Psychosocial benefits of a novel mindfulness intervention versus standard support in distressed women with breast cancer.

OBJECTIVE: It is well documented that stress is associated with negative health outcomes in cancer patients. The purpose of this study was to assess the effects of a novel mindfulness intervention called mindfulness-based art therapy (MBAT) versus standard educational support, on indices of stress and quality of life in breast cancer patients with high stress levels. METHODS: A total of 191 women were enrolled, stratified by age and stress level, and randomized to receive either an 8-week MBAT intervention or a breast cancer educational support program of equal time and duration. Psychosocial stress was measured using the Symptoms Checklist-90-Revised, and quality of life was measured using the Medical Outcomes Study Short-Form Health Survey at baseline, immediately post-intervention, and at 6 months. RESULTS: Results showed overall significant improvements in psychosocial stress and quality of life in both the MBAT and educational support groups immediately post-intervention; however, participants with high stress levels at baseline had significantly improved overall outcomes only in the MBAT group, both immediately post-intervention and at 6 months. In addition, at 6 months follow-up, participants attending five or more sessions trended toward retaining treatment effects better in the MBAT than in the control group. Finally, black women and white women were similar in terms of how they benefited from the MBAT intervention, even though white participants tended to have higher educational level and marital status. CONCLUSIONS: In conclusion, MBAT is associated with significant, sustained benefits across a diverse range of breast cancer patients, particularly those with high stress levels.

Costs and Effectiveness of Mindfulness-Based Art Therapy versus Standard Breast Cancer Support Group for Women with Cancer.

BACKGROUND: The results of several studies have demonstrated that women and men with a cancer diagnosis benefit from interventions to reduce distress and improve quality of life (QOL). However, little is known about the costs and effectiveness of such interventions. Identifying a stress-reduction program that is low cost and effective is important for payers, employers, and healthcare professionals, as well as for patients with cancer. OBJECTIVE: To evaluate the direct costs and effectiveness of the mindfulness-based art therapy (MBAT) program compared with the cost and effectiveness of a breast cancer support group (BCSG). METHODS: This economic pilot study evaluated the direct costs and effectiveness of a mindfulness-based intervention for stress reduction in patients with breast cancer who are receiving care versus the cost of a usual care support group used as the comparator. The cost variables for each cohort included the cost of program delivery (ie, staff and supplies), mileage reimbursements, medication costs, and healthcare utilization costs. Effectiveness was measured by a change in quality-adjusted life-year derived from the 36-Item Short-Form Health Survey (SF-36) QOL battery. RESULTS: Overall, the cost for 191 participants in the MBAT intervention group was $992.49 per participant compared with $562.71 per participant for the BCSG intervention. Both interventions achieved a similar change in healthcare utilization based on the SF-36 QOL battery. Although the MBAT intervention was more costly than a BCSG intervention, sensitivity analysis showed that the cost-effectiveness of the MBAT intervention could achieve parity with that of a BCSG if some intervention-related costs, such as staff time and supplies, were reduced. CONCLUSION: As psychosocial cancer care becomes more refined with time, it will be important to determine the best and most cost-effective interventions for patients with cancer, particularly in light of healthcare reform. Information from this study could help inform payers, employers, and other stakeholders regarding which interventions would be least costly and most effective for patients with cancer.

Psychosocial oncology: supportive care for the cancer patient.

Increasing attention is being paid to the emotional and psychosocial needs of cancer patients. As a result of huge advances in early detection and in treatment modalities, there now are millions of cancer survivors in the United States. There has been a realization that cancer survivors have distinct psychosocial needs. As cancer survivors live longer, reduction of psychological distress has been recognized as being an important part of having an improved quality of life. There have been numerous changes in the field of psychosocial oncology since it first began 25 years ago. Guidelines now exist for the definition of distress and decision trees are available for making the appropriate referrals. Advances in pharmacologic treatment for depression and anxiety have made it possible to decrease distress and increase coping in cancer patients undergoing treatment as well as in cancer survivors. Numerous individual and group therapies have demonstrated effectiveness in improving mood and quality of life in cancer patients and those at high risk for developing cancer. Due to the forthright efforts of cancer patients, there are now many organizations and list serves (e-mailing lists) that cancer survivors can turn to for help before, during, and after cancer treatment. Finally, with the rapid expansion of the internet not only are there websites available as resources, but also the creation of interactive online support is becoming a reality. One of the most important issues in providing supportive care to cancer patients in the future is to meet the individual needs of patients and provide the type of psychological therapy that will work best for them.

Factors predicting prostate specific antigen testing among first-degree relatives of prostate cancer patients.

First-degree relatives (FDRs) of prostate cancer patients are known to be at increased risk for the disease, yet relatively little is known about their screening behaviors. The current lack of consensus about the value of prostate cancer screening underscores the importance of examining why some men at increased risk participate in screening and others do not. In this study, variables from Protection Motivation Theory were used to identify predictors of prostate specific antigen (PSA) testing in this at-risk population. Toward this end, scales assessing perceived vulnerability, perceived severity, response efficacy, and self-efficacy for prostate cancer screening were administered to 82 unaffected male FDRs aged 40 and older. When recontacted approximately 14 months later, 50% of FDRs were found to have undergone PSA testing in the interim. Older age, prior prostate cancer screening, and a greater sense of personal efficacy about being able to undergo prostate cancer screening were found to be significant (P < 0.05) predictors of subsequently undergoing PSA testing. These findings provide partial support for the predictive validity of Protection Motivation Theory variables and suggest the importance of considering efficacy beliefs in attempting to understand decision-making about PSA testing in at-risk individuals.

Changes in cerebral blood flow and anxiety associated with an 8-week mindfulness programme in women with breast cancer.

This study employed functional magnetic resonance imaging to evaluate changes in cerebral blood flow (CBF) associated with the Mindfulness-based Art Therapy (MBAT) programme and correlate such changes to stress and anxiety in women with breast cancer. Eighteen breast cancer patients were randomized to the MBAT or education control group. The patients received the diagnosis of breast cancer between 6 months and 3 years prior to enrollment and were not in active treatment. The age of participants ranged from 52 to 77 years. A voxel-based analysis was performed to assess differences at rest, during meditation and during a stress task. The anxiety sub-scale of the Symptoms Checklist-90-Revised was compared with changes in resting CBF before and after the programmes. Subjects in the MBAT arm demonstrated significant increases in CBF at rest and during meditation in multiple limbic regions, including the left insula, right amygdala, right hippocampus and bilateral caudate. Patients in the MBAT programme also had a significant correlation between increased CBF in the left caudate and decreased anxiety scores. In the MBAT group, responses to a stressful cue resulted in reduced activation of the posterior cingulate. The results demonstrate that the MBAT programme was associated with significant changes in CBF, which correlated with decreased anxiety over an 8-week period.

Population-based worksite obesity management interventions: a qualitative case study.

Due to the increased prevalence of obesity and associated direct and indirect costs to employers, weight management programs have become an integral component of employer and insurer benefits plans. The programs vary in foci, scope, breadth, and implementation. The aim of this study was to explore promising employer-sponsored population-based obesity management programs. A case study that utilized a telephonic semi-structured questionnaire was conducted with small and large organizations located in different regions of the United States that had been recruited to participate. Eight employers and 1 health care advocacy coalition who met the inclusion criteria were interviewed about features of their weight management programs. The case study revealed a number of themes consistent with reports in the literature and reflecting cited best practices. Key findings include confirmation that weight management is a significant component of the wellness strategy in all participating organizations because employers are invested in population health programs and cost savings. Based upon their experience and knowledge, occupational health specialists are responsible for designing, implementing, managing, and evaluating employee health programs. Almost all employers utilize electronic media as a prominent component of wellness and disease management initiatives. Experience has shown that incentives-both financial and nonmonetary-are effective motivators for employee engagement and outcomes. However, while employers report success, favorable outcomes have been difficult to quantify.

Is disease management right for oncology?

The disease management (DM) model for the treatment of chronic conditions has been around for many years and has been found to be effective for diseases of high prevalence and high cost (eg, diabetes, asthma, heart disease). With an increasing number of people living with cancer and the continual escalation of treatment costs, DM vendors have begun to implement DM concepts into cancer care. However, the multitude of cancer types, treatment options, and adverse effects have all presented barriers to oncology DM, and data reflecting the effectiveness of oncology DM have remained scarce. Oncology costs, the lack of congruence between provider and patient expectations of treatment, the lack of prevention and early detection for many cancers, and, most importantly, the inability of people to adhere to healthy lifestyles are additional obstacles that must be overcome. Moreover, when designing an oncology DM program, it is imperative to look at cancers individually as the etiology, treatment, and impact of cancer can be markedly different from one patient to the next. An effective oncology DM program is one that acts to decrease fatigue, reduces nosocomial infections, deals with dehydration and pain, manages anemia, identifies and treats skin infections, recognizes and treats depression and other psychological distress, provides patients access to palliative care services, facilitates informed decision making and end-of-life transitions, and promotes communication between patients and their providers as well as between physicians. Moving forward, DM vendors and health insurance companies capable of incorporating DM with medical management will be in the best position to provide optimal cancer care.

Genetic testing for BRCA1: effects of a randomised study of knowledge provision on interest in testing and long term test uptake; implications for the NICE guidelines.

INTRODUCTION: Interest in searching for mutations in BRCA1 and BRCA2 is high. Knowledge regarding these genes and the advantages and limitations of genetic testing is limited. It is unknown whether increasing knowledge about breast cancer genetic testing alters interest in testing. METHODS: Three hundred and seventy nine women (260 with a family history of breast cancer; 119 with breast cancer) from The Royal Marsden NHS Foundation Trust were randomised to receive or not receive written educational information on cancer genetics. A questionnaire was completed assessing interest in BRCA1 testing and knowledge on breast cancer genetics and screening. Actual uptake of BRCA1 testing is reported with a six year follow-up. RESULTS: Eighty nine percent of women at risk of breast cancer and 76% of women with breast cancer were interested in BRCA1 testing (P < 0.0001). Provision of educational information did not affect level of interest. Knowledge about breast cancer susceptibility genes was poor. According to the NICE guidelines regarding eligibility for BRCA1 and BRCA2 testing, the families of 66% of the at risk group and 13% of the women with breast cancer would be eligible for testing (probability of BRCA1 mutation >or=20%). Within six years of randomisation, genetic testing was actually undertaken on 12 women, only 10 of whom would now be eligible, on the NICE guidelines. CONCLUSIONS: There is strong interest in BRCA1 testing. Despite considerable ignorance of factors affecting the inheritance of breast cancer, education neither reduced nor increased interest to undergo testing. The NICE guidelines successfully triage those with a high breast cancer risk to be managed in cancer genetics clinics.

Quality measurement in diabetes care.

This study aimed to evaluate diabetes quality measurement efforts, assess their strengths and areas for improvement, and identify gaps not adequately addressed by these measures. We conducted an environmental scan of diabetes quality measures, focusing on metrics included in the National Quality Measures Clearinghouse or promulgated by leading measurement organizations. Key informant interviews were also completed with thought leaders who develop, promote, and use quality measures. The environmental scan identified 146 distinct measures spanning 31 clinical processes or outcomes. This suggests a measurement system that is both redundant and inconsistent, with many different measures assessing the same clinical indicators. Interviewees believe that current diabetes measurement efforts are excessively broad and complex and expressed a need for better harmonization of these measures. Several gaps were also found, including a lack of measures focusing on population health, structural elements of health care, and prevention of diabetes.

Genetic and environmental risk assessment for colorectal cancer risk in primary care practice settings: a pilot study.

PURPOSE: The assessment of genetic variants and environmental exposures (i.e., genetic and environmental risk assessment) may permit individualized risk stratification for common diseases as part of routine care. A pilot study was conducted to assess the uptake of, and response to, testing for colorectal cancer risk among average risk patients in primary care practice settings. METHODS: Physicians in primary care practices identified patients eligible for colorectal cancer screening and referred them to the study. Research staff administered a baseline survey to consenting patients. At a scheduled office visit, participants underwent decision counseling with a trained nurse educator to facilitate informed decision making about being tested for methylene tetrahydrofolate reductase status and red blood cell folate level. Combined assessment can stratify colorectal cancer risk. Test results were disclosed within 2 weeks after the visit. Postvisit and 1-month endpoint surveys were administered. Univariable analyses of survey data were performed to assess changes from baseline in genetic and environmental risk assessment and colorectal cancer screening-related knowledge and perceptions. RESULTS: Of the 57 patients who were referred to the study, 25 (44%) consented to participate, and all but one were tested. Participant knowledge about genetic and environmental risk assessment and colorectal cancer screening, perceived colorectal cancer screening response efficacy, and perceived social support for colorectal cancer screening increased significantly from baseline. Participants reported low levels of intrusive thoughts about CRC. CONCLUSION: Knowledge and favorable perceptions of colorectal cancer screening increased, as did knowledge about genetic and environmental risk assessment, after exposure to the study intervention. Further research is needed to assess genetic and environmental risk assessment uptake and impact at the population level.

Psycho-oncology: review and update.

The field of psycho-oncology is moving forward rapidly, especially for a relatively new field. Cancer patients and survivors are willing to discuss their needs and interests relating to diagnosis and treatment. There are guidelines and algorithms for determining levels of distress in cancer patients in both inpatient and outpatient settings. The pharmacologic treatment of distress, particularly depression, has vastly improved. Randomized controlled trials are becoming available for patients in order to determine the efficacy of psychotropic drugs. Numerous interventions are available to help cancer patients move forward with their lives. Some of these interventions began in the 1980s and have progressed to the use of complementary and alternative medicine techniques as coping strategies for cancer. With the rapid expansion of the Internet, cancer survivors' thirst for information also has grown. Many resources are available to help guide cancer patients through the maze of the diagnosis and treatment of cancer.

Relation of family history of prostate cancer to perceived vulnerability and screening behavior.

Men with a positive family history of prostate cancer are known to be at increased risk for the disease; however, relatively little is known about their risk perceptions or screening behavior. To address these issues, the current study examined the relationship of family history of prostate cancer to perceived vulnerability of developing prostate cancer and prostate cancer screening practices. Participants were 83 men with a positive family history of prostate cancer and 83 men with a negative family history of prostate cancer. As predicted, men with a positive family history reported greater (p< or =0.05) perceived vulnerability of developing prostate cancer and stronger intentions to undergo screening (p< or =0.05). They also reported greater past performance of prostate-specific antigen screening and were more likely to request information about prostate cancer (p< or =0.05). Additional analyses indicated that perceived vulnerability mediated the relation between family history and intentions to undergo prostate cancer screening. Findings confirm the increased likelihood of men with a positive family history to undergo prostate cancer screening and suggest that heightened concerns about developing the disease are an important motivating factor.