Resiliency among older adults receiving lung cancer treatment (ROAR-LCT): A novel supportive care intervention for older adults with advanced lung cancer.

INTRODUCTION: Novel supportive care interventions designed for an aging population with lung cancer are urgently needed. We aimed to determine the feasibility of a novel supportive care physical therapy (PT) plus progressive muscle relaxation (PMR) intervention delivered to older adults with advanced lung cancer in the United States (US). MATERIALS AND METHODS: This clinical trial, Resiliency Among Older Adults Receiving Lung Cancer Treatment (ROAR-LCT: NCT04229381), recruited adults aged ≥60 years with unresectable stage III/IV non-small cell (NSCLC) or small cell lung cancer (SCLC) receiving cancer treatment at The James Thoracic Oncology Center (planned enrollment, N = 20). There were no exclusion criteria pertaining to performance status, laboratory values, prior cancer diagnoses, comorbidities, or brain metastases. Participants were evaluated by PT and psychology and given an exercise pedaler, resistance bands, a relaxation voice recording, and instructions at study initiation. Participants were evaluated in-person by PTs and psychologists at the start and end of the 12-session intervention, with the intervening sessions conducted via virtual health. Participants completed self-reported measures of functional status, symptoms, and mood longitudinally with the following instruments: EQ-5D-5L, Patient Health Questionnaire-9, and General Anxiety Disorder-7. PT assessments included the Short Physical Performance Battery (SPPB) and the two-minute walk test. Feasibility was defined as at least 60% of participants completing at least 70% of all intervention sessions. Optional gut microbiome samples and activity monitoring data (ActiGraph®) were also collected. RESULTS: The ROAR-LCT study concluded after consenting 22 patients. Among the 22 consented, 18 (81.8%) started the intervention; 11 participants (61.1%) completed at least 70% of all study sessions. All participants with SCLC completed the intervention. Reasons for withdrawal included progression of disease or hospitalization. The majority (88.9%) of patients who started were able to complete at least one virtual health session. Participants' functional status, SPPB, depression, and anxiety scores were stable from pre- to post-intervention. Participants who withdrew had worse baseline scores across domains. Seven microbiome and six ActiGraph® samples were collected. DISCUSSION: This is one of the first PT + PMR supportive care interventions using virtual health among older adults with advanced lung cancer to achieve feasibility in the US.

Patient Experiences After Aborted Cancer Surgery: A Qualitative Study.

BACKGROUND: Surgical resection is a necessary component of curative-intent treatment for most solid-organ cancers but is occasionally aborted, most often due to occult metastatic disease or unanticipated unresectability. Despite its frequency, little research has been performed on the experiences, care needs, and treatment preferences of patients who experience an aborted cancer surgery. METHODS: Semistructured interviews of patients who had previously experienced an aborted cancer surgery were conducted, focusing on their recalled experiences and stated preferences. All interviews were audio recorded, transcribed, and coded by two independent researchers by using NVivo 12. An integrative approach to qualitative analysis was used-both inductive and deductive methods-and iteratively identifying themes until saturation was reached. RESULTS: Fifteen patients with an aborted cancer surgery participated in the interviews. Cancer types included pancreatic (n = 9), cholangiocarcinoma (n = 3), hepatocellular carcinoma (n = 1), gallbladder (n = 1), and neuroendocrine (n = 1). The most common reasons for aborting surgery included local tumor unresectability (n = 8) and occult metastatic disease (n = 7). Five subthemes that characterized the patient experience following an aborted cancer surgery emerged, including physical symptoms, emotional responses, impact on social and life factors, coping mechanisms, and support received. CONCLUSIONS: This qualitative study characterizes the impact of aborted cancer surgery on multiple domains of quality of life: physical, emotional, social, and existential. These results highlight the importance of developing patient-centered interventions that focus on enhancing quality of life after aborted cancer surgery.

Characterizing the patient experience during neoadjuvant therapy for pancreatic ductal adenocarcinoma: A qualitative study.

BACKGROUND: Neoadjuvant therapy (NT) has increasingly been utilized for patients with localized pancreatic ductal adenocarcinoma (PDAC). It is the recommended approach for borderline resectable (BR) and locally advanced (LA) cancers and an increasingly utilized option for potentially resectable (PR) disease. Despite its increased use, little research has focused on patient-centered metrics among patients undergoing NT, including patient experiences, preferences, and recommendations. A better understanding of all aspects of the patient experience during NT may identify opportunities to design interventions aimed at improving quality of life; it may also facilitate the completion of NT and receipt of surgery, ultimately optimizing long-term outcomes. AIM: To understand the experience of patients initiating and receiving NT to identify opportunities to improve neoadjuvant cancer care delivery. METHODS: Semi-structured interviews of patients with localized PDAC during NT were conducted to explore their experience initiating and receiving NT. Interviews took place between August 2020 and October 2021. Due to the descriptive nature of the research, questions were open ended. Interviews were conducted over the phone, audio recorded and then transcribed. All interviews were coded by two independent researchers using NVivo 12, iteratively identifying themes until thematic saturation was achieved. An integrative approach to qualitative analysis was used, utilizing both inductive and deductive methods. RESULTS: A total of 12 patients with localized PDAC were interviewed. Patients with BR (n = 7), PR (n = 2), and LA (n = 3) cancers participated in the study. All patients indicated that choosing NT was the doctor's recommendation, while most reported not being familiar with the concept of NT (n = 11) and that NT was presented as the only option (n = 8). Five themes describing the patient experience emerged: physical symptoms, emotional symptoms, coping mechanisms, access to care, and life factors. The most commonly cited recommendation for improving the experience of NT was improved education before and during NT (n = 7). Patients highlighted the need for more information on the rationale behind choosing NT prior to surgery, the anticipated surgery and its likelihood of surgery occurring after NT, as well as general information prior to starting NT treatment. The need for seeing different members of the healthcare team, including ancillary services was also frequently cited as a recommendation for improving the experience of NT (n = 5). CONCLUSION: This study provides a framework to allow for a better understanding of the PDAC patient experience during NT and highlights opportunities to improve quality and quantity of life outcomes.

Training to Promote Empathic Communication in Graduate Medical Education: A Shared Learning Intervention in Internal Medicine and General Surgery.

Background: Empathic communication skills have a growing presence in graduate medical education to empower trainees in serious illness communication. Objective: Evaluate the impact, feasibility, and acceptability of a shared communication training intervention for residents of different specialties. Design: A randomized controlled study of standard education v. our empathic communication skills-building intervention: VitalTalk-powered workshop and formative bedside feedback using a validated observable behavioral checklist. Setting/Subjects: During the 2018-2019 academic year, our intervention was implemented at a large single-academic medical center in the United States involving 149 internal medicine and general surgery residents. Measurements: Impact outcomes included observable communication skills measured in standardized patient encounters (SPEs), and self-reported communication confidence and burnout collected by surveys. Analyses included descriptive and inferential statistics, including independent and paired t tests and multiple regression model to predict post-SPE performance. Results: Of residents randomized to the intervention, 96% (n = 71/74) completed the VitalTalk-powered workshop and 42% (n = 30/71) of those residents completed the formative bedside feedback. The intervention demonstrated a 33% increase of observable behaviors (p < 0.001) with improvement in all eight skill categories, compared with the control who only showed improvement in five. Intervention residents demonstrated improved confidence in performing all elicited communication skills such as express empathy, elicit values, and manage uncertainty (p < 0.001). Conclusions: Our educational intervention increased residents' confidence and use of essential communication skills. Facilitating a VitalTalk-powered workshop for medical and surgical specialties was feasible and offered a shared learning experience for trainees to benefit from expert palliative care learning outside their field.

Development of a psychosocial oncology core curriculum for multidisciplinary education and training: Initial content validation using the modified Delphi Method.

OBJECTIVE: Despite its four decade history, the multidisciplinary specialty of psychosocial oncology (PSO) has no official consensus on core content. In 2014, the American Psychosocial Oncology Society (APOS) Board charged the APOS Professional Education Committee with outlining curricular content needed for core competence. METHODS: Content validation was completed using a four-phase modified Delphi Method. During Phase I, a Professional Education Committee subgroup proposed domains and items, which were rated by the APOS Fellows and Board via online survey. During Phase II, Fellows completed a second, revised survey. Phase III incorporated early career members. Developmental and diversity items were integrated into each domain. In Phase IV, a larger group of subject matter experts were surveyed, with feedback incorporated. Validation across phases involved average rating thresholds, intraclass correlations, and final percent agreement. RESULTS: The Delphi Method supported 12 content domains: Cancer Basics, Psychosocial Oncology, Professional Development, Ethics, Emotional/Psychological Concerns, Sexuality and Relationship Concerns, Spiritual/Religious Concerns, Healthcare Communication and Decision Making, Social/Practical Problems, Caregiver Concerns, Cognitive Concerns, Physical Symptoms and Psychosocial Assessment/Treatment. High levels of agreement were achieved across domains (86%-100%) and items, with no significant rating differences by discipline. CONCLUSIONS: This proposed core content can enhance and standardize education and training in PSO including APOS' Virtual Psychosocial Oncology Core Curriculum, focused on broadly expanding the PSO workforce, particularly in underserved areas. Next steps include development of core competencies and establishment of online training modules based on this content validation.

Prospective Study of a Novel Risk Stratification Process for Opioid-Related Harm Reduction in Cancer Patients Seen in an Outpatient Palliative Care Clinic.

Background: Oncologists and palliative specialists prescribe opioids for millions of cancer patients despite limited research on effective screening and mitigation strategies to reduce risk of opioid-related harm in that population. Objective: To evaluate the efficacy of a novel opioid risk stratification process for predicting significant aberrant behaviors (SABs) related to prescribed opioid medications. Design and Setting/Subjects: This is a prospective, longitudinal study of 319 consecutive patients referred to an outpatient palliative care clinic between 2010 and 2012, a period during which prescription opioid-related deaths began to increase in the United States. Measures: Patients completed a psychodiagnostic/substance use risk assessment with a licensed clinical psychologist or social worker at the initial palliative clinic visit. Patients were assigned to Low-, Moderate-, or High-Risk groups based on predetermined stratification criteria and were managed via an opioid harm reduction approach. The primary dependent measure was the presence of at least one SAB after the initial visit. Results: Eighteen percent of patients (n = 56) demonstrated at least one major aberrant behavior. Odds of future aberrant behavior was 15 times greater in the High-Risk versus the Low-Risk category. Five risk factors significantly enhanced our risk model: age 18 to 45 years, job instability, history of bipolar diagnosis, history of substance abuse, and theft. Conclusion: Our risk stratification process provides a useful model for predicting those at greatest risk of future aberrant behaviors and most in need of comanagement. We recommend additional studies to test our proposed streamlined risk stratification tool.

Addressing distress management challenges: Recommendations from the consensus panel of the American Psychosocial Oncology Society and the Association of Oncology Social Work.

Distress management (DM) (screening and response) is an essential component of cancer care across the treatment trajectory. Effective DM has many benefits, including improving patients' quality of life; reducing distress, anxiety, and depression; contributing to medical cost offsets; and reducing emergency department visits and hospitalizations. Unfortunately, many distressed patients do not receive needed services. There are several multilevel barriers that represent key challenges to DM and affect its implementation. The Consolidated Framework for Implementation Research was used as an organizational structure to outline the barriers and facilitators to implementation of DM, including: 1) individual characteristics (individual patient characteristics with a focus on groups who may face unique barriers to distress screening and linkage to services), 2) intervention (unique aspects of DM intervention, including specific challenges in screening and psychosocial intervention, with recommendations for resolving these challenges), 3) processes for implementation of DM (modality and timing of screening, the challenge of triage for urgent needs, and incorporation of patient-reported outcomes and quality measures), 4) organization-inner setting (the context of the clinic, hospital, or health care system); and 5) organization-outer setting (including reimbursement strategies and health-care policy). Specific recommendations for evidence-based strategies and interventions for each of the domains of the Consolidated Framework for Implementation Research are also included to address barriers and challenges.

Association of pre-existing mental illness with all-cause and cancer-specific mortality among Medicare beneficiaries with pancreatic cancer.

BACKGROUND: Among patients with pancreatic cancer, the association of pre-existing mental illness with long-term outcomes remains unknown. METHODS: Individuals diagnosed with pancreatic adenocarcinoma were identified in the SEER-Medicare database. Patients were classified as having mental illness if an ICD9/10CM code for anxiety, depression, bipolar disorder, schizophrenia or other psychotic disorder was recorded. RESULTS: Among the 54,234 Medicare beneficiaries with pancreatic cancer, roughly 1 in 12 (n = 4793, 8.83%) individuals had a diagnosis of a mental illness. The majority (n = 4029, 84.1%) had anxiety or depression, while 16% (n = 764) had bipolar/schizophrenic disorders. On multivariable analysis, among patients with early stage cancer, individuals with pre-existing anxiety/depression and bipolar/schizophrenic disorders had 22% (OR 0.78, 95% CI 0.69-0.86) and 46% (OR 0.54, 95% CI 0.42-0.70) reduced odds, respectively, to undergo cancer-directed surgery. Furthermore, patients with a pre-existing history of bipolar/schizophrenic disorders had a 20% (HR 1.20, 95% CI 1.21-1.40) higher risk of all-cause mortality and 27% (HR 1.27, 95% CI 1.17-1.37) higher risk of pancreatic cancer-specific mortality compared to individuals without a history of mental illness. CONCLUSION: One in twelve patients with pancreatic cancer had a pre-existing mental illness. Individuals with mental illness were more likely to have worse overall and cancer-specific long-term outcomes.

Supportive Care Needs of Patients with Head and Neck Cancer Referred to Palliative Medicine.

OBJECTIVE: Patients with head and neck cancer (HNC) face a unique set of unmet needs. A subset of these patients experience symptom control challenges related to their disease burden and treatments. A multidisciplinary approach involving palliative medicine is underutilized but crucial to identify and address these concerns. There is limited information on palliative integration with head and neck oncology. STUDY DESIGN: Case series with planned data collection. SETTING: Academic quaternary care center. SUBJECTS AND METHODS: We provide descriptive analyses of patients with HNC, including psychodiagnostic assessment and validated quality-of-life screening, from patients' first encounter at outpatient palliative medicine. RESULTS: HNC (N = 80) contributed the greatest number of palliative referrals (25%) between 2010 and 2012. This cohort was 74% male and 79% Caucasian with a mean age of 53 years (95% CI, 51.1-54.9) and with stage IV disease of the oral cavity (28%) or oropharynx (31%). Sixty-three percent of patients had no evidence of disease. Seventy-five percent had a psychological history based on DSM-IV criteria (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), and 70% had a history of substance use disorder. The most distressing quality-of-life concerns were pain, housing and financial problems, and xerostomia. CONCLUSIONS: Patients with HNC who were referred to palliative medicine are burdened by multiple physical, psychological, substance use, and social challenges. We recommend comprehensive cancer-specific screening, such as the James Supportive Care Screening, to triage patients to appropriate supportive care services. Palliative care is one of many services that these patients may need, and it should be utilized at any point of the disease trajectory rather than reserved for end-of-life care.

Pilot randomized controlled trial of a symptom cluster intervention in advanced cancer.

OBJECTIVE: This study evaluated a three-session acceptance-based cognitive behavioral -acceptance and commitment therapy (CBT-ACT) intervention targeting a common symptom cluster in advanced cancer-worry-insomnia-depression-fatigue. METHODS: Twenty-eight patients with advanced cancer were randomly assigned to the CBT-ACT intervention or waitlist. At preintervention, participants completed a psychodiagnostic interview, standardized questionnaires, and a sleep diary. Intervention and waitlist groups were reassessed after 6 weeks, at which point the waitlist group completed the intervention. RESULTS: Participants receiving the intervention demonstrated improved sleep efficiency (P = 0.0062, d = 1.08), sleep latency (P = 0.028, d = -0.86), insomnia severity (P = 0.0047, d = -1.18), and worry (P = 0.026, d = -0.89) compared with waitlist controls. They also demonstrated a 7-point reduction on depression (P = 0.03, d = -0.88), reduced hyperarousal (P = 0.005, d = -1.51), and a decrease in distress (P = 0.032, d = -0.83). Effects were maintained for the whole sample in sensitivity analyses. Effects on uncertainty intolerance approached significance (P = 0.058). No effect was found on fatigue. CONCLUSIONS: The CBT-ACT group performed significantly better than the waitlist control group. CBT-ACT yielded strong effects for worry, sleep, depression, emotional distress, total distress, and hyperarousal. Future studies will enhance the fatigue and uncertainty tolerance components of the intervention.

Suffering compounded: the relationship between abuse history and distress in five palliative care domains.

BACKGROUND: Research with breast cancer patients suggests that abuse survivors experience more psychological distress and disorders, particularly depression and anxiety, than patients without abuse histories. However, we do not yet understand the impact of abuse on other palliative care domains for individuals with other cancer types. OBJECTIVES: This study explores the relationship between past abuse and distress in a group of cancer patients referred for palliative care. This study also explores differences in distress level and likelihood of meeting diagnostic criteria for major depression and generalized anxiety disorder between patients with and without abuse histories. SETTING/SUBJECTS: Data were from 164 new, palliative care outpatients who completed an initial clinician-administered assessment and the James Supportive Care Screening patient self-report. DESIGN: Multivariate analyses of variance were conducted to explore differences between patients who reported an abuse history and those who did not on the number of items endorsed and associated distress on five palliative care domains. Chi-square tests were conducted to identify differences in diagnosis of depression and anxiety between patients with and without abuse histories. RESULTS: Twenty-eight percent reported abuse histories. Patients with abuse histories endorsed more physical problems, psychological concerns, and spiritual concerns and greater distress related to psychological and spiritual concerns than patients without abuse histories. Patients with abuse histories more frequently received diagnoses of major depression disorder and generalized anxiety disorder. CONCLUSIONS: These differences underscore the impact of abuse on the adjustment of cancer patients referred for palliative care. Assessment of patient abuse history by palliative care teams and referral for psychological treatment may help reduce patient distress.

The James Supportive Care Screening: integrating science and practice to meet the NCCN guidelines for distress management at a Comprehensive Cancer Center.

BACKGROUND: Selecting a measure for oncology distress screening can be challenging. The measure must be brief, but comprehensive, capturing patients' most distressing concerns. The measure must provide meaningful coverage of multiple domains, assess symptom and problem-related distress, and ideally be suited for both clinical and research purposes. METHODS: From March 2006 to August 2012, the James Supportive Care Screening (SCS) was developed and validated in three phases including content validation, factor analysis, and measure validation. Exploratory factor analyses were completed with 596 oncology patients followed by a confirmatory factor analysis with 477 patients. RESULTS: Six factors were identified and confirmed including (i) emotional concerns; (ii) physical symptoms; (iii) social/practical problems; (iv) spiritual problems; (v) cognitive concerns; and (vi) healthcare decision making/communication issues. Subscale evaluation reveals good to excellent internal consistency, test-retest reliability, and convergent, divergent, and predictive validity. Specificity of individual items was 0.90 and 0.87, respectively, for identifying patients with DSM-IV-TR diagnoses of major depression and generalized anxiety disorder. CONCLUSIONS: Results support use of the James SCS to quickly detect the most frequent and distressing symptoms and concerns of cancer patients. The James SCS is an efficient, reliable, and valid clinical and research outcomes measure.

Optimism, social support, and adjustment in African American women with breast cancer.

Past studies show that optimism and social support are associated with better adjustment following breast cancer treatment. Most studies have examined these relationships in predominantly non-Hispanic White samples. The present study included 77 African American women treated for nonmetastatic breast cancer. Women completed measures of optimism, social support, and adjustment within 10-months of surgical treatment. In contrast to past studies, social support did not mediate the relationship between optimism and adjustment in this sample. Instead, social support was a moderator of the optimism-adjustment relationship, as it buffered the negative impact of low optimism on psychological distress, well-being, and psychosocial functioning. Women with high levels of social support experienced better adjustment even when optimism was low. In contrast, among women with high levels of optimism, increasing social support did not provide an added benefit. These data suggest that perceived social support is an important resource for women with low optimism.

Traumatic stress, perceived global stress, and life events: prospectively predicting quality of life in breast cancer patients.

The authors investigated the relationship between stress at initial cancer diagnosis and treatment and subsequent quality of life (QoL). Women (n = 112) randomized to the assessment-only arm of a clinical trial were initially assessed after breast cancer diagnosis and surgery and then reassessed at 4 months (during adjuvant treatment) and 12 months (postadjuvant treatment). There were 3 types of stress measured: number of stressful life events (K. A. Matthews et al., 1997), cancer-related traumatic stress symptoms (M. J. Horowitz, N. Wilner, & W. Alvarez, 1979), and perceived global stress (S. Cohen, T. Kamarck, & R. Mermelstein, 1983). Using hierarchical multiple regressions, the authors found that stress predicted both psychological and physical QoL (J. E. Ware, K. K. Snow, & M. Kosinski, 2000) at the follow-ups (all ps < .03). These findings substantiate the relationship between initial stress and later QoL and underscore the need for timely psychological intervention.