1
|
Liu Y, Li RL, Chen L, Zhao FY, Su YL, Jin S, Liu JE. Construction and validation of a risk-prediction model for chemotherapy-related cognitive impairment in patients with breast cancer. J Cancer Surviv 2024:10.1007/s11764-024-01566-7. [PMID: 38512563 DOI: 10.1007/s11764-024-01566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE To identify risk factors of chemotherapy-related cognitive impairment (CRCI) and construct and validate a visual prediction model of such for patients with breast cancer. METHODS A multicenter, descriptive, and cross-sectional design was adopted. Data were collected from ten public tertiary hospitals in China. Cognitive function was assessed by using Functional Assessment of Cancer Therapy-cognitive function. Socio-demographic, clinical, psychological, and physical indicators were also assessed. The logistic prediction model was constructed by fivefold cross-validation. Then, a nomogram was utilized to visualize the prediction model, which was also evaluated via discrimination, calibration, and decision curve analysis. RESULTS A total of 71 breast cancer patients had CRCI with a prevalence of 9.58%. This visual prediction model was constructed based on education background, exercise frequency, chemotherapy times, and fatigue and demonstrated good discrimination, with an area under the receiver operating characteristic curve of 0.882. The calibration curve indicated good agreement between experimental and projected values, and the decision curve proved good clinical applicability. CONCLUSION Education background, exercise frequency, chemotherapy times, and fatigue were associated with high incidence of CRCI. The prediction model exhibits superior performance and has promise as a useful instrument for assessing the likelihood of CRCI in breast cancer patients. IMPLICATIONS FOR CANCER SURVIVORS Our findings could provide breast cancer survivors with risk screening based on CRCI predictors to implement prevention and early intervention, and help patients integrate into society and achieve comprehensive recovery.
Collapse
Affiliation(s)
- Yu Liu
- School of Nursing, Capital Medical University, You An Men, 100069, Beijing, China
| | - Ruo-Lin Li
- School of Nursing, Capital Medical University, You An Men, 100069, Beijing, China
| | - Lu Chen
- School of Nursing, Capital Medical University, You An Men, 100069, Beijing, China
| | - Fu-Yun Zhao
- School of Nursing, Capital Medical University, You An Men, 100069, Beijing, China
| | - Ya-Li Su
- Department of Breast Oncology, Beijing Tiantan Hospital, Capital Medical University, South 4th Ring Road West, 100050, Beijing, China
| | - Shuai Jin
- School of Nursing, Capital Medical University, You An Men, 100069, Beijing, China
| | - Jun-E Liu
- School of Nursing, Capital Medical University, You An Men, 100069, Beijing, China.
| |
Collapse
|
2
|
Garland SN, Tulk J, Rodriguez N, Rash JA, Fawcett JM, McCarthy J, Seal M, Laing K. Perceived Executive Functioning Deficits After Diagnosis in Women with Non-Metastatic Breast Cancer Prior to Adjuvant Therapies. Int J Behav Med 2024; 31:31-40. [PMID: 36720774 DOI: 10.1007/s12529-023-10153-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Perceived deficits in executive functioning are among the many difficulties that women diagnosed with breast cancer experience. This study assessed the presence of perceived deficits in executive functioning among women with breast cancer prior to systemic treatment and radiation and associations between perceived deficits in executive function and comorbid fatigue, sleep, and mood disturbance. METHOD Participants were recruited following their breast cancer diagnosis and assessed using the Behavior Rating Inventory of Executive Function for Adults (BRIEF-A), subjective and objective measures of sleep duration and efficiency, and self-report measures of insomnia severity, sleep quality, fatigue, and mood disturbance. Hierarchical regression was used to examine associations between symptoms, adjusting for age and education. RESULTS The final sample included 92 women with a mean age of 60.7 years and 13.5 years of education. Thirteen percent of participants reported global executive dysfunction. After partitioning out variability from other independent variables, fatigue (p = < .001), perceived sleep quality (p = .030), and symptoms of insomnia (p = .008) accounted for 13.3%, 5.7%, and 8.5% of unique variance in perceived executive functioning, respectively. Emotional fatigue was most strongly associated with perceived deficits in executive functioning. Neither subjective or objective sleep duration or efficiency was associated with perceived deficits in executive functioning. CONCLUSION Fatigue, particularly emotional fatigue, insomnia, and poor sleep quality had the strongest associations with perceived deficits in executive functioning. Sleep interventions and fatigue management strategies may prove useful for women who seek to improve their perceived executive functioning.
Collapse
Affiliation(s)
- Sheila N Garland
- Department of Psychology, Faculty of Science, Memorial University, St. John's, Newfoundland and Labrador, A1B 3X9, Canada.
- Discipline of Oncology, Faculty of Medicine, Memorial University , St. John's, Newfoundland and Labrador, Canada.
- Beatrice Hunter Cancer Research Institute, Halifax, Nova Scotia, Canada.
| | - Joshua Tulk
- Department of Psychology, Faculty of Science, Memorial University, St. John's, Newfoundland and Labrador, A1B 3X9, Canada
| | - Nicole Rodriguez
- Department of Psychology, Faculty of Science, Memorial University, St. John's, Newfoundland and Labrador, A1B 3X9, Canada
| | - Joshua A Rash
- Department of Psychology, Faculty of Science, Memorial University, St. John's, Newfoundland and Labrador, A1B 3X9, Canada
| | - Jonathan M Fawcett
- Department of Psychology, Faculty of Science, Memorial University, St. John's, Newfoundland and Labrador, A1B 3X9, Canada
| | - Joy McCarthy
- Discipline of Oncology, Faculty of Medicine, Memorial University , St. John's, Newfoundland and Labrador, Canada
| | - Melanie Seal
- Discipline of Oncology, Faculty of Medicine, Memorial University , St. John's, Newfoundland and Labrador, Canada
| | - Kara Laing
- Discipline of Oncology, Faculty of Medicine, Memorial University , St. John's, Newfoundland and Labrador, Canada
| |
Collapse
|
3
|
Lozano-Lozano M, Galiano-Castillo N, Gonzalez-Santos A, Ortiz-Comino L, Sampedro-Pilegaard M, Martín-Martín L, Arroyo-Morales M. Effect of mHealth plus occupational therapy on cognitive function, mood and physical function in people after cancer: Secondary analysis of a randomized controlled trial. Ann Phys Rehabil Med 2022; 66:101681. [PMID: 35671976 DOI: 10.1016/j.rehab.2022.101681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 04/29/2022] [Accepted: 05/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Medical and surgical treatments for breast cancer have various adverse effects. Both mobile health and supervised intervention strategies have been implemented to overcome these effects, but some gaps remain to be addressed. Scientific evidence for the effectiveness of occupational therapy in cancer is limited. OBJECTIVE To compare the clinical effectiveness of the BENECA mHealth app used alone or combined with an integral supervised rehabilitation strategy that focused on cognitive performance, mood state, functional capacity, and cancer-related pain and fatigue in overweight women after breast cancer. METHODS In this secondary analysis of an assessor-blinded randomized controlled clinical trial, 80 overweight women after breast cancer (stage I-IIIA) were randomly allocated to an integral approach group (IA; n=40) or a control group (CG; n=40). All participants participated in an 8-week intervention. Assessments were performed at baseline, 8 weeks, and 6 months and included cognitive performance (Trial Making Test and Wechsler Adult Intelligence Scale), psychological state (Hospital Anxiety and Depression Scale), pain (Brief Pain Inventory), fatigue (Piper Fatigue Scale), and physical function (6 min walk test). An intention-to-treat analysis was conducted with analysis of covariance. RESULTS Selective attention (TMT) was significantly higher in the IA group, with a moderate to large effect size for TMT A (T2: d=1.1; T 3: d=1.2), working memory and processing speed (WAIS), anxiety and general HADS score (d=1.6), and functional capacity at 8 weeks and 6 months (d=1.5). Fatigue perception (mean difference, -0.6; 95% CI -1.4 to 0.04; p=0.009) and pain (intensity level p<0.001; interference level p=0.002) were also significantly more improved in the IA group. CONCLUSIONS An integral strategy involving the BENECA mHealth app with a supervised, multimodal intervention improved cognitive, psychological, and functional performance in women after breast cancer more than mHealth alone. Occupational therapy has a role to play in breast cancer rehabilitation.
Collapse
Affiliation(s)
- Mario Lozano-Lozano
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Spain; Sport and Health Joint University Institute (iMUDS), Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain; "Cuídate" Support Unit for Oncology Patients, Granada, Spain; Unit of Excellence on Exercise and Health (UCEES), University of Granada, Granada, Spain
| | - Noelia Galiano-Castillo
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Spain; Sport and Health Joint University Institute (iMUDS), Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain; "Cuídate" Support Unit for Oncology Patients, Granada, Spain; Unit of Excellence on Exercise and Health (UCEES), University of Granada, Granada, Spain
| | - Angela Gonzalez-Santos
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Spain; Sport and Health Joint University Institute (iMUDS), Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain; "Cuídate" Support Unit for Oncology Patients, Granada, Spain; Unit of Excellence on Exercise and Health (UCEES), University of Granada, Granada, Spain
| | - Lucía Ortiz-Comino
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Spain; Sport and Health Joint University Institute (iMUDS), Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain; "Cuídate" Support Unit for Oncology Patients, Granada, Spain
| | - Marc Sampedro-Pilegaard
- The Research Initiative of Activity Studies and Occupational Therapy, Department of Public Health, University of Southern Denmark, Denmark; REHPA, the Danish Knowledge Centre for Rehabilitation and Palliative care, Odense University Hospital, Denmark
| | - Lydia Martín-Martín
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Spain; Sport and Health Joint University Institute (iMUDS), Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain; "Cuídate" Support Unit for Oncology Patients, Granada, Spain; Unit of Excellence on Exercise and Health (UCEES), University of Granada, Granada, Spain.
| | - Manuel Arroyo-Morales
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Spain; Sport and Health Joint University Institute (iMUDS), Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain; "Cuídate" Support Unit for Oncology Patients, Granada, Spain; Unit of Excellence on Exercise and Health (UCEES), University of Granada, Granada, Spain
| |
Collapse
|
4
|
Distinct sleep disturbance and cognitive dysfunction profiles in oncology outpatients receiving chemotherapy. Support Care Cancer 2022; 30:9243-9254. [PMID: 36066629 DOI: 10.1007/s00520-022-07350-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/24/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Sleep disturbance and cancer-related cognitive impairment (CRCI) are two of the most common symptoms reported by patients undergoing chemotherapy. Less is known about how these symptoms co-occur and their associated risk factors. Study purposes were to identify subgroups of patients with distinct sleep disturbance and CRCI profiles and evaluate for differences among the subgroups in demographic and clinical characteristics, symptom severity scores, and QOL outcomes. METHODS A total of 1,333 oncology outpatients receiving chemotherapy completed self-report questionnaires on sleep disturbance and cognitive dysfunction six times over two cycles of chemotherapy. Latent profile analysis was used to identify distinct sleep disturbance AND cognitive dysfunction profiles. Parametric and non-parametric tests were used to evaluate for differences among the classes. RESULTS Two distinct profiles were identified (i.e., Low = low levels of both sleep disturbance and cognitive dysfunction (53.5%); High = high levels of both sleep disturbance and cognitive dysfunction (45.5%)). Patients in the High class were younger, more likely to be female, had a lower functional status and a higher level of comorbidity. In addition, these patients had a higher symptom burden and a lower quality of life. CONCLUSION Almost half of the patients undergoing chemotherapy experienced clinically meaningful levels of both symptoms. Of note, sleep disturbance is frequently overlooked by both clinicians and patients. Clinicians need to recommend cognitive rehabilitation and physical activity programs to decrease patients' symptom burden.
Collapse
|
5
|
The relationship between symptoms of obsessive compulsive disorder and depression during therapy: A random intercept cross-lagged panel model. J Behav Ther Exp Psychiatry 2022; 76:101748. [PMID: 35738694 DOI: 10.1016/j.jbtep.2022.101748] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/04/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES We know little about how symptoms of obsessive-compulsive disorder and depression interact during psychological therapy. Although some previous research suggests that reductions in the severity of depression are driven by reductions in OCD, support for this conclusion is limited due to the exclusion of individuals with severe depression and limitations of the statistical approaches used. METHODS This study re-examined the interaction between symptoms of OCD and depression during therapy in a sample of 137 adults with a primary diagnosis of OCD and a full range of depression severity. All participants received a 12 to 16-week specialist residential treatment. Participants completed the Florida Obsessive Compulsive Inventory and Patient Health Questionnaire for depression weekly. The relationship between severity of OCD and depression was examined using a random intercept cross-lagged panel model. RESULTS Both cross-lagged paths were significant, with prior levels of OCD influencing subsequent levels of depression, and prior levels of depression influencing subsequent levels of OCD. LIMITATIONS The present study was conducted in a residential setting, meaning the findings may not generalise to outpatient settings characterised by less severe OCD and depression. CONCLUSIONS Contrary to previous findings, which suggest that the influence of OCD on depression is far greater than the reverse, our findings suggest that OCD and depression influence each other equally. As improvements in mood can help to improve symptoms of OCD, it appears important to target depression concurrently during treatment for OCD. This would be a new treatment target for improvement outcomes in OCD.
Collapse
|
6
|
Vizer LM, Mikles SP, Piepmeier AT. Cancer-related cognitive impairment in survivors of adolescent and young adult non-central nervous system cancer: A scoping review. Psychooncology 2022; 31:1275-1285. [PMID: 35726379 DOI: 10.1002/pon.5980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Cancer-related cognitive impairments (CRCI) are common after treatment and can have important impacts on the lives of adolescent and young adult (AYA) cancer survivors-those cancer survivors diagnosed between ages 15 and 39. However, most research focuses on survivors diagnosed under age 15 or over age 39 so we know relatively little about CRCI among AYA survivors of non-central nervous system (CNS) cancers. Here we review the research on CRCI among AYA survivors of non-CNS cancers to determine prevalence, associated factors, and impact on survivors' lives as well as implications for future research. METHODS In November 2021 we performed a systematic search of the literature in MEDLINE, Web of Science, PsycInfo, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials to identify peer-reviewed English language articles describing original research with at least one cognitive outcome and conducted with AYA survivors of non-CNS cancer diagnosed as AYAs. We screened 6003 articles and 21 met eligibility criteria. Guided by the PRISMA-ScR Checklist, we extracted study information to meet review objectives. RESULTS Most studies employed cross-sectional surveys or interviews, though some employed longitudinal methods, neurocognitive assessments, or brain imaging. From the subset of articles that reported a prevalence we calculated a weighted mean prevalence of 25.75% and weighted median prevalence of 27.8%. The factors associated with CRCI included female gender, higher dose chemotherapy, and comorbidities. CRCI impacted the lives of AYA survivors through impaired role functioning, financial toxicity, and unmet needs. CONCLUSIONS CRCI is highly prevalent among non-CNS cancer survivors diagnosed as AYAs and impacts quality of life and role functioning. This review suggests a need for further longitudinal, imaging, and mixed methods research and provision of resources to help achieve better quality of life and educational and occupational attainment during what is potentially a decades-long survivorship period. However, although interventions might improve cognition and functioning, the review identified only one pilot study. Digital interventions may be a practical and effective option for this age group, but they have yet to be adequately investigated. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Lisa M Vizer
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Sean P Mikles
- Lineberger Comprehensive Cancer Outcomes Program, University of North Carolina, Chapel Hill, NC, USA
| | | |
Collapse
|
7
|
Tulk J, Garland SN, Howden K, Glidden C, Scott I, Chalifour K, Eaton G, Mahar A, Oberoi S. Prevalence and factors associated with insomnia symptoms in adolescents and young adults with cancer during the COVID-19 pandemic. Sleep Health 2022; 8:410-416. [PMID: 35729003 PMCID: PMC9212947 DOI: 10.1016/j.sleh.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/22/2022] [Accepted: 04/30/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The COVID-19 pandemic has been particularly distressing for adolescents and young adults (AYAs) diagnosed with cancer. High levels of distress are associated with sleep disturbances. This study examined the prevalence of insomnia symptoms in AYAs during the COVID-19 pandemic and identified factors related to greater insomnia severity. DESIGN, SETTING, AND PARTICIPANTS An online survey was administered to Canadian AYAs (N = 805) diagnosed with cancer between 15 and 39 years from January to February 2021. MEASUREMENTS The primary measure was the Insomnia Severity Index (ISI). Univariable and multivariable binomial logistic regression examined demographic, clinical, and psychological factors associated with significant insomnia symptoms (ISI score ≥12). RESULTS Three hundred twelve (38.8%) participants reported insomnia symptoms. In the multivariable model, severe psychological distress (ie, depression and anxiety; adjusted odds ratio (AOR) = 28.75, p ≤.001), having a pre-existing mental health condition (AOR = 1.92, p = .03), worsened mental health during the pandemic (AOR = 1.73, p = .02), finished cancer treatment ≥1 year ago (AOR = 1.72, p = .03), and experiencing no changes to schooling during the COVID-19 pandemic (AOR = 2.18, p = .004) were associated with significant insomnia symptoms. Standardized coefficients also indicated that worrying about possible disruptions to cancer care and being a homemaker/caretaker contributed to insomnia symptoms. CONCLUSIONS Nearly 40% of AYAs with cancer reported insomnia symptoms during the COVID-19 pandemic. Insomnia was associated with potentially modifiable factors such as psychological distress, highlighting possible targets for intervention.
Collapse
Affiliation(s)
- Joshua Tulk
- Department of Psychology, Faculty of Science, Memorial University, St. John's, Canada
| | - Sheila N Garland
- Department of Psychology, Faculty of Science, Memorial University, St. John's, Canada; Discipline of Oncology, Faculty of Medicine, Memorial University, St. John's, Canada.
| | - Kaitlyn Howden
- Department of Psychiatry, University of Manitoba, Winnipeg, Canada
| | - Camille Glidden
- Department of Psychiatry, University of Manitoba, Winnipeg, Canada
| | - Ian Scott
- Department of Psychosocial Oncology, CancerCare Manitoba, Winnipeg, Canada
| | | | - Geoff Eaton
- Young Adult Cancer Canada, St. John's, NL, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Sapna Oberoi
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada; Section of Pediatric Hematology-Oncology, CancerCare Manitoba, Winnipeg, Canada
| |
Collapse
|
8
|
Garland SN, Ivers H, Savard J. Prospective Rates, Longitudinal Associations, and Factors Associated With Comorbid Insomnia Symptoms and Perceived Cognitive Impairment. Front Neurosci 2022; 15:817933. [PMID: 35140586 PMCID: PMC8819074 DOI: 10.3389/fnins.2021.817933] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/30/2021] [Indexed: 01/14/2023] Open
Abstract
BackgroundInsomnia and cognitive impairment are both common conditions experienced by people diagnosed with cancer. Individually, these conditions have negative impacts on functioning, but the combined burden has yet to be evaluated. The purpose of this research was to estimate rates of comorbid insomnia and perceived cognitive impairments, examine the longitudinal associations between these two conditions, and identify demographic and clinical factors associated with reporting both insomnia and perceived cognitive impairment.MethodsIn this secondary analysis, a heterogeneous sample of 962 patients completed the Insomnia Severity Index (ISI) and the Cognitive Failures Questionnaire (CFQ) at the time of their cancer surgery (baseline; T1) and then again at 2 (T2), 6 (T3), 10 (T4), 14 (T5), and 18 (T6) months. Correlations and partial correlations, controlling for age and education level, were computed at each time point to assess the relationship between ISI and CFQ scores. Cross-lagged correlations assessed associations between ISI and CFQ scores over time. Proportions of patients with comorbid insomnia and cognitive impairments were calculated and logistic regressions investigated changes over time in these proportions. ANOVAs, logistic regressions, ordinal regressions, and multinomial regressions were used to identify risk factors of having comorbid insomnia and cognitive difficulties.ResultsSignificant and bidirectional correlations between ISI and CFQ scores were observed at each time point and over time. The proportion of patients having both clinical levels of insomnia and perceived cognitive difficulties ranged from 18.73 to 25.84% across time points and this proportion was significantly greater at T1 and T2 than T4, T5, and T6. Participants who reported comorbid insomnia and cognitive impairment were more likely to be younger, female, not currently working, currently receiving chemotherapy, with clinical levels depression and anxiety, and using antidepressants or anxiolytics.ConclusionComorbid insomnia and perceived cognitive impairment affects around one in five patients and is more frequent at the beginning of the cancer care trajectory. The relationship between insomnia and cognitive impairment appears to be bidirectional. Insomnia may represent an important patient level vulnerability that when identified and treated can improve perception of cognitive function.
Collapse
Affiliation(s)
- Sheila N. Garland
- Department of Psychology, Faculty of Science, Memorial University, St. John’s, NL, Canada
- Discipline of Oncology, Faculty of Medicine, Memorial University, St. John’s, NL, Canada
| | - Hans Ivers
- School of Psychology, Université Laval, Quebec City, QC, Canada
- CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
- Laval University Cancer Research Center, Quebec City, QC, Canada
| | - Josée Savard
- School of Psychology, Université Laval, Quebec City, QC, Canada
- CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
- Laval University Cancer Research Center, Quebec City, QC, Canada
- *Correspondence: Josée Savard,
| |
Collapse
|