The Implications of Racialized Economic Segregation and Allostatic Load on Mortality in Patients with Breast Cancer.

BACKGROUND: The objective of this study was to examine the association between racialized economic segregation, allostatic load (AL), and all-cause mortality in patients with breast cancer. PATIENTS AND METHODS: Women aged 18+ years with stage I-III breast cancer diagnosed between 01/01/2012 and 31/12/2020 were identified in the Ohio State University cancer registry. Racialized economic segregation was measured at the census tract level using the index of concentration at the extremes (ICE). AL was calculated with biomarkers from the cardiac, metabolic, immune, and renal systems. High AL was defined as AL greater than the median. Univariable and multivariable regression analyses using restricted cubic splines examined the association between racialized economic segregation, AL, and all-cause mortality. RESULTS: Among 4296 patients, patients residing in neighborhoods with the highest racialized economic segregation (Q1 versus Q4) were more likely to be Black (25% versus 2.1%, p < 0.001) and have triple-negative breast cancer (18.2% versus 11.6%, p < 0.001). High versus low racialized economic segregation was associated with high AL [adjusted odds ratio (aOR) 1.40, 95% confidence interval (CI) 1.21-1.61] and worse all-cause mortality [adjusted hazard ratio (aHR) 1.41, 95% CI 1.08-1.83]. In dose-response analyses, patients in lower segregated neighborhoods (relative to the 95th percentile) had lower odds of high AL, whereas patients in more segregated neighborhoods had a non-linear increase in the odds of high AL. DISCUSSION: Racialized economic segregation is associated with high AL and a greater risk of all-cause mortality in patients with breast cancer. Additional studies are needed to elucidate the causal pathways and mechanisms linking AL, neighborhood factors, and patient outcomes.

Oncology mental health providers' adaptation of an evidence-based intervention: A mixed-methods study.

BACKGROUND: Adaptations are intentional modifications maximizing the fit of an evidence-based intervention (EBI) in new context. Little is known about EBI adaptation within psychosocial oncology. Guided by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME), this mixed-methods study describes oncology mental health providers' planned adaptations to a psychosocial oncology EBI and examines the relationship between planned adaptations and longitudinal EBI usage. METHODS: Providers (N = 128) were social workers (47%) and psychologists (40%) practicing in community settings (44%) or academic medical centers (41%). They attended a 3-day training on a multicomponent psychosocial oncology EBI, the Biobehavioral Intervention (BBI). During training, providers prepared an "adaptation plan" describing necessary adaptations to BBI and rationales for change. Qualitative data from adaptation plans were analyzed using directed content analysis. Linear mixed models examined the relationship between adaptation characteristics (number, similarity to the manualized BBI) and EBI usage across 12 months post-training. RESULTS: Three sets of qualitative themes reflecting FRAME elements emerged: (1) content modifications (e.g., shortening/condensing, selecting elements, adding/removing elements); (2) contextual changes (e.g., alternative group formats); and (3) reasons for adaptations (e.g., organization/setting, provider, and recipient factors). Neither number of adaptations nor adaptation similarity were associated with BBI usage across 12 months post-training. CONCLUSIONS: To our knowledge, this study is the first to characterize oncology mental health providers' planned adaptations to a psychosocial oncology EBI. Planned adaptations did not increase usage, but importantly they did not decrease usage. The adaptation process enabled providers to make thoughtful adaptation choices, with implementation successful irrespective of setting constraints.

Racial Disparities in Breast Cancer: from Detection to Treatment.

PURPOSE OF REVIEW: Update on current racial disparities in the detection and treatment of breast cancer. RECENT FINDINGS: Breast cancer remains the leading cause of cancer death among Black and Hispanic women. Mammography rates among Black and Hispanic women have surpassed those among White women, with studies now advocating for earlier initiation of breast cancer screening in Black women. Black, Hispanic, Asian, and American Indian and Alaskan Native women continue to experience delays in diagnosis and time to treatment. Further, racial discrepancies in receipt of guideline-concordant care, access to genetic testing and surgical reconstruction persist. Disparities in the initiation, completion, toxicity, and efficacy of chemotherapy, endocrine therapy, and targeted drug therapy remain for racially marginalized women. Efforts to evaluate the impact of race and ethnicity across the breast cancer spectrum are increasing, but knowledge gaps remain and further research is necessary to reduce the disparity gap.

COVID-19 or Cancer Stress? Anxiety and Depressive Symptoms in Patients with Advanced Lung Cancer.

BACKGROUND: Of all cancer patients, those with lung cancer are among the highest risk for infection, pneumonia, hospitalization, and early death from COVID-19. As cancer stress is ubiquitous, this exploratory study examines patients' COVID-19 stress and cancer stress in relation to their depressive and anxiety symptoms. METHOD: Newly diagnosed advanced lung cancer patients (N = 76) completed measures of cancer stress, COVID-19 illness perceptions and stress, and depressive and anxiety symptoms at a single monthly follow-up early in the pandemic (May 2020 to July 2020; Clinicaltrials.gov #NCT03199651). Hierarchical linear multiple regression analysis was used to identify the relationship of stressor variables to depressive and anxiety symptoms in this cross-sectional study. RESULTS: Hierarchical linear models revealed cancer stress was a significant predictor of both depressive symptoms (F(14,30) = 5.327, p < 0.001, R2 = 0.71, adjusted R2 = 0.58) and anxiety symptoms (F(14,30) = 4.513, p < 0.001, R2 = 0.68, adjusted R2 = 0.53) for patients at the start of the COVID-19 pandemic. By contrast, COVID-19 stress was not a significant predictor of depressive (F(13,31) = 1.415 p = .21, R2 = .37, adjusted R2 = .11) or anxiety symptoms (F(13,31) = 1.23, p = .30, R2 = .34, adjusted R2 = - .07). CONCLUSIONS: Advanced lung cancer patients during the early phase of the COVID-19 pandemic reported cancer stress as more important than COVID-19 stress in relation to their mental health. Empirically supported biobehavioral and cognitive behavioral treatments remain important to reducing psychological symptoms and enhancing patients' quality of life.

Risk Factors for Immune Checkpoint Inhibitor Immunotherapy Toxicity Among Older Adults with Cancer.

OBJECTIVES: Immune checkpoint inhibitor immunotherapy (IO) is revolutionizing cancer care but can lead to significant toxicity. This study seeks to describe potential risk factors for immune-related adverse events (irAEs) specifically among older adults. MATERIALS AND METHODS: This was a retrospective study at a single academic comprehensive cancer center based on chart review data abstracted by physicians. For patients aged ≥70 years, frequency, type, and grade of irAEs and their association with baseline patient demographics, comorbidities, mobility, and functional status were characterized using bivariate analysis. Based on those results, multivariable logistic regressions were constructed to model the association between these characteristics with any grade and grade 3 or higher irAEs. RESULTS: Data were analyzed for 238 patients aged ≥70 years who received IO for mostly (≥90%) advanced cancer between 2011 and 2018. Thirty-nine percent of older adults experienced an irAE and 13% experienced one that was grade 3 or higher. In the multivariable analysis, depression was associated with an increased incidence of any grade irAE, while decreased life-space mobility was associated with an increased incidence of grade ≥3 irAEs. CONCLUSION: Most characteristics of special interest among older adults, include fall risk, weight loss, cognitive limitations, and hearing loss, were not associated with irAEs in our study. However, decreased life-space mobility and depression are potential risk factors for IO toxicity among older adults with advanced cancer. Interventions designed to evaluate and mitigate modifiable risk factors for treatment-related toxicity are needed, and the results of this study may be useful for guiding those efforts.

Short-term and long-term financial toxicity from breast cancer treatment: a qualitative study.

PURPOSE: The rising cost of breast cancer treatment has increased patients' financial burden, intensifying an already stressful treatment process. Although researchers increasingly recognize the harmful impact of medical and nonmedical costs associated with cancer treatment, understanding patients' perspectives of financial toxicity is limited. We aimed to explore the topic of financial toxicity through the lived experiences of patients with breast cancer from groups at risk of social and economic marginalization. METHODS: We conducted semi-structured interviews with 50 women with breast cancer from four specific groups: Black women, Medicaid enrollees, rural residents, and women age ≤ 40. We transcribed, coded, and analyzed the data using deductive and inductive approaches. RESULTS: Two overarching themes captured patients' experiences of financial toxicity: short-term and long-term impacts. Short-term stressors included direct medical (e.g., co-pays, premiums), nonmedical (e.g., transportation, lodging), and indirect (e.g., job loss, reduced work hours) costs. Early in their treatments, patients' focus on survival took precedence over financial concerns. However, as the treatment course progressed, fear of consequences from compounding costs of care and financial distress negatively impacted patients' lifestyles and outlooks for the future. CONCLUSION: Programs addressing financial toxicity that look beyond early-phase interventions are needed. Specifically, patients struggling with the accumulation of treatment costs and the resultant stress require ongoing support. Long-term support is especially needed for groups vulnerable to financial instability and social marginalization.

A cognitive-behavioral model of dyspnea: Qualitative interviews with individuals with advanced lung cancer.

OBJECTIVES: Shortness of breath, or dyspnea, is the subjective experience of breathing discomfort and is a common, distressing, and debilitating symptom of lung cancer. There are no efficacious pharmacological treatments, but there is suggestive evidence that cognitive-behavioral treatments could relieve dyspnea. For this, understanding the psychological, behavioral, and social factors that may affect dyspnea severity is critical. To this end, patients with dyspnea were interviewed with questions framed by the cognitive-behavioral model-emphasizing thoughts, emotions, and behaviors as contributors and outcomes of dyspnea. METHODS: Two trained individuals conducted semi-structured interviews with lung cancer patients (N = 15) reporting current dyspnea. Interviews assessed patients' cognitive-behavioral experiences with dyspnea. Study personnel used a grounded theory approach for qualitative analysis to code the interviews. Inter-rater reliability of codes was high (κ = 0.90). RESULTS: Thoughts: Most common were patients' catastrophic thoughts about their health and receiving enough oxygen when breathless. Emotions: Anxiety about dyspnea was the most common, followed by anger, sadness, and shame related to dyspnea. Behaviors: Patients rested and took deep breaths to relieve acute episodes of dyspnea. To reduce the likelihood of dyspnea, patients planned their daily activity or reduced their physical activity at the expense of engagement in hobbies and functional activities. SIGNIFICANCE OF RESULTS: Patients identified cognitive-behavioral factors (thoughts, emotions, and behaviors) that coalesce with dyspnea. The data provide meaningful insights into potential cognitive-behavioral interventions that could target contributors to dyspnea.

Psychological Symptom Trajectories and Non-Small Cell Lung Cancer Survival: A Joint Model Analysis.

OBJECTIVE: Lung cancer remains the number one cause of cancer-related mortality worldwide, but less known is that lung cancer patients are among the most psychologically disabled of all cancer groups. Patients with stage IV non-small cell lung cancer (NSCLC) were studied to test the hypothesis that trajectories of depression and/or anxiety symptoms after diagnosis would show an adverse relationship with survival, beyond relevant controls. METHODS: Patients with stage IV NSCLC (n = 157) were enrolled (ClinicalTrials.gov Identifier: NCT03199651) at diagnosis and completed validated measures for depressive symptoms (Patient Health Questionnaire-9) and anxiety symptoms (Generalized Anxiety Disorder-7). Patients were reassessed every 1 to 2 months through 24 months (16 assessments; 80% average completion rate) and survival monitored. Joint statistical models provided simultaneous modeling of longitudinal (psychological) and time-to-event (survival) processes. Control variables were age, sex, marital status, education, smoking status, cancer type, and treatment received. RESULTS: Depression and anxiety symptoms significantly decreased with time since diagnosis. The 2-year trajectory of depressive symptoms was significantly associated with cancer survival after adjustment for covariates (hazard ratio = 1.09 per unit increase in the Patient Health Questionnaire-9, 95% confidence interval = 1.03-1.15, p = .002). Anxiety was marginally significant in the unadjusted (p = .053) but not the adjusted (p = .39) model. CONCLUSIONS: For the first time, joint model analyses test the interaction of a longitudinal trajectory of psychological symptoms, assessed from diagnosis to 24 months, and cancer survival. New data show the continuation of depressive and anxiety symptoms through treatment and thereafter. Immunotherapy and targeted therapies have dramatically improved survival for patients with advanced NSCLC; however, novel data suggest their benefit may be constrained by depressive symptoms.

Cancer Treatment During COVID-19: Resilience of Individuals With Advanced Non-Small Cell Lung Cancer Versus Community Controls.

BACKGROUND: Among all patients with cancer, those with advanced non-small cell lung cancer (NSCLC) experience the most distress. Although new therapies are improving survival, it is unknown whether receiving immunotherapy or targeted therapy during the COVID-19 pandemic increases patients' psychological vulnerability. To meet clinical needs, knowledge of patients' COVID-19 perceptions and safety behaviors is essential. Thus, this study compared patients' psychological responses at diagnosis and during COVID-19 and compared patients with similar individuals without cancer during the same period. PATIENTS AND METHODS: Patients with advanced NSCLC enrolled at diagnosis for cohort study participated (ClinicalTrials.gov identifier: NCT03199651). Those with follow-ups from April 28, 2020, through July 14, 2020 (n=76), were assessed again including COVID-19 measures. Simultaneously, community controls with similar sociodemographics and smoking histories were solicited (n=67). Measures were COVID-19 perceptions (Brief Illness Perception Questionnaire), social distancing, and depressive (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) symptoms. First, analyses evaluated differences in the psychological responses of patients with NSCLC at diagnosis and during COVID-19. Second, patients and controls were contrasted on COVID-19 perceptions, social distancing, and psychological symptoms. RESULTS: The depressive and anxious symptoms of patients with NSCLC were greater at diagnosis (P<.02) than during COVID-19, approximately 1 year later. Patients with NSCLC and controls did not differ in terms of sociodemographics, except those with NSCLC were more racially diverse and older, and had greater smoking history (P<.03). Groups did not differ regarding concern, understanding, or perceived control over COVID-19 (P>.406). Notably, controls anticipated the COVID threat would last longer, practiced more social distancing, were more concerned about family (P<.04), and reported worse psychological symptoms (P<.023). With less depression and anxiety, patients with NSCLC viewed COVID-19 as a shorter-term threat and had fewer COVID-19-related worries than did controls. For controls, COVID-19 was more salient, heightening worries and psychological symptoms. CONCLUSIONS: Despite multiple health stressors, patients with NSCLC demonstrated resilience when receiving cancer treatment during COVID-19. Nonetheless, this population remains psychologically vulnerable, requiring support at diagnosis and thereafter.

Affect regulation as a moderator of intentions for breast cancer chemoprevention.

Women at high risk for breast cancer (BC) may consider chemoprevention for risk reduction, but uptake is low. This study examined the role of affect regulation (the attempt to alter or control one's emotions) in decision-making about BC chemoprevention. A cross-sectional, single group design was used. High-risk women (N = 81) were surveyed. Moderation analyses specified cancer-specific distress as the independent variable, affect regulation (cognitive reappraisal or expressive suppression) as the moderator, and chemoprevention intentions (yes = 1, unsure = 0, no = -1) as the dependent variable. Cognitive reappraisal significantly moderated the relationship between cancer-specific distress and chemoprevention intentions (p = 0.03), but expressive suppression did not (p = 0.31). For the 44% of participants who were highest on reappraisal, higher cancer-specific distress was associated with greater intentions for chemoprevention. For the remaining 56%, there was no relationship between cancer-specific distress and chemoprevention intentions. Cognitive reappraisal may play an important role in decisions regarding uptake of chemoprevention.

Achieving oncology mental health providers' usage of an empirically supported treatment: Lessons learned.

OBJECTIVE: There is a need for oncology mental health providers to receive training to use empirically supported psychological treatments (ESTs) with their patients. The purpose of this editorial is to describe "lessons learned" from disseminating-conducting EST trainings-and supporting providers' capacity and confidence to use the EST. METHOD: Processes and outcomes from conducting six, 3-days (18 h) EST training institutes from 2012-2016 are discussed. Institutes trained 166 full time oncology mental health providers from more than 100 different settings. The dissemination was intentionally designed to achieve EST implementation, i.e., therapists' sustained usage of the EST for at least 12 months post training. RESULTS: Previously published discussion and findings show the effort was successful in achieving positive EST dissemination outcomes and sustained EST implementation by providers. Thus, "lessons learned" include discussions of (1) orientation to design education/training to achieve EST usage using theory based aims and outcomes of training efficacy; (2) multimodal, educational strategies used to achieve therapists' positive attitudes toward and self-efficacy to implement the EST; (3) guidance to therapists for adapting the EST to their practice settings while maintaining fidelity; (4) assistance to therapists to identify and problem solve implementation challenges; and (5) using patient reported outcome measures to determine clinical change. CONCLUSION: Our discussion of the plan, methods, and goals of EST training contributes to the science of dissemination/implementation by providing support for (1) theory-informed EST dissemination, and (2) mechanisms of EST implementation. For researchers, our experience may guide future EST dissemination/implementation efforts in psycho-oncology. For therapists, lessons learned provide criteria for evaluating future continuing education options.

Factors associated with intentions for breast cancer risk management: Does risk group matter?

OBJECTIVE: National guidelines provide breast cancer (BC) risk management recommendations based on estimated lifetime risk. Despite this specificity, it is unclear if women's risk management intentions are or are not guideline concordant. To address this knowledge gap, women at varying risk levels reported intentions for risk-reducing behaviors. Factors associated with intentions, informed by the Health Beliefs Model, were also studied. METHODS: Women with elevated BC risk (N = 103) were studied and categorized by risk level: moderate (15%-20%), high (greater than or equal to 20%), or very high (BRCA1/2 positive). Participants self-reported BC susceptibility, self-efficacy, and benefits, barriers, and intentions for risk-reducing mastectomy (RRM), risk-reducing salpingo-oophorectomy (RRSO), chemoprevention, improving diet or physical activity, and reducing alcohol use. RESULTS: Groups significantly differed in RRSO intentions (P < .01); BRCA1/2 positive women had greater intentions for RRSO. Groups did not differ in intentions for RRM, chemoprevention, or lifestyle changes (Ps > .28). In hierarchical linear regression models examining Health Belief Model (HBM) factors, perceived susceptibility was associated with intentions for RRM (ß = .169, P = .08). Perceived benefits was associated with intentions for RRM (ß = .237, P = .02) and chemoprevention (ß = .388, P < .01). Self-efficacy was associated with intentions for physical activity (ß = .286, P < .01). CONCLUSIONS: Consistent with guidelines, BRCA1/2 positive women reported greater intentions for RRSO, and risk groups did not differ in intentions for lifestyle changes. Notably, women's intentions for RRM and chemoprevention were guideline discordant; groups did not differ in intentions for these behaviors. Accounting for the effects of risk group, modifiable health beliefs were also associated with risk management intentions; these may represent targets for decision support interventions.

Illness Perceptions in Chronic Lymphocytic Leukemia: Testing Leventhal's Self-regulatory Model.

BACKGROUND: Leventhal's Self-regulatory Model proposes that somatic characteristics of a health threat (e.g., symptom severity), and prior experience with the threat (e.g., unsuccessful treatment), are determinants of illness perceptions. Chronic lymphocytic leukemia (CLL) is appropriate for test of these postulates, having three phases differing in symptom severity and prior treatment experiences: indolent disease requiring no treatment (active surveillance; AS), symptomatic disease requiring a first treatment (FT), and highly symptomatic disease in those who have relapsed and/or failed to respond to prior treatments (relapsed/refractory; RR). PURPOSE: To test symptom severity and prior treatment experiences as determinants of illness perceptions, illness perceptions were characterized and contrasted between CLL groups. METHODS: Three hundred and thirty CLL patients (AS, n = 100; FT, n = 78; RR, n = 152) provided illness perception data on one occasion during a surveillance visit (AS) or prior to beginning treatment (FT, RR). RESULTS: Analysis of variance with planned comparisons revealed that consequences, identity, and concern were least favorable among RR patients, followed by FT, then AS (ps < .01). AS patients endorsed the lowest levels of coherence (ps < .01), and the most chronic illness timeline (ps < .01). FT patients endorsed the highest levels of personal and treatment control (ps < .01). CONCLUSIONS: Data provide preliminary empirical support for Self-regulatory Model postulates that symptom severity and prior disease experiences influence illness perceptions. Unique knowledge needs for AS patients and elevated psychological/physical symptoms for later-stage CLL patients may warrant clinical attention.

Cells, cytokines, chemokines, and cancer stress: A biobehavioral study of patients with chronic lymphocytic leukemia.

BACKGROUND: Chronic lymphocytic leukemia (CLL) is the most prevalent adult leukemia, with profound disease-related cellular, humoral, and innate immune suppression. The objective of this study was to study the correlations between stress and disease-specific, negative prognostic cellular, cytokine, and chemokine markers in patients with CLL. METHODS: A single-group, observational design was used. Patients with relapsed/refractory CLL (N = 96) who were entering a phase 2 trial of an experimental therapy (ibrutinib) were studied. Before the first dose, a validated self-report measure of stress (the Impact of Event Scale) was completed, and blood was drawn for absolute lymphocyte counts (ALCs) and for cytokine and chemokine enzyme-linked immunosorbent assays. Multiple linear regression models tested stress as a concurrent predictor of ALCs; of cytokines (tumor necrosis factor α [TNFα], a proliferation-inducing ligand [APRIL], B-cell activating factor [BAFF], interleukin 6 [IL-6], IL-10, IL-16, and vascular endothelial growth factor [VEGF]); and of the chemokine (C-C motif) ligand 3 (CCL3). RESULTS: Controlling for relevant demographic variables, comorbidities, CLL genetic risk (deletion of the short arm of chromosome 17 [del17p]), and correlates of inflammation, stress predicted higher ALCs (P < .05), and higher levels of TNFα (P < .05), IL-16 (P < .01), and CCL3 (P < .05). Stress was not associated with APRIL, BAFF, IL-6, IL-10, or VEGF. CONCLUSIONS: Novel biobehavioral data from patients with relapsed/refractory CLL demonstrate that stress is related to heightened levels of cellular, cytokine, and chemokine markers associated previously with progressive disease in CLL. The current results indicate that stress is related to immune and inflammatory processes that contribute to cancer cell proliferation and survival. These data provide a first look into these processes. Cancer 2018. © 2018 American Cancer Society.

Cancer-Specific Stress and Trajectories of Psychological and Physical Functioning in Patients With Relapsed/Refractory Chronic Lymphocytic Leukemia.

Background: Chronic lymphocytic leukemia is the most prevalent adult leukemia. The disease is incurable with a cycling of treatment and relapse common. Little is known about the psychological and physical functioning of patients with relapsed/refractory chronic lymphocytic leukemia. Cancer-specific stress is an important individual difference variable that predicts psychological and physical outcomes. Purpose: To examine cancer-specific stress at treatment initiation as a predictor of psychological and physical functioning trajectories in patients with relapsed/refractory chronic lymphocytic leukemia during the first 5 months of treatment. Methods: Patients with relapsed/refractory chronic lymphocytic leukemia (N = 152) enrolled in a phase II clinical trial completed self-report measures at treatment initiation (baseline), 1, 2, and 5 months of treatment. Cancer-specific stress at baseline was examined as a predictor of psychological (cognitive-affective depressive symptoms, negative mood, mental health quality of life) and physical functioning (fatigue interference, sleep problems, physical health quality of life), controlling for demographic and treatment variables. Results: Using multilevel modeling, higher baseline cancer-specific stress was related to worse psychological (cognitive-affective depressive symptoms, negative mood, mental health quality of life) and physical functioning (fatigue interference, sleep problems) at baseline and more rapid improvements during the next 5 months. Despite these improvements, higher baseline cancer-specific stress remained associated with poorer 5-month psychological, though not physical, functioning. Conclusions: Findings suggest cancer-specific stress at treatment initiation may be a risk factor for poorer psychological functioning during treatment for patients with relapsed/refractory chronic lymphocytic leukemia.

Individual differences in physical symptom burden and psychological responses in individuals with chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is an incurable illness, with some patients requiring no treatment until disease progression. Burden from physical symptoms has been associated with depression, anxiety, and stress in cancer patients. Additionally, patient factors, i.e., individual differences, have been associated with worse psychological outcomes. There are few psychological studies of CLL, with no examination of individual differences. A cross-sectional design studied the covariation of symptom burden with depressive and anxiety symptoms and cancer-specific stress, and tested patients' individual differences as predictors and as moderators. CLL patients (N = 112) receiving active surveillance participated. They were Caucasian (100 %) and predominately male (55 %) with a mean age of 61; most (62.5 %) had stage 0 disease. A composite measure of physical symptom burden (CLL symptoms, fatigue, pain, impaired functional status) was tested as a predictor of psychological responses. Individual differences in psychiatric history and social support were tested as moderators. Using multiple linear regression, greater symptom burden covaried with higher levels of depressive and anxiety symptoms and cancer stress (ps < .05). Those with a psychiatric history, low social support, and low relationship satisfaction with one's partner reported greater symptom burden and more psychological symptoms and stress (ps < .05). Findings suggest that CLL patients in surveillance with a psychiatric history and/or low social support are at risk for greater distress when coping with high symptom burden. These new data clarify the experience of CLL surveillance and identify characteristics of patients with heightened risk for symptom burden, stress, and anxiety or depressive symptoms.

Evidence-based psychosocial treatment in the community: considerations for dissemination and implementation.

BACKGROUND: In psycho-oncology care, steps toward dissemination and implementation of evidence-based treatments (EBTs) have not been made. For this to change, factors associated with real-world dissemination and implementation must be identified. In the community, providers, their organizations, and patients are key stakeholders. METHOD: A focused review of literatures in continuing education, dissemination, and implementation of mental health services is provided. RESULTS: Early-career providers are most ready to implement as they have greater openness and more positive attitudes toward EBTs. Current continuing education practices to teach EBTs have limited effectiveness. Instruction using interactive strategies tailored to therapists' clinical needs and the provision of post-education consultation is needed. There is tension between EBT delivery with fidelity and the necessity for adaptation. EBT service provision is the key outcome of implementation, and documenting such is important to patients, providers, and organizations. CONCLUSION: A multilevel conceptual framework, Setting, Therapist, Education, imPlementation, and Sustainability, is offered and provides directions for dissemination and sustainable implementation. Guidelines from the Commission on Cancer of the American College of Surgeons and the American Society of Clinical Oncology underscore the timeliness of the proposed framework to move EBTs from the research settings where they were developed to the practice settings where they are needed.

Implementing evidence-based psychological treatments for cancer patients.

OBJECTIVE: New regulations and guidelines require implementation of screening and evidence based psychological treatment (EBT) for cancer patients, but little research exists to assist psychosocial care providers with implementation. This study aimed to develop a conceptual framework for community providers to consider as they embark on implementation of EBTs. METHODS: Full-time psychosocial care providers received dissemination training in delivery of a cancer-specific EBT and then received implementation support. Qualitative data were collected in two phases. In Phase I, after training, trainees (N = 52) participated in six monthly group conference calls with six to eight trainees and EBT trainers. Qualitative data from the calls were analyzed using a grounded theory paradigm. In Phase II, the resultant framework was piloted with additional trainees (N = 73) during EBT training to prompt early planning for implementation at their home institutions. RESULTS: In Phase I, themes of 'person' (i.e. attitudes, vocalizations, and behaviors of others) and 'environment' factors (i.e. material, monetary, and time resources of organizations) affecting implementation emerged. It appeared that both factors influenced how easily barriers could be addressed, although positive person factors also appeared to positively influence environment factors. In Phase II, trainees found the framework acceptable and considered it when generating solutions for implementation challenges. CONCLUSIONS: The framework suggests tailoring implementation efforts to consider person and environment factors. As person support is developed, resource limitations of the environment may be more easily addressed.

Self-Reported Sexual Function Measures Administered to Female Cancer Patients: A Systematic Review, 2008-2014.

A systematic review was conducted to identify and characterize self-reported sexual function (SF) measures administered to women with a history of cancer. Using 2009 PRISMA guidelines, we searched electronic bibliographic databases for quantitative studies published January 2008-September 2014 that used a self-reported measure of SF, or a quality of life (QOL) measure that contained at least 1 item pertaining to SF. Of 1,487 articles initially identified, 171 were retained. The studies originated in 36 different countries with 23% from US-based authors. Most studies focused on women treated for breast, gynecologic, or colorectal cancer. About 70% of the articles examined SF as the primary focus; the remaining examined QOL, menopausal symptoms, or compared treatment modalities. We identified 37 measures that assessed at least one domain of SF, eight of which were dedicated SF measures developed with cancer patients. Almost one third of the studies used EORTC QLQ modules to assess SF, and another third used the Female Sexual Function Inventory. There were few commonalities among studies, though nearly all demonstrated worse SF after cancer treatment or compared to healthy controls. QOL measures are better suited to screening while dedicated SF questionnaires provide data for more in depth assessment. This systematic review will assist oncology clinicians and researchers in their selection of measures of SF and encourage integration of this quality of life domain in patient care.

Association of the physiological stress response with depressive symptoms in patients with breast cancer.

OBJECTIVE: The literature on the relationship of depressive symptoms and stress hormones after cancer diagnosis has been mixed, with some studies showing a relationship and other studies showing none. Time since diagnosis may explain these contradictory findings. This study examined the relationship of depressive symptoms to stress hormones in patients with breast cancer using 12-month longitudinal data. METHODS: Patients with Stage II or III breast cancer (n = 227) were assessed every 4 months from diagnosis/surgery to 12 months. They completed the Centers for Epidemiological Studies Depression Scale (CES-D) Iowa Short Form and the Perceived Stress Scale and blood samples were obtained to measure stress hormones (i.e., cortisol, adrenocorticotropin hormone, norepinephrine, and epinephrine). RESULTS: Depressive symptoms were negatively related to cortisol levels (ß= -0.023, p = .002) but were positively related to rate of change in cortisol (ß = 0.003, p = .003). Adrenocorticotropin hormone, epinephrine, and norepinephrine did not covary with depressive symptoms (all p values > .05). When the CES-D and Perceived Stress Scale were both used to predict cortisol, only the CES-D was significantly related (ß = -0.025, p = .017). CONCLUSIONS: Depressive symptoms were negatively related to cortisol, but this relationship changed from the time of diagnosis/surgery through 12 months. Cortisol may initially provide a buffering effect against depression during the stress of initial diagnosis and treatment, but this relationship seems to change over time.