Linkage between Psychological Factors and Response to Immune Checkpoint Inhibitor Therapy: A Preliminary Study.

Substantial evidence has accumulated showing that psychological distress affects immune regulation, the response to cancer treatment, and survival. The effect of psychological parameters on the effectiveness of immune checkpoint inhibitor (ICI) treatment has not yet been studied. This preliminary study aimed to (a) examine the associations between psychological factors and responses to ICI treatment and (b) assess the associations between psychological factors and blood measures of sPD-1, sCTLA-4, and cytokines that may alter the effect of ICI treatment. The participants were 62 individuals with advanced cancer, aged 18 years or older, who were candidates for ICI treatment as a new line of treatment. The participants answered questionnaires and provided blood samples and medical data prior to the start of ICI treatment and 3 months after. Perceived health status was positively associated with better responses to ICI treatment. In the subsample of participants with biomarkers, worse health-related quality of life was associated with higher IL-6 and sCTLA-4; emotional distress and sleep difficulties were associated with higher sCTLA-4; and better perceived health was associated with lower IL-6 and TNFα. sPD-1 was not associated with psychological measures. This preliminary study found for the first time that some psychological measures could be linked to responses to cancer treatment, possibly via pro-inflammatory cytokines and sCTLA-4.

Emotional Processing, Coping, and Cancer-Related Sickness Symptoms in Breast Cancer Survivors: Cross- Sectional Secondary Analysis of the REPAT Study.

Purpose: The study aims to provide a better understanding of the relationship between emotional processing, coping, and cancer-related sickness symptoms. Methods: The study used a cross-sectional, secondary analysis of data from 179 Israeli Jewish women who were breast cancer survivors (BCS) 3 to 18 months after completing primary treatment and who participated in a larger randomized controlled trial (REPAT study). Data were collected at baseline. Participants completed questionnaires measuring emotion acceptance, situational approach, avoidance coping, and cancer-related sickness symptoms (depression, fatigue, and pain) and a performance measure of emotional awareness. Hierarchical linear regressions were performed, controlling for background variables. Results: Participants experienced significant clinical depression (51.7%), cancer-related fatigue (CRF, 78.8%), pain interference (78%), and pain intensity (66%) levels. There were strong correlations between cancer-related symptoms. After controlling for confounders, emotional processing (acceptance) was negatively associated with depression, and avoidance coping was positively associated with depression, CRF, and pain interference (i.e., higher use of avoidance related to higher cancer-related symptoms; higher acceptance was associated with lower depression). Emotional awareness and coping by approaching emotions were not related to cancer-related symptoms. Conclusions: The BCS posttreatment period presents the challenge of dealing with elevated cancer-related symptoms. Regardless, BCS who used high emotional processing levels-especially acceptance of emotion and lower reliance on avoidance to cope-experienced fewer cancer-related symptoms. Implications for Cancer Survivors: Professionals should recognize the potential role of emotional processing and avoidant coping relative to cancer-related symptoms and recognize their patterns in posttreatment patients.

The role of emotion processing in art therapy (REPAT) intervention protocol.

Psychological and physical health are known to improve with emotion processing, which is becoming aware of bodily sensations, accepting them as information that can be translated into emotion concepts and expressing them symbolically and linguistically as emotions. Art therapy utilizes the visual arts for processing emotions to facilitate self-expression and communication with the goal of improving psychological wellbeing. The mental health of individuals coping with and recovering from cancer is known to benefit from art therapy. The purpose of this paper is to describe the development of the role of emotion processing in art therapy (REPAT) intervention, which is an 8 week, one and a half hour art therapy intervention created to target emotion processing as a primary mechanism of change, through which art therapy has the potential to reduce symptoms (i.e., depression, pain and fatigue) of women coping with breast cancer. To obtain this goal we used template for intervention description and replication (TIDieR) and GUIDance for the rEporting of intervention Development (GUIDED) guidelines for intervention development description, with the goal of ensuring successful implementation for clinical and research use.

Values and their relationship with emotion processing and physical and psychological symptoms among Jewish and Arab breast cancer survivors.

Introduction: Individuals from different cultures differ in their values, which encompass belief systems that individuals develop based on their culture, and play a pivotal role in shaping their perspectives. These values may affect emotion processing (EP): the recognition, interpretation, expression and response to bodily sensations, translated as emotions. These varying values may contribute to distinct emotional experiences, impacting physical and psychological symptoms in breast cancer (BC) survivors. Methods: This cross-sectional study investigated how EP including acceptance, expression (avoidance and approach coping), and awareness, may mediate the relationship between conservation values and symptoms of pain, fatigue, and depression among Arab (n = 62) and Jewish (n = 179) women BC survivors in Israel. Conservation values include tradition, conformity, and security. Results: Depression and fatigue were negatively correlated with acceptance of emotions, and positively correlated with avoidance and conservation levels. Emotion processing mediated the relationship between conservation and fatigue and depression. Arab women reported higher levels of various values, emotional acceptance, pain, fatigue, and depression symptoms compared to Jewish women. Conservation was higher in Arab women and correlated with both approach and avoidance coping which was not the case in Jewish women. Avoidance coping had a positive relationship with fatigue in the Jewish, but not the Arab women. Similarly, approach coping was negatively related to depression in Jewish, but not in Arab women. Discussion: Cultural differences are important for understanding the experience of cancer in individuals from different cultures. Future interventions for more conservative BC survivors should take culture into account.

Top Ten Tips Palliative Care Clinicians Should Know About Music Therapy and Art Therapy.

Palliative care is provided by an interdisciplinary team, including physicians, advanced practice providers, nurses, social workers, chaplains, and other disciplines based on need. Music therapists and art therapists are becoming increasingly available to palliative care teams and are advancing the diverse and unique clinical services available to effectively meet the holistic needs of patients with serious illnesses and their families. This article provides a concrete exploration of clinical music therapy and art therapy within palliative care and hospice paradigms, with discussion of therapists' training and expertise, therapeutic approaches within the setting of interprofessional team-based care, and discussion of evidence-based symptom management and outcomes supporting the inclusion of music and art therapies within medical education and clinical employment.

I Feel Like I Am Flying and Full of Life: Contemporary Dance for Parkinson's Patients.

Parkinson's is a neurodegenerative disease characterized by motor and non-motor symptoms which are strongly associated with patients' quality of life, affecting social skills and support. It strikes not only the motor abilities but may harm cognitive and emotional functioning. For the past 15 years, contemporary dance has been employed as an intervention to help people diagnosed with Parkinson's disease cope physically and mentally by way of motor, vestibular, and sensory stimulation as well as social interaction. In this study we aimed to examine psychological flexibility, creative self-efficacy and quality of life of Parkinson's patients participating in contemporary dance sessions. To obtain this goal we conducted a cross-sectional comparative study of 50 Parkinson's patients aged 50-87 years, half of which had been participating for at least 3 months once a week, in contemporary dance classes, and the matched controls participated in a verbal support group. Study participants completed questionnaires after participating in a dance class (Intervention) or in a support group (control). Participants in the intervention group were also asked to answer three open-ended questions that examined the experience of participating in contemporary dance classes. We found that psychological flexibility and quality of life were significantly higher in the dance class participants. Participants reported positive changes that occur in their overall feeling and quality of life following their participation in dance classes. Since PD patients' experiences are deeply embedded in the body, it is significant to explore the use of movement in treatment. The importance of the study is in its potential to highlight the relationship between psychological flexibility and quality of life and to increase awareness of clinicians treating Parkinson's patients to the importance of incorporating dance as an inherent part of a multidisciplinary team effort.

Examining Changes in HRV and Emotion Following Artmaking with Three Different Art Materials.

This protocol enables the examination of psychological and physiological responses to different types of behavioral engagements. Specifically, in this study example, the emotional response and changes in heart rate variability are examined in response to artmaking with three different art materials that vary in their levels of fluidity. This protocol can be adapted to examine other types of behavior or engagement in artmaking with other materials. There are several benefits to using this protocol. Firstly, the order randomization of the materials improves the probability that the response measured is associated with its qualities and not the order of presentation. Secondly, the continuous measuring of electrocardiogram enables the examination of changes in heart rate variability after engagement with each art material and changes that might occur during the artmaking itself. The advantages of this protocol should be considered with their limitations. The music listening is before each art making session; thus, the return to baseline can only be measured in the first two conditions. The return to baseline provides information on how fast individuals recover after response to working with each of the materials. Furthermore, a more liquid material instead of gouache paint with a brush, such as finger paints, provides more difference between materials. Finally, this protocol can be adapted to specific research needs.

Protocol for the REPAT study: role of emotional processing in art therapy for breast cancer palliative care patients.

INTRODUCTION: Patients with breast cancer (BC) cope with depression which is linked to functional limitations in survivorship and to physical symptoms. Pain and fatigue are prominent symptoms that affect the well-being of cancer survivors. Emotional processing has been associated with improved physical and psychological health in survivors. Art therapy is a form of psychotherapy that involves the use of visual art-making for expression and communication. It encourages emotional processing and has been linked to symptom reduction in patients with cancer. This protocol is designed to examine two mechanistic changes: emotional processing (awareness, expression and acceptance) and cholinergic anti-inflammatory processes (heart rate variability and cytokine expression) through which an art therapy intervention may reduce depression, pain and fatigue. In addition, we will examine ethnocultural differences in the effect of art therapy in women from different ethnocultural backgrounds. METHODS AND ANALYSIS: A randomised controlled study with careful controls will randomise 240 patient with BC (50% Jewish and 50% Arab) to an 8-week group art therapy intervention or an 8-week Mandala colouring comparison group. This design will test the mechanisms of art therapy on the targeted outcomes beyond the effects of time with a group, focus on a task and engagement with art materials. We will examine two potential mechanisms: emotional processing and cholinergic anti-inflammatory processes; of the intervention effects on depression, pain and fatigue and compare these effects in Arab versus Jewish women. ETHICS AND DISSEMINATION: Participants will sign informed consent before participation and will be informed that they can leave the study at any point in time without effect on their medical treatment. The Helsinki committees of each participating hospital have approved the study. Data collected in this study will be published in peer-review journals, and we will use the platform of the study website (http://repat.haifa.ac.il/en/) for further dissemination to the general public. TRIAL REGISTRATION NUMBER: The study is registered in ClinicalTrials.gov: NCT03377816; Pre-results.

Multidisciplinary staff perspectives on the integration of spiritual care in a new setting: Israel.

OBJECTIVE: Integrating spiritual care into multidisciplinary care teams has seen both successful thoughtful collaboration and challenges, including feelings of competition and poor cross-disciplinary understanding. In Israel, where the profession is new, we aimed to examine how spiritual care is perceived by other healthcare professionals learning to integrate spiritual caregivers into their teams. METHOD: Semi-structured qualitative interviews of 19 professionals (seven physicians, six nurses, three social workers, two psychologists, and one medical secretary) working with spiritual caregivers in three Israeli hospitals, primarily in oncology/hematology. The interviews were transcribed and subjected to thematic analysis. RESULTS: Respondents' overall experience with adding a spiritual caregiver was strongly positive. Beneficial outcomes described included calmer patients and improved patient-staff relationships. Respondents identified reasons for a referral not limited to the end of life. Respondents distinguished between the role of the spiritual caregiver and those of other professions and, in response to case studies, differentiated when and how each professional should be involved. CONCLUSION: Despite its relative newness in Israel, spiritual care is well received by a wide variety of professionals at those sites where it has been integrated. Steps to improve collaboration should include improving multidisciplinary communication to broaden the range of situations in which spiritual caregivers and other professionals work together to provide the best possible holistic care.

The role of emotional processing in art therapy (REPAT) for breast cancer patients.

Emotional awareness and acceptance of emotion are associated with improved health in breast cancer (BC) patients. Art therapy (AT) uses visual art-making for expression and communication and has been shown to reduce psychological and physical symptoms in individuals with cancer. A major objective of AT is to encourage increases in emotion processing; however, few studies examine these changes. Purpose: To examine the effect of an eight-week AT group on emotion processing as a mechanism of symptom reduction in women with BC. Design: Randomized clinical trial. Sample: Twenty women diagnosed with breast cancer whom had completed primary treatment. Methods: Participants were randomized to participate in eight-weeks of AT or sham AT, which was a mandala coloring group. Participants answered questionnaires before and after the intervention. We used a Cohen's D calculator for effect sizes and a t-test to examine group differences. Findings: Statistically significant between-group differences in emotional awareness and acceptance of emotion were found after the intervention. We found large effect sizes between groups and over time in acceptance of emotion, emotional awareness and depressive symptoms. Conclusions: We conclude that emotion processing in AT may be a potential mechanism reducing depression and somatic symptoms in cancer patients. Implications for Psychosocial Providers: Art Therapy is a feasible intervention to increase emotional processing. A larger study is required to further examine its effect on psychological and physical symptoms in breast cancer patients.

Emotional Response and Changes in Heart Rate Variability Following Art-Making With Three Different Art Materials.

Art therapy encourages the use of art materials to express feelings and thoughts in a supportive environment. Art materials differ in fluidity and are postulated to thus differentially enhance emotional response (the more fluid the material the more emotion elicited). Yet, to the best of our knowledge, this assumption has not been empirically tested. The current study aimed to examine the emotional and physiological responses to art-making with different art materials. We were particularly interested in vagal activity, indexed by heart rate variability (HRV), because of its association with numerous health related outcomes. In this study, 50 adults (mean age 33 ± 10.27 years, 52% males) participated in a repeated measures experiment, in which they were requested to draw with three art materials (order randomized) differing in their level of fluidity (pencil, oil-pastels, and gouache paint) intermittent with periods of music. We measured the emotional response to art-making with each material using a self-report measure and matrices of HRV using a wearable electrocardiogram device. We calculated two indices of HRV, one indicative of parasympathetic nervous system (PNS) activity, and one indicative of sympathetic nervous system (SNS) activity. Art-making with gouache paint and oil-pastels resulted in improved positive mood, while pencil did not. Art-making explained approximately 35% of the variability in parasympathetic reactivity, which may indicate changes in emotional regulation processes during the art-making task. Yet, fluidity was not sufficient to explain the reaction to art-making. Surprisingly, the largest suppression of PNS and augmentation of the SNS occurred during art-making with oil-pastels and not with Gouache. Moreover, PNS and SNS reactivity to oil-pastels were related to emotional valance, which may point to emotional engagement. We can conclude that art-making with oil-pastels, first created in Japan in 1924 to increase self-expression of students, results in a unique emotional and physiological responses. These findings might be explained by the enhanced tactile experience of art-making with oil-pastels along with their relative fluidity, triggering an arousal pattern. Further studies that take the format and presentation of the materials as well as the content of the artwork, into account, are needed.

Treating women with perinatal mood and anxiety disorders (PMADs) with a hybrid cognitive behavioural and art therapy treatment (CB-ART).

This paper presents an overview of a combined, evaluated protocol, cognitive behavioural and art therapy treatment (CB-ART), for the treatment of women with perinatal mood and anxiety disorders (PMADs). The protocol integrates cognitive behavioural interventions and art therapy. CB-ART focuses on changing distressing image, symptom or memory (ISM) that interferes with functioning. The method directs clients to identify compositional elements that characterize their stressful ISM and to alter the element in their imagination, in bodily sensations and on the page. Examples are provided to illustrate the therapeutic process.

Implicit loneliness, emotion regulation, and depressive symptoms in breast cancer survivors.

Among individuals coping with cancer, emotional approach coping-expressing and processing emotions following negative events-has been identified as a potentially adaptive form of emotion regulation. However, its mental health benefits may depend on social-cognitive factors and on how it is implemented. This study examined loneliness as a determinant of emotion regulation associations with depressive symptoms in women with breast cancer. Loneliness was examined as an implicit social-cognitive phenomenon (i.e., automatic views of oneself as lonely), and emotional expression and processing were examined as both explicit and implicit processes. Approximately 11 months after diagnosis, 390 women completed explicit measures of coping through cancer-related emotional expression and processing; an implicit measure of expression and processing (an essay-writing task submitted to linguistic analysis); and an implicit association test measuring loneliness. Depressive symptoms were assessed 3 months later. Regardless of implicit loneliness, self-reported emotional expression (but not emotional processing) predicted fewer depressive symptoms, whereas implicit expression of negative emotion during essay-writing predicted more symptoms. Only among women high in implicit loneliness, less positive emotional expression and more causal processing during the writing task predicted more depressive symptoms. Results suggest that explicit and implicit breast cancer-related emotion regulation have distinct relations with depressive symptoms, and implicit loneliness moderates effects of implicit emotional approach. Findings support implicit processes as influential mechanisms of emotion regulation and suggest targets for intervention among breast cancer survivors.

The effects of the Make a Wish intervention on psychiatric symptoms and health-related quality of life of children with cancer: a randomised controlled trial.

OBJECTIVE: Children with life-threatening medical conditions frequently undergo invasive medical procedures that may elicit anxiety and distress. However, there are few empirically validated interventions that reduce mental health symptoms and increase the resilience of children during the acute stages of illness. This study aimed to evaluate the efficacy of the Make a Wish intervention for children with life-threatening cancer. METHODS: The design was a wait-list-controlled trial with two parallel groups. Sixty-six children aged 5-12 with an initial diagnosis of life-threatening cancer were identified and randomly assigned to the Make a Wish intervention (n = 32) or a wait-list control group (n = 34). Children completed measures of psychiatric and health-related symptoms, positive and negative affect, hope, and optimism pre-intervention and post-intervention. After baseline data collection, children were interviewed and made an authentic wish that they wanted to come true. These wishes were made possible 5-6 months after baseline data collection, to fuel anticipation and excitement over the wish-fulfillment event. The post-intervention assessment point was 5 weeks after wish fulfillment (approximately 7 months after baseline data collection). RESULTS: Children in the intervention group exhibited a significant reduction in general distress (d = 0.54), depression (d = 0.70), and anxiety symptoms (d = 0.41), improved health-related quality of life (d = 0.59), hope (d = 0.71), and positive affect (d = 0.80) compared to decrease in positive affect and no significant changes in the other measures in the control group. CONCLUSIONS: These findings emphasize the role of hope and positive emotions in fostering the well-being of children who suffer from serious illnesses.

Decrease in cell free DNA levels following participation in stress reduction techniques among women undergoing infertility treatment.

This pilot study examined differences in plasma cell free DNA (CFD) levels based on practice of stress reduction techniques among 14 women undergoing in vitro fertilization (IVF) and embryo transfer (ET) treatment who had higher than normal levels of plasma CFD before beginning IVF treatment. Wilcoxon nonparametric tests were used to examine the significance of the rate of decline in CFD levels between the time points in each of the groups. A paired sample t-test examined the changes in CFD levels among each participant in each of the groups separately. We found that women who engaged in these techniques had reduced plasma CFD, below what is considered elevated in comparison to those who did not practice. High plasma CFD levels have been associated with IVF failure. Stress reduction techniques may facilitate physiological changes that lead to the reduction of plasma CFD levels.

The vagina dialogues: genital self-image and communication with physicians about sexual dysfunction and dissatisfaction among Jewish patients in a women's health clinic in southern Israel.

INTRODUCTION: The health-care system offers a variety of solutions for problems related to sexual dysfunction. To gain access to treatment options, women must be willing to discuss these issues with their physicians. AIM: To examine the extent to which women discuss issues of sexual dysfunction with their physicians and to examine the contribution of aspects of sexual dysfunction, level of satisfaction, body image, and genital self-image to their comfort with communicating with physicians about these issues. METHODS: One hundred ten secular-appearing, Hebrew-speaking Jewish women waiting for a routine gynecological appointment at a clinic in southern Israel responded to a self-report questionnaire. MAIN OUTCOME MEASURES: The Female Sexuality Function Index was used to assess sexual dysfunction, Gray's Modified Questionnaire to assess body image, and the Genital Self-Image Scale to assess genital self-image. We compiled a new measure to assess level of comfort in discussing sexual functioning and satisfaction with a physician. RESULTS: Forty-four percent of the women had discussed sexual functioning issues with a gynecologist. Of those, 91.7% reported that the gynecologist initiated the discussion. The proportion of participants who would consult a gynecologist about sexual dysfunction was 74.5%, but only 41% would consult a family physician. Half of the women would expect a gynecologist to initiate such consultations, but only 20% would expect a family physician to do so. In a multivariate regression analysis, genital self-image was the only significant predictor of women's comfort level with discussing sexual dysfunction with a gynecologist. CONCLUSIONS: The respondents perceived the gynecologist, rather than the family physician, as an appropriate professional to consult regarding sexual dysfunction. However, they expected the gynecologist to initiate the discussion. Women with a positive genital self-image are more comfortable in consulting about sexual dysfunction. Gynecologists should be made aware of their significant role in eliciting women's cooperation in such consultations and in contributing to improving women's genital perception.

Increased plasma cell-free DNA is associated with low pregnancy rates among women undergoing IVF-embryo transfer.

This prospective repeated measures study was designed to examine the cell-free DNA (cfDNA) concentrations during ovarian stimulation and the relationship between cfDNA concentration and pregnancy rates in women undergoing IVF-embryo transfer. The study examined 37 women undergoing IVF treatment in an IVF unit in a university medical centre in southern Israel. cfDNA concentrations were measured by a direct fluorescence assay, pregnancy rates were identified by plasma ß human chorionic gonadotrophin (HCG) concentrations and verified by vaginal ultrasound to determine gestational sac and fetal heart beats. Throughout the IVF cycle, at the three time points measured, the mean concentration of plasma cfDNA among all participants did not statistically significantly change. However, on the day of ßHCG test in patients undergoing IVF-embryo transfer, plasma cfDNA concentrations were statistically significantly higher among women who did not conceive in comparison to those who conceived. Plasma cfDNA may reflect the presence of factors which interfere with embryo implantation. Further research is required to determine the usefulness of cfDNA as a biomarker of IVF outcome and to examine the underlying pathologies as potential sources for increased plasma cfDNA concentrations. Cell-free DNA (cfDNA) is particles of DNA which are released from the cell nucleus and are found in high concentrations during a variety of illnesses and injuries. This study was designed to examine the cfDNA concentrations during IVF treatment and the relationship between cfDNA concentration in the bloodstream and pregnancy rates in women undergoing IVF. This study examined 37 women in treatment at the IVF unit of the University Medical Centre in southern Israel. cfDNA concentrations in the bloodstream were measured at three time points by a direct test. Pregnancy rates were identified by pregnancy hormone concentrations in the bloodstream and verified by vaginal ultrasound to determine a pregnancy sac and fetal heart beats. Throughout the IVF cycle, at the three time points measured, the average concentration of cfDNA among all participants did not change. However, on the day of the pregnancy test, blood cfDNA concentrations were significantly higher among women who were not pregnant in comparison to those who were. Plasma cfDNA may reflect the presence of factors which interfere with embryo implantation. Further research is required to determine the usefulness of cfDNA as a biological marker of IVF outcome and examine underlying illnesses and problems as potentials sources for increased cfDNA concentrations.