CAPO Digest

CAPO Digests are summaries of recent psychosocial oncology research which have published in peer-reviewed journals in and out of the main psychosocial oncology outlets that may be of interest to CAPO members. We hope you enjoy these Digests. If you are interested in submitting a CAPO Digest please contact the CAPO office at [email protected].


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  • 14 May 2019 3:16 PM | Amy Snow (Administrator)

    Digest Commentator: Nicole Anna Rutkowski, PhD student in Clinical Psychology, School of Psychology, University of Ottawa

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto


    Digest Commentary

    Returning to work is an important milestone and financial necessity for many cancer survivors, however many misperceptions and barriers preclude survivors from successfully transitioning back into a working environment. This article addresses an important gap in cancer survivorship, as little research has been done within the Canadian context on cancer survivors’ experiences returning to work. The Canadian Partnership Against Cancer launched a Return to Work Initiative to gain a better understanding of Canadian cancer survivors’ needs as they transition back into the work force.  The purpose of this study was to determine survivors’ and caregivers’ concerns related to working, challenges employers face accommodating survivors, and ways to better support employees, managers, and caregivers.  

    In order to gain a comprehensive understanding, the Return to Work Initiative examined the perspectives of survivors, caregivers, and workplace representatives. During the preliminary phase, the researchers conducted a literature review, an environmental scan, and conducted key informant interviews. The findings suggested a shortage of services available to survivors experiencing challenges resuming work activities. With a greater understanding of the lack of resources and programs available for survivors, the researchers turned their focus to trying to understand the individual experience of survivors and their caregivers. A national online survey captured cancer survivors’ (n=410) and caregivers’ (n=60) challenges when returning to work. To gain the perspective of employers, in-depth interviews were conducted with 41 workplace representatives (i.e. managers, union leaders, insurers). After the initial analysis, results were reviewed and discussed with cancer survivors and employers through separate focus groups to develop solutions for identified challenges. Recommendations were developed on how to better meet the needs of cancer survivors returning to work.       

    Despite many survivors reporting feeling supported by employers, concerns remained. Major concerns for survivors included decreased income, an inability to resume previous work activities, a lack of accommodations, difficulties negotiating with employers, and a lack of information on assistive programs. Interestedly, many similar concerns were raised amongst employers, survivors, and caregivers. All expressed a need for more education on workplace accommodations, improved communication, and a need for additional community resources and supports. Additionally, receiving more information on how to access financial supports was deemed to be important by survivors and caregivers.  Employers expressed interested in addressing survivors’ return to work concerns, however they also encountered difficulties navigating insurance and government sponsored benefits for employees. Unfortunately, survivors re-entering the workplace were not seen as a priority due to the relatively low numbers of cases and an absence of re-entry policies for cancer survivors. Importantly, survivors expressed fears of informing employers of their diagnosis due to perceived negative repercussions on job duties, promotions, and possible termination. Limitations of the study included convenience sampling which likely contributed to a well-educated, predominately female sample and a high portion of breast cancer survivors (46%). Further, employers may have over emphasized the support provided to employees and minimized weaknesses.   

    Why I liked this article:

    This article provides insight into some of the barriers cancer survivors, caregivers, and employers face regarding return to work. By understanding the challenges and unique experiences of these groups we can begin to develop and implement adequate re-entry policies and programs to ensure cancer survivors receive appropriate support as they transition back to the work place.

    Fitch MI & Nicoll I. (2019). Returning to work after cancer: Survivors’, caregivers’ and employers’ perspectives. Psycho‐Oncology; 1-7. doi.org/10.1002/pon.5021

    Journal website: https://onlinelibrary.wiley.com/journal/10991611

    website: http://www.ccsrc.ca/AboutUs/our-team/margaret_fitch


  • 1 Apr 2019 4:56 PM | Jason Bell (Administrator)

    Digest Commentator: Breanna Lane, B.A. (Hons), Department of Psychology, Faculty of Science, Memorial University of Newfoundland

    Digest Editor: Mary Ann O'Brien, Ph.D., Department of Family and Community Medicine, University of Toronto


    Digest Commentary

    Fear of cancer recurrence (FCR) is one of the most prevalence, high priority and lasting psychosocial implications of a cancer diagnosis. Researchers have begun to examine the cognitive mechanisms that perpetuate FCR. Exploration of avoidance and cognitive appraisal as moderating factors for FCR and functioning has been unsuccessful. Rumination plays a disruptive role in cognitive functioning and emotional distress associated with anxiety and depression, and therefore may provide insight into the development of psychological illness for individuals with cancer. Liu et al. reported data from a cross-sectional study that examined potential interactions between FCR and rumination in relation to self-reported symptoms of anxiety and depression.

    Of the 927 approached to participate in the study, 388 eligible adults diagnosed with cancer were recruited following service utilization at the National University Cancer Institute Singapore. Eligible participants could understand English or Mandarin, were currently in remission, and completed treatment at least one year ago. Participants had a mean age of 55.6y(SD = 11.6y), 80.2% identified as female, and 70.7% reported being diagnosed with Stage I/II cancer. Participants completed a series of outcome measures including the Fear of Cancer Recurrence Inventory (FCRI), Ruminative Response Scale (RRS), and the Hospital Anxiety and Depression Scale (HADS). The FCRI severity scale, which has been validated independently as the FCRI Short Form, was also used in subsequent analysis.

    An interaction between FCR and rumination was associated with depression symptoms. When rumination was high in individuals with high FCR, rumination was associated with more severe depression symptoms compared to those with high FCR and low rumination. Independent of rumination, a significant relationship between high FCR and more severe depression symptoms remained. These relationships suggest that individuals with high FCR may ruminate or fixate on cancer fears, which contribute to low mood, negative thoughts, and distress. Using anxiety as the outcome the interaction between FCR and rumination was not replicated; individually FCR and rumination were associated with anxiety. Body-checking is a frequent behavioural reaction to FCR which can perpetuate fears and compulsive checking, and therefore it is possible that FCR could contribute to anxiety without individuals engaging in rumination. Finally, the significant association between rumination and anxiety suggests that anxious thoughts and feelings can create a cognitive cycle that contributes to anxiety symptoms. The cross-sectional design and symptom self-report limits the ability to determine causal factors contributing to mental health symptoms. However, overall, this study provides crucial insights into the relationships between essential psychological concerns often experienced by cancer survivors and illustrates the potential implications of maladaptive cognitive coping styles.


    Why I liked this article:

    With the development of novel treatments to target psychological symptoms associated with coping with cancer, greater insight into the mechanisms of change is essential for enhancing the efficacy and effectiveness of interventions. Individuals with high FCR and maladaptive coping strategies, like rumination, may be particularly vulnerable for developing severe symptoms of depression. Therefore, this study provides preliminary evidence for the use of interventions that disrupt rumination and teach alternative skills to assist with positive coping and reduce the risk for the development of psychopathology.

    Liu, J., Peh, C.-X., Simard, S., Griva, K. &  Mahendran R. (2018). Beyond the fear that lingers: The interaction between fear of cancer recurrence and rumination in relation to depression and anxiety symptoms. Journal of Psychosomatic Research, 111, 120-126. DOI: https://doi.org/10.1016/j.jpsychores.2018.06.004.

    Journal of Psychosomatic Research website: https://www.journals.elsevier.com/journal-of-psychosomatic-research

    Author Website: http://nusmedicine.nus.edu.sg/pcm/faculty-staff/expert-team-physicians-psychologist/rathi-mahendran/


  • 22 Jan 2019 3:58 PM | Anonymous

    Digest Commentator(s): David Michael Langelier MD, FRCPC, Dip CSCN (EMG), Cancer Rehabilitation Fellow, Princess Margaret Hospital, University of Toronto

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Digest Commentary

    Background: The expectation of health care providers to understand and appropriately prescribe complimentary therapies (CT) to cancer patients increases on an annual basis. Unfortunately, this increasing demand for physician competency in complimentary services have not yet been appropriately reflected in the way physicians are trained. Therefore, when confronted with a patient inquiring about various CTs, clinicians often look to clinical practice guidelines in order to safely and effectively prescribe outside their scope of knowledge. This article highlights areas of CT interest to patients and suggests particular CTs for future research and guideline development based on patient preferences.

    Research Design: In April 2018, Qureschi et al. published a more extensive analysis into survivor’s interest and use of CTs in the journal of Integrative Cancer Therapies. This involved a cross-sectional survey of 212 ambulatory cancer patients with no restrictions on tumor type, stage, or current treatment status. The study’s goals were to gather a more comprehensive picture of which CTs were being used, which were of highest interest, and whether particular physical symptoms, perceived stress, and spirituality were related to certain interests. The authors also examined barrier perception and whether clinical practice guidelines were available for CTs with the highest interest.

    Results: Overall, 75% of patients had used or were currently using CTs. The most frequently reported CTs were biologic (e.g. vitamins B12 and D, calcium) followed by mind/body (e.g. yoga, massage, mindfulness-based stress reduction), then energy-based (e.g. acupuncture) and alternative CTs (e.g. naturopathy). The largest perceived barriers were a lack of CT awareness and insufficient evidence on the CTs effectiveness. Lack of support from health providers contributed only minimally to CT participation. In all CTs except cannabinoids, higher levels of perceived stress corresponded to higher levels of CT interest.

    Importance: In the era of patient-centered-care, health care practitioners must acknowledge the high use of CTs and be attune to which CTs are important to the patient. This article highlights the specific CTs requiring a research focus and this corresponds to the gap in available clinical practice guidelines. To fill this gap, guidelines are needed particularly in the areas of biologic (i.e. vitamin B12, vitamin D) and mind-body (i.e. breathing/relaxation) CTs. Additionally, as a health care provider this article flags awareness and further education as two specific barriers to CT involvement. Health care providers in oncology have a shared responsibility to know and share the evidence behind various CTs with patients, even if the evidence is limited.

    Citation: Qureshi M, Zelinski E, Carlson LE. Cancer and Complimentary Therapies: Current Trends in Survivors’ Interest and Use. Integrative Cancer Therapies. 2018 Apr 1:1534735418762496. DOI: 101177/1534735418762496.

    Journal website: http://journals.sagepub.com/home/ict

    Author Website: https://lindacarlson.ca/about

  • 15 Aug 2018 2:10 PM | Anonymous

    Digest Commentator: Julia Parrott, Undergraduate student, School of Psychology, University of Ottawa

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Adolescents and young adults (AYA) (ages 15-39) with long term illnesses present a unique challenge for the clinicians addressing their palliative care. Spirituality and religiosity have previously been identified as important parts of helping cancer patients increase their quality of life. Yet, there is a lack of research in exactly how to address AYA religious and spiritual perspectives. AYA are in the process of defining who they are; shaping their own opinions on the meaning of life, independence and identity. Being sick while in this transitional phase makes them vulnerable to decreased physical and mental health outcomes. The purpose of this study was to identify ways to address the spiritual and/or religious components of palliative care in AYA’s with long term illness.

    Methods: The “Resilience in Adolescence and Young Adults” study was used for a subset of the sample (n=17). The authors looked at one site from this multisite, prospective longitudinal study and only included individuals aged 14-25 years at the time of their cancer diagnosis. To be eligible, the diagnosis required immediate treatment with multi-agent systemic chemotherapy. Nervous-system tumors were excluded because of the difference in treatment protocol. Quantitative data were analyzed from questionnaires completed at enrollment and qualitative data were collected from one-on-one semi-structured interviews. These interviews were transcribed and analyzed in three steps at three different time points; six months, six to 12 months and 12 to 18 months post-diagnosis. Researchers focused on the participants’ self-reported “religiousness” and “spirituality” and categorized the participants according to how they self-identified and not according to their qualitative narratives. The participants were not provided with definitions of religiousness and spirituality. The theme of hope was included in the qualitative analysis due to the frequency with which it was mentioned.

    Results:  Collectively, participants completed 44 interviews. Participants were about 17 years old and most were non-Hispanic white. More participants self-identified as “spiritual” rather than “religious”. Those who identified as “spiritual” and not necessarily “religious” were more likely to look for meaning but struggled with articulating their needs. This group was also more likely to express hopeful statements. Most AYA expressed some existential questioning. There was no consistent definition of religion or spirituality, but there was a common theme of hope. The AYA used hope to discuss the lessons they have learned, how they are going to approach the future and reconcile with the diagnosis. Those who rejected “religion” and “spirituality” demonstrated a negative perception of the divine or were truly agnostic. In the development of palliative guidelines for AYA, the authors emphasized respecting the AYA developing autonomy, while encouraging the exploration of spirituality even if the AYA do not outwardly express this interest. They recommend doing this through discussing hopes, worries, meaning, and changing life perspectives.

    Why I liked the article: I liked how the authors focused on respecting the AYA self-identification and allowed them to explore their own interpretation of spirituality and religion. By focusing on constructs that relate to spirituality like hope, worries, and meaning, care providers can help make these existential concepts more accessible. This could lead to improved support for AYAs in their spiritual journeys while battling cancer.

    Citation: Barton, K. S., Tate, T., Lau, N., Taliesin, K. B., Waldman, E. D., & Rosenberg, A. R. (2018). “I’m Not a spiritual person.” How hope might facilitate conversations about spirituality among teens and young adults with cancer. Journal of Pain and Symptom Management. doi:10.1016/j.jpainsymman.2018.02.001

    Journal website: http://www.jpsmjournal.com/


  • 15 Aug 2018 2:10 PM | Anonymous

    Digest Commentator: Maclean Thiessen MD MN BSc FRCPC, Breast and GI Medical Oncology Fellow, Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, Alberta; Scholar in Residence, The College, University of Calgary, Calgary, Alberta

    Digest Editor:  Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    In general, chemotherapy is administered for one of two reasons: 1) As part of a strategy to cure cancer or 2) as part of a strategy to control disease and improve survival and/or symptoms for patients whose malignancy cannot be cured. In many types of cancer, when chemotherapy is being used as part of a curative strategy, the most important part of the treatment strategy is surgery – with chemotherapy

    being given either before or after surgery to improve the chance that the cancer will not come back. Colon cancer patients who have disease limited to the colon, but have involvement of regional lymph nodes, are usually offered chemotherapy after surgery. Chemotherapy has been demonstrated to improve survival by about one third in patients with lymph node positive colon cancer (1, 2). Historically, chemotherapy is given for a total of six months to these patients. While chemotherapy can substantially reduce the risk of recurrence, receiving chemotherapy for half a year can have a substantial impact on a person’s life for many reasons including cumulative toxicity and prolonged time away from work.

    At the 2017 American Society of Clinical Oncology (ASCO) meeting, prospectively-designed pooled analysis of individual patient data from six large clinical trials was presented (3). In this analysis, patients with node positive, resected colon cancer had been randomized to receive either three or six months of standard post-surgical chemotherapy. At 39 months median follow-up, the shorter three-month treatment was found to be non-inferior(4) to the six-month treatment. In simple terms, non-inferiority means that, statistically, the three-month duration of treatment was found to be no worse than the six- month duration of treatment. In a subset analysis, three months of treatment was found to be inferior to six months, with three-year disease free survival decreased by 1.7% (95% CI = -4.3% to 0.9%) from 64.4% to 62.7% for patients who received three months of chemotherapy compared to those who received six months. Six months of treatment compared to three months of treatment was associated with higher rates of neurotoxicity, severe enough to interfere with activities of daily living.

    Why I liked the article: Less toxicity and faster completion of treatment will undoubtedly help to lessen the psycho-social impact of the colon cancer experience for many patients. While the results of this study have not matured, and other studies exploring three versus six months in this same population are underway, this report is exciting. These early results suggest that the biggest benefit of chemotherapy in this population occurs in the first three months, after which there may be an opportunity to further tailor treatment around patient’s pathological risk features and psycho-social needs.

    Citation:

    1. Andre T, de Gramont A, Study Group of Clinical Research in Radiotherapies Oncology OMRG. An overview of adjuvant systemic chemotherapy for colon cancer. Clin Colorectal Cancer. 2004;4 Suppl 1:S22-8.

    2. Andre T, de Gramont A, Vernerey D, Chibaudel B, Bonnetain F, Tijeras-Raballand A, et al. Adjuvant fluorouracil, leucovorin, and oxaliplatin in stage II to III colon cancer: Updated 10-year survival and outcomes according to BRAF mutation and mismatch repair status of the MOSAIC study. J Clin Oncol. 2015;33(35):4176-87.

    3. Shi Q, Sobrero A, Shields A, Yoshino T, Paul J, Taieb J, et al., editors. Prospective pooled analysis of six phase III trials investigating duration of adjuvant (adjuv) oxaliplatin-based therapy (3 vs 6 months)

    for patients (pts) with stage III colon cancer (CC): The IDEA (International Duration Evaluation of Adjuvant chemotherapy) collaboration. American Society of Clinical Oncology; 2017; Chicago, Illinois, USA. J Clin Oncol. 2017;35 (suppl; abstr LBA1).

    4. Mauri L, D&#39;Agostino RB, Sr. Challenges in thedesign and interpretation of noninferiority trials. N Engl J Med. 2017;377(14):1357-67.

    Journal website: http://ascopubs.org/doi/abs/10.1200/JCO.2017.35.18_suppl.LBA1

    Author Blog: http://macthiessen.weebly.com/


  • 15 Aug 2018 2:09 PM | Anonymous

    Digest Commentator: Sophie Lebel, PhD, C.Psych, School of Psychology, University of Ottawa

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Fear of cancer recurrence is a growing area of research, now with its own IPOS Special Interest Group called FORWARDS. As a researcher and clinician working on fear of cancer recurrence, I frequently get asked this question: “Fear of cancer recurrence is present in almost all of my patients but how can I help them deal with this fear? I am not sure it is something that can be changed”. Until recently, this feeling was warranted as there was only one published trial of an intervention to address fear of cancer recurrence (Herschbach et al, 2009), which showed that both group Cognitive Behavioral Therapy and group supportive expressive therapy were efficacious in reducing this fear. In November 2017, Butow and colleagues published the results of their trial of an individual therapy to address fear of cancer recurrence in cancer survivors in the Journal of Clinical Oncology. The intervention is called ConquerFear and consists of five face-to face individual sessions that cover attention training, metacognitions, acceptance/mindfulness, screening behavior, and values-based goal setting. Specifically, the intervention teaches strategies for controlling worry and excessive threat monitoring, modifying unhelpful beliefs about worry, and developing appropriate monitoring and screening behaviors, educates about follow-up and strategies (e.g., exercise) to reduce risk of recurrence, addresses existential issues, and promotes goal setting. One of the interesting features of this trial is that the intervention was compared to a nonspecific attention control intervention (five sessions of face-to-face relaxation training). The effects of the therapy were also assessed at 3- and 6-months post therapy. Participants (95% female) were 222 stage 0 to III breast, Dukes’ stage A to C colorectal, and Stage IA to IIB melanoma survivors who were disease-free and who displayed elevated levels of fear of cancer recurrence before being enrolled in the trial (as defined as a score of ≥ 13 on the Fear of Cancer Recurrence Inventory). Participants had completed adjuvant treatment 2 months to 5 years previously. They were randomly assigned to either ConquerFear or the control group. Twenty-six therapists from 17 sites across Australia participated and delivered both interventions. ConquerFear participants had clinically and statistically greater improvements than control participants from baseline to completion of the intervention on their fear of cancer recurrence score and these differences were still statistically significant at 3- and 6-month post-intervention. There were also significantly greater improvements reported by ConquerFear participants in general anxiety, cancer-specific distress, and mental quality of life and metacognitions from baseline to end of the intervention, however few of these differences were significant at the subsequent follow-ups. Interestingly, ConquerFear was effective regardless of baseline fear of cancer recurrence levels, stage of disease, age, education, and country of birth.

    Why I liked the article: In conclusion, yes, it is possible to help patients deal with their fear of cancer recurrence. A next step will be to see how these interventions fare when implemented in clinical settings.

    Citation: Butow PN, Turner J, Gilchrist J, Sharpe L, Smith AB, Fardell JE, Tesson S,O’Connell R, Girgis A, Gebski VJ, Asher R, Mihalopoulos C, Bell ML, Zola KG, Beith J, Thewes B. Randomized Trial of ConquerFear: A Novel, Theoretically Based Psychosocial Intervention for Fear of Cancer Recurrence. J Clin Oncol. 2017 Nov 2:JCO2017731257. doi: 10.1200/JCO.2017.73.1257.

    Journal website: http://ascopubs.org/doi/full/10.1200/JCO.2017.73.1257


  • 15 Aug 2018 2:08 PM | Anonymous

    Digest Commentator: Andrea Johnson, PhD (C), School of Social Work, University of British Columbia

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    As more adolescents and young adults (AYAs) (ages 15-39) are surviving a diagnosis of cancer, greater attention is being directed towards their psychosocial wellbeing as cancer survivors. Over the past decade, there has been increasing research and practice interest in the prevalence of mental health outcomes (eg. mood and anxiety disorders) experienced by this cohort after treatment. There is a small but robust literature base that has demonstrated peaks of psychological distress experienced by AYAs following treatment completion. However, what remains unknown are the associations between developmental life stage, cancer survivorship, and mental health outcomes for people diagnosed with cancer. Specifically, are AYAs at greater risk for adverse mental health outcomes when compared to cancer-free AYAs and older adult cancer survivors. This article reports on a study designed to answer this question.

    The Canadian Community Health Survey (CCHS) was used as a population-based instrument in this study. This survey collects annual health-related data from Canadians of different ages. The final sample size in this study was 239, 316 and this included four combined annual cycles (2007-2010) of respondents. This sample was dichotomized into AYAs (ages 15-39) and older adults (ages 40+). Outcomes of interest in this study were: self-perceived general health status, self-perceived mental health status, and self-reported mood and anxiety disorders diagnosed by a professional. Weighted logistic regression was used to analyze the relationships between age, cancer survivorship, and psychosocial outcomes of respondents.

    Cancer survivorship was found to be strongly associated with poor self-perceived mental health and mood and anxiety disorders among AYAs. AYA survivors of cancer were more likely to report mood and anxiety disorders than both AYAs without a history of cancer and older adults who were cancer survivors. This increased prevalence held for both self-perceptions of mental health and self-reported clinically diagnosed mood and anxiety disorders. Notably, 15.1% of AYA cancer survivors and 5.4% of AYAs without cancer reported a diagnosis of anxiety. 14.8% of AYA cancer survivors and 5.7% of AYAs without cancer reported a diagnosis of a mood disorder.

    This study advances understanding of the mental health outcomes of AYA cancer survivors. It clearly argues that it is the intersection between developmental stage and a history of cancer that leaves AYA cancer survivors vulnerable to distress.

    Why I liked the article: I really liked how this study compared psychological outcomes between AYAs with and without cancer. The psychological distress observed of AYA cancer survivors may be wrongly dismissed in practice as typical “storm and stress” expected of AYAs. The adverse mental health outcomes experienced by AYAs in this survey however surpassed those of AYAs without cancer. There remain significant gaps in AYA psychosocial oncology care. Greater efforts must be made to both understand and respond to the psychological distress experiences of AYAs.

    Article: Lang, M.J., Giese-Davis, J., Patton, S.B. & Campbell, J.T. (2017). Does age matter? Comparing post-treatment psychosocial outcomes in young adult and older adult cancer survivors with their cancer-free peers. Psycho-Oncology. Advance online publication. doi:10.1002/pon.4490.

    Journal website: http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1099-1611


  • 15 Aug 2018 2:07 PM | Anonymous

    Digest Commentators: Chelsea Moran, BSc, MA (c) &amp; Adina Coroiu, MA, PhD (c), Department of Educational

    and Counselling Psychology, McGill University

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Early detection and timely treatment of melanoma improves survival. Given that most melanomas are self-detected (by individuals or their partners), skin self-examination (SSE) is an important adjunct to yearly skin examinations by a physician. Partners can help at-risk individuals check body areas that are more difficult to examine carefully, such as the scalp and back. Robinson and colleagues (2016) examined the long-term effect of a structured educational intervention on participant frequency of SSE conducted with a partner.

    This study analyzed data from a randomized controlled trial (RCT; NCT01432860), in which melanoma patients with stage 0 to IIB melanoma and their skin-checking partners were randomized to one of three active intervention conditions or a control. The three active conditions included identical content, which was delivered in three different formats: in-person education, workbook education, and electronic tablet education. The active intervention included monthly SSE recommendations, written materials about how to use the ABCDE (asymmetry, border, color, diameter and evolution) criteria to identify suspicious lesions, a diary and body maps to record SSE and track mole history, and reinforcement of skills by dermatologists at 4-month intervals. The control condition included customary education, as per usual care. The aim of the study was to assess the effect of the intervention compared to the control on three outcomes: 1) frequency of SSE (objective 1); 2) patient-detected and physician-detected new or recurrent melanomas (objective 2); and 3) number of unscheduled physician appointments (objective 3). The three outcomes of interest were assessed at 4, 12, and 24-months post-intervention.

    In total, 494 dyads were randomized with 59% completion by the 24-month follow-up. Since there were no significant differences in SSE frequency among the intervention groups, the three groups (in-person, workbook, tablet) were collapsed into one group. From baseline to 24-months post-intervention, participants in the intervention groups (in-person, workbook, tablet) performed SSE with a partner at a significantly higher frequency than participants in the control group (objective 1). From baseline to 24-months post-intervention, dyads in the intervention groups identified 43 melanomas compared to none identified in the control group (objective 2). Across the entire sample, approximately 13% of participants developed new melanomas. Finally, 28 participants in the intervention groups and 2 participants in the

    control group requested unscheduled appointments with the study physicians due to concerning lesions, accounting for only 1.0% of total physician visits (objective 3). The authors concluded that the interventions led to increased SSE performance and increased detection of melanoma in patient-partner dyads, without leading to unnecessary visits to the dermatologist.

    Why we liked this article: We liked this article because it underscored the importance of interventions for the early detection of melanoma, as well as the importance of partner assistance with skin self-examination among high-risk groups. Further, this trial is one of the first studies with a rigorous design to show that interventions targeting SSE did not actually increase the number of unscheduled medical visits lending some support to claims that SSE may be a cost-effective behaviour. This is valuable work that will generate further research on the effect of SSE interventions on melanoma early detection and melanoma-related mortality.

    This study is a step forward in melanoma prevention literature in that it shows that receiving education about monthly SSE using the ABCDE criteria and tools such as body maps and checking diaries is associated with an increase in SSE with the help of a partner when compared to customary education. The results of this study have important implications for psychosocial professionals working with melanoma cancer survivors, as they reaffirm the need for specific education to promote regular SSE performance. When possible, practitioners should also encourage patients to obtain assistance from their partners when checking their skin to ensure more complete self-exams.

    Article: Robinson, J. K., Wayne, J. D., Martini, M. C., Hultgren, B. A., Mallett, K. A., &amp; Turrisi, R. (2016). Early detection of new melanomas by patients with melanoma and their partners using a structured skin self-examination skills training intervention: A randomized clinical trial. JAMA Dermatology, 152(9), 979-985.

    Journal website: http://jamanetwork.com/journals/jamadermatology/

    Author website: http://www.feinberg.northwestern.edu/faculty-profiles/az/profile.html?xid=12499


  • 15 Aug 2018 2:07 PM | Anonymous

    Digest Commentator: Marguerite Gollish, B.A., University of Ottawa

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Latino cancer patients present a higher risk for poor mental health outcomes than non-Latino whites, with higher rates of depressive symptoms for Latinas with breast cancer. Given these results, it is concerning that Latinos are also less likely than non-Latino whites to receive treatment and services to improve these outcomes. The study by Costas-Muniz and colleagues aimed to investigate interest in and self-reported use of psychosocial services before and after a breast cancer diagnosis, comparing groups of Latina and non-Latina white cancer survivors.

    Methods: A questionnaire was mailed to 409 Latina and 514 non-Latina white breast cancer survivors who were in remission and who had received treatment at a single comprehensive oncology centre in the United States. Ninety-seven Latinas and 168 non-Latina white patients returned the questionnaire with an overall response rate of 30%. The questionnaire contained demographic and medical items, and self-reported use of psychosocial services before and after the cancer diagnosis. The type of service and type of professional was assessed, as well as frequency of service use.

    Results: Both Latinas and non-Latina white breast cancer survivors had similar rates of contact with a psychological service provider prior to diagnosis (34%), except for religious counselling. Non-Latina whites were less likely (6%) to have had contact with a religious counsellor than Latinas (13%). After diagnosis, 43% of participants (49% Latinas and 40% non-Latina whites) reported needing or wanting psychosocial services, but of these only 61% reported using a psychosocial service. While Latinas were less likely to have had contact with social workers and to use psychotropic medication, there were no significant differences between the groups when it came to contact with psychologists or psychiatrists, or the use of psychotherapy or counselling. Although there were no significant differences in the proportion of Latinas and non-Latina whites who reported needing psychosocial services, non-Latina whites were overall more likely to have had more frequent contact with a mental health professional.

    Why I liked the article: The authors provided particularly interesting considerations of how cultural and linguistic issues could explain the differences in the use of religious counselling and the use of psychotropic medication. It demonstrated a need for interventions for breast cancer survivors that take these cultural and linguistic differences into account.

    Article: Costas-Muñiz, R., Hunter-Hernández, M., Garduño-Ortega, O., Morales-Cruz, J., & Gany, F. (2017). Ethnic differences in psychosocial service use among non-Latina white and Latina breast cancer survivors. Journal of Psychosocial Oncology, 1–14.  https://doi.org/10.1080/07347332.2017.1310167

    Journal website: http://www.tandfonline.com/toc/wjpo20/current

    Author website: http://vivo.med.cornell.edu/display/cwid-roc2032


  • 15 Aug 2018 2:06 PM | Anonymous

    Digest Commentator: Keith Wilson, PhD, CPsych. Emeritus Clinician Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute

    Edited by: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    For most women undergoing chemotherapy for breast cancer, hair loss (alopecia) is a distressing side effect of treatment. It has been known for some time that cooling the scalp during chemotherapy sessions can reduce the extent of alopecia in some people. The mechanism seems to be that cooling the scalp reduces blood flow – and the corresponding delivery of toxic chemotherapy drugs – to the sensitive hair follicles. Commercial cooling machines have been developed, and are available for use in some centres. To date, however, the efficacy of scalp cooling for preventing chemotherapy-induced alopecia has never been evaluated in a large randomized controlled trial.

    Nangia et al (2017) conducted a multi-centre study of 182 women with Stage I-II breast cancer who were receiving adjunct taxane-based or anthracycline-based chemotherapy which typically cause marked alopecia. Participants were assigned randomly to a scalp-cooling protocol or to a control group that did not receive scalp cooling. The cooling protocol required patients to wear a helmet-like cap for 30 minutes before each chemotherapy session, during the session, and for 90 minutes after. A liquid coolant was circulated through the cap to reduce scalp temperature. The primary outcome for hair preservation was a standard grading system, in which a clinician rated the extent of the patient’s hair loss.

    The authors reported that 142 patients, 95 in the cooling group and 47 in the control were evaluable in a planned interim analysis. Of the 95 patients who received the cooling protocol, 5%  had no hair loss at all, and a further 45% had <50% loss: an overall response rate of 50%. None of the control participants achieved that degree of hair preservation. Furthermore, all of the control participants went on to wear a wig or head wrap in their daily lives, whereas 37% of the treatment group felt no need to do so.

    This study also examined whether broad domains of quality of life were improved with the scalp cooling intervention, but there was no evidence that depression, anxiety, or social functioning were different between the two groups. It was also noted that different sites of the multi-centre trial had different success rates; apparently, there are technical issues involved in fitting the cooling caps that require training. Interestingly, however, a companion article in the same issue of JAMA reported that in routine use, up to 66% of patients can be helped with this approach.

    Why I liked this article: There are individual differences in how people respond to chemotherapy-induced alopecia. Some women embrace their hair loss, some accept it with resignation, and others feel stigmatized. The value of scalp cooling in reducing this troubling side effect seems to be underestimated. As with most novel interventions, there are unanswered questions – including who will pay the estimated $2000 to $4000 cost per patient. Concurrent scalp cooling during a chemotherapy session can also be quite uncomfortable for some individuals. In general, however, it is remarkable that a cosmetically meaningful reduction in alopecia can be achieved in about 50% of women who are receiving chemotherapy for breast cancer, using such a low-tech concept. That’s pretty cool.

    Article. Nangia, J., Wang, T., Osborne, C., Niravath, P., Otte, K., Papish, S., Holmes, F., Abraham, J., Lacouture, M., Courtwright, J., Paxman, R., Rude, M., Hilsenbeck, S., Osborne, C.K., & Rimawi, M. (2017). Effect of a scalp cooling device on alopecia in women undergoing chemotherapy for breast cancer: the SCALP randomized clinical trial. Journal of the American Medical Association, 317, 596-605. doi:10.1001/jama.2016.20939

    Journal website: http://jamanetwork.com/

    Dr. Morris’ university webpage: http://surgery.med.umich.edu/general/patient/faculty/ammsurg.shtml


    CAPO Digests are summaries of recent psychosocial oncology research which have been published in peer-reviewed journals in and out of the main psychosocial oncology outlets that may be of interest to CAPO members. We hope you enjoy these Digests. If you are interested in submitting a Digest please contact the CAPO office at [email protected]


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