Sleep Disturbance as a Mediator of Lung Cancer Stigma on Psychological Distress and Physical Symptom Burden.

OBJECTIVE: This study tested sleep disturbance as a mediator through which stigma and discrimination predict psychological distress and physical symptom burden in adults with lung cancer. METHODS: Lung cancer patients on active oncological treatment ( N = 108; 74.1% stage IV) completed questionnaires on lung cancer stigma, sleep, distress, and physical symptoms at study entry and at 6- and 12-week follow-up. Mediation analyses were conducted to investigate whether stigma and discrimination predicted distress and physical symptoms at study entry and across 12 weeks through disrupted sleep. RESULTS: Higher discrimination ( b = 5.52, 95% confidence interval [CI] = 2.10-8.94) and constrained disclosure ( b = 0.45, 95% CI = 0.05-0.85) were associated significantly with higher sleep disruption at study entry. Sleep disruption, in turn, was associated with higher distress ( b = 0.19, 95% CI = 0.09-0.29) and physical symptoms ( b = 0.28, 95% CI = 0.17-0.40) at study entry. Sleep disruption significantly mediated relationships between higher discrimination and the outcomes of distress (indirect effect = 1.04, 95% CI = 0.13-1.96) and physical symptoms (indirect effect = 1.58, 95% CI = 0.37-2.79) at study entry. Sleep disruption also mediated relationships between constrained disclosure and the outcomes of distress (indirect effect = 0.85, 95% CI = < 0.01-0.17) and physical symptoms (indirect effect = 0.13, 95% CI = 0.01-0.25). CONCLUSIONS: Lung cancer patients evidenced pronounced sleep disruption, which mediated relationships between indicators of lung cancer stigma and distress and physical symptoms at study entry. Research is needed to test additional mechanisms through which lung cancer stigma predicts these outcomes longitudinally.

"No Complaining, No Crying": A Qualitative Study of the Strong Black Woman Schema in the Breast Cancer Context.

BACKGROUND: Black women have the highest mortality from breast cancer compared with other racial/ethnic groups. Black women with breast cancer also evidence compromised quality of life in some domains. Culturally relevant aspects of their experience are understudied. PURPOSE: The goal of this qualitative study was to examine the relevance of the Strong Black Woman schema in the cancer context. METHODS: Three Gatherings (i.e., culturally curated focus groups) were conducted with Black women who had been diagnosed with breast cancer and recruited from cancer-related listservs and events. A five-person team conducted reflexive thematic analysis of Gathering transcripts. RESULTS: The 37 participants ranged in age (30 to 94 years) and in diagnosis duration (2 months to 29 years). Reflexive thematic analysis yielded six themes that characterized the women's experience: historical legacy of the Strong Black Woman, navigating intersecting Strong Black Woman identities, everyday challenges encountered on the battlefield by Strong Black Women, Strong Black Woman in action during the breast cancer journey, the complexities of seeking and accepting support, and the liberated Strong Black Woman. The schema's negative consequences included the oncologic team and others expecting the participants to be strong and not to need support. Expectations to suppress emotions and continue caring for others to the neglect of the self also were evident. Positive consequences included engaging in self-advocacy in the oncologic context and redefining strength to include expressing emotions and accepting help. CONCLUSIONS: The Strong Black Woman schema is highly relevant in the breast cancer context and could be addressed in culturally centered interventions.

Compared with other racial/ethnic groups, Black American women diagnosed with breast cancer have the highest death rate and some aspects of their quality of life is lower. The authors developed Project SOAR (Speaking Our African American Realities) to shed light on the experiences of Black American women diagnosed with breast cancer. In one Project SOAR study, 37 women took part in Gatherings­small group meetings conducted in an all-Black, all-woman space­in which they talked about the relevance of the Strong Black Woman (or Black Superwoman) concept during breast cancer. Arising from a history of enslavement, the concept involves suppressing emotions, always acting strong, taking care of others while neglecting care of oneself, and declining others' support. Gathering participants ranged in age (30 to 94 years) and time elapsed since diagnosis (2 months to 29 years). Their breast cancer experiences often corresponded with the Strong Black Woman concept. For example, some medical professionals and others expected them to act strong, to keep caring for others, not to need support, and not to voice their emotions during the cancer experience. Some women redefined strength to include expressing emotions and accepting help. The authors are developing resources for Black American women breast cancer survivors.

Depression in Uveal Melanoma Survivorship: Examining Psychological Predictors of Adjustment in the First Year Following Diagnosis.

BACKGROUND: A rare cancer, uveal melanoma (UM) affects 5 in 1 million adults annually. Research on predictors of mental health in UM survivors is scarce. PURPOSE: In this prospective study, we tested models that postulate interactions between illness perceptions and coping processes in predicting depressive symptoms 1 year following UM diagnosis. METHODS: Participants' approach- and avoidance-oriented coping processes and illness perceptions specific to control and chronicity were assessed. Participants (N = 107) completed assessments prior to diagnosis (T0), and 1 week (T1), 3 months (T2), and 12 months after UM diagnosis (T3). RESULTS: At T1, a significant avoidance coping × chronicity perception interaction (b = 1.84, p = .03) indicated that the link between higher avoidance coping and greater T3 depressive symptoms was stronger for participants with prolonged chronicity perceptions (b = 17.13, p < .001). Chronicity perceptions at T2 interacted significantly with approach-oriented coping at all time points; the link between higher approach coping and lower T3 depressive symptoms was stronger for participants with prolonged chronicity perceptions at T2. Interactions between control perceptions and coping did not significantly predict T3 depressive symptoms. CONCLUSIONS: Findings lend partial support to predictive models that consider the combined, interacting influence of chronicity perceptions and coping processes on depressive symptoms in survivors of eye cancer.

The present study sought to identify psychological factors that were associated with depressive symptoms in adults diagnosed with uveal melanoma, a rare cancer. Understanding risk factors for depressive symptoms in cancer survivors is important, as heightened depressive symptoms have been shown to be associated with worse mental, physical, and disease-related outcomes in various cancer populations. In this study, uveal melanoma patients at University of California, Los Angeles were given questionnaires before their diagnosis, as well as 1 week, 3 months, and 1 year later. These questionnaires asked patients about their mental health, their efforts to cope with their cancer, and how they viewed their cancer. Adults with uveal melanoma were more likely to experience depressive symptoms 1 year after diagnosis when they had viewed their illness as more chronic in nature and also engaged in higher levels of cancer-related avoidance coping or lower levels of approach coping 3 months after their diagnosis. Findings highlight the impact that coping and perceptions of one's illness can have on mental health in the year following an uveal melanoma diagnosis. Future work should test whether mental health interventions targeting coping behaviors and/or illness perceptions can help to prevent or reduce depressive symptoms in uveal melanoma survivors.

Greater Social Isolation and Social Constraints Prior to Hematopoietic Stem Cell Transplant Are Associated with Greater Anxiety and Depressive Symptoms.

BACKGROUND: Hematopoietic stem cell transplantation (hereafter "HCT") is a physically and psychologically difficult treatment for patients with hematological cancers. This study examined relationships among patients' reports of pre-transplant social isolation, social constraints, and psychological distress. METHOD: We used baseline data from a multisite randomized controlled trial evaluating the effects of expressive helping writing to reduce physical and emotional symptoms in HCT patients. We collected data prior to randomization and before either allogenic or autologous HCT using validated scales to assess social constraints, social isolation, anxiety, and depressive symptoms. We analyzed data using bivariate analysis and multivariate linear regression. We also explored whether social isolation mediated the effect of social constraints on both of our outcomes: anxiety and depressive symptoms. RESULTS: Among 259 adults recruited prior to transplant, 43.6% were women (mean age = 57.42 years, SD = 12.34 years). In multivariate analysis controlling for relevant covariates, both social isolation (ß = 0.24, p < 0.001) and social constraints (ß = 0.28, p < 0.001) were associated with anxiety. When both social constraints and social isolation were in the model, only greater social isolation (ß = 0.79, p < 0.001) was associated with depressive symptoms. Social isolation fully mediated the association between social constraints and anxiety and depressive symptoms. CONCLUSION: For patients awaiting either allogenic or autologous HCT, the negative association between social constraints and anxiety and depressive symptoms may be related, in part, to the mechanism of perceived social isolation. Interventions prior to and during HCT are needed to support patients' psychological health and sense of social connectedness.

"I'm Fighting for My Life": Exploring Interactions Between Black Women with Breast Cancer and Healthcare Providers.

Black Americans face a multitude of problems in the healthcare system, including challenges during interactions with healthcare providers. The present study examined the quality of healthcare provider-Black patient interactions in a sample of Black American women with a breast cancer diagnosis. More specifically, the study examined potential contributors to Black Americans' current healthcare experiences and lack of trust by identifying their specific negative and positive encounters in the healthcare system. Three in-person Gatherings (i.e., culturally curated focus groups; N = 37) were conducted as part of a community-academic research partnership, Project SOAR (Speaking Our African American Realities). Four themes were identified through reflexive thematic analysis: Individual and Systemic Injustice Directed at Black Breast Cancer Survivors; Protecting Myself from an Untrustworthy Medical System; Stereotypes Interfered with My Care; and Good Care Should Include Compassion, Respect, Shared Decision Making, and Tailored Support. The present findings highlight the importance of addressing systemic and individual injustice toward Black Americans in healthcare settings generally, and Black women diagnosed with breast cancer specifically.

A mixed-methods study of the technical feasibility and patient acceptability of a real-time adherence monitor in breast cancer survivors taking adjuvant endocrine therapy.

PURPOSE: Oral anti-cancer medications are increasingly common and endocrine therapies represent the most common oral anti-cancer medications in breast cancer. Adjuvant endocrine therapies reduce the likelihood of recurrence and mortality in the approximately 80% of women diagnosed with hormone-receptor-positive breast cancer, thus rendering adherence essential. Real-time medication adherence monitors, such as the Wisepill electronic pillbox, transmit adherence data remotely, allowing for early intervention for non-adherence. However, their feasibility and acceptability have yet to be examined among breast cancer survivors taking endocrine therapies. METHODS: This study presents quantitative patient-report and technical support data and qualitative patient acceptability data on Wisepill, a common real-time adherence monitor, among 88 breast cancer survivors prescribed adjuvant endocrine therapy. RESULTS: This mixed-methods study of a common real-time adherence monitor, among the first in breast cancer survivors taking adjuvant endocrine therapy, demonstrates its technical feasibility and patient acceptability. CONCLUSION: The use of wireless medication monitors that transmit real-time adherence data is uniquely promising for maximizing the benefits of adjuvant endocrine therapy by allowing for continuous tracking, ongoing communication with oncologic or research teams, and early intervention. This study demonstrates the feasibility and patient acceptability of one such real-time adherence monitor.

The Impact of COVID-19 on Routine Medical Care and Cancer Screening.

BACKGROUND: COVID-19 restrictions and fear dramatically changed the use of medical care. Understanding the magnitude of cancelled and postponed appointments and associated factors can help identify approaches to mitigate unmet need. OBJECTIVE: To determine the proportion of medical visits cancelled or postponed and for whom. We hypothesized that adults with serious medical conditions and those with higher anxiety, depressive symptoms, and avoidance-oriented coping would have more cancellations/postponements. DESIGN: Four nationally representative cross-sectional surveys conducted online in May, July, October, and December 2020. PARTICIPANTS: 59,747 US adults who completed 15-min online surveys. 69% cooperation rate. MEASURES: Physical and mental health visits and cancer screening cancelled or postponed over prior 2 months. Plan to cancel or postpone visits over the next 2 months. Relationship with demographics, medical conditions, local COVID-19 death rate, anxiety, depressive symptoms, coping, intolerance of uncertainty, and perceived COVID-19 risk. KEY RESULTS: Of the 58% (N = 34,868) with a medical appointment during the 2 months before the survey, 64% had an appointment cancelled or postponed in May, decreasing to 37% in December. Of the 41% of respondents with scheduled cancer screening, 20% cancelled/postponed, which was stable May to December. People with more medical conditions were more likely to cancel or postpone medical visits (OR 1.19 per condition, 95% CI 1.16, 1.22) and cancer screening (OR 1.20, 95% CI 1.15, 1.24). Race, ethnicity, and income had weak associations with cancelled/postponed visits, local death rate was unrelated, but anxiety and depressive symptoms were strongly related to cancellations, and this grew between May and December. CONCLUSIONS: Cancelled medical care and cancer screening were more common among persons with medical conditions, anxiety and depression, even after accounting for COVID-19 deaths. Outreach and support to ensure that patients are not avoiding needed care due to anxiety, depression and inaccurate perceptions of risk will be important.

Socioeconomic Status and Inflammation in Women with Early-stage Breast Cancer: Mediation by Body Mass Index.

BACKGROUND: Breast cancer is the most common cancer among women in the US, and women of low socioeconomic status (SES) show markedly poorer outcomes than those of high SES. SES may influence health through inflammation, although links between SES and inflammatory biomarkers have not been investigated in women with breast cancer. This study tested the hypothesis that breast cancer patients of lower SES would show higher levels of inflammation than those of higher SES. BMI was examined as a mediator of this association. METHODS: Women recently diagnosed with early-stage breast cancer (N = 194) were recruited before neoadjuvant or adjuvant therapy. Participants completed questionnaires and provided blood samples for immune assessment. SES was indexed by participants' self-reported education and annual household income, BMI was determined by height and weight measurements, and blood was assayed for inflammatory biomarkers linked with cancer outcomes: IL-6, CRP, TNF-α, and sTNF-RII. General linear models tested associations between SES and inflammation, and mediation models examined indirect effects through BMI. RESULTS: Consistent with hypotheses, education status was associated with CRP, (F(2,185) = 4.72, p = 0.001), and sTNF-RII, (F(2,185) = 4.19, p = 0.02), such that lower education was associated with higher levels of both biomarkers. Further, BMI mediated the associations between education and CRP, (95% CIs [-0.62, -0.11; -0.76, -0.21]), sTNF-RII, (95% CIs [-0.09, -0.01; -0.10, -0.02]), and IL-6, (95% CIs [-0.32, -0.05; -0.38, -0.09]). Annual household income was not significantly associated with inflammation (ps > 0.25), and indirect effects on inflammation through BMI were not significant. CONCLUSIONS: Lower education was associated with higher levels of inflammation in this sample, which may presage poor breast cancer-related and clinical outcomes. SES should inform the development of interventions targeting BMI and inflammation in breast cancer.

Optimizing use of written peer support as a supportive resource in cancer: Focus group insights.

PURPOSE: Cancer survivors frequently describe wanting to learn from others who have had similar diagnoses or treatments (peer support). We conducted focus groups to investigate hematopoietic stem cell transplant survivors' attitudes and preferences regarding accessing written peer support through a website. Although written peer support does not allow for interpersonal interactions with peers, it could increase transplant recipients' access to evidence-based benefits of informational and emotional peer support. METHODS: We conducted four videoconference focus groups with 34 adult transplant survivors who were diverse in their medical and sociodemographic characteristics and geographic location. Discussions were recorded, transcribed, and content analyzed. RESULTS: Many participants reported need for information about transplant beyond what they received from their healthcare providers. Needs varied across participants, as did preferences for characteristics and timing of information optimally provided through peer support. Participants were enthusiastic about the value of written peer support but emphasized that it should be delivered in a way that accommodates variation in transplant experiences, underscores its trustworthiness, and pairs it with useful psychoeducational content. CONCLUSIONS: Findings provide guidance for making written peer support an accessible, supportive resource for transplant survivors. Future research should evaluate personalized online delivery of written peer support paired with psychoeducational content that enhances its benefits. IMPLICATIONS FOR CANCER SURVIVORS: Written peer support delivered online could be a useful, valued resource for transplant survivors.

Randomized Controlled Pilot Trial of a Low-Touch Remotely-Delivered Values Intervention to Promote Adherence to Adjuvant Endocrine Therapy Among Breast Cancer Survivors.

BACKGROUND: Oral anti-cancer treatments such as adjuvant endocrine therapies (AET) for breast cancer survivors are commonly used but adherence is a challenge. Few low-touch, scalable interventions exist to increase ET adherence. PURPOSE: To evaluate the acceptability, feasibility, and initial efficacy of a low-touch, remotely-delivered values plus AET education intervention (REACH) to promote AET adherence. METHODS: A mixed-methods trial randomized 88 breast cancer survivors 1:1 to REACH or Education alone. Wisepill real-time electronic adherence monitoring tracked monthly AET adherence during a 1-month baseline through 6-month follow-up (FU) (primary outcome). Patient-reported outcomes were evaluated through 3- and 6-month FU (secondary). Multiple indices of intervention feasibility and acceptability were evaluated. Qualitative exit interviews (n = 38) further assessed participants' perceptions of feasibility/acceptability and recommendations for intervention adaptation. RESULTS: The trial showed strong feasibility and acceptability, with an eligible-to-enrolled rate of 85%, 100% completion of the main intervention sessions, and "good" intervention satisfaction ratings on average. For Wisepill-assessed AET adherence, REACH outperformed Education for Month 1 of FU (p = .027) and not thereafter. Participants in REACH maintained high adherence until Month 4 of FU, whereas in Education, adherence declined significantly in Month 1. Conditions did not differ in self-reported adherence, positive affective attitudes, future intentions, or necessity beliefs. REACH trended toward less negative AET attitudes than Education at 3-month FU (p = .057) reflecting improvement in REACH (p = .004) but not Education (p = .809). Exploratory moderator analyses showed that average to highly positive baseline AET affective attitudes and oncologist-patient communication each predicted higher adherence following REACH than Education; low levels did not. Participants identified recommendations to strengthen the interventions. CONCLUSIONS: REACH, a low-touch values intervention, showed good feasibility and acceptability, and initial promise in improving objectively-assessed AET adherence among breast cancer survivors (relative to education alone). Future research should target improving REACH's tailoring and endurance.

Executive Functioning and Depressive Symptoms After Cancer: The Mediating Role of Coping.

OBJECTIVE: Cognitive difficulties are a common complaint among patients with breast cancer and may adversely affect psychological well-being. In particular, problems with executive functioning (EF) may interfere with coping, which is known to influence depressive symptoms. The current study was designed to examine correlations between EF, coping, and depressive symptoms in breast cancer survivors and to longitudinally test the hypothesis that coping mediates the relationship between EF and depressive symptoms. METHODS: Participants included 171 women with early-stage breast cancer assessed at the end of primary treatment with surgery, radiation, and/or chemotherapy and at 6 months, 1 year, and 2 years after treatment follow-ups as part of the Mind-Body Study. Participants completed questionnaires to assess subjective EF, approach and avoidant coping, and depressive symptoms, and neuropsychological testing was conducted to assess objective EF. Bivariate correlations were used to examine associations between EF, coping, and depressive symptoms. Mediation analyses were conducted using a bootstrapping approach (PROCESS). RESULTS: At 1 year after treatment, objective and subjective EFs were correlated with avoidant coping (r = -0.172 [p = .024] and r = 0.297 [p < .001], respectively). In longitudinal analyses, use of the avoidant strategy behavioral disengagement at 1 year mediated the association between objective (95% bootstrap confidence interval = -0.282 to -0.042) and subjective (95% bootstrap confidence interval = 0.020 to 0.254) EFs at 6 months and depressive symptoms at 2 years. CONCLUSIONS: This study highlights how problems with EF during survivorship are associated with avoidant coping and depressive symptoms. Thus, these findings identify potential cognitive and affective targets for depression intervention in this population.

Transitions in coping profiles after breast cancer diagnosis: implications for depressive and physical symptoms.

The objective of this study was to determine whether: (a) cancer-related coping profiles change across time; (b) coping profile transition types predict changes in depressive and physical symptoms. Latent transition analysis was conducted with repeated measures of seven cancer-related coping processes from 460 women recently diagnosed with breast cancer. In multilevel models, coping profile transition groups were entered as predictors of symptoms across 12 months. Three coping profiles emerged at study entry, with two profiles at later assessments. Forty-eight percent of women maintained high-moderate approach-oriented coping over time. Specific factors (e.g., age, acceptance of emotions) differentiated the transition groups. Women who increased and then maintained high-moderate approach-oriented coping had relatively high initial depressive symptoms that declined steeply. When cancer-related acceptance predominated, women experienced increasing physical symptoms. Distinct cancer-related coping patterns are related to the level of and change in depressive and physical symptoms longitudinally. Early intervention to increase approach-oriented coping strategies could yield favorable outcomes.

A prospective study of cancer-related benefit finding in uveal melanoma patients.

Little is known about contributors to the psychosocial impact of uveal melanoma, a rare cancer. Predictors and outcomes of benefit finding, a potentially favorable outcome, were investigated. Adults (n = 107) completed assessments prior to diagnosis of uveal melanoma and one week, three months and 12 months after diagnosis. Path analyses with the full information maximum likelihood estimation method were conducted. Objective disease impact on vision did not predict benefit finding (p > .05). Approach-oriented coping prior to diagnosis and one week later significantly predicted greater benefit finding 12 months later (p < .01). Avoidance-oriented coping at three months moderated the concurrent relationship of benefit finding and positive affect at 12 months (p < .001). This first study of predictors of benefit finding in uveal melanoma patients suggests that greater approach-oriented coping prospectively predicts higher benefit finding. Further, avoidance may condition the association of benefit finding with psychosocial outcomes.

Insomnia and Fatigue Symptom Trajectories in Breast Cancer: A Longitudinal Cohort Study.

Objective: Insomnia and fatigue are common, although not inevitable, during breast cancer. This study is one of the first aiming to describe distinct trajectory classes of insomnia and fatigue symptoms, and their correlates, from diagnosis through treatment.Methods: This longitudinal cohort study was conducted at a comprehensive cancer center and community oncology practices. Participants (N = 460) were women diagnosed with any stage of breast cancer in the previous 4 months. Primary outcomes for this ancillary study of the existing cohort were self-reported insomnia and fatigue symptoms assessed repeatedly across 12 months.Results: Four distinct classes of insomnia symptoms emerged: persistently very high, clinically elevated symptoms (13.7%); high, clinically elevated symptoms (65.9%); stable low (17.2%) or very low (2.6%) symptoms. Five fatigue symptom classes included high, increasing fatigue (9.6%), two recovery classes starting at high (26.3%), or moderate (18.0%) severity at diagnosis, stable low (33.3%) or very low (12.2%) classes. In multivariate analyses, higher depressive symptoms, anxiety, and chronic life stress were associated with being in the very high insomnia class versus the low symptom class. Oncologic factors were not associated with insomnia class membership. Receiving chemotherapy was linked significantly to high and recovery fatigue symptom classes versus the low class. Higher chronic life stress was associated with more persistent fatigue symptoms.Conclusions: Distinct classes of insomnia and fatigue symptoms were evident; 79.6% of the women had clinically elevated, persistent insomnia symptoms, 53.9% had elevated fatigue. A substantial minority evidenced low symptoms, suggesting targeted or stepped-care approaches to symptom management.

Effects of stress-induced inflammation on reward processing in healthy young women.

BACKGROUND: Anhedonia, or loss of interest or pleasure, is a feature of depression and transdiagnostic construct in psychopathology. Theory and compelling evidence from preclinical models implicates stress-induced inflammation as a psychobiological pathway to anhedonic behavior; however, this pathway has not been tested in human models. Further, although anhedonia may reflect dysregulation in multiple dimensions of reward, the extent to which stress-induced inflammation alters these dimensions is unclear. Thus, the current experimental study used a standardized laboratory stressor task to elicit an inflammatory response and evaluate effects of stress-induced inflammation on multiple behavioral indices of reward processing. METHODS: Healthy young women (age 18-25) completed behavioral reward tasks assessing reward learning, motivation, and sensitivity and were randomized to undergo an acute psychosocial stressor (n = 37) or a no-stress active control (n = 17). Tasks were re-administered 90-120 min post-stress to coincide with the peak of the stress-induced inflammatory response. Blood samples were collected for assessment of the pro-inflammatory cytokine interleukin-6 (IL-6) at baseline and 90 and 120 min post stressor. RESULTS: Stress-induced IL-6 was associated with increased response bias during reward learning and increased motivation when probability of receiving a reward was low. Sensitivity to reward in the context of a motivation task was not altered in association with stress-induced IL-6. CONCLUSIONS: Contrary to hypotheses, mild increases in IL-6 following acute stress were associated with increased reward responsiveness during reward learning and selective increases in motivation. Results contribute to an emerging and nuanced literature linking inflammation to reward processing, and demonstrate that behavioral effects of stress-induced inflammation may be detected in the laboratory setting. CLINICAL TRIAL REGISTRATION: NCT03828604.

Presence and predictors of anxiety disorder onset following cancer diagnosis among anxious cancer survivors.

PURPOSE: Despite cancer survivors' frequent endorsement of anxiety symptoms, assessing the full range of anxiety disorders (AD), their timing of onset relative to cancer diagnosis, co-morbidity with mood disorder, and predictors of post-cancer onset, is rare or absent to date. This study provides a step toward addressing these gaps. METHODS: Cancer survivors at re-entry after primary treatment completion who screened positively for anxiety symptoms (N = 133) and sought care through an intervention trial completed standardized diagnostic interviews, dimensional assessment of disorder severity, and timing of disorder onset relative to cancer diagnosis. We evaluated sociodemographic and medical predictors of developing a first AD after cancer diagnosis. RESULTS: Most ADs began after cancer diagnosis (58%); for 68% of affected patients, this represented their first AD episode. The most common was generalized anxiety disorder (GAD; 41%), where "cancer-focused GAD" was distinguished from "typical GAD"; the next most common were specific phobia (14%) and social anxiety disorder (13%). A minority (31%) of ADs were comorbid with major depression. Relative to having no AD, experiencing more lingering treatment side effects predicted developing a first AD after cancer diagnosis. Relative to having an AD that began before cancer diagnosis, reporting a higher cancer stage predicted developing a first AD after diagnosis. CONCLUSIONS: Cancer survivors at re-entry seeking care for anxiety symptoms manifested a broad range of ADs which most commonly developed after cancer diagnosis and were prompted by the experience of cancer. Such disorders represent an unusually late-life, cancer-linked etiology that warrants further investigation and clinical attention.

A randomized controlled trial of a group acceptance-based intervention for cancer survivors experiencing anxiety at re-entry ('Valued Living'): study protocol.

BACKGROUND: Anxiety is a common concern of cancer survivors during the transition from active cancer treatment to cancer survivorship (the re-entry phase). This paper presents the study protocol for a novel group-based behavioral intervention to improve mental health, well-being, and medical use outcomes among anxious cancer survivors at re-entry. METHODS/DESIGN: This two-armed, prospective randomized controlled trial will randomize a minimum of 100 re-entry-phase cancer survivors with moderate to high anxiety to the intervention or a usual care control condition. The intervention is delivered in a group format over 7 weeks; content is based on Acceptance and Commitment Therapy (ACT), an acceptance, mindfulness, and values-based intervention. Participants will be recruited from community cancer care centers and the intervention will be led by the onsite clinical social workers. Participants will be assessed at baseline, mid-intervention, post-intervention, and 3- and 6-month follow-up. ACT participants will complete process measures before the beginning of group sessions 2, 4, and 6; all participants will complete the process measures during the regular assessments. The primary outcome is anxiety symptoms; secondary outcomes include anxiety disorder severity, fear of recurrence, depressive symptoms, cancer-related trauma symptoms, sense of life meaning, vitality/fatigue, and medical utilization. DISCUSSION: This clinical trial will provide valuable evidence regarding the efficacy of the group ACT intervention in community oncology settings. TRIAL REGISTRATION: Clinicaltrials.gov NCT02550925 .

A preventive intervention to modify depression risk targets after breast cancer diagnosis: Design and single-arm pilot study.

OBJECTIVE: Apply the National Institutes of Health (NIH) Stage Model to design and test an intervention to prevent depression in breast cancer patients at risk for depression. METHODS: We identified mindful emotion awareness, along with approach and avoidance strategies for cancer-related coping and emotion regulation, as targets for a preventive intervention adapted from the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Patients' preferences for individual, in-person, and time-efficient sessions informed the design. Patients at risk for depression received a 6-week, 5-hour intervention with daily exercises. Intervention targets were assessed at baseline, before each session, and 4-weeks post intervention. Mixed effects analysis of variance (ANOVA) assessed change over the follow-up period, controlling for age, partnered status, and disease stage. RESULTS: Fifty-five percent (40/72) of women screened within 6 months of diagnosis had elevated depression risk. Of these, 24 (60%) signed consent. Sixteen received intervention after five were excluded for current depressive disorder, cognitive impairment, or death. Three dropped out. Ninety-eight percent attendance and 77% practice days indicated feasibility. Effect sizes (Cohen's d) corrected for regression to the mean (RTM) were 0.82 for cancer-related acceptance coping, 0.65 for cancer-related emotional expression, and 0.32 and 0.42 for decreased cancer-related avoidance coping and depressive symptoms, respectively. Effect sizes for variables lacking data to correct for RTM were 1.0, 0.7, and 0.5 for decreased rumination, experiential avoidance, and fear of depression, respectively, and 1.3, 0.6, and 0.4 for increased cognitive flexibility, distress tolerance, and describing/not judging emotions, respectively. CONCLUSIONS: The feasibility of this intervention and malleability of its targets support its further investigation.

Risk estimation, anxiety, and breast cancer worry in women at risk for breast cancer: A single-arm trial of personalized risk communication.

OBJECTIVE: Elevated anxiety and breast cancer worry can impede mammographic screening and early breast cancer detection. Genetic advances and risk models make personalized breast cancer risk assessment and communication feasible, but it is unknown whether such communication of risk affects anxiety and disease-specific worry. We studied the effect of a personalized breast cancer screening intervention on risk perception, anxiety, and breast cancer worry. METHODS: Women with a normal mammogram but elevated risk for breast cancer (N = 122) enrolled in the Athena Breast Health risk communication program were surveyed before and after receiving a letter conveying their breast cancer risk and a breast health genetic counselor consultation. We compared breast cancer risk estimation, anxiety, and breast cancer worry before and after risk communication and evaluated the relationship of anxiety and breast cancer worry to risk estimation accuracy. RESULTS: Women substantially overestimated their lifetime breast cancer risk, and risk communication somewhat mitigated this overestimation (49% pre-intervention, 42% post-intervention, 13% Gail model risk estimate, P < .001). Both general anxiety and breast cancer worry declined significantly after risk communication in women with high baseline anxiety. Baseline anxiety and breast cancer worry were essentially unrelated to risk estimation accuracy, but risk communication increased alignment of worry with accuracy of risk assessment. CONCLUSIONS: Personalized communication about breast cancer risk was associated with modestly improved risk estimation accuracy in women with relatively low anxiety and less anxiety and breast cancer worry in women with higher anxiety. We detected no negative consequences of informing women about elevated breast cancer risk.

Correspondence Between Objective and Self-reported Endocrine Therapy Adherence Among Women With Breast Cancer.

BACKGROUND: Among the approximately 70% of women with hormone receptor-positive breast cancer, endocrine therapies lower the likelihood of recurrence. Nonadherence to endocrine therapy predicts lower survival. PURPOSE: We examined concordance between self-reported and objective indicators of adherence and predictors of over-reporting endocrine therapy adherence among survivors of breast cancer. METHODS: Women with breast cancer (N = 112) receiving their initial endocrine therapy prescription completed three assessments at prescription initiation (Time 1), 1 month (Time 2), and 4 months later (Time 3). At Time 1, participants were provided a medication event monitoring system (MEMS) cap to assess adherence; it was collected at Time 3. Women completed items regarding self-reported adherence, depressive symptoms, cancer-related coping processes, and the patient-physician relationship. RESULTS: MEMS was significantly negatively correlated with the self-reported nonadherence measurements of occasionally forgetting (Time 2, ρ = -.29, p < .01; Time 3, ρ = -.24, p < .01), nonadherence in the past week (Time 2, ρ = -.53, p < .01; Time 3, ρ = -.45, p < .01), and nonadherence in an average week in the past month (Time 2, ρ = -.38, p < .01; Time 3, ρ = -.39, p < .01). Concordance in objective and self-reported adherence measures was evident in 83% of women at Time 2 and 73% at Time 3. Older age was significantly associated (p < .01) with discordance. CONCLUSIONS: Findings reveal moderate correspondence between objective and self-report measures, with self-report overestimating objective adherence. Clinicians should be aware when treating older breast cancer survivors that they are more likely to over self-report their endocrine therapy adherence.