulness, repressive, and suppressive emotional styles, and the relative importance of these traits in their association with self-reported psychological health among women with breast cancer.

METHOD

Of the 277 women with breast cancer accrued in the study, 227 (81.9%) completed a set of questionnaires assessing personality traits, stress symptoms, and mood.

RESULTS

High levels of mindfulness were associated with fewer stress-related symptoms and less mood disturbance, while high levels of suppression were associated with poorer self-reported health.

CONCLUSION

Individuals' dispositional ways to manage negative emotions were associated with the experience of symptoms and aversive moods. Helping patients cultivate mindful insights and reduce deliberate emotional inhibition may be a useful focus for psycho-oncological interventions.

Screening for distress, the 6th vital sign: common problems in cancer outpatients over one year in usual care: associations with marital status, sex, and age

BACKGROUND

Very few studies examine the longitudinal prevalence of problems and the awareness or use of clinical programs by patients who report these problems. Of the studies that examine age, gender and marital status as predictors of a range of patient outcomes, none examines the interactions between these demographic variables. This study examined the typical trajectory of common practical and psychosocial problems endorsed over 12 months in a usual-care sample of cancer outpatients. Specifically, we examined whether marital status, sex, age, and their interactions predicted these trajectories. We did not actively triage or refer patients in this study in order to examine the natural course of problem reports.

METHODS

Patients completed baseline screening (N = 1196 of 1707 approached) and the sample included more men (N = 696) than women (N = 498), average age 61.1 years. The most common diagnoses were gastrointestinal (27.1%), prostate (19.2%), skin (11.1%) and gynecological (9.2%). Among other measures, patients completed a Common Problem Checklist and Psychosocial Resources Use questions at baseline, 3, 6, and 12 months using paper and pencil surveys.

RESULTS

Results indicated that patients reported psychosocial problems more often than practical and both decreased significantly over time. Younger single patients reported more practical problems than those in committed relationships. Younger patients and women of all ages reported more psychosocial problems. Among a number of interesting interactions, for practical problems, single older patients improved more; whereas among married people, younger patients improved more. For psychosocial problems we found that older female patients improved more than younger females, but among males, it was younger patients who improved more. Young single men and women reported the most past-and future-use of services.

CONCLUSIONS

Younger women are particularly vulnerable to experiencing practical and psychosocial problems when diagnosed with cancer, but being married protects these younger women. Marriage appeared to buffer reports of both practical and psychosocial problems, and led to less awareness and use of services. Unexpectedly, young men reported the highest use of psychosocial services. This study informs clinical program development with information on these risk groups.

Exercise and nutrition for head and neck cancer patients: a patient oriented, clinic-supported randomized controlled trial

Background

Research on physical activity and nutrition interventions aimed at positively impacting symptom management, treatment-related recovery and quality of life has largely excluded head and neck (HN) cancer populations. This translates into a lack of clinical programming available for these patient populations. HN cancer patients deal with severe weight loss, with more than 70% attributed to lean muscle wasting, leading to extended recovery times, decreased quality of life (QoL), and impaired physical functioning. To date, interventions to address body composition issues have focused solely on diet, despite findings that nutritional therapy alone is insufficient to mitigate changes. A combined physical activity and nutrition intervention, that also incorporates important educational components known to positively impact behaviour change, is warranted for this population. Our pilot work suggests that there is large patient demand and clinic support from the health care professionals for a comprehensive program.

Methods/Design

Therefore, the purpose of the present study is to examine the impact and timing of a 12-week PA and nutrition intervention (either during or following treatment) for HN cancer patients on body composition, recovery, serum inflammatory markers and quality of life. In addition, we will examine the impact of a 12-week maintenance program, delivered immediately following the intervention, on adherence, patient-reported outcomes (i.e., management of both physical and psychosocial treatment-related symptoms and side-effects), as well as return to work.

Discussion

This research will facilitate advancements in patient wellness, survivorship, and autonomy, and carve the path for a physical-activity and wellness-education model that can be implemented in other cancer centers.

Trial registration

Current Controlled Trials NCT01681654

Contemplative/emotion training reduces negative emotional behavior and promotes prosocial responses

Contemplative practices are believed to alleviate psychological problems, cultivate prosocial behavior and promote self-awareness. In addition, psychological science has developed tools and models for understanding the mind and promoting well-being. Additional effort is needed to combine frameworks and techniques from these traditions to improve emotional experience and socioemotional behavior. An 8-week intensive (42 hr) meditation/emotion regulation training intervention was designed by experts in contemplative traditions and emotion science to reduce "destructive enactment of emotions" and enhance prosocial responses. Participants were 82 healthy female schoolteachers who were randomly assigned to a training group or a wait-list control group, and assessed preassessment, postassessment, and 5 months after training completion. Assessments included self-reports and experimental tasks to capture changes in emotional behavior. The training group reported reduced trait negative affect, rumination, depression, and anxiety, and increased trait positive affect and mindfulness compared to the control group. On a series of behavioral tasks, the training increased recognition of emotions in others (Micro-Expression Training Tool), protected trainees from some of the psychophysiological effects of an experimental threat to self (Trier Social Stress Test; TSST), appeared to activate cognitive networks associated with compassion (lexical decision procedure), and affected hostile behavior in the Marital Interaction Task. Most effects at postassessment that were examined at follow-up were maintained (excluding positive affect, TSST rumination, and respiratory sinus arrhythmia recovery). Findings suggest that increased awareness of mental processes can influence emotional behavior, and they support the benefit of integrating contemplative theories/practices with psychological models and methods of emotion regulation.

Decrease in depression symptoms is associated with longer survival in patients with metastatic breast cancer: a secondary analysis

PURPOSE

Numerous studies have examined the comorbidity of depression with cancer, and some have indicated that depression may be associated with cancer progression or survival. However, few studies have assessed whether changes in depression symptoms are associated with survival.

METHODS

In a secondary analysis of a randomized trial of supportive-expressive group therapy, 125 women with metastatic breast cancer (MBC) completed a depression symptom measure (Center for Epidemiologic Studies-Depression Scale [CES-D]) at baseline and were randomly assigned to a treatment group or to a control group that received educational materials. At baseline and three follow-up points, 101 of 125 women completed a depression symptom measure. We used these data in a Cox proportional hazards analysis to examine whether decreasing depression symptoms over the first year of the study (the length of the intervention) would be associated with longer survival.

RESULTS

Median survival time was 53.6 months for women with decreasing CES-D scores over 1 year and 25.1 months for women with increasing CES-D scores. There was a significant effect of change in CES-D over the first year on survival out to 14 years (P = .007) but no significant interaction between treatment condition and CES-D change on survival. Neither demographic nor medical variables explained this association.

CONCLUSION

Decreasing depression symptoms over the first year were associated with longer subsequent survival for women with MBC in this sample. Further research is necessary to confirm this hypothesis in other samples, and causation cannot be assumed based on this analysis.

Increasing the ranks of academic researchers in mental health: a multisite approach to postdoctoral fellowship training

This report highlights the use of multisite training for psychiatry and psychology postdoctoral fellows developing careers in academic clinical research in the field of mental health. The objective is to describe a model of training for young investigators to establish independent academic clinical research careers, including (1) program structure and eligibility, (2) program goals and development of a multisite curriculum, (3) use of technology for implementing the program across multiple sites, and (4) advantages and challenges of this multisite approach. In 2000, in collaboration with the Veterans Affairs (VA) Mental Illness Research, Education and Clinical Centers (MIRECCs), the VA Office of Academic Affiliations launched the Special Fellowship Program in Advanced Psychiatry and Psychology. Each of the 10 currently participating VA sites across the United States is affiliated with a MIRECC and an academic medical institution. In the first five years of this fellowship program, 83 fellows (34 psychiatrists and 49 psychologists) have participated. The success of this multisite approach is evidenced by the 58 fellows who have already graduated from the program: 70% have entered academic clinical research positions, and over 25 have obtained independent extramural grant support from the VA or the National Institutes of Health. Multisite training results in a greater transfer of knowledge and capitalizes on the nationwide availability of experts, creating unique networking and learning opportunities for trainees. The VA's multisite fellowship program plays a valuable role in preparing substantial numbers of psychiatry and psychology trainees for a range of academic clinical research and leadership positions in the field of mental health.

Effects of supportive-expressive group therapy on pain in women with metastatic breast cancer

OBJECTIVE

To examine whether a group intervention including hypnosis can reduce cancer pain and trait hypnotizability would moderate these effects.

DESIGN

This randomized clinical trial examined the effects of group therapy with hypnosis (supportive-expressive group therapy) plus education compared to an education-only control condition on pain over 12 months among 124 women with metastatic breast cancer.

MAIN OUTCOME MEASURES

Pain and suffering, frequency of pain, and degree of constant pain were assessed at baseline and 4-month intervals. Those in the treatment group also reported on their experiences using the hypnosis exercises.

RESULTS

Intention-to-treat analyses indicated that the intervention resulted in significantly less increase in the intensity of pain and suffering over time, compared to the education-only group, but had no significant effects on the frequency of pain episodes or amount of constant pain, and there was no interaction of the intervention with hypnotizability. Within the intervention group, highly hypnotizable participants, compared to those less hypnotizable, reported greater benefits from hypnosis, employed self-hypnosis more often outside of group, and used it to manage other symptoms in addition to pain.

CONCLUSION

These results augment the growing literature supporting the use of hypnosis as an adjunctive treatment for medical patients experiencing pain.

Does improving mood in depressed patients alter factors that may affect cardiovascular disease risk?

To determine if improvement in mood would ameliorate autonomic dysregulation, HPA dysfunction, typical risk factors and C-reactive protein in depressed patients with elevated cardiovascular disease risk (CVD), 48 depressed participants with elevated cardiovascular risk factors were randomized to a cognitive behavioral intervention (CBT) or a waiting list control (WLC) condition. Twenty non-depressed age and risk-matched controls were also recruited. Traditional risk factors (e.g., lipids, blood pressure) and C-reactive protein were assessed pre- and post-treatment six months later. Subjects also underwent a psychophysiological stress test while cardiovascular physiology was measured. Salivary cortisol was measured during the day and during the psychological stress test. At post-treatment, the CBT subjects were significantly less depressed than WLC subjects. There was no significant difference in change scores on any of the traditional risk factors or C-reactive protein, cortisol measures, or cardiovascular physiology, except for triglyceride levels and heart rate, which were significantly lower in treatment compared to control subjects. The normal controls exhibited no change in the variables measured during the same time. A significant improvement in mood may have little impact on most traditional or atypical risk factors, cortisol or cardiophysiology.

Vagal regulation, cortisol, and sleep disruption in women with metastatic breast cancer

STUDY OBJECTIVES

To determine the relationship between hypothalamic pituitary axis (HPA) dysregulation, vagal functioning, and sleep problems in women with metastatic breast cancer.

DESIGN

Sleep was assessed by means of questionnaires and wrist actigraphy for 3 consecutive nights. The ambulatory, diurnal variation in salivary cortisol levels was measured at 5 time points over 2 days. Vagal regulation was assessed via respiratory sinus arrhythmia (RSA(TF)) during the Trier Social Stress Task.

PARTICIPANTS

Ninety-nine women (54.6 +/- 9.62 years) with metastatic breast cancer.

RESULTS

Longer nocturnal wake episodes (r = 0.21, p = 0.04, N=91) were associated with a flatter diurnal cortisol slope. Sleep disruption was also associated with diminished RSA(TF). Higher RSA baseline scores were significantly correlated with higher sleep efficiency (r = 0.39, p = 0.001, N=68) and correspondingly lower levels of interrupted sleep (waking after sleep onset, WASO; r = -0.38, p = 0.002, N=68), lower average length of nocturnal wake episodes (r = -0.43, p < 0.001, N=68), and a lower self-reported number of hours of sleep during a typical night (r = -0.27, p = 0.02, N=72). Higher RSA AUC was significantly related to higher sleep efficiency (r = 0.45, p < 0.001, N=64), and a correspondingly lower number of wake episodes (r = -0.27, p = 0.04, N=64), lower WASO (r = -0.40, p = 0.001, N=64), and with lower average length of nocturnal wake episodes (r = -0.41, p = 0.001, N=64). While demographics, disease severity, and psychological variables all explained some portion of the development of sleep disruption, 4 of the 6 sleep parameters examined (sleep efficiency, WASO, mean number of waking episodes, average length of waking episode) were best explained by RSA.

CONCLUSIONS

These data provide preliminary evidence for an association between disrupted nocturnal sleep and reduced RSA the subsequent day, confirming an association between disrupted nocturnal sleep and flattened diurnal cortisol rhythm in women with metastatic breast cancer. They suggest that the stress-buffering effects of sleep may be associated with improved parasympathetic tone and normalized cortisol patterns during the day.

Detecting emotional expression in face-to-face and online breast cancer support groups

Accurately detecting emotional expression in women with primary breast cancer participating in support groups may be important for therapists and researchers. In 2 small studies (N = 20 and N = 16), the authors examined whether video coding, human text coding, and automated text analysis provided consistent estimates of the level of emotional expression. In Study 1, the authors compared coding from videotapes and text transcripts of face-to-face groups. In Study 2, the authors examined transcripts of online synchronous groups. The authors found that human text coding significantly overestimated Positive Affect and underestimated Defensive/Hostile Affect compared with video coding. They found correlations were low for Positive Affect but moderate for negative affect between Linguistic Inquiry Word Count (LIWC) and video coding. The implications of utilizing text-only detection of emotion are discussed.

Supportive-expressive group therapy for primary breast cancer patients: a randomized prospective multicenter trial

OBJECTIVE

The aim is to evaluate the effectiveness of a manualized 12-week supportive-expressive group therapy program among primary breast cancer patients treated in community settings, to determine whether highly distressed patients were most likely to benefit and whether therapist's training or experience was related to outcome.

METHOD

Three hundred and fifty-three women within one year of diagnosis with primary breast cancer were randomly assigned to receive supportive-expressive group therapy or to an education control condition. Participants were recruited from two academic centers and nine oncology practices, which were members of NCI's Community Clinical Oncology Program (CCOP) and were followed over 2 years.

RESULTS

A 2x2x19 analysis of variance was conducted with main effects of treatment condition, cohort, and baseline distress and their interactions. There was no main effect for treatment condition after removing one subject with an extreme score. Highly distressed women did not derive a greater benefit from treatment. Therapist training and psychotherapy experience were not associated with a treatment effect.

CONCLUSIONS

This study provides no evidence of reduction in distress as the result of a brief supportive-expressive intervention for women with primary breast cancer. Future studies might productively focus on women with higher initial levels of distress.

Exploring Emotion-Regulation and Autonomic Physiology in Metastatic Breast Cancer Patients: Repression, Suppression, and Restraint of Hostility

We examined relationships between three emotion-regulation constructs and autonomic physiology in metastatic breast cancer patients (N = 31). Autonomic measures are not often studied in breast cancer patients and may provide evidence of an increase in allostatic load. Patients included participated as part of a larger clinical trial of supportive-expressive group therapy. Systolic and diastolic blood pressure and heart rate were assessed at a semi-annual follow-up. We averaged 3 resting assessments and used measures of Repression, Suppression, Restraint of Hostility, and Body Mass Index as predictors of autonomic response. We found that higher repression was significantly associated with higher diastolic blood pressure, while higher restraint of hostility was significantly associated with higher systolic blood pressure. A repressive emotion regulation style may be a risk factor for higher sympathetic activation possibly increasing allostatic load, while restraint of hostility may be a protective factor for women with metastatic breast cancer.

Effects of supportive-expressive group therapy on survival of patients with metastatic breast cancer: a randomized prospective trial

BACKGROUND

This study was designed to replicate our earlier finding that intensive group therapy extended survival time of women with metastatic breast cancer. Subsequent findings concerning the question of whether such psychosocial support affects survival have been mixed.

METHODS

One hundred twenty-five women with confirmed metastatic (n = 122) or locally recurrent (n = 3) breast cancer were randomly assigned either to the supportive-expressive group therapy condition (n = 64), where they received educational materials plus weekly supportive-expressive group therapy, or to the control condition (n = 61), where they received only educational materials for a minimum of 1 year. The treatment, 90 minutes once a week, was designed to build new bonds of social support, encourage expression of emotion, deal with fears of dying and death, help restructure life priorities, improve communication with family members and healthcare professionals, and enhance control of pain and anxiety.

RESULTS

Overall mortality after 14 years was 86%; median survival time was 32.8 months. No overall statistically significant effect of treatment on survival was found for treatment (median, 30.7 months) compared with control (median, 33.3 months) patients, but there was a statistically significant intervention site-by-condition interaction. Exploratory moderator analysis to explain that interaction revealed a significant overall interaction between estrogen-receptor (ER) status and treatment condition (P = .002) such that among the 25 ER-negative participants, those randomized to treatment survived longer (median, 29.8 months) than ER-negative controls (median, 9.3 months), whereas the ER-positive participants showed no treatment effect.

CONCLUSIONS

The earlier finding that longer survival was associated with supportive-expressive group therapy was not replicated. Although it is possible that psychosocial effects on survival are relevant to a small subsample of women who are more refractory to current hormonal treatments, further research is required to investigate subgroup differences.

Stress history and breast cancer recurrence

BACKGROUND

There is mixed evidence regarding the possible association between a history of stressful or traumatic life events and more rapid breast cancer progression.

METHOD

Retrospective reports of past experiences of traumatic life events were assessed among 94 women with metastatic or recurrent breast cancer. A traumatic event assessment was conducted using the event-screening question from the posttraumatic stress disorder (PTSD) module of the Structured Clinical Interview for the DSM-IV-TR (SCID; 2002). Each reported event was judged by two independent raters to determine whether it met DSM-IV-TR PTSD A1 criteria for a traumatic event. Those events that did not meet such criteria were designated "stressful events."

RESULTS

Nearly 42% of the women in the sample were judged to have experienced one or more traumatic events; 28.7% reported only stressful events. A Kruskal-Wallis test found significant differences in disease-free interval among the three groups [chi2 (2, N=94)=6.09, P<.05]. Planned comparisons revealed a significantly longer disease-free interval among women who had reported no traumatic or stressful life events (median=62 months) compared to those who had experienced one or more stressful or traumatic life events (combined median=31 months).

CONCLUSIONS

A history of stressful or traumatic life events may reduce host resistance to tumor growth. These findings are consistent with a possible long-lasting effect of previous life stress on stress response systems such as the hypothalamic-pituitary-adrenal (HPA) axis.

Stress sensitivity in metastatic breast cancer: analysis of hypothalamic-pituitary-adrenal axis function

The normal diurnal cortisol cycle has a peak in the morning, decreasing rapidly over the day, with low levels during the night, then rising rapidly again to the morning peak. A pattern of flatter daytime slopes has been associated with more rapid cancer progression in both animals and humans. We studied the relationship between the daytime slopes and other daytime cortisol responses to both pharmacological and psychosocial challenges of hypothalamic-pituitary-adrenal (HPA) axis function as well as DHEA in a sample of 99 women with metastatic breast cancer, in hopes of elucidating the dysregulatory process. We found that the different components of HPA regulation: the daytime cortisol slope, the rise in cortisol from waking to 30 min later, and cortisol response to various challenges, including dexamethasone (DEX) suppression, corticotrophin releasing factor (CRF) activation, and the Trier Social Stress Task, were at best modestly associated. Escape from suppression stimulated by 1mg of DEX administered the night before was moderately but significantly associated with flatter daytime cortisol slopes (r=0.28 to .30 at different times of the post DEX administration day, all p<.01). Daytime cortisol slopes were also moderately but significant associated with the rise in cortisol from waking to 30 min after awakening (r=.29, p=.004, N=96), but not with waking cortisol level (r=-0.13, p=.19). However, we could not detect any association between daytime cortisol slope and activation of cortisol secretion by either CRF infusion or the Trier Social Stress Task. The CRF activation test (following 1.5mg of DEX to assure that the effect was due to exogenous CRF) produced ACTH levels that were correlated (r=0.66, p<.0001, N=74) with serum cortisol levels, indicating adrenal responsiveness to ACTH stimulation. Daytime cortisol slopes were significantly correlated with the slope of DHEA (r=.21, p=.04, N=95). Our general findings suggest that flatter daytime cortisol slopes among metastatic breast cancer patients may be related to disrupted feedback inhibition rather than hypersensitivity in response to stimulation.

Depression and stress reactivity in metastatic breast cancer

OBJECTIVE

Cancer-related distress due to the psychological and physical challenges of metastatic breast cancer (MBC) may result in symptoms of depression, which negatively affects quality and may influence quantity of life. This study investigated how depression affects MBC stress reactivity, including autonomic (ANS) and hypothalamic-pituitary-adrenal (HPA) axis function.

METHOD

Forty-five nondepressed and 45 depressed patients with MBC underwent a modified Trier Social Stress Test (TSST) while affect, cardiovascular, respiratory, and cortisol responses were measured.

RESULTS

At study entry, depressed compared with nondepressed patients had significantly lower log cortisol waking rise levels (p = .005) but no other HPA differences. Positive affect (p = .025) and high-frequency heart-rate variability (lnHF) (p = .002) were significantly lower at TSST baseline in depressed patients. In response to the TSST, depressed patients reported significantly lower positive (p = .050) and greater negative affect (p = .037) and had significantly reduced lnHF (p = .031). In secondary analyses, at TSST baseline both low-frequency (lnLF) (p = .002) and very-low-frequency (lnVLF) (p = .0001) heart rate variability were significantly lower in the depressed group. In secondary analyses during the TSST, those who were depressed had significantly lower lnVLF (p = .008) and did not increase aortic impedance reactivity as much as did the nondepressed during the stressor (p = .005).

CONCLUSION

Depression in patients with MBC was associated with alterations in autonomic regulation, particularly reductions in respiratory sinus arrhythmia, a measure of cardiac vagal control, at baseline and during the TSST. In addition, depression was associated with blunted HPA response to awakening. Both MBC groups had relative cortisol hyporesponsiveness to acute stress.

The abuse-related beliefs questionnaire for survivors of childhood sexual abuse

OBJECTIVE

To evaluate the psychometric properties of a new measure, the Abuse-Related Beliefs Questionnaire (ARBQ), designed to assess abuse-related beliefs among adult survivors of childhood sexual abuse (CSA). Study 1 examined the structure of the scale, and Study 2 evaluated its reliability and validity.

METHOD

One hundred and seventy female CSA survivors recruited into a group psychotherapy intervention study were administered the ARBQ in Study 1. A subsample of 45 women completed the ARBQ again 12 months later. In Study 2, 70 women from a health maintenance organization who identified themselves as survivors of CSA completed the ARBQ along with the Trauma Symptom Checklist-40 (TSC-40) and the Symptom Checklist 90R (SCL-90-R).

RESULTS

Three reliable ARBQ subscales emerged in Study 1: Guilt, Shame, and Resilience. Twelve-month test-retest reliability was high (r=.60-.64). The internal consistency of the subscales was further supported in Study 2, and validity was demonstrated by moderate to high correlations with the distress measures.

CONCLUSIONS

The results indicate that the ARBQ has good psychometric characteristics, supporting the feasibility of its use in measuring abuse-related beliefs in research on survivors of CSA. A next step for validation of the ARBQ would be to evaluate its sensitivity in measuring changes in studies of interventions for treating CSA survivors.

Self-report and linguistic indicators of emotional expression in narratives as predictors of adjustment to cancer

Emotional expression and cognitive efforts to adapt to cancer have been linked to better psychological adjustment. However, little is known about the relationship between linguistic indicators of emotional and cognitive coping efforts and corresponding self-report measures of related constructs. In this study, we sought to evaluate the interrelationships between self-reports of emotional suppression and linguistic indicators of emotional and cognitive coping efforts in those living with cancer. Seventy-one individuals attending a community cancer support group completed measures of emotional suppression and mood disturbance and provided a written narrative describing their cancer experience. Self-reports of emotional suppression were associated with more rather than less distress. Although linguistic indicators of both emotional expression and cognitive processing were generally uncorrelated with self-report measures of emotional suppression and mood disturbance, a significant interaction was observed between emotional suppression and use of cognitive words on mood disturbance. Among those using higher levels of emotional suppression, increasing use of cognitive words was associated with greater levels of mood disturbance. These findings have implications for a) the therapeutic use of emotion in psychosocial interventions and b) the use of computer-assisted technologies to conduct content analysis.