Quality of Life and Prognostic Awareness in Caregivers of Patients Receiving Chimeric Antigen Receptor T Cell Therapy

Caregivers of patients undergoing chimeric antigen receptor T cell therapy (CAR-T) play a critical role during treatment, yet their experience remains largely unaddressed. We aimed to longitudinally describe quality of life (QoL) and psychological distress, as well as prognostic awareness, in caregivers and explore the association of prognosis awareness with baseline psychological distress. We conducted a longitudinal study of caregivers of patients undergoing CAR-T and examined QoL (CAReGiverOncology QoL questionnaire) and psychological distress (Hospital Anxiety and Depression Scale) prior to CAR-T (baseline) and at days 7, 30, 90, and 180 post-CAR-T. At baseline, caregivers and patients completed the Prognostic Awareness Impact Scale, which examines cognitive understanding of prognosis, emotional coping with prognosis, and adaptive response (ie, capacity to use prognostic awareness to inform life decisions). We enrolled 58% (69 of 120) of eligible caregivers. Caregivers reported QoL impairments that did not change over time (B = 0.09; P = .452). The rates of clinically significant depression and anxiety symptoms were 47.7% and 20.0%, respectively, at baseline, and 39.1% and 17.4% at 180 days. One-third (32%) of the caregivers and patients reported that their oncologist said the cancer is curable. Caregivers' greater emotional coping with prognosis was associated with fewer symptoms of anxiety (B = -.17; P < .001) and depression (B = -.02; P < .001). Cognitive understanding of prognosis and adaptive response were not associated with psychological distress. Caregivers reported QoL impairments throughout the study period. A substantial proportion of caregivers experienced psychological distress and reported misperceptions about the prognosis, highlighting the need for supportive care interventions.

Communication About Chimeric Antigen Receptor T-Cell (CAR-T) Therapy

Chimeric Antigen Receptor T-cell (CAR-T) therapy has revolutionized the treatment of patients with hematologic malignancies, yet treatment may coincide with the potential for life-threatening toxicities. Currently, no studies have investigated how oncologists communicate with patients about CAR-T therapy or what patients and their caregivers want to know prior to consenting for CAR-T therapy. This study characterizes the content of oncologist communication with patients and caregivers about the risks and benefits of CAR-T therapy and explore the information preferences of patients and their caregivers about CAR-T therapy. We conducted a multimethod study of 20 patients with hematologic malignancies referred for CAR-T therapy at the Massachusetts General Hospital and 10 caregivers. We audio recorded the initial outpatient visit with the oncologist to review and sign consent for CAR-T therapy. We subsequently surveyed patients and caregivers about information gaps that remained after consent. We then interviewed patients and caregiver about their perceptions of oncologist communication and information preferences after the consent visit, 1 month, and 3 months post-CAR-T therapy treatment. Qualitative data analysis was conducted using the framework approach. Six major themes regarding communication about CAR-T therapy were identified: (1) oncologists create a narrative of power and innovation about CAR-T therapy, (2) oncologists set clear expectations regarding CAR-T therapy, (3) oncologists preferentially discuss positive treatment outcomes and less frequently address treatment failures or uncertainties, (4) oncologists couple their discussion about risks of CAR-T therapy with assurances about risk mitigation strategies, (5) oncologists engage in empathetic communication throughout the consent visit, (6) patients and caregivers vary in their preferences regarding communication about CAR-T therapy but largely favor a positive discourse during the consent visit and (7) patients who completed CAR-T therapy and their caregivers report significant knowledge gaps during and after treatment. Overall, patients and caregivers felt well informed about CAR T-therapy yet identified communication gaps regarding, advanced care planning, treatment failure and treatment toxicities. A predominantly positive discourse between patients, caregivers, and oncologists around CAR-T therapy leaves patients and caregivers with significant knowledge gaps about negative outcomes. Further research is needed to help oncologists communicate about treatment uncertainties and help patients and their caregivers prepare for negative outcomes of CAR-T therapy.

A Positive Psychology Intervention for Caregivers of Hematopoietic Stem Cell Transplantation Survivors (PATH-C): Initial Testing and Single-Arm Pilot Trial

Caregivers of patients with hematologic malignancies undergoing allogeneic hematopoietic stem cell transplantation (HSCT) play a crucial role in supporting their loved ones through physical, emotional, and practical challenges. This role has been associated with high levels of psychological distress and low levels of positive psychological well-being (PPWB). Positive psychology interventions for caregivers in other disease groups (eg, breast cancer) have been associated with improved outcomes. However, positive psychology interventions that specifically address HSCT caregivers' psychological needs are currently lacking. The goal of this single-arm open-pilot trial was to determine the feasibility and acceptability of the Positive Affect in the Transplantation of Hematopoietic Stem Cells (PATH) intervention for HSCT Caregivers to identify caregiver preferences to tailor PATH for HSCT caregivers. Adult caregivers of HSCT recipients were eligible for PATH during the HSCT recipient's first 100 d post-transplant. We defined, a priori, feasibility as >60% of participants who start the intervention completing ≥6/9 intervention sessions and acceptability as weekly ratings of ease and utility of the PP exercises ≥7/10 on a 10-point Likert Scale (0 = very difficult/not helpful; 10 = very easy/very helpful). We conducted semistructured qualitative exit interviews (n = 15) to explore HSCT caregivers' perception of PATH's content, benefits of PATH, as well as facilitators and barriers to engaging with the intervention. Transcribed interviews were analyzed using framework-guided rapid analysis by 2 coders. The intervention was feasible with 83% (15/18) of caregivers who started the intervention completing ≥6/9 intervention sessions. Among caregivers who completed ≥6/9 intervention sessions, ratings of ease (mean = 8.1; 95% CI: 7.4, 8.7) and utility (mean = 8.3; 95% CI: 7.8, 8.9) also exceeded our a priori threshold of ≥7/10. Caregivers identified benefits of PATH, including identifying and responding to emotions, dedicating time to self-care, and cultivating important relationships. Sociodemographic factors (eg, being retired) and the manualized structure of PATH were cited as facilitators to intervention engagement. Barriers to PATH engagement included lack of time and competing caregiving responsibilities. Caregivers preferred remote intervention delivery within the first 100 d post HSCT. This is the first study to show a 9-wk, phone-delivered positive psychology intervention is feasible in caregivers of allogeneic HSCT recipients. Our findings also underscore the specific preferences of this population for positive psychology interventions. Larger studies are warranted to establish the efficacy of these interventions in addressing persistent unmet psychological needs for HSCT caregivers.

Coping in patients with hematologic malignancies undergoing hematopoietic cell transplantation

ABSTRACT

Patients undergoing hematopoietic cell transplantation (HCT) must cope with physical and psychological symptoms. Yet, studies examining pre-HCT coping are limited. We aimed to characterize pre-HCT coping, evaluate the association of coping with baseline quality of life (QOL) and psychological distress, and identify sociodemographic factors associated with pre-HCT coping. We conducted a cross-sectional analysis of baseline data from a multisite randomized supportive care intervention trial among patients with hematologic malignancies undergoing allogeneic or autologous HCT. We assessed patient-reported QOL, psychological distress, and coping within 72 hours of admission for HCT. We used the median split method to dichotomize coping and multivariate regression analyses to characterize the association of coping with psychological distress and QOL. Of patients awaiting HCT (n = 360; mean age, 55.4 years; 49.7% autologous), 43.5% were high users of approach-oriented coping, whereas 31.3% were high users of avoidant coping. Patients reported high use of emotional support (60.9%), acceptance (51.2%), self-blame (33%), and denial (31.3%). Older age (≥65 years) was associated with less frequent use of avoidant coping (odds ratio, 0.5; P = .01). Approach-oriented coping was associated with better pre-HCT QOL (Beta(B) = 6.7; P = .001), and lower depression (B = -1.1; P = .001) and anxiety (B = -0.9; P = .02) symptoms. Avoidant coping was associated with worse pre-HCT QOL (B = -13.3; P < .001) and symptoms of depression (B = 1.9; P < .001), anxiety (B = 3.1; P < .001), and posttraumatic stress disorder (B = 8.1; P < .001). Pre-HCT coping is strongly associated with psychological distress and QOL. These data support the need for interventions to address coping during HCT hospitalization. This clinical trial was registered at www.clinicaltrials.gov as #NCT03641378.

Barriers, Facilitators, and Preferences for Mental Health Services Among Patients With Systemic Lupus Erythematosus: A Qualitative Study

OBJECTIVE

Although patients with systemic lupus erythematosus (SLE) experience high levels of depression and anxiety disorders, evidence concerning patient perceptions of facilitators and barriers to effective uptake of mental health services (eg, referral to therapists and psychiatrists, psychoeducational interventions, or support groups) is limited.

METHODS

We conducted semistructured qualitative interviews with 15 adults with SLE to explore patient experiences and perceptions of mental health services to identify facilitators and barriers to accessing mental health care among patients with SLE. Qualitative interviews were conducted via telephone and audio recorded for transcription and directed content analysis using NVivo software by two coders.

RESULTS

The median age of the 15 participants was 48 years, 87% were female, 33% identified as Black or African American, and 33% identified as Hispanic or Latino. Qualitative themes were organized into three domains: barriers, facilitators, and preferences for mental health services. Barriers to the use of mental health services include mental health stigma, sociodemographic factors, lack of autonomy, and time commitment. Facilitators to the use of mental health services included strong relationships with their rheumatologists and mental health care clinician experience with patients with SLE. Preferences for mental health services included education-based formats, mental health providers who work with patients with SLE, peer group formats, demographically and disease-matched psychological resources, and an emphasis on non-disease-related activities.

CONCLUSION

In the setting of persistent unmet psychosocial needs of patients living with SLE, data from this qualitative study will inform the development and refinement of mental health interventions that bolster psychological wellbeing in the SLE population.

Pilot Randomized Controlled Trial of an Educational Video for CAR T-Cell Therapy Recipients

BACKGROUND

CAR T-cell therapy has transformed the treatment of hematologic malignancies, but it is complex and challenging to convey to patients. Educational video interventions are efficacious for improving patient knowledge about cancer therapeutics and informing their care preferences, yet no educational videos have been evaluated in CAR T-cell therapy.

METHODS

We conducted a randomized controlled trial comparing an educational video versus usual care in adults (age ≥18 years) with hematologic malignancies receiving CAR T-cell therapy at Massachusetts General Hospital. Intervention participants watched a 13-minute video depicting how CAR T-cell therapy works, logistics, toxicities, prognosis, recovery, and approaches for dealing with prognostic uncertainty. The primary outcome was feasibility (≥60% enrollment rate). Secondary outcomes included acceptability (≥80% reporting comfort with the video), patients' knowledge about CAR T-cell therapy (10-item test), and self-efficacy (Communication and Attitudinal Self-Efficacy Scale-Cancer), decision satisfaction (Decision Conflict Scale), psychological distress (Hospital Anxiety and Depression Scale), and preference for CAR T-cell therapy.

RESULTS

We enrolled 79% (80/101) of eligible patients. Of that group, 91% (30/33) reported being very or somewhat comfortable watching the video, and 94% (31/33) would definitely or probably recommend the video. At 1 month, participants in the video arm reported higher self-efficacy (mean difference [MD], 9.2 [95% CI, -4.0 to 22.3]; Cohen's d, 0.32), decision satisfaction (MD, 2.5 [95% CI, 0.7-4.2]; Cohen's d, 0.67), and lower anxiety (MD, -0.8 [95% CI, -2.5 to 0.7]; Cohen's d, 0.26) compared with participants in the usual care arm. At 1 week, both arms reported high preferences for CAR T-cell therapy (video arm, 94% [33/35]; usual care, 84% [27/32]).

CONCLUSIONS

We found that an educational video for patients receiving CAR T-cell therapy was feasible and acceptable. The educational video demonstrated promising preliminary effects on patient self-efficacy and decision satisfaction and warrants further study.

Annual Meeting Content Analysis: Leveraging Annual Meetings to Promote Diversity, Equity, Inclusion, and Belonging in the Academy of Consultation-Liaison Psychiatry

BACKGROUND

There is an increasing need to promote diversity, equity, and inclusion (DEI) in all aspects of academic medicine, including through continuing medical education. Although professional medical organizations' annual meetings play an instrumental role in continuing medical education for physicians, there are no studies describing DEI content in the annual meeting programming of professional medical organizations, including the Academy of Consultation-Liaison Psychiatry (ACLP), the primary professional organization for consultation-liaison psychiatrists.

OBJECTIVE

To examine the ACLP annual meeting titles using Content Analysis.

METHODS

We examined the publicly available ACLP annual meeting content titles on the ACLP website from 2010 to 2021. National DEI leaders from ACLP's DEI subcommittee iteratively generated keywords that covered a broad scope of DEI-related themes. Each annual meeting's content was independently coded by 2 members of the DEI subcommittee with discrepancies adjudicated by 2 additional members. Descriptive statistics were used to characterize the content of the annual meeting.

RESULTS

Of the 2615 annual meeting titles from 2010 to 2021 that were analyzed, 2531 were not coded to have DEI themes. Three percent (n = 84) of titles were coded to have a DEI theme as follows: Culture/diversity (n = 20, 24%), bias/disparities (n = 17, 20%), race/racism (n = 17, 20%), social justice (n = 12, 14%), gender/sexism (n = 10, 12%), and LGBTQ+ (n = 8, 10%). The frequency of DEI titles each year ranged from 1% (2010, 2018) to 17% (2021) with an increase in DEI content in 2021 (n = 24, 17%).

CONCLUSIONS

Although professional medical organizations like the ACLP are poised to leverage their continuing medical education platforms embedded in annual meeting programming to train consultation-liaison psychiatrists on DEI topics, our findings suggest more work is needed to develop and promote DEI-focused educational programming for their annual meetings.

Associations between Health-Related Use of Social Media and Positive Lifestyle Behaviors: Findings from a Representative Sample of US Adult Smokers

Background: Cigarette smokers have elevated cardiovascular risk factors, which contributes significantly to mortality. Although social media is a potential avenue to deliver smoking interventions, its role in health promotion among smokers remains relatively unexplored.Objective: To examine the uptake and impact of health-related social media use in cigarette smokers.Methods: Using data from the 2017-2020 Health Information National Trends Survey, we evaluated differences in health-related social media use between smokers and nonsmokers. Multivariable logistic regression was performed to examine the association between social media use and positive health behaviors.Results: We included 1863 current smokers and 13,560 nonsmokers; Most participants were women (51.0%), White (64.6%), and 49.2% were aged ≥50 years. Smokers who used ≥1 social media site for health-related purposes in the past year were significantly more likely to meet the guideline recommendations for: (i) weekly physical activity (AOR 2.00, 95% CI 1.23-3.24), (ii) daily vegetable intake (AOR 2.48, 95% CI 1.10-5.59), and (iii) weekly strength training (AOR 1.80, 95% CI 1.10-2.94). However, the odds of reporting intentions to quit smoking (AOR 1.81, 95% CI 0.98-3.34) and attempts at smoking cessation (AOR 1.68, 95% CI 0.90-3.12) did not differ by health-related social media use.Conclusion: Smokers use social media for health-related purposes at comparable rates to nonsmokers. While our findings indicate that these platforms present a novel opportunity for health promotion among smokers, future research exploring the utility of social media in smoking cessation is crucial.

Gratitude, optimism, and satisfaction with life and patient-reported outcomes in patients undergoing hematopoietic stem cell transplantation

OBJECTIVE

Associations between positive psychological well-being (PPWB) and patient-reported outcomes (PROs, e.g., quality of life [QOL]) have yet to be studied extensively in patients with hematologic malignancies who are allogeneic hematopoietic stem cell transplant (HSCT) survivors, despite substantial evidence that PPWB impacts PROs of other medical populations.

METHODS

We conducted a secondary analysis of cross-sectional data examining the association of PPWB and PROs at day 100 post-transplant among 158 allogeneic HSCT recipients. Optimism, gratitude, life satisfaction, and PROs (i.e., QOL, anxiety, depression, and PTSD symptoms) were assessed using the Life Orientation Test-Revised, Gratitude Questionnaire, Satisfaction with Life Scale, Functional Assessment of Cancer Therapy-Bone Marrow Transplant, Hospital Anxiety and Depression Scale, and Post-Traumatic Stress Disorder (PTSD) Checklist-Civilian Version, respectively. We used linear and multivariate regressions for all analyses and controlled for patient factors.

RESULTS

Optimism was associated with better QOL (β = 1.46; p < 0.001) and lower levels of anxiety (β = -0.28; p < 0.001), depression (β = -0.31; p < 0.001), and PTSD (β = -0.58; p < 0.001). Gratitude was associated with better QOL (β = 1.11; p < 0.001) and lower levels of anxiety (β = -0.21; p = 0.001), depression (β = -0.14; p = 0.021), and PTSD (β = -0.32; p = 0.032). Finally, satisfaction with life was associated with better QOL (β = 1.26; p < 0.001) and lower levels of anxiety (β = -0.18; p < 0.001), depression (β = -0.21; p < 0.001), and PTSD (β = -0.49; p < 0.001).

CONCLUSION

Optimism, gratitude, and satisfaction with life were all associated with better QOL and lower levels of psychological distress in allogeneic HSCT survivors. These data support studies to harness PPWB as a therapeutic intervention for this population throughout HSCT recovery.

Social media use and health promotion among cancer survivors

OBJECTIVE

Social media is becoming recognized as an effective platform for cancer health promotion, education, care, and support. However, its utility as a health promotion tool remains relatively unexplored.

METHODS

Using cross-sectional data from the 2017-2020 Health Information National Trends Survey, we evaluated health-related usage of social media among cancer survivors and individuals without a history of cancer. We also examined the participant characteristics associated with social media usage and evaluated the relationship between social media use and positive health behaviors among the cancer survivors.

RESULTS

Overall, cancer survivors (n = 2579) were as likely as individuals without a history of cancer to use social media for health promotion. Males [OR 0.65; 95% CI (0.45, 0.93)] and older adults (>60 years old) [OR 0.27; 95% CI(0.10, 0.77)] were less likely to use social media, while higher income [OR 2.27; 95% CI (1.05, 4.92) middle income; OR 1.90; 95% CI (1.17, 3.09) high income] and educational levels [OR 3.29; 95% CI (1.85, 5.84) some college; OR 2.36; 95% CI (1.30, 4.28) college graduate or more] were associated with more health-related social media use among survivors. Cancer survivors used social media for online support groups more than other individuals, and those who used at least one form of social media for health-related purposes increasingly meet national recommendations for strength training compared to non-users [OR 2.15; 95% CI (1.48, 3.13)].

CONCLUSIONS

Our findings demonstrate the potential utility of social media to promote positive health behaviors among cancer survivors. Further research is needed to describe the efficacy of social media-based interventions for improving health behaviors in diverse cancer populations.

Psychosocial assessment practices for hematopoietic stem cell transplantation: a national survey study

Psychosocial health predicts and contributes to medical outcomes for patients undergoing hematopoietic stem cell transplantation (HSCT). Yet, there are no standards for psychosocial assessments or support for both patients and caregivers across the care continuum. To examine the current state of psychosocial care, clinicians were sent a survey of their psychosocial assessment practices for patients and caregivers undergoing HSCT via the Listservs of professional organizations. Descriptive statistics and bivariate analyses were performed to summarize the findings. While 96% of participants reported routine pre-HSCT psychosocial assessment of patients, only 10.6% routinely used a validated transplant risk-assessment measure. Just 27% routinely performed follow-up psychosocial assessments. In contrast, only 47% of participants routinely assessed the psychosocial needs of family caregivers pre-HSCT, and 13% routinely performed follow-up assessments for caregivers. Most (90%) reported social workers were the primary providers of assessments. While patient-report measures were used for evaluation, the majority of assessments were clinical interviews. No significant differences were found between programs that treated adult and pediatric patients versus those only treating adult patients. Our findings highlight the lack of standard psychosocial practices for patients and family caregivers undergoing HSCT and we offer recommendations to fill this gap.

The influence of political ideology on clinical trial knowledge, invitation, and participation among adults in the United States

BACKGROUND

Clinical trials remain a critical component of medical innovation. Evidence suggests that individuals' political ideologies may impact their health behaviors. However, there is a paucity of literature examining the relationship between political ideologies and clinical trial knowledge and participation.

METHODS

Study data were derived from Health Information National Trends Survey 5 Cycle 4 (n = 3300), which was conducted from February to June 2020. We used participants' characteristics to estimate the prevalence of clinical trial knowledge and participation. We used multivariable logistic regressions to investigate whether political ideology had a significant impact on clinical trial knowledge and participation. Jack-knife replicate weights were applied for population-level estimates.

RESULTS

Most participants were White (64.2%), earned above US$50,000 (62.4%), and lived in urban areas (88.0%). About 59.2% reported having some knowledge of clinical trials, and only 8.9% had ever been invited to participate in clinical trials. A total of 37.0%, 29.5%, and 33.5% of the population endorsed moderate, liberal, and conservative political viewpoints respectively. In the adjusted logistic regression analysis, compared to conservatives, liberals (adjusted odds ratio, 1.92; 95% confidence interval, 1.31-2.80) and moderates (adjusted odds ratio, 1.43; 95% confidence interval, 1.09-1.88) had significantly greater odds of having knowledge of clinical trials. Also, liberals had higher odds of receiving invitations to participate in clinical trials (odds ratio, 1.76; 95% confidence interval, 1.08-2.85; p = 0.023) and greater odds of trial participation (odds ratio, 3.90; 95% confidence interval, 1.47-10.33; p = 0.007) compared to moderates.

CONCLUSIONS

The mechanism underlying the higher rates of clinical trial invitations to liberals is unclear and requires further comprehensive investigation. Similarly, further qualitative studies are needed to understand the attributes that promote knowledge and increased likelihood of clinical trial participation among liberals. This will provide crucial insight to help design interventions that further involve conservatives and moderates in clinical trials and scientific enterprise.

Coping and Perception of Prognosis in Patients With Indolent Non-Hodgkin's Lymphoma

BACKGROUND

Indolent non-Hodgkin's lymphomas (iNHL) are a heterogenous group of mostly incurable diseases with prolonged illness courses and prognostic uncertainty. Yet, studies evaluating coping and perception of prognosis are limited.

METHODS

We conducted a cross-sectional study of adults newly diagnosed with iNHL in the past 3 months at a single academic center. We assessed quality of life (QOL: Functional Assessment of Cancer Therapy-General), psychological symptoms (Hospital Anxiety and Depression Scale), coping (Brief-COPE), and perception of prognosis (Prognosis Awareness Impact Scale).

RESULTS

We enrolled 70.6% (48/68) of eligible patients. Patients had older age (mean = 66.9,sd = 10.5), were female (60.4%), predominantly identified as White (85.4%), and had at least received a college degree (75%). Chronic lymphocytic leukemia (39.6%) and follicular lymphoma (33.3%) were the most common diagnoses. Overall, 27.1% and 14.6% of patients reported clinically significant anxiety and PTSD symptoms, respectively. Patients highly utilized acceptance (56.2%), seeking emotional support (47.9%), and denial (47.9%) as coping strategies at diagnosis. While 66.7% of patients recalled their oncologist assessment of illness as incurable, only 35.4% reported that the illness is unlikely to be cured. Overall, 45.8% indicated that they were worried about prognosis and 31.2% reported perseverating on their prognosis. Higher emotional coping with prognosis was associated with fewer anxiety (B = -0.6, SE = 0.2, P < .001), depression (B = -0.3, SE = .1, P = .005), and PTSD (B = -1.3, SE = 0.4, P < .001) symptoms and better QOL (B = 1.7, SE = 0.4, P < .001).

DISCUSSION

Patients with iNHL report substantial psychological distress, a diversity of coping strategies, and complex cognitive understanding of their prognosis. Interventions, which address prognostic uncertainty and promote positive emotional coping with prognosis, may ameliorate psychological distress in this population.

Political Ideology and Trust in Government Health Agencies for Cancer Information

This cross-sectional study assesses the association between political ideology and trust in government health agencies for cancer information.

Medication Adherence in Patients with Hematologic Malignancies Who Are Hematopoietic Stem Cell Transplantation Survivors: A Qualitative Study

Medication adherence is critical for optimal health outcomes in patients with hematologic malignancies who have undergone allogeneic hematopoietic stem cell transplants (HSCT). However, this population struggles with medication nonadherence. Research that comprehensively describes the complex patient- and medication-related factors which impact medication adherence in this population is lacking. Hence, we used semistructured qualitative interviews to explore the diverse and complex factors contributing to medication adherence in HSCT recipients. We conducted 30 in-depth interviews with patients who were more than 180 days post-allogeneic HSCT at the Dana-Farber Cancer Institute. The interviews explored the physical, social, psychological, and sociodemographic factors that facilitate or discourage adherence to the post-transplantation medication regimen. Interviews were audio-recorded, transcribed, and coded using NVivo software. Two themes emerged that characterized the barriers patients face with their medication regimen. Patients reported factors outside of their control, such as managing multiple pharmacies, health insurance difficulties, and dosage timing, as significant barriers to medication adherence. Patients also reported barriers within their control, such as familial responsibilities. Important facilitators for medication adherence included caregiver and clinician support, previous experience managing a medication regimen, and tools that aid pill organization and timing. Furthermore, patients reported that although medication side effects and quantity of pills did not directly impact medication adherence, it increased their psychological distress. Facilitators and barriers to medication adherence can be physical, psychological, organizational, and social. There are many aspects of medication regimens that significantly increase patient distress. Hence, supportive interventions to improve medication adherence in patients undergoing HSCT may need to incorporate strategies to manage medication side effects and skills to improve psychological well-being and social support.

Family Caregiver Experiences in the Inpatient and Outpatient Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation Settings: A Qualitative Study

Caregivers (ie, family and friends) are essential in providing care and support for patients undergoing hematopoietic cell transplantation (HCT) and throughout their recovery. Traditionally delivered in the hospital, HCT is being increasingly provided in the outpatient setting, potentially heightening the burden on caregivers. Extensive work has examined the inpatient HCT caregiving experience, yet little is known about how caregiver experiences may differ based on whether the HCT was delivered on an inpatient or outpatient basis, particularly during the acute recovery period post-HCT. This study explored the similarities and differences in caregiver experiences in the inpatient and outpatient settings during the early recovery from reduced-intensity conditioning (RIC) allogeneic HCT. We conducted semistructured interviews (n = 15) with caregivers of adults undergoing RIC allogeneic HCT as either an inpatient (n = 7) or an outpatient (n = 8). We recruited caregivers using purposeful criterion sampling, based on the HCT setting, until thematic saturation occurred. Interview recordings were transcribed and coded through thematic analysis using Dedoose v.9.0. The study analysis was guided by the transactional model of stress and coping and the model of adaptation of family caregivers during the acute phase of BMT. Three themes emerged to describe similar experiences for HCT caregivers regardless of setting: (1) caregivers reported feeling like they were a necessary yet invisible part of the care team; (2) caregivers described learning to adapt to changing situations and varying patient needs; and (3) caregivers recounted how the uncertainty following HCT felt like existing between life and death while also maintaining a sense of gratitude and hope for the future. Caregivers also reported distinct experiences based on the transplantation setting and 4 themes emerged: (1) disrupted routines: inpatient caregivers reported disrupted routines when caring for the HCT recipient while simultaneously trying to manage non-caregiving responsibilities at home and work, and outpatient caregivers reported having to establish new routines that included frequent clinic visits with the patient while altering or pausing home and work responsibilities; (2) timing of caregiver involvement: inpatient caregivers felt more involved in care after the patient was discharged from the HCT hospitalization, whereas outpatient caregivers were already providing the majority of care earlier in the post-transplantation period; (3) fear of missing vital information: inpatient caregivers worried about missing vital information about the patient's care and progress if not physically present in the hospital, whereas outpatient caregivers feared overlooking vital information that may warrant contacting the care team as they monitored the patient at home; and (4) perceived adequacy of resources to meet psychosocial and practical needs: inpatient caregivers reported having adequate access to resources (ie, hospital-based services), whereas outpatient caregivers felt they had more limited access and needed to be resourceful in seeking out assistance. Inpatient and outpatient HCT caregivers described both similar and distinct experiences during the acute recovery period post-HCT. Specific interventions should address caregiver psychosocial needs (ie, distress, illness uncertainty, communication, and coping) and practical needs (ie, community resource referral, preparedness for home-based caregiving, and transplantation education) of HCT caregivers based on setting.

Positive Psychological Well-Being in Hematopoietic Stem Cell Transplantation Survivors

Positive thoughts and emotions contribute to overall psychological health in diverse medical populations, including patients undergoing HSCT. However, few studies have described positive psychological well-being (eg, optimism, gratitude, flourishing) in patients undergoing HSCT using well-established, validated patient-reported outcome measures. We conducted cross-sectional secondary analyses of baseline data in 156 patients at 100 days post-HSCT enrolled in a randomized controlled trial of a psychological intervention (ClinicalTrials.gov identifier NCT05147311) and a prospective study assessing medication adherence at a tertiary care academic cancer center from September 2021 to December 2022. We used descriptive statistics to outline participant reports of positive psychological well-being (PPWB) using validated measures for optimism, gratitude, positive affect, life satisfaction, and flourishing. The participants had a mean age of 57.4 ± 13.1 years, and 51% were male (n = 79). Many, but not all, participants reported high levels of PPWB (ie, optimism, gratitude, positive affect, life satisfaction, and flourishing), defined as agreement with items on a given PPWB measure. For example, for optimism, 29% of participants did not agree that "overall, I expect more good things to happen to me than bad." Aside from life satisfaction, mean PPWB scores were higher in the HSCT population than in other illness populations. Although many patients with hematologic malignancies undergoing HSCT report high levels of PPWB, a substantial minority of patients reported low PPWB (i.e., no agreement with items on a given PPWB measure). Because PPWB is associated with important clinical outcomes in medical populations, further research should determine whether an intervention to promote PPWB can improve quality of life in HSCT recipients.

Peer support interventions in patients with kidney failure: A systematic review

BACKGROUND

Peer support has been associated with improved health-related outcomes (e.g., psychological well-being and treatment adherence) among patients with serious, chronic conditions, including kidney disease. Yet, there is little existing research evaluating the effects of peer support programs on health outcomes among patients with kidney failure being treated with kidney replacement therapy.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we conducted a systematic review using five databases to assess the effects of peer support programs on health-related outcomes (e.g., physical symptoms, depression) among patients with kidney failure undergoing kidney replacement therapy.

RESULTS

Peer support in kidney failure was assessed across 12 studies (eight randomized controlled trials, one quasi-experimental controlled trial, and three single-arm trials) with 2893 patients. Three studies highlighted the links between peer support and improved patient engagement with care, while one found peer support did not significantly impact engagement. Three studies showed associations between peer support and improvements in psychological well-being. Four studies underscored the effects of peer support on self-efficacy and one on treatment adherence.

CONCLUSIONS

Despite preliminary evidence of the positive associations between peer support and health-related outcomes among patients with kidney failure, peer support programs for this patient population remain poorly understood and underutilized. Further rigorous prospective and randomized studies are needed to evaluate how peer support can be optimized and incorporated into clinical care for this vulnerable patient population.

Feasibility of a positive psychology intervention (PATH) in allogeneic hematopoietic stem cell transplantation survivors: Randomized pilot trial design and methods

BACKGROUND

Although patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) experience low levels of positive psychological well-being (PPWB), interventions that specifically boost PPWB in this population are lacking.

OBJECTIVE

To describe the methods of a randomized controlled trial (RCT) designed to assess the feasibility, acceptability, and preliminary efficacy of a positive psychology intervention (PATH) tailored to the unique needs of HSCT survivors and aimed to decrease anxiety and depression symptoms and boost quality of life (QOL).

METHODS

We will conduct a single-institution RCT of a novel nine-week phone-delivered manualized positive psychology intervention compared to usual transplant care in 70 HSCT survivors. Allogeneic HSCT survivors at 100 days post-HSCT are eligible for the study. The PATH intervention, tailored to the needs of HSCT survivors in the acute recovery phase, focuses on gratitude, strengths, and meaning. Our primary aims are to determine feasibility (e.g., session completion, rate of recruitment) and acceptability (e.g., weekly session ratings). Our secondary aim is to test the preliminary efficacy of the intervention on patient-reported outcomes (e.g., anxiety symptoms, QOL).

DISCUSSION

If the PATH intervention is feasible, a larger randomized, controlled efficacy trial will be indicated. Additionally, we anticipate that the results from this RCT will guide the development of other clinical trials and larger efficacy studies of positive psychology interventions in vulnerable oncological populations beyond HSCT.

Longitudinal patient-reported outcomes in patients receiving chimeric antigen receptor T-cell therapy

Chimeric antigen receptor T-cell therapy (CAR-T) has transformed the treatment for relapsed/refractory hematologic malignancies; however, data on patient-reported outcomes in CAR-T are limited. We conducted a longitudinal study of adults with hematologic malignancies receiving CAR-T. We assessed quality of life (QOL; functional assessment of cancer therapy-general), psychological distress (hospital anxiety and depression scale, patient health questionnaire-9, posttraumatic stress disorder [PTSD] checklist), and physical symptoms (Edmonton symptom assessment scale-revised) at baseline, 1 week, 1, 3, and 6 months after CAR-T. We used linear mixed models to identify factors associated with QOL trajectory. We enrolled 103 of 142 eligible patients (3 did not receive CAR-T). QOL (B = 1.96; P < .001) and depression (B = -0.32; P = .001) worsened by 1 week and improved by 6 months after CAR-T. At 6 months, 18%, 22%, and 22% reported clinically significant depression, anxiety, and PTSD symptoms, respectively. At 1 week, 52% reported severe physical symptoms, declining to 28% at 6 months after CAR-T. In unadjusted linear mixed models, worse Eastern Cooperative Oncology Group performance status (B = 1.24; P = .042), receipt of tocilizumab (B = 1.54; P = .042), and receipt of corticosteroids for cytokine release syndrome and/or neurotoxicity (B = 2.05; P = .006) were associated with higher QOL trajectory. After CAR-T, QOL declined, and depression increased early, followed by improvements in QOL, psychological distress, and physical symptoms by 6 months after infusion. A significant minority of patients reported substantial psychological distress and physical symptoms longitudinally.

Delirium and Healthcare Utilization in Patients Undergoing Hematopoietic Stem Cell Transplantation

Delirium, a common neuropsychiatric syndrome among hospitalized patients, has been associated with significant morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT). Although delirium is often reversible with prompt diagnosis and appropriate management, timely screening of hospitalized patients, including HSCT recipients at risk for delirium, is lacking. The association between delirium symptoms and healthcare utilization among HSCT recipients is also limited. We conducted a retrospective analysis of 502 hospitalized patients admitted for allogeneic or autologous HSCT at 2 tertiary care hospitals between April 2016 and April 2021. We used Natural Language Processing (NLP) to identify patients with delirium symptoms, as defined by an NLP-assisted chart review of the electronic health record (EHR). We used multivariable regression models to examine the associations between delirium symptoms, clinical outcomes, and healthcare utilization, adjusting for patient-, disease-, and transplantation-related factors. Overall, 44.4% (124 of 279) of patients undergoing allogeneic HSCT and 39.0% (87 of 223) of those undergoing autologous HSCT were identified as having delirium symptoms during their index hospitalization. Two-thirds (139 of 211) of the patients with delirium symptoms were prescribed treatment with antipsychotic medications. Among allogeneic HSCT recipients, delirium symptoms were associated with longer hospital length of stay (β = 7.960; P < .001), fewer days alive and out of the hospital (β = -23.669; P < .001), and more intensive care unit admissions (odds ratio, 2.854; P = .002). In autologous HSCT recipients, delirium symptoms were associated with longer hospital length of stay (β = 2.204; P < .001). NLP-assisted EHR review is a feasible approach to identifying hospitalized patients, including HSCT recipients at risk for delirium. Because delirium symptoms are negatively associated with health care utilization during and after HSCT, our findings underscore the need to efficiently identify patients hospitalized for HSCT who are at risk of delirium to improve their outcomes. © 2023 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

Does self-compassion explain variance in sleep quality in women experiencing hot flushes?

OBJECTIVES

With poor sleep highly prevalent during the menopause transition, there is a need to better understand modifiable psychological resources that may be associated with improved sleep. Hence, we investigated whether self-compassion can explain variance in self-reported sleep quality in midlife women, over and above vasomotor symptoms.

METHODS

This cross-sectional study (N = 274) used questionnaire data from self-report measures of sleep, hot flushes and night sweats, hot flush interference, and self-compassion, with analyses conducted using sequential (hierarchical) regression.

RESULTS

Poor sleep, as measured by the Pittsburgh Sleep Quality Index, was prevalent and significantly worse in the subsample of women with hot flushes and night sweats, g = 0.28, 95 % CI [0.04, 0.53]. The interference of hot flushes in everyday life (β = 0.35, p < .01), but not their frequency, predicted self-reported sleep quality. Once self-compassion was added to the model it was the only predictor of poor sleep (β = -0.32, p < .01). When positive self-compassion and self-coldness were considered separately, the effect on sleep quality appeared to be attributable to self-coldness scores alone (β = 0.29, p < .05).

CONCLUSIONS

Self-compassion may have a stronger relationship with self-reported sleep quality in midlife women than vasomotor symptoms. Future intervention-based research could test the efficacy of self-compassion training for midlife women experiencing sleep disturbances, as this may be an important and modifiable psychological resilience factor.

Coping in caregivers of patients with hematologic malignancies undergoing hematopoietic stem cell transplantation

Caregivers of patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) must cope with substantial caregiving burden, high rates of psychological distress, and diminished quality of life (QOL). However, data describing coping strategies before HSCT and the association between coping, QOL, and psychological outcomes in this population are lacking. We conducted a secondary analysis of data collected during a multisite randomized clinical trial of a supportive care intervention in HSCT recipients and their caregivers. Caregivers completed the Brief COPE, Hospital Anxiety and Depression Scale, and the Caregiver Oncology Quality of Life Questionnaire to measure coping strategies, psychological distress, and QOL, respectively. We grouped coping into 2 higher-order domains: approach-oriented (ie, emotional support and active coping) and avoidant (ie, self-blame and denial). We used the median split method to describe the distribution of coping and multivariate linear regression models to assess the relationship between coping and caregiver outcomes. We enrolled 170 caregivers, with a median (range) age of 53 (47-64) years. Most were White (87%), non-Hispanic (96%), and female (77%). Approach-oriented coping was associated with less anxiety (β = -0.210, P = .003), depression symptoms (β = -0.160, P = .009), and better QOL (β = 0.526, P = .002). In contrast, avoidant coping was associated with more anxiety (β = 0.687, P<.001), depression symptoms (β = 0.579, P < .001), and worse QOL (β = -1.631, P < .001). Our findings suggest that coping is related to distress and QOL among caregivers of HSCT recipients even before transplant. Hence, caregivers of patients with hematologic malignancies undergoing HSCT may benefit from resources that facilitate adaptive coping with the demands of caregiving.

Positive psychological well-being and clinical characteristics in IBS: A systematic review

OBJECTIVE

Psychological factors (e.g., depression, anxiety) are known to contribute to the development and maintenance of irritable bowel syndrome (IBS). Less is known, however, about the role of positive psychological well-being (PPWB) in IBS. Accordingly, we completed a systematic review of the literature examining relationships between PPWB and clinical characteristics in IBS.

METHOD

A systematic review using search terms related to PPWB and IBS from inception through July 28, 2022, was completed. Quality was assessed with the NIH Quality Assessment Tool. A narrative synthesis of findings, rather than meta-analysis, was completed due to study heterogeneity.

RESULTS

22 articles with a total of 4285 participants with IBS met inclusion criteria. Individuals with IBS had lower levels of PPWB (e.g., resilience, positive affect, self-efficacy, emotion regulation) compared to healthy populations, which in turn was associated with reduced physical and mental health and health-related quality of life (HRQoL). Limited exploration of potential biological mechanisms underlying these relationships has been described.

CONCLUSIONS

PPWB is diminished in individuals with IBS compared to other populations, and greater PPWB is linked to superior physical, psychological, and HRQoL outcomes. Interventions to increase PPWB may have the potential to improve IBS-related outcomes.

REGISTRATION

Prospective Register of Systematic Reviews CRD42022304767.

Fit for Duty: Lessons Learned from Outpatient and Homebound Hematopoietic Cell Transplantation to Prepare Family Caregivers for Home-Based Care

In the past decade, the demand for home-based care has been amplified by the Coronavirus disease 2019 pandemic. Home-based care has significant benefits for patients, their families, and healthcare systems, but it relies on the often-invisible workforce of family and friend caregivers who shoulder essential health care responsibilities, frequently with inadequate training and support. Hematopoietic cell transplantation (HCT), a potentially curative but intensive treatment for many patients with blood disorders, is being increasingly offered in home-based care settings and necessitates the involvement of family caregivers for significant patient care responsibilities. However, guidelines for supporting and preparing HCT caregivers to effectively care for their loved ones at home have not yet been established. Here, informed by the literature and our collective experience as clinicians and researchers who care for diverse patients with hematologic malignancies undergoing HCT, we provide considerations and recommendations to better support and prepare family caregivers in home-based HCT and, by extension, family caregivers supporting patients with other serious illnesses at home. We suggest tangible ways to screen family caregivers for distress and care delivery challenges, educate and train them to prepare for their caregiving role, and create an infrastructure of support for family caregivers within this emerging care delivery model.

Proxy ratings of psychological well-being in patients with primary brain tumors: A systematic review

OBJECTIVE

This systematic review examined the agreement of proxy ratings of depression and anxiety in neuro-oncology patients.

METHODS

Searches were conducted across 4 databases (MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science) to identify studies that compared proxy ratings (non-health care providers) of anxiety and depression in patients with brain cancer. Methodological quality and potential risk of bias were evaluated using the Joanna Briggs Institute Critical Appraisal Checklist.

RESULTS

Out of the 936 studies that were screened for inclusion, 6 were included for review. The findings were mixed in terms of whether patient and proxy ratings were accurate (e.g., deemed equivalent), with many of the selected studies suggesting moderate level of agreement for several of the selected studies and, when both depression and anxiety were included, depression ratings from proxy raters were more accurate than for anxiety. We identified important limitations across the selected articles, such as low sample size, clarity on defining proxy raters and the different instructions that proxy raters are given when asked to assess patients' mood symptoms.

CONCLUSIONS

Our findings suggest that proxy ratings of depression and anxiety should be interpreted with caution. While there is some agreement in proxy and patients with brain cancer ratings of depression and anxiety (greater agreement for depression), future work should recruit larger samples, while also remaining mindful of defining proxy raters and the instructions given in collecting these ratings.

The link between post-traumatic stress disorder and systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a heterogeneous, multisystem autoimmune disorder characterized by unpredictable disease flares. Although the pathogenesis of SLE is complex, an epidemiologic link between posttraumatic stress disorder (PTSD) and the development of SLE has been identified, suggesting that stress-related disorders alter the susceptibility to SLE. Despite the strong epidemiologic evidence connecting PTSD and SLE, gaps remain in our understanding of how the two may be connected. Perturbations in the autonomic nervous system, neuroendocrine system, and at the genomic level may cause and sustain immune dysregulation that could lower the threshold for the development and propagation of SLE. We first describe shared risk factors for SLE and PTSD. We then describe potential biological pathways which may facilitate excessive inflammation in the context of PTSD. Among those genetically predisposed to SLE, systemic inflammation that accompanies chronic stress may fan the flames of smoldering SLE by priming immune pathways. Further studies on the connection between trauma and inflammation will provide important data on pathogenesis, risk factors, and novel treatments for SLE.

Latent growth curve modeling of physical activity trajectories in a positive-psychology and motivational interviewing intervention for people with type 2 diabetes

Background: Physical activity is critical for preventing and treating Type 2 diabetes (T2D). It is important to identify different profiles of physical activity change among those participating in behavioral interventions to optimize intervention-person fit.

Methods: This study analyzes longitudinal trajectories of change in moderate-to-vigorous physical activity (MVPA) in a positive psychology (PP) and motivational interviewing (MI) intervention for T2D, using latent growth curve modeling (LGCM). Objective measures of MVPA were collected using accelerometers at three time points: pre-intervention, immediately post-intervention, and eight weeks post-intervention. LGCM analyses identified subpopulations of participants who responded similarly to the intervention and examined if sociodemographic, medical and psychosocial characteristics were associated with MVPA trajectories.

Results: Analyses included 47 participants with complete follow-ups: 49% male, 81% non-Hispanic white, average age 66.1 (SD = 10.1). Overall, 36% of the participants increased MVPA while 57% did not. LGCM identified three profiles with distinct MVPA trajectories. Profile 1 (‘Started Low, No Change’; 65.8% of participants) with a starting mean of 4.54 min of MVPA/day and decreased by −3.36 min. Profile 2 (‘Moderate-High Start, Minimal Change,’ 27.4% of participants) and had a starting mean of 22.86 min/day of MVPA with an average increase of 1.03 min. Profile 3 (‘Moderate Start, Ended High’; 6.8% of participants), had a starting mean of 7.33 min MVPA/day, and increased by 28.4 min. Being male, younger, having fewer medical and psychiatric comorbidities were associated with increases in MVPA.

Conclusions: This secondary analysis detected three distinct physical activity profiles during and after a PP-MI intervention. Future interventions can target individuals with characteristics that showed the greatest benefit and add additional supports to people in groups that did not increase physical activity as much. These findings show a need for targeted and sustained behavior change strategies during and after physical activity interventions.

Trial registration: ClinicalTrials.gov; identifier: NCT03001999.

Pharmacologic treatment of delirium symptoms: A systematic review

OBJECTIVE

We conducted an updated, comprehensive, and contemporary systematic review to examine the efficacy of existing pharmacologic agents employed for management of delirium symptoms among hospitalized adults.

METHODS

Searches of PubMed, Scopus, Embase, and Cochrane Library databases from inception to May 2021 were performed to identify studies investigating efficacy of pharmacologic agents for management of delirium.

RESULTS

Of 11,424 articles obtained from searches, a total of 33 articles (N = 3030 participants) of randomized or non-randomized trials, in which pharmacologic treatment was compared to active comparator, placebo, or no treatment, met all criteria and were included in this review. Medications used for management of delirium symptoms included antipsychotic medications (N = 27), alpha-2 agonists (N = 5), benzodiazepines (N = 2), antidepressants (n = 1), acetylcholinesterase inhibitors (N = 2), melatonin (N = 2), opioids (N = 1), and antiemetics (N = 2). Despite somewhat mixed findings and a relative lack of high-quality trials, it appears that antipsychotic medications (e.g., haloperidol, olanzapine, risperidone, or quetiapine) and dexmedetomidine have the potential to improve delirium outcomes.

CONCLUSIONS

Pharmacologic agents can reduce delirium symptoms (e.g., agitation) in some hospitalized patients. Additional double-blinded, randomized, placebo-controlled clinical trials are critically needed to investigate the efficacy of pharmacologic agents for diverse hospitalized populations (e.g., post-surgical patients, patients at the end-of-life, or in intensive care units).

Can positive psychological interventions improve health behaviors? A systematic review of the literature

Positive psychological interventions (PPIs), which aim to cultivate psychological well-being, have the potential to improve health behavior adherence. This systematic review summarized the existing literature on PPI studies with a health behavior outcome to examine study methodology, quality, and efficacy. Of the 27 identified studies, 20 measured physical activity, eight measured medication adherence, seven measured diet, and three measured smoking (eight targeted multiple behaviors). Twenty studies were randomized controlled trials (RCTs; 13 fully powered), and seven had a single-arm design. Study samples were usually adults (n = 21), majority non-Hispanic white (n = 15) and female (n = 14), and with a specific disease (e.g., diabetes, n = 16). Most interventions combined a PPI with health behavior-focused content (n = 17), used a remote delivery method (n = 17), and received a moderate or low study quality rating. Overall, 19/27 studies found a health behavior improvement of at least medium effect size, while six of the 13 studies powered to detect significant effects were statistically significant. Of the behaviors measured, physical activity was most likely to improve (14/20 studies). In summary, PPIs are being increasingly studied as a strategy to enhance health behavior adherence. The existing literature is limited by small sample size, low study quality and inconsistent intervention content and outcome measurement. Future research should establish the most effective components of PPIs that can be tailored to different populations, use objective health behavior measurement, and robustly examine the effects of PPIs on health behaviors in fully powered RCTs.

Relationship Between Longitudinal Coping Strategies and Outcomes in Patients With Acute Myeloid Leukemia

Background: Patients with acute myeloid leukemia (AML) face an abrupt life-threatening illness and experience immense physical and psychological symptoms. However, no data describe how patients with AML cope longitudinally with their illness or the relationship between longitudinal coping and outcomes. Methods: We conducted a secondary analysis of longitudinal data from 160 patients with high-risk AML enrolled in a supportive care intervention trial to describe coping strategies longitudinally across the illness course. We used the Brief COPE questionnaire, the Hospital Anxiety and Depression Scale, the Post-Traumatic Stress Disorder (PTSD) Checklist-Civilian Version, and the Functional Assessment of Cancer Therapy-Leukemia to measure coping strategies, psychological distress, and quality of life (QoL) at baseline and at weeks 2, 4, 12, and 24 after diagnosis. Electronic health records were used to assess healthcare utilization and end-of-life (EoL) outcomes, and multivariate analyses were used to assess the relationship between coping and outcomes. Results: Longitudinal utilization of approach-oriented coping strategies was significantly associated with less distress (anxiety: β, –0.18; P<.001; depression symptoms: β, –0.42; P<.001; PTSD symptoms: β, –0.60; P<.001) and better QoL (β, 2.00; P<.001). Longitudinal utilization of avoidant coping strategies was significantly associated with greater distress (anxiety: β, 0.64; depression symptoms: β, 0.54; PTSD symptoms: β, 2.13; P<.001 for all) and worse QoL (β, –4.27; P<.001). Although the use of approach-oriented and avoidant coping strategies was not significantly associated with hospitalization, chemotherapy administration, or hospice use in the last 30 days of life, approach-oriented coping was associated with lower odds of ICU admissions (odds ratio, 0.92; P=.049). Conclusions: Longitudinal use of approach-oriented coping strategies was associated with less psychological distress, better QoL, and a lower likelihood of ICU admission, suggesting a possible target for supportive oncology interventions. Coping strategies did not impact EoL outcomes, and further research is needed to elucidate which patient factors impact EoL decision-making.

Biobehavioral Implications of Covid-19 for Transplantation and Cellular Therapy Recipients

A growing body of literature has emphasized the importance of biobehavioral processes - defined as the interaction of behavior, psychology, socioenvironmental factors, and biological processes - for clinical outcomes among transplantation and cellular therapy (TCT) patients. TCT recipients are especially vulnerable to distress associated with pandemic conditions and represent a notably immunocompromised group at greater risk for SARS-CoV-2 infection with substantially worse outcomes. The summation of both the immunologic and psychologic vulnerability of TCT patients renders them particularly susceptible to adverse biobehavioral sequelae associated with the Covid-19 pandemic. Stress and adverse psychosocial factors alter neural and endocrine pathways through sympathetic nervous system and hypothalamic-pituitary-adrenal axis signaling that ultimately affect gene regulation in immune cells. Reciprocally, global inflammation and immune dysregulation related to TCT contribute to dysregulation of neuroendocrine and central nervous system function, resulting in the symptom profile of depression, fatigue, sleep disturbance, and cognitive dysfunction. In this article, we draw upon literature on immunology, psychology, neuroscience, hematology and oncology, Covid-19 pathophysiology, and TCT processes to discuss how they may intersect to influence TCT outcomes, with the goal of providing an overview of the significance of biobehavioral factors in understanding the relationship between Covid-19 and TCT, now and for the future. We discuss the roles of depression, anxiety, fatigue, sleep, social isolation and loneliness, and neurocognitive impairment, as well as specific implications for sub-populations of interest, including pediatrics, caregivers, and TCT donors. Finally, we address protective psychological processes that may optimize biobehavioral outcomes affected by Covid-19.

“More than conquerors”: A qualitative analysis of war metaphors for patients with cancer

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Background: Limited research suggests that war metaphors may be harmful for patients with cancer. For instance, it has been claimed that the use of war metaphors is associated with increased anxiety and depression, as well as poor coping for patients with cancer. However, little is known about how patients use and perceive these metaphors. Metaphors, which are intrinsic to the human conceptual system, help articulate patients’ experiences and needs. In this study, we explored patient narratives of illness metaphors in cancer, focusing particularly on war metaphors. Methods: Fifteen patients diagnosed with various stages of lung, colorectal or breast cancer completed semi-structured qualitative interviews about their use of metaphors after their cancer diagnoses. Interviews explored war metaphors in the context of treatment decisions, aggressiveness of care, and quality of life. Patients were also provided with a curated list of metaphors and asked about their use and experience thereof. Transcribed interviews were organized and analyzed by descriptive content analysis using NVivo software. Results: The most used metaphor categories were: 1) nature (e.g., journey, season); 2) militaristic (e.g., battle, victory, fight); and 3) uncertainty (e.g., mystery, puzzle). War metaphors were frequently referenced in patients’ support communities rather than in hospital or clinician encounters. Next, all patients with non-metastatic disease (n = 7) used war metaphors to describe their illness experience. Among all patients who used metaphorical language to describe their experience (n = 14), the only ones who did not use war metaphors (n = 2) had metastatic disease; these patients found war metaphors to be unhelpful due to their sense of having no control over the outcome. Lastly, participants reported that war metaphors served the following purposes in their illness experience with cancer: 1) promoted perseverance in the face of adversity, 2) expressed optimism, and 3) allowed them to relate cancer to previous life challenges. Conclusions: The hypothesis that war metaphors are invariably counterproductive for patients appears to be misguided. Metaphors of fighting, victory and battle worked both to empower and harm patients in this study, depending on the individual patient and their prognosis. While more prospective studies with robust sample sizes are needed to elucidate the role of metaphors in the lived experience of patients with cancer, our patients suggest the need to individualize, acknowledge and explore these metaphors for cancer populations.

The role of health information technology in improving awareness of HPV and HPV vaccine among U.S. adults: Insights from the health information national trends survey

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Background: Despite advances in cancer prevention and wide-spread availability of Human papilloma virus (HPV) vaccines, US adults continue to have suboptimal HPV vaccination uptake with less than 50% vaccinated. Strategies aimed at enhancing HPV-related awareness are considered one of the most effective ways to improve HPV vaccine adoption and potentially eliminate HPV-related cancers. Health information technology (HIT) may influence HPV-related awareness and subsequently drive vaccine adoption. This study assessed the impact of HIT utilization on HPV and HPV vaccine awareness. Methods: Data was obtained from Health Information National Trends Survey (HINTS 5 cycles 1 and 2). Cross-sectional sample of 6,522 individuals aged 18 years or more was analyzed. The independent variables were use of smartphone, computer, or electronic means to (i) look up health information, (ii) fill a prescription online, (iii) communicate with a doctor or doctor’s office, (iv) look up test results of and (v) track health care charges. The dependent variables were HPV and HPV vaccine awareness. Chi-square analysis was used to evaluate group differences, and a multiple logistic regression was used to analyze the association between HIT utilization and HPV-related awareness controlling for sociodemographic and health-related factors. Results: Of the total sample, awareness of HPV and HPV vaccine was 62.7% and 61.8% respectively. In adjusted multivariable logistic regression analysis, those who utilized a smartphone, computer, or electronic means to look up health information (aOR 2.23; 95% CI 1.68 – 2.97, p < 0.001), communicate with healthcare provider (aOR 1.53; 95% CI 1.23 – 1.91, p < 0.001), look up test results (aOR 1.67; 95% CI 1.35 – 2.08, p < 0.001), and track health care charges (aOR 1.61; 95% CI 1.26 – 2.05, p < 0.001), were more likely to endorse HPV awareness than those who did not. Similar positive associations were observed for HIT utilization and HPV vaccine awareness. Conclusions: Our findings showed a positive association between HIT utilization and HPV-related awareness. Amid a background of sub-optimal HPV vaccination and explosion in technology, these results emphasize the potential for the role of HIT in preventive medicine. Strategies that integrate HIT into vaccine interventions and communications should be encouraged as a medium to expand HPV awareness and vaccine coverage.

Peer support in patients with hematologic malignancies: a systematic review

BACKGROUND

Peer support has been utilized and associated with clinical outcomes (e.g., improved mood) in patients with solid malignancies. However, to date, there is minimal literature examining peer support among patients with hematologic malignancies and/or patients who have undergone hematopoietic stem cell transplantation (HSCT).

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we completed a systematic review using five databases to assess the relationship between peer support and clinical outcomes (e.g., distress, physical symptoms) among patients with hematologic malignancies or HSCT recipients.

RESULTS

The eight included studies examined peer support in a total of 574 patients. Four intervention studies highlighted the potential benefits of peer support, such as improved physical symptoms. Two studies, one interventional and one cross-sectional, highlighted the need for more empirically based peer support interventions in the HSCT population.

CONCLUSION

Among patients with hematologic malignancies and/or HSCT recipients, there is a dearth of literature examining the association between peer support and outcomes, although few studies have described a positive association between peer support and better health outcomes. More randomized controlled studies are needed to better understand the role of peer support and peer support interventions on outcomes in these vulnerable populations.

It Takes a Village: The Importance of Social Support after Hematopoietic Stem Cell Transplantation, A Qualitative Study

BACKGROUND/OBJECTIVE

Social support is essential to the recovery of patients who have undergone hematopoietic stem cell transplants (HSCT). We undertook a qualitative study to explore the specific sources and benefits of social support as experienced by HSCT recipients, as well as their unmet social support needs.

METHODS

We conducted semi-structured interviews with 25 patients who had undergone HSCT and were recruited from the Dana Farber Cancer Institute's HSCT database. The interviews explored the sources of support patients receive, the type of assistance social support networks provide to patients, and unmet needs of social support. Interviews were audio-recorded, transcribed, and coded using the Dedoose software.

RESULTS

The median (range) age of participants was 63 (22-73) years, and 13 (52%) were female, 20 (80%) were White, and 9 (36%) were diagnosed with acute myeloid leukemia. Participants reported receiving a majority of support from immediate family and close friends, with the primary benefits of social support including help with essential daily tasks, household chores, and receipt of emotional support. Participants reported occasional support from other patients but highlighted a desire for increased connection with patients who have undergone the same treatment. Participants also communicated a desire to have more guidance on how to optimize the support they do receive and the need for more educational resources for caregivers and supporters to enhance understanding of the HSCT process and lessen patient burden.

CONCLUSION

Participants rely on support from their family, friends, and other social connections for essential aspects of their recovery and daily living following HSCT. While there are many benefits to these relationships, patients emphasized the need for more guidance and resources to facilitate the aid and support they receive post-transplant.

Diversity, Equity, and Inclusion Committee: An Instrument to Champion Diversity Efforts Within a Large Academic Psychiatry Department

Diversity, equity, and inclusion (DEI) have become increasingly recognized as essential to the practice of high-quality patient care delivery and the support of members of the clinical environment. A solid understanding of DEI contributes to a better grasp of what drives health care disparities and yields improved clinical outcomes for minority populations. This column discusses how individuals can practically promote DEI by describing the design and implementation of DEI in an academic psychiatry department. The authors highlight the powerful role of departmental initiatives in establishing best practices for DEI and lessons learned through the work of the psychiatry department's DEI committee.

Palliative care and coping in patients with acute myeloid leukemia: Mediation analysis of data from a randomized clinical trial

BACKGROUND

It has been shown previously that integrated palliative care for patients with acute myeloid leukemia (AML) during intensive chemotherapy leads to improvements in quality of life (QOL) and mood. Coping has been shown to mediate palliative care interventions in advanced cancer; the mechanisms by which improvements occur among patients with AML remain unexplained.

METHODS

The authors conducted a secondary analysis of data from a multisite randomized trial of integrated palliative and oncology care (IPC; n = 86) versus usual care (n = 74) for hospitalized patients with AML undergoing intensive chemotherapy. IPC patients met with palliative care at least twice weekly during their initial and subsequent hospitalizations. Patients completed the Functional Assessment of Cancer Therapy-Leukemia, the Hospital Anxiety and Depression Scale, and the Brief Coping Orientation to Problems Experienced Inventory to assess QOL, mood, and coping at the baseline and at weeks 2, 4, 12, and 24. Linear regression models were used to assess the effect of IPC on coping. Causal mediation regression models were used to examine whether changes in coping mediated intervention effects on patient-reported outcomes at week 2.

RESULTS

One hundred sixty eligible patients (68.1%) were enrolled. Those randomized to IPC reported improvements in approach-oriented coping (P < .01) and reductions in avoidant coping (P < .05). These changes in coping mediated the intervention effects on QOL (95% CI, 2.14-13.63), depression (95% CI, -2.05 to -0.27), and anxiety symptoms (95% CI, -1.25 to -0.04). Changes in approach-oriented and avoidant coping accounted for 78% of the total palliative care intervention effect on QOL, for 66% of the effect on depression, and for 35% of the effect on anxiety symptoms.

CONCLUSIONS

Palliative care integrated during intensive chemotherapy for patients with AML facilitates coping strategy use. Improvement in coping skills accounts for a substantial proportion of the effect from a palliative care intervention on patient-reported outcomes.

Sources of Resilience in Frontline Health Professionals during COVID-19

BACKGROUND

While the challenges for psychological well-being for Australian healthcare workers have been documented, there has been a dearth of qualitative research on the sources of resilience that sustained workers during the COVID-19 pandemic. This study identified sources of resilience that clinicians used to cope with frontline challenges during the COVID-19 pandemic.

METHODS

Semi-structured interviews were conducted with 20 frontline health professionals, across five Australian hospitals, between October 2020 and April 2021. The interviews were recorded and transcribed, and the results were analysed using thematic analysis based on a phenomenological approach.

RESULTS

Three sources of resilience were identified by respondents: personal, relational, and organisational. A positive mindset, sense of purpose, and self-care behaviours emerged as key sources of personal resilience. Teamwork, altruism, and social support from family and friends contributed to relational resilience. Leadership, effective communication, and effective implementation of COVID-19 policies were associated with resilience at the organisational level. Frontline healthcare workers also voiced the need for the implementation of further strategies to support personal resilience whilst nurturing resilience within clinical teams and across entire healthcare organisations.

CONCLUSIONS

Trust in healthcare systems, organisation leaders, colleagues, and personal support teams was an overarching theme supporting resilience.

End-of-Life Care for Older Adults with Aggressive Non-Hodgkin Lymphoma

Background: Aggressive non-Hodgkin lymphoma (NHL) commonly affects older adults and is often treated with intensive therapies. Receipt of intensive therapies and absence of a clear transition between the curative and palliative phases of treatment yield prognostic uncertainty and risk for poor end-of-life (EOL) outcomes. However, data regarding the EOL outcomes of this population are lacking. Methods: We conducted a retrospective analysis of adults ≥65 years with aggressive NHL treated with systemic therapy at Massachusetts General Hospital from April 2000 to July 2020 who subsequently died. We abstracted patient and clinical characteristics and EOL outcomes from the medical record. Using multivariable logistic regression, we examined factors associated with hospitalization within 30 days of death and hospice utilization. Results: Among 91 patients (median age = 75 years; 37.4% female), 70.3% (64/91) were hospitalized, 34.1% (31/91) received systemic therapy, and 23.3% (21/90) had an intensive care unit admission within 30 days of death. The rates of palliative care consultation and hospice utilization were 47.7% (42/88) and 39.8% (35/88), respectively. More than half of patients (51.6%, 47/91) died in a hospital or health care facility. In multivariable analysis, elevated lactic acid dehydrogenase was associated with risk of hospitalization within 30 days of death (odds ratio [OR] 3.61, p = 0.014). Palliative care consultation (OR 4.45, p = 0.005) was associated with a greater likelihood of hospice utilization, whereas hypoalbuminemia (OR 0.29, p = 0.026) was associated with a lower likelihood of hospice utilization. Conclusions: Older adults with aggressive NHL often experience high health care utilization and infrequently utilize hospice care at the EOL. Our findings underscore the need for interventions to optimize the quality of EOL care for this population.

Distress in a Pandemic: Association of the Coronavirus Disease-2019 Pandemic with Distress and Quality of Life in Hematopoietic Stem Cell Transplantation

The global coronavirus disease 2019 (COVID-19) pandemic has drastically disrupted cancer care, potentially exacerbating patients’ distress levels. Patients undergoing hematopoietic stem cell transplantation (HSCT) may be especially vulnerable to this pandemic stress. However, the associations of the COVID-19 pandemic with distress, fatigue, and quality of life (QoL) are not well understood in this population. In a cross-sectional analysis of data from 205 patients undergoing HSCT enrolled in a supportive care trial, we compared baseline pre-HSCT distress symptoms (depression, anxiety, and posttraumatic stress disorder [PTSD]), fatigue, and QoL between enrollees before (ie, March 2019-January 2020) and during (ie, March 2020-January 2021) the COVID-19 pandemic. We used linear regression models adjusting for sociodemographics and cancer diagnosis to examine the associations between enrollment period and patient-reported outcomes. We used semistructured qualitative interviews in 20 allogeneic HSCT recipients who were ≥3-months post-HSCT to understand the impact of the COVID-19 pandemic on their recovery post-HSCT. One hundred twenty-four participants enrolled before COVID-19, and 81 participants enrolled during the pandemic. The 2 cohorts had similar baseline demographics and disease risk factors. In multivariate regression models, enrollment during COVID-19 was not associated with pre-HSCT symptoms of depression, anxiety, PTSD, fatigue, or QoL impairment. COVID-19-era participants reported themes of negative (eg, increased isolation) and positive (eg, engagement with meaningful activities) implications of the pandemic on HSCT recovery. We found no differences in pre-HSCT distress, fatigue, or QoL in patients undergoing HSCT before or during the COVID-19 pandemic; however, patients in early recovery post-HSCT report both negative and positive implications of the COVID-19 pandemic in their lives.

A positive psychology intervention to promote health outcomes in hematopoietic stem cell transplantation: the PATH proof-of-concept trial

Allogeneic hematopoietic stem cell transplantation (HSCT) recipients often experience deficits in positive psychological well-being (PPWB) due to intensive treatment and follow-up care. Positive psychology interventions (PPIs) that promote PPWB via deliberate and systematic exercises (e.g., writing a gratitude letter) have consistently improved PPWB in medical populations, yet have never been studied in early HSCT recovery. In this single-arm, proof-of-concept study, we assessed the feasibility and acceptability of a novel eight-session, telephone-delivered PPI in early HSCT recovery. A priori, we defined feasibility as >50% of eligible patients enrolling in the study and >50% of participants completing 5/8 sessions, and acceptability as mean ease and utility scores of weekly participant ratings of PP exercises as 7/10. Of 45 eligible patients, 25 (55.6%) enrolled, 20 (80%) completed baseline assessments, 15 (75%) started the intervention, and 12 (60%) completed the intervention and follow-up assessments. The intervention was feasible (55.6% of eligible participants enrolled; 60% of baseline assessment completers finished 5/8 sessions) and led to very small-to-medium effect-size improvements in patient-reported outcomes. A novel, eight-week, telephone-delivered PPI was feasible and acceptable in allogeneic HSCT recipients. Larger, randomized studies are needed to examine the efficacy of PPIs for improving outcomes in this population.

Clinical Outcomes, Treatment Toxicity, and Health Care Utilization in Older Adults with Aggressive Non-Hodgkin Lymphoma

BACKGROUND

Although balancing treatment efficacy with risks of complications is critical for older adults with aggressive non-Hodgkin lymphoma (NHL), few studies have described these patients' clinical outcomes, rates of toxicities, and health care utilization.

METHODS

We conducted a retrospective analysis of adults ≥65 years diagnosed with aggressive NHL and receiving systemic therapy at Massachusetts General Hospital from April 2000 to July 2020. We abstracted patient characteristics, clinical outcomes, treatment toxicity, unplanned hospitalizations, and intensive care unit (ICU) admissions within 6 months of treatment initiation from the medical record. Using multivariable logistic regression, we examined factors associated with rates of grade 3+ nonhematologic toxicity and unplanned hospitalization.

RESULTS

Among 295 patients (median age, 73 years; 39.0% female), 5-year overall survival (OS) was 74.2%. Five-year OS by age group (65-69, 70-74, 75-79, and 80+ years) was 82.2%, 72.0%, 73.6%, and 66.4%, respectively. Overall, 42.4% experienced grade 3+ toxicity, with 8.1% experiencing grades 4-5. The rates of unplanned hospitalization and ICU admission were 41.0% and 6.1%, respectively. In multivariable analysis, hypoalbuminemia (odds ratio [OR], 4.29; p < .001) and high comorbidity score (OR, 4.22; p < .001) were associated with likelihood of grade 3+ toxicity. Hypoalbuminemia (OR, 2.83; p = .003), high comorbidity score (OR, 3.93; p = .001), and receipt of EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin; OR, 5.45; p = .012) were associated with likelihood of unplanned hospitalization.

CONCLUSIONS

The majority of older adults receiving upfront therapy for aggressive NHL survive beyond 5 years, yet nearly half experience substantial treatment toxicities and unplanned hospitalizations. Our findings underscore the need for supportive care interventions to enhance the care experience of this population.

IMPLICATIONS FOR PRACTICE

The results of this study highlight the potential benefits of intensive chemoimmunotherapy for the majority of older adults with aggressive non-Hodgkin lymphoma, even at advanced ages. Nearly half of older adults experienced substantial treatment toxicities and unplanned hospitalizations, emphasizing the unmet need for supportive care interventions in this population. The present study also identified hypoalbuminemia and patient comorbidity score as factors associated with grade 3+ nonhematologic toxicity and unplanned hospitalization. These findings may guide the development and implementation of targeted supportive care interventions in high-risk older adults with aggressive non-Hodgkin lymphoma.

Giving Feedback

Effective feedback is critical to medical education in that it promotes learning and ensures that benchmark learning objectives are achieved. Yet the nature of and response to feedback is variable. In this article, the authors provide a comprehensive review of the effective feedback literature. Namely, they discuss the various approaches to feedback, their advantages and disadvantages, as well as barriers to providing effective feedback. Finally, they offer suggestions for steps both the feedback giver and receiver can take to foster a culture of successful feedback in an academic and clinical setting.

Types of Learners

There is a robust literature on learning styles. This literature rests on 3 assumptions: (1) Individuals have a preference for a particular style of learning, (2) Individuals learn better using their preferred style, and (3) Teachers should adjust their teaching to accommodate their learner's style. One benefit of understanding learning styles is to encourage in-depth learning. This article outlines commonly used learning styles and provides a literature review on the 3 assumptions. The authors conclude that although there is some evidence for learning styles, there is little justification for adjusting teaching methods to match individual styles.