Pre-operative expectations in patients with endometriosis - a qualitative interview study

BACKGROUND

Expectations determine treatment outcomes in several medical conditions. The significance of expectations for treatment outcomes in patients with endometriosis remains unknown. Endometriosis is a painful and debilitating disease that negatively affects quality of life. Up to 30% of surgically treated patients report persistent post-operative complaints and pain disability without sufficient medical explanation, indicating the impact of non-medical factors on treatment outcomes.

AIM

The present qualitative study aimed to describe and understand pre-operative patient expectations, facilitators of and barriers to positive treatment outcomes.

METHOD

As part of a large mixed-method cohort study, a subsample of N = 33 patients with endometriosis were interviewed before laparoscopy. Structured content analysis was performed.

RESULTS

Positive expectations included significant improvement or absence of complaints, receiving a diagnosis, and subsequently improved health-related quality of life. However, patients also reported negative expectations such as invalidation of their experience, persistence of complaints, or post-operative side effects. Patients perceived positive expectations as facilitators for positive treatment outcomes. Further facilitators included enhanced patient and treatment information, gynaecologists specialized in endometriosis, and greater awareness of endometriosis. Perceived barriers to good post-operative quality of life included post-operative pain and scarring, insufficient rest, avoidance behaviour, and stress.

CONCLUSION

Positive and negative expectations coexisted. Positive expectations suggest that participants place much hope in laparoscopy. However, these positive expectations may exceed probable treatment outcomes for some patients. Negative expectations were also expressed and constituted a risk for nocebo effects. Further identified facilitators and barriers show that patients are very clear about what is helpful or not for their health-related quality of life after laparoscopy. Patient and treatment information may be enhanced to prevent unrealistic treatment expectations and nocebo effects.

Practical guidance on the prevention and management of infection in multiple myeloma patients: A case-based approach

The risk of infection in multiple myeloma patients is significant, due to immune dysfunction secondary to myeloma, immunosenescence and age-related comorbidities, given the elderly myeloma patient demographic. Newer treatments, despite providing unprecedented improvements in disease-control, have further elevated infection risk. This risk is so substantial that we are approaching a period where a subset of older myeloma patients may be more likely to die secondary to infectious complications imposed by redirected T-cell therapy rather than from myeloma. As a result, it is essential to provide myeloma patients with the appropriate prophylaxis and monitoring against infection. In this review, we discuss disease-related, patient-related and treatment-related reasons for the increased infection risk in myeloma patients, and how to both prevent and manage this risk through creating a dynamic, infection prevention plan that is personalised to the individual patient.

Patients' and clinicians' knowledge in cancer-related cognitive impairment and its implications: current perspective

Health literacy is essential in cancer care. Low health literacy compromises the capacity to maintain one's health through self-management and collaboration with healthcare providers, especially when facing cognitive side effects related to cancer and its treatments. Cancer-related cognitive impairment (CRCI) is a common phenomenon among cancer patients and might determine a significant impact on their quality of life, yet it is still under identified by both clinicians and patients. This perspective aims to discuss the implications of patients' and healthcare professionals' lack of awareness on the matter and argues about the importance of improving the level of information on CRCI to mitigate difficulties in identifying and managing such manifestations on various levels.

Modifiable factors for somatic symptom persistence in patients with somatic symptom disorder: study protocol for a longitudinal cohort with an embedded ecologically momentary assessment (SOMA.SSD)

INTRODUCTION

Somatic symptom disorder (SSD) is a distressing mental disorder characterised by the presence of at least one persistent somatic symptom and a significant psychological burden due to the symptom(s), as well as excessive thoughts, feelings or behaviours related to them or associated health concerns. The primary aim of our study is to deepen the understanding of risk factors and mechanisms for somatic symptom persistence. Specifically, we will investigate the role of patients' expectations and somatic comorbidity regarding symptom persistence.

METHODS AND ANALYSIS

In a prospective 12-month cohort study, n=240 patients with SSD will be recruited from the outpatient clinics of the Department of Psychosomatic Medicine and Psychotherapy at the University Medical Center Hamburg-Eppendorf. The roles of two hypothesised predictors (ie, expectations and comorbidity) will be analysed together with known predisposing and maintaining factors of persistent somatic symptoms. The study entails macrolevel and microlevel assessments to investigate symptom severity over different timespans. Assessments at the macrolevel take place at baseline, 6 and 12 months. At the microlevel, a 10-day ecological momentary assessment study will be implemented to elucidate patients' dynamic experience with somatic symptoms in their natural environments. In order to elicit possible framing effects on the 10-day course of symptom severity, participants are randomised to either a positive or a negative expectation framing group. Cross-lagged panel models will be used to analyse data at the macrolevel. At the microlevel, multivariate latent growth curve models will be conducted to relate temporal changes in predictor and outcome variables to one another.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Medical Associations Hamburg, Germany (2020-10197-BO-ff). The results will enable us to draw conclusions regarding the role of expectations for future targeted treatment options and regarding the utility of somatic comorbidity as a potential diagnostic specifier of SSD. Dissemination of our results will be achieved through scientific publications, and lay summaries for study participants, patient advocacy groups and the general public.

TRIAL REGISTRATION NUMBER

ISRCTN36251388.

Treatment expectations of patients and clinicians: a cross-sectional study

Importance

Understanding treatment expectations of patients and their clinicians is of great importance in improving personalized medical services and enhancing patient safety systems.

Objective

To investigate treatment expectations of patients and their clinicians and compare differences between both, by using a pair of validated structured assessment tools covering three key aspects/dimensions of clinical interests.

Design setting and participants

This single-center cross-sectional study was conducted at Peking Union Medical College Hospital in China. The study enrolled patients aged 16 years and older receiving inpatient care and their clinicians. Patient recruitment was conducted from March 2023 to November 2023.

Assessments

In addition to demographic and clinical characteristics, this study employed two validated structured assessment tools to evaluate treatment expectations among patients and their clinicians: the Hospitalized Patients' Expectations for Treatment Scale-Patient version (HOPE-P) and its counterpart, the Hospitalized Patients' Expectations for Treatment Scale-Clinician version (HOPE-C).

Results

A total of 233 patients (mean [SD] age, 52.3 [15.1] years; 108 [46.4%] female) along with their clinicians, who numbered 75 in total were enrolled in this study. The distribution of total scores for HOPE-P and HOPE-C displayed similar patterns, with most scores concentrated in the higher range (above 50% of the full score). The mean HOPE-P total score was higher than that of HOPE-C (mean [SD] score, 38.78 [4.86] vs 37.49 [4.32]; t = 3.12, P = 0.002). In Dimension 2, the HOPE-P score was higher than HOPE-C (23.67 [3.20] vs 21.72 [3.03]; t = 6.98, P < 0.001). However, in Dimensions 1 and 3, HOPE-P scored lower than HOPE-C (13.37 [2.44] vs 13.84 [1.73]; t = -2.384, P < 0.018; 1.74 [1.14] vs 1.94 [1.00]; t = -2.00, P = 0.047). Certain demographic and clinical characteristics led to variations in patients' treatment expectations, including marital status, monthly family income, and smoking history.

Conclusions and relevance

This cross-sectional study revealed significant differences between patients' and doctors' treatment expectations. Notably, it highlighted the need for clinicians to focus on rationalizing patients' expectations concerning treatment outcomes.

Trial Registration Chinese Clinical Trial Registry Identifier

ChiCTR2300075262.

"I Was Almost in Disbelief" - Qualitative Analysis of Experiences and Expectations Among Psoriasis Patients Undergoing Biologic Treatment with Secukinumab

Purpose

Psoriasis is a highly debilitating chronic inflammatory disease. Increased understanding of its pathophysiology has enabled development of targeted treatments such as biologics. Several medical treatments have been shown to be influenced by patients' experiences and expectations. However, only little is known about patients' experiences with and expectations towards biologics. Our objectives were to identify patients' treatment experiences and treatment expectations and assess their trajectories over the course of treatment with the IL-17A inhibitor secukinumab. Moreover, we aimed to document effects of psoriasis, factors that influence symptomatology, and prior treatment experiences.

Patients and Methods

We conducted semi-structured interviews with n = 24 patients with moderate-to-severe plaque psoriasis and employed a qualitative content analysis to derive thematic and evaluative codes. Findings were validated via peer debriefings with experienced dermatologists.

Results

Patients reported burdensome physical and psychological psoriasis symptoms and identified factors that can improve or worsen symptomatology, including stress and self-efficacy. Prior treatment experiences were mostly negative. Past barriers to effective treatment included time constraints or limited access. Concerning secukinumab, patients initially expected complete to partial remission of symptoms and occurrence or absence of side effects. Closer inspection of expectations and experiences revealed three trajectories. For most patients, initial expectations were met and future expectations remained unchanged. For the other patients, however, the experience did not match their initial expectation. One group then adapted their future expectations according to their experience, while the other group did not.

Conclusion

To our knowledge, this is the first qualitative study to assess expectations towards treatment effectiveness and side effects, their trajectories, and interplay with experiences among psoriasis patients. Our findings highlight the value of further research on the subject in order to optimize care for psoriasis patients and to learn more about the trajectories and influence of treatment expectations in general.

Persistent physical symptoms: definition, genesis, and management

Persistent physical symptoms (synonymous with persistent somatic symptoms) is an umbrella term for distressing somatic complaints that last several months or more, regardless of their cause. These symptoms are associated with substantial disability and represent a major burden for patients, health-care professionals, and society. Persistent physical symptoms can follow infections, injuries, medical diseases, stressful life events, or arise de novo. As symptoms persist, their link to clearly identifiable pathophysiology often weakens, making diagnosis and treatment challenging. Multiple biological and psychosocial risk factors and mechanisms contribute to the persistence of somatic symptoms, including persistent inflammation; epigenetic profiles; immune, metabolic and microbiome dysregulation; early adverse life experiences; depression; illness-related anxiety; dysfunctional symptom expectations; symptom focusing; symptom learning; and avoidance behaviours, with many factors being common across symptoms and diagnoses. Basic care consists of addressing underlying pathophysiology and using person-centred communication techniques with validation, appropriate reassurance, and biopsychosocial explanation. If basic care is insufficient, targeted psychological and pharmacological interventions can be beneficial. A better understanding of the multifactorial persistence of somatic symptoms should lead to more specific, personalised, and mechanism-based treatment, and a reduction in the stigma patients commonly face.

Negative expectations (nocebo phenomenon) in clinical interventions: A scoping review

Unpredictable, undesirable, and confusing reactions in the face of psychological or medical interventions make the clinical presentation more complicated and may represent clinically unexplained symptoms and also disturbed the doctor-patients relationship and decrease patients' benefits of treatment. It seems that negative expectations from the treatment (nocebo phenomenon) can explain such reactions. The aim of the current study is a scoping review and investigate different aspects of the nocebo phenomenon (negative expectations) in clinical interventions. This paper follows a scoping review of the existence, importance, and multidimensions of the nocebo phenomenon in medical and psychological interventions. Data sources include literature databases (ProQuest, PubMed, Google Scholar, and Scopus) reviewed from inception dates to 2023, and the terms negative expectations, nocebo effect, placebo effect, negative placebo, and clinical interventions were searched. The review of the available articles showed that negative expectations play an important role in the process and effectiveness of clinical interventions. Negative expectations (here named nocebo effect) can significantly interfere with rapport and treatment processes. Some underlying components of the nocebo effect include negative expectancies, conditioning, social learning, memory, cognitive distortions, meaning, motivation, somatic focus, negative reinforcements, personality, anxiety, and neurophysiological factors such as CCK, dopamine, and cortisol are proposed for development and presence of nocebo phenomenon in clinical practice. Negative expectations with its biopsychosocial aspects play an important and amazing role in disorganizing medical and psychological interventions. Using appropriate methods to reduce nocebo effects in therapeutic interventions may increase treatment compliance and adherence and increase the effectiveness of interventions.

Discontinuation of Fumaric Acid Esters is Affected by Depressive Symptomatology: A Retrospective Analysis

Fumaric acid esters (FAEs) remain a widespread therapy option for moderate-to-severe psoriasis. However, drug survival of FAEs is limited by adverse events (AEs) or inadequate treatment response. Depressive disturbances are highly prevalent in psoriasis patients and are hypothesized to be associated with the reporting of AEs and therapy discontinuation. This study's aim was to analyze whether psoriasis patients with comorbid depressive symptomatology are more likely to discontinue treatment with FAEs due to AEs and/or inadequate treatment response. Data were retrospectively extracted from the records of patients starting therapy with FAEs in the Department of Dermatology, University Hospital Essen, Germany between 2017 and 2022, covering the first 52 weeks of treatment. Psoriasis severity and depressive symptomatology, as well as AEs and therapy discontinuation, were analyzed. Psoriasis patients (N = 95, 47.37% female) with depressive symptomatology (42.11%) were more likely to discontinue therapy due to patient-reported AEs, while the total number of reported AEs was not associated with depression. The results support the hypothesis that among psoriasis patients with depressive symptoms, the associated introspection and somatization may result in increased sensitivity for AEs and thus in quicker therapy discontinuation. In these patients, the occurrence of nocebo effects should be minimized, e.g. by special communication techniques.

Vague sensations. About the background and consequences of discordance between actual and perceived physiological changes

Empirical evidence consistently shows that discordance, also called dissociation or discrepancy, between actual physiological (mainly visceral) events and their perceived counterparts is substantial. On the one hand, we typically do not perceive actual visceral events occurring in our bodies; on the other hand, sometimes we do perceive bodily changes that do not really take place. This narrative review presents the available empirical findings on the discordance, and summarizes possible explanations that approach the phenomenon from the viewpoint of evolution, cognitive development, and predictive processing. Also, the role of top-down factors, such as expectations and experiences is discussed. Finally, practically relevant consequences of the discordance are presented using the examples of mind-body practices, the placebo and nocebo phenomenon, and medically unexplained symptoms. It is concluded that the discordance between actual and perceived body changes can have a negative impact on health, mainly through issues with adherence and other behavioral factors. The existence of actual-perceived discordance should be taught and demonstrated in the elementary and high school, as well as in many areas of higher education.

"SO FAR AWAY" How Doctors Can Contribute to Making Endometriosis Hell on Earth. A Call for Humanistic Medicine and Empathetic Practice for Genuine Person-Centered Care. A Narrative Review

"SO FAR AWAY" * How Doctors Can Contribute to Making Endometriosis Hell on Earth [* by Knopfler M. In Dire Straits. Brothers in Arms. Vertigo Records, U.K., 1985].

Abstract

The distance physicians may create within the relationship with their patients by not having a humanistic approach to their practice may strongly influence clinical outcomes. The purpose of this paper is to convey the well-known narrative of patient dissatisfaction into pro-action by discussing the aspects of dehumanization, which may occur in the relationship between physicians and women with endometriosis. Eight dimensions of dehumanization are examined and related to everyday scenarios occurring in endometriosis care settings and the possible downstream consequences on patients' clinical outcomes are described. Objectification, which may come across as minimization of pain, may not only increase patients' perception of pain but also lead to undertreatment of unrecognized forms of endometriosis, especially among adolescents. Passivity, that is not favoring shared decision-making nor self-management, may compromise adherence to treatment, reducing patients' trust in physicians and quality of life. The same consequences may result from homogenization, that is giving for granted that all patients have the same access to care. Both isolation, ie not practicing therapeutic empathy, and loss of meaning, ie not supporting patients in the re-definition of their life plans, may affect women's psychological wellbeing and further increase pain perception. Ignoring women's personal journey by not providing clear information on the consequences endometriosis may have on their lives may favor women's self-silencing. Not promoting an un-biased communication and not setting aside scientific polarization are the main features of dislocation, which may jeopardize patient empowerment. Lastly, having a reductionist approach to the body may contribute to chronicization of pain, thus compromising quality of life. This considered, taking time to listen to women with endometriosis and tailoring decisions on the basis of their individual needs should be fostered as a moral duty. Physicians should always keep in mind that they are not only deliverers of treatment; they are a form of treatment themselves.

Bibliometric analysis and visualization of endocrine therapy for breast cancer research in the last two decade

Background

Breast cancer endocrine therapy research has become a crucial domain in oncology since hormone receptor-positive breast cancers have been increasingly recognized, and targeted therapeutic interventions have been advancing over the past few years. This bibliometric analysis attempts to shed light on the trends, dynamics, and knowledge hotspots that have shaped the landscape of breast cancer endocrine therapy research between 2003 and 2022.

Methods

In this study, we comprehensively reviewed the scientific literature spanning the above-mentioned period, which included publications accessible through the database of the Web of Science (WOS) and the National Center for Biotechnology Information (NCBI). Next, a systematic and data-driven analysis supported by sophisticated software tools was conducted, such that the core themes, prolific authors, influential journals, prominent countries, and critical citation patterns in the relevant research field can be clarified.

Results

A continuous and substantial expansion of breast cancer endocrine therapy research was revealed over the evaluated period. A total of 1,317 scholarly articles were examined. The results of the analysis suggested that research on endocrine therapy for breast cancer has laid a solid basis for the treatment of hormone receptor-positive breast cancer. From a geographical perspective, the US, the UK, and China emerged as the most active contributors, illustrating the global impact of this study. Furthermore, our analysis delineated prominent research topics that have dominated the discourse in the past two decades, including drug therapy, therapeutic efficacy, molecular biomarkers, and hormonal receptor interactions.

Conclusion

This comprehensive bibliometric analysis provides a panoramic view of the ever-evolving landscape of breast cancer endocrine therapy research. The findings highlight the trajectory of past developments while signifying an avenue of vast opportunities for future investigations and therapeutic advancements. As the field continues to burgeon, this analysis will provide valuable guidance for to researchers toward pertinent knowledge hotspots and emerging trends, which can expedite the discoveries in the realm of breast cancer endocrine therapy.

Role of expectations in clinical outcomes after deep brain stimulation in patients with Parkinson's disease: a systematic review

Deep brain stimulation (DBS) is a well-established treatment that significantly improves the motor symptoms of patients with Parkinson's disease (PD); however, patients may experience post-operative psychological distress and social maladjustments. This phenomenon has been shown to be related to patients' pre-operative cognitive representations, such as expectations. In this systematic review, we discuss the findings on the role of the expectations of patients with PD regarding the clinical outcomes of DBS to identify areas of intervention to improve pre-operative patient education and promote successful post-operative psychosocial adjustment. PubMed was searched for relevant articles published up to 16 January 2023. Of the 84 identified records, 10 articles focusing on the treatment expectations of patients with PD undergoing DBS were included in this review. The selected studies were conducted among cohorts of patients with different DBS targets, among which the most common was the bilateral subthalamic nucleus. Overall, the data showed that patients' expectations contribute to treatment efficacy. Experiments investigating the placebo effect itself have shown clinical improvement after the induction of positive therapeutic expectations; conversely, unrealistic treatment expectations can affect patient satisfaction after surgery, clinical outcomes, and subjective well-being. This review highlights the need for routine clinical practice to better investigate and manage patients' pre-operative expectations, as well as multidisciplinary education to improve patient satisfaction and psychosocial adjustment after DBS.

Optimization of an Information Leaflet to Influence Medication Beliefs in Women With Breast Cancer: A Randomized Factorial Experiment

BACKGROUND

Adherence to adjuvant endocrine therapy (AET) is low in women with breast cancer. Negative beliefs about the necessity of AET and high concerns are barriers to adherence.

PURPOSE

To use the multiphase optimization strategy to optimize the content of an information leaflet intervention, to change AET beliefs.

METHODS

We conducted an online screening experiment using a 25 factorial design to optimize the leaflet. The leaflet had five components, each with two levels: (i) diagrams about AET mechanisms (on/off); (ii) infographics displaying AET benefits (enhanced/basic); (iii) AET side effects (enhanced/basic); (iv) answers to AET concerns (on/off); (v) breast cancer survivor (patient) input: quotes and photographs (on/off). Healthy adult women (n = 1,604), recruited via a market research company, were randomized to 1 of 32 experimental conditions, which determined the levels of components received. Participants completed the Beliefs about Medicines Questionnaire before and after viewing the leaflet.

RESULTS

There was a significant main effect of patient input on beliefs about medication (β = 0.063, p < .001). There was one significant synergistic two-way interaction between diagrams and benefits (β = 0.047, p = .006), and one antagonistic two-way interaction between diagrams and side effects (β = -0.029, p = .093). There was a synergistic three-way interaction between diagrams, concerns, and patient input (β = 0.029, p = .085), and an antagonistic four-way interaction between diagrams, benefits, side effects, and concerns (β = -0.038, p = .024). In a stepped approach, we screened in four components and screened out the side effects component.

CONCLUSIONS

The optimized leaflet did not contain enhanced AET side effect information. Factorial experiments are efficient and effective for refining the content of information leaflet interventions.

Influence of side effect information on patient willingness to take medication: consequences for informed consent and medication adherence

Medication side effect information can create negative patient expectations of side effects, but such information is considered crucial to informed consent. The current study investigated the effect of informing participants of different numbers of medication side effects. Willingness to take the medication was highest for those informed of one or four compared with none or 26 side effects, and memory of side effects was also more accurate. Findings suggest that informing patients of some, but not several, side effects may optimise both medication adherence and accuracy of informed consent.

Investigation of Factors Affecting Adherence to Adjuvant Hormone Therapy in Early-Stage Breast Cancer Patients: A Comprehensive Systematic Review

PURPOSE

Adherence and persistence to adjuvant hormone therapy (AHT) are seldom maintained among early-stage hormone receptor-positive breast cancer (BC) survivors, despite the significant clinical benefits of long-term AHT. As the factors influencing adherence to AHT remain unclear, this study aimed to comprehensively identify such factors and classify them into specific dimensions.

METHODS

PubMed, Cochrane Library, Embase, PsycINFO, and CINAHL were searched for qualified articles. The search mainly focused on three components: early-stage (0-III) BC, oral AHT administration, and adherence to AHT, with keywords derived from MeSH and entry terms. The factors identified were then classified into six categories based on a modified WHO multidimensional model.

RESULTS

Overall, 146 studies were included; the median sample size was 651 (range, 31-40,009), and the mean age of the population was 61.5 years (standard deviation, 8.3 years). Patient- and therapy-related factors were the most frequently investigated factors. Necessity/concern beliefs and self-efficacy among patient-related factors were consistently related to better adherence than depression. Although drug side effects and medication use cannot be modified easily, a refined prescription strategy for the initiation and switching of AHT is likely to increase adherence levels.

CONCLUSION

An effective psychological program that encourages positive views and beliefs about medication and management strategies for each therapy may be necessary to improve adherence to AHT. Social support and a sense of belonging can be enhanced through community participation and social media for better adherence to AHT. Patient-centered communication and appropriate recommendations by physicians may be attributable to better adherence outcomes. Findings from systematically organized factors that influence adherence to AHT may contribute to the establishment of intervention strategies to benefit patients with early-stage BC to achieve optimal health.

Expectations and Prior Experiences Associated With Adverse Effects of COVID-19 Vaccination

Importance

Uptake of vaccination against COVID-19 is strongly affected by concerns about adverse effects. Research on nocebo effects suggests that these concerns can amplify symptom burden.

Objective

To investigate whether positive and negative expectations prior to COVID-19 vaccination are associated with systemic adverse effects.

Design, Setting, and Participants

This prospective cohort study analyzed the association of expected benefits and risks of vaccination, adverse effects at first vaccination, and observed adverse effects in close contacts with severity of systemic adverse effects among adults receiving a second dose of messenger RNA (mRNA)-based vaccines between August 16 and 28, 2021. A total of 7771 individuals receiving the second dose at a state vaccination center in Hamburg, Germany, were invited to participate; of these, 5370 did not respond, 535 provided incomplete information, and 188 were excluded retrospectively. The mobile application m-Path was used for data collection.

Main Outcomes and Measures

Primary outcome was a composite severity index of systemic adverse effects in 12 symptom areas measured once daily with an electronic symptom diary over 7 consecutive days. Data were analyzed by mixed-effects multivariable ordered logistic regression adjusted for prevaccine symptom levels and observation times.

Results

A total of 10 447 observations from 1678 individuals receiving vaccinations (BNT162b2 [Pfizer BioNTech] in 1297 [77.3%] and mRNA-1273 [Moderna] in 381 [22.7%]) were collected. The participants' median age was 34 (IQR, 27-44) years, and 862 (51.4%) were women. The risk for more severe adverse effects was higher for persons expecting a lower benefit of vaccination (odds ratio [OR] for higher expectations, 0.72 [95% CI, 0.63-0.83]; P < .001), expecting higher adverse effects of vaccination (OR, 1.39 [95% CI, 1.23-1.58]; P < .001), having experienced higher symptom burden at the first vaccination (OR, 1.60 [95% CI, 1.42-1.82]; P < .001), scoring higher on the Somatosensory Amplification Scale (OR, 1.21 [95% CI, 1.06-1.38]; P = .004), and if the vaccine mRNA-1273 was given rather than BNT162b2 (OR, 2.45 [95% CI, 2.01-2.99]; P < .001). No associations were seen for observed experiences.

Conclusions and Relevance

In this cohort study, several nocebo effects occurred in the first week after COVID-19 vaccination. The severity of systemic adverse effects was associated not only with vaccine-specific reactogenicity but also more negative prior experiences with adverse effects from the first COVID-19 vaccination, more negative expectations regarding vaccination, and tendency to catastrophize instead of normalize benign bodily sensations. Clinician-patient interactions and public vaccine campaigns may both benefit from these insights by optimizing and contextualizing information provided about COVID-19 vaccines.

Refining and optimising a behavioural intervention to support endocrine therapy adherence (ROSETA) in UK women with breast cancer: protocol for a pilot fractional factorial trial

INTRODUCTION

Women with breast cancer who do not adhere to adjuvant endocrine therapy (AET) have increased risks of mortality and recurrence. There are multiple barriers to AET adherence, including medication side-effects, beliefs about medication, memory and psychological distress. We developed four intervention components, each targeting a different barrier. This pilot trial is part of the preparation phase of the Multiphase Optimisation Strategy, and aims to establish key trial parameters, establish intervention component adherence, establish availability and feasibility of outcome and process data, estimate variability in planned outcome measures and estimate cost of developing and delivering each intervention component.

METHODS AND ANALYSIS

The four intervention components are as follows: short message service text reminders (target: memory); a written information leaflet (target: medication beliefs); a guided self-help Acceptance and Commitment Therapy programme (target: psychological flexibility to reduce distress) and a self-management website (target: side-effect management). To evaluate the feasibility of recruitment, acceptability of the intervention components and the availability of outcome data, we will conduct a multisite, exploratory pilot trial using a 24-1 fractional factorial design, with a nested process evaluation. We will randomise 80 women with early-stage breast cancer who have been prescribed AET to one of eight experimental conditions. This will determine the combination of intervention components they receive, ranging from zero to four, with all conditions receiving usual care. Key outcomes of interest include medication adherence and quality of life. Progression to the optimisation phase will be based on predefined criteria for consent rates, patient adherence to intervention components and availability of medication adherence data.

ETHICS AND DISSEMINATION

The study was reviewed by the Wales Research Authority Research Ethics Committee 3 (21/WA/0322). Written informed consent will be obtained from all patients before randomisation. The results of this trial will be disseminated in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRTCN10487576.

Preventing metastatic recurrence in low-risk ER/PR + breast cancer patients-a retrospective clinical study exploring the evolving challenge of persistence with adjuvant endocrine therapy

PURPOSE

In the genomic era, more women with low-risk breast cancer will forego chemotherapy and rely on adjuvant endocrine therapy (AET) to prevent metastatic recurrence. However, some of these patients will unfortunately relapse. We sought to understand this outcome. Preliminary work suggested that early discontinuation of AET, also known as non-persistence, may play an important role. A retrospective analysis exploring factors related to our breast cancer patients' non-persistence with AET was performed.

METHODS

Women who underwent Oncotype-DX® testing between 2011 and 2014 with minimum 5 years follow-up were included. 'Low risk' was defined as Oncotype score < 26. Outcomes of recurrence and persistence were determined by chart review. Patient, tumor and treatment factors were collected, and persistent versus non-persistent groups compared using multivariable ANOVA and Fisher Chi square exact test.

RESULTS

We identified six cases of distant recurrence among low-risk patients with a median follow-up of 7.7 years. Among them, five of six patients (83%) were non-persistent with AET. The non-persistence rate in our cohort regardless of recurrence was 57/228 (25%). Non-persistent patients reported more severe side effects compared with persistent patients (p = 0.002) and were more likely to be offered a switch in endocrine therapy, rather than symptom-relief (p = 0.006). In contrast, persistent patients were 10.3 times more likely to have been offered symptom-alleviating medications compared with non-persistent patients (p < 0.001). A subset analysis revealed that patients who persisted with therapy had a higher Oncotype-DX® score than patients who discontinued early (p = 0.028).

CONCLUSION

Metastatic recurrence in low-risk breast cancer patients may be primarily due to non-persistence with endocrine therapy. Further work is needed to optimize care for patients who struggle with side effects. To our knowledge, these are the first published data suggesting that Oncotype-DX® score may influence persistence with AET.

Quality of Life and Sense of Coherence in Cancer Patients of German, Turkish and Polish Origin-A Cross-Sectional Study

BACKGROUND

Due to a variety of symptoms and side-effects of cancer treatment, quality of life can be considerably impaired in cancer patients. Especially, cancer patients with a migration background seem to be at risk. The objective of our study is to investigate the quality of life and sense of coherence in adult cancer patients of German, Turkish and Polish origin.

METHODS

We assessed sociodemographic, migration-specific and cancer-related parameters. Quality of life was measured via the EORTC QLQ-C30, sense of coherence was measured with the SOC-13.

RESULTS

We included 227 patients in the study (59.5% native Germans, 40.5% with migration background). Native Germans did not differ in quality of life compared to all migrants. However, more nausea and vomiting (NV) and higher appetite loss (AP) was found in Turkish migrants compared to Polish migrants and native Germans. For sense of coherence, we observed significantly higher scores for native Germans compared to all migrants. Turkish migrants had significantly lower scores compared to native Germans.

CONCLUSIONS

A Turkish migration background seems to play an important role in the perception of symptoms, especially of nausea and vomiting and appetite loss. Culture-specific aspects should be considered in cancer care.

Social communication pathways to COVID-19 vaccine side-effect expectations and experience

OBJECTIVE

Negative beliefs about medication and vaccine side-effects can spread rapidly through social communication. This has been recently documented with the potential side-effects from the COVID-19 vaccines. We tested if pre-vaccination social communications about side-effects from personal acquaintances, news reports, and social media predict post-vaccination side-effect experiences. Further, as previous research suggests that side-effects can be exacerbated by negative expectations, we assessed if personal expectations mediate the relationships between social communication and side-effect experience.

METHOD

In a prospective longitudinal survey (N = 551), COVID-19 vaccine side-effect information from three sources-social media posts, news reports, and first-hand accounts from personal acquaintances-as well as side-effect expectations, were self-reported pre-vaccination. Vaccination side-effect experience was assessed post-vaccination.

RESULTS

In multivariate regression analyses, the number of pre-vaccination social media post views (β = 0.17) and impressions of severity conveyed from personal acquaintances (β = 0.42) significantly predicted an increase in pre-vaccination side-effect expectations, and the same variables (βs = 0.11, 0.14, respectively) predicted post-vaccination side-effect experiences. Moreover, pre-vaccination side-effect expectations mediated the relationship between both sources of social communication and experienced side-effects from a COVID-19 vaccination.

CONCLUSIONS

This study identifies links between personal acquaintance and social media communications and vaccine side-effect experiences and provides evidence that pre-vaccination expectations account for these relationships. The results suggest that modifying side-effect expectations through these channels may change the side-effects following a COVID-19 vaccination as well as other publicly discussed vaccinations and medications.

How do patients interpret and respond to a single-item global indicator of cancer treatment tolerability?

BACKGROUND

There is increasing interest in patient-reported measures of cancer treatment tolerability. A global measure of bother, the FACT GP5 item ("I am bothered by side effects of treatment") is potentially useful for regulatory, research, and clinical use. To understand this item's appropriateness for capturing treatment tolerability, we conducted cognitive interviews on this item with 3 samples of cancer patients.

METHODS

Patients with ovarian cancer (Study 1: N = 21; on treatment), lymphoma (Study 2: N = 14; on treatment), and colorectal or lung cancer (Study 3: N = 16; treatment naïve) were interviewed about GP5's understandability and relevance to their treatment side effects. What patients think about when answering GP5 was also assessed. In all studies, the interview included both structured and open-ended questions. Qualitative data were coded to extract themes and responses to structured questions were tallied.

RESULTS

Most patients on treatment (Studies 1 and 2) reported that the GP5 item wording is appropriate (88%) and its meaning is clear (97%). They were very confident or confident in their response (97%) and stated that GP5 was relevant to their cancer experience (97%). When answering GP5, patients considered their treatment and specific side effects. A large proportion (40%) of the treatment-naïve (Study 3) patients reported that GP5 was not relevant to their cancer treatment, and the largest proportion responded to GP5 thinking of negative side effect expectancies.

CONCLUSION

This study provides assurance that GP5 is a useful indicator of treatment tolerability, and is meaningful to people with cancer, especially once they have started treatment.

Predictors of adherence and the role of primary non-adherence in antihormonal treatment of breast cancer

BACKGROUND

Antihormonal treatment for hormone receptor (HR) positive breast cancer has highly beneficial effects on both recurrence rates and survival. We investigate adherence and persistence in this group of patients.

METHODS

The study population comprised 1192 patients with HR-positive breast cancer who were prescribed adjuvant antihormonal treatment from 2004 to 2013. Adherence was defined as a medical possession ratio (MPR) of ≥80.

RESULTS

Of the 1192 included patients, 903 (75.8%) were adherent and 289 (24.2%) were non-adherent. Primary non-adherence was seen in 101 (8.5%) patients. The extremes of age (< 40 and ≥ 80 years) were associated with poor adherence. Patients with metastasis to axillary lymph nodes and those who received radiotherapy and/or chemotherapy were more likely to be adherent. Better adherence was also shown for those who switched medication at 2 years after diagnosis. Primary non-adherence seems to be associated with cancers with a good prognosis.

CONCLUSION

Adherence to antihormonal therapy for breast cancer is suboptimal. Primary non-adherence occurs among patients with a relatively good prognosis. Non-adherent patients tend to terminate their antihormonal therapy in the initial part of the treatment period. Targeted interventions to improve adherence should be focused on the first part of the treatment period.

Possible alleviation of symptoms and side effects through clinicians' nocebo information and empathy in an experimental video vignette study

To alleviate anti-cancer treatment burden in advanced breast cancer, patient-clinician communication strategies based on nocebo-effect mechanisms are promising. We assessed distinct/combined effects on psychological outcomes (e.g. anxiety; main outcome) and side-effect expectations of (1) nocebo information about the (non)pharmacological origin of side effects, and (2) clinician-expressed empathy through reassurance of continuing support. Furthermore, we explored whether information and empathy effects on side-effect expectations were mediated by decreased anxiety. In a two-by-two experimental video-vignette design, 160 cancer patients/survivors and healthy women watched one of four videos differing in level of nocebo information (±) and empathy (±). Regression and mediation analysis were used to determine effects of information/empathy and explore anxiety's mediating role. Anxiety was not influenced by empathy or information (Stai-state: p = 0.295; p = 0.390, VAS p = 0.399; p = 0.823). Information improved (specific) side-effect coping expectations (p < 0.01). Empathy improved side-effect intensity expectations (p < 0.01 = specific; p < 0.05 = non-specific/partial) and specific side-effect probability expectations (p < 0.01), and increased satisfaction, trust, and self-efficacy (p < 0.001). No mediating effects were found of anxiety on expectations. Mainly empathy, but also nocebo information improved psychological outcomes and-mainly specific-side-effect expectations. Exploring the power of these communication elements in clinical practice is essential to diminish the anti-cancer treatment burden in advanced breast cancer.

Preventing adverse events of chemotherapy for gastrointestinal cancer by educating patients about the nocebo effect: a randomized-controlled trial

BACKGROUND

Adverse events of chemotherapy may be caused by pharmacodynamics or psychological factors such as negative expectations, which constitute nocebo effects. In a randomized controlled trial, we examined whether educating patients about the nocebo effect is efficacious in reducing the intensity of self-reported adverse events.

METHODS

In this proof-of-concept study, N = 100 outpatients (mean age: 60.2 years, 65% male, 54% UICC tumour stage IV) starting first-line, de novo chemotherapy for gastrointestinal cancers were randomized 1:1 to a nocebo education (n = 49) or an attention control group (n = 51). Our primary outcome was patient-rated intensity of four chemotherapy-specific and three non-specific adverse events (rated on 11-point Likert scales) at 10-days and 12-weeks after the first course of chemotherapy. Secondary outcomes included perceived control of adverse events and tendency to misattribute symptoms.

RESULTS

General linear models indicated that intensity of adverse events differed at 12-weeks after the first course of chemotherapy (mean difference: 4.04, 95% CI [0.72, 7.36], p = .02, d = 0.48), with lower levels in the nocebo education group. This was attributable to less non-specific adverse events (mean difference: 0.39, 95% CI [0.04, 0.73], p = .03, d = 0.44) and a trend towards less specific adverse events in the nocebo education group (mean difference: 0.36, 95% CI [- 0.02, 0.74], p = .07, d = 0.37). We found no difference in adverse events at 10-days follow-up, perceived control of adverse events, or tendency to misattribute non-specific symptoms to the chemotherapy.

CONCLUSIONS

This study provides first proof-of-concept evidence for the efficacy of a brief information session in preventing adverse events of chemotherapy. However, results regarding patient-reported outcomes cannot rule out response biases. Informing patients about the nocebo effect may be an innovative and clinically feasible intervention for reducing the burden of adverse events.

TRIAL REGISTRATION

Retrospectively registered on March 27, 2018 to the German Clinical Trial Register (ID: DRKS00009501).

The impact of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: A quantitative systematic review

BACKGROUND

Hormone Therapy (HT) is recommended for most women with HR-positive primary breast cancer. When taken as intended, HT reduces breast cancer recurrence by 40% and mortality by one-third. The recommended duration of treatment ranges from 5 to 10 years depending on risk of recurrence and the specific HT regimen. However, recent data indicates that rates of HT non-adherence are high and research suggests this may be due to the impact of HT side effects. The contribution of side effects to non-adherence and non-persistence behaviours has rarely been systematically explored, thereby hindering the implementation of targeted intervention strategies. Our aim is to identify, evaluate and summarise the relationship between HT side effects and patterns of adherence and persistence.

METHODS

Electronic searches were conducted from inception and were completed by September 2021, utilising Cochrane CENTRAL, Medline, Embase, Web of Science and PsycINFO databases. Searches included a combination of terms related to breast cancer, adherence, hormone therapy and side effects.

RESULTS

Sixty-two eligible papers were identified and study quality varied by study type. Most observational and cross-sectional studies were rated good quality, whereas most controlled intervention studies were rated fair quality. Three studies were rated poor quality. The most frequently measured side effects were pain, low mood, hot flashes, insomnia, anxiety, fatigue, weight gain, concentration/memory problems.

CONCLUSIONS

This review identified a lack of consistency in the measurement of adherence and the definition of persistence across studies. The instruments used to measure side effects also varied significantly. This variation and lack of consistency makes it difficult to evaluate and summarise the role of HT side effects in HT adherence and persistence behaviour.

Persistence of gastrointestinal symptoms in irritable bowel syndrome and ulcerative colitis: study protocol for a three-arm randomised controlled trial (SOMA.GUT-RCT)

INTRODUCTION

Ulcerative colitis (UC) and irritable bowel syndrome (IBS) are distressing chronic diseases associated with abdominal pain and altered bowel habits of unknown aetiology. Results from previous studies indicate that, across both diseases, increased levels of illness-related anxiety and dysfunctional symptom expectations contribute to symptom persistence. Thus, comparing both disorders with regard to common and disease-specific factors in the persistence and modification of gastrointestinal symptoms seems justified. Our primary hypothesis is that persistent gastrointestinal symptoms in UC and IBS can be improved by modifying dysfunctional symptom expectations and illness-related anxiety using expectation management strategies.

METHODS AND ANALYSIS

To assess the extent to which persistent somatic symptoms are modifiable in adult patients with UC and IBS, we will conduct an observer-blinded, three-arm randomised controlled trial. A total of 117 patients with UC and 117 patients with IBS will be randomised into three groups of equal size: targeted expectation management aiming to reduce illness-related anxiety and dysfunctional symptom expectations in addition to standard care (SC, intervention 1), non-specific supportive treatment in addition to SC (intervention 2) or SC only (control). Both active intervention groups will comprise three individual online consultation sessions and a booster session after 3 months. The primary outcome is baseline to postinterventional change in gastrointestinal symptom severity.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Hamburg Medical Association (2020-10198-BO-ff). The study will shed light onto the efficacy and mechanisms of action of a targeted expectation management intervention for persistent gastrointestinal symptoms in patients with UC and IBS. Furthermore, the detailed analysis of the complex biopsychosocial mechanisms will allow the further advancement of aetiological models and according evidence-based intervention strategies.

TRIAL REGISTRATION NUMBER

ISRCTN30800023.

Acceptance and Commitment Therapy to support medication decision-making and quality of life in women with breast cancer: protocol for a pilot randomised controlled trial

BACKGROUND

Adherence to adjuvant endocrine therapy is affected by medication side-effects and associated distress. Previous interventions focused on educating women to enhance adherence have proved minimally effective. We co-designed an Acceptance and Commitment Therapy (ACT) intervention to enhance medication decision-making and quality of life by targeting a broader range of factors, including side-effect management and psychological flexibility. This study aims to establish key trial parameters, assess the acceptability of the intervention and the extent to which it can be delivered with fidelity, and to demonstrate "proof of principle" regarding its efficacy on primary and process outcomes.

METHODS

The ACTION intervention includes an individual 1:1 ACT session followed by three group sessions involving 8-10 women and two practitioner psychologists. Participants are also provided with access to a website containing evidence-based methods for self-managing side-effects. The ACT sessions were adapted during the COVID-19 pandemic to be remotely delivered via video conferencing software. To evaluate the feasibility and acceptability of this intervention, a multi-site, exploratory, two-arm, individually randomised external pilot trial with a nested qualitative study will be undertaken. Eighty women with early stage breast cancer prescribed adjuvant endocrine therapy will be randomised (1:1) to receive treatment as usual or treatment as usual plus the ACTION intervention. The planned future primary outcome is medication adherence assessed by the ASK-12 measure. Progression to a phase III RCT will be based on criteria related to recruitment and follow-up rates, acceptability to patients, competency and fidelity of delivery, and proof of principle for change in medication adherence.

DISCUSSION

This external pilot trial will be used to ascertain the feasibility of undertaking a future phase III RCT to definitively evaluate an ACT-based intervention to support medication taking behaviour and quality of life in women with early stage breast cancer on adjuvant endocrine therapy.

TRIAL REGISTRATION

ISRCTN: 12027752. Registered 24 December 2020, https://doi.org/10.1186/ISRCTN12027752.

Persistent SOMAtic symptoms ACROSS diseases - from risk factors to modification: scientific framework and overarching protocol of the interdisciplinary SOMACROSS research unit (RU 5211)

INTRODUCTION

Persistent somatic symptoms (PSS) are highly prevalent in all areas of medicine; they are disabling for patients and costly for society. The subjective symptom burden often correlates poorly with the underlying disease severity, and patients' needs for effective treatment are far from being met. Initial evidence indicates that, in addition to disease-specific pathophysiological processes, psychological factors such as expectations, somatosensory amplification and prior illness experiences contribute to symptom persistence in functional as well as in somatic diseases. However, prospective studies investigating the transition from acute to chronic somatic symptoms, integrating pathophysiological, psychological and social factors, are scarce. A better understanding of the multifactorial mechanisms of symptom persistence is crucial for developing targeted mechanism-based interventions for effective prevention and treatment of PSS. Thus, the overall aim of the interdisciplinary SOMACROSS research unit is to identify generic and disease-specific risk factors and aetiological mechanisms of symptom persistence across a range of diseases.

METHODS AND ANALYSIS

Seven projects will investigate risk factors and mechanisms of symptom persistence in a total of 3916 patients across 10 medical conditions. All study designs are prospective and share common assessment points, core instruments and outcome variables to allow comparison and validation of results across projects and conditions. Research will focus on the identification of generic and disease-specific mechanisms associated with unfavourable symptom course. The development of a multivariate prediction model will facilitate the understanding of the course of PSS across diseases.

ETHICS AND DISSEMINATION

All individual SOMACROSS studies were approved by the ethics committees of the Medical Chambers Hamburg and Münster, Germany. Findings will be disseminated through peer-reviewed publications, scientific conferences and the involvement of relevant stakeholders, patients and the lay public. This interdisciplinary research unit will fundamentally contribute to earlier recognition of patients at risk, and to the development of prevention and tailored treatment concepts for PSS.

Association between Endocrine Therapy and Weight Gain after Breast Cancer Diagnosis among Japanese Patients: A Retrospective Cohort Study

BACKGROUND

This study aimed to investigate the association between endocrine therapy and weight gain with a history of breast cancer.

METHODS

This was a retrospective cohort study. Recruited patients consisted of those receiving endocrine therapy and those not receiving endocrine therapy. Weight at diagnosis was collected from medical records, and current body mass was measured using a digital scale (time since diagnosis was 4.0 ± 1.9 years). Moreover, we measured current physical activity using an accelerometer and dietary intake using a validated questionnaire. The primary analysis was a t-test for the body-mass change after diagnosis between the two groups.

RESULTS

We recruited 300 patients and collected data from 292. Mean weight gain after diagnosis was 1.3 ± 3.9 kg, and the change in body mass of patients taking endocrine therapy (1.3 ± 4.0 kg) was not significantly different from that of patients not taking endocrine therapy (1.4 ± 3.8 kg, p = 0.92). There was no association of endocrine therapy, physical activity, and dietary intake with a 5% weight gain after adjusting confounding factors (e.g., breast cancer stage and chemotherapy).

CONCLUSIONS

Caution is required with generalization because of sampling bias and ethnic differences.

Both "Vitamin L for Life" and "One Milligram of Satan": A Multi-Perspective Qualitative Exploration of Adjuvant Endocrine Therapy Use after Breast Cancer

Adjuvant endocrine therapy (AET) is recommended after hormone receptor-positive breast cancer to reduce risk of recurrence, but adherence is sub-optimal in many women. Behavioral interventions have been ineffective in improving adherence rates to AET. This qualitative descriptive study investigates factors that support women in AET use and suggestions for interventions to improve AET use and management. Interviews with women who persisted with AET (n = 23), women who discontinued AET (n = 15), and healthcare providers (HCPs; oncologists, oncology residents, and pharmacists; n = 9) were conducted, transcribed, and described using thematic analysis. Data collection stopped once saturation occurred (i.e., no new codes or themes emerged during interviews). Two researchers created codes and developed themes in an iterative process; a third researcher verified the representativeness of final themes. This study was approved by the Health Research Ethics Board of Alberta (ID: HREBA.CC-17-0513). Women who persisted described being prepared for side effects and having self-management strategies, strong rationale for AET use, supportive HCPs, and available resources as relevant factors. Women who discontinued described feeling overwhelmed by side effects, information needs, drawbacks of AET, helpful/unhelpful experiences with HCPs, and contextual factors as relevant to their discontinuation. HCPs described health system-related and patient-related barriers, side effect management, and patient-provider interactions as relevant to supporting AET use. The considerable overlap in themes among the three groups suggests broad recognition of salient factors relevant to AET use and that associated strategies to improve use may be acceptable to patients and providers alike. Factors supporting AET use could include the following: education (which may be necessary but insufficient), developing a strong personal rationale for use, being prepared for side effects, having side effect management strategies, reciprocal communication between patients and HCPs, and accessible resources.

Race and Patient-reported Symptoms in Adherence to Adjuvant Endocrine Therapy: A Report from the Women's Hormonal Initiation and Persistence Study

BACKGROUND

Adjuvant endocrine therapy (AET) improves outcomes in women with hormone receptor-positive (HR+) breast cancer. Suboptimal AET adherence is common, but data are lacking about symptoms and adherence in racial/ethnic minorities. We evaluated adherence by race and the relationship between symptoms and adherence.

METHODS

The Women's Hormonal Initiation and Persistence study included women diagnosed with nonrecurrent HR+ breast cancer who initiated AET. AET adherence was captured using validated items. Data regarding patient (e.g., race), medication-related (e.g., symptoms), cancer care delivery (e.g., communication), and clinicopathologic factors (e.g., chemotherapy) were collected via surveys and medical charts. Multivariable logistic regression models were employed to calculate odds ratios and 95% confidence intervals (CIs) associated with adherence.

RESULTS

Of the 570 participants, 92% were privately insured and nearly one of three were Black. Thirty-six percent reported nonadherent behaviors. In multivariable analysis, women less likely to report adherent behaviors were Black (vs. White; OR, 0.43; 95% CI, 0.27-0.67; P < 0.001) and with greater symptom burden (OR, 0.98; 95% CI, 0.96-1.00; P < 0.05). Participants more likely to be adherent were overweight (vs. normal weight) (OR, 1.58; 95% CI, 1.04-2.43; P < 0.05), sat ≤ 6 hours a day (vs. ≥6 hours; OR, 1.83; 95% CI, 1.25-2.70; P < 0.01), and were taking aromatase inhibitors (vs. tamoxifen; OR, 1.91; 95% CI, 1.28-2.87; P < 0.01).

CONCLUSIONS

Racial differences in AET adherence were observed. Longitudinal assessments of symptom burden are needed to better understand this dynamic process and factors that may explain differences in survivor subgroups.

IMPACT

Future interventions should prioritize Black survivors and women with greater symptom burden.

The Illness Belief Network Questionnaire: Development and Evaluation of a Psychosomatic Assessment Tool

Objective: Patients’ beliefs and emotions toward an illness can influence their coping responses, illness behaviors, adherence to treatment, quality of life, and even the psychoneuroimmune responses. The aim of present study was to develop and validate a novel questionnaire assessing both rational and irrational beliefs of patients regarding their illness.

Method: In a cross sectional methodological study, the items of the Illness Belief Network (IBN) were developed regarding patients and clients’ opinions about and attribution of their disease extracted from 400 clinical interviews and were coded based on Leventhal’s self-regulation model. An expert panel coded the items. A total of 400 patients with different medical conditions completed the questionnaire. Participants additionally rated the Illness Perceptions Questionnaire in its revised form (IPQ-R) to assess convergent validity. Construct validity was examined by conducting exploratory and confirmatory factor analysis. The Cronbach alpha and Intracluster Correlation Coefficient (ICC) were used for examining Internal consistency and test-retest reliability of the IBN.

Results: The IBN questionnaire was finalized with 84 items, and the results of factor analysis revealed 5 factors: psychosocial causes, environmental causes, control, meaning, and consequence/timeline; extracted factors were confirmed by confirmatory factor analysis. Cronbach’s α coefficient for scale was 0.92 and it ranged from 0.79 to 0.89 for the subscales. IBN indicated excellent test-retest reliability results based on ICC 0.842(95%CI: 0.798-0.846). The correlation coefficients of all items exceeded the prespecified acceptable value of 0.40, indicating satisfactory item discriminant validity, and correlation between IBN and IPQ-R subscales were statistically significant (all p values < 0.01), indicating acceptable convergent validity.

Conclusion: The IBN questionnaire is a valid and reliable phenomenological, non-judging, and clinical tool to assess patient’s rational and irrational or faith-based beliefs about the illness. This tool can be used to improve doctor-patient communication by exploring the complex nature of human thinking.

Potentially Modifiable Factors Associated with Adherence to Adjuvant Endocrine Therapy among Breast Cancer Survivors: A Systematic Review

Adjuvant endocrine therapy (AET) reduces risk of breast cancer recurrence. However, suboptimal adherence and persistence to AET remain important clinical issues. Understanding factors associated with adherence may help inform efforts to improve use of AET as prescribed. The present systematic review examined potentially modifiable factors associated with adherence to AET in accordance with PRISMA guidelines (PROSPERO registration ID: CRD42019124200). All studies were included, whether factors were significantly associated with adherence or results were null. This review also accounted for the frequency with which a potentially modifiable factor was examined and whether univariate or multivariate models were used. This review also examined whether methodological or sample characteristics were associated with the likelihood of a factor being associated with AET adherence. A total of 68 articles were included. Potentially modifiable factors were grouped into six categories: side effects, attitudes toward AET, psychological factors, healthcare provider-related factors, sociocultural factors, and general/quality of life factors. Side effects were less likely to be associated with adherence in studies with retrospective or cross-sectional than prospective designs. Self-efficacy (psychological factor) and positive decisional balance (attitude toward AET) were the only potentially modifiable factors examined ≥10 times and associated with adherence or persistence ≥75% of the time in both univariate and multivariate models. Self-efficacy and decisional balance (i.e., weight of pros vs. cons) were the potentially modifiable factors most consistently associated with adherence, and hence may be worth focusing on as targets for interventions to improve AET adherence among breast cancer survivors.

Self-reported health without clinically measurable benefits among adult users of multivitamin and multimineral supplements: a cross-sectional study

OBJECTIVE

Multiple clinical trials fail to identify clinically measurable health benefits of daily multivitamin and multimineral (MVM) consumption in the general adult population. Understanding the determinants of widespread use of MVMs may guide efforts to better educate the public about effective nutritional practices. The objective of this study was to compare self-reported and clinically measurable health outcomes among MVM users and non-users in a large, nationally representative adult civilian non-institutionalised population in the USA surveyed on the use of complementary health practices.

DESIGN

Cross-sectional analysis of the effect of MVM consumption on self-reported overall health and clinically measurable health outcomes.

PARTICIPANTS

Adult MVM users and non-users from the 2012 National Health Interview Survey (n=21 603).

PRIMARY AND SECONDARY OUTCOME MEASURES

Five psychological, physical, and functional health outcomes: (1) self-rated health status, (2) needing help with routine needs, (3) history of 10 chronic diseases, (4) presence of 19 health conditions in the past 12 months, and (5) Kessler 6-Item (K6) Psychological Distress Scale to measure non-specific psychological distress in the past month.

RESULTS

Among 4933 adult MVM users and 16 670 adult non-users, MVM users self-reported 30% better overall health than non-users (adjusted OR 1.31; 95% CI 1.17 to 1.46; false discovery rate adjusted p<0.001). There were no differences between MVM users and non-users in history of 10 chronic diseases, number of present health conditions, severity of current psychological distress on the K6 Scale and rates of needing help with daily activities. No effect modification was observed after stratification by sex, education, and race.

CONCLUSIONS

MVM users self-reported better overall health despite no apparent differences in clinically measurable health outcomes. These results suggest that widespread use of multivitamins in adults may be a result of individuals' positive expectation that multivitamin use leads to better health outcomes or a self-selection bias in which MVM users intrinsically harbour more positive views regarding their health.

Why we need more research into the placebo response in psychiatry

Placebos are not inert, but exert measurable biological effects. The placebo response in psychiatric illness is important and clinically relevant, but remains poorly understood. In this paper, we review current knowledge about the placebo response in psychiatric medicine and identify research directions for the future. We argue that more research is needed into the placebo response in psychiatric medicine for three broad reasons. First, awareness of factors that cause placebo response, for whom, and when, within clinical trials will allow us to better evidence efficacy of new treatments. Second, by understanding how placebo mechanisms operate in the clinic, we can take advantage of these to optimise the effects of current treatments. Finally, exploring the biological mechanisms of placebo effects might reveal tractable targets for novel treatment development.

Predictors of increased risk for early treatment non-adherence to oral anti-estrogen therapies in early-stage breast cancer patients

PURPOSE

Non-adherence to the oral anti-estrogen therapies (AET) tamoxifen and aromatase inhibitors in early-stage hormone receptor-positive breast cancer is associated with numerous negative clinical outcomes. Prior studies have identified that non-adherence is associated with psychological and menopause-related factors which are present during AET, but the presence of these characteristics prior to AET initiation has not been investigated.

METHODS

Psychological and menopause symptoms (depression, generalized anxiety, insomnia, somatosensory amplification, hot flash frequency, and hot flash-related interference) were assessed pre-AET initiation as predictors of subsequent non-adherence in 73 participants (M_age = 55.0, SD = 10.1 years). Participants self-reported treatment adherence after three and 6 weeks on AET. Participants who did not initiate treatment were excluded from the analysis.

RESULTS

Discriminant function analyses revealed that the hypothesized set of psychological and menopause symptoms at baseline (pre-AET) together statistically distinguished between those who were non-adherent (n = 19; 26.0%) from adherent (n = 54; 74.0%) at 6 weeks. Model classification accuracy was statistically significant (Wilks' ƛ = 0.782, χ²(6) = 15.50, p = 0.017) at the 6-week timepoint. Results were consistent at 3 weeks. Pre-AET psychological and menopause symptoms correctly classified 6-week treatment adherence 77.9% of the time. Depression contributed most to distinguishing between adherers and non-adherers.

CONCLUSIONS

The presence of a composite profile of psychological and menopause symptoms prior to AET initiation may help to identify early treatment non-adherence. Results can be used to identify patients at risk for non-adherence and to guide psychological and symptom management interventions.

Development of the generic, multidimensional Treatment Expectation Questionnaire (TEX-Q) through systematic literature review, expert surveys and qualitative interviews

OBJECTIVE

Patients' expectations-as a central mechanism of placebo and nocebo effects-are an important predictor of health outcomes. However, the lack of a way to assess expectations across different settings restricts progress in understanding the role of expectations and to quantify their importance in medical and psychological treatments. The aim of this study was to develop a theory-based, generic, multidimensional measure assessing patient expectations of medical and psychological treatments.

DESIGN

The Treatment Expectation Questionnaire (TEX-Q) was developed based on the integrative model of expectations and a systematic literature review of treatment expectation scales. After creating a comprehensive item pool, the scale was further refined by use of expert ratings and patient interviews.

SETTING

Patients were recruited in primary care at two hospitals in Hamburg, Germany.

PARTICIPANTS

13 scientific experts participated in the expert survey. 11 patients waiting for psychological or surgical treatments participated in the qualitative interviews.

RESULTS

The 2×2×2 multidimensional structure of the TEX-Q assesses two expectation constructs (probabilistic vs value-based) across two outcome domains with two valences (direct benefits and adverse events, broader positive and negative impact), plus process and behavioural control expectations. We examined 583 items from 38 scales identified in the systematic review and developed 78 initial items. Content validity was then rated by experts according to item fit and comprehensibility. The best 53 items were further evaluated for comprehensibility, acceptability, phrasing preference and understanding by interviewing patients prior to treatment using the 'think aloud' technique. This resulted in a first 35-item version of the TEX-Q.

CONCLUSIONS

The TEX-Q is a generic, multidimensional measure to assess patient expectations of medical and psychological treatments and allows comparison of the impact of multidimensional expectations across different conditions. The final TEX-Q will be available after psychometric validation.

When Beliefs Face Reality: An Integrative Review of Belief Updating in Mental Health and Illness

Belief updating is a relatively nascent field of research that examines how people adjust their beliefs in light of new evidence. So far, belief updating has been investigated in partly unrelated lines of research from different psychological disciplines. In this article, we aim to integrate these disparate lines of research. After presenting some prominent theoretical frameworks and experimental designs that have been used for the study of belief updating, we review how healthy people and people with mental disorders update their beliefs after receiving new information that supports or challenges their views. Available evidence suggests that both healthy people and people with particular mental disorders are prone to certain biases when updating their beliefs, although the nature of the respective biases varies considerably and depends on several factors. Anomalies in belief updating are discussed in terms of both new insights into the psychopathology of various mental disorders and societal implications, such as irreconcilable political and societal controversies due to the failure to take information into account that disconfirms one’s own view. We conclude by proposing a novel integrative model of belief updating and derive directions for future research.

Patient expectations are better for immunotherapy than traditional chemotherapy for cancer

Purpose

The main aim of the study was to explore the expectations and knowledge of advanced-stage cancer patients about immunotherapy.

Methods

This mixed methods study included 53 cancer patients on immune checkpoint inhibitors (ICIs), 55 cancer patients undergoing chemotherapy (CT), and 53 non-cancer patients. Participants’ expectations about ICIs and CT were compared. Additional qualitative data were derived from semi-structured interviews.

Results

Among patients who did not receive ICIs, 63 (58%) had never heard of ICIs and 94 (87%) had large gaps in their knowledge of ICIs. Among ICI patients, 33 (62%) simply described ICIs without errors. ICI perception was positive, regardless of whether respondents received or had heard of ICIs, which became particularly evident when compared to CT. ICIs were rated as more promising, and all adverse effects were expected to be significantly lower than those of CT. Knowledge about ICIs was also limited in the interviewed ICI patients. Some patients reported adverse effects of ICIs that were mostly mild and well-tolerated or easily treated.

Conclusions

The lack of understanding of ICIs should be improved by activities to increase the knowledge of ICI patients and the general population. In contrast to CT, ICIs invoked fewer negative associations with efficacy and toxicity. Therefore, attention should be paid to risk awareness when educating patients. (Clinical trial registration number: DRKS00011868)

Trial Registration: German clinical trials register, www.germanctr.de, number DRKS00011868.

Influence of placebo analgesia in pharmacological treatment of pain

Placebo effects are relevant to routine clinical practice, even if no traditional placebo is given. The healthcare encounter is often rich in factors that may affect both placebo and nocebo components of care, therefore, an opportunity exists to target elements of this encounter to enhance clinical effectiveness. This review will outline the contemporary conceptualizations of placebo and the mechanisms of placebo effects. Specifically, how to harness these placebo effects in clinical practice. Currently, these include optimizing the therapeutic context, shaping of expectations, assessing belief structures and framing information delivery, utilization of conditioning regimes to augment drug response or reduce overall drug dosing and the potential integration of traditional placebos with scientifically proven treatments to augment care.

Optimizing expectations about endocrine treatment for breast cancer: Results of the randomized controlled psy-breast trial

Background

Medication side effects are strongly determined by non-pharmacological, nocebo mechanisms, particularly patients’ expectations. Optimizing expectations could minimize side effect burden. This study evaluated whether brief psychological expectation management training (EXPECT) optimizes medication-related expectations in women starting adjuvant endocrine therapy (AET) for breast cancer.

Method

In a multisite randomized controlled design, 197 women were randomized to EXPECT, supportive therapy (SUPPORT), or treatment as usual (TAU). The three-session cognitive-behavioral EXPECT employs psychoeducation, guided imagery, and side effect management training. Outcomes were necessity-concern beliefs about AET, expected side effects, expected coping ability, treatment control expectations, and adherence intention.

Results

Both interventions were well accepted and feasible. Patients’ necessity-concern beliefs were optimized in EXPECT compared to both TAU and SUPPORT, d = .41, p < .001; d = .40, p < .001. Expected coping ability and treatment control expectations were optimized compared to TAU, d = .35, p = .02; d = .42, p < 001, but not to SUPPORT. Adherence intention was optimized compared to SUPPORT, d = .29, p = .02, but not to TAU. Expected side effects did not change significantly.

Conclusion

Expectation management effectively and partly specifically (compared to SUPPORT) modified medication-related expectations in women starting AET. Given the influence of expectations on long-term treatment outcome, psychological interventions like EXPECT might provide potential pathways to reduce side effect burden and improve quality of life during medication intake.

A Brief Metric Framework for Patient Adherence to Doctor's Advice Based on Behavioral Economics

PURPOSE

This study tried to establish a metric framework of patient adherence to doctor's advice based on the expected utility and prospect theories, and it explained why the key to patient adherence to doctor's advice is patients' perceptions.

METHODS

Our framework is primarily based on two mature theories: expected utility theory and prospect theory. We started with a basic assumption: the doctor is rational and cares for patient's health utility. We analyzed the expected utility of therapy with a definite diagnosis. Then, we considered the impacts of the accuracy of diagnostic techniques. After that, we explored the patient's response to the doctors' advices based on behavioral economics. In addition, we launched a discrete choice experiment to test our main point: perception is the key to patients' adherence. A total of 200 undergraduate students participated in the discrete choice experiment.

RESULTS

Three main factors might impact a rational clinical decision: the therapeutic and side effects of the treatment, patient's true disease risk, and diagnostic accuracy. However, another factor, patient's individual percepion, was crucial for patient's adherence since it may bias the patient's estimations regarding the above three factors. As a result, doctors and patients would have a cognitive gap in the estimation of the disease and the treatment.

CONCLUSION

The results indicate that without the necessary information, better clinical techniques may not help to improve patient adherence, which support our theoretical reasoning forcefully. Therefore, improving patient adherence should be more of a process of empathy and communication rather than a promotion of medical technology.

[Biosimilars and the nocebo effect]

Biosimilars have been approved for use in Germany for many years and in the meantime also in rheumatology but only a few years ago. Biosimilars, which are biotechnologically manufactured products the same as reference biologicals, have actually now achieved a substantial proportion of the market in some regions but there are still doubters among patients and physicians who fear a loss of quality even if there is no evidence for this. A part of this problem can be explained by the nocebo effect but which furthermore also has a substantial medical importance. This effect is described and explained in this article. Psychosocial and context-related factors, such as the relationship between patient and physician, previous experience with treatment and treatment expectations can either improve or impair the efficacy of treatment interventions. These phenomena are commonly known as placebo and nocebo effects. As placebo and nocebo effects can influence the development of symptoms, the frequency of undesired events and the efficacy of treatment, it is decisive to know these effects and to develop strategies for prevention in order to optimize the treatment results. Although in recent years experimental studies have achieved substantial progress in the clarification of the psychosocial and neurobiological mechanisms of placebo effects, detailed mechanisms of nocebo effects are still widely unexplored. An improved understanding of these mechanisms promises the development of user-friendly strategies for the clinical care to improve treatment results and patient satisfaction.

The Other Side of the Coin: Nocebo Effects and Psychotherapy

Psychotherapy and placebo have a long history, and both have been shown to have significant and clinically meaningful effects. In the last 100 years and up to today, psychotherapy has been subject to an enduring and often heated debate about its mechanisms and its possible relationship to placebos and their effects. However, there is little awareness of the placebo effects' counterpart-nocebo effects (from Latin "I will harm")-in the context of psychotherapy. Embedded in the controversy of whether psychotherapy and placebo share some unwanted proximity in terms of effects and mechanisms, the question arises which role nocebo effects may play in relation to psychotherapy. By using two examples, this article analyzes and discusses two different kinds of possible associations between psychotherapy and nocebo effects. We close with possibilities of how to prevent the occurrence of nocebo effects in psychotherapy, including some specific recommendations for clinical practice.

It is not just the drugs that matter: the nocebo effect

The role of psychological mechanisms in the treatment process cannot be underestimated, the well-known placebo effect unquestionably being a factor in treatment. However, there is also a dark side to the impact of mental processes on health/illness as exemplified by the nocebo effect. This phenomenon includes the emergence or exacerbation of negative symptoms associated with the therapy, but arising as a result of the patient's expectations, rather than being an actual complication of treatment. The exact biological mechanisms of this process are not known, but cholecystokinergic and dopaminergic systems, changes in the HPA axis, and the endogenous secretion of opioids are thought to be involved. The nocebo effect can affect a significant proportion of people undergoing treatment, including cancer patients, leading in some cases to the cessation of potentially effective therapy, because of adverse effects that are not actually part of the biological effect of treatment. In extreme cases, as a result of suggestions and expectations, a paradoxical effect, biologically opposite to the mechanism of the action of the drug, may occur. In addition, the nocebo effect may significantly interfere with the results of clinical trials, being the cause of a significant proportion of complications reported. Knowledge of the phenomenon is thus necessary in order to facilitate its minimalization and thus improve the quality of life of patients and the effectiveness of treatment.

Using Different Expectation Mechanisms to Optimize Treatment of Patients With Medical Conditions: A Systematic Review

OBJECTIVE

Patients' expectations have been shown to predict the course and treatment success of a variety of medical conditions. Therefore, expectation-focused psychological interventions (EFPIs) have been developed to use these expectation effects clinically. Importantly, EFPI differ with regard to the particular expectation mechanism being addressed, i.e., expectation optimization or expectation violation. The aims of this systematic review were to give an overview of the application of these expectation interventions and to evaluate their effectiveness.

METHODS

Several databases were searched to identify clinical trials or experimental studies that conducted EFPI among participants with various medical conditions. Risk of bias was evaluated using the Cochrane Risk of Bias tool.

RESULTS

Eleven studies (N = 944) investigating different medical conditions (coronary heart disease, cancer, chronic pain) were included. Qualitative synthesis revealed positive effects of EFPI on clinical outcome variables in all studies. Expectation optimization approaches yielded particularly promising results. Because of the large heterogeneity of outcome measures, quantitative synthesis was not possible.

CONCLUSION

This review highlights the potential of EFPI for optimizing treatment of patients with medical conditions. However, it seems that different expectation mechanisms might have different application possibilities. Therefore, we provide suggestions for further developing EFPI to tailor treatment and develop personalized psychological interventions. We argue that for this purpose, it is important to consider both disease-specific aspects and patients' personality traits. In addition, we discuss future challenges such as implementing EFPI into routine medical care.