Cognitive-behavioral and mindfulness-based interventions for distress in patients with advanced cancer: A meta-analysis.

OBJECTIVE: Various psychosocial interventions have been developed to reduce distress and improve quality of life (QoL) in patients with advanced cancer, many of which are traditional cognitive-behavioral interventions (CBIs) or mindfulness-based interventions (MBIs). The aims of this meta-analysis were to determine and compare the overall effects of traditional CBIs and MBIs on distress and QoL in this population and to explore potential moderators of intervention efficacy. METHODS: A systematic search was conducted in CINAHL, Embase, PsycINFO, PubMed, and Web of Science. Randomized controlled trials (RCTs) comparing CBIs or MBIs to controls on distress and QoL outcomes were eligible for inclusion. Random effects meta-analyses using standardized baseline to post-intervention mean differences were calculated using Hedges's g. Meta-regressions were used to compare intervention effects and examine potential moderators. RESULTS: Across 37 RCTs (21 CBIs, 14 MBIs, 2 combination therapies), there was a small decrease in distress (Hedges's g = 0.21) and a minimal improvement in QoL (Hedges's g = 0.15). Traditional CBIs and MBIs did not differ in effect sizes. Heterogeneity was significant across distress effect sizes but not across QoL effects. Interventions delivered to individuals (vs. dyads/group) had larger effects on QoL. No moderators of intervention effects on distress were found. CONCLUSIONS: Findings suggest traditional CBIs and MBIs produce small reductions in distress compared to controls in patients with advanced cancer, although effects on QoL appear minimal. Given limitations in the number of studies and their quality, rigorous trials are needed to directly compare the impact of traditional CBIs and MBIs in this population.

Preliminary validation of the Cognitive Affective Mindfulness Scale-Revised in cancer populations.

OBJECTIVE: A brief, valid, and comprehensive measure of mindfulness is needed for cancer populations. This study examined the factor structure, internal consistency, construct validity, and measurement invariance of the 10-item Cognitive Affective Mindfulness Scale-Revised (CAMS-R) in patients with cancer. METHODS: Patients with breast, gastrointestinal, lung, or prostate cancer (N = 404, 50% stage IV cancer, 51% women) were recruited from academic and public clinics in Indianapolis, IN. Patients completed the CAMS-R and other psychological measures at one time point. Confirmatory factor analysis (CFA) was used to examine the dimensionality of the CAMS-R. Internal consistency and construct validity were also assessed. Measurement invariance was examined for gender, cancer type, and cancer stage. RESULTS: CFA showed that the original CAMS-R structure with four first-order factors (attention, present focus, awareness, and acceptance) and one second-order factor (mindfulness) had a reasonable fit (RMSEA = 0.09, CFI = 0.95, SRMR = 0.04). Internal consistency was excellent (α = 0.90). The CAMS-R total score showed significant positive associations with several subscales of a widely used mindfulness questionnaire and self-compassion (rs = 0.61-0.66) and significant negative associations with anxiety, depressive symptoms, rumination, psychological inflexibility, and avoidant coping (rs = -0.35-0.58). Measurement invariance testing indicated that the CAMS-R was invariant across populations of varying genders, cancer types, and stages. CONCLUSIONS: Findings provide preliminary support for using the CAMS-R in cancer populations. Future research should assess the responsiveness of the CAMS-R to intervention.

Relations of perceived injustice to psycho-spiritual outcomes in advanced lung and prostate cancer: Examining the role of acceptance and meaning making.

OBJECTIVE: Many advanced cancer patients struggle with anxiety, depressive symptoms, and anger toward God and illness-related stressors. Patients may perceive their illness as an injustice (i.e., appraise their illness as unfair, severe, and irreparable or blame others for their illness), which may be a risk factor for poor psychological and spiritual outcomes. This study examined relations between cancer-related perceived injustice and psycho-spiritual outcomes as well as potential mediators of these relationships. METHODS: Advanced lung (n = 102) and prostate (n = 99) cancer patients completed a one-time survey. Using path analyses, we examined a parallel mediation model including the direct effects of perceived injustice on psycho-spiritual outcomes (i.e., anxiety, depressive symptoms, anger about cancer, anger towards God) and the indirect effects of perceived injustice on psycho-spiritual outcomes through two parallel mediators: meaning making and acceptance of cancer. We then explored whether these relations differed by cancer type. RESULTS: Path analyses indicated that perceived injustice was directly and indirectly-through acceptance of cancer but not meaning making-associated with psycho-spiritual outcomes. Results did not differ between lung and prostate cancer patients. CONCLUSIONS: Advanced cancer patients with greater perceived injustice are at higher risk for poor psycho-spiritual outcomes. Acceptance of cancer, but not meaning making, explained relationships between cancer-related perceived injustice and psycho-spiritual outcomes. Findings support testing acceptance-based interventions to address perceived injustice in advanced cancer patients.

Symptom experiences in advanced cancer: Relationships to acceptance and commitment therapy constructs.

OBJECTIVE: This study examined relations between acceptance and commitment therapy (ACT) constructs and symptom-based subgroups of advanced cancer patients. METHODS: Patients with advanced breast, gastrointestinal, lung, and prostate cancer (N = 201) completed questionnaires assessing five common symptoms and ACT variables (i.e., psychological inflexibility, cognitive fusion, values obstruction and progress, peaceful acceptance, mindfulness, and activity engagement) on one occasion. RESULTS: Latent profile analysis showed three patient classes: (1) normal levels of all symptoms (32%); (2) normal levels of all symptoms except for mild sleep problems and moderate fatigue (19%); and (3) normal pain, mild levels of sleep problems, anxiety, and depressive symptoms, and moderate fatigue (48%). Controlling for demographic covariates, lower psychological inflexibility, cognitive fusion, and values obstruction were associated with a higher likelihood of being in classes 1 or 2 than class 3. In addition, greater values progress, peaceful acceptance, mindfulness, and activity engagement were associated with a higher likelihood of being in class 1 than class 3. Of these four factors, only greater mindfulness and activity engagement were associated with a higher likelihood of being in class 2 than class 3. CONCLUSIONS: Advanced cancer patients show heterogeneous symptom profiles, and even mild to moderate symptom levels are related to greater withdrawal from personally meaningful activities and less acceptance of cancer and internal experiences (e.g., symptoms, thoughts, feelings). Findings are consistent with the ACT model and support further testing of ACT to address symptom interference with functioning in advanced cancer patients.

Symptom Treatment Preferences of Cancer Survivors: Does Fatigue Level Make a Difference?

BACKGROUND: Cancer-related fatigue (CRF) is among the most prevalent symptoms in cancer survivors and often co-occurs with other symptoms. However, little is known about survivors' preferences for treating CRF and associated symptoms. OBJECTIVE: The aim of this study was to examine cancer survivors' interest in learning skills to manage CRF and associated symptoms and their interest in various nonpharmacologic interventions and modalities. These outcomes were compared between survivors with high and normal fatigue. METHODS: Breast, gastrointestinal, lung, and prostate cancer survivors (N = 338) completed a 1-time survey, including a Patient-Reported Outcomes Measurement Information System fatigue measure and a checklist assessing interest in learning skills to manage CRF and associated symptoms as well as interest in nonpharmacologic interventions and modalities. RESULTS: Many cancer survivors reported interest in learning skills to manage CRF (range, 35%-78%) and associated symptoms (range, 13%-48%). Compared with survivors with normal fatigue (n = 180), highly fatigued survivors (n = 158; Patient-Reported Outcomes Measurement Information System fatigue T score ≥ 55) were more likely to report interest in learning skills to manage various symptoms, self-compassion training, and programs offered individually and in person. Interest in other interventions and modalities did not vary by fatigue level. CONCLUSIONS: Many cancer survivors, especially those with high fatigue, report interest in learning symptom management skills. Given survivors' high level of interest in complementary and integrative health interventions, future research should continue to assess their impact on symptoms and functioning. IMPLICATIONS FOR PRACTICE: Nurses can offer a menu of evidence-based options for symptom management, given survivors' diverse preferences. Nurses can also provide psychoeducation regarding their preferred treatments.

Effects of mindfulness-based interventions on fatigue in cancer survivors: A systematic review and meta-analysis of randomized controlled trials.

This systematic review and meta-analysis was designed to determine the efficacy of mindfulness-based interventions (MBIs) in improving fatigue-related outcomes in adult cancer survivors. Randomized controlled trials (RCTs) were identified from PubMed, MEDLINE, PsycINFO, CINAHL, Web of Science, and EMBASE databases and reference lists of included studies. Separate random-effects meta-analyses were conducted for fatigue and vitality/vigor. Twenty-three studies reporting on 21 RCTs (N = 2239) met inclusion criteria. MBIs significantly reduced fatigue compared to controls at post-intervention (g = 0.60, 95 % CI [0.36, 0.83]) and first follow-up (g = 0.42, 95 % CI [0.20, 0.64]). Likewise, MBIs significantly improved vitality/vigor at post-intervention (g = 0.39, 95 % CI [0.25, 0.52]) and first follow-up (g = 0.35, 95 % CI [0.03, 0.67]). The evidence grade was low due to risk of bias, substantial heterogeneity, and publication bias among studies. MBIs show promise in improving fatigue and vitality/vigor in cancer survivors. More rigorous trials are needed to address current gaps in the evidence base.

Symptom experiences in post-treatment cancer survivors: associations with acceptance and commitment therapy constructs.

PURPOSE: Acceptance and Commitment Therapy (ACT) has improved symptom and quality-of-life outcomes in pilot research with post-treatment cancer survivors. To further test the ACT model, the present study examined relationships between ACT constructs and subgroups of post-treatment survivors based on the severity of common symptoms. METHODS: Survivors who had completed primary treatment for stage I or II cancer (N = 203) participated in this one-time survey. Latent class analysis (LCA) was used to identify subgroups of survivors based on the severity of fatigue, sleep disturbance, pain, anxiety, and depressive symptoms. Multinomial logistic regressions employing Vermunt's 3-step approach were used to examine ACT constructs (e.g., mindfulness, acceptance, values progress) as correlates of survivor subgroups based on symptoms. RESULTS: The LCA showed three survivor classes: (1) mild-to-moderate levels of all symptoms except for normal pain intensity; (2) mild anxiety, moderate fatigue, and normal levels of all other symptoms; and (3) normal levels of all symptoms. Lower mindfulness, acceptance, and values progress and higher cognitive fusion, psychological inflexibility, and values obstruction were associated with a greater likelihood of being in class 1 or 2 than in class 3. CONCLUSION: Findings are consistent with the ACT model. Survivors with greater symptom burden reported greater withdrawal from personally meaningful activities and less acceptance of their cancer diagnosis and internal experiences (e.g., thoughts, feelings, symptoms). Findings provide strong justification for further testing of ACT to reduce symptom-related suffering in cancer survivors.

Relations of Mindfulness and Illness Acceptance With Psychosocial Functioning in Patients With Metastatic Breast Cancer and Caregivers.

OBJECTIVES: To examine relationships in mindfulness and illness acceptance and psychosocial functioning in patients with metastatic breast cancer and their family caregivers. SAMPLE & SETTING: 33 dyads from an academic cancer center in the United States. METHODS & VARIABLES: Participants completed questionnaires on mindfulness, illness acceptance, relationship quality, anxiety, and depressive symptoms. Dyadic, cross-sectional data were analyzed using actor-partner interdependence models. RESULTS: Greater nonjudging, acting with awareness, and illness acceptance among caregivers were associated with patients' and caregivers' perceptions of better relationship quality. Higher levels of these processes were associated with reduced anxiety and depressive symptoms in patients and caregivers. IMPLICATIONS FOR NURSING: Aspects of mindfulness and illness acceptance in dyads confer benefits that are primarily intrapersonal in nature. Nurses may consider introducing mindfulness and acceptance-based interventions to patients and caregivers with adjustment difficulties.

Psychological Processes and Symptom Outcomes in Mindfulness-Based Stress Reduction for Cancer Survivors: A Pilot Study.

OBJECTIVES: Growing evidence supports the efficacy of mindfulness-based interventions for symptoms in cancer survivors. Identifying theory-based psychological processes underlying their effects on symptoms would inform research to enhance their efficacy and cost-effectiveness. We conducted secondary analyses examining the effect of mindfulness-based stress reduction (MBSR) for cancer-related fatigue on mindfulness facets, self-compassion, and psychological inflexibility. We also examined whether changes in these processes were associated with the symptom outcomes of fatigue interference, sleep disturbance, and emotional distress. METHODS: Thirty-five persistently fatigued cancer survivors (94% female, 77% breast cancer survivors) were randomized to either MBSR for cancer-related fatigue or a waitlist control (WC) condition. Self-report measures were administered at pre-intervention, post-intervention, and 1-month follow-up. Then the WC group received MBSR and completed a post-intervention follow-up. RESULTS: Linear mixed modeling analyses of the first three time points showed steady increases over time for certain mindfulness facets (observing, acting with awareness, and nonjudging) and self-compassion in favor of the MBSR group. When analyzing pre- and post-intervention data across study conditions, none of the psychological processes predicted change in fatigue interference. However, increased nonjudging was associated with decreased sleep disturbance (ß = -.39, p = .003), and increased acting with awareness was associated with decreased emotional distress (ß = -.36, p = .003). Self-compassion did not predict change in symptom outcomes. CONCLUSIONS: Results point to specific psychological processes that may be targeted to maximize the efficacy of future MBSR interventions for cancer survivors.

Coping Skills Practice and Symptom Change: A Secondary Analysis of a Pilot Telephone Symptom Management Intervention for Lung Cancer Patients and Their Family Caregivers.

CONTEXT: Little research has explored coping skills practice in relation to symptom outcomes in psychosocial interventions for cancer patients and their family caregivers. OBJECTIVES: To examine associations of coping skills practice to symptom change in a telephone symptom management (TSM) intervention delivered concurrently to lung cancer patients and their caregivers. METHODS: This study was a secondary analysis of a randomized pilot trial. Data were examined from patient-caregiver dyads (n = 51 dyads) that were randomized to the TSM intervention. Guided by social cognitive theory, TSM involved four weekly sessions where dyads were taught coping skills including a mindfulness exercise, guided imagery, pursed lips breathing, cognitive restructuring, problem solving, emotion-focused coping, and assertive communication. Symptoms were assessed, including patients' and caregivers' psychological distress and patients' pain interference, fatigue interference, and distress related to breathlessness. Multiple regression analyses examined associations of coping skills practice during the intervention to symptoms at six weeks after the intervention. RESULTS: For patients, greater practice of assertive communication was associated with less pain interference (ß = -0.45, P = 0.02) and psychological distress (ß = -0.36, P = 0.047); for caregivers, greater practice of guided imagery was associated with less psychological distress (ß = -0.30, P = 0.01). Unexpectedly, for patients, greater practice of a mindfulness exercise was associated with higher pain (ß = 0.47, P = 0.07) and fatigue interference (ß = 0.49, P = 0.04); greater practice of problem solving was associated with higher distress related to breathlessness (ß = 0.56, P = 0.01) and psychological distress (ß = 0.36, P = 0.08). CONCLUSION: Findings suggest that the effectiveness of TSM may have been reduced by competing effects of certain coping skills. Future interventions should consider focusing on assertive communication training for patients and guided imagery for caregivers.

Examining the effect of peer helping in a coping skills intervention: a randomized controlled trial for advanced gastrointestinal cancer patients and their family caregivers.

PURPOSE: At the end of life, spiritual well-being is a central aspect of quality of life for many patients and their family caregivers. A prevalent spiritual value in advanced cancer patients is the need to actively give. To address this need, the current randomized trial examined whether adding a peer helping component to a coping skills intervention leads to improved meaning in life and peace for advanced gastrointestinal cancer patients and their caregivers. Feasibility and acceptability outcomes were also assessed. METHODS: Advanced gastrointestinal cancer patients and caregivers (n = 50 dyads) were randomly assigned to a 5-session, telephone-based coping skills intervention or a peer helping + coping skills intervention. One or both dyad members had moderate-severe distress. Peer helping involved contributing to handouts on coping skills for other families coping with cancer. Patients and caregivers completed measures of meaning in life/peace, fatigue, psychological symptoms, coping self-efficacy, and emotional support. Patient pain and caregiver burden were also assessed. RESULTS: Small effects in favor of the coping skills group were found regarding meaning in life/peace at 1 and 5 weeks post-intervention. Other outcomes did not vary as a function of group assignment, with both groups showing small decreases in patient and caregiver fatigue and caregiver distress and burden. High recruitment and retention rates supported feasibility, and high participant satisfaction ratings supported acceptability. CONCLUSIONS: Although a telephone-based intervention is feasible and acceptable for this population, peer helping in the context of a coping skills intervention does not enhance spiritual well-being relative to coping skills alone.

Coping with physical and psychological symptoms: a qualitative study of advanced lung cancer patients and their family caregivers.

PURPOSE: Advanced lung cancer patients have high rates of multiple physical and psychological symptoms, and many of their family caregivers experience significant distress. However, little is known about strategies that these patients and their family caregivers employ to cope with physical and psychological symptoms. This study aimed to identify strategies for coping with various physical and psychological symptoms among advanced, symptomatic lung cancer patients and their primary family caregivers. METHODS: Patients identified their primary family caregiver. Individual semi-structured qualitative interviews were conducted with 21 advanced, symptomatic lung cancer patients and primary family caregivers. Thematic analysis of interview data was framed by stress and coping theory. RESULTS: Patients and caregivers reported maintaining a normal routine and turning to family and friends for support with symptom management, which often varied in its effectiveness. Whereas support from health-care professionals and complementary and alternative medicine were viewed favorably, reactions to Internet and in-person support groups were mixed due to the tragic nature of participants' stories. Several cognitive coping strategies were frequently reported (i.e., changing expectations, maintaining positivity, and avoiding illness-related thoughts) as well as religious coping strategies. CONCLUSIONS: Results suggest that advanced lung cancer patients and caregivers may be more receptive to cognitive and religious approaches to symptom management and less receptive to peer support. Interventions should address the perceived effectiveness of support from family and friends.

Caregiving experiences predict changes in spiritual well-being among family caregivers of cancer patients.

OBJECTIVE: Although enhanced spiritual well-being has been linked to positive mental health outcomes among family caregivers of cancer patients, little is known regarding predictors of spiritual well-being in this population. The current study aimed to examine caregiving experiences as predictors of change in family caregivers' spiritual well-being during the initial months following the patient's cancer diagnosis. METHODS: Seventy family caregivers of newly diagnosed cancer patients (74% female, mean age = 59 years) participated in this longitudinal survey. Caregivers completed baseline questionnaires shortly before staying with the patient at an American Cancer Society Hope Lodge. Baseline questionnaires assessed caregiving experiences (i.e., self-esteem related to caregiving, family support for providing care, impact of caregiving on finances, and impact of caregiving on one's schedule). In addition, caregivers' spiritual well-being (i.e., meaning in life, peace, and faith) was assessed at baseline and 4-month follow-up. RESULTS: In univariate analyses, all caregiving experiences studied were associated with one or more aspects of spiritual well-being at 4-month follow-up. However, in the multivariate analysis, the only caregiving experience associated with aspects of spiritual well-being at 4-month follow-up was caregivers' perceptions of family support. Specifically, lack of family support was associated with lower levels of meaning and peace. CONCLUSIONS: Findings point to the importance of family support in facilitating the search for meaning and peace shortly after a loved one's cancer diagnosis and suggest that interventions targeting caregivers' support system may enhance their spiritual well-being.

Support service use and interest in support services among lung cancer patients.

OBJECTIVES: This study examined support service use and interest in support services among lung cancer patients (N = 165) at two comprehensive medical centers in the midwestern United States. MATERIALS AND METHODS: Patients completed an assessment of support service use (i.e., receipt of mental health services, complementary and alternative medicine [CAM], and help from a spiritual leader), interest in support services, and physical and psychological symptoms. RESULTS: Only 40% of patients with significant anxiety and depressive symptoms and 28% of the entire sample reported current mental health service use. However, nearly half (47%) of all patients were receiving support from a spiritual leader. Having late-stage lung cancer and a religious affiliation predicted receipt of spiritual support. Few patients who were not receiving mental health services or spiritual support were interested in these services (range = 4-18%). Conversely, although interest in CAM was expressed by a substantial minority of patients (27%) who were not using these services, rates of CAM use were relatively low (22%). CONCLUSIONS: Findings suggest that distressed lung cancer patients underuse mental health services, but many patients receive help from spiritual leaders. Given the lack of interest in mental health services among patients who are not receiving them, efforts are needed to enhance palatability of services and identify and reduce barriers to evidence-based service use.

Support service use and interest in support services among distressed family caregivers of lung cancer patients.

OBJECTIVE: This study examined support service use and interest in support services among distressed family caregivers of patients recently entering comprehensive cancer care facilities. METHODS: Primary family caregivers of lung cancer patients (N=83) were recruited from three medical centers within 12 weeks of the patient's new visit to the oncology clinic. All family caregivers were screened for psychological distress, and those reporting significant anxiety or depressive symptoms were eligible for this study. Caregivers completed a baseline assessment of support service use (i.e., use of mental health services and complementary and alternative medicine [CAM]) and interest in support services. Support service use was also assessed 3 months later. RESULTS: Although all caregivers reported clinically meaningful distress, only 26% used mental health and 39% used CAM services during the 3-month study period. Patients' receipt of chemotherapy was positively associated with caregivers' mental health service use, whereas greater education and receiving assistance with caregiving tasks were associated with CAM use. Forty percent of caregivers who did not use CAM at baseline were interested in CAM. In addition, 29% of caregivers who did not receive mental health services at baseline were interested in professional psychosocial support, and 29% of caregivers who did not receive staff assistance with practical needs at baseline were interested in this service. CONCLUSIONS: Findings suggest that distressed family caregivers of lung cancer patients underuse mental health services and that a sizable minority are interested in professional help with psychosocial and practical needs.

Predictors of tanning salon use: behavioral alternatives for enhancing appearance, relaxing and socializing.

This study investigated cognitive predictors of tanning salon use, based on Jaccard's Theory of Alternative Behavior. A total of 164 undergraduates completed questionnaires that assessed tanning salon use, attitudes toward tanning salon use and attitudes toward behavioral alternatives for enhancing appearance, relaxing and socializing. Results indicated that attitudes toward alternatives for enhancing appearance were not significantly related to tanning salon use. However, favorable attitudes toward engaging in a hobby to relax and going to the gym to socialize were inversely related to frequency of tanning salon use. Findings suggest that interventions for reducing skin cancer risk should focus not only on decreasing favorable attitudes toward tanning, but also on increasing favorable attitudes toward healthier alternatives to tanning salon use.

Post-traumatic growth and psychosocial adjustment of daughters of breast cancer survivors.

PURPOSE/OBJECTIVES: To examine post-traumatic growth, or positive life changes, and its correlates among adult daughters of breast cancer survivors and to compare their psychosocial adjustment to women with healthy parents. DESIGN: Descriptive, cross-sectional survey. SETTING: Outpatient oncology units in two urban hospitals and two breast cancer organizations. SAMPLE: 30 adult daughters of breast cancer survivors (mean age = 38.1 years) and 16 women with healthy parents. METHODS: Participants were recruited by hospital or research staff or responded to an announcement in a newsletter. Respondents completed the Post-Traumatic Growth Inventory and standardized assessments of psychosocial adjustment. MAIN RESEARCH VARIABLES: Post-traumatic growth and demographic, stressor, and psychosocial variables. FINDINGS: Women who cared for their mothers following breast cancer diagnosis and perceived their mothers' illness to be stressful reported greater post-traumatic growth. Life satisfaction, social support, emotional processing strategies, and problem-focused coping strategies also were positively associated with growth. Women with maternal histories of breast cancer and those with healthy parents did not differ in psychosocial well-being, including affect, life satisfaction, and social support. CONCLUSIONS: Findings suggest that some daughters of breast cancer survivors experience positive life changes following their mothers' illness. IMPLICATIONS FOR NURSING: For nurses seeking to adopt a holistic approach to practice, the personal growth of women following life-threatening familial illness warrants attention.