Do cancer curvivors and metavivors have distinct needs for stress management intervention? Retrospective analysis of a mind-body survivorship program.

PURPOSE: Cancer "curvivors" (completed initial curative intent treatment with surgery, radiation, chemotherapy, and/or other novel therapies) and "metavivors" (living with metastatic or chronic, incurable cancer) experience unique stressors, but it remains unknown whether these differences impact benefits from mind-body interventions. This study explored differences between curvivors and metavivors in distress (depression, anxiety, worry) and resiliency changes over the course of an 8-week group program, based in mind-body stress reduction, cognitive-behavioral therapy (CBT), and positive psychology. METHODS: From 2017-2021, 192 cancer survivors (83% curvivors; 17% metavivors) completed optional online surveys of resiliency (CES) and distress (PHQ-8, GAD-7, PSWQ-3) pre- and post- participation in an established clinical program. Mixed effect regression models explored curvivor-metavivor differences at baseline and in pre-post change. RESULTS: Compared to curvivors, metavivors began the program with significantly more resilient health behaviors (B = 0.99, 95% CI[0.12, 1.86], p = .03) and less depression (B = -2.42, 95%CI[-4.73, -0.12], p = .04), with no other significant differences. Curvivors experienced significantly greater reductions in depression (curvivor-metavivor difference in strength of change = 2.12, 95% CI [0.39, 3.83], p = .02) over the course of the program, with no other significant differences. Neither virtual delivery modality nor proportion of sessions attended significantly moderated strength of resiliency or distress change. CONCLUSION: Metavivors entering this mind-body program had relatively higher well-being than did curvivors, and both groups experienced statistically comparable change in all domains other than depression. Resiliency programming may thus benefit a variety of cancer survivors, including those living with incurable cancer.

Promoting Resilience and Flourishing Among Older Adult Residents in Community Living: A Feasibility Study.

BACKGROUND AND OBJECTIVES: The Stress Management and Relaxation Training-Relaxation Response Resiliency Program (SMART-3RP) is a mind-body group intervention that integrates relaxation training with cognitive behavioral and positive psychology techniques. This study assessed SMART-3RP feasibility, acceptability, and preliminary efficacy for enhancing resilience and flourishing among older adults in continuing care retirement communities (CCRCs). RESEARCH DESIGN AND METHODS: We conducted a prospective single-arm study of SMART-3RP groups delivered by clinicians at 4 CCRCs (n = 80). Eligible residents lived in community apartments. Participants completed pre- and postintervention surveys. We evaluated attendance (hypothesis: ≥60% attend ≥6 of 9 sessions), enrollment, and retention. Mixed methods were used to explore acceptability. Paired samples t-tests were conducted to explore changes in resilience, flourishing, and key intervention targets. RESULTS: From March to June 2021, we screened 89 residents with 87 (98%) consenting to participate and 80 (90%) enrolling in the study. Among 80 participants (85% female; 98% non-Hispanic White; M age = 80 years [SD = 6]), 88% attended ≥6 sessions, and 89% completed the postintervention survey. Participants found meaning in participation and practiced skills in the context of challenges such as caregiving burden or bereavement. Survey results, showing increases in resilience, flourishing, and several intervention targets, aligned with participants' perceived intervention value. DISCUSSION AND IMPLICATIONS: SMART-3RP was feasible and acceptable for CCRC residents; participants perceived value in practicing mind-body strategies in a group-based setting. Preliminary evidence suggested a pattern of improvements in resilience, flourishing, and intervention targets. Findings provide insights for mind-body interventions and recommendations for adaptations to late-in-life concerns and community settings. CLINICAL TRIALS REGISTRATION NUMBER: NCT04720014.

Experience and supportive care needs of metastatic lung cancer survivors living with uncertainty: a brief qualitative report.

PURPOSE: Molecularly targeted therapies have revolutionized non-small cell lung cancer (NSCLC) treatment. Many patients with metastatic NSCLC receiving targeted therapy may live several years with incurable cancer. We sought to describe how these metastatic cancer survivors and their caregivers experience uncertainty about the future and identify their unmet supportive care needs. METHODS: We conducted semi-structured interviews with patients with metastatic NSCLC receiving targeted therapy (n = 39) and their caregivers (n = 16). We used a framework approach to code and analyze the qualitative data. RESULTS: Metastatic lung cancer survivors described awareness of their mortality and the possibility that their cancer could progress at any time. Though some found ways to cope, many felt inadequately supported to manage their distress, especially since they were "doing fine medically." Survivors struggled with decisions about working and managing their finances given their uncertain life expectancy and sought trustworthy lung cancer information in plain language. They wished to compare experiences with other patients with their molecular subtype of NSCLC. Participants desired comprehensive cancer care that includes psychosocial support, preparation for the future, and ways to promote their own health, such as through lifestyle changes. CONCLUSIONS: Patients with metastatic NSCLC receiving targeted therapy and their caregivers experience distress related to living with uncertainty and desire more coping support, connection with peers, information, and healthy lifestyle guidance. IMPLICATIONS FOR CANCER SURVIVORS: Patients living with treatable yet incurable cancer and their caregivers are a growing population of cancer survivors. Recognition of their unmet needs may inform the development of tailored support services to help them live well with cancer.

A Virtual Resiliency Intervention Promoting Resiliency for Parents of Children with Learning and Attentional Disabilities: A Randomized Pilot Trial.

OBJECTIVES: One in five children have a learning and attentional disability (LAD). Parents of children with LAD are vulnerable to distress, but an evidence-based treatment has not been developed. METHODS: From June 2016 to November 2017, we conducted a mixed methods study to adapt and assess the virtual delivery of a mind-body group resiliency program, the Stress Management and Resiliency Training-Relaxation Response Resiliency Program (SMART-3RP), to meet the needs of parents of children with LAD; this is an 8-session weekly group intervention. In the first phase, we conducted 4 parent focus group interviews, 2 professional focus group interviews, and 5 professional individual interviews, and 1 pilot group to adapt the SMART-3RP to target the needs of parents of children with LAD. In the second phase, we conducted a pilot wait-list controlled study to assess the feasibility, acceptability, and preliminary efficacy of a videoconferencing delivery of the adapted program. Parents were randomized to an immediate intervention group (IG) or wait-list control group (WC). Surveys were administered at baseline (time 1), end of intervention for the IG or 3 months post-baseline for the WC (time 2), and 3 months post treatment for the IG or end of intervention for the WC (time 3). RESULTS: Qualitative findings illustrated high levels of parental stress, with primary stressors including navigating the educational system, interactions with other parents, familial concerns, and financial and professional sacrifices. We adapted the manual to target these stressors and modified session logistics and delivery. Fifty-three parents (mean age = 46.8; 90.6% female) participated nationally in the pilot trial. 62.5% of participants completed ≥ 6/8 sessions; 81.8% reported continued daily/weekly relaxation response exercise practice. T1-T2 comparisons found that IG versus WC participants showed significant improvements in distress [VAS], ∆M = - 1.95; d = .83 and resilience [CES], ∆M = 6.38; d = .83, as well as stress coping [MOCS-A] ∆M = 8.69; d = 1.39; depression and anxiety [PHQ-4], ∆M = - 1.79; d = .71; social support [MOS-SSS], ∆M = 5.47; d = .71; and empathy [IRI], ∆M = 3.17; d = .77; improvements were sustained at the 3 month post intervention follow-up. CONCLUSION: Pilot wait-list randomized trial findings showed promising feasibility, acceptability, and preliminary efficacy for the SMART-3RP intervention adapted for parents of children with LAD. This virtually-delivered resiliency intervention improved parents' distress, resiliency, and stress coping, which were sustained. CLINICAL TRIALS ID: NCT02772432.

Mentalizing Imagery Therapy Mobile App to Enhance the Mood of Family Dementia Caregivers: Feasibility and Limited Efficacy Testing.

BACKGROUND: Family caregivers of patients with Alzheimer disease and related dementias (AD and ADRD) often experience high stress and are at high risk for depression. Technologically delivered therapy is attractive for AD and ADRD caregivers because of the time demands associated with in-person participation. OBJECTIVE: We aimed to study the feasibility and conduct limited efficacy testing of a mobile app intervention delivering mentalizing imagery therapy (MIT) for family caregivers. METHODS: A 4-week trial of the MIT app for family AD and ADRD caregivers was conducted to assess the feasibility of use and investigate changes in depression symptoms, mood, and caregiving experience. Semistructured interviews were conducted to characterize participants' perceived feasibility and benefits. RESULTS: A total of 17 of the 21 (80%) consented participants (mean age 67 years, range 54-79) utilized the app at least once and were further analyzed. Average usage of audio recordings was on 14 (SD 10) days out of 28 possible and comprised 29 (SD 28) individual sessions. There were improvements in depression with a large effect size for those who used the app at least moderately (P=.008), increases in positive mood postintervention (P<.05), and acute increases in mood following daily guided imagery practice (Stretching and Breathing, P<.001; Eye in the Center, P<.001; Nesting Doll, P=.002; Situation Solver, P=.003; and Life Globe, P=.006). Semistructured interviews revealed perceived benefits such as greater ability to remain "centered" despite caregiving challenges and positive reframing of the caregiver experience. CONCLUSIONS: App delivery of MIT is feasible for family AD and ADRD caregivers, including aging seniors. Results showed moderate to high usage of the app for a majority of users. Limited efficacy testing provides justification for studying the MIT app for AD and ADRD caregivers to improve mood and reduce depression in larger, controlled trials.

Race and Ethnicity in the Evidence for Integrating Palliative Care Into Oncology.

PURPOSE: ASCO recommends early involvement of palliative care for patients with advanced cancers on the basis of evidence from 18 randomized trials. We examined racial and ethnic minority representation in these trials and the role of race and ethnicity in the statistical analyses. The goal was to identify specific gaps in the palliative care evidence base for these individuals and potential strategies to address them. METHODS: We reviewed the 18 trials cited in the 2012 and 2017 ASCO clinical statements on integrating palliative care into oncology. We extracted data on the reporting and categorization of race and ethnicity, on the enrollment of specific racial and ethnic minority groups, and on how race and ethnicity were addressed in the analyses. RESULTS: One third of patient trials reported representation of specific racial and ethnic minority groups, one third reported rates of "white" versus "other," and one third did not report race or ethnicity data. Among the patient trials with race and ethnicity data, 9.9% of participants were Asian, 8.8% Hispanic/Latino, and 5.7% African American. Analyses that used race and ethnicity were primarily baseline comparisons among randomized groups. CONCLUSION: Race and ethnicity were inconsistently reported in the trials. Among those that provided race and ethnicity data, representation of specific racial and ethnic minority groups was low. In addition to more research in centers with large minority populations, consistent reporting of race and ethnicity and supplementary data collection from minority patients who participate in trials may be strategies for improvement.

Building Resiliency in a Palliative Care Team: A Pilot Study.

CONTEXT: Palliative care clinicians (PCCs) are vulnerable to burnout as a result of chronic stress related to working with seriously ill patients. Burnout can lead to absenteeism, ineffective communication, medical errors, and job turnover. Interventions that promote better coping with stress are needed in this population. OBJECTIVES: This pilot study tested the feasibility of the Relaxation Response Resiliency Program for Palliative Care Clinicians, a program targeted to decrease stress and increase resiliency, in a multidisciplinary cohort of PCCs (N = 16) at a major academic medical center. METHODS: A physician delivered the intervention over two months in five sessions (12 hours total). Data were collected the week before the program start and two months after completion. The main outcome was feasibility of the program. Changes in perceived stress, positive and negative affect, perspective taking, optimism, satisfaction with life, and self-efficacy were examined using nonparametric statistical tests. Effect size was quantified using Cohen's d. RESULTS: The intervention was feasible; all participants attended at least four of the five sessions, and there was no attrition. After the intervention, participants showed reductions in perceived stress and improvements in perspective taking. CONCLUSION: Our findings suggest that a novel team-based resiliency intervention based on elicitation of the relaxation response was feasible and may help promote resiliency and protect against the negative consequences of stress for PCCs.

Pain management in cancer patients using a mobile app: study design of a randomized controlled trial.

BACKGROUND: Despite the availability of effective medications and clinical guidelines for pain management, pain control is suboptimal in a sizeable proportion of patients with cancer pain. The National Comprehensive Cancer Network guidelines recommend a comprehensive and multimodal approach for management of cancer pain. We developed a mobile phone application, ePAL, based on clinical guidelines to empower patients for cancer pain management by prompting regular pain assessments and coaching for self-management. OBJECTIVE: The objective of this study is to evaluate the effect of a multidimensional mobile phone-based pain management application, ePAL, on controlling cancer pain and improving quality of life in patients with cancer pain being treated at an academic palliative care clinic. METHODS: The study will be implemented as a 2-arm randomized controlled trial with 110 adult patients with CP who own a mobile phone over a follow-up period of two months. Participants will be randomized to either the intervention group receiving ePAL and usual care or to a control group receiving only usual care. The brief pain inventory will be used to assess our primary outcome which is pain intensity. We will also evaluate the effect of the intervention on secondary outcomes which include the effect of the intervention on hospital utilization for pain crisis, quality of life, adherence to analgesic medications, barriers to pain control, anxiety and patient engagement. Instruments that will be used in evaluating secondary outcomes include the Brief Pain Inventory, Morisky Medication Adherence Scale, Barriers Questionnaire-II, Functional Assessment of Cancer Therapy-General, Edmonton Symptom Assessment System, Generalized Anxiety Disorder 7-item scale, and the Functional Assessment of Chronic Illness Therapy-Fatigue. The intention-to-treat approach will be used to evaluate outcomes. Our primary outcome, pain intensity, measured longitudinally over eight weeks, will be assessed by mixed model repeated analysis. Effect sizes will be calculated as mean group differences with standard deviations. RESULTS: The study is still in progress. We hope to have results by the end of 2015. CONCLUSIONS: The multidimensional approach to pain management implemented on a mobile phone application could lead to significant improvements in patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02069743; https://clinicaltrials.gov/ct2/show/NCT02069743 (Archived by WebCite at http://www.webcitation.org/6Qb65XGGA).

Development and evaluation of targeted psychological skills training for oncology nurses in managing stressful patient and family encounters.

PURPOSE/OBJECTIVES: To reduce workplace stress by developing a brief psychological skills training for nurses and to evaluate program feasibility, acceptability, and preliminary efficacy in decreasing burnout and stress. DESIGN: Intervention development and evaluation. SETTING: Outpatient chemotherapy unit at a comprehensive cancer center. SAMPLE: 26 infusion nurses and oncology social workers. METHODS: Focus groups were conducted with nurses. Results informed the development and evaluation of training for nurses. Participants completed the Maslach Burnout Inventory and Perceived Stress Scale post-training. MAIN RESEARCH VARIABLES: Burnout and stress. FINDINGS: Focus groups indicated strong commitment among nurses to psychosocial care and supported the idea that relationships with patients and families were sources of reward and stress. Stressors included factors that interfered with psychosocial care such as difficult family dynamics, patient behaviors and end-of-life care issues. Psychological skills training was developed to address these stressors. Evaluations suggested that the program was feasible and acceptable to nurses. At two months, participants showed reductions in emotional exhaustion (p = 0.02) and stress (p = 0.04). CONCLUSIONS: Psychological skills training for managing difficult encounters showed feasibility, acceptability, and potential benefit in reducing emotional exhaustion and stress. IMPLICATIONS FOR NURSING: Brief training that targets sources of clinical stress may be useful for nurses in outpatient chemotherapy units. KNOWLEDGE TRANSLATION: Specific stressors in relationships with patients and families present challenges to nurses' therapeutic use of self. Targeted psychological skills training may help nurses problem-solve difficult encounters while taking care of themselves. System-level strategies are needed to support and promote training participation.

A relaxation response training for women undergoing breast biopsy: exploring integrated care.

BACKGROUND: Recent changes in clinical guideline recommendations for age of breast cancer screening initiation highlighted the potential psychological ramifications associated with screening. This study examined the feasibility, acceptability, and preliminary efficacy of a brief Relaxation Response training (RRT) to decrease distress among women undergoing breast biopsy. METHODS: Women scheduled for percutaneous core-needle biopsy were recruited into a single-arm RRT trial, including 3 individual sessions. Psychosocial assessments were completed pre- and postintervention. RESULTS: Forty women were enrolled between 6/1/10 and 8/31/11. Among enrollees, 75% completed all 3 RRT sessions, and 75% completed the post-assessment. Participants showed significant reductions in acute distress following each RRT session. Qualitative feedback indicated a positive impact of RRT on clinic care experiences. CONCLUSIONS: RRT is a portable intervention that was feasible to implement, acceptable to patients and associated with significant decreases in acute emotional distress during the period of diagnostic uncertainty related to percutaneous breast biopsy.

The development of a patient-centered program based on the relaxation response: the Relaxation Response Resiliency Program (3RP).

BACKGROUND: Chronic daily stress has significant physical, emotional, and financial implications; levels of stress are increasing in the US. Dr. Benson highlighted how the mind and body function together in one's experience of the stress response and proposed the existence of the relaxation response (RR). OBJECTIVE: The current paper describes the foundation and development of an 8-session multimodal treatment program for coping with chronic stress: the Relaxation Response Resiliency Program (3RP). METHODS: We review the past decades of RR research, outline the development of the 3RP treatment, and provide an overview of the program's theory and content. RESULTS: Extensive research and clinical work have examined how eliciting the RR may combat stress through down-regulation of the sympathetic nervous system. Related to this work are the multidimensional constructs of resiliency and allostatic load. The 3RP is based on principles from the fields of stress management, cognitive-behavioral therapy, and positive psychology, and has three core target areas: (1) elicitation of the RR; (2) stress appraisal and coping; and (3) growth enhancement. An 8-week patient-centered treatment program has been developed, with the purpose of assisting patients with a variety of psychological and medical issues to better cope with chronic stress. CONCLUSIONS: Mastery of the RR is theorized to maximize one's ability to benefit from multimodal mind body strategies. The goal of the 3RP is to enhance individuals' adaptive responses to chronic stress through increasing awareness and decreasing the physiological, emotional, cognitive, and behavioral effects of the stress response, while simultaneously promoting the effects of being in the RR.