Sexual health in adult survivors of childhood cancer: A Project REACH study.

BACKGROUND: Sexual dysfunction is a significant complication of treatment for many adult-onset cancers. However, comparatively less is known about sexual dysfunction in adult childhood cancer survivors (CCSs). Research has been limited by the exclusion of specific cancers (e.g., central nervous system [CNS] tumors) and the lack of validated measures, which makes it difficult to understand the nature and prevalence of sexual dysfunction in CCSs. METHODS: A total of 249 adult CCSs (aged 18-65 years) enrolled in Project REACH, a prospective cohort study, and completed measures of physical and mental health, including sexual dysfunction. Participants scoring ≤19 on the Female Sexual Function Index 6 or ≤21 on the International Index of Erectile Function 5 were classified as experiencing sexual dysfunction. Analyses examined the relationships between sexual dysfunction and demographic, disease, treatment, and health variables. RESULTS: A total of 78 participants (32%) experienced clinically significant sexual dysfunction. In univariate analysis, sexual dysfunction was significantly associated with CNS tumor diagnosis (odds ratio [OR], 2.56) and surgery (OR, 1.96) as well as with health variables such as fatigue (OR, 3.00), poor sleep (OR, 2.84), pain (OR, 2.04), depression (OR, 2.64), poor physical health (OR, 2.45), and poor mental health (OR, 2.21). Adjusted analyses found that CNS tumor diagnosis (p = .001) and health variables (p = .025) contribute significantly to sexual dysfunction in CCSs. CONCLUSIONS: Approximately one third of adult CCSs report clinically significant sexual dysfunction, which underscores a significant screening and treatment need. However, because available measures were developed for survivors of adult cancers, research to create a sexual health measure specifically for adult CCSs is necessary to better identify the sexual health concerns of this vulnerable population.

A retrospective cost-effectiveness analysis of different cognitive-behavioral therapy for insomnia intervention delivery approaches in adult cancer survivors.

BACKGROUND: Cognitive-behavioral therapy for insomnia (CBT-I) is considered the gold standard treatment for insomnia. Prior trials have delivered CBT-I across a range of treatment sessions. Understanding the economics of varying treatment approaches is essential for future implementation considerations. METHODS: We conducted a retrospective cost-effectiveness analysis from the provider's perspective, comparing the implementation of a three-session CBT-I program for cancer survivors (CBT-I-CS) versus a stepped care treatment approach consisting of an initial single sleep education session followed by CBT-I-CS if elevated insomnia symptoms persisted. The effectiveness measure used was the percentage of participants whose insomnia had remitted by the end of each program. RESULTS: Stepped care delivery was more effective than CBT-I-CS alone, resulting in 35.4% more remitted patients by the end of the overall program. For a $480 willingness to pay threshold per percentage of remitted patients, stepped care CBT-I-CS reached a 98% probability of being cost-effective, while CBT-I-CS alone had only a 2% probability. Larger group sessions in the first step of a stepped care delivery model resulted in more favorable cost-effectiveness. CONCLUSIONS: A stepped care delivery model may be a more cost-effective approach if it can be implemented efficiently. These findings inform policies aimed at improving cancer survivors' access to much-needed insomnia treatment in settings where financial resources for CBT-I may be limited, and be an important barrier to treatment dissemination. CLINICAL TRIAL REGISTRATION: These analyses were not registered.

Screening young adult cancer survivors for depression and anxiety with the Primary Care Evaluation of Mental Disorders (PRIME-MD): Comparisons with a structured clinical diagnostic interview.

OBJECTIVE: Survivorship guidelines recommend screening for depression and anxiety in young adult cancer survivors (YACS), but research validating measures in this population is limited. The current study aimed to examine use of the Primary Care Evaluation of Mental Disorders (PRIME-MD) to screen for depression and anxiety in YACS. METHODS: 249 YACS (aged 18-40, 50% male) completed PRIME-MD via Telephone Automated Computer Assisted Structured Interview and the Structured Clinical Interview for the DSM-IV (SCID) via in-person interview. SCID responses were scored to identify depressive and anxiety symptoms and diagnoses. PRIME-MD was scored to identify YACS reaching the symptom threshold (≥1 depressive or anxiety symptom) and diagnostic threshold for depressive or anxiety disorder. ROC analyses evaluated concordance of the PRIME-MD with the SCID. RESULTS: The PRIME-MD depressive symptom threshold had excellent discrimination compared to SCID depressive diagnosis (AUC = 0.83) with high sensitivity (86%) and specificity (81%). Similarly, the PRIME-MD depressive diagnosis threshold had excellent discrimination compared to SCID depressive diagnosis (AUC = 0.86) as well as high sensitivity (86%) and specificity (86%). No PRIME-MD threshold met sensitivity (≥0.85) and specificity (≥0.75) criteria for identifying SCID depressive symptoms, anxiety disorders, or anxiety symptoms. CONCLUSIONS: PRIME-MD has potential utility as a screening measure of depressive disorders in YACS. The PRIME-MD depressive symptom threshold may be particularly useful in survivorship clinics as it requires only two items be administered. However, PRIME-MD does not meet study criteria for a standalone screen for anxiety disorders, anxiety symptoms, or depressive symptoms in YACS.

Evaluating posttraumatic stress in young adult cancer survivors: Implications of revised DSM-5 traumatic event criteria.

OBJECTIVE: The Diagnostic and Statistical Manual for Psychiatric Diagnoses (DSM-5) significantly narrowed conditions under which life-threatening illnesses meet qualifying traumatic event (QTE) criteria for posttraumatic stress disorder (PTSD). To investigate the impact of this change on identification of PTSD in young adult cancer survivors (YACS), we compared prevalence of QTE exposure using DSM-5 and earlier DSM-IV criteria. METHODS: The Structured Clinical Interview for the DSM-5 (SCID-5) was customized for study goals and administered to a convenience sample of 250 YACS ages 18-40 followed at a single cancer center. RESULTS: The SCID-5 was well-tolerated by participants and estimated duration was brief (33 min; range 12-75). Only 35 interviews (14%) presented complex scoring questions. 168 participants (67.2%) identified cancer as their "most stressful or traumatic experience." Applying DSM-IV criteria, 227 YACS (90.8%) reported any QTEs; prevalence was significantly reduced following more restrictive DSM-5 QTE criteria, with only 124 YACS (49.6%) reporting ≥1 QTE (z = -9.68, p < 0.001). CONCLUSIONS: The SCID-5 can be successfully adapted to assess QTEs in YACS following both DSM-IV and DSM-5 criteria. DSM-5 criteria significantly limit prevalence of QTE exposures compared with DSM-IV. As the majority of YACS identify cancer as their most stressful life event, it is critically important to investigate its impact on their psychological functioning. Until more is known about how PTSD symptoms may arise after cancer, clinicians and researchers should adapt PTSD assessments to systematically evaluate the role of cancer as a traumatic event that may lead to PTSD symptoms in YACS.

Evaluating the Sleep Treatment Education Program (STEP-1): A single-session educational workshop addressing insomnia in cancer survivors.

Insomnia is a common late effect of cancer, affecting as many as 27% of cancer survivors. Although cognitive behavioral therapy for insomnia (CBT-I) is highly effective, treatment-associated burdens and limited availability of providers result in few survivors receiving this treatment. To address this gap, we developed the Sleep Treatment Education Program-1 (STEP-1), a single-session intervention addressing insomnia after cancer. As a preliminary evaluation of STEP-1's potential to improve survivors' insomnia, STEP-1 was delivered to a convenience sample of 34 cancer survivors as an educational workshop in person or by videoconference. Participants completed the Insomnia Severity Index (ISI) at the workshop and at 1-month follow-up; items assessing participants' intentions to implement program suggestions and satisfaction were also collected. At 1-month follow-up, mean insomnia symptoms on the ISI were significantly lower compared to baseline (9.73 vs 15.73; d = 1.38, P < .001); the reduction in mean ISI scores did not significantly differ between in-person and videoconference participants (5.82 vs 6.33; P = .78). These results, along with positive indicators of program engagement and satisfaction, support the potential efficacy of STEP-1 to meet survivors' needs for insomnia care. Particularly when delivered by videoconference, STEP-1 has the potential to dramatically improve access and uptake for insomnia treatment in cancer survivors. Results also more generally support development of low-intensity, self-management insomnia interventions for cancer survivors and potentially other populations.

Recommendations for the surveillance of mental health problems in childhood, adolescent, and young adult cancer survivors: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group.

Survivors of childhood, adolescent, and young adult (diagnosed when <25 years of age) cancer are at risk of mental health problems. The aim of this clinical practice guideline is to harmonise international recommendations for mental health surveillance in survivors of childhood, adolescent, and young adult cancer. This guideline was developed by a multidisciplinary panel of experts under the sponsorship of the International Guideline Harmonization Group. We evaluated concordance among existing survivorship clinical practice guidelines and conducted a systematic review following evidence-based methods. Of 7249 studies identified, 76 articles from 12 countries met the inclusion criteria. Recommendations were formulated on the basis of identified evidence in combination with clinical considerations. This international clinical practice guideline strongly recommends mental health surveillance for all survivors of childhood, adolescent, and young adult cancers at every follow-up visit and prompt referral to mental health specialists when problems are identified. Overall, the recommendations reflect the necessity of mental health surveillance as part of comprehensive survivor-focused health care.

Validating the Patient-Reported Outcomes Measurement Information System Short Form v1.0-Anxiety 8a in a sample of young adult cancer survivors: Comparison with a structured clinical diagnostic interview.

BACKGROUND: The objective of this study was to validate the Patient-Reported Outcomes Measurement Information System Short Form v1.0-Anxiety 8a (PROMIS-A-SF) against a structured diagnostic interview in order to determine its accuracy and the most appropriate cutoff score for identifying anxiety disorders in young adult cancer survivors (YACSs). METHODS: Two hundred forty-nine YACSs aged 18 to 40 years (50% male) completed the PROMIS-A-SF and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). The SCID was used to determine whether participants met the criteria for an anxiety diagnosis. Receiving operator characteristic analyses were performed to determine the concordance of the PROMIS-A-SF and the SCID as well as cutoff scores with sensitivity (≥0.85) and specificity (≥0.75) appropriate for an anxiety screening measure. RESULTS: The PROMIS-A-SF was determined to have good overall discrimination in comparison with the SCID (area under the curve, 0.84). A PROMIS-A-SF t-score cutoff ≥ 53.2 (total predictive value, 67.9%) came closest to meeting the study criteria with a sensitivity of 88%, but the specificity was only 65%. In a hypothetical screening example, this cutoff led to moderate levels of missed cases (14%) and a significant proportion of clinical referrals that were unnecessary by SCID criteria (35%). Of the survivors referred for services according to these criteria, less than one-third (29%) would have a SCID anxiety diagnosis. CONCLUSIONS: The PROMIS-A-SF demonstrated moderately strong concordance with anxiety disorders measured by the SCID, but cutoff scores did not meet study criteria for clinical screening. Although it may not be appropriate as a standalone screener, the PROMIS-A-SF may be useful for assessing anxiety in YACSs when it is incorporated into clinical practice or when it is combined with other measures.

Virtual visits as long-term follow-up care for childhood cancer survivors: Patient and provider satisfaction during the COVID-19 pandemic.

Telemedicine can potentially meet objectives of long-term follow-up care (LTFU) for childhood cancer survivors (CCS) while reducing barriers. We surveyed providers at our institution about their satisfaction with video-conference virtual visits (VV) with 81 CCS during COVID-19 restrictions. The same 81 CCS (or parent proxies) were surveyed about their experience, of which 47% responded. Providers and CCS were highly satisfied with VV (86% and 95% "completely/very satisfied," respectively). CCS rated VV "as/nearly as" helpful as in-person visits (66%) and 82% prefer VV remain an option postpandemic. High levels of survivor and provider satisfaction with VV support ongoing investigation into implementation for LTFU.

Screening young adult cancer survivors with the PROMIS Depression Short Form (PROMIS-D-SF): Comparison with a structured clinical diagnostic interview.

BACKGROUND: The current study was conducted to evaluate the Patient-Reported Outcomes Measurement Information System Depression Short Form (PROMIS-D-SF) as a screening measure for young adult cancer survivors (YACS) compared with a structured diagnostic interview. METHODS: A total of 249 YACS (aged 18-40 years) completed the PROMIS-D-SF and Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (SCID). Based on the SCID, participants were classified as having: 1) an SCID depression diagnosis; 2) depression symptoms without an SCID diagnosis; or 3) no depression symptoms. Receiver operating characteristic analyses evaluated PROMIS-D-SF and SCID concordance and the sensitivity and specificity of PROMIS-D-SF cutoff t -scores. RESULTS: The PROMIS-D-SF had overall good agreement with the SCID for both depression diagnosis (area under the curve, 0.89) and the presence of depressive symptoms (area under the curve, 0.83). A PROMIS-D-SF cutoff t-score of ≥53.2 came closest to meeting study criteria for detecting a SCID depression diagnosis (sensitivity ≥0.85 and specificity ≥0.75), with a sensitivity of 0.81 and a specificity of 0.74. For identifying survivors with depression symptoms, a t-score cutoff value of 49.4 was found to have slightly superior sensitivity (0.84) and inferior specificity (0.64). In hypothetical screening examples, these cutoff scores led to moderate levels of missed cases (15%-19%) and a high percentage of clinical referrals that were unnecessary by SCID criteria (56%-70%). CONCLUSIONS: The PROMIS-D-SF demonstrated moderately strong concordance with depressive diagnoses and symptoms measured by the SCID, but cutoff t-scores did not meet study criteria for clinical screening. The PROMIS-D-SF may be useful for assessing depression in YACS, but the limitations in its sensitivity and specificity identified in the current study are likely to limit its usefulness as a stand-alone screening instrument in this population.

Developing efficient and effective behavioral treatment for insomnia in cancer survivors: Results of a stepped care trial.

BACKGROUND: Insomnia is common among cancer survivors. Although behavioral treatments for insomnia are effective, access is limited. Stepped care delivery models may provide insomnia treatment that is more efficient and accessible to cancer survivors. METHODS: Fifty-one survivors (mean age, 55 years) with elevated Insomnia Severity Index (ISI) scores (≥12) first participated in Sleep Training Education Program (STEP)-1: a single, sleep education session. Those reporting elevated ISI scores 1 month later were offered STEP-2: a 3-session, group cognitive behavioral treatment for insomnia that has been demonstrated to be efficacious. Participants were considered treatment responders if their ISI score improved by ≥6 points and were considered as having remitted if their posttreatment ISI score was <12. Mood was assessed with the Profile of Mood States-Short Form (POMS-SF). RESULTS: Following STEP-1, ISI scores improved (17.1 to 11.2; P < .001), with 45% responding and 41% remitted. Insomnia remission after STEP-1 was associated with lower insomnia severity and shorter duration of sleep problems at baseline. Of the 30 (59%) survivors with unremitted insomnia after STEP-1, 14 (47%) participated in STEP-2. Following STEP-2, ISI scores improved (16.9 to 8.8; P < .001), with 79% responding and 71% remitted. STEP-2 participation was associated with interest in sleep treatment at baseline, but not demographic/health-related variables. Mood improved significantly following both STEP-1 and STEP-2 (P < .001). CONCLUSION: A stepped care approach to treating insomnia among cancer survivors has the potential to improve treatment accessibility. A sizable proportion of survivors can benefit from 2 different low-intensity approaches that could be delivered by nonsleep specialists. For individuals who require more intensive care, assessing treatment interest can identify those who are likely to engage.

Internet-delivered insomnia intervention improves sleep and quality of life for adolescent and young adult cancer survivors.

BACKGROUND: Insomnia is common among adolescent and young adult (AYA) cancer survivors. Cognitive-behavioral therapy for insomnia (CBT-I) is considered the gold standard treatment. Standard CBT-I was designed for adults and not adapted to the unique medical, psychosocial, and developmental needs of AYA cancer survivors, which can exacerbate their insomnia. Further, the vast majority of cancer centers do not have a behavioral sleep medicine expert on staff. Our study objective was to examine the efficacy of an Internet-delivered CBT-I program that was tailored for AYA cancer survivors (NCT03279055). PROCEDURE: Twenty-two AYA cancer survivors (mean age 20.4; range 14-25) with insomnia enrolled in an automated CBT-I program modified for AYA cancer survivors following stakeholder feedback. Participants were blood cancer (54.5%) and solid tumor (45.5%) survivors, an average of 9.7 years postdiagnosis. Sleep health, fatigue, and quality of life were assessed at baseline and at two follow up timepoints (8 and 16 weeks postbaseline). RESULTS: Significant improvements in insomnia severity, daytime sleepiness, fatigue, and quality of life were reported at both follow up timepoints. However, most participants (72.7%) did not complete all of the six study sessions, with a mean completion rate of 3.2 sessions. Participants who completed at least two sessions reported better sleep (insomnia severity index total score) than those who did not. CONCLUSIONS: An Internet-delivered insomnia intervention adapted for AYA cancer survivors was efficacious. This has important implications for access to evidence-based clinical care for this growing population. Future efforts should study stepped care models of care and ways to improve treatment adherence.

Pediatric hematology and oncology fellow education in sexual and reproductive health: A survey of fellowship program directors in the United States.

PURPOSE: Pediatric oncology clinicians identify a need for increased sexual and reproductive health (SRH) education with adolescent and young adult (AYA) cancer patients. By surveying pediatric oncology fellowship directors, this study clarifies the state of current fellowship education about SRH for the AYA patient. METHODS: A survey was sent to all pediatric oncology fellowship program directors (PDs) in the United States consisting of 13 questions pertaining to three primary SRH domains: sexual health, fertility, and safe sex practices. Descriptive statistics and χ2 were used in data analyses. RESULTS: Sixty-three PDs responded to the survey (91% response rate). Of these, 88% reported having formal instruction regarding fertility, 41% reported curriculum regarding contraception and 30% reported some education regarding sexual health. The curriculum "being too full" was identified as a barrier to education on fertility (29%), sexual health (40%), and safe sex practices (38%). Not being a required or expected part of the program was more likely to be endorsed as a barrier for sexual health (26%) and safe sex practices (30%) compared with fertility (8%) (P < 0.005). Lack of experts to teach was a more frequently endorsed barrier to education on sexual health (47%) compared with either fertility (23%) or safe sex practices (25%) (P < 0.005). CONCLUSIONS: This study identifies important gaps in oncology fellow education about SRH. Future research must explore optimal education strategies that are feasible and acceptable by PDs and fellow learners, and effective in optimizing AYA SRH care.

How does a single session group intervention improve sexual function in ovarian cancer survivors? A secondary analysis of effects of self-efficacy, knowledge and emotional distress.

Although sexual dysfunction after ovarian cancer (OC) treatment is a common side effect, intervention for this issue remains largely unaddressed in the literature. To address this gap, we recently developed and tested a theory-driven psychosexual intervention that successfully improved sexual function in OC survivors. This study is a secondary analysis to determine whether the intervention effects were consistent with our theoretical model. We expected that improved self-efficacy, sexual knowledge and emotional distress would relate to improved sexual function, and that effects of sexual knowledge and self-efficacy on sexual function would be mediated by emotional distress. 46 OC survivors completed study measures prior to and two-months following the intervention. Results indicated that self-efficacy, sexual knowledge, and emotional distress improved significantly post-intervention. While self-efficacy and emotional distress were both directly associated with sexual function; contrary to expectation, change in knowledge was not. Results also demonstrated that the relationship between self-efficacy and sexual function was not mediated by emotional distress. Clinical implications underscore the importance of promoting self-efficacy and decreasing emotional distress in the context of sexual rehabilitation treatment for OC survivors. Next steps include refining the intervention based on these findings and testing in a larger, randomized trial of gynecological cancer survivors.

Psychometric properties of the Insomnia Severity Index in cancer survivors.

OBJECTIVE: Insomnia is commonly associated with cancer treatment. Cancer treatments increase risk for numerous psychological and medical late effects, thus making cancer survivors psychologically and medically vulnerable. Prior research examined psychometric properties of the Insomnia Severity Index (ISI) with various populations, including the French version of the ISI, with participants undergoing active cancer treatment. However, no prior studies examined insomnia exclusively with cancer survivors, using the English version of the ISI. METHODS: This study examined internal consistency and factor structure of an English version of the ISI in 100 cancer survivors (Mage  = 51.1; SD = 14.92). This final analytic sample was composed of participants from three different insomnia interventions. Survivors ranged from less than 1 year off treatment (17%) to 21+ years off treatment (6%), with most participants off treatment for 1 to 2 years (24%). RESULTS: The mean ISI score for the total sample was 16.69 (SD = 4.47), indicating clinical insomnia, with moderate severity. Principal Components Analysis (PCA) indicated two factors (five items loading on Factor I and two items loading on Factor II) and acceptable reliability (α = .73). Item-total correlations ranged from .15 to .63. CONCLUSIONS: Findings support the reliability of the ISI in cancer survivors. However, its factor structure warrants additional research with larger samples of cancer survivors. Results suggest inconsistency across participant responses and that ISI items may be functioning differently with this unique population of cancer survivors. Findings indicate that sleep maintenance problems are central to the experience of insomnia in our survivor sample.

Open-label placebo reduces fatigue in cancer survivors: a randomized trial.

PURPOSE: Cancer-related fatigue (CRF) is a common and challenging late effect for many cancer survivors. Clinical trials demonstrate robust placebo effects on CRF in blinded trials. Recently, open-label placebo (OLP) has been shown to improve a variety of symptoms in other populations. We conducted a randomized controlled trial to investigate the effect of OLP on CRF in cancer survivors, and to explore biologic and psychological correlates of placebo efficacy. METHODS: Forty cancer survivors (92.5% female; mean age 47.3 years) were randomized to OLP or no treatment control. OLP participants were prescribed two placebo tablets twice daily, for 3 weeks. All participants completed assessments at Baseline, Day 8, and Day 22. The primary endpoint was change in CRF (FACIT-F), and secondary outcomes included exercise frequency, mood, and quality of life. We examined whether personality characteristics or a genetic variation important in dopamine catabolism (catechol-O-methyltransferase; COMT) affected the placebo response. RESULTS: The OLP group reported significantly improved CRF at both Day 8 (p = 0.005) and Day 22 (p = .02), while the control group did not (ps > .05). CRF improvement differed by COMT genotype, but was not associated with personality characteristics. Marginal improvements were noted in the placebo group for some secondary outcomes (exercise frequency and quality of life), but not in the control group. CONCLUSIONS: Results demonstrate that even when administered openly, placebos improve CRF in cancer survivors and dopaminergic systems may be associated with this response. This novel research has meaningful implications for the use of OLP in symptom management for cancer survivors.

Improvement in sexual function after ovarian cancer: Effects of sexual therapy and rehabilitation after treatment for ovarian cancer.

BACKGROUND: Sexual dysfunction is a distressing long-term effect after gynecological cancer and affects the majority of survivors for years after the completion of therapy. Despite its prevalence, treatment-related sexual dysfunction is underrecognized and undertreated for survivors. Thus, the aim of this study was to develop and test a brief psychoeducational intervention for managing sexual dysfunction for women who have undergone treatment for ovarian cancer (OC). METHODS: Forty-six OC survivors with documented, treatment-related sexual dysfunction received a single half-day group intervention that included sexual health education and rehabilitation training, relaxation and cognitive behavioral therapy skills to address sexual symptoms, and a single tailored booster telephone call 4 weeks after the group. Assessment measures were completed at the baseline (baseline 1), after an 8-week no-treatment run-in period (baseline 2), and then again 2 and 6 months after the intervention. The Female Sexual Function Index (FSFI) was used to assess sexual functioning, and the Brief Symptom Inventory 18 (BSI-18) was used to capture psychological distress. RESULTS: Between baseline 1 and baseline 2, there were no significant changes in the study measures, and this indicated no natural improvement during the run-in period. In contrast, the total FSFI scores improved significantly from baseline 1 to the 2- (n = 45; P < .0005) and 6-month time points (n = 42; P < .05). The BSI-18 scores were also significantly improved at the 2- (P < .005) and 6-month time points (P < .01) in comparison with baseline 1. CONCLUSIONS: This brief behavioral intervention led to significant improvements in overall sexual functioning and psychological distress that were maintained at the 6-month follow-up. The results demonstrate the feasibility of this brief, low-intensity behavioral intervention and support the development of a larger randomized controlled trial. Cancer 2018;124:176-82. © 2017 American Cancer Society.

Sleepless from the Get Go: Sleep Problems Prior to Initiating Cancer Treatment.

PURPOSE: Cancer patients are likely to experience sleep problems. Understanding their perception of sleep problems is important as subjective symptom experience is associated with treatment-seeking behavior. We explored the prevalence of sleep problems and its correlates in a large sample of cancer patients at an important but understudied stage of their cancer journey: prior to initiating treatment. METHODS: Cancer patients (5702) (67.5% female; 76.9% White; 23.0% Hispanic), following diagnosis and prior to initiating cancer treatment, completed an electronic screening instrument. Patients across eight different cancer diagnoses (breast, gastrointestinal, gynecological, head and neck, hematological, lung, prostate, urinary) rated their sleep problems on a five-point scale, with those reporting "severe" or "very severe" sleep problems classified as having high sleep problems. RESULTS: Overall, 12.5% of patients reported high sleep problems. Across diagnoses, the proportion of patients reporting high sleep problems ranged from 4.3 to 13.8%, with prostate cancer patients least likely and gastrointestinal cancer patients most likely to report high sleep problems. Older age, having a partner, higher education, and higher household income were associated with a lower likelihood of experiencing sleep problems. Being female, Black, Hispanic, and reporting anxiety or depression was associated with an increased likelihood of sleep problems. CONCLUSIONS: A sizeable proportion of cancer patients experience significant problems with their sleep before any treatment has occurred. This clinical issue cannot be ignored as treatment is likely to worsen existing sleep problems. Oncology providers should routinely screen for sleep-related problems. Identifying and treating patients for sleep problems during a vulnerable period early in their cancer trajectory should be an essential component of clinical care.

Provision of integrated psychosocial services for cancer survivors post-treatment.

Meeting the psychosocial needs of patients with cancer has been recognised as a priority within oncology care for several decades. Many approaches that address these needs have been developed and described; however, until recently much of this work had focused on patients during treatment and end-of-life care. With continued improvement in therapies, the population of cancer survivors who can expect to live for 5 or more years after cancer diagnosis has increased dramatically, as have associated concerns about how to meet their medical, psychosocial, and health behaviour needs after treatment. Guidelines and models for general survivorship care routinely address psychosocial needs, and similar guidelines for psychosocial care of patients with cancer are being extended to address the needs of survivors. In this Series paper, we summarise the existing recommendations for the provision of routine psychosocial care to survivors, as well as the challenges present in providing this care. We make specific recommendations for the integration of psychosocial services into survivorship care.

Three sides to a story: Child, parent, and nurse perspectives on the child's experience during hematopoietic stem cell transplantation.

BACKGROUND: The experience of children undergoing hematopoietic stem cell transplantation (HSCT), including the ways in which different participants (ie, children, parents, and nurses) contribute to the overall picture of a child's experience, is poorly characterized. This study evaluated parent, child, and nurse perspectives on the experience of children during HSCT and factors contributing to interrater differences. METHODS: Participants were enrolled in a multicenter, prospective study evaluating child and parent health-related quality of life over the year after HSCT. Children (n = 165) and their parents and nurses completed the Behavioral, Affective, and Somatic Experiences Scale (BASES) at baseline (before/during conditioning), 7 days after the stem cell infusion (day+7), and 21 days after the stem cell infusion (day+21). The BASES domains included Somatic Distress, Mood Disturbance, Cooperation, and Getting Along. Higher scores indicated more distress/impairment. Repeated measures models by domain assessed differences by raters and changes over time and identified other factors associated with raters' scores. RESULTS: Completion rates were high (≥73% across times and raters). Multivariate models revealed significant time-rater interactions, which varied by domain. For example, parent-rated Somatic Distress scores increased from baseline to day+7 and remained elevated at day+21 (P < .001); children's scores were lower than parents' scores across time points. Nurses' baseline scores were lower than parents' baseline scores, although by day+21 they were similar. Older child age was associated with higher Somatic Distress and Mood Disturbance scores. Worse parent emotional functioning was associated with lower scores across raters and domains except for Cooperation. CONCLUSIONS: Multirater assessments are highly feasible during HSCT. Ratings differ by several factors; considering ratings in light of such factors may deepen our understanding of the child's experience. Cancer 2017;123:3159-66. © 2017 American Cancer Society.

A pilot trial of brief group cognitive-behavioral treatment for insomnia in an adult cancer survivorship program.

BACKGROUND: Cognitive-behavioral therapy for insomnia (CBT-Insomnia) is effective, yet rarely available for cancer survivors. This is unfortunate because survivors are at elevated risk for insomnia, which is associated with significant health consequences in this already at-risk population. Barriers to delivering CBT-Insomnia in oncology settings include a lack of trained providers, distance to cancer centers, and treatment duration. PURPOSE: To address insomnia treatment barriers, we adapted standard CBT-Insomnia treatment and evaluated a pilot group-based approach for feasibility and efficacy in an adult cancer survivorship program. METHODS: Thirty-eight cancer survivors (mean age = 52.2 years) enrolled in our three-session program delivered over 1 month. They were primarily diagnosed with breast cancer (58.6%) and were an average of 6.0 years post-diagnosis and 3.6 years post-treatment. Participants completed sleep logs throughout the study and measures of sleep at baseline and week 4. RESULTS: Participants reported experiencing insomnia symptoms an average of 2.4 years, with 89.7% indicating that the cancer experience had caused/exacerbated symptoms. Significant pre/post-intervention group improvements in sleep efficiency (77.3% to 88.5%), sleep quality, and insomnia symptoms were reported (all ps < .01). Less than 1 in 3 had discussed insomnia symptoms with their oncology providers in the prior year. CONCLUSIONS: Pilot data indicate that a brief, group-based CBT-Insomnia intervention in a survivorship setting is both feasible and efficacious. There is a need to increase awareness about insomnia and its treatment among both cancer survivors and oncology providers. If validated in future studies, this novel approach can improve cancer survivors' access to much needed insomnia treatment. Copyright © 2016 John Wiley & Sons, Ltd.