End-of-Life Care, Symptom Burden, and Quality of Life in Couples Facing Stage IV Lung Cancer: The Role of Patient and Spousal Psychospirituality and Discussions Around Fear of Death and Disease Progression

Background: As patients live longer with stage IV nonsmall cell lung cancer, correlates of end-of-life (EOL) care and experience are increasingly relevant. Methods: We, therefore, prospectively examined associations among psychospirituality (Center for Epidemiologic Studies Depression Scale, Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being), discussions around fear of death and disease progression, and hospital-based EOL care in patients and caregivers. Patients additionally reported symptom burden (MD Anderson Symptom Inventory-Lung Cancer total) and quality of life (QOL) (quality-of-life at EOL). Results: Of the baseline patients (n = 75), 32% were alive at time of the analyses (mean = 4.6 years postbaseline). Deceased patients (n = 51) were middle aged (mean = 65.3 years) and non-Hispanic White (81%). Caregiver spiritual well-being (r = 0.34, p = 0.02) and depression (r = -0.31, p = 0.03) were associated with EOL care metrics. Patients who "held back" more of their fear of death or disease progression experienced greater symptom burden (r = 0.41, p < 0.001) and poorer QOL (r = -0.44, p < 0.001). Conclusion: For couples facing prolonged metastatic disease, psychospirituality is highly relevant to EOL care with potential sequelae of withholding one's fear regarding death or disease progression.

Treatment of Cancer-related-Fatigue in Acute Hematological Malignancies: Results of a Feasibility Study of using Cognitive Behavioral Therapy

BACKGROUND

Despite cancer related fatigue (CRF) being the most common, and debilitating symptom in patients with recently diagnosed acute hematological malignancies (HM), there are limited effective treatments for CRF in HM. The aim of this study was to determine the feasibility of cognitive behavioral therapy (CBT) for CRF in HM.

METHODS

In this preliminary longitudinal prospective study, HM patients diagnosed a median of one month previously with moderate to severe fatigue were enrolled. Patients received CBT in seven weekly sessions for eight weeks. Change in Functional Assessment of Cancer Illness Therapy (FACIT) - Fatigue (primary), FACT-G, Pittsburg Sleep Quality Index (PSQI), Hospital Anxiety Depression Scale (HADS), M.D. Anderson Symptom Inventory - Acute Myeloid Leukemia (MDASI-AML/MDS), and Herth Hope Index (HHI) were analyzed.

RESULTS

Twenty-seven of 36 (75 %) patients were evaluable. Adherence and satisfaction rates to the CBT intervention were 78.6% (95% CI 67.2%, 89.9%), and 92% (95% CI 76.7%, 98.3%) respectively. The median age 66, 64% female, the most common HM was AML (60%), median FACIT-F was 27. The mean (SD) improvement at end eight weeks for FACIT-F was 5.5(13.6), Cohen δ 0.4, P=0.046; and for PSQI total was 2.9 (3), Cohen δ -1, P=0.006. We also found significant improvement in HADS anxiety -2.7(4.5), P=0.049, MDASI Sleep -1.8(3.0), P=0.022, MDASI mean module symptom severity -0.7(1.6), P=0.006. However, no significant improvements were found in FACT-G, HHI, and HADS-depression scores.

CONCLUSIONS

The use of CBT was feasible with improvement of CRF, sleep quality, and anxiety scores in HM. Randomized controlled trials are justified.

Treating Radiation Anxiety with Systematic Desensitization: Head and Neck Cancer Case Reports

Introduction: Head and neck cancer patients have high rates of psychological distress, which may be exacerbated by the treatments they receive. Many patients who undergo radiation therapy report significant anxiety associated with the thermoplastic mask required for immobilization during treatment. Case Description: This report presents two examples of head and neck cancer patients reporting high mask anxiety, along with a history of claustrophobia, who expressed concern about their abilities to initiate and adhere to treatment. Both were referred to supportive care psychology before radiation treatment initiation. With counseling and the use of systematic desensitization, they were successfully able to complete their treatments. Discussion: Results of these case reports highlight the value of integrating early supportive care in the treatment of head and neck cancer and support the need for further study in future randomized controlled trials.

Social isolation at the end of life: A case report of one person's journey navigating the medical landscape during the COVID-19 pandemic

BACKGROUND

In addition to physical symptom burden, psychological suffering at end of life (EOL) is quite pervasive. As such, the interdisciplinary team in our Palliative and Supportive Care Unit strives to provide quality care sensitive to the physical and psychosocial needs of patients. Involving and allowing for the presence of family members is one way in which we afford our patients some additional comfort. Unfortunately, the current pandemic has placed limitations on this rather fundamental need for both patients and their family members. Here, we present a case illustrating the effects of visitor restrictions/isolation due to COVID-19 on the suffering of a patient at the EOL.

CASE DESCRIPTION

A male in his 20s with a refractory hematologic malignancy decided to pursue a comfort-based approach to care after a rapid clinical deterioration. Due to visitor restrictions, he had to face this decision with limited support at the bedside, which caused significant distress. He was forced to choose among several immediate family members who would be at his side through his hospitalization, to be his advocate, at times his voice, his confidant, and the person to relay all information to those on the outside. He expressed a wish to be married before he died, which occurred in our palliative care unit. This life goal was one we would normally encourage those he loved to gather around him, but this was not possible. He passed peacefully two days after he was married.

CONCLUSION

Although social limitations are necessary to help provide safety to the patients and staff in a hospital, they can have a direct impact on the suffering of patients and families at the EOL. Helping to maintain dignity, reflect on their life, and resolve any conflicts in the presence of family members is a benchmark for providing quality palliative care. Being barred from visitation due to isolation, threatens this care and lays the foundation for complicated grief among family members. Further research is needed to help balance the needs of those at the EOL with public safety. One such measure to help ease distress is to allow for more virtual visitation through electronic measures.

Physical and Psychosocial Symptoms of Young Adult Patients Referred to the Supportive Care Mobile Team

Young adult (YA) aged cancer patients have unique psychosocial needs with studies indicating more symptoms and emotional distress compared to older patients. Our study aimed to compare clinical characteristics and symptom distress between YAs and older adults. We retrospectively studied 896 randomly selected patients across 3 age groups: 18-39 YAs (n = 297), 40-64 (n = 300), and 65 and older (n = 299). We compared medical, psychosocial history, Morphine Equivalent Daily Dose (MEDD), Edmonton Symptom Assessment Scale (ESAS) scores, and Eastern Cooperative Oncology Group (ECOG) scores at the time of initial inpatient consultation with supportive care. YAs were more frequently female and white, with higher ECOG scores, had more self-reported psychiatric history and worse ESAS sleep scores compared to the other age cohort groups. YAs had higher pain expression than those of 65 years and older. YAs were more likely to have children younger than 18 years old, which was associated with worse pain, sleep, and financial distress. In general, YAs did not report higher symptoms distress, with the exception of insomnia and self-reported psychiatric history. Importantly, YAs with children was associated with higher ratings of pain, sleep difficulties, and financial distress. Overall, results suggest YAs may benefit from specialized services to address their unique psychosocial needs.

Healthy Moves to Improve Lifestyle Behaviors of Cancer Survivors and Their Spouses: Feasibility and Preliminary Results of Intervention Efficacy

Spouses offer a primary source of support and may provide critical assistance for behavior change. A diet-exercise intervention previously found efficacious in improving cancer survivors' lifestyle behaviors was adapted to utilize a couples-based approach. The aims were to test the feasibility of this couples-based (CB) intervention and compare its efficacy to the same program delivered to the survivor-only (SO). Twenty-two survivor-spouse couples completed baseline assessments and were randomized to the CB or SO interventions. The study surpassed feasibility benchmarks; 91% of survivors and 86% of spouses completed a 6-month follow-up. Survivors and spouses attended 94% and 91% of sessions, respectively. The SO survivors showed significant improvements on the 30-s chair stand and arm curl tests, weight, and fruit and vegetable (F and V) consumption. The CB survivors showed significant improvements on the 6-min walk and 2-min step tests, body weight, and fat and F and V consumption. Improvement in the 30-s chair stand and arm curl tests was significantly better for SO survivors. The SO spouses showed no significant changes in outcome measures, but the CB spouses showed significant improvements in moderate-to-strenuous physical activity, weight, and fat and F and V consumption. Weight loss was significantly greater in CB spouses compared to SO spouses. Findings demonstrate feasibility, warranting further investigation of CB approaches to promote lifestyle change among cancer survivors and spouses.

Adaptive and maladaptive coping strategies among patients with advanced cancer

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Background: Few studies have examined the coping mechanisms among patients with advanced cancer seen by palliative care. The objective of the study was to evaluate coping strategies in advanced cancer patients and identity risk factors for maladaptive coping. Methods: The authors conducted a secondary analysis of a cross-sectional survey on chemical coping. We prospectively enrolled patients with advanced cancer from a Supportive Care Clinic and documented the patient demographics, symptom expression (Edmonton Symptom Assessment System), Zubrod performance status, substance use history including tobacco, and coping strategies (the Brief COPE Questionnaire). Univariate and multivariate analyses were performed to identify risk factors for the use of maladaptive coping strategies. Results: Among 399 patients, the most common malignancies were gastrointestinal (21%) and breast (19%). Cancer patients frequently incorporated adaptive coping strategies including acceptance (86.7%), emotional support (79.9%), religion (69.4%), active coping (62.4%), instrumental support (48.4%), positive reframing (48.6%), planning (49.6%), and infrequently, humor (18.5%). Common maladaptive strategies included self-distraction (36.6%) and venting (14.5%), while self-blame (6.3%), denial (4.5%), behavioral disengagement (1.8%), and substance use (1.0%) were infrequently reported. On univariate analysis, venting was significantly associated with anxiety and depression, female gender, and tobacco use; and self-distraction was significantly associated with younger age, gender, depression, dyspnea, and a post-secondary education (P<0.05 for all). On multivariate analysis, male gender (OR -1.22, p<0.0001) and smoking (non-smoker vs everyday OR -1.9, P=0.008 ) remained significant for maladaptive venting; and age (HR -0.026, p=0.005), male gender (OR -0.65, p=0.004), dyspnea (OR -0.12, p=0.01) and post-secondary education (OR 0.596, p=0.022) remained significant for self-distraction. Conclusions: The vast majority of patients with advanced cancer seen by palliative care reported using adaptive coping strategies. We identified subgroup of patients who may be more likely to use maladapative coping strategies and may benefit from further psychological support.

Enhancing palliative care patient access to psychological counseling through outreach telehealth services

CONTEXT

Palliative care encompasses an interdisciplinary team, including mental health care professionals, to address psychological distress of cancer patients.

OBJECTIVES

To present the implementation of an outreach counseling program via videoconferencing or telephone to patients receiving care in an outpatient palliative care clinic and to compare patients using this service to those who only received psychological counseling in our outpatient clinic.

METHODS

We conducted a retrospective chart review of cancer patients seen for psychology counseling services in an outpatient supportive care center between June 2015 and March 2017.

RESULTS

We reviewed 2072 unique patients (52% of the total patients seen at the outpatient Supportive Care Center), who had 4567 total counseling encounters across outreach and outpatient settings. A total of 452 (22%) patients participated in a combination of outpatient and outreach counseling services. Patients who participated in outreach services had significantly more encounters (311 [69%] had two to five sessions) compared with those who had outpatient services only (1137 [70%] had one session only) (P < .001). Outreach patients also had shorter times between the initial and follow-up encounters (median 14 days) compared with those who had outpatient services only (median 30 days) (P < .0001).

CONCLUSIONS

Outreach telehealth counseling services was found to enhance palliative care patient access to psychological counseling. These services represent an additional modality for providing continuous psychological care.

Introducing psychology services to advanced cancer patients: A randomized double-blind trial

CONTEXT

Psychology services utilization in cancer patients remains low due to barriers such as patient/caregiver acceptance of counseling.

OBJECTIVE

We aimed to determine if the manner of introducing psychology services impacted patients' acceptance of services and to identify factors associated with acceptance and barriers to psychology utilization.

METHODS

In this double-blind randomized cross-over trial, cancer patients with no prior psychology services observed two video vignettes: (a) physician introducing counselor and psychology services to the patient (PI) and (b) counselor introducing psychology services alone (CI). A counterbalanced design was used to control for order effects. After viewing both videos, patients completed a survey regarding preference, attitudes, and barriers for psychology services. Patients and investigators were blinded to the purpose of the study and content and order of videos, respectively. We hypothesized that patients would prefer physician introduction of counselor.

RESULTS

One hundred patients participated: 40 (40%) expressed no difference, 34 (34%) preferred PI, and 26 (26%) preferred CI (P > .2). Younger patients (less than 40 years) either preferred PI (86%) or had no preference (14%, P = .01). Most reported awareness of available psychology services (N = 63), and half (N = 50) were offered psychology services by their physician. Only 40 (40%) and 43 (43%) patients felt psychology services would be helpful for them and their family/caregivers, respectively. Patients who perceived psychology as helpful for self or family had higher anxiety (P = .01 and P = .006, respectively).

CONCLUSIONS

No significant difference was found in patient preference of introducing psychology services except in patients less than 40 years old who preferred PI.

Change in physical activity and quality of life in endometrial cancer survivors receiving a physical activity intervention

Background

Endometrial cancer survivors are at an increased risk of poor quality of life outcomes. Physical activity is positively associated with general quality of life in this population, however, little is known about how changes in physical activity may be associated with changes in specific aspects of quality of life. The aim of this secondary data analysis was to explore the relationships between change in physical activity and change in physical, mental, social, and other aspects of quality of life in endometrial cancer survivors receiving a physical activity intervention.

Methods

Endometrial cancer survivors (N = 100) participated in a telephone-based physical activity intervention for six months. At baseline and post-intervention we measured physical activity via accelerometry and ecological momentary assessment, and quality of life via the Short Form Health Survey (SF-36), the Quality of Life of Adult Cancer Survivors instrument, the Brief Symptom Inventory, the Pittsburgh Sleep Quality Index, and the Perceived Stress Scale. We conducted structural equation modeling path analyses to investigate how physical activity post-intervention was associated with the quality of life measures’ subscales post-intervention, adjusting for baseline levels and potentially confounding covariates.

Results

Increasing physical activity was positively associated with improvements in general health (p = .044), role limitation due to physical health (p = .005), pain (p = .041), and somatic distress (p = .023). There was no evidence to indicate that change in physical activity was associated with change in other aspects of quality of life.

Conclusions

Endometrial cancer survivors are at higher risk for suffering from challenges to physical quality of life, and findings from this study suggest that increasing physical activity may alleviate some of these problems. Further research is needed to determine whether other aspects of quality of life are linked to change in physical activity.

Trial registration

Trial registration number: NCT00501761

Name of registry: clinicaltrials.gov

Date of registration: July 16, 2007.

Date of enrollment: June 16, 2005.

Multimodal therapy for the treatment of sleep disturbance in patients with advanced cancer

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Background: Poor sleep quality is frequent in patients with advanced cancer (62%), and is associated with a severe symptom distress and mortality. There are limited evidence based treatment options in advanced cancer patients.To obtain feasibility, preliminary estimates of the effects of various treatments [light therapy, melatonin, Methylphenidate] and combinations of treatments in multimodal therapy (MMT) to improve sleep quality, as measured by change in Pittsburg Sleep Quality Index (PSQI) scores from baseline to Day 15. We also examined MMT effects on FACT-G, insomnia - Insomnia severity index (ISI), actigraphy. Methods: Cancer patients with moderate sleep disturbance were eligible. Using a double-blind (patient, investigators) randomized factorial study design, eligible Pts were randomized into 1 of the 8 arms of the study which included all possible combinations of the interventions (light therapy, melatonin, and methylphenidate) and/or their corresponding placebo treatments for a duration of 2 weeks. All patients received 3 sessions of standardized CBT. Linear regression analysis was used to assess treatment effects. Results: 84% (54/ 64) randomized Pts were evaluable. At baseline, median (IQR) total PSQI was 13 (12, 15); and ISI was 18 (14, 21). There were no differences in the demographics and baseline sleep quality between groups. The adherence rates for light therapy, melatonin, and methylphenidate were 93%, 100%, and 100% respectively. Light therapy had moderate effects on sleep quality (effect size .43, P=0.017). No significant differences in ISI, FACT-G scores, and objective sleep variables between groups. There were no significant difference in adverse events by groups (P=.97). Conclusions: MMT interventions to treat sleep disturbance were feasible. Light therapy provided the best signal for improvement in sleep quality, and should proceed to large randomized control trials. Clinical trial information: NCT0168029. [Table: see text]

Clinical and demographic variables of young adult (YA) patients referred to inpatient supportive care

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Background: Literature suggests that YA cancer patients have unique psychosocial issues and more emotional distress compared to older aged patients. Our study aimed to evaluate clinical and demographic factors of YA cancer patients that may impact physical and psychosocial symptom expression. Methods: A retrospective review was conducted on randomly selected patients seen during 2013-2015 of 3 age groups: 18-39 (YA), 40-64, and 65 and older on demographic, medical, psychosocial history, Morphine Equivalent Daily Dose (MEDD), Edmonton Symptom Assessment Scare (ESAS) scores, and Eastern Cooperative Oncology Group (ECOG) scores which are completed at time of initial consultation with the supportive care inpatient mobile team. Results: 896 (YA = 297, 40-64 cohort = 300, 65 and older = 299) patients were reviewed. YA cohort was associated with being female (n = 179 (60%), p = 0.03), more frequently non-white (Black and Hispanic = 124 (42%), p < 0.00), higher ECOG scores (ECOG 0-2 = 83(39%), p < 0.00) more psychiatric history (n = 95(32%), p = 0.00) and worse ESAS sleep scores (median = 6, p = 0.02). The YA cohort also had higher pain expression than the 65 and older cohort (p = .02). The YA group was more likely to have children younger than 18 years old (n = 171(58%), p < 0.00). Patients with children less than 18 years of age reported higher pain expression (median = 6, p = .05), sleep (median = 6, p = 0.01), and financial distress (median = 2, p = 0.02). Conclusions: Contrary to other findings, YA cancer patients did not report higher symptoms or distress when compared to older age cohorts, with the exception of higher insomnia compared to other age cohorts and higher pain expression than the oldest age cohort. YA with young children reported higher level of pain, sleep and financial distress. Our findings suggest that the YA population may benefit from specialized psychosocial services to address their unique social needs, particularly to address concerns related to being parents of young children.

Communicating the introduction of psychology services in the palliative care (PC) cancer setting: A randomized double blind trial

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Background: Despite high distress and empirical support for psychosocial services for cancer patients, the utilization of these services continue to be low. Our aims are to ascertain if the manner of introducing psychology services impact patients’ acceptance of services and identify factors associated with acceptance and barriers of psychology utilization. Methods: 100 PC cancer patients who have not received prior psychology services were randomized to observe two video vignettes: one showed a physician introducing a counselor and psychology services to the patient (PI); another showed a counselor entering and introducing psychology services alone (CI). Randomization was stratified using baseline Hospital Anxiety and Depression Scale scores. After viewing both videos, patients completed a survey regarding preference, attitudes, and barriers for psychology services. Patients were blinded regarding the purpose of the study and investigators were blinded to content and order of videos presented. Results: 64 patients reported a preference with 34 preferring PI (p=0.37) and 36 reporting no difference. Younger patients preferred PI (85.7%) versus CI (14.3%, p=0.03). Most reported being aware of available psychology services (N=63), and half (N=50) had been offered psychology services by their physician. Only 40 (40%) patients felt psychology services would be helpful for them, and 43 (43%) reported it would be beneficial for their family/caregivers. Those who found it helpful for themselves or family had higher anxiety than those who did not find it helpful (p=0.03 and p=.02 respectively). The most commonly endorsed barriers for psychology services were travel (N=25) and finances (N=21). Conclusions: We found no significant difference in preference of introduction of psychology services except in patients less than 40 years old who preferred PI. Patients with higher anxiety felt psychology services were helpful for self and family. Only 40% perceived psychology services as useful for self and family. More research is needed to investigate the most effective approach for introducing psychology services to increase perception of usefulness and utilization in cancer patients. Clinical trial information: NCT03035448.

Characteristics and Outcomes of Psychology Referrals in a Palliative Care Department

CONTEXT

Psychologists can provide unique contributions to interdisciplinary palliative care. Despite research indicating high distress in palliative care cancer patients, little has been reported regarding the feasibility and practice of psychology in this setting.

OBJECTIVES

To review the integration of clinical psychology practice in a palliative care department at a major comprehensive cancer center.

METHODS

Retrospective chart review of 1940 unique cancer patients (6451 total patient contacts) referred for psychology services provided by clinical psychologists in palliative care from September 1, 2013 to February 29, 2016.

RESULTS

Psychologists provided services to 1644 inpatients (24% of palliative care inpatients) and 296 outpatients (19% of palliative care outpatients). Most of them (85%) received services in the inpatient setting. Most patients were females (57%) and white (68%) with a variety of cancer diagnoses. Adjustment disorders were the most prevalent in both settings with significant differences in other Diagnostic and Statistical Manual of Mental Disorders (5th Edition) diagnoses by service location (P < 0.0001). Psychological assessment (86%) and supportive expressive counseling (79%) were the most frequent services provided in the initial consult. Duration of initial visit was significantly longer in outpatient (median 60 minutes) compared with inpatient setting (median 40 minutes) (P < 0.0001). No significant differences were noted between settings regarding the median number of counseling sessions per patient; however, most (70%) only received one or two sessions. Over time, total patient encounters increased in the inpatient setting (P < 0.0001), whereas session lengths in both settings significantly decreased (P < 0.0001).

CONCLUSION

Palliative care psychology services successfully integrated into an interdisciplinary palliative care department and rapidly grew in both inpatient and outpatient settings.

Characteristics of patients referred for psychology services by a palliative care inpatient consult team

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Background: From Jan 2013 to Dec 2015, only 23% of inpatient palliative care consults were referred for psychology (PSY) services. In an effort to better understand referral practices, we compared those who were referred for PSY services to those who were not. Methods: A retrospective chart review of 930 consecutive patients from Jan 2013 to Dec 2015 was conducted to collect demographic and clinical variables. 455 patients who had at least one PSY contact and 475 patients who had no PSY contact were randomly selected. In an effort to control for age, we selected 330 patients 18-39 years, 300 patients 40-64 years, and 300 patients 65 and older. Descriptive, univariate and logistic regression analyses were conducted. Results: Patients referred to PSY services (N = 455) included 267(59%) females. Majority were White(60%) and English speaking(93%). Majority were married(62%) and parents(79%). The largest cancer type was GI(20%) followed by hematological(15%). Majority had ECOG status of 3(39%) and CAGE-AID negative (82%). Patients with no psychology consult(N = 475) included 50% females. Majority were White(60%) and English speaking(79%). Majority were married(56%) and parents(70%). This sample also had majority GI cancers(18%) followed by hematological(15%). Majority had ECOG status of 3(34%) and was CAGE-AID negative(75%). Univariate variables significant for those referred for PSY services included: Female(p = .01), English language(p = .018), ECOG score of 3(p = .006), psychiatric history(p = .008), higher MEDD(p = .001) and several ESAS subscales including depression(p = .000), anxiety(p = .000), shortness of breath(p = .017), sleep (p. = .029) and spiritual pain(p = .001). Logistic regression identified psychiatric history and ESAS depression scores as significant predictors of PSY referral. Conclusions: Several univariate factors were significantly associated with referral to PSY services. Psychiatric history and ESAS depression score showed to be strong independent predictors. These results help us to understand how palliative care providers determine those they consult for PSY services. More research is needed to investigate who may benefit most from PSY referrals.

Enhancing palliative care patient access to outpatient and outreach counseling services

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Background: MD Anderson’s interdisciplinary out-patient clinic, palliative care team includes mental health professionals who provide psychological care, including 3 full time Master’s level counselors. Counseling sessions are offered during the patient’s clinic appointments. To increase opportunity and access for additional counseling, patients are offered follow-up counseling through an outreach program which includes videoconferencing or telephone sessions. The data presented represents almost 2 years of our Master’s level clinicians’ practices. Methods: Retrospective chart review of 2041 consecutive patients (3606 total contacts) seen for psychology counseling services in the Supportive Care Center between 6/2015 and 3/2017. Results: Counselors saw 2041 consecutive patients (52% of the patients seen at the out-patient Supportive Care Center). Most patients only had 1 session in clinic (63%); almost 1/3 received 2-5 sessions (33.9%). Median time for the follow-up visit was 30.5 days. Approximately 25% (N = 511) were offered outreach services; 79% (N = 405) of those offered received these services. Median number of outreach sessions received was 1 (57%); 2-5 (38%); 6-9 (4%) and 10+ (1%). Sessions lasted 10-15 minutes (58%); 20-35 minutes (31%); and 40+ minutes (11%). Patient preferred mode of outreach included telephone (93%), Facetime (5.0%), and videoconferencing (2%). In total, 798 outreach sessions were provided representing 18% of total counseling sessions offered. Conclusions: The out-patient palliative care service is able to offer psychological assessment and counseling to more than half of the patients they serviced due to the addition of 3 Master’s level counselors embedded in the clinic. Follow-up counseling for these patients can be challenged for those residing in rural areas, with limited resources and/or transportation problems, and with physical limitations that make travel difficult. Our outreach program has successfully enhanced access to services to patients who otherwise may have had limited to no follow-up psychosocial care.

Comparison of Internet and Telephone Interventions for Weight Loss Among Cancer Survivors: Randomized Controlled Trial and Feasibility Study

Background

Weight loss interventions have been successfully delivered via several modalities, but recent research has focused on more disseminable and sustainable means such as telephone- or Internet-based platforms.

Objective

The aim of this study was to compare an Internet-delivered weight loss intervention to a comparable telephone-delivered weight loss intervention.

Methods

This randomized pilot study examined the effects of 6-month telephone- and Internet-delivered social cognitive theory–based weight loss interventions among 37 cancer survivors. Measures of body composition, physical activity, diet, and physical performance were the outcomes of interest.

Results

Participants in the telephone intervention (n=13) showed greater decreases in waist circumference (–0.75 cm for telephone vs –0.09 cm for Internet, P=.03) than the Internet condition (n=24), and several other outcomes trended in the same direction. Measures of engagement (eg, number of telephone sessions completed and number of log-ins) suggest differences between groups which may account for the difference in outcomes.

Conclusions

Cancer survivors in the telephone group evidenced better health outcomes than the Internet group. Group differences may be due to higher engagement in the telephone group. Incorporating a telephone-based component into existing weight loss programs for cancer survivors may help enhance the reach of the intervention while minimizing costs. More research is needed on how to combine Internet and telephone weight loss intervention components so as to maximize engagement and outcomes.

Trial Registration

ClinicalTrials.gov NCT01311856; https://clinicaltrials.gov/ct2/show/NCT01311856 (Archived by WebCite at http://www.webcitation.org/6tKdklShY)

Randomized Trial of a Lifestyle Physical Activity Intervention for Breast Cancer Survivors: Effects on Transtheoretical Model Variables

This study examined whether a physical activity intervention affects transtheoretical model (TTM) variables that facilitate exercise adoption in breast cancer survivors. Sixty sedentary breast cancer survivors were randomized to a 6-month lifestyle physical activity intervention or standard care. TTM variables that have been shown to facilitate exercise adoption and progress through the stages of change, including self-efficacy, decisional balance, and processes of change, were measured at baseline, 3 months, and 6 months. Differences in TTM variables between groups were tested using repeated measures analysis of variance. The intervention group had significantly higher self-efficacy ( F = 9.55, p = .003) and perceived significantly fewer cons of exercise ( F = 5.416, p = .025) at 3 and 6 months compared with the standard care group. Self-liberation, counterconditioning, and reinforcement management processes of change increased significantly from baseline to 6 months in the intervention group, and self-efficacy and reinforcement management were significantly associated with improvement in stage of change. The stage-based physical activity intervention increased use of select processes of change, improved self-efficacy, decreased perceptions of the cons of exercise, and helped participants advance in stage of change. These results point to the importance of using a theory-based approach in interventions to increase physical activity in cancer survivors.

Multimodal therapy for cancer related fatigue in patients with prostate cancer receiving radiotherapy and androgen deprivation therapy

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Background: There are limited studies to evaluate treatments that target causative mechanisms of Cancer-related-fatigue (CRF) using validated tools in a defined population. The objective is to determine the feasibility, and the preliminary estimates of the effects of various combinations of standardized exercise, cognitive behavioral therapy (CBT), and methylphenidate (multimodal therapy, or MMT) on CRF as measured by AUC of Functional Assessment of Chronic Illness Therapy- Fatigue (FACIT-F) subscale scores in Pts with prostate cancer receiving radiotherapy with androgen deprivation therapy. Methods: Prostate cancer Pts with CRF scheduled to receive radiotherapy with androgen deprivation therapy were eligible. Using a double blind (patient, investigators) randomized factorial study design, eligible Pts were randomized into 1 of the 8 arms, which included all possible combinations of the interventions (exercise, CBT, and methylphenidate) and/or their corresponding placebo treatments for a duration of 8 weeks. Results: 62/69 (89%) randomized Pts were evaluable. There were no differences in the demographics and baseline fatigue between groups. The adherence rates for pills, exercise and CBT were 96.5%, 67%, and 90% respectively. The study was feasible and there was no significant difference in adverse events by groups. Table 1 shows the comparison of AUC by treatment. For Pts receiving drug compared to placebo, the median FACIT-F AUC was 2328 vs 2095. The drug effect (estimate, 95% CI) in Pts who received Exercise was 596 (68.3, 1125); CBT was 354 (-121, 830); combined Exercise and CBT was -187 (-802,427); and control Exercise, control CBT was 294 (-192,781). Conclusions: Methylphenidate containing combinations were superior to no drug combinations. Methylphenidate + Exercise provided the best signal and should proceed to large randomized control trials. Clinical trial information: NCT01410942. [Table: see text]

A Comprehensive Lifestyle Randomized Clinical Trial: Design and Initial Patient Experience

Background: Although epidemiological research demonstrates that there is an association between lifestyle factors and risk of breast cancer recurrence, progression of disease, and mortality, no comprehensive lifestyle change clinical trials have been conducted to determine if changing multiple risk factors leads to changes in biobehavioral processes and clinical outcomes in women with breast cancer. This article describes the design, feasibility, adherence to the intervention and data collection, and patient experience of a comprehensive lifestyle change clinical trial (CompLife). Methods: CompLife is a randomized, controlled trial of a multiple-behavior intervention focusing on diet, exercise, and mind-body practice along with behavioral counseling to support change. The initial exposure to the intervention takes place during the 4 to 6 weeks of radiotherapy (XRT) for women with stage III breast cancer and then across the subsequent 12 months. The intervention group will have 42 hours of in-person lifestyle counseling during XRT (7-10 hours a week) followed by up to 30 hours of counseling via video connection for the subsequent 12 months (weekly sessions for 6 months and then monthly for 6 months). The primary outcome is disease-free survival. Multiple secondary outcomes are being evaluated, including: (1) biological pathways; (2) overall survival; (3) patient-reported outcomes; (4) dietary patterns/fitness levels, anthropometrics, and body composition; and (5) economic outcomes. Qualitative data of the patient experience in the trial is collected from exit interviews, concluding remarks, direct email correspondences, and web postings from patients. Results: Fifty-five patients have been recruited and randomized to the trial to date. Accrual of eligible patients is high (72%) and dropout rates extremely low (5%). Attendance to the in-person sessions is high (95% attending greater than 80% of sessions) as well as to the 30 hours of video counseling (88% attending more than 70% of sessions). Adherence to components of the behavior change intervention is high and compliance with the intensive amount of data collection is exceptional. Qualitative data collected from the participants reveals testimonials supporting the importance of the comprehensive nature of intervention, especially the mind-body/mindfulness component and social support, and meaningful lifestyle transformations. Conclusion: Conducting a comprehensive, multicomponent, lifestyle change clinical trial for women with breast was feasible and collection of biobehavioral outcomes successful. Adherence to behavior change was high and patient experience was overwhelmingly positive.

Characteristics and outcomes of psychology referrals in palliative care

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Background: Despite high distress, a small percentage of cancer patients are referred for psychological care. MD Anderson’s interdisciplinary Palliative Care team recruited 2 clinical psychologists in 9/2013. The demand for services exceeded capacity; thus a 3rd psychologist and 3 counselors were added in 6/2015. Methods: Retrospective review of 2827 unique patients (6451 total contacts) from 9/1/2013 to 2/29/2016, including billable (psychologists) and non-billable (counselors) services. Results: Psychologists saw 1958 unique patients (4987 contacts): 1662 (85%) inpatients and 296 (15%) outpatients. Mean inpatient and outpatient session length was 37 (SD = 15) and 51 (SD = 19) minutes, respectively. 865 (44%) patients had 1 session, 507 (26%) had 2, and 585 (30%) had 3 or more. At first visit, DSM-5 diagnoses were: 1681 (86%) adjustment disorders and 226 (12%) major mood or anxiety disorders. Most first visits included assessment (N = 1666; 85%); other services were also provided: 1545 (79%) supportive expressive counseling; 300 (15%) family counseling; 114 (6%) cognitive-behavioral therapy (CBT); and 40 (2%) relaxation skills. From 6/2015-2/2016, counselors saw 869 unique patients (1464 contacts): 759 (87%) outpatients, 99 (11%) inpatients, and 11 (1%) outreach through web-based video or phone. Mean session length for outpatient, inpatient, and outreach was respectively, 37 (SD = 17), 34 (SD = 18), and 17 (SD = 8) minutes. 560 (64%) patients had 1 session, 166 (19%) had 2, and 143 (17%) had 3 or more. Services at first visit included: 994 (93%) supportive expressive counseling; 654 (61%) assessment; 139 (13%) relaxation skills; 99 (9%) CBT; and 73 (7%) acceptance and commitment therapy (ACT). Conclusions: The 128% increase in psychology services after expanding providers underscores the value placed by the Palliative Care team. With the majority receiving only 1 session, results indicate the need to improve screening for earlier referral, allowing for more sophisticated services such as CBT and ACT, which are most effective for major mood or anxiety disorders and may prevent adjustment disorders from progressing to greater clinical distress. Our new efforts at outreach could also enhance access and types of services provided.

Association between tobacco use, pain expression, and maladaptive coping among patients with advanced cancer

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Background: Cancer patients who smoke have been reported to have higher pain expression and increased risk for opioid abuse. The purpose of our study is to evaluate the association between tobacco use, symptom expression, and maladaptive coping in advanced cancer patients. Methods: We prospectively enrolled advanced cancer patients evaluated in an outpatient Supportive Care Center and collected data on patient demographics, cancer diagnosis, morphine equivalent daily dose (MEDD), cigarette smoking status using Behavioral Risk Factor Surveillance System, symptom expression as measured by Edmonton Symptom Assessment Scale, Cut down/Annoyed/Guilty/Eye opener (CAGE alcoholism questionnaire), short form Screener and Opioid Assessment for Patients with Pain (SOAP-SF) survey, and Brief COPE Questionnaire. Results: Among399 patients, 195 (49%) were never smokers, 158 (40%) former smokers, and 46 (11%) current smokers. The most common malignancies were gastrointestinal (21.1%) and breast (19.5%). Never smokers were more likely to be female (p = 0.005). Current smokers expressed significantly higher pain scores at consultation than former or never smokers [median 7 vs. 6 vs. 5, respectively (p = 0.015)], increased MEDD (median 90 vs. 60 vs. 50, p = 0.002), and more likely to screen CAGE positive (33% vs. 24% vs. 8.7%, p < 0.0001). Compared with former and never smokers, current smokers were significantly more likely to cope with substance use (p = 0.02), denial (p = 0.007), and self-blame (< 0.0001), while both current and former smokers significantly more likely to use venting (p = 0.04). In addition, current smokers compared with former and never smokers were significantly more likely screen positive (≥ 4) on the SOAP-SF survey (74% vs. 13% vs. 9.3%, p = < 0.0001) and clinicians rated patients to be at higher risk for maladaptive coping (6.5% vs 2.5% vs. 1.5%, p = 0.003). Conclusions: In advanced cancer, current and former smokers were significantly more likely to have higher pain expression, CAGE positivity, and increased MEDD at consultation. In addition, a history of current or past tobacco use in advanced cancer patients was associated with increased risk of maladaptive coping.

Changing the culture for psychosocial care: Does it need changing?

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Background: National organizations recommend routine screening for psychosocial distress in cancer patients. American College of Surgeons (ACoS) Commission on Cancer mandates screening for accreditation with requirements for timing/method/tool for screening; assessment/referral; and documentation. Methods: MD Anderson routinely screens patients for distress with policies and algorithms for the process. We sought to enhance this standard process by incorporating a dedicated psychosocial liaison in the clinic to ensure screening based on NCCN guidelines, follow-up with patients at the medical visit, and clear documentation and referral per ACoS standards. This study compared the standard process to the enhanced process (which occurred in parallel) through a 6-month retrospective chart review of Thoracic Center patients identified as distressed by either process. Results: The enhanced process utilized the Distress Thermometer (DT) cut-off > 4 resulting in optimal specificity (.77) and sensitivity (.64) compared to the standard process using > 6 (specificity = .87; sensitivity = .34). In the enhanced process (N = 71), 99% were seen during the clinic visit, compared to 13% in the standard process (N = 92) (Fishers Exact; P < .0001). In the standard process, 18% were contacted by phone, 10% were seen later while in-patient, and 33% received a phone message; for 26%, no note was dictated. In the enhanced process, there were high rates of documentation of assessments of suicide (100%), depressive symptoms (100%) and anxiety symptoms (96%) compared to the standard process where documentation occurred less often (suicide 5%; depressive symptoms 11%; anxiety symptoms 11%) (Fishers Exact; all P’s < .0001). Conclusions: Results support the institution’s recent practice change to > 4 on the DT. The enhanced process utilizing a psychosocial liaison facilitates screening at the clinic visit and can support existing mental health providers who may have competing responsibilities. Findings also suggest having standards for distress documentation. Overall, the enhanced process fully meets ACoS standards in all required areas.

Natural language use and couples' adjustment to head and neck cancer

OBJECTIVE

This multimethod prospective study examined whether emotional disclosure and coping focus as conveyed through natural language use are associated with the psychological and marital adjustment of head and neck cancer patients and their spouses.

METHOD

One-hundred twenty-three patients (85% men; age X¯ = 56.8 years, SD = 10.4) and their spouses completed surveys prior to, following, and 4 months after engaging in a videotaped discussion about cancer in the laboratory. Linguistic inquiry and word count (LIWC) software assessed counts of positive/negative emotion words and first-person singular (I-talk), second person (you-talk), and first-person plural (we-talk) pronouns. Using a grounded theory approach, discussions were also analyzed to describe how emotion words and pronouns were used and what was being discussed.

RESULTS

Emotion words were most often used to disclose thoughts/feelings or uncertainty about the future, and to express gratitude or acknowledgment to one's partner. Although patients who disclosed more negative emotion during the discussion reported more positive mood following the discussion (p < .05), no significant associations between emotion word use and patient or spouse psychological and marital adjustment were found. Patients used significantly more I-talk than spouses and spouses used significantly more you-talk than patients (ps < .01). Patients and spouses reported more positive mood following the discussion when they used more we-talk. They also reported less distress at the 4-month follow-up when their partners used more we-talk during the discussion (p < .01).

CONCLUSION

Findings suggest that emotional disclosure may be less important to one's cancer adjustment than having a partner who one sees as instrumental to the coping process. (PsycINFO Database Record

Sexual health of endometrial cancer survivors before and after a physical activity intervention: A retrospective cohort analysis

OBJECTIVE

Sexual dysfunction is common in endometrial cancer survivors (ECS). Our group previously tested a six-month exercise intervention in ECS. We performed a secondary analysis to determine intervention's impact on sexual health.

METHODS

We studied 100 post-treatment Stage I-IIIa sedentary ECS who participated in a non-controlled, single-arm, home-based exercise intervention utilizing telephone counseling, printed material, and pedometers. Quality-of-life and physical activity measures were collected at baseline and six months. Sexual function (SF) and sexual interest (SI) scores were extracted from the QLACS questionnaire.

RESULTS

Baseline SF and SI were lower in survivors with less than a four-year college degree (P<0.001). Baseline SI was higher in survivors who were married or living with a significant other (P=0.012). No significant differences in SF or SI were observed based on obesity status, race, time since diagnosis, or treatment type. Post-intervention, mean SF score improved (P=0.002), 51% of participants had improved SI, and 43% had improved SF. When controlled for age and time since diagnosis, a one-hour increase in weekly physical activity was associated with a 6.5% increased likelihood of improved SI (P=0.04). Increased physical activity was not associated with improved SF.

CONCLUSIONS

Although causation cannot be determined in this study, the correlation between receipt of an exercise intervention and improved sexual health for ECS is a novel finding. This finding suggests a role for physical activity as a strategy to improve the sexual health of ECS, which our group is examining in a larger prospective study.

Interest in Health Behavior Intervention Delivery Modalities Among Cancer Survivors: A Cross-Sectional Study

Background

Effective, broad-reaching channels are important for the delivery of health behavior interventions in order to meet the needs of the growing population of cancer survivors in the United States. New technology presents opportunities to increase the reach of health behavior change interventions and therefore their overall impact. However, evidence suggests that older adults may be slower in their adoption of these technologies than the general population. Survivors’ interest for more traditional channels of delivery (eg, clinic) versus new technology-based channels (eg, smartphones) may depend on a variety of factors, including demographics, current health status, and the behavior requiring intervention.

Objective

The aim of this study was to determine the factors that predict cancer survivors’ interest in new technology-based health behavior intervention modalities versus traditional modalities.

Methods

Surveys were mailed to 1871 survivors of breast, prostate, and colorectal cancer. Participants’ demographics, diet and physical activity behaviors, interest in health behavior interventions, and interest in intervention delivery modalities were collected. Using path analysis, we explored the relationship between four intervention modality variables (ie, clinic, telephone, computer, and smartphone) and potential predictors of modality interest.

Results

In total, 1053 respondents to the survey (56.3% response rate); 847 provided complete data for this analysis. Delivery channel interest was highest for computer-based interventions (236/847, 27.9% very/extremely interested) and lowest for smartphone–based interventions (73/847, 8.6%), with interest in clinic-based (147/847, 17.3%) and telephone-delivered (143/847, 16.9%) falling in between. Use of other technology platforms, such as Web cameras and social networking sites, was positively predictive of interest in technology-based delivery channels. Older survivors were less likely to report interest in smartphone–based diet interventions. Physical activity, fruit and vegetable consumption, weight status, and age moderated relationships between interest in targeted intervention behavior and modality.

Conclusions

This study identified several predictors of survivor interest in various health behavior intervention delivery modalities. Overall, computer-based interventions were found to be most acceptable, while smartphones were the least. Factors related to survivors’ current technology use and health status play a role in their interest for technology-based intervention versus more traditional delivery channels. Future health behavior change research in this population should consider participants’ demographic, clinical, and lifestyle characteristics when selecting a delivery channel. Furthermore, current health behavior interventions for older cancer survivors may be best delivered over the Internet. Smartphone interventions may be feasible in the future following further adoption and familiarization by this particular population.

Grasping the 'teachable moment': time since diagnosis, symptom burden and health behaviors in breast, colorectal and prostate cancer survivors

BACKGROUND

A cancer diagnosis may provide a 'teachable moment' in cancer recovery. To better understand factors influencing lifestyle choices following diagnosis, we examined associations between time since diagnosis and symptom burden with recommended dietary (e.g., five or more fruit/vegetable servings/day), physical activity (e.g., >150 active min, 3-5 times/week), and smoking behaviors (i.e., eliminate tobacco use) in cancer survivors.

METHODS

We analyzed cross-sectional survey data collected from breast (n = 528), colorectal (n = 106), and prostate (n = 419) cancer survivors following active treatment at The University of Texas MD Anderson Cancer Center. Four regression models were tested for behaviors of interest. Additionally, we assessed symptom burden as a potential moderator and/or mediator between time since diagnosis and behaviors.

RESULTS

Respondents were mostly female (55%) and non-Hispanic White (68%) with a mean age of 62.8 ± 11.4 years and mean time since diagnosis of 4.6 ± 3.1 years. In regression models, greater time since diagnosis predicted lower fruit and vegetable consumption (B = -0.05, p = 0.02) and more cigarette smoking (B = 0.06, p = 0.105). Greater symptom burden was a significant negative predictor for physical activity (B = -0.08, p < .001). We did not find evidence that symptom burden moderated or mediated the association between time since diagnosis and health behaviors.

CONCLUSION

We assessed the prevalence of recommended behaviors in the context of other challenges that survivors face, including time since diagnosis and symptom burden. Our results provide indirect evidence that proximity to a cancer diagnosis may provide a teachable moment to improve dietary and smoking behaviors and that symptom burden may impede physical activity following diagnosis. Copyright © 2015 John Wiley & Sons, Ltd.

Psychosocial interventions for patients and caregivers in the age of new communication technologies: opportunities and challenges in cancer care

Interactive health communication technologies (IHCTs) present a new opportunity and challenge for cancer control researchers who focus on couple- and family-based psychosocial interventions. In this article, the authors first present findings from a systematic review of 8 studies that used IHCTs in psychosocial interventions with cancer patients and their caregivers. Although this research area is still in its infancy, studies suggest that it is feasible to incorporate IHCTs in such interventions, that IHCTs are generally well accepted by patients and caregivers, and that the choice of technology is largely dependent on intervention target (i.e., patient, caregiver, or both) and outcomes (e.g., decision making, symptom management, lifestyle behaviors). A major research gap has been the lack of integration of Web 2.0 technologies (e.g., social media), despite the fact that social support and communication are frequently targeted components of interventions that involve cancer patients and their caregivers. Given this, the authors next present findings from a qualitative study that they conducted to describe the different needs and preferences of 13 cancer survivors and 12 caregivers with regard to social media use. Last, the authors discuss some of the opportunities and challenges of using IHCTs in psychosocial interventions for cancer patients and their caregivers and propose directions for future research.

CHESS improves cancer caregivers' burden and mood: results of an eHealth RCT

OBJECTIVE

Informal caregivers (family and friends) of people with cancer are often unprepared for their caregiving role, leading to increased burden or distress. Comprehensive Health Enhancement Support System (CHESS) is a Web-based lung cancer information, communication, and coaching system for caregivers. This randomized trial reports the impact on caregiver burden, disruptiveness, and mood of providing caregivers access to CHESS versus the Internet with a list of recommended lung cancer websites.

METHODS

A total of 285 informal caregivers of patients with advanced nonsmall cell lung cancer were randomly assigned to a comparison group that received Internet or a treatment group that received Internet and CHESS. Caregivers were provided a computer and Internet service if needed. Written surveys were completed at pretest and during the intervention period bimonthly for up to 24 months. Analyses of covariance (ANCOVAs) compared the intervention's effect on caregivers' disruptiveness and burden (CQOLI-C), and negative mood (combined Anxiety, Depression, and Anger scales of the POMS) at 6 months, controlling for blocking variables (site, caregiver's race, and relationship to patient) and the given outcome at pretest.

RESULTS

Caregivers randomized to CHESS reported lower burden, t(84) = 2.36, p = .021, d = .39, and negative mood, t(86) = 2.82, p = .006, d = .44, than those in the Internet group. The effect on disruptiveness was not significant.

CONCLUSIONS

Although caring for someone with a terminal illness will always exact a toll on caregivers, eHealth interventions like CHESS may improve caregivers' understanding and coping skills and, as a result, ease their burden and mood.

The role of blame in the psychosocial adjustment of couples coping with lung cancer

BACKGROUND

Lung cancer patients and their spouses may engage in blame attributions regarding the cancer cause, which may adversely affect their psychological adjustment.

PURPOSE

The aim of this study was to examine whether dyadic adjustment and network support moderate the association between blame and distress in couples affected by lung cancer.

METHODS

Patients and their spouses completed questionnaires within 1 month of treatment initiation (baseline) and at 6-month follow-up.

RESULTS

Multilevel modeling of data from 158 couples revealed that, at baseline, dyadic adjustment moderated the association between blame and distress for patients but not spouses (p < 0.05). Controlling for baseline distress, baseline blame predicted later distress (p < 0.05) for both patients and spouses regardless of dyadic adjustment. Network support moderated this association at follow-up.

CONCLUSION

For patients experiencing low dyadic adjustment, blame was associated with increased distress. Not initially but later, network support may protect against low levels but not high levels of blame in patients and spouses.

Longitudinal associations between caregiver burden and patient and spouse distress in couples coping with lung cancer

PURPOSE

While spouses play a vital role in the care of cancer patients, caregiving exerts a physical and psychological toll. Caregiving burden may not only compromise spouses' quality of life but also the quality of care and support they are able to provide. Consequently, spousal caregiving burden may also negatively impact patients' psychological adjustment. However, the effect of caregiving burden on patients' psychological distress is unknown. Thus, this 6-month longitudinal study examined the associations between caregiving burden and distress in both lung cancer patients and their spouses.

METHODS

Patients and their spouses individually completed questionnaires within 1 month of treatment initiation (baseline) and at 3- and 6-month follow-up. Distress was measured with the Brief Symptom Inventory and caregiving burden with the Caregiver Reaction Assessment.

RESULTS

Multilevel modeling of data from 158 couples revealed that baseline spouses' reports of caregiving-related health problems were significantly associated with 3-month (p < 0.001) and 6-month (p = 0.01) follow-up distress in both patients and spouses even when controlling for baseline distress and dyadic adjustment. Furthermore, there was evidence that baseline spouses' reports of schedule disruption (p = 0.05) predicted 3-month patients' distress and baseline spouses' reports of financial strain (p < 0.05) and lack of support (p < 0.10) predicted their own distress at 6 month.

CONCLUSION

Caregiving burden is problematic for both patients and spouses. Couples in which spouses report caregiving-related health problems may be at particular high risk of long-term elevated distress. Targets of future couple-focused interventions such as self-care and use of social support are discussed.

Social-cognitive theory predictors of exercise behavior in endometrial cancer survivors

OBJECTIVE

This study evaluated whether social-cognitive theory (SCT) variables, as measured by questionnaire and ecological momentary assessment (EMA), predicted exercise in endometrial cancer survivors.

METHOD

One hundred posttreatment endometrial cancer survivors received a 6-month home-based exercise intervention. EMAs were conducted by using hand-held computers for 10- to 12-day periods every 2 months. Participants rated morning self-efficacy and positive and negative outcome expectations by using the computer, recorded exercise information in real time and at night, and wore accelerometers. At the midpoint of each assessment period, participants completed SCT questionnaires. Using linear mixed-effects models, the authors tested whether morning SCT variables predicted minutes of exercise that day (Question 1) and whether exercise minutes at time point Tj could be predicted by questionnaire measures of SCT variables from time point Tj-1 (Question 2).

RESULTS

Morning self-efficacy significantly predicted that day's exercise minutes (p < .0001). Morning positive outcome expectations were also associated with exercise minutes (p = .0003), but the relationship was attenuated when self-efficacy was included in the model (p = .4032). Morning negative outcome expectations were not associated with exercise minutes. Of the questionnaire measures of SCT variables, only exercise self-efficacy predicted exercise at the next time point (p = .003).

CONCLUSIONS

The consistency of the relationship between self-efficacy and exercise minutes over short (same day) and longer (Tj to Tj-1) time periods provides support for a causal relationship. The strength of the relationship between morning self-efficacy and exercise minutes suggest that real-time interventions that target daily variation in self-efficacy may benefit endometrial cancer survivors' exercise adherence.

An eHealth system supporting palliative care for patients with non-small cell lung cancer: a randomized trial

BACKGROUND

In this study, the authors examined the effectiveness of an online support system (Comprehensive Health Enhancement Support System [CHESS]) versus the Internet in relieving physical symptom distress in patients with non-small cell lung cancer (NSCLC).

METHODS

In total, 285 informal caregiver-patient dyads were assigned randomly to receive, for up to 25 months, standard care plus training on and access to either use of the Internet and a list of Internet sites about lung cancer (the Internet arm) or CHESS (the CHESS arm). Caregivers agreed to use CHESS or the Internet and to complete bimonthly surveys; for patients, these tasks were optional. The primary endpoint-patient symptom distress-was measured by caregiver reports using a modified Edmonton Symptom Assessment Scale.

RESULTS

Caregivers in the CHESS arm consistently reported lower patient physical symptom distress than caregivers in the Internet arm. Significant differences were observed at 4 months (P = .031; Cohen d = .42) and at 6 months (P = .004; d = .61). Similar but marginally significant effects were observed at 2 months (P = .051; d = .39) and at 8 months (P = .061; d = .43). Exploratory analyses indicated that survival curves did not differ significantly between the arms (log-rank P = .172), although a survival difference in an exploratory subgroup analysis suggested an avenue for further study.

CONCLUSIONS

The current results indicated that an online support system may reduce patient symptom distress. The effect on survival bears further investigation.

Survivors at higher risk for adverse late outcomes due to psychosocial and behavioral risk factors

Cancer survivors face significant morbidity and mortality associated with their disease and treatment regimens, some of which can be improved through modifying behavioral and psychosocial risk factors. This article examines risk factors for adverse late effects that contribute to morbidity and mortality in cancer survivors, provides a literature review on interventions to modify these risks factors, and summarizes the national recommendations and associated current practices for identifying and managing these risk factors. Finally, future directions for research and clinical practice are discussed.

Feasibility of an expressive-disclosure group intervention for post-treatment colorectal cancer patients: results of the Healthy Expressions study

BACKGROUND

Adjusting to cancer requires effective cognitive and emotional processing. Written and verbal disclosure facilitate processing and have been studied independently in cancer survivors. Combined written and verbal expression may be more effective than either alone, particularly for patients with difficult to discuss or embarrassing side effects. Thus, the authors developed and tested the efficacy of a 12-session combined written and verbal expression group program for psychologically distressed colorectal cancer (CRC) patients.

METHODS

Forty post-treatment patients with CRC (stages I-III) identified as psychologically distressed using the Brief Symptom Inventory (BSI) were randomized to an intervention group (Healthy Expressions; n = 25) or standard care (control group; n = 15). Assessments were completed at baseline, Month 2, and Month 4 (postintervention). Primary outcomes were psychological functioning and quality of life (QOL).

RESULTS

Most participants were women (63%), white (63%), and non-Hispanic (75%). The Healthy Expressions group demonstrated significantly greater changes in distress compared with the control group at Month 2 on the BSI Global Severity Index (GSI) and the Centers for Epidemiologic Studies Depression scale (CES-D) scores (P < .05 for each); differences in the European Organization for Research and Treatment of Cancer (EORTC) global QOL scores approached significance (P = .063). The BSI GSI and Positive Symptom Total, CES-D, and EORTC emotional functioning subscale scores were all significant at Month 4 (P < .05 for each).

CONCLUSIONS

The Healthy Expressions program improved psychological functioning in CRC patients who reported experiencing distress. Findings demonstrate the program's feasibility and provide strong support for conducting a larger randomized trial.

Grief in healthcare chaplains: an investigation of the presence of disenfranchised grief

We examined how chaplains respond to grief and determined the prevalence of disenfranchised grief (i.e., grief that is not or cannot be acknowledged or supported by society) in healthcare chaplains. We conducted an online survey of members of the Association of Professional Chaplains. Of 3131 potential participants, 577 (18%) responded to the survey. In response to grief in the workplace, chaplains stated they would have low energy (78%), feel sad or moody (63%), feel like they had no time for themselves (44%), go through the motions (41%), and distance themselves from others (31%). As an indicator of disenfranchised grief, 21% of chaplains felt that their grief was not supported and affirmed in the workplace and 63% listed circumstances of death about which they felt very uncomfortable hearing or talking about. The results suggest that grief, and disenfranchised grief in particular, may be an important concern to address in healthcare chaplaincy.

Design of the Steps to Health Study of Physical Activity in Survivors of Endometrial Cancer: Testing a Social Cognitive Theory Model

Physical activity has been shown to benefit cancer survivors' physical functioning, emotional well-being, and symptoms. Physical activity may be of particular benefit to survivors of endometrial cancer because they are more likely to be obese and sedentary than the general population, as these are risk factors for the disease, and thus experience a number of related co-morbid health problems. However, there is little research systematically studying mechanisms of physical activity adherence in cancer survivor populations. This paper describes the design of the Steps to Health study, which applies a Social Cognitive Theory-based model of endometrial cancer survivors' adoption and maintenance of exercise in the context of an intervention to increase walking or other moderate intensity cardiovascular activity. In Steps to Health we will test the influence of self-efficacy and outcome expectations on adherence to exercise recommendations, as well as studying the determinants of self-efficacy. Endometrial cancer survivors who are at least 6 months post-treatment are provided with an intervention involving print materials and telephone counseling, and complete assessments of fitness, activity, self-efficacy and outcome expectations, and determinants of self-efficacy every two months for a six month period. In addition to testing an innovative model, the Steps to Health study employs multiple assessment methods, including ecological momentary assessment, implicit tests of cognitive variables, and ambulatory monitoring of physical activity. The study results can be used to develop more effective interventions for increasing physical activity in sedentary cancer survivors by taking into account the full complement of sources of self-efficacy information and outcome expectations.

Mediating processes of two communication interventions for breast cancer patients

OBJECTIVE

Test whether three mediating processes of Self-Determination Theory are involved in intervention effects on quality of life for breast cancer patients.

METHODS

A randomized clinical trial recruited newly diagnosed breast cancer patients for 6 months of (1) Internet training and access, (2) access to an integrated eHealth system for breast cancer (CHESS), (3) a series of phone conversations with a Human Cancer Information Mentor, or (4) both (2) and (3).

RESULTS

This paper reports results after the initial 6 weeks of intervention, at which point patients in the combined condition had higher quality of life scores than those in the other three conditions. All three Self-Determination Theory constructs (autonomy, competence, and relatedness) mediated that effect as hypothesized. In addition, the single-intervention groups were superior to the Internet-only group on relatedness, though perhaps this was too soon for that to carry through to quality of life as well.

CONCLUSIONS

The SDT constructs do mediate these interventions' effects.

PRACTICE IMPLICATIONS

Intervention design can profitably focus on enhancing autonomy, competence and relatedness.

Dyadic coping in metastatic breast cancer

OBJECTIVE

Couples facing metastatic breast cancer (MBC) must learn to cope with stressors that can affect both partners' quality of life as well as the quality of their relationship. Common dyadic coping involves taking a "we" approach, whereby partners work together to maintain their relationship while jointly managing their shared stress. This study prospectively evaluated whether common dyadic coping was associated with less cancer-related distress and greater dyadic adjustment for female MBC patients and their male partners.

DESIGN

Couples (N = 191) completed surveys at the start of treatment for MBC (baseline), and 3 and 6 months later.

MAIN OUTCOME MEASURES

Cancer-related distress was assessed with the Impact of Events Scale; dyadic adjustment was assessed using the short-form of the Dyadic Adjustment Scale.

RESULTS

Multilevel models using the couple as the unit of analysis showed that the effects of common positive dyadic coping on cancer-related distress significantly differed for patients and their partners. Whereas partners experienced slightly lower levels of distress, patients experienced slightly higher levels of distress. Although patients and partners who used more common negative dyadic coping experienced significantly greater distress at all times, the association was stronger for patients. Finally, using more common positive dyadic coping and less common negative dyadic coping was mutually beneficial for patients and partners in terms of greater dyadic adjustment.

CONCLUSION

Our findings underscore the importance of couples working together to manage the stress associated with MBC. Future research may benefit from greater focus on the interactions between patients and their partners to address ways that couples can adaptively cope together.

Depression, anxiety, and quality of life in patients with epithelial ovarian cancer

OBJECTIVE

The aims of this study were to evaluate psychological distress and quality of life (QOL) in patients with epithelial ovarian cancer (EOC) and to examine the relationship between these problems and health and demographic variables.

METHODS

Of 344 consecutive patients identified, 246 completed questionnaires. Four dimensions of QOL were assessed including physical, functional, emotional, and social/family well-being, as well as concerns specific to ovarian cancer patients. Depression was measured with the Center for Epidemiologic Studies-Depression (CES-D) scale and anxiety was measured by the State Anxiety Subscale of the Spielberger State-Trait Anxiety Inventory. Performance status was evaluated by the Zubrod score.

RESULTS

Sixty-five patients (26%) had early stage disease; 181 (74%) had advanced disease. One hundred twenty-one patients (49%) were under active treatment, while 124 (51%) were seen for posttherapy surveillance. Forty-eight (21%) met CES-D cutoff criteria for a clinical evaluation for depression, and 29% scored above the 75th percentile for anxiety. Performance status was related to depression, anxiety, and QOL problems, except in the domain of social well-being.

CONCLUSIONS

Clinically significant depression and anxiety may be more prevalent in patients with EOC than previously reported. Future studies of screening for and treating psychological distress are being designed to improve QOL in these women.

Aerobic fitness and leisure physical activity as moderators of the stress-illness relation

Exercise as a moderator of the stress-illness relation was examined by exploring leisure physical activity and aerobic fitness as potential "buffers" of the association between minor stress on physical and psychological symptoms in a sample of 135 college students. The goal was to gather information regarding the mechanisms by which exercise exhibits its buffering effects. Researchers have examined both physical activity and physical fitness in an attempt to demonstrate this effect; however, whether both of these components are necessary to achieve the protective effects against stress is unknown. This study examined engaging in leisure physical activity and having high aerobic fitness to determine if both were necessary for the stress-buffering effects or if one factor was more important than the other. Findings suggested a buffering effect for leisure physical activity against physical symptoms and anxiety associated with minor stress. This effect was not found with depression. Additionally, there was no moderating effect for aerobic fitness on physical or psychological symptoms. Collectively, the data suggested that participation in leisure physical activity as opposed to level of aerobic fitness is important to the stress-buffering effect of exercise. Implications for exercise prescription are discussed.

Prevalence of high-risk behaviors and obesity among low-income patients attending primary care clinics in Louisiana

This study examined the prevalence of the most prominent high-risk behaviors that contribute to mortality in the United States (i.e., sedentary lifestyle, cigarette smoking, and high dietary fat intake) and obesity among low-income patients attending primary care clinics in Louisiana. The sample consisted of 1,132 patients attending primary care clinics that were randomly selected and administered a demographic questionnaire, the 1994 Behavioral Risk Factor Surveillance System, and the Eating Patterns Questionnaire. Participants consisted predominantly of African-American (67.7%), uninsured (73.3%), low-income, middle-aged females. Prevalence of high-risk behaviors included sedentary lifestyle (47.1%), cigarette smoking (26.2%), and high dietary fat intake (61.3%). Prevalence of obesity was 63.5%. In conclusion, low-income patients attending primary care clinics in Louisiana display a high frequency of important high-risk behaviors that contribute to mortality in this country. Obesity is also extremely prevalent in this population. Clinical implications and directions for future studies are discussed.

First year after head and neck cancer: quality of life

PURPOSE

Treatment regimens for head and neck cancer patients profoundly affect several quality-of-life domains. Rehabilitative needs have been identified through cross-sectional analyses; however, few studies have prospectively assessed quality of life, included assessment of psychosocial variables, and identified predictors of long-term follow-up.

PARTICIPANTS AND METHODS

The present study addresses these limitations through a prospective assessment of 105 patients with a newly diagnosed first primary squamous cell carcinoma of the oral cavity, pharynx, or larynx. Participants were enrolled onto a larger randomized controlled trial comparing a provider-delivered smoking cessation intervention with a usual-care-advice control condition. Participants completed a battery of self-report measures after diagnosis and before treatment and additional quality-of-life instruments at 1 and 12 months after initial smoking cessation advice.

RESULTS

Participants displayed improvements at 12 months in functional status (P = .006) and in the areas of eating, diet, and speech; however, the latter three represent areas of continued dysfunction, and the changes were not statistically significant. Despite these improvements, patients reported a decline in certain quality-of-life domains, including marital (P = .002) and sexual functioning (P = .017), as well as an increase in alcohol use (P < .001). Predictors of quality of life at 12 months included treatment type, the Vigor subscale of the Profile of Mood States instrument, and quality-of-life scores obtained 1 month after initial smoking cessation advice.

CONCLUSION

Results reinforce the need for rehabilitation management through the integration of psychologic and behavioral interventions in medical follow-up.

Predicting smoking stage of change among a sample of low socioeconomic status, primary care outpatients: replication and extension using decisional balance and self-efficacy theories

An expanding body of research using the transtheoretical model with both self-change and treatment programs suggests that differences in readiness for smoking cessation are important predictors of successful abstinence. Understanding the cognitive processes underlying these differences may hold tremendous potential for improving the efficacy and efficiency of intervention strategies. Decisional balance theory and self-efficacy theory have been used to help explore how and why people move through the stages of change, but they have been validated almost exclusively with middle-class, educated White samples This study sought to investigate whether these theories relate in each other in the same manner among low socioeconomic status (SES) primary care outpatients. Results indicated that variables from decisional balance theory (pros, cons) and self-efficacy theory successfully differentiated stage membership and yielded results consistent with the extant literature. Self-efficacy demonstrated the most powerful association with stage membership, whereas pros, cons, and temptations exhibited varying degrees of association. Clinical implications and special considerations when conducting research and implementing interventions with low-SES smokers are discussed.

Pittsburgh pneumonia agent: direct isolation from human lung tissue

Pittsburgh pneumonia agent (PPA) was recently cultivated from infected egg yold on charcoal yeast extract agar. PPA has now been isolated both from infected egg yolk and human lung tissue on charcoal yeast extract agar and on a new medium, buffered charcoal yeast extract agar. PPA resembles Legionella pneumophila and other Legionella-like organisms in requirements for growth and composition of fatty acids. It differs in genetic relatedness, antigenic composition, and colonial morphology and has distinctive characteristics that allow it to be identified. The name Legionella pittsburgensis species nova is proposed for this organism.