CAPO CAPO Digest

LAST THREE DAYS TO REGISTER FOR THE CAPO CONFERENCE SOCIAL AND NETWORKING EVENT

Mon, 27 May 2024 13:54:37 GMT

LAST THREE DAYS TO REGISTER!

CAPO Conference Social & Networking event

Thursday, June 6, 2024, 7 to 10 p.m., National 10th Avenue, 341 10 Ave SW, Calgary AB.

Come join us for a special meet up of friends and colleagues at National 10th Avenue. Pack your best western accessory and get ready to eat, laugh and dance!

National is a restaurant & entertainment venue inspired by North American tastes, with games and events, extraordinary food, and select craft beers. A place filled with Calgarians who embrace being Calgarian, National is the ideal place to unwind with friends or host a private event.

Registration to the social includes light food to suit all tastes, and two drink tickets.

Advanced registration is required.

Fees: $65 (Open to all)

REGISTER HERE: https://www.capo.ca/event-5725513

(Ex‑) breast cancer patients with (pre‑existing) symptoms of anxiety and/or depression experience higher barriers to contact health care providers during the COVID‑19 pandemic

Peter Traversa — Fri, 23 Apr 2021 21:19:04 GMT

Digest commentator: Tori Langmuir, BSc, clinical research coordinator at the Ottawa Hospital Research Institute and the University of Ottawa

Background

The impact of the COVID-19 pandemic on the health care system needs no introduction; it has been unprecedented. During the early months of the pandemic, Canada, the Netherlands, and the United Kingdom reported sharp decreases in cancer diagnoses, screening, and surgeries, leading many experts to express concern about “a tsunami of cancer” after the pandemic. Delayed appointments due to increased real or perceived barriers to accessing health care may negatively affect a patient’s psychosocial and physical wellbeing, as well as their prognosis. Among cancer patients and survivors, symptoms of anxiety and/or depression have been shown to negatively affect health care consumption, particularly during a health threat as significant as COVID-19. The present study measured the prevalence of anxiety and depression among a large cohort of breast cancer survivors during the early months of the COVID-19 pandemic, as well as the association between the presence of these symptoms and health care consumption impacted by COVID-19.

Method

This cross-sectional study was conducted with a large prospective observational multi-centre cohort of ex-breast cancer patients called the “Utrecht cohort for Multiple BREast cancer intervention studies and Long-term evaLuAtion” (UMBRELLA). All participants completed self-report questionnaires including the Hospital Anxiety and Depression Scale (HADS) at regular time points during and after their breast cancer treatment. Active participants who enrolled in the UMBRELLA cohort between October 2013 and April 2020 were sent an online survey on April 7, 2020 that included the HADS and COVID-19-related questionnaires.

Results

Of the 3239 participants enrolled in the UMBRELLA cohort, 1595 met the inclusion criteria. Of those, 1051 (66.0%) completed the COVID-19-specific questionnaire. Overall, 284 (27.0%) of participants experienced clinically relevant symptoms of anxiety and/or depression during COVID-19. Of the participants who experienced symptoms of anxiety and/or depression during COVID-19, 62.7% (n = 156) had experienced these symptoms prior to the COVID-19 pandemic. During the pandemic, a total of 18.2% (n = 191) of all participants reported symptoms of anxiety and 16.0% (n = 168) reported symptoms of depression. The reported rates of anxiety and/or depression were slightly but significantly lower than before the pandemic (23.4%, n = 220). Factors associated with anxiety and/or depression during COVID-19 were lower age, higher stage of cancer, receipt of systemic therapy or radiotherapy and pre-existing symptoms of anxiety or depression.

Participants with anxiety and/or depression reported significantly higher barriers to contacting their general practitioner (GP; 47.5% vs. 25.0%, resp.) and their oncologists (26.8% vs. 11.2%, resp.) compared to patients without these symptoms. A higher proportion of participants with anxiety and/or depression reported that their current treatment (or follow-up treatment) was affected by COVID-19 compared to those without symptoms (32.7% vs. 20.5%, resp.).

Why I liked this article

This study has two important findings. First, breast cancer survivors experienced increased barriers to accessing important health care services during the COVID-19 pandemic, and those who have reported symptoms of depression and/or anxiety were more likely to report barriers. Second, survivors with pre-existing anxiety and/or depression were more likely to report increased symptoms of anxiety and depression during the COVID-19 pandemic. These survivors may have a higher risk of not only experiencing increased distress during the pandemic [relative to their non-anxious and/or depressed counterparts], but of not accessing health care services. These two groups may benefit from psychosocial support to improve their mental well-being and decrease perceived barriers to accessing health care.

I also would like to acknowledge the use of the phrase “(ex-)breast cancer patients” used throughout this article. In my interactions with cancer survivors, some have expressed disdain or frustration with the term “survivor”; it seems to trigger the occasional emotional reaction. Consequently, in some of our research, we have replaced the term with “patients who have completed cancer treatment”. The phrase “ex-breast cancer patients” could be a useful alternative.

Caution:

The data collection for this study began on April 7, 2020 and it is unclear when data collection ended. The article was submitted to the journal in late October, so one could estimate that data collection lasted no longer than a few months. It is worth considering that symptoms of anxiety and/or depression in ex-breast cancer patients (including those with pre-existing symptoms) may have been higher during the early spring months of the COVID-19 pandemic, which were marked by global uncertainty and fear, compared to the later summer months, when case numbers decreased, or the fall months, when vaccines were announced. It is possible that symptoms of anxiety and/or depression may have continued to decrease throughout the course of the pandemic, impacted by factors such as habituation, coping, and increased public knowledge/preventative measures (masks, social distancing, lockdowns). This of course would be mediated by several factors including employment, social support, financial support, diagnosis, and severity of pre-existing symptoms.

Additionally, this study was conducted with breast-cancer patients only, therefore generalization to men, or other cancer diagnoses, is not direct.

Original Article

Mink van der Molen, D. R., Bargon, C. A., Batenburg, M., Gal, R., Young-Afat, D. A., van Stam, L. E., van Dam, I. E., van der Leij, F., Baas, I. O., Ernst, M. F., Maarse, W., Vermulst, N., Schoenmaeckers, E., van Dalen, T., Bijlsma, R. M., Doeksen, A., Verkooijen, H. M., & UMBRELLA study group (2021). (Ex-)breast cancer patients with (pre-existing) symptoms of anxiety and/or depression experience higher barriers to contact health care providers during the COVID-19 pandemic. Breast cancer research and treatment, 186(2), 577–583. https://doi.org/10.1007/s10549-021-06112-y

Association of Mental Health Treatment With Outcomes for US Veterans Diagnosed With Non–Small Cell Lung Cancer

Mon, 22 Feb 2021 15:58:22 GMT

Digest Commentator: David Mackay, MD Student, Cumming School of Medicine Class of 2021, University of Calgary

Digest Editor:

Jacob E. Berchuck, MD; Craig S. Meyer, PhD, MPH; Ning Zhang, MS; Caroline M. Berchuck, MD; Neil N. Trivedi, MD; Beth Cohen, MD; SunnyWang, MD

Background:

The link between mental and physical health is an important aspect of health outcomes. Numerous studies have explored this fundamental connection. Researchers have long established a relationship between pre-existing mental health disorders and poorer health outcomes. In psychosocial oncology, studies have found higher rates of cancer-related mortality among individuals with pre-existing mental health disorders than in the general population. Lung cancer is the leading cause of cancer related death in Canada and the US. In Canada, in 2020, it was the cause of 1 in 4 cancer related deaths. Roughly half of all lung cancers diagnosed in Canada are diagnosed at stage 4. Non-small cell lung cancer is the most common type of lung cancer diagnosed. Studies have shown that preexisting mental health disorders in patients diagnosed with lung cancer are associated with increased mortality. This study asks the question “Is mental health treatment associated with improved outcomes for people with pre-existing mental health disorders after they are diagnosed with cancer?” It evaluates the association of participation in mental health treatment programs, housing support programs, or employment support programs associated with stage at non-small cell lung cancer diagnosis, receipt of stage-appropriate treatment, and mortality among patients with a pre-existing mental health disorder.

Methods:

This retrospective, population-based cohort study looked at data on 55,315 veterans using the Veterans Affairs Central Cancer Registry. This group of veterans all had newly diagnosed non–small cell lung cancer (diagnosed between September 30, 2000, to December 31, 2011). This cohort was separated into three groups: mental health disorder, other mental health disorder, and no mental health disorder. Data were analyzed from January 15, 2017, to March 17, 2020.

Mental health disorders were identified using ICD-9 Codes. To fall in to the mental health disorder category, participants had to have an ICD-9 Code for schizophrenia, bipolar disorder, depressive disorder, anxiety disorder, posttraumatic stress disorder, or substance use disorder linked to their name and listed twice in an outpatient setting or once in an inpatient setting. Researchers also included an other mental health disorder group for participants with diagnoses not specified in the mental health disorder group. These included ICD-9 diagnosis codes 290 to 310 – organic psychotic conditions, other psychoses, neurotic disorders, personality disorders, and other nonpsychotic mental disorders – (except for dementia and tobacco use disorder).

Researchers then determined which participants in the mental health disorder and other mental health disorder groups participated in evidence based programs designed to address mental health needs, substance use, housing and employment needs. Specific programs looked at in this study were mental health intensive case management for schizophrenia and bipolar disorder, psychotherapy for depressive and anxiety disorders, PTSD therapy, and substance use treatment programs. To ascertain participation in these programs, researchers used Current Procedural Terminology codes and Veteran Affairs stop codes (this is a Veteran Affairs coding system used to capture workload data).

As outcome variables, researchers in this study compared (1) the hazard of mortality between patients with individual mental health disorders versus those with no mental health disorder; and (2) patients with individual mental health disorders who participated in evidence-based mental health treatment programs specific to that mental health disorder versus those that did not. Patients with multiple ICD-9 codes associated with their name, and thus multiple mental health disorders, were included in the analysis for each individual mental health disorder.

Results:

Of 55,315 veterans with a new diagnosis of non-small cell lung cancer included in the analysis (98.1% men; mean [SD] age, 68.1 [9.8] years), 18,229 had a preexisting mental health disorder. Patients with any mental health disorder had increased all-cause mortality (adjusted hazard ratio [AHR], 1.03; 95% CI, 1.01-1.06; P = .008) and lung cancer–specific mortality (AHR,1.03; 95% CI, 1.01-1.06; P = .02). Schizophrenia and other mental health disorders were the only individual mental health disorders that were associated with an increased hazard of all-cause mortality (AHRs, 1.09 [95% CI, 1.03-1.16; P = .047] and 1.09 [95% CI, 1.04-1.13; P < .001], respectively) and lung cancer–specific mortality (AHRs, 1.10 [95% CI, 1.02-1.18; P = .01] and 1.07 [95% CI, 1.02-1.13; P = .006], respectively).

Among individuals with both a diagnosis of non-small cell lung cancer and a pre-existing diagnosis of a mental health disorder, participation in mental health treatment programs was associated with a lower likelihood of being diagnosed in a late stage (odds ratio [OR], 0.62; 95%CI, 0.58-0.66; P < .001), a higher likelihood of receiving stage-appropriate treatment (OR, 1.55; 95%CI, 1.26-1.89; P < .001), lower all-cause mortality (AHR, 0.74; 95%CI, 0.72-0.77; P < .001), and lower lung cancer-specific mortality (AHR, 0.77; 95%CI, 0.74-0.80; P < .001). Participation in housing and employment support programs was also associated with similar improvements in all of the outcomes listed above.

Why I Like This Article:

The link between physical and mental health is a fascinating and important one. Systemic hurdles in accessing care and delayed treatment affect mortality outcomes for patients with mental health disorders. This article highlights how mental health support and treatment programs can have a positive impact on health and mortality outcomes for a specific disease.

Evidently, discrepancies in access to mental health resources continue to affect outcomes for patients. This is concerning and an area of research and policy change that I think we will continue to see grow over the coming years. The bottom line of this research is that the association between mental health disorders and an increased risk of mortality due to non-small cell lung cancer is a notable one; participation in programs that support mental health and social needs can improve health outcomes for this group.

Caution:

The strong association between mental health disorders and increased mortality does not mean that this is the sole, or even the greatest contributing factor.

In this study, multivariate models were adjusted for age, sex, race, marital status, Charlson comorbidity score, smoking status (never, former, or current), substance

use (except for patients with substance use disorder), and year of diagnosis. Understandably, not all variables can be controlled for in this type of research. Factors possibly predictive of outcomes, such as education, socioeconomic status, severity of mental health disorder, and urban vs rural residency were not controlled for.

Of note, the population studied here consists almost entirely of men, so generalization of the results to women is not direct or clear. Patients who participated in mental health treatment programs in this study were younger and had fewer comorbidities. This study also did not include participants who were diagnosed with a mental health disorder after their cancer diagnosis. Finally, treatment outside of the Veterans Health Administration may not have been captured.

Citation of Original Article:

Berchuck JE, Meyer CS, Zhang N, et al. Association of Mental Health Treatment With Outcomes for US Veterans Diagnosed With Non–Small Cell Lung Cancer. JAMA Oncol. 2020;6(7):1055–1062. doi:10.1001/jamaoncol.2020.1466

(https://jamanetwork.com/journals/jamaoncology/article-abstract/2766567)

Other Research Mentioned:

Kisely S, Crowe E, Lawrence D. Cancer-Related Mortality in People With Mental Illness. JAMA Psychiatry. 2013;70(2):209–217. doi:10.1001/jamapsychiatry.2013.278

Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics: A 2020 special report on lung cancer. Toronto, ON: Canadian Cancer Society; 2020. Available at: cancer.ca/Canadian-Cancer-Statistics-2020-EN

Arrieta O, Angulo LP, Núñez-Valencia C, et al. Association of Depression and Anxiety on Quality of Life, Treatment Adherence, and Prognosis in Patients with Advanced Non–Small Cell Lung Cancer. Ann Surg Oncol. 2013;20(6):1941-1948. doi:10.1245/s10434-012-2793-5

Lin J, McGlynn KA, Carter CA, et al. The Impact of Preexisting Mental Health Disorders on the Diagnosis, Treatment, and Survival Among Lung Cancer Patients in the US Military Health System. Cancer Epidemiol Biomarkers Prev. 2016;25(12): 1564-1571. doi:10.1158/1055-9965.EPI-16-0316

Disparity in Cancer on All Levels

Thu, 10 Sep 2020 12:34:08 GMT

Digest Commentator: Dr. Violet D'Souza, PhD, MS, MSc, BDS. Research Associate, Faculty of Dentistry, University of Toronto

Background:

Cancer disparity continues to exist worldwide, affecting those with limited access to care, especially those living in rural areas. Compared to those living in urban areas, rural cancer survivors are less informed and experience higher levels of anxiety and distress, non-cancer-related comorbidities, and mortality. The study described the common health information needs of breast, prostate, and colorectal cancer survivors living in rural areas.

Methods:

This cross-sectional study was conducted with breast, prostate, and colorectal cancer survivors who received treatment at the Wake Forest Baptist Comprehensive Cancer Center in North Carolina. Participants were between two to five years post-diagnosis, at least 40 years of age, spoke English, and lived in a small town or rural area. The rurality was defined based the Zip code. The data were collected through a mailed/telephone-administered survey, which included 23 health information needs questions (binary outcomes) on follow-up care topics under eight domains: tests and treatment, side effects and symptoms, emotional and interpersonal needs, health promotion, fertility, occupation, and insurance. A large proportion of the questions were taken from a National Cancer Institute study on health information needs in adult cancer survivors.

Results:

Of the contacted 345 cancer survivors, 170 with complete data were included in the analyses. Of them, 74 had prostate cancer, 69 had breast cancer, and 27 had colorectal cancers. The most common information needs were about side effects and symptoms (58%), health promotion (54%), tests and treatment (41%), decreasing the risk of future cancers (36%), nutrition and diet (30 %), weight (26 %), and physical fitness (25 %). Furthermore, over 25% reported needing more information about symptoms, late and long-term side effects, how to deal with fatigue, and when to seek medical attention. The number of endorsed needs were significantly higher for younger participants, those belonging to an ethnic minority, the less educated, and the financially stressed when compared with older participants who were not a member of an ethnic minority, possessed higher levels of education, and were not financially stressed.

Why I like this article:

The findings of this study are valuable given the paucity of literature on rural cancer survivors. Indeed, this is one of the largest studies ever conducted on rural cancer survivors. This study helps to identify vulnerable survivors among those living in rural areas: those with a younger age, lower education, lower income, and ethnic minority members. The side-effect-related questions were endorsed by 20-30% of participants, suggesting their value in exploring the unmet informational needs of cancer survivors. Given the differences in the healthcare system and demographics between the US and Canada, it might be interesting to explore them in Canadian cancer survivors.

Caution:

Even though risk cannot be estimated in cross-sectional studies, the authors of this study used risk ratios as the measure of effects.

Original article:

Palmer NR, Avis NE, Fino NF, Tooze JA, Weaver KE. Rural cancer survivors' health information needs post-treatment. Patient Educ Couns. 2020;103(8):1606-14.

Journal website: https://www.sciencedirect.com/journal/patient-education-and-counseling/vol/103/issue/8

A Speedy Rehabilitation: A One-Week Scandinavian Inpatient Rehabilitation Program

(Past member) — Wed, 26 Jun 2019 16:20:42 GMT

Digest Commentator: Georden Jones, Ph.D. Student in Clinical Psychology, University of Ottawa, supervised by Dr. Sophie Lebel

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

Background:
Cancer survivors are faced with multiple physical and psychological symptoms which significantly impact their quality of life. Rehabilitation programs including physical and psychological components have demonstrated effectiveness to improve patients’ function and return to normal lives, however little is known about optimal duration of rehabilitation programs and factors associated with clinically relevant change. This study aimed to assess outcomes (health-related quality of life (HRQOL), fatigue, and level of physical activity) following a one-week Inpatient Educational Program (IEP) and investigate factors associated with clinically relevant change.

Methods:
Breast, prostate and gastrointestinal patients who were diagnosed within the past ten years and referred to the IEP at The Norwegian Resource Center for Coping with Cancer (Montebello-Center) were invited to participate in the study. A Norwegian general population sample (NORMS) was used as a comparison group. The IEP was offered over 6 days for a total of 30 hours and aimed to improve participants’ level of coping with cancer-specific health problems and to motivate the participants to adopt a healthy lifestyle. The IEP was facilitated by a multidisciplinary healthcare team and was comprised of lectures (50-55%), guided group physical activity (20-25%), and group sessions (25%). Topics included: cancer and its treatment, risk of adverse effects, work, social resources and support, sexuality, psychological reactions, and lifestyle.

Participants completed questionnaires prior to the IEP (T0) and three months post-IEP (T1). The questionnaire package included sociodemographic and medical questions, the Fatigue Questionnaire, the Medical Outcomes Study Short Form 36 (SF-36), and the Nord-Trondelag Health Study Physical Activity Questionnaire (HUNT 1 PA-Q).

Results:
Of the 482 patients who were invited to participate, 332 (69%) agreed. At T1 235/482 (49%) participants completed pre and post measures. The median age of participants was 59.4 y, 63% of participants were female, 57% were diagnosed with breast cancer, 32% prostate cancer, and 11% gastrointestinal cancer. At both time points, participants had higher levels of fatigue and lower levels of HRQOL than the NORMS. Females showed significant changes in physical and total fatigue and in general health and vitality. Males showed improvement in role limitations due to physical problems. No changes were found in level of physical activity. Clinically relevant improvements on significant outcomes ranged from 30-36% and higher education and relapse or progression before T0 were associated with higher improvement in total fatigue scores for females. Study limitations include the lack of a control group, low participation rates at T1 (49%), and the sample may be more representative of females diagnosed with breast cancer.

Why I liked this article:
This study demonstrated that short-term rehabilitation programs may be effective in improving psychosocial outcomes for cancer survivors and that tailoring content and activities by gender may be needed to target specific outcomes.

Health rehabilitation programs are available in Canada for diverse chronic illnesses such as cardiac illnesses, stroke, and acquired brain injuries whereas such programs are less common in oncology. However, oncology rehabilitation programs are more commonly offered in other Western countries such as Norway. This raises questions for me 1) Does the Canadian healthcare system perceive cancer more as an acute illness compared to other countries? 2) Could moving towards a rehabilitation model of cancer survivorship care improve survivors’ transition from tertiary to primary care in the Canadian healthcare system?

Citation of original article: Gjerset, G. M., Kiserud, C. E., Loge, J. H., Fosså, S. D., Wisløff, T., Gudbergsson, S. B., ... & Thorsen, L. (2019). Changes in fatigue, health-related quality of life and physical activity after a one-week educational program for cancer survivors. Acta Oncologica, 1-8.

Journal website: https://www.tandfonline.com/toc/ionc20/current

"Rather one more chemo than one less...": Oncologists and oncology nurses' reasons for aggressive treatment of young adults with advanced cancer

(Past member) — Wed, 29 May 2019 17:18:29 GMT

Digest Commentator(s): Jonathan Avery, Ph.D., Post-Doctoral Research Fellow, Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network, Toronto)

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

In caring for patients with advanced cancer, there may come a time when clinicians have to tell their patients that tumor-directed treatments are no longer effective, and the side-effects and complications outweigh the benefits. In such cases, a timely decision to stop this type of treatment is associated with better patient outcomes. However, empirical research has demonstrated a tendency towards more aggressive tumor directed therapy closer to end of life (EOL) particularly in the adolescent and young adult (AYA) population. In the article “Rather one more chemo than one less. . .”: Oncologists and Oncology Nurses’ Reasons for Aggressive Treatment of Young Adults with Advanced Cancer, Laryionava et al. explored the reasons as to why this tendency occurs.

Twenty-nine qualitative face-to-face semi-structured interviews were conducted with oncologists (n= 22) and nurses (n= 7) working at the Department of Hematology & Oncology at the University Hospital of Munich, Germany. The sample consisted of fellows (n= 13; 45%), senior physicians (n= 9; 31%), and nurses (n= 7; 24%), who varied in their working experience from 8 months to 34 years. Their age range was 22–64 years. An interview guide was developed that asked specific questions and probes about oncologists and oncology nurses’ views on treatment decisions with young adult patients with advanced cancer. Interviews were analyzed using the grounded theory approach.

The authors highlight three themes that explain the tendency for more aggressive treatments with AYA closer to EOL: 1) Patient’s preference for further treatment; 2) Oncologists and nurses’ perception of unfairness of dying at a young age; 3) Oncologist’s identification with patients.

Why I liked this article

What is most interesting about this article is how the results illustrate the decision to stop tumor-directed therapy with AYA is complicated and multi-factorial involving the consideration of patient preferences and, what the authors describe as, the “emotional entanglement” of clinicians. This entanglement emerges from the clinicians’ own thoughts and feelings from treating a young adult dying from cancer. Participant quotations highlight that not only does it feel unfair when young adult dies from cancer, there appears to be something inherent with the stage of life of the AYA that “we”, as health professionals, reflect fondly on. Falling in love, having a family, and establishing our lives are significant and meaningful life experiences that we value and cherish. Caring for young adults with advanced cancer and seeing their hopes and dreams ripped away is very difficult to witness because of our own experiences and fondness for that stage of life. This difficulty appears to be impacting the clinical judgement as to whether aggressive tumor-directed treatments close to end of life would be an appropriate or effective mode of therapy for AYA.

As a post-doctoral research fellow developing my own program of research, I find this type social dynamic between clinician and patient very interesting. For better or for worse, the emotional entanglement emerging from this study can at times impact how care is provided. I hope to explore this type of dynamism in my own research particularly in the area of AYA palliative care to ensure that both clinicians’ and patients’ well-being are considered when approaching difficult circumstances such as EOL care.

Laryionava K, Heubner P, Hiddemann W, Winkler E. "Rather one more chemo than one less...":Oncologists and oncology nurses' reasons for aggressive treatment of young adults with advanced cancer. Oncologist. 2018;23(2):256-262.

https://www.ncbi.nlm.nih.gov/pubmed/29133515

Returning to Work after Cancer: Survivors, caregivers, and employers report similar challenges.

(Past member) — Tue, 14 May 2019 19:16:46 GMT

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

Is rumination the explanation? The relationship between fear of cancer recurrence, cognitive processing, and depression and anxiety

Mon, 01 Apr 2019 20:56:22 GMT

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/

A Call to Action – Utilizing Patient Interest in Complementary Therapy as a Blueprint to Guideline Development

Brandon Davenport — Tue, 22 Jan 2019 20:58:31 GMT

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

First Steps in Navigating Spiritual Palliative Care in AYA Cancer Patients

Brandon Davenport — Wed, 15 Aug 2018 18:10:58 GMT

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/

Reducing the Impact of Treatment Without Decreasing the Chance of Cure: Examining Duration of Adjuvant Chemotherapy for Colon Cancer

Brandon Davenport — Wed, 15 Aug 2018 18:10:19 GMT

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'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/

A brief individual psychological intervention can address fear of cancer recurrence in cancer survivors

Brandon Davenport — Wed, 15 Aug 2018 18:09:48 GMT

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

AYA cancer survivors DO experience distinct distress: Results from a population-based survey

Brandon Davenport — Wed, 15 Aug 2018 18:08:54 GMT

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

Individuals with Melanoma and their Partners Can Be Taught Skin Self-Examination Practices

Brandon Davenport — Wed, 15 Aug 2018 18:07:58 GMT

Digest Commentators: Chelsea Moran, BSc, MA (c) & 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., & 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

Latina breast cancer survivors may be less likely to use psychosocial services

Brandon Davenport — Wed, 15 Aug 2018 18:07:31 GMT

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

Preventing Chemotherapy-Induced Hair Loss in Women with Breast Cancer: How Cool is That?

Brandon Davenport — Wed, 15 Aug 2018 18:06:53 GMT

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 capo@funnel.ca

Indigenous patients rate providers as competent, less so faithful

Brandon Davenport — Wed, 15 Aug 2018 18:06:11 GMT

Digest Commentator: Chad Hammond, PhD, Postdoctoral Fellow, School of Rehabilitation Sciences, University of Ottawa

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

Indigenous peoples are often left behind other populations in terms of accessing quality healthcare. In the area of cancer care, for example, their survival rates have lagged behind those of non-Indigenous populations despite recent improvements in cancer screening techniques and treatments. A long, continuing history of institutional racism, dismissal, and mistreatment leaves many Indigenous peoples distrustful and fearful of ‘becoming a patient.’ In many ways, the article by Morris and colleagues captures the current status of Indigenous patient-provider relationships among American Indian and Alaskan Native (AI/AN) patients. Their investigation was sparked by a very appropriate and timely question: how do AI/AN patients and their surgeons perceive the decision-making process around cancer treatment?

Over three years, Dr. Morris and colleagues recruited AI/AN patients (multiple cancer sites) and their surgeons to rate their exchanges with each other. Although somewhat vaguely stated, the authors mention they abided by research protocols developed for respectful engagement with Indigenous communities—an essential ingredient toward developing trust between communities and institutions of research as well as of healthcare. A total of 49 AI/AN patients (62% response rate) completed a host of surveys, among them the Collaboration and Satisfaction about Care Decision scale, Ethnic Identity scale, Everyday Discrimination scale, and the Wake Forest Trust scale. Fourteen surgeons (37% response rate) were also surveyed and interviewed.

The results of this study presented a promising image of patient-provider collaboration. Several domains of trust in providers (including honesty, confidentiality, collaborative decision-making, etc.) were rated quite highly, especially the domain of competence with 78% of patients agreeing or strongly agreeing with a statement about physician competence. Provider fidelity (caring/advocating for patient) was rated the lowest with 53% of patients agreeing or strongly agreeing with a statement about physician fidelity. Without making any causal claims, the authors reported that patients’ higher satisfaction, perceived quality of care, and sense of collaboration were correlated with their adherence to treatment. Twenty-six percent of patients reported non-adherence to treatment and their reasons were mostly non-clinical, citing personal and socio-economic circumstances (e.g., poverty), lack of proper access, and mistrust as potential factors in reducing adherence. Importantly, in all domains providers rated the quality of interaction and collaboration higher than AI/AN patients.

This article is a hopeful gem, asking hard questions around Indigenous participation in healthcare and discovering that the default patient-provider relationship is not adversarial—many AI/AN patients give a vote of confidence in their providers. There are, however, domains needing improvement toward more cooperative, coordinated planning of treatments. The stark difference in patient ratings of provider competence versus fidelity is a powerful one; it suggests that Indigenous patients usually see their healthcare providers as effective healers but not always as loyal allies. The authors suggest that for AI/AN patients trust may matter more than satisfaction. Many Indigenous peoples, bearing the memories of trust betrayed by settler institutions and governments, know this intuitively.

Morris, A. M., Doorenbos, A. Z., Haozous, E., Meins, A., Javid, S., & Flum, D. R. (2016). Perceptions of cancer treatment decision making among American Indians/Alaska Natives and their physicians. Psycho‐Oncology 25,1050-6. doi: 10.1002/pon.4191. Epub 2016 Jul 6

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

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

Delivering exercise to rectal cancer patients during neoadjuvant chemotherapy: Safe, feasible, and poised for evaluation

Brandon Davenport — Wed, 15 Aug 2018 18:05:29 GMT

Digest Commentator: Stephanie Saunders, MA student, Jennifer Brunet PhD

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

Medical advancement in cancer treatments have led to improved surgical outcomes and survival in locally advanced rectal cancer patients. In particular, neoadjuvant chemoradiation therapy (NACRT), followed by surgical resection, has become the standard regimen for rectal cancer patients, as it improves local control of cancer. Although this leads to enhanced prognosis, NACRT is associated with a host of adverse side effects that negatively impact patients’ wellbeing. Whereas many researchers have reported that exercise is an effective strategy to mitigate these negative treatment side effects in a range of cancers (e.g., breast, prostate, colon), few of these studies have been performed in patients with rectal cancer, and, to date, no studies have looked at the influence of exercise on NACRT side effects.

The current study examined study feasibility and safety of an aerobic exercise intervention in 18 patients diagnosed with rectal cancer during and immediately after NACRT. Forty-five participants were screened for eligibility by their medical oncologist at the time of their first radiation consultation. The study coordinator followed-up with 32 patients who were deemed eligible to participate, and scheduled initial exercise assessment for 18 interested participants.

Morielli and colleagues (2016) had participants engage in a supervised aerobic exercise program, consisting of warm up and cool down, and a tailored session on a variety of aerobic modalities (e.g., treadmill, upright bike, recumbent bike, elliptical, and rower). The program ran three times per week throughout their NACRT treatment (6 weeks). Upon completion of their NACRT treatment, participants were given an unsupervised aerobic exercise program, cumulating in 150 minutes per week, for 6-8 weeks until their surgical resection.

The authors found a high study eligibility (32/45,71%), high recruitment rate (18/32, 56%), and high retention rate (14/18, 78%), all of which are comparable to rates of other Phase 1 exercise intervention studies in other commonly studied cancers (e.g., breast and lymphoma). Additionally, secondary findings suggest that while health-related fitness outcomes (i.e., cardiorespiratory fitness level, psychosocial functioning, quality of life) declined during NACRT, they recovered afterwards to baseline levels, and in some cases improved beyond pre-NACRT levels. These results provide early evidence that exercise training among eligible patients with rectal cancer undergoing NACRT is both safe and feasible. In addition, exercise may have potential protective health effects during NACRT, as health-related fitness outcomes increased upon completion of treatment of NACRT prior to surgery. As this was a feasibility study without a control group, more research is needed to determine the effectiveness of the intervention and the effect of exercise on health outcomes.

What I liked about this article: The current literature has shown that exercise is beneficial to a range of cancer populations; however its effects on patients with rectal cancer are understudied. Morielli and colleagues’ (2016) article is among the first to provide an indication of the role exercise can play in ameliorating negative side effects of NACRT in patients with rectal cancer. Further, as the authors have shown eligibility and recruitment rates over 50%, patients with rectal cancer are both highly interested, and able, to participate in exercise training opportunities. As a result of this study, researchers have an exciting opportunity to further explore the relationship between exercise and NACRT side effects, as well as investigate the benefits of exercise training in a population that has shown interest in participating in exercise-based studies.

Journal website: https://onf.ons.org

Morielli, A. R., Usmani, N., Boulé, N. G., Tankel, K., Severin, D., Nijjar, T., … & Courneya, K. S. (2016). A phase I study examining the feasibility and safety of an aerobic exercise intervention in patients with rectal cancer during and after neoadjuvant chemoradiotherapy. Oncology Nursing Forum, 43(3), 352-362.

Optimizing outcomes for women with breast cancer with prescriptions for smoking cessation

Brandon Davenport — Wed, 15 Aug 2018 18:05:02 GMT

Digest Commentator: Joan L. Bottorff, PhD, RN, FCAHS, FAAN, School of Nursing and Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia’s Okanagan Campus

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

Tobacco use has been established as a causal factor for a number of cancers and has been a primary focus for cancer prevention efforts. However, less attention has been given to the risks of tobacco use among patients with cancer who continue to smoke. The evidence presented in the article by Passarelli and colleagues adds to the growing body of literature that we need to address continued smoking among those with cancer to reduce mortality and morbidity. In this observational study, the authors followed up a sample of 20,691 breast cancer survivors in the United States to evaluate the association between smoking status before and after a breast cancer diagnosis, and mortality from breast cancer and smoking-related disease. Persistent smoking among survivors in this study was associated with a statistically significant 25% increase in relative risk of breast cancer death. Women who continued to smoke also had a higher risk of death from respiratory cancer, noncancer respiratory disease, and cardiovascular disease. Women who quit smoking post-diagnosis had a 33% lower relative risk of death from breast cancer and other causes compared to those who continued to smoke, although this was not statistically significant.

What I liked about this article: This is a large population based study that provides a solid evidence base for promoting smoking cessation. Although the factors by which smoking effects tumor progression are not fully understood, the results not only point to the adverse outcomes for those with a history of breast cancer who continue to smoke but also obligate us all to offer smoking cessation to women with breast cancer. Respectful, women-centred approaches to smoking cessation can serve as an important foundation for offering cessation support to women with breast cancer. This study suggests the time is now for prescribing and supporting smoking cessation with every woman with breast cancer who smokes at every visit in order to optimize survival and overall health. The findings of Passarelli et al. can help us advocate for the resources we need to augment resources for smoking cessation in clinical practice.

Article: Passarelli, M.N., Newcomb, P.A., Hampton, J.M., Trentham-Dietz, A., Titus, L.J., Egan, K.M., Baron, J.A., & Willett, W.C. (2016). Cigarette smoking before and after breast cancer diagnosis: Mortality from breast cancer

Journal website: http://jco.ascopubs.org/content/34/12/1315.full.pdf+html?sid=8fa86d13-4eaa-4135-8e87-2c87c6456da1

Author website: http://profiles.ucsf.edu/michael.passarelli

Medical trainees view cultural barriers as a major challenge to patient-centered end-of-life discussions

Brandon Davenport — Wed, 15 Aug 2018 18:03:26 GMT

Digest Commentator: Teja Voruganti, MD-PhD student, University of Toronto

Edited by: Mary Ann O’Brien, Department of Family and Community Medicine, University of Toronto and Jennifer Brunet, School of Human Kinetics, University of Ottawa

With a patient population that is aging and increasingly diverse, it is crucial that doctors be aware of and incorporate patient values and preferences into end-of-life (EOL) discussions, However, these conversations can be challenging to initiate for a number of reasons, though there is a dearth of research as to what these are. Periyakoil et al. 2015 have conducted a study to identify and explore doctor-reported barriers to having EOL discussions with patients.

Using a cross-sectional design, 1040 of 1234 (84%) senior medical residents at two academic hospitals were recruited to complete a survey. Participants were sampled from a variety of medical subspecialties and were advanced enough in their training to have experienced caring for seriously ill patients at the end of life. The survey consisted of three questions, one of which asked for a rating on a 5-point scale of whether EOL discussions with patients of diverse backgrounds was challenging and another was an open-ended question of barriers faced in conducting EOL conversations. A mixed methods approach to analysis was done. The quantified responses were analyzed with respect to medical specialty, identifying barriers more important to specific specialties. A qualitative approach was used to analyze open-ended responses from all participants.

The majority of participants were Caucasian or Asian (82.3%). Most trainees (85.7%) reported that having EOL conversations was challenging, with participants of Asian and African American ethnicities indicating that they struggled most. Of six barriers identified, “language and medical interpretation” in interactions with patients and families was reported to be most problematic by all participating residents. Other barriers included perceptions of patients’ religious beliefs and expectations about EOL, physicians’ ignorance about cultural practices at EOL, patients’ cultural differences in decision making and truth handling, limited patient health literacy, and patient mistrust of the medical system. Specialty-based differences in rating the relative importance of each barrier were observed. Emergency medicine specialists rated limited patient health literacy as higher relative to other specialties; neurologists reported that doctors’ ignorance of cultural beliefs/practices was a major barrier; and psychiatrists rated patients’ cultural differences in decision making/truth handling as more challenging to EOL discussions.

Why I liked this article: This study has identified six major barriers to the effective conduct of EOL discussions. An important implication of this study is that it demonstrates a clear need to better train doctors in ways to facilitate EOL discussions that are culturally-sensitive and meaningful to a patient’s own situation. As the population lives longer and becomes more ethnically diverse, an awareness of these barriers may serve as a framework for developing appropriate knowledge and attitudes in the care management of patients especially in fields such as oncology.

Article. Periyakoli, VS, Neri, E, Kraemer, H (2015). No easy talk: a mixed methods study of doctor reported barriers to conducting effective end-of-life conversations with diverse patients. PLoS ONE 10(4): e0122321. doi:10.1371/journal.pone.0122321

Journal website: http://journals.plos.org/plosone/

Author website: https://med.stanford.edu/profiles/vj-periyakoil

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 capo@funnel.ca

Oncologists’ Exercise Recommendations are not Enough

Brandon Davenport — Wed, 15 Aug 2018 18:01:42 GMT

Digest Commentator:

Paquito Bernard a,b,c , Josée Savard a,b,c

Université Laval Cancer Research Center, Québec, Québec, Canada
School of Psychology, Université Laval, Québec, Québec, Canada
CHU de Québec – Université Laval Research Center, Québec, Québec, Canada

Edited by: Jennifer Brunet, School of Human Kinetics, University of Ottawa, Mary Ann O’Brien, Department of Family and Community Medicine, University of Toronto

Park et al. (2015) examined the effects of oncologists’ exercise recommendations among breast and colorectal cancer survivors. The investigators assigned participants, after completion of cancer treatments, to one of three conditions: control (i.e., conventional consultation); exercise recommendations only (i.e., emphasizing possible benefits from moderate intensity physical activity on risk of cancer recurrence); exercise recommendations with motivation tools (i.e., DVDs, diary and pedometers) plus one educational session administered by an exercise specialist. DVDs presented 3 sets of different resistance exercises without equipment. Participants recorded steps walked by day in diary. Self-reported physical activity assessed 4 weeks after brief intervention was the primary outcome. Quality of life was also measured with European Organization for Research and Treatment of Cancer (EORTC) QLQ C-30 questionnaire.

121 breast cancer survivors and 41 colorectal cancer survivors were recruited. The study retention rate was good (80%). Intent-to-treat analyses indicated that the addition of motivation tools and one educational session to the oncologist’s exercise recommendation significantly increased self-reported duration of moderate intensity exercise and duration of total exercise as compared to the control group. Participants who received the motivation tools and one educational session in addition to the exercise recommendations increase their total exercise time by almost 80 minutes per week. Participants who were assigned to the control group or who only received oncologist’s exercise recommendations did not significantly modify their exercise behaviours. No between-group difference was found on global quality of life.

This recent investigation shows that oncologists’ recommendations to increase exercise may not enough to change breast cancer survivors and colorectal cancer survivors’ exercise behaviour, which supports the idea that exercise recommendations should be accompanied by adapted motivational tools and a consultation with an exercise specialist.

Why we liked this article: Unfortunately, too often, physical activity promotion in oncology is conceptualized as a simple prescription from the oncologist. But physical activity is a complex health behaviour and becoming physically active is an important challenge for cancer survivors. This study highlights that a tailored intervention is effective. This investigation also suggests that integrating exercise specialists in oncology services may be important.

Park, J.-H., Lee, J., Oh, M., Park, H., Chae, J., Kim, D.-I., … Jeon, J. Y. (2015). The effect of oncologists’ exercise recommendations on the level of exercise and quality of life in survivors of breast and colorectal cancer: A randomized controlled trial. Cancer, 121(16), 2740‑2748. http://doi.org/10.1002/cncr.29400

Women are Unequal in the Face of Breast Cancer: The Influence of Childhood Trauma on Psychological Adjustment

Brandon Davenport — Wed, 15 Aug 2018 18:01:15 GMT

Digest Commentator: Josée Savard, Ph.D., School of Psychology, Université Laval, CHU de Québec-Université Laval Research Center, and Université Laval Cancer Research Center

Edited by: Jennifer Brunet, School of Human Kinetics, University of Ottawa

Childhood trauma is far too common as some research indicates that 45% of primary care patients have experienced some form of abuse during their childhood. In people diagnosed with cancer, childhood adversity has previously been found to be associated with higher levels of symptoms such as fatigue, psychological distress, and stress. This article reports on a pilot longitudinal study aiming to explore associations of childhood trauma with fatigue, depression, and stress in women undergoing radiotherapy for breast cancer. Another goal, more groundbreaking, was to investigate the possible role of inflammation.

Twenty women with 0-IIIA breast cancer about to receive whole-breast radiotherapy were enrolled in this study. They were evaluated 1 week before radiation (T1), week 6 of radiation (T2) and 6 weeks after radiation (T3). At each time point, participants completed the Multidimensional Fatigue Inventory, the Inventory of Depression Symptomatology and the Perceived Stress Scale (PSS). Peripheral blood draws were taken at T1 to measure various markers of inflammation. At T3, participants filled out the Childhood Trauma Questionnaire (CTQ), a 28-item questionnaire that assesses a history of childhood physical, sexual, and emotional abuse, and physical and emotional neglect.

Eight participants (40%) reported a history of childhood trauma (CTQ+). CTQ+ women obtained significantly higher fatigue, depression, and stress scores across all time points than women who did not report childhood abuse and neglect (CTQ-), although post hoc analyses indicated that differences between both groups of women were significant at T1 only. In addition, after controlling for some potential confounding variables (e.g., age, education, marital status), the differences in levels of cancer-related symptoms between CTQ+ and CTQ- women generally diminished, except for PSS scores. Analyses also indicated that radiotherapy did not significantly exacerbate any of the symptoms differentially in CTQ+ women as compared to CTQ- women. More severe symptoms of fatigue, depression and stress were associated with higher baseline levels of several inflammatory markers, namely c-reactive protein, interleukin (IL)-6 and IL-1 receptor agonist, but only in CTQ+ women. Overall, although replication with a larger sample is warranted, this study suggests that childhood trauma is a significant risk factor for cancer-related psychological distress and that inflammation could constitute a mechanism through which early negative experiences may have such a detrimental effect.

Why I liked this article: While this is a small-scale pilot study and mediation could not really be tested, I liked that it was a first attempt to identify inflammation as a possible underlying biological mechanism linking childhood trauma with cancer-related psychological symptoms. In terms of clinical implications, this literature generally suggests that patients with a history of childhood adversity constitute a high-risk group for psychological distress before and after cancer treatment that could be specifically targeted in a screening and prevention program. Moreover, if the role of inflammatory processes is confirmed in future research, it could inspire the development of new pharmacological and non-pharmacological treatment avenues directly targeting inflammation.

Article. Han, T. J., Felger, J. C., Lee, A., Mister, D., Miller, A. H., & Torres, M. A. (2015). Association of childhood trauma with fatigue, depression, stress, and inflammation in breast cancer patients undergoing radiotherapy. Psycho-Oncology. doi:10.1002/pon.3831

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

Author website: http://radiationoncology.emory.edu/people/physicians/torres-mylin.html

Identifying inactivity among breast cancer survivors has just become easier

Brandon Davenport — Wed, 15 Aug 2018 18:00:46 GMT

Digest Commentators:

Adina Coroiu1 & Elena Ivanova2

1Department of Educational and Counselling Psychology, McGill University

2Department of Psychology, McGill University

Edited by: Jennifer Brunet, School of Human Kinetics, University of Ottawa

Physical activity (PA) is a widely studied topic within psycho-oncology, with over 9,000 articles recently identified on the subject by Kampshoff and colleagues. Despite the growing interest in PA, a valid measure to quantify and determine if cancer survivors’ levels of PA meet the recommended levels of at least 150 minutes of moderate activity or at least 75 minutes of vigorous activity is lacking. Amireault, Godin, Lacombe, and Sabiston (2015) addressed this gap in the literature by validating the Godin-Shephard Leisure-Time Physical Activity Questionnaire (GSLTPAQ). The GSLTPAQ is a brief self-report measure that assesses the duration, intensity (i.e., mild, moderate, and vigorous), and frequency of PA performed during the past 7 days. This scale can be used to classify individuals into two activity categories: active (scores ≥ 24) or insufficiently active (scores ≤ 23). The GSLTPAQ is an ideal measure to quantify and compare cancer survivors’ levels of PA against the recommended levels of PA due to its brief format and low administration burden. If validated, this questionnaire could be used in studies seeking to understand the impact of PA behavior on physical and psychosocial health outcomes, as well as in epidemiological studies to determine the prevalence of (in)activity in this clinical population.

In their study, Amireault and colleagues compared PA data obtained using the GSLTPAQ with PA data obtained using accelerometers (GT3X, Actigraph, Pensacola, Florida), with the aim of assessing the accuracy of the GSLTPAQ to classify cancer survivors’ activity levels according to the aforementioned PA guidelines. A total of 199 adult women with a first diagnosis of breast cancer were recruited from various hospitals in Montreal, QC. They were asked to wear an accelerometer (i.e., a physical activity monitoring device) for 7 consecutive days and complete the GSLTPAQ. Based on the accelerometer data, 27.2% of the sample were active. This percentage was lower than the percentage obtained using the GSLTPAQ (i.e., 33.8%). Further, 75.3% of sample were correctly categorized using the GSLTPAQ as being insufficiently active, that is as notmeeting PA guidelines. A smaller percentage, however, were correctly categorized as active (58.5%), that is as meeting PA guidelines.Overall, the authors suggested that the GSLTPAQ is more accurate at identifying insufficiently active women than at identifying active women.

Why we liked this article: We liked this article because the GSLTPAQ has research and practical implications, and the authors established its validity for use with breast cancer survivors. The practical and research implications include: low administration burden, minimum training demands, and low cost, which makes the GSLTPAQ feasible to use for large-scale studies. Further, this measure has clinical utility in that it can be used as a screener to identify inactive breast cancer survivors who would benefit from interventions designed to increase physical activity levels.

Article: Amireault, S., Godin, G., Lacombe, J., & Sabiston, C. M. (2015). Validation of the Godin-Shephard Leisure-Time Physical Activity Questionnaire classification coding system using accelerometer assessment among breast cancer survivors. Journal of Cancer Survivorship, 1-9. doi: 10.1007/s11764-015-0430-6

Journal Website: http://link.springer.com/article/10.1007/s11764-015-0430-6

Authors Websites: http://www.jgh.ca/en/BHRG_AdinaCoroiu; https://www.mcgill.ca/healthpsychologylab/health-psychology-laboratory

Pain assessment and management at home: challenges faced by older cancer patients and their family caregivers.

Brandon Davenport — Wed, 15 Aug 2018 18:00:14 GMT

Digest Commentators: Beth Edwards, PhD Candidate, Dalla Lana School of Public Health, University of Toronto & Lynn R Gauthier, Postdoctoral Fellow, ELLICSR Health Wellness and Cancer Survivorship Centre, Princess Margaret Cancer Centre, University Health Network

With the aging population and focus on community-based care, more older patients and their caregivers will manage cancer pain at home. Age-related comorbidities and functional decline add to pain management complexity. Little is known about how older patients and caregivers navigate these challenges. Therefore, McPherson et al. conducted a study to describe the roles and perceptions of older cancer patients and their caregivers managing cancer pain at home.

Using a qualitative descriptive approach with an inductive thematic analysis, they analyzed data collected through semi-structured interviews with 18 patients and 15 caregivers. Although the goal was to understand pain management among patient-caregiver dyads, interviews were primarily conducted with patients and caregivers separately. Patients were 65 years of age or older, had advanced cancer, experienced pain for at least 1 month, and received home palliative care. Most patients required assistance with daily activities and had moderate pain. Most caregivers lived with and were partners of the patients they cared for.

A qualitative approach is especially suited to understanding such a complex phenomenon. McPherson et al. clearly outlined their methods including interview guides, detailed analytic description, and appropriate references. As such, this article is appropriate for those interested in qualitative research approaches, as well as those interested in understanding the challenges of pain management among older patients and caregivers.

Analysis revealed two main themes related to pain assessment and management, with four subthemes each. Briefly, in one theme, patients and caregivers discussed challenges related to “adopting roles in pain assessment”. While patients adopted the lead role, they were not always forthcoming about reporting pain. Caregivers adopted the communication role when patients did not communicate with healthcare professionals. Elsewhere within this theme, patients described the multidimensional experience of pain. Some did not use the word “pain”, but used words like “discomfort”, “cramp”, and “ache”. They also described their reluctance to burden caregivers, especially when caregivers had health challenges themselves. Caregivers described verbal and nonverbal cues and relied on their personal history with the patient to assess pain. Some caregivers’ assessments were impacted by their own pain and health history. In the other theme, caregivers described patients’ desire to remain in control of pain management, but age-related impairments and treatment side effects made self-management difficult. Patients described reluctance towards pharmacological management, whereas caregivers remained open to pharmacological approaches. Some patients described a desire to sacrifice pain control to avoid analgesic side effects. Both patients and caregivers discussed fears of addiction and beliefs that pain is an inevitable consequence of aging and cancer. Here, an interesting dyadic analysis revealed that patient and caregiver pain management goals were not always congruent. Cognitive impairment was identified throughout as a challenge to pain assessment and management.

These data outline for healthcare professionals the challenges faced by older patients and their caregivers managing pain at home, including the impact of functional limitations, cognitive impairment, and the potential impact of caregivers’ own health challenges. As a result, this study clearly identifies an urgent need for education to address fears of addiction and side effects, and beliefs about the inevitability of pain as well as future research to further elucidate dyadic coping with cancer pain across the adult lifespan.

McPherson, C.J., Hadjistavropoulos, T., Devereaux, A., Lobchuk, M. (2014). A qualitative investigation of the roles and perspectives of older patients with advanced cancer and their family caregivers in managing pain in the home. BMC Palliative Care, 13(39). http://dx.doi.org/10.1186/1472-684X-13-39

Journal website: http://www.biomedcentral.com/bmcpalliatcare

Author website: http://www.health.uottawa.ca/sn/personnel/cmcpherson.htm

Depression Care in Cancer Comes of Age

Brandon Davenport — Wed, 15 Aug 2018 17:59:42 GMT

Written by: Keith Wilson, PhD, CPsych, Department of Psychology, The Ottawa Hospital Rehabilitation Centre

Psychosocial oncology has done a good job of documenting the 10% – 20% prevalence of major depression (MD) among people with cancer, as well as the fact that MD accounts for a disproportionate amount of suffering. Where we have lagged is in demonstrating that we can treat MD with a sensible, evidence-based, practical and efficient intervention suitable for integration into oncology settings. With this study by Sharpe et al., we may finally have caught up.

“Depression Care for People with Cancer” consists, in part, of a brief (up to 10 sessions), manualised psychotherapy that draws on the cognitive-behavioural strategies of behavioural activation and problem-solving. In this trial, the therapy was administered by nurses who received rigorous training in these therapeutic techniques. The nurse-therapists were supervised by psychiatrists, who also consulted on medications and worked with patients who were not improving.

Sharpe et al. randomized 500 patients diagnosed with MD at three Scottish cancer centres to receive either the Depression Care for People with Cancer program or usual care (which could include referral to existing psychosocial oncology services). The trial endpoint was depression status at 24 weeks, but patients were followed for almost a year.

The authors describe the results as “striking”. Among patients who received the Depression Care for People with Cancer program, 62% reached the pre-specified primary outcome of a 50% reduction in depression symptoms. In contrast, only 17% of those receiving usual care achieved this degree of improvement. Moreover, a third of patients receiving the Depression Care for People with Cancer program met criteria for full remission of MD, compared to only 4% of those receiving usual care. In addition to these statistically robust differences in depression itself, secondary outcomes of anxiety, pain, fatigue, social participation, and quality of life were all reliably better for those receiving the Depression Care for People with Cancer program, and sustained over the duration of follow-up. Interestingly, the researchers also kept careful records of the time spent administering the intervention. They calculated the cost as £613 – about $1,100 Canadian.

Why I like this article: It is rare in psychosocial research to read individual studies that have the potential to be game-changers for an entire field, but this work comes close. Methodologically, this is a textbook example of how to design a rigorous clinical trial of a complex intervention. The findings should be appreciated widely by everyone involved in cancer care. If this treatment was available in a pill form that could reduce the suffering of that many people, for that duration of time, in multiple dimensions of distress, at such a low cost, we can speculate that it would quickly become a routine standard of care. Our challenge now is to translate this compelling research knowledge into genuine and widely available integrated care in cancer treatment programs.

Article: Sharpe, M., Walker, J., Hansen, C.H., Martin, P., Symeonides, S., Gourley, C., Wall, L., Weller, D., Murray, G., for the SMaRT (Symptom Management Research Trials) Oncology-2 Team. (2014). Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial. Lancet, 384, 1099-1108.

Journal Website: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61231-9/abstract

Author Website: http://www.psych.ox.ac.uk/team/PIs/michael-sharpe

Advocacy Versus Avoidance

Brandon Davenport — Wed, 15 Aug 2018 17:58:24 GMT

Digest commentator: Andrea Feldstain, Ph.D. Candidate, University of Ottawa; Resident in Clinical Psychology, Alberta Health Services

The field of palliative care is advancing, developing, and innovating. In the past few decades, it has evolved from care at end-of-life to a practice seeking to relieve or prevent suffering as early as diagnosis. Palliative care can entail symptom control, improving quality of life, increasing engagement of patients in their own care, potentially extending life expectancy, and/or increasing comfort when dying. However, the integration of palliative care into the full cancer trajectory is still a work in progress, as exemplified in the selected article.

Wentlandt and colleagues (2014) examined the referral practices to palliative care of pediatric oncologists versus adult oncologists. To compare these two groups, the researchers surveyed the majority of Canadian medical, radiation, surgical, and pediatric oncologists. Topics discussed included the availability of specialized palliative care services (i.e., inpatient consultation, inpatient units, outpatient clinics), referral practices (e.g., timing of referrals, life expectancy at time of referral), and attitudes (e.g., referring to palliative care adds too many care providers, uncomfortable referring before end-of-life).

Their study provides some good news in that both pediatric oncologists and adult oncologists perceived excellent access to at least one form of specialized palliative care, with consultation being the most available and outpatient services being the least available. In addition, the majority of pediatric oncologists and adult oncologists reported they were comfortable referring patients to palliative care as early as at diagnosis (87% and 70%, respectively). Unfortunately, despite perceiving excellent access and confidence, the bad news is that this is not reflected in practice. Both pediatric oncologists (79%) and adult oncologists (84%) reported that the large majority of their palliative care referrals were for patients with uncontrolled symptoms and a life expectancy of 1 to 6 months. Approximately 90% of pediatric oncologists and adult oncologists reported they would refer patients with uncontrolled symptoms for a prognosis of less than 1 year but only 57% would refer for uncontrolled symptoms and a prognosis of greater than 1 year. Less than 1% reported having referred patients with a prognosis of greater than 1 year (0% pediatric oncologists; 0.6% adult oncologists). So, why is there this discrepancy between perceptions and practice?

Two possible explanations can be found in Wentlandt and colleagues’ (2014) Table 4. On one hand, they found that oncologists may believe they can provide palliative treatment themselves. On the other hand, they found some may avoid palliative care referrals because they believe their patients associate palliative care with impending death. The majority of pediatric oncologists (58%) reported that they would refer earlier if palliative care was renamed Supportive Care, while adult oncologists were equally split. This is unfortunate because (1) it robs patients/caregivers of the expertise of palliative care, (2) misconceptions of palliative care could be easily clarified with a discussion, and (3) delaying referrals until disease is terminal reinforces this misconception. Although pediatric oncologists and adult oncologists both seem aware of the evolving scope of palliative care practice and associated benefits, referral practices have yet to catch up. Echoing Wentlandt et al.’s (2014) suggestion, more education and advocacy is needed as this may be a more viable option than hiding behind a new name.

Article: Wentlandt, K., Krzyzanowska, M.K, Swami, N., Rodin, G., Le, L.W., Sung, L., & Zimmerman, C. (2014). Referral practices of pediatric oncologists to specialized palliative care. Support Care Cancer, 22, 2315-22. DOI: 10.1007/s00520-014-2203-6.

Journal website: http://www.springer.com/medicine/oncology/journal/520.

Author website: http://ca.linkedin.com/pub/kirsten-wentlandt/18/595/11a

Attending summer camp as a pediatric cancer patient may provide benefits into adulthood

Brandon Davenport — Wed, 15 Aug 2018 17:57:52 GMT

Digest commentators: Gaya Narendran and Dr. Fiona Schulte, The University of Calgary

Specialized summer camps have been established as an environment where children faced with chronic illnesses, such as pediatric cancers, may find a place to have fun in a safe way. Currently, few studies have investigated the influence of attending specialized summer camps on children with cancer. Reports indicate that attending camp positively influences camper’s quality of life by affecting factors such as mood, and social interaction skills. The role of specialized summer camp in the long-term psychosocial development of children affected by cancer has not been addressed until recently.

Beckwitt (2014) investigated the potential for long-term influences of attending specialized camp programs for children who had been affected by cancer. Twenty-three Adults Surviving Childhood Cancers (ASCCs) were involved in the study. ASCCs face ongoing psychosocial challenges into adulthood. During time of treatment, they are often isolated from social interactions and consequently often develop social adjustment problems that have the potential to continue into adult life.

ASCCs were identified as having been diagnosed with cancer at 1 to 18 years of age. The study consisted of a demographic survey and illness narrative interviews. Illness narratives were carried out using in-depth interview techniques in order to gain understanding and insight into how ASCCs view their camp experience. As a result from these interviews, three themes were identified: (1) attending camp provided normalcy, (2) meaningful camp experiences, and (3) access to information. This investigation reports that ASCCs recognized camp as a setting in which they could feel “normal” and relate with other children facing similar challenges. Furthermore, ASCCs’ responses indicated that camp provided a source of long-lasting relationships facilitated by the meaningful experiences felt while attending camp. ASCCs also reported that they were given informational support to learn and discuss potential physical, emotion, and cognitive late-onset effects of their cancer during camp. Together, the results of this investigation indicate that specialized childhood camps play a significant role in ASCCs’ survivorship.

This study provides strong testimonies for the effectiveness and importance of the childhood camp experience from multiple ASCCs. However, due to the small sample size and the similarity of participants, such that most were female and Caucasian, these results cannot readily be generalized. Future research utilizing objective measures, such as psychological assessments and questionnaires, are needed to establish the benefits of attending specialized summer camp programs for ASCCs.

Why I liked this article

This article works to fill a gap in the literature in a way that is easily understood. The included quoted testimonies that were appropriate and supported the conclusions they made. The quotes were also insightful into the emotional and social challenges of ASCCs but also work together with the author’s conclusions to illustrate a strong and complete image of the cancer experience and the role of camp in easing the challenges of this experience.

Article: Beckwitt, A. E. (2014). Childhood Cancer Camps Their Role in Adults Surviving Childhood Cancers Lives. Journal of Pediatric Oncology Nursing, 1043454213515335.

Journal website: http://jpo.sagepub.com/

Author website: http://www.ncu.edu/about-northcentral/our-people/faculty-members/asher-beckwitt

The Power of Exercise – How Does It Improve Quality of Life?

Brandon Davenport — Wed, 15 Aug 2018 17:57:04 GMT

Digest commentators: Lauren C. Capozzi & S. Nicole Culos-Reed

Digest editor: Jennifer Brunet, University of Ottawa

It has been well established that exercise has numerous benefits for cancer survivors, both during and after treatment. In a population where psychosocial concerns like fatigue, pain, anxiety, depression, and decreased physical functioning are a reality for most patients, exercise can positively impact overall quality of life (QOL). But how does this happen? There are few researchers who have examined the underlying mechanisms responsible for improvements in QOL in patients with cancer who exercise. Identifying these mechanisms will aid in developing better targeted interventions, which will likely enhance the impact of exercise interventions on QOL.

Buffart and colleagues were determined to further analyze the factors mediating improvements in QOL during a 12-week group-based exercise program. They hypothesized that the intervention would increase activity levels, as well as perceptions of general self-efficacy and mastery. In turn, this would decrease fatigue and distress, which would then improve QOL. For their study, which was part of a larger multi-site trial, they recruited 209 patients diagnosed with different types of cancer who were on average 48.8 ± 10.9 years of age. A total of 147 patients were included in the exercise intervention group, and 62 were included in the wait list control group. The exercise intervention consisted of two weekly sessions targeting aerobic and strength components.

Interestingly, Buffart and colleagues found that there was no significant direct effect of the group-based exercise intervention on QOL. Rather, the intervention had an indirect positive effect on QOL. Specifically, the intervention positively impacted QOL by increasing physical activity, self-efficacy, and mastery, and subsequently decreasing fatigue and distress. The improvements in fatigue management were partially explained by the indirect effect of increased physical activity and self-efficacy, while the improvements in distress management were partially explained by the indirect effect of increased self-efficacy and mastery. Increased physical activity was directly linked to enhanced QOL. This study not only supports previous findings linking exercise with symptom management and QOL, but also provides insight into the mechanisms linking exercise with improvements in QOL. Accordingly, researchers and health professionals developing exercise intervention should consider approaches and strategies shown to increase perceptions of self-efficacy and mastery as this may decrease fatigue and distress, and in turn improve QOL.

Why I liked this article?

This article is important as it helps identify ways through which exercise can lead to improvements in QOL. This knowledge is also valuable when considering the design of effective exercise interventions as well as sustainable clinic or community-based exercise programs for cancer patients. Further work in this area is needed to identify additional pathways that are perhaps unique to specific cancer groups so we can not only develop targeted interventions, but also developed tailored intervention for patient diagnosed with different types of cancer.

Article: Buffart, L. M., Ros, W. J. G., Chinapaw, M. J. M., Brug, J., Knol, D. L., Korstjens, I., Weert, E van, Mesters, I., Borne, B. van den, Hoekstra-Weebers, J. E. H. M., May, A. M. (2014). Mediators of physical exercise for improvement in cancer survivors’ quality of life. Psycho-oncology, 23: 330-338.

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

Author website: http://www.emgo.nl/team/924/laurienbuffart/personal-information/

Using Health Behavior Models to Predict Physical Activity and Nutrition Behavior in Breast and Prostate Cancer Survivors

Brandon Davenport — Wed, 15 Aug 2018 17:47:21 GMT

Digest commentators: Nicole Culos-Reed and Heather Leach, University of Calgary

Digest editor: Jennifer Brunet, University of Ottawa

Many prostate cancer (PC) and breast cancer (BC) survivors are interested in optimizing their health through lifestyle behaviors. The use of health behavior theories can help to understand patterns of nutrition and physical activity following a cancer diagnosis. In this study, predictors from the Commonsense Self-Regulation Model (CSM) and the Transtheoretical Model (TTM) were examined for associations with adherence to physical activity (PA) and healthy diet in PC or BC survivors. PA was measured using the International Physical Activity Questionnaire (IPAQ), assessing PA in the past seven days. Nutrition was assessed using the Past Seven Days Nutrition, assigning a score of 0-6, with higher scores indicating healthier eating guidelines adhered to. Participants were also asked the extent to which their diet and PA behavior had changed since diagnosis, and their preferences for interventions. CSM constructs were measured by the Illness Perception Questionnaire-Revised (IPQR). TTM constructs were represented by a previously developed scale that measured exercise stage of change, which ranges from pre-contemplation (not thinking about exercise), through contemplation, preparation (making small steps towards regular exercise), action (exercising regularly), to maintenance (over 6 months of regular exercise). Self-efficacy was measured using the Exercise and Nutrition Self-Efficacy Scales. Participants in this study were ninety-two men with PC (M age=66.6±7.7 years) and 145 women (M age=56.8±10.5 years) with BC. The median time since diagnosis was 30.0 months for PC and 53.5 months for BC participants. PA guidelines were met by 88% of PC and 85% of BC participants based on self-reported data. PC respondents met on average 2.2 healthy eating guidelines and BC respondents met 2.7. Higher self-efficacy and stage of change from the TTM model were associated with increased PA and greater adherence to nutritional guidelines. Increased PA since diagnosis was associated with higher stage of change and lower illness identity and higher personal control. Healthier eating since diagnosis was associated with longer time since diagnosis, higher stage of change, and higher personal control and higher negative emotional representations. The majority of participants indicated they would be very interested in receiving interventions to assist with improving nutrition or PA, and that they would prefer these interventions at the time of diagnosis or soon after. The associations between a higher TTM stage of change and self-efficacy with adherence were consistent with findings of other studies that have examined PA and healthy eating. No CSM variables were associated with adherence, but some did predict changes in health behaviors. Lower illness identity was associated with increased PA after diagnosis, which suggests that cancer related symptoms may act as a barrier to PA. Higher negative emotions related to cancer was associated with improved post diagnosis diet, suggesting that concerns about cancer may motivate healthy eating behaviors. Associations between higher personal and treatment control beliefs and improved health behaviors since diagnosis suggests that PC and BC survivors are more likely to change health behaviors if they believe that their actions can make a difference in their cancer outcome. The application of theoretical models to explain health behaviors can enhance knowledge of how to provide effective support for the PA and healthy eating needs of PC and BC survivors.

Green HJ, Steinnagel G, Morris C & Laakso EL (2014). Health behaviour models and patient preferences regarding nutrition and physical activity after breast or prostate cancer diagnosis. European Journal of Cancer Care. Advance online publication. doi:10.1111/ecc.12190.

Journal website: http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-2354

Author website: http://www.griffith.edu.au/health/school-applied-psychology/staff/dr-heather-green

Adventure-based activities: A new frontier in physical activity for childhood Cancer survivors?

Brandon Davenport — Wed, 15 Aug 2018 17:46:14 GMT

Li, H.C., Chung, O.K., Ho, K.Y., Chiu, S.Y., & Lopez, V (2013). Effectiveness of an integrated adventure-based training and health education program in promoting regular physical activity among childhood cancer survivors. Psycho-Oncology, 22, 2601-2610.

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

Advances in treatment protocols have resulted in improved rates of survival for childhood cancer patients. Despite enhanced prognosis, treatment regimens are associated with a myriad of adverse side effects. Physical activity has been shown to be a safe and effective strategy to ameliorate and potentially reverse the sequelae of cancer and its treatments in children with cancer. Moreover, it is a beneficial strategy to promote improved psychosocial and physical health. Unfortunately, there is growing concern about low rates of physical activity in childhood cancer survivors. Previous research shows that education alone is not enough to increase physical activity levels; therefore, more research is needed to explore alternative strategies. In this study, Li et al. examined if an integrated adventure-based training and health education program would increase perceptions of self-efficacy, physical activity levels, and quality of life (QOL) in 71 cancer survivors between the ages of 9 and 16 years. They found that participants reported increased perceptions of self-efficacy, physical activity levels, and QOL over the course of the intervention. Additionally, they found that participants who completed the program had greater perceptions of self-efficacy, were more active, and were more willing to participate in physical activity than participants who did not complete the program.

This study provides compelling evidence that an alternative type of physical activity program (e.g., adventure-based training such as rock wall climbing, relay games and three-legged races) can effectively promote positive changes in physical activity behaviour, as well as psychosocial constructs. While these findings are promising, more research is needed to determine if the length and format of the program should be modified based on participants’ personal and/or cancer-related characteristics in order to optimize outcomes. Furthermore, greater research efforts exploring dissemination strategies should be conducted to ensure a greater number of childhood cancer survivors are impacted.

Why I like this article: Currently, data supporting effective means to promote physical activity behaviour, and in turn QOL, for older childhood cancer survivors are lacking. This study sheds light on an exciting alternative type of physical activity that may be more readily adopted and maintained by this age group – adventure-based activities. Accordingly, it offers a novel approach to potentially address the physical inactivity epidemic in childhood cancer survivors.

Digest writer: Amanda Wurz, MSc.

Digest editor: Jennifer Brunet, PhD

Strong Backs and Soft Fronts

Brandon Davenport — Wed, 15 Aug 2018 17:44:45 GMT

Wenger, L. (2013). Moving through illness with Strong Backs and Soft Fronts: A substantive theory of men’s help-seeking during cancer. Men and Masculinities, 16, 517-539.

Journal Website: http://jmm.sagepub.com

In recent years, we have begun to understand men’s responses to prostate cancer and its treatment in order to provide psychosocial support. However, men experience a wide range of other types of cancer. When it comes to these other types of cancer, we often assume that men and women respond to a cancer diagnosis in similar ways and need similar types of support. In Dr. Lisa Wenger’s recent publication, she turns this assumption on its head. Drawing on a growing body of knowledge constructing health and illness as opportunities for gendered practices, she asks how men navigate the disruptions to life and identity that are triggered by a diagnosis of cancer. Based on in-depth interviews with 30 men, ranging in age from 30 to early 80s with a range of cancer diagnoses, she details patterns of help-seeking using the metaphor of “strong backs” and “soft fronts.” Dr. Wenger explains that, in line with hegemonic masculinities, men present themselves as strong, stoic and brave. So for the men in her study, the “strong back” approach felt natural and they were comfortable with clinicians and family who wanted to support them in recovering who they were. However, difficulties were often experienced as the men confronted losses, uncertainties and the profound disruptions to their identity. These difficulties were related to their discomforts in expressing vulnerability and resistance to identity changes, and the lack of responsiveness of our health system to men’s emotional pain. Dr. Wenger explains that we have been pretty good at “strong back” supports to help men hold onto familiar selves by focusing on information, stress management and healthy living. She encourages us to ask how we are addressing men’s “soft front” needs and challenges us to develop innovative approaches that assist men in balancing “strong backs” and “soft fronts” as they learn to live with cancer.

Why I like this article: The article provides a new window into men’s experiences of a range of cancers and raises questions about how cancer supports should be designed for men. I think the rich descriptions of men’s experiences in balancing “strong backs” and “soft fronts” as they confront cancer hold great potential in increasing our ability to be gender aware in our interactions with men with cancer. The time has come to recognize the limits of a one-size-fits-all approach to psychosocial oncology.

Prepared by Dr. Joan Bottorff

I know they are distressed. What do I do now?

Brandon Davenport — Wed, 15 Aug 2018 17:44:16 GMT

Moorey, S. (2013). “I know they are distressed. What do I do now?” Psycho-Oncology,22, 1946-1952.

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

Author Website: http://www.national.slam.nhs.uk/stirlingmoorey/

Stirling Moorey has been at the forefront of psychotherapy research in palliative cancer care, and he is particularly known for his work in cognitive behaviour therapy (CBT). In this personal perspective, Moorey describes the evolution of psychotherapy research in oncology as a movement through three phases. The first consisted of identifying the prevalence of psychosocial problems and the corresponding need for interventions. The second, which is still in early stages but is making great strides, has tested treatment protocols derived from mental health research, as well as those developed specifically within cancer care. The third phase has to do with the dissemination of effective interventions, which in a Canadian context would be known as knowledge translation. Like other guidelines for screening and intervening with distress, including CAPO’s own depression guideline, Moorey proposes a stepped-care approach for people who have psychological problems of differing severity. Some basic communication skills should be part of the training of all professionals, but brief psychotherapy, internet, and telephone counselling have a place for providers with additional expertise. Patients with the most serious difficulties should be seen by team members with some specialization in mental health.

Importantly, Moorey introduces the concept of “first aid CBT,” which comprises a core set of therapeutic techniques for defining and explaining problems, devising simple behavioural experiments, and applying time-limited problem-solving. In Moorey’s opinion, this type of approach can be implemented by various members of the treatment team, and is even applicable in palliative care. Moorey, a psychiatrist, then describes the success of his own recent research in training nurses in the model.

Why I like this article: The tone of this paper is one of thoughtful reflection as it provides a personal overview of the literature; it is not intended to be a rigorously scientific systematic review. However, it outlines a sensible and practical way to conceptualize how to intervene with distressed patients. Since CBT is currently the predominant form of psychotherapy in the community generally, there is a place for more clinicians in cancer care to have a basic sense of how it works and how it can be applied to their patients. First aid CBT is probably a concept whose time has come.

Prepared by Dr. Keith Wilson

Bridging the gap between what to do and how to do it: the pathway to enhancing access to exercise and physical activity among adults diagnosed with cancer

Brandon Davenport — Fri, 10 Aug 2018 19:55:48 GMT

Digest Commentators:

Amanda Wurz, ACSM-CPT, MSc, PhD candidate, University of Ottawa
Anika Petrella, RP, MA, PhD candidate, University of Toronto

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

Evidence for why exercise and physical activity is important for individuals diagnosed with cancer is well established. However, pervasive uncertainty remains about how to connect this population to relevant services and resources (i.e., who should be involved/responsible and where to refer to). To address this gap, Santa Mina et al. (2018) proposed a model or pathway that goes beyond the what and systematically delineates how individuals diagnosed with cancer can be engaged in exercise programming and physical activity promotion. In addition, the authors tackle an existing barrier related to the lack of knowledge surrounding accessible services and resources by describing what is currently available across North America.

The proposed pathway is depicted visually and described utilizing empirical evidence and clinical knowledge. At the beginning of the pathway are healthcare providers (e.g., oncologists, family physician, nurses, psychologists, social workers), who are described as playing a critical role in enhancing access to exercise programming and physical activity promotion resources for individuals diagnosed with cancer. Following this, the pathway forks to illustrate the parallel steps for exercise engagement (i.e., referral to a qualified exercise professional and screening/risk stratification) and/or physical activity promotion.

Notably, Santa Mina et al. (2018) adopt a person-centred approach considering facilitators and barriers faced by individuals diagnosed with cancer, acknowledge the entire healthcare team by emphasizing a shared model of responsibility, and incorporate services (e.g., exercise programming) alongside self-management and behaviour change resources (e.g., online education). Thus, the emergent model is amenable to modification based on the individual and context. Finally, the authors flag areas requiring further attention/clarification (e.g., exploring home-based exercise programming) and conclude by encouraging future investigation of the applicability and economic sustainability of the pathway.

Why we liked this article: First, the pathway was developed by a team of leading experts in the field of exercise, physical activity, rehabilitation, and cancer survivorship and represents an important step to bridging the gap between what to do (i.e., recommend/refer individuals diagnosed with cancer to exercise/physical activity) and how to do it (i.e., specific steps, guidance, and access to resources). Second, the authors clearly underscore that individuals diagnosed with cancer are not static throughout survivorship. As such, a non-prescriptive approach, acknowledging potential fluctuations in health status, changes in self-motivation and empowerment, and differing needs with regards to addressing barriers over time was adopted. The fluidity and flexibility inherent in this model have the potential to significantly impact the wellbeing of individuals from cancer diagnosis onward across a variety of contexts.

Citation: Santa Mina D, Sabiston C, Au D, Fong AJ, Capozzi LC, Langelier D, Chasen M, Chiarotto J, Tomasone J, Jones J, Chang E, & Culos-Reed SN. (2018). Connecting people with cancer to physical activity and exercise programs: a pathway to create accessibility and engagement. Current Oncology, 25(2):149-162.

Journal website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5927786/