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Dhawale T, Johnson PC, Boateng K, Barata A, Traeger L, Nelson AM, Lavoie MW, Holmbeck K, Choe J, Nabily A, Tripathi A, Amonoo HL, Frigault M, El-Jawahri A. Communication About Chimeric Antigen Receptor T-Cell (CAR-T) Therapy. Transplant Cell Ther 2024; 30:402.e1-402.e12. [PMID: 38262530 DOI: 10.1016/j.jtct.2024.01.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 01/25/2024]
Abstract
Chimeric Antigen Receptor T-cell (CAR-T) therapy has revolutionized the treatment of patients with hematologic malignancies, yet treatment may coincide with the potential for life-threatening toxicities. Currently, no studies have investigated how oncologists communicate with patients about CAR-T therapy or what patients and their caregivers want to know prior to consenting for CAR-T therapy. This study characterizes the content of oncologist communication with patients and caregivers about the risks and benefits of CAR-T therapy and explore the information preferences of patients and their caregivers about CAR-T therapy. We conducted a multimethod study of 20 patients with hematologic malignancies referred for CAR-T therapy at the Massachusetts General Hospital and 10 caregivers. We audio recorded the initial outpatient visit with the oncologist to review and sign consent for CAR-T therapy. We subsequently surveyed patients and caregivers about information gaps that remained after consent. We then interviewed patients and caregiver about their perceptions of oncologist communication and information preferences after the consent visit, 1 month, and 3 months post-CAR-T therapy treatment. Qualitative data analysis was conducted using the framework approach. Six major themes regarding communication about CAR-T therapy were identified: (1) oncologists create a narrative of power and innovation about CAR-T therapy, (2) oncologists set clear expectations regarding CAR-T therapy, (3) oncologists preferentially discuss positive treatment outcomes and less frequently address treatment failures or uncertainties, (4) oncologists couple their discussion about risks of CAR-T therapy with assurances about risk mitigation strategies, (5) oncologists engage in empathetic communication throughout the consent visit, (6) patients and caregivers vary in their preferences regarding communication about CAR-T therapy but largely favor a positive discourse during the consent visit and (7) patients who completed CAR-T therapy and their caregivers report significant knowledge gaps during and after treatment. Overall, patients and caregivers felt well informed about CAR T-therapy yet identified communication gaps regarding, advanced care planning, treatment failure and treatment toxicities. A predominantly positive discourse between patients, caregivers, and oncologists around CAR-T therapy leaves patients and caregivers with significant knowledge gaps about negative outcomes. Further research is needed to help oncologists communicate about treatment uncertainties and help patients and their caregivers prepare for negative outcomes of CAR-T therapy.
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Affiliation(s)
- Tejaswini Dhawale
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts.
| | - P Connor Johnson
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Kofi Boateng
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Anna Barata
- Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Lara Traeger
- Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashley M Nelson
- Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Mitchell W Lavoie
- University of Massachusetts T.H. Chan School of Medicine, Worcester, Massachusetts
| | - Katherine Holmbeck
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Joanna Choe
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Anisa Nabily
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Astha Tripathi
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Hermioni L Amonoo
- Harvard Medical School, Boston, Massachusetts; Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Matt Frigault
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Nelson AM, Yang D, Jagielo AD, D'Alotto J, Poliquin C, Rabideau DJ, Cronin KG, Newcomb RA, Chen YB, DeFilipp Z, Greer JA, El-Jawahri A, Traeger L. Group Coping Intervention in Patients With Chronic Graft-Versus-Host Disease: A Pilot Randomized Clinical Trial. J Natl Compr Canc Netw 2024; 22:34-42. [PMID: 38394783 DOI: 10.6004/jnccn.2023.7080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/31/2023] [Indexed: 02/25/2024]
Abstract
BACKGROUND More than half the long-term survivors of allogeneic hematopoietic cell transplantation develop chronic graft-versus-host disease (GVHD), a debilitating inflammatory syndrome. Supportive interventions to assist survivors in coping with chronic GVHD are critically needed. PATIENTS AND METHODS We conducted a pilot randomized clinical trial of a multidisciplinary group intervention (Horizons Program; n=39) versus minimally enhanced usual care (n=41) for patients with moderate or severe chronic GVHD. Horizons participants received 8 weekly sessions about GVHD and coping co-led by a transplant clinician and a behavioral health expert via a secure videoconferencing platform. Participants completed the following surveys before randomization, at 10 weeks, and at 18 weeks: Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale (FACT-BMT) for quality of life (QoL), Lee Symptom Scale for symptom burden, and Hospital Anxiety and Depression Scale-Depression Symptoms (HADS) for mood. The primary endpoint was feasibility (≥50% enrollment, ≥80% attendance in half the sessions for the Horizons arm only, and ≥80% retention). We also explored preliminary efficacy of the Horizons intervention on changes in patient-reported outcomes with linear mixed effects models and estimates of effect size at 10 weeks. RESULTS We enrolled and registered 80 (67.2%) of 119 eligible patients (mean age, 62 years; 48.8% female). Of the participants in the Horizons Program, 84.6% attended at least half the sessions. Of registered participants, 91.3% completed assessment follow-ups (Horizons, 35/39 [89.7%]; minimally enhanced usual care, 38/41 [92.7%]). Horizons participants reported improvements in QoL (b = 2.24; d=0.53), anxiety symptoms (b = -0.10; d=0.34), and depression symptoms (b = -0.71; d=0.44) compared with participants who received minimally enhanced usual care. CONCLUSIONS Participation in a multidisciplinary group intervention study was feasible for patients with chronic GVHD, with promising signals for improving QoL and mood. A full-scale efficacy trial is needed to confirm effects on patient-reported outcomes.
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Affiliation(s)
- Ashley M Nelson
- 1Massachusetts General Hospital, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
| | - Daniel Yang
- 1Massachusetts General Hospital, Boston, Massachusetts
| | | | - Jennifer D'Alotto
- 1Massachusetts General Hospital, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
| | - Cathleen Poliquin
- 1Massachusetts General Hospital, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
| | - Dustin J Rabideau
- 1Massachusetts General Hospital, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
| | | | - Richard A Newcomb
- 1Massachusetts General Hospital, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
| | - Yi-Bin Chen
- 1Massachusetts General Hospital, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
| | - Zachariah DeFilipp
- 1Massachusetts General Hospital, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- 1Massachusetts General Hospital, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- 1Massachusetts General Hospital, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
| | - Lara Traeger
- 1Massachusetts General Hospital, Boston, Massachusetts
- 3University of Miami, Coral Gables, Florida
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Traeger L, Bedrikovetski S, Nguyen TM, Kwan YX, Lewis M, Moore JW, Sammour T. The impact of preoperative sarcopenia on postoperative ileus following colorectal cancer surgery. Tech Coloproctol 2023; 27:1265-1274. [PMID: 37184771 PMCID: PMC10638111 DOI: 10.1007/s10151-023-02812-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE Sarcopenia is associated with poor short- and long-term patient outcomes following colorectal surgery. Despite postoperative ileus (POI) being a major complication following colorectal surgery, the predictive value of sarcopenia for POI is unclear. We assessed the association between sarcopenia and POI in patients with colorectal cancer. METHODS Elective colorectal cancer surgery patients were retrospectively included (2018-2022). The cross-sectional psoas area was calculated using preoperative staging imaging at the level of the 3rd lumbar vertebrae. Sarcopenia was determined using gender-specific cut-offs. The primary outcome POI was defined as not achieving GI-2 by day 4. Demographics, operative characteristics, and complications were compared via univariate and multivariate analyses. RESULTS Of 297 patients, 67 (22.6%) were sarcopenic. Patients with sarcopenia were older (median 74 (IQR 67-82) vs. 69 (58-76) years, p < 0.001) and had lower body mass index (median 24.4 (IQR 22.2-28.6) vs. 28.8 (24.9-31.9) kg/m2, p < 0.001). POI was significantly more prevalent in patients with sarcopenia (41.8% vs. 26.5%, p = 0.016). Overall rate of complications (85.1% vs. 68.3%, p = 0.007), Calvien-Dindo grade > 3 (13.4% vs. 10.0%, p = 0.026) and length of stay were increased in patients with sarcopenia (median 7 (IQR 5-12) vs. 6 (4-8) days, p = 0.013). Anastomotic leak rate was higher in patients with sarcopenia although the difference was not statistically significant (7.5% vs. 2.6%, p = 0.064). Multivariate analysis demonstrated sarcopenia (OR 2.0, 95% CI 1.1-3.8), male sex (OR 1.9, 95% CI 1.0-3.5), postoperative hypokalemia (OR 3.2, 95% CI 1.6-6.5) and increased opioid use (OR 2.4, 95% CI 1.3-4.3) were predictive of POI. CONCLUSION Sarcopenia demonstrates an association with POI. Future research towards truly identifying the predictive value of sarcopenia for postoperative complications could improve informed consent and operative planning for surgical patients.
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Affiliation(s)
- L Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia.
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.
| | - S Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - T M Nguyen
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
| | - Y X Kwan
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - M Lewis
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
| | - J W Moore
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - T Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
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Kuhlthau KA, Traeger L, Luberto CM, Perez GK, Goshe BM, Fell L, Iannuzzi D, Park ER. Resiliency Intervention for Siblings of Children With Autism Spectrum Disorder: A Randomized Pilot Trial. Acad Pediatr 2023; 23:1187-1195. [PMID: 36460184 DOI: 10.1016/j.acap.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND /OBJECTIVES Neurotypical siblings (NT siblings) of children with autism spectrum disorder (ASD) are at elevated risk for emotional distress and adjustment problems. Resiliency is the ability to cope and adapt with ongoing stressors. We conducted a randomized waitlist-controlled pilot trial to examine the feasibility, acceptability, and preliminary efficacy of an adapted virtual mind-body resiliency group intervention for teen NT siblings of children with ASD. METHODS We modified the Stress Management and Resiliency Training-Relaxation Response Resiliency Program for NT siblings of children with ASD (SibChat). We randomly assigned teens (aged 14-17) to immediate intervention (IG) versus waitlist control (WLC). The intervention included eight 60-minute weekly video conference group sessions. We assessed feasibility (enrollment, attendance, and retention) and acceptability (post treatment survey and weekly relaxation response practice). We explored group differences in pre-post change scores for 1) stress coping (Measure of Current Status-A) and 2) resiliency (Current Experiences Scale) using independent samples t tests and effect size calculations. RESULTS We enrolled 83% of screened eligible teens. A total of 90% IG and 75% WLC participants attended at least 6/8 sessions. Among IG participants who completed the post treatment survey, 79% reported practicing relaxation response exercises at least "a few times a week". Comparing change in baseline to time 1, the IG showed better relative changes than the WLC group in stress coping (d = 0.60) and resiliency (d = 0.24). CONCLUSIONS Our pilot trial showed promising feasibility, acceptability, and preliminary efficacy of SibChat on at least one of the 2 primary outcomes supporting further testing of the SibChat intervention. CLINICAL TRIAL REGISTRATION US National Library of Medicine. REGISTRATION NUMBER NCT04369417. https://clinicaltrials.gov/ct2/show/NCT04369417.
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Affiliation(s)
- Karen A Kuhlthau
- Division of General Academic Pediatrics (KA Kuhlthau, L Fell, and D Iannuzzi), Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Mass; Department of Pediatrics (KA Kuhlthau), Harvard Medical School, Boston, Mass.
| | - Lara Traeger
- Department of Psychiatry (L Traeger, CM Luberto, GK Perez, BM Goshe, and ER Park), Massachusetts General Hospital/Harvard Medical School, Boston, Mass; Health Promotion and Resiliency Intervention Research Program (L Traeger, CM Luberto, GK Perez, and ER Park), Massachusetts General Hospital, Departments of Psychiatry & Medicine, Boston, Mass
| | - Christina M Luberto
- Department of Psychiatry (L Traeger, CM Luberto, GK Perez, BM Goshe, and ER Park), Massachusetts General Hospital/Harvard Medical School, Boston, Mass; Health Promotion and Resiliency Intervention Research Program (L Traeger, CM Luberto, GK Perez, and ER Park), Massachusetts General Hospital, Departments of Psychiatry & Medicine, Boston, Mass; MGH Benson-Henry Institute for Mind-Body Medicine (CM Luberto, GK Perez, BM Goshe, and ER Park), Boston, Mass
| | - Giselle K Perez
- Department of Psychiatry (L Traeger, CM Luberto, GK Perez, BM Goshe, and ER Park), Massachusetts General Hospital/Harvard Medical School, Boston, Mass; MGH Benson-Henry Institute for Mind-Body Medicine (CM Luberto, GK Perez, BM Goshe, and ER Park), Boston, Mass; Health Promotion and Resiliency Intervention Research Program (L Traeger, CM Luberto, GK Perez, and ER Park), Massachusetts General Hospital, Departments of Psychiatry & Medicine, Boston, Mass
| | - Brett M Goshe
- Department of Psychiatry (L Traeger, CM Luberto, GK Perez, BM Goshe, and ER Park), Massachusetts General Hospital/Harvard Medical School, Boston, Mass; MGH Benson-Henry Institute for Mind-Body Medicine (CM Luberto, GK Perez, BM Goshe, and ER Park), Boston, Mass
| | - Lucy Fell
- Division of General Academic Pediatrics (KA Kuhlthau, L Fell, and D Iannuzzi), Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Dorothea Iannuzzi
- Division of General Academic Pediatrics (KA Kuhlthau, L Fell, and D Iannuzzi), Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Elyse R Park
- Department of Psychiatry (L Traeger, CM Luberto, GK Perez, BM Goshe, and ER Park), Massachusetts General Hospital/Harvard Medical School, Boston, Mass; Health Promotion and Resiliency Intervention Research Program (L Traeger, CM Luberto, GK Perez, and ER Park), Massachusetts General Hospital, Departments of Psychiatry & Medicine, Boston, Mass; MGH Benson-Henry Institute for Mind-Body Medicine (CM Luberto, GK Perez, BM Goshe, and ER Park), Boston, Mass
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Steinhilber KM, Chabria RS, Clara A, Temel JS, Greer JA, Traeger L, Jacobs JM. Shifting behavioral intervention research to virtual methods: Challenges and solutions in practice, during and after the COVID-19 pandemic. J Telemed Telecare 2023:1357633X231167899. [PMID: 37125429 PMCID: PMC10130932 DOI: 10.1177/1357633x231167899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Behavioral medicine researchers have rapidly adapted study procedures and interventions to telehealth modalities during the pandemic. We rely heavily on telehealth research methods to avoid study delays and mitigate risk to chronically ill patients our studies aim to support. We implemented methods to virtually recruit, enroll, and retain patients and their families on clinical trials, and virtually deliver study interventions. These adaptations are likely to become permanent amid ongoing virus variants and surges in cases. However, little has been written about how remote methods apply in practice. This paper documents these processes to maximize efficiency across our research studies and systems and highlights the strengths and challenges of transitioning our research protocols to telehealth. We outline solutions to using remote methods across the entire span of the research process, including study recruitment, data collection, and intervention delivery. We offer insight into the implications of these transitions on research staff and interventionists. In providing a transparent review of the advantages and challenges of implementing remote methods, we encourage discourse around remote methods implementation, share the lessons we learned, and inform the design of future trials. Further research is needed to review the clinical feasibility and acceptability of these procedures.
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Affiliation(s)
- Kylie M Steinhilber
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, USA
- Suffolk University, Department of Psychology, Boston, MA, USA
| | - Reena S Chabria
- Drexel University, Department of Psychology, Philadelphia, PA, USA
| | - Amy Clara
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, USA
- Harvard Medical School, Department of Medicine, Boston, MA, USA
| | - Jennifer S Temel
- Harvard Medical School, Department of Medicine, Boston, MA, USA
- Massachusetts General Hospital, Department of Medicine, Boston, MA, USA
| | - Joseph A Greer
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, USA
- Harvard Medical School, Department of Medicine, Boston, MA, USA
| | - Lara Traeger
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, USA
- Harvard Medical School, Department of Medicine, Boston, MA, USA
| | - Jamie M Jacobs
- Massachusetts General Hospital, Department of Psychiatry, Boston, MA, USA
- Harvard Medical School, Department of Medicine, Boston, MA, USA
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El-Jawahri A, Luskin MR, Greer JA, Traeger L, Lavoie M, Vaughn DM, Andrews S, Yang D, Boateng KY, Newcomb RA, Ufere NN, Fathi AT, Hobbs G, Brunner A, Abel GA, Stone RM, DeAngelo DJ, Wadleigh M, Temel JS. Psychological mobile app for patients with acute myeloid leukemia: A pilot randomized clinical trial. Cancer 2023; 129:1075-1084. [PMID: 36655338 DOI: 10.1002/cncr.34645] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/28/2022] [Accepted: 12/08/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Patients with acute myeloid leukemia (AML) experience a substantial decline in quality of life (QoL) and mood during their hospitalization for intensive chemotherapy, yet few interventions have been developed to enhance patient-reported outcomes during treatment. METHODS We conducted a pilot randomized trial (ClinicalTrials.gov identifier NCT03372291) of DREAMLAND, a psychological mobile application for patients with a new diagnosis of AML who are receiving intensive chemotherapy. Patients were randomly assigned to DREAMLAND or usual care. DREAMLAND included four required modules focused on: (1) supportive psychotherapy to help patients deal with the initial shock of diagnosis, (2) psychoeducation to manage illness expectations, (3) psychosocial skill-building to promote effective coping, and (4) self-care. The primary end point was feasibility, which was defined as ≥60% of eligible patients enrolling and 60% of those enrolled completing ≥60% of the required modules. We assessed patient QoL (the Functional Assessment of Cancer Therapy-Leukemia), psychological distress (the Hospital Anxiety and Depression Scale and the Patient Health Questionnaire-9), symptom burden (the Edmonton Symptom Assessment Scale), and self-efficacy (the Cancer Self-Efficacy Scale) at baseline and at day 20 after postchemotherapy. RESULTS We enrolled 60 of 90 eligible patients (66.7%), and 62.1% completed ≥75% of the intervention modules. At day 20 after chemotherapy, patients who were randomized to DREAMLAND reported improved QoL scores (132.06 vs. 110.72; p =.001), lower anxiety symptoms (3.54 vs. 5.64; p = .010) and depression symptoms (Hospital Anxiety and Depression Scale: 4.76 vs. 6.29; p = .121; Patient Health Questionnaire-9: 4.62 vs. 8.35; p < .001), and improved symptom burden (24.89 vs. 40.60; p = .007) and self-efficacy (151.84 vs. 135.43; p = .004) compared with the usual care group. CONCLUSIONS A psychological mobile application for patients with newly diagnosed AML is feasible to integrate during hospitalization for intensive chemotherapy and may improve QoL, mood, symptom burden, and self-efficacy.
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Affiliation(s)
- Areej El-Jawahri
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Marlise R Luskin
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joseph A Greer
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Mitchell Lavoie
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dagny Marie Vaughn
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stephanie Andrews
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniel Yang
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kofi Y Boateng
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Richard A Newcomb
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nneka N Ufere
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amir T Fathi
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Hobbs
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Brunner
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory A Abel
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Richard M Stone
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniel J DeAngelo
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Martha Wadleigh
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Divsion of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Traeger L, Styklunas GM, Park EY, Lee MT, Fricchione G, Park ER. Promoting Resilience and Flourishing Among Older Adult Residents in Community Living: A Feasibility Study. Gerontologist 2022; 62:1507-1518. [PMID: 35235940 DOI: 10.1093/geront/gnac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Stress Management and Relaxation Training-Relaxation Response Resiliency Program (SMART-3RP) is a mind-body group intervention that integrates relaxation training with cognitive behavioral and positive psychology techniques. This study assessed SMART-3RP feasibility, acceptability, and preliminary efficacy for enhancing resilience and flourishing among older adults in continuing care retirement communities (CCRCs). RESEARCH DESIGN AND METHODS We conducted a prospective single-arm study of SMART-3RP groups delivered by clinicians at 4 CCRCs (n = 80). Eligible residents lived in community apartments. Participants completed pre- and postintervention surveys. We evaluated attendance (hypothesis: ≥60% attend ≥6 of 9 sessions), enrollment, and retention. Mixed methods were used to explore acceptability. Paired samples t-tests were conducted to explore changes in resilience, flourishing, and key intervention targets. RESULTS From March to June 2021, we screened 89 residents with 87 (98%) consenting to participate and 80 (90%) enrolling in the study. Among 80 participants (85% female; 98% non-Hispanic White; M age = 80 years [SD = 6]), 88% attended ≥6 sessions, and 89% completed the postintervention survey. Participants found meaning in participation and practiced skills in the context of challenges such as caregiving burden or bereavement. Survey results, showing increases in resilience, flourishing, and several intervention targets, aligned with participants' perceived intervention value. DISCUSSION AND IMPLICATIONS SMART-3RP was feasible and acceptable for CCRC residents; participants perceived value in practicing mind-body strategies in a group-based setting. Preliminary evidence suggested a pattern of improvements in resilience, flourishing, and intervention targets. Findings provide insights for mind-body interventions and recommendations for adaptations to late-in-life concerns and community settings. CLINICAL TRIALS REGISTRATION NUMBER NCT04720014.
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Affiliation(s)
- Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Grace M Styklunas
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Health Promotion and Resiliency Intervention Research Program (HPRIR), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ellen Y Park
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew T Lee
- Human Flourishing Program, Institute for Quantitative Social Science, Harvard University, Cambridge, Massachusetts, USA
| | - Gregory Fricchione
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elyse R Park
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Health Promotion and Resiliency Intervention Research Program (HPRIR), Massachusetts General Hospital, Boston, Massachusetts, USA
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Skurla SE, Friedman ER, Park ER, Cannon S, Kilbourne GA, Pirl WF, Traeger L. Perceptions of somatic and affective symptoms and psychosocial care utilization in younger and older survivors of lung cancer. Support Care Cancer 2022; 30:5311-5318. [PMID: 35278137 DOI: 10.1007/s00520-022-06926-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Rates of depression identification in oncology settings and referral to psychosocial services remain low. Patients with lung cancer face an elevated risk of depression relative to patients with other cancers. This study explored perceptions of somatic and affective symptoms and psychosocial care utilization among younger and older lung cancer survivors. METHODS We conducted in-depth interviews with 20 adults at two academic medical centers in Boston, MA, who had received a lung cancer diagnosis in the past 24 months. A semi-structured interview guide was used to assess experiences with, and perceptions of, depression symptoms and psychosocial services. Interviews were audio-recorded, transcribed, and coded to identify themes. We also explored differences between younger (<65years; N=9) and older (>65years; N=11) patients. RESULTS Participants commonly described somatic symptoms (i.e., changes in appetite, sleep, or energy levels) and affective symptoms (i.e., worry, fear, sadness) as side effects of cancer treatment. Older participants more commonly contextualized these symptoms with information about how they impacted daily life. Both younger and older participants faced barriers to accessing psychosocial services, with older adults more commonly referencing stigma of service referral and utilization. DISCUSSION Patients with lung cancer associated both somatic and affective symptoms with their cancer and its treatment, with age differences in how symptoms were described and how psychosocial referrals may be perceived. More systematic integration of psychosocial care into cancer care may help to increase the identification of depression in lung cancer and reduce barriers to psychosocial service utilization.
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Affiliation(s)
- Sarah E Skurla
- Center for Clinical Management Research, Department of Veterans Affair, Ann Arbor, MI, USA
| | - Emily R Friedman
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, MA, USA
- Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA, USA
| | - Elyse R Park
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, MA, USA.
- Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA, USA.
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
| | - Sheila Cannon
- School of Nursing, Fayetteville State University, Fayetteville, NC, USA
| | | | - William F Pirl
- Division of Adult Psychosocial Oncology and Palliative Care, Harvard Medical School, Boston, MA, USA
| | - Lara Traeger
- Cancer Outcomes Research and Education Program, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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9
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Cadieux M, Healy M, Petrusa E, Cooke L, Traeger L, Kesselheim JC, Riva-Cambrin J, Phitayakorn R. Implementation of competence by design in Canadian neurosurgery residency programs. Med Teach 2022; 44:380-387. [PMID: 34726559 DOI: 10.1080/0142159x.2021.1994937] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The Royal College of Physicians and Surgeons of Canada (RCPSC) recently redesigned the Canadian neurosurgery residency training curriculum by implementing a competency-based model of training known as Competence by Design (CBD) centered around the assessment of Entrustable Professional Activities (EPAs). This sequential explanatory mixed-methods study evaluated potential benefits and pitfalls of CBD in Canadian neurosurgery residency education. METHODS Two four-month interval surveys were distributed to all Canadian neurosurgery residents participating in CBD. The surveys assessed important educational components: CBD knowledge of key stakeholders, potential system barriers, and educational/psychological impacts on residents. Paired t-tests were done to assess changes over time. Based on longitudinal survey responses, semi-structured interviews were conducted to investigate in-depth residents' experience with CBD in neurosurgery. The qualitative analysis followed an explanatory approach, and a thematic analysis was performed. RESULTS Surveys had 82% average response rate (n = 25). Over time, most residents self-reported that they retrospectively understood concepts around CBD intentions (p = 0.02). Perceived benefits included faculty evaluations with more feedback that was clearer and more objective (53% and 51%). Pitfalls included the amount of time needed to navigate through EPAs (90%) and residents forgetting to initiate EPA forms (71%). There was no significant change over time. During interviews, five key themes were found. Potential solutions identified by residents to enhance their experience included learning analytics data availability, mobile app refinement, and dedicated time to integrate EPAs in the workflow. CONCLUSION This study was the first to assess resident-perceived benefits and pitfalls of the neurosurgery CBD training program in an educational framework context. In general, residents believed that theoretical principles behind CBD were valuable, but that technological ability and having enough time to request EPA assessments were significant barriers to success. Long-term studies are required to determine the definitive outcomes of CBD on residents' performance and ultimately, on patient care.
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Affiliation(s)
- Magalie Cadieux
- Harvard Medical School, Boston, MA, USA
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Michael Healy
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Emil Petrusa
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Lara Cooke
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Lara Traeger
- Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer C Kesselheim
- Harvard Medical School, Boston, MA, USA
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Roy Phitayakorn
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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10
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Lee HJ, Qian CL, Landay SL, O'Callaghan D, Kaslow-Zieve E, Azoba CC, Fuh CX, Temel B, Ufere N, Petrillo LA, Fong ZV, Greer JA, El-Jawahri A, Temel JS, Traeger L, Nipp RD. Communicating the Information Needed for Treatment Decision Making Among Patients With Pancreatic Cancer Receiving Preoperative Therapy. JCO Oncol Pract 2022; 18:e313-e324. [PMID: 34618600 DOI: 10.1200/op.21.00388] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/06/2021] [Accepted: 09/13/2021] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Preoperative therapy for pancreatic cancer represents a new treatment option with the potential to improve outcomes for patients, yet with complex risks. By not discussing the potential risks and benefits of new treatment options, clinicians may hinder patients from making informed decisions. METHODS From 2017 to 2019, we conducted a mixed-methods study. First, we elicited clinicians' (n = 13 medical, radiation, and surgery clinicians), patients' (n = 18), and caregivers' (n = 14) perceptions of information needed for decision making regarding preoperative therapy and generated a list of key elements. Next, we audio-recorded patients' (n = 20) initial multidisciplinary oncology visits and used qualitative content analyses to describe how clinicians discussed this information and surveyed patients to ask if they heard each key element. RESULTS We identified 13 key elements of information patients need when making decisions regarding preoperative therapy, including treatment complications, alternatives, logistics, and potential outcomes. Patients reported hearing infrequently about complications (eg, hospitalizations [n = 3 of 20]) and alternatives (n = 8 of 20) but frequently recalled logistics and potential outcomes (eg, likelihood of surgery [n = 19 of 20]). Clinicians infrequently discussed complications (eg, hospitalizations [n = 7 of 20]), but frequently discussed alternatives, logistics, and potential outcomes (eg, likelihood of surgery [n = 20 of 20]). No overarching differences in clinician discussion content emerged to explain why patients did or did not hear about each key element. CONCLUSION We identified key elements of information patients with pancreatic cancer need when considering preoperative therapy. Patients infrequently heard about treatment complications and alternatives, while frequently hearing about logistics and potential outcomes, underscoring areas for improvement in educating patients about new treatment options in oncology.
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Affiliation(s)
- Howard J Lee
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Carolyn L Qian
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sophia L Landay
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Deirdre O'Callaghan
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emilia Kaslow-Zieve
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Chinenye C Azoba
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Charn-Xin Fuh
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Brandon Temel
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Nneka Ufere
- Harvard Medical School, Boston, MA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA
| | - Laura A Petrillo
- Harvard Medical School, Boston, MA
- Division of Palliative Care, Massachusetts General Hospital, Boston, MA
| | - Zhi Ven Fong
- Harvard Medical School, Boston, MA
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Joseph A Greer
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Areej El-Jawahri
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA
| | - Jennifer S Temel
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA
| | - Lara Traeger
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Ryan D Nipp
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA
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11
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Xu L, Sommer RK, Nyeko L, Michael C, Traeger L, Jacobsen J. Patient Perspectives on Serious Illness Conversations in Primary Care. J Palliat Med 2022; 25:940-944. [PMID: 35196134 DOI: 10.1089/jpm.2021.0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The Serious Illness Care Program has been shown to improve quality and feasibility of value-based end-of-life conversations in primary care. Objectives: To elicit patients' perspectives on serious illness conversations conducted by primary care clinicians. Subjects and Methods: Telephone interviews were conducted with patients at an academic center in the United States, who had a recent serious illness conversation with their primary care clinician. Interviews were audio-recorded and qualitatively analyzed using thematic analysis. Results: A total of eleven patients were enrolled. We identified three major themes: (1) positive emotional experiences are facilitated by established patient-clinician relationships and/or clinicians' skills in navigating emotional challenges, (2) patients appreciate a personalized conversation, and (3) clinicians should orchestrate the experience of the conversation, from preparation through follow-up. Conclusion: Patients appreciate having serious illness conversations in the primary care setting. Future efforts can be focused on improving clinicians' skills in navigating emotional challenges during conversations and implementing system changes to optimize orchestration.
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Affiliation(s)
- Luyi Xu
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Robert K Sommer
- Department of Educational and Psychological Studies, University of Miami, Coral Gables, Florida, USA
| | - Liza Nyeko
- Office of Patient Experience and Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians Organization, Boston, Massachusetts, USA
| | - Carol Michael
- Massachusetts General Hospital Patient and Family Advisory Council, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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12
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Bannon SM, Reichman M, Popok P, Grunberg VA, Traeger L, Gates MV, Krahn EA, Brandt K, Quimby M, Wong B, Dickerson BC, Vranceanu AM. Psychosocial Stressors and Adaptive Coping Strategies in Couples After a Diagnosis of Young-Onset Dementia. Gerontologist 2022; 62:262-275. [PMID: 33893481 PMCID: PMC8827317 DOI: 10.1093/geront/gnab053] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Diagnoses of young-onset dementias (YODs) are devastating for persons with dementia and spousal caregivers yet limited work has examined both partners' perceptions of challenges and coping after diagnosis. This qualitative study investigated the psychosocial stressors and adaptive coping strategies in couples diagnosed with YOD to inform the development of psychosocial support resources. RESEARCH DESIGN AND METHODS We conducted live video dyadic interviews with couples (persons with YOD and spousal caregivers together; N = 23 couples). We transcribed interviews and coded data based on a hybrid deductive-inductive approach, with the structure of the coding framework informed by the stress and coping framework, and all codes derived from the data. We derived themes and subthemes related to psychosocial stressors and adaptive coping. RESULTS We identified 5 themes related to psychosocial stressors: the impact of diagnosis, social and family relationships, changing roles and responsibilities, planning for an uncertain future, and couple communication and relationship strain. We identified 7 themes related to adaptive coping strategies: processing emotions and cultivating acceptance, promoting normalcy, efforts to preserve persons with YOD's independence and identity, collaborative and open communication, social support, meaning-making, humor, and positivity, and lifestyle changes and self-care. DISCUSSION AND IMPLICATIONS We replicated several themes regarding stressors and adaptive coping strategies from prior YOD research and identified novel themes and subthemes related to dyadic stressors, sources of couples' relationship strain, and the ways in which couples effectively cope with YOD. Findings inform the development of dyadic interventions to reduce YOD-related distress for both persons with dementia and spousal caregivers.
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Affiliation(s)
- Sarah M Bannon
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mira Reichman
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Paula Popok
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Victoria A Grunberg
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa V Gates
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A Krahn
- Harvard Medical School, Boston, Massachusetts, USA
- Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine Brandt
- Harvard Medical School, Boston, Massachusetts, USA
- Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Megan Quimby
- Harvard Medical School, Boston, Massachusetts, USA
- Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bonnie Wong
- Harvard Medical School, Boston, Massachusetts, USA
- Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bradford C Dickerson
- Harvard Medical School, Boston, Massachusetts, USA
- Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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13
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Daubman BR, Stoltenberg M, Spence D, Krakauer EL, Farrell S, Traeger L, Thomas R, Bromfield B, Sharpe N, Toppin PJ, Paul T, Schachter AB, Shields AE. Implementing Palliative Care Training in the Caribbean: Development and Assessment of a Basic Palliative Care Training Course in Jamaica. J Pain Symptom Manage 2021; 62:1145-1153. [PMID: 34146660 DOI: 10.1016/j.jpainsymman.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/14/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT The majority of people in need of palliative care (PC) in low- and middle-income countries lack access to it and suffer unnecessarily as a consequence. This unmet need is due, in part, to the lack of trained PC providers. OBJECTIVES This study aims to assess the effects of regional training in PC for doctors, nurses, and pharmacists in the Caribbean through assessment of participant satisfaction, anticipated course impact on participants' clinical practice, barriers to changing practice, and perceived course impact on achievement of key PC milestones. METHODS We created and taught a course in basic PC for clinicians from the Caribbean region and collected and analyzed postcourse quantitative and qualitative data on satisfaction and expected impact. RESULTS Eighty-three clinicians from five Caribbean countries participated in this workshop. Thirty participants completed the post-course survey. One hundred percent of these participants ranked the quality of the course as "very high quality" or "high quality." The majority of participants anticipated changing their practice as a result of this course. Several barriers were reported, including lack of formal PC training in participants' home countries. Results of participants' retrospective pre- and postcourse self-assessment for achievement of key PC milestones showed a statistically significant mean increase of at least one point on the seven-point Likert scale for each milestone. CONCLUSION Overall satisfaction with the course was high, and self-assessed competency in PC improved. These data suggest that an intensive training over several days is an effective format for increasing providers' perceived efficacy in delivering PC.
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Affiliation(s)
- Bethany-Rose Daubman
- Division of Palliative Care and Geriatrics, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Jamaica Cancer Care and Research Institute, Kingston, Jamaica.
| | - Mark Stoltenberg
- Division of Palliative Care and Geriatrics, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Jamaica Cancer Care and Research Institute, Kingston, Jamaica
| | - Dingle Spence
- Jamaica Cancer Care and Research Institute, Kingston, Jamaica; Hope Institute Hospital, Kingston, Jamaica
| | - Eric L Krakauer
- Division of Palliative Care and Geriatrics, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Jamaica Cancer Care and Research Institute, Kingston, Jamaica
| | - Susan Farrell
- Harvard Medical School, Boston, MA, USA; Office of Continuing and Professional Development, Massachusetts General Hospital Institute of Health Professions, Boston, MA, USA
| | - Lara Traeger
- Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Boston MA, USA
| | - Robert Thomas
- Jamaica Cancer Care and Research Institute, Kingston, Jamaica; Harvard/Massachusetts General Hospital Center on Genomics, Vulnerable Populations and Health Disparities, Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Brittany Bromfield
- Jamaica Cancer Care and Research Institute, Kingston, Jamaica; Harvard/Massachusetts General Hospital Center on Genomics, Vulnerable Populations and Health Disparities, Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Patrick Jason Toppin
- University of the West Indies, Mona, Section of Anaesthesia and Intensive Care, Mona, Jamaica
| | - Tomlin Paul
- Jamaica Cancer Care and Research Institute, Kingston, Jamaica; The Faculty of Medical Sciences, The University of the West Indies (Mona), Kingston, Jamaica
| | - Anna Boonin Schachter
- Jamaica Cancer Care and Research Institute, Kingston, Jamaica; Harvard/Massachusetts General Hospital Center on Genomics, Vulnerable Populations and Health Disparities, Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Alexandra E Shields
- Harvard Medical School, Boston, MA, USA; Jamaica Cancer Care and Research Institute, Kingston, Jamaica; Harvard/Massachusetts General Hospital Center on Genomics, Vulnerable Populations and Health Disparities, Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA, USA; The Faculty of Medical Sciences, The University of the West Indies (Mona), Kingston, Jamaica
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14
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Mesa M, Kaslow-Zieve E, Traeger L, Temel J, Forst D. QOLP-06. THE CHALLENGE OF FACING A NEW MALIGNANT GLIOMA DIAGNOSIS: PATIENT EXPERIENCES LEARNING ABOUT THEIR ILLNESS AND COMMUNICATING WITH THEIR PROVIDERS IN THE NEURO-ONCOLOGY CLINIC. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab196.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Patients with newly diagnosed malignant gliomas (MG) face the sudden and unexpected news that they have a terminal neurological illness. However, little is known about these patients’ experiences learning about their illness and communicating with their oncology providers.
METHODS
We conducted semi-structured interviews with patients with MG who had recently completed chemoradiation, to explore patient-clinician communication and evaluate how patients process information about their diagnosis. We excluded patients with marked cognitive dysfunction, with eligible patients required to have a Mini-Mental Status Exam score of 24/30 or greater. We terminated enrollment once we reached thematic saturation, after a total of 9 patient interviews. We thematically analyzed qualitative data to describe patterns common to the patients’ experiences.
RESULTS
Most patients were male (6/9, 66.7%), with median age of 55 years (range 26-72) and had a diagnosis of glioblastoma (6/9, 66.7%). The majority of patients described a positive experience communicating with their providers, noting that information was delivered clearly, and visits were not rushed. Despite this, patients found it difficult to absorb and process the large volume of new information, particularly in the setting of their shock and dismay about the diagnosis and their ongoing neurological deficits. Emergent themes included concerns about the impact of the disease on their loved ones, struggles in coping with uncertainty, and worries about preserving their quality of life and functioning. Additionally, patients described their efforts to balance their knowledge about their poor prognosis with their desire to maintain hope, with many patients expressing a goal to “beat the odds” or exceed expectations with respect to their survival.
CONCLUSION
Although patients with newly diagnosed MG describe effective communication with their providers, they face many challenges coping with their terminal diagnosis. Supportive interventions aimed at this population are needed.
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Affiliation(s)
| | | | - Lara Traeger
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Temel
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Deborah Forst
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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15
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Rhee J, Mesa M, Kaslow-Zieve E, Traeger L, El-Jawahri A, Temel J, Forst D. QOLP-12. ILLNESS UNDERSTANDING AND PERCEPTIONS ABOUT PROGNOSIS IN PATIENTS WITH MALIGNANT GLIOMAS AND THEIR CAREGIVERS. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab196.733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Malignant gliomas (MG) are incurable tumors with limited survival. Prognostic awareness is essential for informed decision making, but patients’ and caregivers’ perceptions about their illness and prognosis are not well understood.
METHODS
We conducted a prospective, single-institution study in patients with newly diagnosed MG and their caregivers, following the outpatient visit in which their neuro-oncologist disclosed pathology results and discussed treatment options. Participants (patients and caregivers) completed the Prognosis and Treatment Perceptions Questionnaire to assess information preferences, treatment goals and prognostic understanding.
RESULTS
Of patients approached, 82% (14/17) were eligible and enrolled in the study. The majority of patients were male (9/14, 64%), median age 60 years (range 26-76) and had a glioblastoma (11/14, 79%). Most caregivers were female (8/11, 73%) and married to the patient (7/11, 64%). The majority of patients said their cancer was curable (10/13, 77%, one patient did not answer), while only 3/11 caregivers (27%) said the patient’s cancer was curable. Furthermore, 7/13 patients (54%) and 8/11 caregivers (73%) reported that their oncologist said their cancer was not curable, and the remainder (6/13 patients, 46% and 3/11 caregivers, 27%) said the oncologist “did not say” whether it was curable. Most patients (10/14, 71%) and caregivers (8/11, 73%) expressed a tendency to focus on the best-case scenario in response to information from their oncology team about their cancer.
CONCLUSION
Although most patients with MG and their caregivers acknowledged being told that their cancer was incurable, the majority of patients reported that their cancer was curable. Patients and caregivers often reported focusing on the best-case scenario regarding their cancer. Further investigation is warranted to explore strategies to support patients and caregivers learning about their incurable cancer.
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Affiliation(s)
- John Rhee
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Emilia Kaslow-Zieve
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Lara Traeger
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Areej El-Jawahri
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Temel
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Deborah Forst
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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16
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Petrillo LA, Zhou A, Gui H, Sommer R, Lin JJ, Nipp RD, Traeger L, Greer JA, Temel JS. Types of information that patients with lung cancer with targetable driver mutations and their caregivers learn from online forums: Results of a qualitative study. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
161 Background: Patients and caregivers seek information about cancer from a variety of sources in addition to their medical team. In recent years, patients with specific lung cancer subtypes have created advocacy groups with active online forums for networking, support, and information exchange. We sought to describe the types of information that patients and caregivers learned from their peers online about lung cancer with targetable driver mutations. Methods: In this qualitative study, we enrolled patients with lung cancer with targetable driver alterations in EGFR, ALK, or ROS1 genes and their caregivers. We conducted individual, semi-structured interviews with participants from a single academic center, asking about their experiences learning about and living with lung cancer. Three reviewers used a framework analysis to code transcripts, and we synthesized the codes into themes. In this analysis, we focused on one theme that emerged from the data related to the information that participants learned from online forums. Results: Of 59 patients approached, 39 patients (mean age = 59, 56% female, median time from diagnosis 16 months) and 16 caregivers (69% male, all spouses or long-term partners) agreed to participate and completed interviews. Participants used online forums to compare their experiences with others to gain a preview of what might lie ahead. Specifically, they read about patients with long survival that were a source of hope, as well as patients’ experiences of progression and dying from cancer that made clinical estimates of prognosis more personal and vivid. Online forums provided a venue to learn about the latest research, available clinical trials, how to manage side effects, and where to find expert clinicians. Participants learned about the treatments received by patients at other centers. They were also exposed to emotionally intense stories of patients from around the world who lacked access to targeted therapy and sought advice from other forum members about how to find specialized care. Caregivers pointed out the distressing effect on patients of learning bad news about online peers as a downside of online forums, but overall found them beneficial and supported patients’ engagement with them. Conclusions: Online forums, particularly those that narrowly focus on specific diseases or treatments, provide patients and caregivers with anecdotal evidence that helps them with practical matters, such as how to manage side effects, as well as more existential issues, such as how long they can expect to live. These results suggest that clinicians should be open to and curious about the information that patients and caregivers learn from online forums in order to better understand the perspectives that patients and caregivers bring to discussions and decisions about their cancer.
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Affiliation(s)
- Laura A Petrillo
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Haiwen Gui
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | - Joseph A. Greer
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Massad K, Traeger L, Greer JA, Temel J. Development of a virtual intervention for patients with lung cancer transitioning to surveillance after curative treatment. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
181 Background: Patients with lung cancer who are treated with curative intent are rarely included in quality-of-life (QOL) intervention research in cancer, and the transition from treatment to surveillance is an understudied phase in lung cancer. Given the high risk of recurrence in this population, we aimed to 1) characterize the QOL challenges of patients with lung cancer who complete curative treatment and 2) develop and refine an intervention to support patients during their transition to surveillance. Methods: We first conducted semi-structured interviews to explore the QOL challenges of patients in transition from lung cancer treatment to surveillance (n = 12). Interviews were transcribed, coded, and analyzed using a thematic analysis approach. Results were used to develop the content, timing, and delivery of a cognitive behavioral intervention to enhance patient QOL during the transition to surveillance. We conducted an open pilot with patients within 3 weeks of completing lung cancer treatment (systemic therapy +/- radiation) to test and refine the intervention (n = 5). Mixed methods data were collected to evaluate intervention feasibility, acceptability, and areas for refinement. All study procedures were conducted at an academic medical center in the New England region. Results: Qualitative study results indicated that during the transition to surveillance, patients with lung cancer (6 female, 6 male; age range: 26-76) faced unexpected challenges in coping with residual symptoms (e.g., dyspnea, fatigue), uncertainty about future health, and changes in close relationships. Results were used to develop a 5-session intervention to address patient challenges with a coping skills framework that balanced acceptance-and change-oriented approaches. Study clinicians delivered intervention sessions remotely (video or telephone). Of 6 patients approached, 5 enrolled in the pilot (all female; age range: 62-73; 1 declined due to time commitment). Pilot patient feedback indicated that the intervention timing and content targeted patients’ current needs and concerns. Patients valued the opportunity to normalize and address current challenges and to cope with difficult emotions. Results suggested further refinements to the timing for patient recruitment and the order of session content to enhance skills uptake. Conclusions: Patients who are treated for lung cancer with curative intent may face unexpected QOL challenges related to residual symptoms, health uncertainty, and changes in close relationships during the transition to surveillance. Results enhance our understanding of lung cancer survivorship and provide a framework for addressing QOL challenges in this population. Remote delivery of this manualized intervention supports scalability for survivors of cancers with high risk of recurrence. This model will be tested further in a larger scale efficacy trial. Clinical trial information: 04450043.
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Affiliation(s)
| | | | - Joseph A. Greer
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
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18
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Ufere NN, Donlan J, Indriolo T, Richter J, Thompson R, Jackson V, Volandes A, Chung RT, Traeger L, El-Jawahri A. Burdensome Transitions of Care for Patients with End-Stage Liver Disease and Their Caregivers. Dig Dis Sci 2021; 66:2942-2955. [PMID: 32964286 DOI: 10.1007/s10620-020-06617-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) experience frequent readmissions; however, studies focused on patients' and caregivers' perceptions of their transitional care experiences to identify root causes of burdensome transitions of care are lacking. AIM To explore the transitional care experiences of patients with ESLD and their caregivers in order to identify their supportive care needs. METHODS We conducted interviews with 15 patients with ESLD and 14 informal caregivers. We used semi-structured interview guides to explore their experiences since the diagnosis of ESLD including their care transitions. Two raters coded interviews independently (κ = 0.95) using template analysis. RESULTS Participants reported feeling unprepared to manage their informational, psychosocial, and practical care needs as they transitioned from hospital to home after the diagnosis of ESLD. Delay in the timely receipt of supportive care services addressing these care needs resulted in hospital readmissions, emotional distress, caregiver burnout, reduced work capacity, and financial hardship. Participants shared the following resources that they perceived would improve their quality of care: (1) discharge checklist, (2) online resources, (3) mental health support, (4) caregiver support and training, and (5) financial navigation. CONCLUSION Transitional care models that attend to the informational, psychosocial, and practical domains of care are needed to better support patients with ESLD and their caregivers at the time of diagnosis and beyond. Without attending to the multidimensional care needs of newly diagnosed patients with ESLD and their caregivers, they are at risk of burdensome transitions of care, high healthcare utilization, and poor health-related quality of life.
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Affiliation(s)
- Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
| | - John Donlan
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Teresa Indriolo
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - James Richter
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ryan Thompson
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Angelo Volandes
- Section of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raymond T Chung
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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19
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Nipp RD, Temel B, Fuh CX, Kay P, Landay S, Lage D, Franco-Garcia E, Scott E, Stevens E, O'Malley T, Mohile S, Dale W, Traeger L, Hashmi AZ, Jackson V, Greer JA, El-Jawahri A, Temel JS. Pilot Randomized Trial of a Transdisciplinary Geriatric and Palliative Care Intervention for Older Adults With Cancer. J Natl Compr Canc Netw 2021; 18:591-598. [PMID: 32380460 DOI: 10.6004/jnccn.2019.7386] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/04/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Oncologists often struggle with managing the unique care needs of older adults with cancer. This study sought to determine the feasibility of delivering a transdisciplinary intervention targeting the geriatric-specific (physical function and comorbidity) and palliative care (symptoms and prognostic understanding) needs of older adults with advanced cancer. METHODS Patients aged ≥65 years with incurable gastrointestinal or lung cancer were randomly assigned to a transdisciplinary intervention or usual care. Those in the intervention arm received 2 visits with a geriatrician, who addressed patients' palliative care needs and conducted a geriatric assessment. We predefined the intervention as feasible if >70% of eligible patients enrolled in the study and >75% of eligible patients completed study visits and surveys. At baseline and week 12, we assessed patients' quality of life (QoL), symptoms, and communication confidence. We calculated mean change scores in outcomes and estimated intervention effect sizes (ES; Cohen's d) for changes from baseline to week 12, with 0.2 indicating a small effect, 0.5 a medium effect, and 0.8 a large effect. RESULTS From February 2017 through June 2018, we randomized 62 patients (55.9% enrollment rate [most common reason for refusal was feeling too ill]; median age, 72.3 years; cancer types: 56.5% gastrointestinal, 43.5% lung). Among intervention patients, 82.1% attended the first visit and 79.6% attended both. Overall, 89.7% completed all study surveys. Compared with usual care, intervention patients had less QoL decrement (-0.77 vs -3.84; ES = 0.21), reduced number of moderate/severe symptoms (-0.69 vs +1.04; ES = 0.58), and improved communication confidence (+1.06 vs -0.80; ES = 0.38). CONCLUSIONS In this pilot trial, enrollment exceeded 55%, and >75% of enrollees completed all study visits and surveys. The transdisciplinary intervention targeting older patients' unique care needs showed encouraging ES estimates for enhancing patients' QoL, symptom burden, and communication confidence.
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Affiliation(s)
- Ryan D Nipp
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Brandon Temel
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Charn-Xin Fuh
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Paul Kay
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Sophia Landay
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Daniel Lage
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Esteban Franco-Garcia
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Erin Scott
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Erin Stevens
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Terrence O'Malley
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,3Partners Continuing Care, Partners HealthCare System, Boston, Massachusetts
| | - Supriya Mohile
- 4Department of Medicine, Division of Hematology and Oncology, University of Rochester Medical Center, Rochester, New York
| | - William Dale
- 5Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - Lara Traeger
- 6Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Ardeshir Z Hashmi
- 7Department of Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, Ohio
| | - Vicki Jackson
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- 6Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Areej El-Jawahri
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Jennifer S Temel
- 1Department of Medicine, Division of Hematology and Oncology, and
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20
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Aaronson EL, Daubman BR, Petrillo L, Bowman J, Ouchi K, Gips A, Traeger L, Jackson V, Grudzen C, Ritchie CS. Emerging Palliative Care Innovations in the ED: A Qualitative Analysis of Programmatic Elements During the COVID-19 Pandemic. J Pain Symptom Manage 2021; 62:117-124. [PMID: 33161031 PMCID: PMC7645272 DOI: 10.1016/j.jpainsymman.2020.10.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Health systems have aspired to integrate palliative care (PC) into the emergency department (ED) to improve care quality for over a decade, yet there are very few examples of implemented models in the literature. The coronavirus disease 2019 (COVID-19) pandemic led to an increase in the volume of seriously ill patients in EDs and a consequent rapid increase in PC integration in many EDs. OBJECTIVES To describe the new PC-ED delivery innovations that emerged during the COVID-19 pandemic. METHODS For this qualitative study of PC programs in EDs, semistructured interviews were conducted with ED and PC clinicians between June 30, 2020 and August 18, 2020. Participants were asked about PC-ED integration before, during, and after COVID. We conducted a two-phased rapid analysis using a rapid analysis template and consolidated matrix to identify innovations. RESULTS Using purposive and snowball sampling, we interviewed 31 participants, representing 52 hospitals. Several new innovations in care delivery were identified. These included elements of fully embedded PC, the use of PC extenders, technology both within the electronic medical record and outside it, and innovations in training emergency clinicians in primary PC skills to support care delivery. Most PC efforts focused on increasing goals-of-care conversations. Institutions that implemented these programs reported that they increased PC utilization in the ED, were well received by clinicians, and changed patient's care trajectories. CONCLUSION Several new innovations in PC-ED care delivery emerged during COVID. Many innovations leveraged different types of clinicians to deliver care, an increased physical presence of PC in the ED, and used technology to enhance care delivery. These innovations may serve as a framework for institutions as they plan for evolving needs in the ED during and after COVID. Additional research is needed to evaluate the impact of these programs and understand their applicability beyond the pandemic.
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Affiliation(s)
- Emily Loving Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA.
| | - Bethany-Rose Daubman
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura Petrillo
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Bowman
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexa Gips
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Palliative Care Service, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lara Traeger
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Corita Grudzen
- Department of Emergency Medicine, NYU Langone Health/Bellevue Hospital Center, NYU Grossman School of Medicine, New York, USA
| | - Christine Seel Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
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21
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Waldman LP, Nelson AM, Jacobs JM, Gray TF, Clay M, Jagielo AD, Rice J, Traeger L, El-Jawahri A. Anxiety and Depression Symptoms in Caregivers Prior to Hematopoietic Stem Cell Transplantation (HCT). Transplant Cell Ther 2021; 27:517.e1-517.e5. [PMID: 33812804 PMCID: PMC8217210 DOI: 10.1016/j.jtct.2021.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 11/25/2022]
Abstract
Family and friends caring for hematopoietic stem cell transplantation (HCT) recipients experience substantial disruptions in daily life as they prepare for transplant. These disruptions may increase their psychological distress, yet little research has described the extent of this distress. The goals of the present study were to characterize rates of anxiety and depression symptoms immediately prior to HCT and their relationship with modifiable caregiving domains. We conducted a secondary analysis of cross-sectional data of caregivers of patients undergoing HCT. Caregivers completed self-report measures to assess 8 domains of caregiving (Caregiver Oncology Quality of Life Questionnaire) and anxiety and depression symptoms (Hospital Anxiety and Depression Scale [HADS]) prior to transplant. Scores ≥8 on the HADS anxiety and depression subscales signified clinically significant symptoms. We used multivariable regression models adjusting for age, sex, caregiver relationship, and HCT type to examine the associations between caregiving domains and anxiety and depression symptoms. We enrolled 193 caregivers (median age = 60 years, 70.0% female, 52.3% allogeneic transplant). A majority of participants were providing care for a spouse (79.8%), followed by a child (7.8%) or parent (5.2%). On average, caregivers reported more anxiety (mean = 7.04, SD = 3.94) than depression symptoms (mean = 4.18, SD = 3.49), with 46.6% and 16.1% endorsing clinically significant anxiety and depression symptoms, respectively. Caregiver anxiety was associated with worse physical well-being, less leisure time, and poorer coping (Ps < .05). Caregiver depression symptoms were associated with worse physical well-being and less leisure time (Ps < .05). Caregivers of HCT recipients experience substantial psychological distress, particularly anxiety, prior to transplant. This distress is linked to modifiable caregiving domains. Study findings identify possible targets for psychosocial interventions aimed at managing caregiver anxiety and depression symptoms as well as highlight the need for intervention early during the course of transplant.
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Affiliation(s)
| | - Ashley M Nelson
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Jamie M Jacobs
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Tamryn F Gray
- Harvard Medical School, Boston, Massachusetts; Dana Farber Cancer Institute, Boston, Massachusetts
| | - Madison Clay
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Julia Rice
- Massachusetts General Hospital, Boston, Massachusetts
| | - Lara Traeger
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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22
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Abrams HR, Nipp RD, Traeger L, Lavoie MW, Reynolds MJ, LeBlanc TW, El-Jawahri A. Code status transitions in patients with high-risk acute myeloid leukemia (AML). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e19009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19009 Background: Patients with high-risk AML often experience aggressive medical care at the end of life (EOL) such as hospitalization and intensive care unit (ICU) admission. Despite this, studies examining code status transitions in this population are lacking. Methods: We conducted a mixed methods study of 107 patients with high-risk AML enrolled in supportive care studies at Massachusetts General Hospital between 2014-2019. High-risk AML was defined as 1) new diagnosis > 60 years or 2) relapsed/refractory AML. Two physicians used consensus-driven medical record review to characterize code status transitions. Code statuses were coded as ‘full’ (confirmed or presumed), ‘restricted’ (i.e., do not resuscitate), or ‘comfort measures only’ (CMO); confirmations of presumed status were not coded as transitions. Results: At diagnosis of high-risk AML, 91.9% of patients were ‘full code’ (48.5% presumed, 43.4% confirmed) and 8.1% had restrictions on life-sustaining therapies. Overall, 55.1% (59/107) of patients experienced a code status transition, with a median of two transitions (range 1-4). Median time from first to last transition was 11 days (range 1-306) and from last transition to death was 1 day (range 0-11). Most of these transitions (79.6%; 48/59) were transitions to CMO near EOL. We identified three processes leading to code status transitions (Table): 1) pre-emptive conversations prior to any clinical change (15.3%; 9/59); 2) anticipatory conversations at the time of acute clinical deterioration (15%; 9/59); and 3) futility conversations after acute clinical deterioration, focused on withdrawing life-sustaining therapy (64.4%; 38/59). Only 55.9% (33/59) of patients participated in their last code status transition and 22.0% (13/59) of these transitions occurred in the ICU or Emergency Room. Conclusions: Most patients with high-risk AML had code status transitions at EOL, often following clinical deterioration that limited their ability to engage in EOL discussions. Interventions to promote earlier and more specific code status conversations are needed to improve patients’ ability to voice their EOL preferences.[Table: see text]
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Affiliation(s)
| | - Ryan David Nipp
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA
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23
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Bannon SM, Grunberg VA, Reichman M, Popok PJ, Traeger L, Dickerson BC, Vranceanu AM. Thematic Analysis of Dyadic Coping in Couples With Young-Onset Dementia. JAMA Netw Open 2021; 4:e216111. [PMID: 33856476 PMCID: PMC8050740 DOI: 10.1001/jamanetworkopen.2021.6111] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/25/2021] [Indexed: 12/17/2022] Open
Abstract
Importance A diagnosis of young-onset dementia (YOD) is a life-altering event for both persons with dementia and their spousal caregivers. Dyadic coping (DC) theoretical models acknowledge that dyads cope with stressors as a unit, but these models have yet to be used in YOD. Objective To explore the lived experiences of couples managing YOD using an integrated DC model. Design, Setting, and Participants This qualitative study recruited couples from a single major medical setting and through social media. Eligibility criteria included cohabitation, 1 partner diagnosed with YOD and able to participate, and both partners willing to participate. Live online video interviews were conducted from March to June 2020. Exposures One semistructured interview, which was recorded and subsequently transcribed. Recruitment was stopped once thematic saturation was reached. Main Outcomes and Measures Five themes were deductively derived based on the integrated DC framework, including stress communication, positive individual DC, positive conjoint DC, negative individual DC, and negative conjoint DC. Within each theme, subthemes were inductively identified to further characterize couples' dyadic coping experiences with YOD. Results A total of 23 couples were interviewed, comprising persons with dementia (11 women [48%]; mean [SD] age, 61.3 [4.65] years; mean [SD] time from diagnosis, 3.11 [3.85]) years; and spousal caregivers (13 women [57%]; mean [SD] age, 60.5 [5.40] years). Data supported the 5 a priori DC themes and novel subthemes describing couples' experiences with YOD. Specifically, couples enacted positive conjoint DC by approaching challenges using a teamwork approach to problem solving and relying on collaborative communication. In contrast, couples engaged in negative conjoint DC through mutual avoidance, leading to increased negative communication and conflict. Couples described initially engaging in avoidance and withdrawal to navigate YOD-related stressors. While these strategies provided short-term relief from challenging emotions, they prevented engagement in adaptive coping (eg, acceptance and collaborative problem-solving) to promote long-term adjustment. Conclusions and Relevance This study used an evidence-based integrated DC approach to identify the positive and negative coping behaviors of couples managing YOD. To our knowledge, this is the first study to use a DC framework to guide qualitative analysis, and it provides valuable insights into DC strategies used by couples navigating YOD-related stressors. Findings can inform the development of dyadic psychosocial services for couples managing YOD and have implications for other progressive illnesses.
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Affiliation(s)
- Sarah M. Bannon
- Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Victoria A. Grunberg
- Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mira Reichman
- Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Paula J. Popok
- Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Bradford C. Dickerson
- Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ana-Maria Vranceanu
- Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston
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24
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Fenech AL, Van Benschoten O, Jagielo AD, Ufere NN, Topping CEW, Clay M, Jones BT, Traeger L, Temel JS, El-Jawahri A. Post-Traumatic Stress Symptoms in Hematopoietic Stem Cell Transplant Recipients. Transplant Cell Ther 2021; 27:341.e1-341.e6. [PMID: 33836886 PMCID: PMC10636532 DOI: 10.1016/j.jtct.2021.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 02/02/2023]
Abstract
Hematopoietic stem cell transplantation (HCT) is an intensive and potentially curative therapy for patients with hematologic malignancies. Patients admitted for HCT experience a prolonged, isolating hospitalization and endure substantial physical and psychological symptoms. However, there is a paucity of research on the impact of HCT on post-traumatic stress disorder (PTSD) symptoms in transplant recipients. This secondary analysis of 250 patients who underwent autologous and allogeneic HCT examined PTSD using the PTSD Checklist-Civilian measured at 6 months after HCT. We used the Functional Assessment of Cancer Therapy-Bone Marrow Transplant, and the Hospital Anxiety and Depression Scale to assess quality of life (QOL) and depression and anxiety symptoms at the time of admission for HCT, week 2 during hospitalization, and 6 months after HCT. We used multivariate regression models to assess factors associated with PTSD symptoms. Given collinearity between QOL, depression, and anxiety symptoms, we modeled these separately. The rate of clinically significant PTSD symptoms at 6 months after HCT was 18.9% (39/206). Participants with clinically significant PTSD symptoms experienced hypervigilance (92.3%), avoidance (92.3%), and intrusion (76.9%) symptoms. Among patients without clinically significant PTSD symptoms, 24.5% had clinically significant hypervigilance symptoms and 13.7% had clinically significant avoidance symptoms. Lower QOL at time of HCT admission (B = -0.04, P = .004) and being single (B = -3.35, P = .027) were associated with higher PTSD symptoms at 6 months after HCT. Higher anxiety at time of HCT admission (B = 1.34, P <.001), change in anxiety during HCT hospitalization (B = 0.59, P =.006), and being single (B = -3.50, P = .017) were associated with higher PTSD symptoms at 6 months. In a separate model using depression, younger age (B = -0.13, P = .017), being single (B = -3.58, P = .018), and higher baseline depression symptoms were also associated with higher PTSD symptoms at 6 months (B = 0.97, P < .001). Approximately one fifth of patients undergoing HCT experience clinically significant PTSD symptoms at 6 months after transplantation. The prevalence of hypervigilance and avoidance symptoms are notable even among patients who do not have clinically significant PTSD symptoms. Interventions to prevent and treat PTSD symptoms in HCT recipients are clearly warranted.
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Affiliation(s)
- Alyssa L Fenech
- Bone Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.
| | - Olivia Van Benschoten
- Bone Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Annemarie D Jagielo
- Bone Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Nneka N Ufere
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Carlisle E W Topping
- Bone Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Madison Clay
- Bone Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Bailey T Jones
- Bone Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Center for Thoracic Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Bone Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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25
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Park ER, Luberto CM, Chad-Friedman E, Traeger L, Hall DL, Perez GK, Goshe B, Vranceanu AM, Baim M, Denninger, MD, PhD JW, Fricchione, MD G, Benson, MD H, Lechner SC. A Comprehensive Resiliency Framework: Theoretical Model, Treatment, and Evaluation. Glob Adv Health Med 2021; 10:21649561211000306. [PMID: 34377598 PMCID: PMC8327002 DOI: 10.1177/21649561211000306] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 01/28/2021] [Accepted: 02/15/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There is heterogeneity in conceptualizations of resiliency, and there is, to date, no established theoretically driven resiliency assessment measure that aligns with a targeted resiliency intervention. We operationalize resiliency as one's ability to maintain adaptive functioning in response to the ongoing, chronic stress of daily living, and we use a novel resiliency measure that assesses the target components of an evidence based resiliency intervention. We present our resiliency theory, treatment model, and corresponding assessment measure (Current Experience Scale; CES). METHODS To establish the psychometric properties of the CES, we report the factor structure and internal consistency reliability (N = 273). Among participants in our resiliency intervention (N = 151), we explored construct validity in terms of associations with theoretical model constructs, a validated resiliency measure, and sensitivity to change from before to after the intervention. RESULTS Results indicated that a 23-item, 6-factor solution was a good fit to the data (RMSEA = .08, CFI = .97; TLI =.96) and internal consistency was good (α = .81 to .95). The CES showed correlations in the expected direction with resiliency model constructs (all p's < .001) and significant post intervention improvements. CONCLUSION Our resiliency theory, treatment model, and outcome appear aligned; the CES demonstrated promise as a psychometrically sound outcome measure for our resiliency intervention and may be used in future longitudinal studies and resiliency building interventions to assess individuals' resiliency to adapt to ongoing stress.
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Affiliation(s)
- Elyse R Park
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Christina M Luberto
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Emma Chad-Friedman
- Department of Psychology, University of Maryland, College Park,
Maryland
| | - Lara Traeger
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Daniel L Hall
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Giselle K Perez
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Brett Goshe
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Ana-Maria Vranceanu
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Margaret Baim
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - John W Denninger, MD, PhD
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Gregory Fricchione, MD
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Herbert Benson, MD
- Benson-Henry Institute for Mind Body Medicine, Massachusetts
General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital/Harvard
Medical School, Boston, Massachusetts
| | - Suzanne C Lechner
- Department of Psychiatry, University of Miami Miller School of
Medicine, Miami, Florida
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26
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Amonoo HL, Johnson PC, Dhawale TM, Traeger L, Rice J, Lavoie MW, Ufere NN, Longley RM, Harnedy LE, Clay MA, Topping CEW, DeFilipp Z, Chen YBA, El-Jawahri A. Sharing and caring: The impact of social support on quality of life and health outcomes in hematopoietic stem cell transplantation. Cancer 2021; 127:1260-1265. [PMID: 33598938 DOI: 10.1002/cncr.33455] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Social support is crucial for successful recovery after hematopoietic stem cell transplantation (HSCT) and has the potential to affect patient quality of life (QOL) and health outcomes. However, there are limited data on the relationship between a patient's perception of his or her social support and these outcomes. METHODS The authors conducted a secondary analysis of 250 autologous and allogeneic HSCT recipients enrolled in 2 supportive care trials at Massachusetts General Hospital from April 2011 through February 2016. They assessed social support as a patient's perception of his or her social well-being via the social well-being subscale of the Functional Assessment of Cancer Therapy. The authors used multivariate regression analyses to examine the relationship between pretransplant social well-being and QOL (Functional Assessment of Cancer Therapy-Treatment Outcome Index), psychological distress (Hospital Anxiety and Depression Scale), posttraumatic stress disorder [PTSD] symptoms (PTSD Checklist), fatigue (Functional Assessment of Cancer Therapy-Fatigue), and health care utilization (hospitalizations and days alive and out of the hospital) 6 months after HSCT. RESULTS Participants were on average 56.4 years old (SD, 13.3 years); 44% (n = 110) and 56% (n = 140) received autologous and allogeneic HSCT, respectively. Greater pre-HSCT social well-being was associated with higher QOL (B = 0.10; 95% CI, 0.06-0.13; P < .001), lower psychological distress (B = -0.21; 95% CI, -0.29 to -0.12; P < .001), and lower PTSD symptoms (B = -0.12; 95% CI, -0.19 to -0.06; P < .001). Pre-HSCT social well-being was not significantly associated with fatigue or health care utilization 6 months after HSCT. CONCLUSIONS Patients with higher pre-HSCT perceptions of their social support reported better QOL and lower psychological distress 6 months after HSCT. These findings underscore the potential for social support as a modifiable target for future supportive care interventions to improve the QOL and care of HSCT recipients.
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Affiliation(s)
- Hermioni L Amonoo
- Brigham and Women's Hospital, Boston, Massachusetts.,Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - P Connor Johnson
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts
| | - Tejaswini M Dhawale
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts
| | - Lara Traeger
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts
| | - Julia Rice
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Nneka N Ufere
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Zachariah DeFilipp
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts
| | - Yi-Bin A Chen
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts
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27
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Nelson AM, Rapoport CS, Traeger L, Greer JA. Anxiety Disorders. Psychooncology 2021. [DOI: 10.1093/med/9780190097653.003.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The focus of this chapter is on the clinical manifestation of anxiety disorders in patients diagnosed with cancer. We review the prevalence and correlates, presenting characteristics, assessment methods and recommendations, and evidence-based pharmacologic and psychosocial treatments of anxiety in this population. Cancer-related considerations that may impact care and treatment planning are highlighted. Close collaboration between oncology and mental health clinicians as well as between the patient and their multidisciplinary team is essential for developing a patient-centered approach for managing anxiety, improving quality of life, and supporting participation in cancer care. The chapter concludes with discussion of key directions for future research on anxiety disorders in the oncology setting.
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28
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Fong ZV, Traeger L. ASO Author Reflections: How Do Patients and Caregivers Select Hospitals for Complex Cancer Care? Ann Surg Oncol 2021; 28:4193-4194. [PMID: 33423124 DOI: 10.1245/s10434-020-09538-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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29
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Park ER, Sylvia LG, Streck JM, Luberto CM, Stanton AM, Perez GK, Baim M, Bliss CC, Convery MS, Crute S, Denninger JW, Donelan K, Dossett ML, Fava M, Fredriksson S, Fricchione G, George N, Hall DL, Hart BR, Herman J, Hirschberg A, Holt D, Looby SE, Malloy L, Meek J, Mehta DH, Millstein RA, Mizrach H, Rosa K, Slawsby E, Stupinski AC, Traeger L, Vanderkruik R, Vogeli C, Wilhelm S. Launching a resiliency group program to assist frontline clinicians in meeting the challenges of the COVID-19 pandemic: Results of a hospital-based systems trial. Gen Hosp Psychiatry 2021; 68:111-112. [PMID: 33229013 PMCID: PMC7605784 DOI: 10.1016/j.genhosppsych.2020.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Elyse R. Park
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America,Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America,Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America,Corrresponding author at: Health Policy Research Center, Mongan Institute, Massachusetts Hospital and Harvard Medical School, 100 Cambridge Street, Suite 1600, Boston, MA 02114, USA
| | - Louisa G. Sylvia
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Joanna M. Streck
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America,Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Christina M. Luberto
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America,Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America,Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Amelia M. Stanton
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Giselle K. Perez
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America,Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Margaret Baim
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Cayley C. Bliss
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America
| | - Mary Susan Convery
- Social Service Department, Massachusetts General Hospital, Boston, MA, United States of America
| | - Sydney Crute
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America
| | - John W. Denninger
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America,Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Karen Donelan
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America,Harvard Medical School, Boston, MA, United States of America
| | - Michelle L Dossett
- UC Davis Health, Department of Internal Medicine, Sacramento, CA, United States of America
| | - Maurizio Fava
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Stacie Fredriksson
- Home Base Program, Massachusetts General Hospital, Boston, MA, United States of America
| | - Gregory Fricchione
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America,Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Nevita George
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Daniel L. Hall
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America,Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Betsy Remington Hart
- Home Base Program, Massachusetts General Hospital, Boston, MA, United States of America
| | - John Herman
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - April Hirschberg
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Daphne Holt
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Sara E. Looby
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, United States of America
| | - Laura Malloy
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Jocelyn Meek
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Darshan H. Mehta
- Harvard Medical School, Boston, MA, United States of America,Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America,Home Base Program, Massachusetts General Hospital, Boston, MA, United States of America
| | - Rachel A. Millstein
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Helen Mizrach
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America
| | - Katherine Rosa
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Ellen Slawsby
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - A. Clare Stupinski
- Home Base Program, Massachusetts General Hospital, Boston, MA, United States of America
| | - Lara Traeger
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Rachel Vanderkruik
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
| | - Christine Vogeli
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America,Harvard Medical School, Boston, MA, United States of America
| | - Sabine Wilhelm
- Harvard Medical School, Boston, MA, United States of America,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
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30
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Jacobs JM, Nelson AM, Traeger L, Waldman L, Nicholson S, Jagielo AD, D’Alotto J, Greer JA, Temel JS, El-Jawahri A. Enhanced coping and self-efficacy in caregivers of stem cell transplant recipients: Identifying mechanisms of a multimodal psychosocial intervention. Cancer 2020; 126:5337-5346. [PMID: 33026658 PMCID: PMC7950641 DOI: 10.1002/cncr.33191] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/23/2020] [Accepted: 08/07/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND In a recent trial, a 6-session intervention (BMT-CARE) integrating medical information with cognitive-behavioral strategies improved quality of life (QOL), mood, coping skills, and self-efficacy for family/friend caregivers of hematopoietic stem cell transplantation (HCT) recipients. This study examined whether improvements in coping and self-efficacy mediated the intervention effects on QOL and mood. METHODS From December 2017 to April 2019, 100 caregivers of HCT recipients were enrolled into a randomized clinical trial of BMT-CARE versus usual care. Caregivers completed self-report measures of QOL (CareGiver Oncology Quality of Life questionnaire), depression and anxiety symptoms (Hospital Anxiety and Depression Scale), coping skills (Measure of Current Status), and self-efficacy (Cancer Self-Efficacy Scale-Transplant) at enrollment (before HCT) and 60 days after HCT. Causal mediation regression models were used to examine whether changes in coping and self-efficacy mediated intervention effects on QOL as well as depression and anxiety symptoms. RESULTS Improvements in 60-day QOL in patients assigned to BMT-CARE were partially mediated by improved coping and self-efficacy (indirect effect, 6.93; SE, 1.85; 95% CI, 3.71-11.05). Similarly, reductions in 60-day depression and anxiety symptoms were partially mediated by improved coping and self-efficacy (indirect effect for depression, -1.19; SE, 0.42; 95% CI, -2.23 to -0.53; indirect effect for anxiety, -1.46; SE, 0.55; 95% CI, -2.52 to -0.43). Combined improvements in coping and self-efficacy accounted for 67%, 80%, and 39% of the total intervention effects on QOL and depression and anxiety symptoms, respectively. CONCLUSIONS Coping and self-efficacy are essential components of a brief psychosocial intervention that improves QOL and mood for caregivers of HCT recipients during the acute recovery period. LAY SUMMARY A 6-session program (BMT-CARE) focused on providing medical information, caregiving skills, and self-care and coping strategies has been previously reported to improve the quality of life and mood of caregivers of hematopoietic stem cell transplantation recipients in comparison with caregivers who receive care as usual. Using statistical models, this study suggests that learning coping skills and improving self-efficacy are the most essential components of this program that likely lead to better quality of life and mood for caregivers.
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Affiliation(s)
- Jamie M. Jacobs
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114
- Harvard Medical School, Boston, Massachusetts, 02115
| | - Ashley M. Nelson
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114
- Harvard Medical School, Boston, Massachusetts, 02115
| | - Lara Traeger
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114
- Harvard Medical School, Boston, Massachusetts, 02115
| | - Lauren Waldman
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114
| | - Showly Nicholson
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114
| | | | - Jennifer D’Alotto
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114
- Harvard Medical School, Boston, Massachusetts, 02115
| | - Joseph A. Greer
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114
- Harvard Medical School, Boston, Massachusetts, 02115
| | - Jennifer S. Temel
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114
- Harvard Medical School, Boston, Massachusetts, 02115
| | - Areej El-Jawahri
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114
- Harvard Medical School, Boston, Massachusetts, 02115
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31
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Traeger L, Schnittker J, Dogan DY, Oguama D, Kuhlmann T, Muckenthaler MU, Krijt J, Urzica EI, Steinbicker AU. HFE and ALK3 act in the same signaling pathway. Free Radic Biol Med 2020; 160:501-505. [PMID: 32861780 DOI: 10.1016/j.freeradbiomed.2020.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/21/2020] [Indexed: 12/27/2022]
Abstract
Hepcidin deficiency leads to iron overload by increased dietary iron uptake and iron release from storage cells. The most frequent mutation in Hfe leads to reduced hepcidin expression and thereby causes iron overload. Recent findings suggested that HFE activates hepcidin expression predominantly via the BMP type I receptor ALK3. Here, we investigated whether HFE exclusively utilizes ALK3 or other signaling mechanisms also. We generated mice with double deficiency of Hfe and hepatocyte-specific Alk3 and compared the iron overload phenotypes of these double knockout mice to single hepatocyte-specific Alk3 deficient or Hfe knockout mice. Double Hfe-/-/hepatic Alk3fl/fl;Alb-Cre knockouts develop a similar iron overload phenotype compared to single hepatocyte-specific Alk3 deficient mice hallmarked by serum iron levels, tissue iron content and hepcidin levels of similar grades. HFE protein levels were increased in Alk3fl/fl;Alb-Cre mice compared to Alk3fl/fl mice, which was caused by iron overload - and not by Alk3 deficiency. The data provide evidence by genetic means that 1. HFE exclusively uses the BMP type I receptor ALK3 to induce hepcidin expression and 2. HFE protein expression is induced by iron overload, which further emphasizes the iron sensing function of HFE.
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Affiliation(s)
- L Traeger
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Muenster, Germany.
| | - J Schnittker
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Muenster, Germany.
| | - D Y Dogan
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Muenster, Germany.
| | - D Oguama
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Muenster, Germany.
| | - T Kuhlmann
- Institute of Neuropathology, University Hospital Muenster, University of Muenster, Muenster, Germany.
| | - M U Muckenthaler
- Department of Pediatric Oncology, Hematology and Immunology, Molecular Medicine Partnership (MMPU), European Molecular Biology Laboratory (EMBL), University of Heidelberg, Heidelberg, Germany.
| | - J Krijt
- Institute of Pathological Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - E I Urzica
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Muenster, Germany.
| | - A U Steinbicker
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Muenster, Germany.
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32
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Aaronson EL, Petrillo L, Stoltenberg M, Jacobsen J, Wilson E, Bowman J, Ouchi K, Traeger L, Daubman BR, Ritchie CS, Jackson V. The Experience of Emergency Department Providers With Embedded Palliative Care During COVID. J Pain Symptom Manage 2020; 60:e35-e43. [PMID: 32882358 PMCID: PMC7456836 DOI: 10.1016/j.jpainsymman.2020.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/08/2020] [Accepted: 08/12/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT Although the importance of palliative care (PC) integration in the emergency department (ED) has long been recognized, few formalized programs have been reported, and none have evaluated the experience of ED clinicians with embedded PC. OBJECTIVES We evaluate the experience of ED clinicians with embedded PC in the ED during the coronavirus disease pandemic. METHODS ED clinicians completed a survey about their perceptions of embedded PC in the ED. We summarized responses to closed-ended items using descriptive statistics and analyzed open-ended items using thematic analysis. RESULTS There were 134 ED clinicians surveyed. About 101 replied (75% response rate). Of those who had interacted with PC, 100% indicated a benefit of having PC involved. These included freeing up ED clinicians for other tasks (89%), helping them feel more supported (84%), changing the patients care trajectory (67%), and contributing to clinician education (57%) and skills (49%). Among barriers related to engaging PC were difficulty locating them (8%) and lack of time to consult because of ED volume (5%). About 98% of respondents felt that having PC in the ED was either valuable or very valuable. Open-ended responses reflected a positive impact on clinician wellness and improvement in access to high-quality goal-concordant care. Clinicians expressed gratitude for having PC in the ED and noted the importance of having readily available and easily accessible PC in the ED. CONCLUSION ED clinicians' perception of embedded PC was overall positive, with an emphasis on the impact related to task management, enrichment of PC skills, providing support for the team, and improved care for ED patients.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA.
| | - Laura Petrillo
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark Stoltenberg
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Erica Wilson
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Bowman
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany-Rose Daubman
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine S Ritchie
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vicki Jackson
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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33
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Kuhlthau KA, Luberto CM, Traeger L, Millstein RA, Perez GK, Lindly OJ, Chad-Friedman E, Proszynski J, Park ER. A Virtual Resiliency Intervention for Parents of Children with Autism: A Randomized Pilot Trial. J Autism Dev Disord 2020; 50:2513-2526. [PMID: 30900195 DOI: 10.1007/s10803-019-03976-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Parents of children with Autism experience high levels of stress. Resiliency is the ability to cope and adapt when faced with stressful events. This randomized, waitlist controlled pilot trial examines the feasibility, acceptability, and preliminary efficacy of an adapted virtual mind-body group intervention for parents of children with ASD. The intervention was feasible and acceptable. The immediate treatment group showed no difference in distress and greater improvement in resiliency and stress reactivity/coping relative to the delayed treatment group, (M difference 5.78; p = .038 and M difference 7.78; p = .001 respectively). Findings showed promising feasibility, acceptability, and preliminary efficacy for parents of children with ASD.
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Affiliation(s)
- Karen A Kuhlthau
- Department of Pediatrics, Massachusetts General Hospital, 125 Nashua Street Suite 860, Boston, MA, 02114, USA. .,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Christina M Luberto
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Rachel A Millstein
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA, 02114, USA.,Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Giselle K Perez
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA, 02114, USA.,Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Olivia J Lindly
- Department of Pediatrics, Massachusetts General Hospital, 125 Nashua Street Suite 860, Boston, MA, 02114, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Emma Chad-Friedman
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA, 02114, USA.,Department of Psychology, University of Maryland, College Park, MD, USA
| | - Jacqueline Proszynski
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA, 02114, USA.,Pratt Institute, New York, NY, USA
| | - Elyse R Park
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA, 02114, USA.,Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Lee HJ, Qian CL, Landay SL, O'Callaghan D, Kaslow-Zieve E, Azoba CC, Fuh CX, Temel B, Fong ZV, Greer JA, El-Jawahri A, Temel JS, Traeger L, Nipp RD. Communicating the components of informed treatment decision-making in patients with pancreatic cancer receiving preoperative therapy. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
147 Background: Preoperative therapy for localized pancreatic cancer represents an emerging treatment paradigm with the potential to provide significant benefits, yet with complex risks. Research is lacking about whether clinicians effectively communicate key components of informed decision-making for patients considering this treatment. Methods: From 2017-2019, we conducted a two-part, mixed methods study. In part 1, we conducted interviews with clinicians (medical/radiation/surgical oncology, n = 13) and patients with pancreatic cancer who had received preoperative therapy (n = 18) to explore perceptions of information needed to make informed decisions about preoperative therapy, from which we generated a list of key elements. In part 2, we audio recorded the initial multidisciplinary visits of patients with pancreatic cancer eligible for preoperative therapy (n = 20). Two coders (94% concordance) independently identified whether clinicians discussed key elements from part 1. Patients also completed a post-visit survey reporting whether clinicians discussed the key elements. We explored discordance between audio recordings and patient reports using qualitative, explanatory themes. Results: In part 1, we identified 13 key elements of informed treatment decision-making, including treatment logistics, alternatives, and potential risks/benefits. In part 2, recordings showed that most visits included discussions about logistics, such as the chemotherapy schedule (n = 20) and use of a port-a-cath (n = 20), whereas few included discussions about risks, such as the potential for hospitalizations (n = 7), urgent visits (n = 6), or needing help with daily tasks (n = 6). Patients reported hearing about potential benefits, such as likelihood of achieving surgery (n = 10) and cure (n = 7), even when these were not discussed. Qualitative themes across these discordant cases included clinician optimism regarding present day results versus historical findings and mentions of positive outcomes from prior patients without citing specific data or potential adverse outcomes. Conclusions: We identified key elements of information patients with pancreatic cancer need to make informed decisions about preoperative therapy. Although clinicians frequently disclosed much of this information, we found multiple cases of patient-clinician discordance for certain key elements, which underscores the need for interventions to enhance patient-clinician communication regarding pancreatic cancer treatment decisions.
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Donlan J, Ufere NN, Indriolo T, Jackson V, Chung RT, El-Jawahri A, Traeger L. Patient and Caregiver Perspectives on Palliative Care in End-Stage Liver Disease. J Palliat Med 2020; 24:719-724. [PMID: 32996824 DOI: 10.1089/jpm.2020.0551] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Specialty palliative care (PC) is underutilized for patients with end-stage liver disease (ESLD); however, studies exploring patient and caregiver perceptions of PC are lacking. Objectives: To explore patient and caregiver knowledge, perceptions, and preferences about PC in ESLD management. Setting/Subjects: Individuals with ESLD and their informal caregivers were recruited from a large academic medical center in the United States. Design: We conducted semistructured interviews with 15 patients with ESLD and 14 informal caregivers. Purposive sampling was used to balance both transplant-listed and transplant-ineligible patients. We used a brief description of PC to explore participants' knowledge, perceptions, and preferences about PC. Two raters coded interviews independently (κ = 0.95) using template analysis. Results: Participants' knowledge about PC came primarily from their loved ones' experiences with PC, with many conflating PC with end-of-life care. Transplant-listed patients expressed concern that a PC referral would negatively impact their likelihood of receiving a liver transplant. After hearing a brief description of PC, nearly all participants believed that patients with ESLD should learn about PC soon after diagnosis to help support their illness understanding and coping. Conclusions: Study participants reported limited knowledge of PC and often perceived it as hospice care. After receiving education on PC, nearly all participants, regardless of transplant eligibility, advocated for early introduction of PC in ESLD care. Interventions are needed to educate patients with ESLD and their caregivers on the potential role of PC to overcome misperceptions of PC and allow earlier integration of PC into ESLD management.
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Affiliation(s)
- John Donlan
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Teresa Indriolo
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T Chung
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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El-Jawahri A, Traeger L, Greer JA, Vanbenschoten O, Markovitz N, Cashavelly B, Tata LA, Nipp RD, Reynolds KL, Goyal L, Bhatt S, Fishman S, Horick N, Li Z, Volandes A, Temel JS. Randomized trial of a hospice video educational tool for patients with advanced cancer and their caregivers. Cancer 2020; 126:3569-3578. [PMID: 32508043 DOI: 10.1002/cncr.32967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/28/2020] [Accepted: 04/22/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients with advanced cancer and their caregivers have substantial misperceptions regarding hospice, which contributes to its underuse. METHODS The authors conducted a single-site randomized trial of a video educational tool versus a verbal description of hospice in 150 hospitalized patients with advanced cancer and their caregivers. Patients without a caregiver were eligible. Intervention participants (75 patients and 18 caregivers) viewed a 6-minute video depicting hospice. Control participants (75 patients and 26 caregivers) received a verbal description identical to the video narrative. The primary outcome was patient preference for hospice. Secondary outcomes included patient and/or caregiver knowledge and perceptions of hospice, and hospice use. RESULTS Between February 2017 and January 2019, approximately 55.7% of eligible patients (150 of 269 eligible patients) and 44 caregivers were enrolled. After the intervention, there was no difference noted with regard to patients' preferences for hospice (86.7% vs 82.7%; P = .651). Patients in the video group reported greater knowledge regarding hospice (9.0 vs 8.4; P = .049) and were less likely to endorse that hospice is only about death (6.7% vs 21.6%; P = .010). Among deceased patients, those assigned to the intervention were more likely to have used hospice (85.2% vs 63.6%; P = .01) and to have had a longer hospice length of stay (median, 12 days vs 3 days; P < .001). After the intervention, caregivers assigned to view the video were more likely to prefer hospice for their loved ones (94.4% vs 65.4%; P = .031), reported greater knowledge concerning hospice (9.7% vs 8.0%; P = .001), and were less likely to endorse that hospice is only about death (0.0% vs 23.1%; P = .066). CONCLUSIONS A hospice video did not significantly impact patients' preferences for hospice care. Patients with advanced cancer and their caregivers who were assigned to view the video were more informed regarding hospice and reported more favorable perceptions of hospice. Patients were more likely to use hospice and to have a longer hospice length of stay.
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Affiliation(s)
- Areej El-Jawahri
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph A Greer
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Olivia Vanbenschoten
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Netana Markovitz
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Barbara Cashavelly
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lee Ann Tata
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ryan D Nipp
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Lipika Goyal
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Sunil Bhatt
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah Fishman
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nora Horick
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zhigang Li
- University of Florida at Gainesville, Gainesville, Florida, USA
| | - Angelo Volandes
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Department of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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El-Jawahri A, Forst D, Fenech A, Brenner KO, Jankowski AL, Waldman L, Sereno I, Nipp R, Greer JA, Traeger L, Jackson V, Temel J. Relationship Between Perceptions of Treatment Goals and Psychological Distress in Patients With Advanced Cancer. J Natl Compr Canc Netw 2020; 18:849-855. [PMID: 32634779 DOI: 10.6004/jnccn.2019.7525] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 12/16/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Studies have shown gaps in prognostic understanding among patients with cancer. However, few studies have explored patients' perceptions of their treatment goals versus how they perceive their oncologist's goals, and the association of these views with their psychological distress. METHODS We conducted a cross-sectional study of 559 patients with incurable lung, gastrointestinal, breast, and brain cancers. The Prognosis and Treatment Perception Questionnaire was used to assess patients' reports of their treatment goal and their oncologist's treatment goal, and the Hospital Anxiety and Depression Scale was used to assess patients' psychological symptoms. RESULTS We found that 61.7% of patients reported that both their treatment goal and their oncologist's treatment goal were noncurative, whereas 19.3% reported that both their goal and their oncologist's goal were to cure their cancer, 13.9% reported that their goal was to cure their cancer whereas their oncologist's goal was noncurative, and 5% reported that their goal was noncurative whereas their oncologist's goal was curative. Patients who reported both their goal and their oncologist's goal as noncurative had higher levels of depression (B=0.99; P=.021) and anxiety symptoms (B=1.01; P=.015) compared with those who reported that both their goal and their oncologist's goal was curative. Patients with discordant perceptions of their goal and their oncologist's goal reported higher anxiety symptoms (B=1.47; P=.004) compared with those who reported that both their goal and their oncologist's goal were curative. CONCLUSIONS One-fifth of patients with incurable cancer reported that both their treatment goal and their oncologist's goal were to cure their cancer. Patients who acknowledged the noncurative intent of their treatment and those who perceived that their treatment goal was discordant from that of their oncologist reported greater psychological distress.
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Affiliation(s)
- Areej El-Jawahri
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
| | - Deborah Forst
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
| | - Alyssa Fenech
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
| | - Keri O Brenner
- 2Harvard Medical School, and.,3Department of Medicine, Division of Palliative Care, Massachusetts General Hospital, Boston, Massachusetts; and.,4Department of Medicine, Section of Palliative Care, Stanford University, Stanford, California
| | - Amanda L Jankowski
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
| | - Lauren Waldman
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
| | - Isabella Sereno
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
| | - Ryan Nipp
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
| | - Joseph A Greer
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
| | - Lara Traeger
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
| | - Vicki Jackson
- 2Harvard Medical School, and.,3Department of Medicine, Division of Palliative Care, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Jennifer Temel
- 1Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center.,2Harvard Medical School, and
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Abstract
e24079 Background: One of the most common concerns of cancer survivors is cancer-related cognitive impairment (CRCI), which affects an individual’s ability to return to work, school, or other life activities. The etiology of CRCI is poorly understood. Numerous studies have demonstrated a relationship between emotional distress and cognitive dysfunction, though the core psychological construct underlying this relationship has been elusive. Resilience, defined as the ability to function well despite adversity, reflects individual capacity to manage stress and reduce allostatic load. We hypothesized that low resilience contributes to stress-related cognitive symptoms in cancer survivors, and that improvement in resilience through the Relaxation Response Resiliency Program (3RP), a psychotherapy group that reduces emotional distress, would reduce cognitive symptoms in cancer survivors. Methods: Consistent with prior protocols, adult cancer survivors participated in the 3RP program, a 9-week resiliency mind-body group treatment led by psychologists and/or psychiatrists. Survivors completed measures of cognitive symptoms (Patient Reported Outcome Measure Information System – Cognitive function; PROMIS-Cog) and resilience (Current Experiences Scale; CES) before and after treatment. Pearson correlations evaluated relationships between resilience and cognition. Results: 46 cancer survivors (mean age = 57, 85% female, 94% White, 4% Asian, 2% Black) completed \ CES and PROMIS-Cog at therapy intake, with 41% of subjects reporting significant cognitive impairment at baseline (defined as scores of < 1.0 SD on PROMIS-Cog). There was a significant correlation between these two scales prior to treatment (r = 0.33; p = 0.025), indicating that subjects with lower resilience reported poorer cognition. Thus far, 13 survivors have completed the 8-week therapy program, with 46% of these patients reporting significant cognitive difficulties. The post-treatment correlation between resilience and cognition was nonsignificant (r = 0.19;p = ns). Treatment effects were operationalized by change scores (follow up – baseline) for CES and PROMIS-Cog. The relationship between CES and PROMIS-Cog change scores was positive but not significant with the small sample size (r = 0.35; p = 0.028). Conclusions: This preliminary study suggests that there is a relationship between resilience and cognition in cancer survivors. Improvements in resilience through the 3RP treatment may reduce cognitive symptoms, though further work is needed to determine the significance of this effect.
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Elyze M, Jacobs JM, Nelson A, Traeger L, Jagielo A, Greer JA, Temel JS, El-Jawahri A. Enhanced coping and self-efficacy in caregivers of hematopoietic stem cell transplant (HCT) recipients: Identifying mechanisms of a multimodal psychosocial intervention. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.12122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12122 Background: A brief multimodal psychosocial intervention (BMT-CARE) for caregivers of HCT recipients demonstrated promising efficacy for improving caregiver quality of life (QOL), mood, coping skills, and self-efficacy. We examined whether improvements in coping and self-efficacy mediated the intervention effects on QOL and mood. Methods: We conducted a randomized clinical trial of BMT-CARE for caregivers of patients undergoing autologous or allogeneic HCT at a single institution. Caregivers were randomly assigned to BMT-CARE or usual care. BMT-CARE was tailored to the HCT trajectory and integrated treatment-related education and self-care with cognitive-behavioral skills and caregiving-specific strategies to promote coping. Caregivers completed self-report measures of QOL (CareGiver Oncology QOL), depression and anxiety symptoms (Hospital Anxiety and Depression Scale), coping skills (Measure of Current Status), and self-efficacy (Cancer Self-Efficacy Scale-Transplant) at enrollment and 60 days post-HCT. We used causal mediation regression models to examine whether changes in coping and self-efficacy mediated intervention effects on QOL, depression and anxiety symptoms. Results: Caregivers randomized to BMT-CARE reported improved self-efficacy (adjusted means: 156.20 vs. 147.06, P=0.023) and coping skills (adjusted means: 36.54 vs. 25.41, P<0.001). Improved coping and self-efficacy partially mediated the intervention effects on 60-day QOL (indirect effect=6.93, SE=1.85, 95% CI [3.71, 11.05]). Similarly, improved coping and self-efficacy partially mediated reductions in 60-day depression and anxiety symptoms (indirect effect depression=-1.19, SE=0.42, 95% CI [-2.23, -0.53]; indirect effect anxiety=-1.46, SE=0.55, 95% CI [-2.52, -0.43]). Combined improvements in coping and self-efficacy accounted for 67%, 80%, and 39% of the total intervention effect on QOL and depression and anxiety symptoms, respectively. Conclusions: A brief multimodal intervention for caregivers of HCT recipients may improve QOL and mood by enhancing coping skills and self-efficacy. These findings offer important insights into the mechanisms by which caregiver-directed interventions may enhance caregiver QOL and reduce their psychological distress.
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El-Jawahri A, Jacobs JM, Nelson AM, Traeger L, Greer JA, Nicholson S, Waldman LP, Fenech AL, Jagielo AD, D’Alotto J, Horick N, Spitzer T, DeFilipp Z, Chen YBA, Temel JS. Multimodal psychosocial intervention for family caregivers of patients undergoing hematopoietic stem cell transplantation: A randomized clinical trial. Cancer 2020; 126:1758-1765. [PMID: 31899552 PMCID: PMC7103553 DOI: 10.1002/cncr.32680] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/20/2019] [Accepted: 12/03/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Caregivers of patients undergoing hematopoietic stem cell transplantation (HCT) experience an immense caregiving burden before, during, and after HCT. METHODS We conducted an unblinded, randomized trial of a psychosocial intervention (BMT-CARE) for caregivers of patients undergoing autologous and allogeneic HCT at Massachusetts General Hospital. Caregivers were randomly assigned to BMT-CARE or usual care. BMT-CARE was tailored to the HCT trajectory and integrated treatment-related education and self-care with cognitive-behavioral skills to promote coping. Caregivers assigned to BMT-CARE met with a trained interventionist (a psychologist or a social worker) in person, via telephone, or via videoconferencing for 6 sessions starting before HCT and continuing up to day +60 after HCT. The primary endpoint was feasibility, which was defined as at least 60% of eligible caregivers enrolling and completing 50% or more of the intervention sessions. We assesed caregiver quality of life (QOL; Caregiver Oncology Quality of Life Questionnaire), caregiving burden (Caregiver Reaction Assessment), psychological distress (Hospital Anxiety and Depression Scale), self-efficacy (Cancer Self-Efficacy Scale-Transplant), and coping (Measures of Current Status) at baseline and 30 and 60 days after HCT. We used mixed linear effect models to assess the effect of BMT-CARE on outcomes longitudinally. RESULTS We enrolled 72.5% of eligible caregivers (100 of 138), and 80% attended 50% or more of the intervention sessions. Caregivers randomized to BMT-CARE reported improved QOL (B = 6.11; 95% CI, 3.50-8.71; P < .001), reduced caregiving burden (B = -6.02; 95% CI, -8.49 to -3.55; P < .001), lower anxiety (B = -2.18; 95% CI, -3.07 to -1.28; P < .001) and depression symptoms (B = -1.23; 95% CI, -1.92 to -0.54; P < .001), and improved self-efficacy (B = 7.22; 95% CI, 2.40-12.03; P = .003) and coping skills (B = 4.83; 95% CI, 3.04-6.94; P < .001) in comparison with the usual-care group. CONCLUSIONS A brief multimodal psychosocial intervention tailored for caregivers of HCT recipients is feasible and may improve QOL, mood, coping, and self-efficacy while reducing the caregiving burden during the acute HCT period.
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Affiliation(s)
- Areej El-Jawahri
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Jamie M. Jacobs
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Ashley M. Nelson
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Lara Traeger
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Joseph A. Greer
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Showly Nicholson
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Lauren P. Waldman
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Alyssa L. Fenech
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Annemarie D. Jagielo
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Jennifer D’Alotto
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Nora Horick
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Thomas Spitzer
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Zachariah DeFilipp
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Yi-Bin A. Chen
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
| | - Jennifer S. Temel
- Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02134
- Harvard Medical School, Boston, Massachusetts, 02114
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Nipp RD, Thompson LL, Temel B, Fuh CX, Server C, Kay PS, Landay S, Lage DE, Traeger L, Scott E, Jackson VA, Horick NK, Greer JA, El-Jawahri A, Temel JS. Screening Tool Identifies Older Adults With Cancer at Risk for Poor Outcomes. J Natl Compr Canc Netw 2020; 18:305-313. [PMID: 32135520 DOI: 10.6004/jnccn.2019.7355] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 09/03/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Oncologists often struggle with managing the complex issues unique to older adults with cancer, and research is needed to identify patients at risk for poor outcomes. METHODS This study enrolled patients aged ≥70 years within 8 weeks of a diagnosis of incurable gastrointestinal cancer. Patient-reported surveys were used to assess vulnerability (Vulnerable Elders Survey [scores ≥3 indicate a positive screen for vulnerability]), quality of life (QoL; EORTC Quality of Life of Cancer Patients questionnaire [higher scores indicate better QoL]), and symptoms (Edmonton Symptom Assessment System [ESAS; higher scores indicate greater symptom burden] and Geriatric Depression Scale [higher scores indicate greater depression symptoms]). Unplanned hospital visits within 90 days of enrollment and overall survival were evaluated. We used regression models to examine associations among vulnerability, QoL, symptom burden, hospitalizations, and overall survival. RESULTS Of 132 patients approached, 102 (77.3%) were enrolled (mean [M] ± SD age, 77.25 ± 5.75 years). Nearly half (45.1%) screened positive for vulnerability, and these patients were older (M, 79.45 vs 75.44 years; P=.001) and had more comorbid conditions (M, 2.13 vs 1.34; P=.017) compared with nonvulnerable patients. Vulnerable patients reported worse QoL across all domains (global QoL: M, 53.26 vs 66.82; P=.041; physical QoL: M, 58.95 vs 88.24; P<.001; role QoL: M, 53.99 vs 82.12; P=.001; emotional QoL: M, 73.19 vs 85.76; P=.007; cognitive QoL: M, 79.35 vs 92.73; P=.011; social QoL: M, 59.42 vs 82.42; P<.001), higher symptom burden (ESAS total: M, 31.05 vs 15.00; P<.001), and worse depression score (M, 4.74 vs 2.25; P<.001). Vulnerable patients had a higher risk of unplanned hospitalizations (hazard ratio, 2.38; 95% CI, 1.08-5.27; P=.032) and worse overall survival (hazard ratio, 2.26; 95% CI, 1.14-4.48; P=.020). CONCLUSIONS Older adults with cancer who screen positive as vulnerable experience a higher symptom burden, greater healthcare use, and worse survival. Screening tools to identify vulnerable patients should be integrated into practice to guide clinical care.
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Affiliation(s)
- Ryan D Nipp
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Leah L Thompson
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Brandon Temel
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Charn-Xin Fuh
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | | | - Paul S Kay
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Sophia Landay
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Daniel E Lage
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | | | - Erin Scott
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Vicki A Jackson
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Nora K Horick
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Areej El-Jawahri
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
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El-Jawahri AR, Jacobs J, Nelson A, Traeger L, Greer J, Nicholson S, Waldman L, Fenech A, Jagielo A, D'Alotto J, Spitzer TR, DeFilipp Z, Chen YB, Temel J. Multimodal Psychosocial Intervention for Caregivers of Patients Undergoing Hematopoietic Stem Cell Transplantation (HCT): A Randomized Clinical Trial. Biol Blood Marrow Transplant 2020. [DOI: 10.1016/j.bbmt.2019.12.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Zehm A, Hazeltine AM, Greer JA, Traeger L, Nelson-Lowe M, Brizzi K, Jacobsen J. Neurology clinicians' views on palliative care communication: "How do you frame this?". Neurol Clin Pract 2019; 10:527-534. [PMID: 33520415 DOI: 10.1212/cpj.0000000000000794] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/06/2019] [Indexed: 12/15/2022]
Abstract
Background The communication process of preparing patients and families facing progressive neurodegenerative diseases for future illness has not been empirically elucidated; the goal of this qualitative study was to explore neurology interdisciplinary health professionals' communication experiences, including current approaches, facilitators, and challenges. Methods Three focus groups were conducted with 22 clinicians representing a range of health professions from several multidisciplinary neurology outpatient clinics at a large academic medical center. A thematic analysis approach was used to develop a coding structure and identify overarching themes. Results Neurology clinicians highlighted that in their practice, (1) conversations are triggered by acute events and practical needs; (2) conversations occur routinely but are rarely documented; (3) loss of patient capacity and resultant surrogate decision-making can be ethically fraught, especially in times of family conflict; (4) prognostic uncertainty, unfamiliarity with disease trajectories, and patient or surrogate avoidance pose communication challenges; and (5) generalist- and specialty-level palliative care roles should be better defined. Conclusions There is a need for a systematic, structured approach to communication that can be applied early in the disease trajectory and considered when developing integrated neuro-palliative care programs.
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Affiliation(s)
- April Zehm
- Division of Palliative Care and Geriatric Medicine (AZ, AMH, KB, JJ), Department of Medicine, Massachusetts General Hospital; Harvard Medical School (AZ, JAG, LT, KB, JJ); Department of Psychiatry (JAG, LT, MN-L), Massachusetts General Hospital, Boston
| | - Amanda M Hazeltine
- Division of Palliative Care and Geriatric Medicine (AZ, AMH, KB, JJ), Department of Medicine, Massachusetts General Hospital; Harvard Medical School (AZ, JAG, LT, KB, JJ); Department of Psychiatry (JAG, LT, MN-L), Massachusetts General Hospital, Boston
| | - Joseph A Greer
- Division of Palliative Care and Geriatric Medicine (AZ, AMH, KB, JJ), Department of Medicine, Massachusetts General Hospital; Harvard Medical School (AZ, JAG, LT, KB, JJ); Department of Psychiatry (JAG, LT, MN-L), Massachusetts General Hospital, Boston
| | - Lara Traeger
- Division of Palliative Care and Geriatric Medicine (AZ, AMH, KB, JJ), Department of Medicine, Massachusetts General Hospital; Harvard Medical School (AZ, JAG, LT, KB, JJ); Department of Psychiatry (JAG, LT, MN-L), Massachusetts General Hospital, Boston
| | - Margaret Nelson-Lowe
- Division of Palliative Care and Geriatric Medicine (AZ, AMH, KB, JJ), Department of Medicine, Massachusetts General Hospital; Harvard Medical School (AZ, JAG, LT, KB, JJ); Department of Psychiatry (JAG, LT, MN-L), Massachusetts General Hospital, Boston
| | - Kate Brizzi
- Division of Palliative Care and Geriatric Medicine (AZ, AMH, KB, JJ), Department of Medicine, Massachusetts General Hospital; Harvard Medical School (AZ, JAG, LT, KB, JJ); Department of Psychiatry (JAG, LT, MN-L), Massachusetts General Hospital, Boston
| | - Juliet Jacobsen
- Division of Palliative Care and Geriatric Medicine (AZ, AMH, KB, JJ), Department of Medicine, Massachusetts General Hospital; Harvard Medical School (AZ, JAG, LT, KB, JJ); Department of Psychiatry (JAG, LT, MN-L), Massachusetts General Hospital, Boston
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Traeger L, Rapoport C, Wright E, El-Jawahri A, Greer JA, Park ER, Jackson VA, Temel JS. Nature of Discussions about Systemic Therapy Discontinuation or Hospice among Patients, Families, and Palliative Care Clinicians during Care for Incurable Cancer: A Qualitative Study. J Palliat Med 2019; 23:542-547. [PMID: 31721642 DOI: 10.1089/jpm.2019.0402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Patient/clinician communication is critical to quality cancer care at the end-of-life (EOL). Yet discussions about systemic therapy discontinuation or hospice as a care option are commonly deferred. Real-time communication about these complex topics has not been evaluated. Palliative care visits may provide useful insight into how communication about EOL care occurs over time. Objective: To explore the nature of discussions about systemic therapy discontinuation and hospice among patients, families, and palliative care clinicians during care for incurable cancer. Design: Qualitative study of palliative care visits. Setting/Subjects: We audiorecorded visits of patients and families who participated in a palliative care trial from diagnosis of incurable lung or noncolorectal gastrointestinal cancer through the course of cancer care (n = 30). Measurements: We used thematic analysis to characterize communication patterns in the context of clinical events. Results: Content and tenor of discussions shifted in relation to patient health status. In the absence of acute medical deterioration, discussions addressed hospice broadly as an EOL care option. Candid exchanges between patients and families and their clinicians supported increasing depth and specificity of EOL care communication. As clinicians identified that patients were not tolerating treatment, the clinicians encouraged contemplation about quality-of-life implications of continuing treatment or the possibility that treatment might harm more than help, in anticipation of change in health status. Conclusions: Longitudinal relationships with palliative care clinicians functioned through multiple pathways to support patients and families in making complex EOL care decisions. Results inform models and interventions of communication at the EOL.
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Affiliation(s)
- Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Chelsea Rapoport
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily Wright
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Areej El-Jawahri
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Elyse R Park
- Mongan Health Policy Research Center, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Vicki A Jackson
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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45
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El-Jawahri A, VanDusen H, Fenech AL, Kavanaugh A, Jackson VA, Traeger L, Greer J, Spitzer TR, Chen YBA, Temel JS. Effect of inpatient palliative care on supportive care measures in patients undergoing hematopoietic cell transplantation (HCT). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.31_suppl.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
70 Background: Inpatient palliative care integrated with transplant care has been shown to improve patient-reported quality of life (QOL), symptom burden, and psychological distress during hospitalization for HCT. However, the impact of palliative care on supportive care practices during HSCT remains unknown. Methods: This secondary analysis is based on a single-site randomized clinical trial of 160 patients with hematologic malignancies undergoing HSCT between 8/2014 and 1/2016. Participants received either inpatient palliative care integrated with transplant care (n = 81) or transplant care alone (n = 79). We used the electronic health record to obtain data on supportive care measures during HSCT including the use of patient-controlled analgesia (PCA), intravenous pain medications, atypical antipsychotics (used to treat nausea/anxiety), psychostimulants, antidepressants, hypnotics, and the use of standing orders (as opposed to as needed ‘PRN’) for supportive care medications. We compared the proportion of subjects in each group receiving these supportive care measures using Fisher’s exact test. Results: Patients randomized to the palliative care intervention were more likely to use PCA (32.1% vs. 15.19%, P = 0.015), and atypical antipsychotics (35.8% vs. 17.7%, P = 0.012) compared to those receiving transplant care alone. Intervention participants were also more likely to have standing orders for their supportive care medications (74.1% vs. 56.9%, P = 0.030) compared to those receiving transplant care alone. Study groups did not differ in the of intravenous pain medications, psychostimulants, antidepressants, or hypnotics. Conclusions: Patients receiving inpatient integrated palliative and transplant care were more likely to utilize PCA and atypical antipsychotics during HCT compared to those receiving transplant care alone. Future work should examine whether these differences in supportive care practices mediate the effect of the palliative care intervention on patient-reported outcomes. Clinical trial information: NCT02207322.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yi-Bin Albert Chen
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
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46
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El-Jawahri A, Vanbenschoten O, Bhatt SM, Fenech AL, Markovitz N, Traeger L, Greer J, Volandes AE, Temel JS. Randomized trial of a hospice video decision aid for patients with advanced cancer and their caregivers. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.31_suppl.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
42 Background: Although hospice provides high-quality end-of-life care for patients with advanced cancer, the service remains underutilized in part due to lack of adequate information provided to patients and families about hospice care. Methods: We conducted a single-site randomized clinical trial of a hospice video decision aid versus a verbal description in 150 hospitalized patients with advanced cancer and their caregivers. Patients without an available caregiver were eligible to participate. Intervention participants (75 patients; 18 caregivers) received a verbal description about hospice plus a six-minute video depicting hospice care. Control participants (75 patients; 26 caregivers) received only the verbal description. The primary endpoint was patient preference for hospice care immediately after the intervention, adjusting for baseline preferences. Secondary outcomes included patient and caregiver knowledge and perceptions of hospice, and hospice utilization. Results: Between 2/2017 and 1/2019, we enrolled 55.7% (150/269) of potentially eligible patients and 44 caregivers. Post-intervention, patients assigned to the video group were more likely to prefer hospice care (86.7% vs. 82.7%, OR = 2.85, P = 0.08), but this was not statistically significant. Patients in the video group reported greater knowledge about hospice (B = 0.50, P = 0.024) and were less likely to endorse that hospice care is only about death (6.7% vs. 21.6%, OR = 0.28, P = 0.035). Among patients who died (n = 116), those assigned to the intervention were more likely to utilize hospice (85.2% vs. 63.6%, P = 0.01) and had a longer hospice length-of-stay (LOS) (median 12 vs. 3 days, P < 0.001). Post-intervention, caregivers assigned to the video were more likely to prefer hospice care for their loved ones (94.4% vs. 65.4%, P = 0.031), reported greater knowledge about hospice (B = 1.94, P < 0.001), and were less likely to endorse that hospice care is only about death (0.0% vs. 23.1%, P = 0.066). Conclusions: Patients with advanced cancer and their caregivers who viewed a hospice video decision aid were more informed about hospice, reported more favorable perceptions of hospice, and were more likely to utilize hospice and have a longer hospice LOS. Clinical trial information: NCT03040102.
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47
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Jacobs JM, Fishman S, Sommer R, Sereno I, Fenech A, Jankowski AL, Traeger L, Greer JA, Vanderklish J, Hunnewell C, Saylor M, Chen YB, Spitzer T, DeFilipp Z, Temel JS, El-Jawahri A. Coping and Modifiable Psychosocial Factors are Associated with Mood and Quality of Life in Patients with Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2019; 25:2234-2242. [PMID: 31260800 DOI: 10.1016/j.bbmt.2019.06.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/20/2019] [Accepted: 06/24/2019] [Indexed: 12/14/2022]
Abstract
Chronic graft-versus-host disease (GVHD) is one of most common complications following allogeneic hematopoietic cell transplantation (HCT) and the most significant contributor to morbidity and nonrelapse mortality. The physical burdens and psychosocial difficulties of these patients have not been described systematically. An exploration into the rates and correlates of mood and quality of life (QOL) in patients with chronic GVHD is necessary to develop a clinically relevant, evidence-based intervention to promote well-being. From July 2015 to July 2017, adult allogeneic HCT survivors with established moderate to severe chronic GVHD (N = 52) enrolled in a prospective, longitudinal study at a tertiary academic center. We examined the rates and correlates of depression and anxiety symptoms (Hospital Anxiety and Depression Scale) and explored whether constructs including coping strategies (Coping Inventory for Stressful Situations), symptom burden (Lee Symptom Assessment Scale), physical functioning (Human Activity Profile), and perceived social support (Medical Outcomes Study Social Support Survey) predicted QOL trajectory over time (Functional Assessment of Cancer Therapy-Bone Marrow Transplant) at the baseline, 3-month, and 6-month follow-up. Analyses adjusted for age, sex, chronic GVHD severity, and time since chronic GVHD diagnosis. At the baseline, 3-month, and 6-month follow-up, 32.7%, 31.1%, and 37.8% of patients reported clinically significant depression symptoms, and 30.8%, 20.0%, and 36.4% reported clinically elevated anxiety symptoms, respectively. Adjusting for covariates, greater use of negative emotion-oriented coping (β = 0.20, P = .002), less use of task-oriented coping (β = -0.10, P = .021), worse physical functioning (β = -0.07, P = .004), and higher symptom burden (β = 0.07, P = .002) were independently associated with depression symptoms at baseline. Greater use of negative emotion-oriented coping (β = 0.28, P < .001) and worse physical functioning (β = -0.05, P = .034) were independently associated with anxiety at baseline. Patients who used more negative emotion-oriented coping (β = -0.58, P = .035), had less task-oriented (β = 0.40, P = .028) and social diversion-oriented coping (β = 0.35, P = .039), and had higher symptom burden (β = -0.30, P = .001), worse physical functioning (β = 0.32, P < .001), and lower perceived social support (β = 6.47, P = .003) at baseline reported poorer QOL over time. The unmet physical and psychosocial needs of patients with chronic GVHD are substantial and warrant investigation into evidence-based interventions that may improve QOL and mood by targeting modifiable psychosocial constructs identified in this study.
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Affiliation(s)
- Jamie M Jacobs
- Center for Psychiatric Oncology and Behavioral Sciences, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Sarah Fishman
- Center for Psychiatric Oncology and Behavioral Sciences, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert Sommer
- Center for Psychiatric Oncology and Behavioral Sciences, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Isabella Sereno
- Center for Psychiatric Oncology and Behavioral Sciences, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Alyssa Fenech
- Center for Psychiatric Oncology and Behavioral Sciences, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Amanda L Jankowski
- Center for Psychiatric Oncology and Behavioral Sciences, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Lara Traeger
- Center for Psychiatric Oncology and Behavioral Sciences, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Center for Psychiatric Oncology and Behavioral Sciences, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Julie Vanderklish
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Chrisa Hunnewell
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Meredith Saylor
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Yi-Bin Chen
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas Spitzer
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Zachariah DeFilipp
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer S Temel
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, Massachusetts
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48
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Wright EM, El-Jawahri A, Temel JS, Carr A, Safren SA, Park ER, Pirl WF, Bruera E, Traeger L. Patient Patterns and Perspectives on Using Opioid Regimens for Chronic Cancer Pain. J Pain Symptom Manage 2019; 57:1062-1070. [PMID: 30831237 PMCID: PMC6557123 DOI: 10.1016/j.jpainsymman.2019.02.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/21/2019] [Accepted: 02/21/2019] [Indexed: 01/24/2023]
Abstract
CONTEXT With increasing attention to the undertreatment of cancer pain in parallel with concerns about opioid misuse, little is known about how patients with advanced cancer adhere to opioid regimens for chronic cancer pain. OBJECTIVES We explored patient approaches to managing chronic cancer pain with long-acting opioids. METHODS In a multimethods study at an academic medical center, adult patients with chronic cancer pain (n = 17) used electronic pill caps to record adherence to prescribed long-acting opioid regimens. After eight weeks, patients viewed their adherence records and completed a semistructured interview about their opioid use. With a framework approach, we coded interview data (Kappa >0.95) and identified themes in how patients perceived and used opioids to manage cancer pain. RESULTS Patients (59% female; 94% non-Hispanic white; median age = 65 years) felt grateful about pain benefit from opioids yet concerned about opioid side effects and addiction/tolerance. Main reasons for nonadherence included both intentional decisions (e.g., skipping doses) and unintentional barriers (e.g., missing doses due to inconsistent sleep schedules). Overall, patients set their own opioid adherence goals and developed routines to achieve them. Residual pain varied and was not consistently linked with opioid adherence. CONCLUSION Patients commonly felt conflicted about using prescribed long-acting opioids to manage cancer pain due to concurrent perceptions of their risks and benefits, and they set their own parameters for opioid-taking practices. Intentional and unintentional deviations from prescribed opioid schedules highlight the need to enhance adherence communication, education, and counseling, to optimize the use of long-acting opioids as a component of cancer pain management.
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Affiliation(s)
- Emily M Wright
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Alaina Carr
- Department of Psychology, University of Colorado Denver, Denver, Colorado, USA
| | - Steven A Safren
- Department of Psychology, University of Miami, Coral Gables, Florida, USA
| | - Elyse R Park
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - William F Pirl
- Harvard Medical School, Boston, Massachusetts, USA; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Lara Traeger
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
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Kay P, El-Jawahri A, Fuh CX, Temel B, Landay S, Lage D, Franco-Garcia E, Scott E, Stevens E, O'Malley T, Mohile SG, Dale W, Traeger L, Jackson V, Greer J, Temel JS, Nipp RD. Pilot randomized trial of a transdisciplinary geriatric intervention for older adults with cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11549 Background: Oncologists often struggle with managing the unique care needs of older adults with cancer. We sought to determine the feasibility of delivering a transdisciplinary geriatric intervention designed to address the geriatric (physical function & comorbidity) and palliative care (symptoms & prognostic understanding) needs of older adults with cancer. Methods: We randomly assigned patients age ≥65 with newly diagnosed incurable gastrointestinal (GI) or lung cancer to receive a transdisciplinary geriatric intervention or usual care. Intervention patients received two visits with a geriatrician who was trained to address patients’ palliative care needs in addition to conducting a geriatric assessment. We defined the intervention as feasible if > 70% of patients enrolled in the study and > 75% completed study visits and surveys. At baseline and week 12, we assessed patients’ quality of life (QOL, Functional Assessment of Cancer Therapy General), symptoms (Edmonton Symptom Assessment System), and communication confidence (Perceived Efficacy in Patient Physician Interactions). As this was a pilot study, we calculated mean change scores in outcomes and estimated intervention effect sizes (ES). Results: From 2/2017-6/2018, we randomized 62 patients (55.9% enrollment rate [most common reason for refusal was feeling too ill]; median age = 72.3 [range 65.2-91.8]; 45.2% female; cancer types: 56.5% GI, 43.5% lung). Among intervention patients, 82.1% attended the first visit and 76.2% attended both. Overall, 77.8% completed all study surveys. Compared to usual care, intervention patients had less decrement in QOL scores (-0.77 vs -3.84, ES = .21), greater reduction in the number of moderate/severe symptoms (-0.69 vs +1.04, ES = .58), and more improvement in communication confidence (+1.06 vs -0.80, ES = .38). Conclusions: In this trial of older adults with advanced cancer, more than half enrolled in the study and over 75% of those who enrolled completed all study visits and surveys. Our effect size estimates suggest that a transdisciplinary intervention targeting patients’ geriatric and palliative care needs may be a promising approach to improve patients’ QOL, symptom burden, and communication confidence. Clinical trial information: NCT02868112.
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Affiliation(s)
- Paul Kay
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | | | | | | | | | | | - Erin Scott
- Massachusetts General Hospital, Boston, MA
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Kamdar M, Centi AJ, Agboola S, Fischer N, Rinaldi S, Strand JJ, Traeger L, Temel JS, Greer J, El-Jawahri A, Jackson V, Kvedar J, Jethwani K. A randomized controlled trial of a novel artificial intelligence-based smartphone application to optimize the management of cancer-related pain. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11514] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11514 Background: Cancer pain is a significant problem that impairs patient quality of life and increases healthcare utilization. ePAL is a smartphone application that utilizes patient-reported outcomes (PROs) and artificial intelligence (AI) to optimize cancer pain management. This randomized controlled trial examined the impact of ePAL on cancer pain severity, attitudes toward cancer pain, and healthcare utilization. Methods: Patients with pain from metastatic solid tumors (n = 112) undergoing treatment in a palliative care clinic were randomized to either a control group (n = 56) that received usual care or an intervention group (n = 56) that received ePAL in addition to usual care for 8 weeks. Measures of pain severity (Brief Pain Inventory), attitudes towards cancer treatment (Barriers Questionnaire II) and anxiety (General Anxiety Disorder-7) were assessed. We used repeated measures mixed modeling to assess change in outcome measures over time. We also conducted a chart review to identify pain-related hospital admissions and emergency department (ED) visits and compared risk between study groups. Results: Pain severity (BPI) and negative attitudes toward cancer treatment (BQ-II) decreased significantly for those assigned to ePAL compared to controls (ß = -0.09, p = 0.034 and ß = -0.037, p = 0.042, respectively). Patients assigned to ePAL reported higher anxiety scores compared to controls (ß = 0.21, p = 0.015). Patients assigned to ePAL had significantly fewer pain-related hospital admissions (n = 4 vs. n = 20, per patient risk ratio 0.31, p = 0.018) and fewer pain-related admissions through the ED (n = 2 vs. n = 14, per patient risk ratio 0.18, p = 0.008) compared to control group. Conclusions: To our knowledge, this is the first mobile app to utilize patient reported outcomes and artificial intelligence to significantly decrease pain scores and pain-related hospitalizations in patients with cancer-related pain. Future directions include examining the efficacy of ePAL in settings with limited access to palliative care.
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Affiliation(s)
| | | | | | - Nils Fischer
- Connected Health Innovation, Partners Healthcare, Boston, MA
| | | | | | | | | | | | | | | | | | - Kamal Jethwani
- Connected Health Innovation, Partners Healthcare, Boston, MA
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