Psychosocial factors related to non-persistence with adjuvant endocrine therapy among women with breast cancer: the Breast Cancer Quality of Care Study (BQUAL).

Non-adherence to adjuvant endocrine therapy (ET) for breast cancer (BC) is common. Our goal was to determine the associations between psychosocial factors and ET non-persistence. We recruited women with BC receiving care in an integrated healthcare system between 2006 and 2010. Using a subset of patients treated with ET, we investigated factors related to ET non-persistence (discontinuation) based on pharmacy records (≥90 days gap). Serial interviews were conducted at baseline and every 6 months. The Functional Assessment of Cancer Therapy (FACT), Medical Outcomes Survey, Treatment Satisfaction Questionnaire (TSQM), Impact of Events Scale (IES), Interpersonal Processes of Care measure, and Decision-making beliefs and concerns were measured. Multivariate models assessed factors associated with non-persistence. Of the 523 women in our final cohort who initiated ET and had a subsequent evaluation, 94 (18 %) were non-persistent over a 2-year follow-up. The cohort was primarily white (74.4 %), stage 1 (60.6 %), and on an aromatase inhibitor (68.1 %). Women in the highest income category had a lower odds of being non-persistent (OR 0.43, 95 % CI 0.23-0.81). Quality of life and attitudes toward ET at baseline were associated with non-persistence. At follow-up, the FACT, TSQM, and IES were associated with non-persistence (p < 0.001). Most women continued ET. Women who reported a better attitude toward ET, better quality of life, and more treatment satisfaction, were less likely to be non-persistent and those who reported intrusive/avoidant thoughts were more likely to be non-persistent. Interventions to enhance the psychosocial well-being of patients should be evaluated to increase adherence.

Depressive Symptoms in Patients Scheduled for Hyperthermic Intraperitoneal Chemotherapy With Cytoreductive Surgery: Prospective Associations With Morbidity and Mortality.

PURPOSE: The current study examined prospective relationships between preoperative depressive symptoms and short-term (30-day morbidity and readmission) and long-term (overall survival) outcomes after hyperthermic intraperitoneal chemotherapy with cytoreductive surgery (HIPEC + CS). METHODS: Ninety-eight patients scheduled for HIPEC + CS completed the Center for Epidemiologic Studies-Depression (CES-D) scale before surgery. Demographic and disease-specific factors and information about morbidity and readmission within 30 days after discharge were gathered from medical records. Survival was measured from date of surgery to death. RESULTS: Twenty-eight percent of patients had CES-D scores indicative of clinically significant depressive symptoms. Thirty-day morbidity occurred in 31.9% of patients and readmission in 22.2%. At the time of analysis (median follow-up of 49 months), 71.6% of patients were deceased, with median survival time of 11 months for those who died. After adjusting for relevant preoperative demographic and disease-specific factors, depressive symptoms were associated with greater odds of 30-day morbidity (n = 68; odds ratio, 5.50; 95% CI, 1.23 to 24.73; P = .03) and greater likelihood of 30-day readmission (n = 72; odds ratio, 5.92; 95% CI, 1.27 to 27.64; P = .02). Depressive symptoms were associated with shorter survival after adjustment for preoperative demographic and disease-specific factors (n = 87; hazard ratio, 1.88; 95% CI, 1.07 to 3.31; P = .03). This association was no longer significant when intraoperative/postoperative prognostic variables were added to the statistical model (n = 87; hazard ratio, 1.31; 95% CI, 0.72 to 2.37; P = .37). CONCLUSION: Patients with clinically significant levels of preoperative depressive symptoms are at risk for poor clinical outcomes after HIPEC + CS, including greater risk of 30-day morbidity and readmission. Further research is warranted to determine biobehavioral mechanisms and examine whether effective interventions targeting preoperative depressive symptoms can reduce postoperative risk in this patient population.

Depressive symptoms in patients with cancer: does cortisol keep cytokines from singing the blues?

Depressive symptoms are common among patients with cancer, and both psychological stress and physiological factors have been implicated in the etiology of depression. Scientific progress in this area is challenged by the changing nature of psychological and physiological processes over the course of cancer diagnosis and treatment. The article by Wu and colleagues in the current issue of Psychosomatic Medicine provides an example of thoughtful consideration of the complex longitudinal relationships between psychological stress, physiology, and depressive symptoms. These findings are put into context by discussing broader challenges in this area, with a focus on the contribution of inflammatory processes caused by cancer and/or its treatment to depressive and related sickness behavior symptoms. We outline several regulatory pathways by which cortisol, inflammatory processes, and depressive symptoms may interact in the context of cancer and highlight implications of these interactions for tumor progression. Additional research is needed to delineate these pathways and advance scientific understanding of the biobehavioral mechanisms underlying depressive symptoms in the context of cancer, with important implications for the development of effective interventions for patients undergoing initial cancer treatment, as well as for long-term survivors.

Association between serotonin transport polymorphisms and postdischarge nausea and vomiting in women following breast cancer surgery.

PURPOSE/OBJECTIVES: To examine the association of the serotonin transport gene and postdischarge nausea and vomiting (PDNV) in women following breast cancer surgery. DESIGN: A cross-sectional study. SETTING: A comprehensive cancer center in Pittsburgh, PA. SAMPLE: 80 post-menopausal women treated surgically for early-stage breast cancer. METHODS: Data were collected using standardized instruments after surgery but before the initiation of chemotherapy. Blood or saliva were used for DNA extraction and analyzed following standardized protocols. Data were analyzed using descriptive statistics and logistic regression. MAIN RESEARCH VARIABLES: Serotonin transport gene (SLC6A4), nausea, vomiting, pain, and anxiety. FINDINGS: Women who inherited the LA/LA genotypes were at greater risk for nausea and vomiting when compared to women who carried any other combination of genotypes. Twenty-one percent of women reported nausea and vomiting an average of one month following surgery and prior to initiation of adjuvant therapy. Those women who experienced PDNV reported significantly higher anxiety and pain scores. CONCLUSIONS: Findings of this study suggest that variability in the genotypes of the serotonin transport gene may help to explain the variability in PDNV in women following breast cancer surgery and why 20%-30% of patients do not respond to antiemetic medications. IMPLICATIONS FOR NURSING: Nurses need to be aware that women who do not experience postoperative nausea and vomiting following surgery for breast cancer continue to be at risk for PDNV long after they have been discharged from the hospital, and this frequently is accompanied by pain and anxiety.

Randomized controlled trial of a cognitive-behavioral therapy plus hypnosis intervention to control fatigue in patients undergoing radiotherapy for breast cancer.

PURPOSE: The objective of this study was to test the efficacy of cognitive-behavioral therapy plus hypnosis (CBTH) to control fatigue in patients with breast cancer undergoing radiotherapy. We hypothesized that patients in the CBTH group receiving radiotherapy would have lower levels of fatigue than patients in an attention control group. PATIENTS AND METHODS: Patients (n = 200) were randomly assigned to either the CBTH (n = 100; mean age, 55.59 years) or attention control (n = 100; mean age, 55.97 years) group. Fatigue was measured at four time points (baseline, end of radiotherapy, 4 weeks, and 6 months after radiotherapy). Fatigue was measured using the Functional Assessment of Chronic Illness Therapy (FACIT) -Fatigue subscale and Visual Analog Scales (VASs; Fatigue and Muscle Weakness). RESULTS: The CBTH group had significantly lower levels of fatigue (FACIT) at the end of radiotherapy (z, 6.73; P < .001), 4-week follow-up (z, 6.98; P < .001), and 6-month follow-up (z, 7.99; P < .001) assessments. Fatigue VAS scores were significantly lower in the CBTH group at the end of treatment (z, 5.81; P < .001) and at the 6-month follow-up (z, 4.56; P < .001), but not at the 4-week follow-up (P < .07). Muscle Weakness VAS scores were significantly lower in the CBTH group at the end of treatment (z, 9.30; P < .001) and at the 6-month follow-up (z, 3.10; P < .02), but not at the 4-week follow-up (P < .13). CONCLUSION: The results support CBTH as an evidence-based intervention to control fatigue in patients undergoing radiotherapy for breast cancer. CBTH is noninvasive, has no adverse effects, and its beneficial effects persist long after the last intervention session. CBTH seems to be a candidate for future dissemination and implementation.

Noninitiation of adjuvant chemotherapy in women with localized breast cancer: the breast cancer quality of care study.

PURPOSE: For some women, adjuvant chemotherapy for nonmetastatic breast cancer decreases recurrences and increases survival; however, patient-physician decisions regarding chemotherapy receipt can be influenced by medical and nonmedical factors. PATIENTS AND METHODS: We used a prospective cohort design and multivariate modeling to investigate factors related to noninitiation of chemotherapy among women with newly diagnosed breast cancer recruited from three US sites. We interviewed patients at baseline and during treatment on sociodemographic, tumor, and treatment decision-making factors. Patients were categorized according to National Comprehensive Cancer Network guidelines as those for whom chemotherapy was definitely indicated, clinically discretionary, or discretionary based on age greater than 70 years. RESULTS: Of 1,145 patients recruited, chemotherapy was clinically indicated for 392 patients, clinically discretionary for 459 patients, discretionary because of age for 169 patients, and not indicated for 93 patients; data were insufficient for 32 patients. Chemotherapy rates were 90% for those in whom chemotherapy was clinically indicated, 36% for those in whom it was discretionary because of clinical factors, and 19% for those in whom it was discretionary based on age greater than 70 years. Nonreceipt of chemotherapy was associated with older age, more negative beliefs about treatment efficacy, less positive beliefs about chemotherapy, and more concern about adverse effects. In the two discretionary groups, clinical predictors of worse outcome (greater tumor size, positive nodes, worse grade, and estrogen receptor- and progesterone receptor-negative status) were associated with increased chemotherapy initiation. CONCLUSION: Utilization of adjuvant chemotherapy was most common among patients who, based on clinical criteria, would most likely benefit from it, patients with more positive than negative beliefs regarding treatment efficacy, and patients with few concerns about adverse effects.

Pretreatment depressive symptoms and treatment modality predict post-treatment disease-specific quality of life among patients with localized prostate cancer.

PURPOSE: This study examines the prevalence of depressive symptoms before prostate cancer treatment and explores associations among pre-treatment depressive symptoms and post-treatment disease-specific QOL, controlling for treatment modality, and demographic and clinical covariates. MATERIALS AND METHODS: A case series of patients diagnosed with localized prostate cancer (T1-2N0M0) at a comprehensive cancer center was assessed. Of the 1,370 eligible patients, 869 (63.34%) completed questionnaires at diagnosis (baseline) and 6 months following treatment. Patients were treated with surgery (16.8%), brachytherapy (27.6%), or external beam radiation (EBRT; 55.6%). Depressive symptoms and disease-specific QOL were assessed with established measures (i.e., Center for Epidemiologic Studies Depression Scale (CES-D); sexual adjustment questionnaire (SAQ); and the American Urological Association symptom index). RESULTS: A fifth of the sample (19.7%) reported clinically elevated levels of depressive symptoms at baseline. The proportion of clinically elevated levels of baseline depressive symptoms was higher among surgery patients compared with patients treated with brachytherapy or external beam radiation. Depressive symptoms at baseline and treatment modality significantly predicted sexual and urinary dysfunction, related bother, activity limitation due to urinary dysfunction at 6 months, controlling for, age, PSA level, Gleason score, relevant baseline indicators of sexual and urinary dysfunction, related bother, and activity limitation (P < 0.05). CONCLUSIONS: Pretreatment depressive symptoms and treatment modality predict QOL after PrCa treatment. Health care providers should be sensitive to the display of depressive symptoms before PrCa treatment and consider preventative interventions, including preparing patients for the changes in disease-specific QOL and related bother following prostate cancer treatment.

Exposure to smoking cues: cardiovascular and autonomic effects.

Laboratory exposures to smoking cues have been shown to reliably induce self-reported cigarette cravings among smokers, a model of environmentally triggered urges to smoke that can contribute to poorer cessation success. Several studies have also demonstrated that cue exposures give rise to changes in heart rate and blood pressure. Few studies, however, have investigated possible cue effects on heart rate and blood pressure variability (HRV and BPV). Particularly intriguing in this regard are cardiac oscillations in the low (i.e., 0.04-0.15 Hz), and high (i.e., 0.15-0.50 Hz) frequency range, which are thought to reflect components of autonomic control and response to environmental challenges. A closer examination of cardiovascular reactivity may thus help characterize the autonomic response to smoking cue exposure. To that end, an experimental study was conducted in which nicotine dependent daily smokers (n=98) were exposed to guided imagery of neutral and smoking situations, while continuous, noninvasive, beat-to-beat cardiovascular data were collected. Consistent with previous research, the findings revealed significant increases in both systolic and diastolic blood pressure during smoking imagery, relative to neutral imagery. In addition, power spectral density analyses of heart rate and blood pressure variability revealed elevated HRV and BPV in both the low- and high-frequency ranges during the smoking imagery. The results suggest the presence of an autonomic component to smoking cue reactivity, and also raise the possibility of long-term negative cardiac consequences for smokers who ubiquitously encounter cues in their daily environments.

A biobehavioral perspective on depressive symptoms in patients with cerebral astrocytoma.

More than 51,000 individuals are diagnosed with a primary brain tumor in the United States each year, and for those with the most common type of malignant tumor, an astrocytoma, almost 75% will die within 5 years of diagnosis. Although surgery, radiation, and chemotherapy have improved length of survival, mortality remains high, which underscores the need to understand how other factors affect the disease trajectory. Several recent studies have shown that depressive symptoms are independently associated with reduced quality of life and survival time after controlling for other variables in patients with an astrocytoma. Thus, depressive symptoms represent a significant risk factor for adverse outcomes in this patient population. A growing body of evidence indicates that depressive symptoms are linked to underlying biological phenomena, particularly inflammatory activation modulated through increased peripheral levels of proinflammatory cytokines. Recent research has shown that neoplastic astrocytes respond to elevated proinflammatory cytokine levels by secreting immune mediators within the central nervous system, including cytokines and glial fibrillary acidic protein that promote astrogliosis and angiogenesis and may increase tumor growth and metastasis. However, because these biological factors have not as yet been measured in conjunction with depressive symptoms in these patients, little is known about the interactions that potentially influence the treatment trajectory. To guide future research and to provide a deeper understanding of the factors that may influence depressive symptoms and length of survival in patients with an astrocytoma, a review of the literature was undertaken. Publications over the past 10 years were analyzed to examine the theoretical models and measures of depressive symptoms used in previous research. Although numerous studies have documented the relationship between depression and reduced length of survival, there were several methodological concerns identified, and there were no studies that included biological variables. Yet, research in the basic sciences provides compelling evidence of specific neuroendocrine-immune interactions orchestrated by astrocytes that can cause depressive symptoms and alter the tumor microenvironment so that standard treatments are not as effective. These findings support the need for clinically based research so that we can begin to understand the potentially modifiable biobehavioral mechanisms underlying depressive symptoms in patients with an astrocytoma. Grounded in the biobehavioral research paradigm of psychoneuroimmunology, a novel research program is presented that may provide a new level of understanding regarding the high prevalence of depressive symptoms in patients with an astrocytoma and lead to new treatment strategies, with possible implications for improved symptom management and quality of life in patients with brain tumors.

Influence of psychological stress on upper respiratory infection--a meta-analysis of prospective studies.

OBJECTIVE: To quantify the available evidence for the hypothesis that reduced resistance caused by psychological stress may influence the development of clinical disease in those exposed to an infectious agent. METHODS: We conducted a systematic review and meta-analysis of 27 prospective studies examining the association between psychological stress and subsequent upper respiratory infection (URI). RESULTS: The results revealed a significant overall main effect of psychological stress on the risk of developing URI (effect size correlation coefficient, 0.21; 95% confidence interval, 0.15-0.27). Further analyses showed that effect sizes for the association did not vary according to type of stress, how URI was assessed, or whether the studies had controlled for preexposure. CONCLUSIONS: The meta-analytical findings confirmed the hypothesis that psychological stress is associated with increased susceptibility to URI, lending support to an emerging appreciation of the potential importance of psychological factors in infectious disease.

Mediators of a brief hypnosis intervention to control side effects in breast surgery patients: response expectancies and emotional distress.

OBJECTIVE: The present study was designed to test the hypotheses that response expectancies and emotional distress mediate the effects of an empirically validated presurgical hypnosis intervention on postsurgical side effects (i.e., pain, nausea, and fatigue). METHOD: Women (n = 200) undergoing breast-conserving surgery (mean age = 48.50 years; 63% White, 15% Hispanic, 13% African American, and 9% other) were randomized to a hypnosis or to an attention control group. Prior to surgery, patients completed assessments of hypothesized mediators (response expectancies and emotional distress), and following surgery, patients completed assessments of outcome variables (pain, nausea, and fatigue). RESULTS: Structural equation modeling revealed the following: (a) Hypnotic effects on postsurgical pain were partially mediated by pain expectancy (p < .0001) but not by distress (p = .12); (b) hypnotic effects on postsurgical nausea were partially mediated by presurgical distress (p = .02) but not by nausea expectancy (p = .10); and (c) hypnotic effects on postsurgical fatigue were partially mediated by both fatigue expectancy (p = .0001) and presurgical distress (p = .02). CONCLUSIONS: The results demonstrate the mediational roles of response expectancies and emotional distress in clinical benefits associated with a hypnotic intervention for breast cancer surgical patients. More broadly, the results improve understanding of the underlying mechanisms responsible for hypnotic phenomena and suggest that future hypnotic interventions target patient expectancies and distress to improve postsurgical recovery.

Fatigue during breast cancer radiotherapy: an initial randomized study of cognitive-behavioral therapy plus hypnosis.

OBJECTIVE: The study purpose was to test the effectiveness of a psychological intervention combining cognitive-behavioral therapy and hypnosis (CBTH) to treat radiotherapy-related fatigue. DESIGN: Women (n = 42) scheduled for breast cancer radiotherapy were randomly assigned to receive standard medical care (SMC) (n = 20) or a CBTH intervention (n = 22) in addition to SMC. Participants assigned to receive CBTH met individually with a clinical psychologist. CBTH participants received training in hypnosis and CBT. Participants assigned to the SMC control condition did not meet with a study psychologist. MAIN OUTCOME MEASURES: Fatigue was measured on a weekly basis by using the fatigue subscale of the Functional Assessment of Chronic Illness Therapy (FACIT) and daily using visual analogue scales. RESULTS: Multilevel modeling indicated that for weekly FACIT fatigue data, there was a significant effect of the CBTH intervention on the rate of change in fatigue (p < .05), such that on average, CBTH participants' fatigue did not increase over the course of treatment, whereas control group participants' fatigue increased linearly. Daily data corroborated the analyses of weekly data. CONCLUSION: The results suggest that CBTH is an effective means for controlling and potentially preventing fatigue in breast cancer radiotherapy patients.

A randomized trial of a cognitive-behavioral therapy and hypnosis intervention on positive and negative affect during breast cancer radiotherapy.

Breast cancer radiotherapy can be an emotionally difficult experience. Despite this, few studies have examined the effectiveness of psychological interventions to reduce negative affect, and none to date have explicitly examined interventions to improve positive affect among breast cancer radiotherapy patients. The present study examined the effectiveness of a multimodal psychotherapeutic approach, combining cognitive-behavioral therapy and hypnosis (CBTH), to reduce negative affect and increase positive affect in 40 women undergoing breast cancer radiotherapy. Participants were randomly assigned to receive either CBTH or standard care. Participants completed weekly self-report measures of positive and negative affect. Repeated and univariate analyses of variance revealed that the CBTH approach reduced levels of negative affect [F(1, 38)=13.49; p=.0007, omega(2)=.56], and increased levels of positive affect [F(1, 38)=9.67; p=.0035, omega(2)=.48], during the course of radiotherapy. Additionally, relative to the control group, the CBTH group demonstrated significantly more intense positive affect [F(1, 38)=7.09; p=.0113, d=.71] and significantly less intense negative affect [F(1, 38)=10.30; p=.0027, d=.90] during radiotherapy. The CBTH group also had a significantly higher frequency of days where positive affect was greater than negative affect (85% of days assessed for the CBTH group versus 43% of the Control group) [F(1, 38)=18.16; p=.0001, d=1.16]. Therefore, the CBTH intervention has the potential to improve the affective experience of women undergoing breast cancer radiotherapy.

Script-guided imagery of social drinking induces both alcohol and cigarette craving in a sample of nicotine-dependent smokers.

Laboratory exposure to alcoholic beverage cues has been demonstrated to elicit urges to drink. Less well examined is the possibility that imaginal cues also elicit such urges, providing a model of conditioned effects not dependent on the presence of physical stimuli associated with alcohol. Studies of possible cross-reactivity between smoking and drinking cues are also scarce. To that end, nicotine-dependent nonalcoholic smokers (n=54) were exposed to social drinking-relevant, and for comparison, neutral and smoking-relevant standardized script-guided imagery. Cravings were measured before and after each imaginal exposure. As hypothesized, the drinking script induced alcohol and cigarette cravings, providing support for both direct and cross-cue reactivity effects. Further validating the social-drinking script, craving reactions were significantly stronger among participants who reported frequent drinking in social situations. Finally, smoking imagery induced both cigarette and alcohol cravings, providing further support for the cross-cue-induced craving phenomenon. Results suggest that the present alcohol script may be a useful tool for eliciting craving responses under laboratory conditions, and provide an additional means for better understanding addiction.

Hypnosis decreases presurgical distress in excisional breast biopsy patients.

BACKGROUND: Excisional breast biopsy is associated with presurgical psychological distress. Such distress is emotionally taxing, and may have negative implications for postsurgical side effects and satisfaction with anesthesia. We investigated the ability of a brief hypnosis session to reduce presurgical psychological distress in excisional breast biopsy patients. METHODS: Ninety patients presenting for excisional breast biopsy were randomly assigned to receive either a 15-minute presurgery hypnosis session (n = 49, mean age: 46.4 (95% CI: 42.3-50.4)) or a 15-minute presurgery attention control session (n = 41, mean age: 45.0 (95% CI: 40.8-49.2)). The hypnosis session involved suggestions for increased relaxation and decreased distress. The attention control session involved nondirective empathic listening. Presurgery distress was measured using visual analog scales (VAS) and the short version of the Profile of Mood States (SV-POMS). Data were analyzed using analysis of variance and chi2 procedures. RESULTS: Groups did not differ in terms of the following: demographics (age, education, ethnicity, marital status, all P's > 0.28); medical variables (presurgery diagnosis, previous excisional biopsy, previous breast cancer, all P's > 0.11); or preintervention distress (SV-POMS P > 0.74) assessed on the day of surgery. Postintervention, and before surgery, patients in the hypnosis group had significantly lower mean values for presurgery VAS emotional upset (16.5 vs 38.2, P < 0.0001, d = .85), VAS depressed mood (6.6 vs 19.9, P < 0.02, d = .67), and SV-POMS anxiety (10.0 vs 5.0, P < 0.0001, d = 0.85); and significantly higher levels for VAS relaxation (75.7 vs 54.2, P < 0.001, d = -0.76) than attention controls. CONCLUSIONS: The study results indicate that a brief presurgery hypnosis intervention can be an effective means of controlling presurgical distress in women awaiting diagnostic breast cancer surgery.

A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients.

BACKGROUND: Breast cancer surgery is associated with side effects, including postsurgical pain, nausea, and fatigue. We carried out a randomized clinical trial to test the hypotheses that a brief presurgery hypnosis intervention would decrease intraoperative anesthesia and analgesic use and side effects associated with breast cancer surgery and that it would be cost effective. METHODS: We randomly assigned 200 patients who were scheduled to undergo excisional breast biopsy or lumpectomy (mean age 48.5 years) to a 15-minute presurgery hypnosis session conducted by a psychologist or nondirective empathic listening (attention control). Patients were not blinded to group assignment. Intraoperative anesthesia use (i.e., of the analgesics lidocaine and fentanyl and the sedatives propofol and midazolam) was assessed. Patient-reported pain and other side effects as measured on a visual analog scale (0-100) were assessed at discharge, as was use of analgesics in the recovery room. Institutional costs and time in the operating room were assessed via chart review. RESULTS: Patients in the hypnosis group required less propofol (means = 64.01 versus 96.64 microg; difference = 32.63; 95% confidence interval [CI] = 3.95 to 61.30) and lidocaine (means = 24.23 versus 31.09 mL; difference = 6.86; 95% CI = 3.05 to 10.68) than patients in the control group. Patients in the hypnosis group also reported less pain intensity (means = 22.43 versus 47.83; difference = 25.40; 95% CI = 17.56 to 33.25), pain unpleasantness (means = 21.19 versus 39.05; difference = 17.86; 95% CI = 9.92 to 25.80), nausea (means = 6.57 versus 25.49; difference = 18.92; 95% CI = 12.98 to 24.87), fatigue (means = 29.47 versus 54.20; difference = 24.73; 95% CI = 16.64 to 32.83), discomfort (means = 23.01 versus 43.20; difference = 20.19; 95% CI = 12.36 to 28.02), and emotional upset (means = 8.67 versus 33.46; difference = 24.79; 95% CI = 18.56 to 31.03). No statistically significant differences were seen in the use of fentanyl, midazolam, or recovery room analgesics. Institutional costs for surgical breast cancer procedures were $8561 per patient at Mount Sinai School of Medicine. Patients in the hypnosis group cost the institution $772.71 less per patient than those in the control group (95% CI = 75.10 to 1469.89), mainly due to reduced surgical time. CONCLUSIONS: Hypnosis was superior to attention control regarding propofol and lidocaine use; pain, nausea, fatigue, discomfort, and emotional upset at discharge; and institutional cost. Overall, the present data support the use of hypnosis with breast cancer surgery patients.

Stress- and cue-induced cigarette craving: effects of a family history of smoking.

Individuals with multiple smokers among first-degree relatives (FH+) are significantly more likely to be persistent smokers themselves. The mechanisms underlying this relationship are unknown. An independent line of research has suggested that persistent smoking is more common among smokers with heightened levels of cigarette craving after being exposed to smoking cues and stressors. The present study experimentally tested the hypothesis that FH+ smokers would exhibit stronger stress- and cue-induced craving reactions compared to FH- smokers. We also explored gender and ethnicity-related differences in these effects. To that end, 160 smokers were recruited by advertisement and exposed to neutral (changing a light bulb), stressful (dental work), and smoking (lighting up after a meal) situations, using script-guided imagery under controlled laboratory conditions. Participants completed craving questionnaires before and after each condition. Supporting the hypotheses, even after controlling smoking history and strength of habit, FH+ smokers (n=86) displayed stronger craving reactions to both dental and smoking imagery (p's<0.05) than FH- smokers (n=74). Interestingly, women had higher stress-, but not smoking cue-induced cravings, than men, with FH+ women exhibiting the highest levels of stress-induced craving. Findings suggest a mechanism through which a family history of smoking leads to poorer cessation success, especially among women.

A family history of smoking predicts heightened levels of stress-induced cigarette craving.

AIMS: Individuals with histories of smoking in first-degree relatives are significantly more likely to be persistent smokers themselves. The mechanisms underlying this relationship are unknown. Considerable research has demonstrated that smokers display heightened levels of cigarette craving after being exposed to stressful situations, and the magnitude of these craving responses is thought to be predictive of later cessation failure. Based on this research, we tested experimentally the hypothesis that smokers with two or more first-degree relatives who smoked (FH+) would exhibit stronger craving reactions following stressful stimuli than smokers without such family histories (FH-). PARTICIPANTS: We recruited 83 smokers by advertisement (mean age = 41.2 years, 57% female, 41% completed some college, 59% African American). SETTING: The study was conducted in an interview room in an urban medical center. DESIGN: Participants were exposed to a neutral situation (changing a lightbulb) and a stressful situation (dental work) using script-guided imagery. MEASUREMENTS: Participants completed background measures of demographics, distress and smoking behavior. In addition, participants completed cigarette craving and anxiety questionnaires immediately before and after each condition. FINDINGS: Supporting the study hypothesis, FH+ smokers (n = 39) selectively displayed stronger craving reactions to dental imagery (P < 0.03) than did FH- smokers (n = 44). CONCLUSION: The higher levels of stress-induced cigarette craving demonstrated experimentally for individuals with family histories of smoking suggest one mechanism for their poorer cessation success.

The effectiveness of adjunctive hypnosis with surgical patients: a meta-analysis.

UNLABELLED: Hypnosis is a nonpharmacologic means for managing adverse surgical side effects. Typically, reviews of the hypnosis literature have been narrative in nature, focused on specific outcome domains (e.g., patients' self-reported pain), and rarely address the impact of different modes of the hypnosis administration. Therefore, it is important to take a quantitative approach to assessing the beneficial impact of adjunctive hypnosis for surgical patients, as well as to examine whether the beneficial impact of hypnosis goes beyond patients' pain and method of the administration. We conducted meta-analyses of published controlled studies (n = 20) that used hypnosis with surgical patients to determine: 1) overall, whether hypnosis has a significant beneficial impact, 2) whether there are outcomes for which hypnosis is relatively more effective, and 3) whether the method of hypnotic induction (live versus audiotape) affects hypnosis efficacy. Our results revealed a significant effect size (D = 1.20), indicating that surgical patients in hypnosis treatment groups had better outcomes than 89% of patients in control groups. No significant differences were found between clinical outcome categories or between methods of the induction of hypnosis. These results support the position that hypnosis is an effective adjunctive procedure for a wide variety of surgical patients. IMPLICATIONS: A meta-analytical review of studies using hypnosis with surgical patients was performed to determine the effectiveness of the procedure. The results indicated that patients in hypnosis treatment groups had better clinical outcomes than 89% of patients in control groups. These data strongly support the use of hypnosis with surgical patients.

Brief presurgery hypnosis reduces distress and pain in excisional breast biopsy patients.

Each year, hundreds of thousands of women undergo excisional breast biopsies for definitive diagnosis. Not only do these patients experience pain associated with the procedure, but they also endure distress associated with the threat of cancer. Hypnosis has been demonstrated as effective for controlling patients' pain in other surgical settings, but breast surgery patients have received little attention. To determine the impact of brief presurgical hypnosis on these patients' postsurgery pain and distress and to explore possible mediating mechanisms of these effects, 20 excisional breast biopsy patients were randomly assigned to a hypnosis or control group (standard care). Hypnosis reduced postsurgery pain and distress. Initial evidence suggested that the effects of hypnosis were mediated by presurgery expectations.