Psychological predictors of chemotherapy-induced nausea in women with breast cancer: Expectancies and perceived susceptibility.

OBJECTIVE: Chemotherapy-induced nausea is challenging to predict and treat. Research indicates that pretreatment psychological variables including patients' perceptions of their susceptibility to nausea, expectancies of treatment-related nausea and nausea history (i.e., motion sickness, morning sickness and baseline levels of nausea) may aid in predicting nausea severity during chemotherapy. However, this research is dated and limited in quantity. We investigated whether psychological variables could improve prediction of nausea severity to inform interventions targeting chemotherapy-induced nausea. METHODS: In this secondary analysis, a subgroup of women receiving chemotherapy (for the first time) for breast cancer completed pretreatment measures: perceived nausea susceptibility, nausea expectancies, nausea history and baseline nausea. They rated subsequent nausea severity across 4-days, during treatment and posttreatment in a self-report diary. Structural Equation Modelling was used to explore associations. RESULTS: Across the women (N = 481), perceived nausea susceptibility predicted subsequent nausea severity (ß = 0.16), but nausea expectancies did not (ß = 0.05). Nausea history variables demonstrated small-moderate associations with perceived susceptibility (ß = 0.21-0.32) and negligible-small associations with nausea expectancies (ß = 0.07-0.14). CONCLUSION: Perceived nausea susceptibility appears to capture patients' nausea history, to a degree, and is related to nausea severity during treatment. This is an important variable to include in pretreatment prediction of patients at risk of severe nausea.

'Measuring up': A comparison of two response expectancy assessment formats completed by men treated with radiotherapy for prostate cancer.

OBJECTIVE: Response expectancies of cancer treatment toxicities are often, but not always, associated with subsequent experiences. A recent meta-analysis indicated that response expectancies, measured using different assessment formats, reveal different effect sizes, potentially explaining mixed outcomes. Utilizing a clinical sample, we compared 5-point assessments and visual analogue scales, as measures of response expectancies for the incidence and severity of subsequent toxicities. METHODS: Four weeks pre-radiotherapy, 45 men with prostate cancer rated their response expectancies of the same 18 toxicities on 5-point assessments and visual analogue scales, presented in random order. Descriptors anchored each end of visual analogue scales and every point of 5-point assessments was labelled, including an 'unsure' midpoint. Toxicities were subsequently assessed 2-weeks into radiotherapy on 100-point visual analogue scales. RESULTS: Across all toxicities, 17.5-62.8% of patients selected 'unsure' on 5-point assessments. No response expectancies were reported on 5-point assessments for 'blood in stools' or 'rectal urgency' yet 54.8%-64.3% of patients indicated response expectancies for these toxicities on visual analogue scales. Visual analogue scales and 5-point scales demonstrated small-to-moderate associations (r = 0.30-0.58) as measures of response expectancy incidence, but mostly large associations when visual analogue scales captured severity (r = 0.43-0.76). Response expectancies measured with visual analogue scales predicted more toxicities to a moderate degree or greater (68.8%) than 5-point assessments (37.5%). CONCLUSION: This novel investigation demonstrated an 'unsure' midpoint is often selected, potentially reducing the sensitivity of 5-point assessments. Based on their associations, and outcomes, these assessment formats should be considered independent in response expectancy research of cancer treatment toxicities.

The impact of chemotherapy on cognitive function: a multicentre prospective cohort study in testicular cancer.

PURPOSE: The causal link between chemotherapy and cognitive impairment is unclear. We studied testicular cancer patients' objective and subjective cognitive function longitudinally, comparing a surgery group with a surgery + chemotherapy group, addressing prior methodological issues using a computerized test to limit assessment issues, and controlling for confounding variables. METHODS: Prospectively, of 145 patients from 16 centres with sufficient data, n = 61 receiving surgery + chemotherapy (etoposide and cisplatin ± bleomycin, BEP/EP; or single agent carboplatin) were compared to n = 41 receiving surgery alone. CogHealth assessed six objective cognitive tasks. The Cognitive Failures Questionnaire assessed self-perceived cognitive dysfunction. The Functional Assessment of Chronic Illness Therapy-Fatigue and the Hospital Anxiety and Depression Scale assessed psychological influences. Linear mixed models compared changes from baseline (< 6 months post-surgery/pre-chemotherapy) to follow-up (12-18 months post-baseline), controlling covariates. RESULTS: There were no significant interaction effects for five objective cognitive function tasks suggesting that changes over time were not due to group membership. However, psychomotor function (controlling for age) and physical well-being were significantly worse for the chemotherapy versus the surgery group at baseline, with groups converging by follow-up. Groups showed no differences in subjective cognitive dysfunction. The chemotherapy group showed higher anxiety, poorer functional well-being and worse fatigue compared to the surgery-only group at baseline, but not by follow-up. For both groups, emotional well-being, functional well-being and anxiety significantly improved over time. CONCLUSION: No substantive differences in objective or subjective cognitive dysfunction in either group persisted 12-18 months post-baseline. Patients undergoing chemotherapy for testicular cancer differ from findings in breast cancer populations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: ACTRN12609000545268.

Pain Education for Adolescents and Young Adults Living Beyond Cancer: An Interdisciplinary Meeting Report.

Pain is an understudied and undertreated consequence of cancer survival. Pain education is now a recommended treatment approach for persistent non-cancer pain, yet it has not been well applied to the context of adolescent and young adult (AYA) cancer survival. In March 2018, an interdisciplinary meeting was held in Adelaide, South Australia to set a research agenda for pain education in AYA cancer survivors. We identified that AYAs with persistent pain and those with heightened pain-related fear have the potential to benefit from pain education. We identified a number of unique challenges of engaging AYA survivors in pain education, and point towards future research directions.

The impact of valence framing on response expectancies of side effects and subsequent experiences: a randomised controlled trial.

Objective: Pre-treatment side effect expectancies often influence subsequent experiences; however, expectancy-based reduction strategies are lacking. We explored whether framing information about adverse responses (in positive or negative formats) altered expectancies and experiences of a cold pressor task. We further investigated associations between expectancies and experiences, to inform potential interventions. Design: Healthy volunteers (N = 134), randomised to receive positively- or negatively-framed pre-cold pressor task information, self-rated 12 expectancies for cold pressor experiences, emotional state and coping style. Main Outcome Measures: Self-reports of the same 12-experiences (recorded during and after the experiment) were assessed. Results: Framing had minimal impact on expectancies and experiences; however, discomfort threshold (p = .08, d = 0.22) showed a trend in the expected direction. Hierarchical regressions revealed expectancies uniquely, significantly predicted 6-23% of the variance for 11 subsequent experiences. Following a popular charity event (Ice Bucket Challenge), all participants showed higher 'discomfort thresholds' (p = .001, d = 0.59), and those in the negative frame reported more overall 'discomfort' (p = .01, d = 0.60) than participants in the positive condition. Conclusion: Expectancies uniquely influenced subsequent cold pressor experiences. Framing had minimal impact in this 'analogue' medical setting, only influencing 'discomfort threshold'. 'Discomfort threshold' and overall 'discomfort' were also impacted by a social media challenge, highlighting a potential area for intervention.

"Just As I Expected": A Longitudinal Cohort Study of the Impact of Response Expectancies on Side Effect Experiences During Radiotherapy for Prostate Cancer.

CONTEXT: Previous research has indicated that pretreatment response expectancies of side effects often predict subsequent toxicity severity. However, this has been largely based on female patients undergoing chemotherapy. OBJECTIVES: We tested whether this association also occurred in a novel cohort, men with prostate cancer undergoing radiotherapy. We investigated these associations throughout treatment (before and after side effects were medically predicted to occur), controlling known and novel variables. METHODS: Homogenous male patients scheduled for radiotherapy (N = 35, mean age 71 years) completed baseline (pretreatment) measures; response expectancies of 18 treatment-related side effects; questions about baseline health and hormonal treatment, emotional state, and coping style. Response expectancies of the side effects were again measured two weeks into treatment. The severity of the same 18 toxicities was assessed two and seven weeks into treatment. RESULTS: Hierarchical multiple linear regressions revealed baseline response expectancies significantly and independently predicted six of 18 toxicities two weeks into radiotherapy, contributing 12%-30% of explained variance (ß = 0.39-0.59). Response expectancies assessed two weeks into treatment significantly and uniquely predicted seven of 17 experienced toxicities at seven weeks, explaining 17%-50% of variance (ß = 0.49-0.91). Sexual toxicity response expectancies revealed the strongest associations with experience throughout treatment (ß = 0.46-0.91), with "inability to reach orgasm" showing the largest effect. CONCLUSION: In this older male sample, response expectancies of side effects predicted experiences throughout treatment, including the period before toxicities were medically expected. Response expectancies of sexual side effects were robust, independent predictors of subsequent toxicities across treatment, especially issues with orgasm, warranting focus in practice and future research.

Cancer Treatment Side Effects: A Meta-analysis of the Relationship Between Response Expectancies and Experience.

CONTEXT: Although previous research has, overall, suggested a moderate relationship between response expectancies (REs) and cancer treatment-related side effects, empirical results have been mixed. OBJECTIVES: We aimed to further explore these relationships, hypothesizing that REs would predict subsequent toxicities with the inclusion of more recent studies, across a broader range of side effects, while incorporating the impact of potential moderators including patients' experience with treatment and measurement methods. We further investigated the impact of REs across individual toxicities. METHODS: A systematic search and analysis were conducted across four databases (PsychInfo, PubMed, CINAHL, and Embase) and reference lists, from 1985 to February 2016. This provided 27 eligible studies with 4474 participants, through which the main analysis, moderator analyses, and individual side-effect analyses were explored. RESULTS: REs were moderately related to side effects overall (r = 0.26), and effect sizes were significantly influenced by sample diagnostic homogeneity, whereas differences between type and timing of measurement showed trends. Of the 16 toxicities examined, 15 demonstrated significant relationships between REs and side-effect experience, with hair loss (r = 0.48) the strongest. No clear difference emerged between objective and subjective side effects; however, significant differences across individual toxicities were revealed. CONCLUSION: Findings support a relationship between REs and a wide range of subsequent side effects, yet differences between individual RE-toxicity associations emerged. These findings provide direction for the measurement of side effects and REs and support REs as potential targets for intervention during the informed consent process.

Burden on informal caregivers of elderly cancer survivors: risk versus resilience.

This study assessed psychological morbidity and resilience, including the subjective burden of 76 caregivers of elderly cancer survivors utilizing a cross-sectional questionnaire. Participants were mainly elderly female spouses, sole-caregiving > 35 hours per week; 19.1% and 23.6% reported moderate or greater anxiety and depression, respectively. A significant regression model found depression, emotion-focused coping, and greater years since diagnosis as significant predictors of subjective caregiver burden. Thus, caregiving appears a dominant role for this group and the Brief Assessment Scale for Caregivers of the Medically Ill (BASC) appears to be an efficient screening tool for psychological morbidity in this under-supported group.

When expectations predict experience: the influence of psychological factors on chemotherapy toxicities.

CONTEXT: Patients with cancer undergoing similar treatments experience variable severity and frequency of side effects not adequately explained by pharmacological mechanisms, suggesting psychological influence. OBJECTIVES: First, this study aimed to further examine the relationship between patients' expectations of multiple chemotherapy-related toxicities and experiences. Second, this study aimed to explore the impact of anxiety and cancer coping styles to aid in informing interventions to lessen such expectations. METHODS: A total of 59 eligible, consenting patients with cancer rated their expectations of 20 chemotherapy toxicities on 100-point linear analogue self-assessment indicators before treatment and completed the Spielberger State Anxiety Inventory and the Mental Adjustment to Cancer scale. Patients then rated their experience of side effects after one chemotherapy session. RESULTS: Regressions controlling primary treating nurse influence and patient performance status showed toxicity experience was significantly predicted by patient expectations of mood changes, bleeding, skin itchiness, hair loss, feeling tired, and sleep disturbance (ß=0.30-0.55). Anxiety was significantly related to expectations of nervousness and mood changes; the coping style Fighting Spirit showed no significant associations, whereas conversely, Anxious Preoccupation showed some degree of association with all 20 toxicities (r=0.11-0.34). CONCLUSION: Findings support the growing contention that patient expectations influence experience, negatively impacting quality of life. As it is unethical to withhold treatment information, research into screening for at-risk patients and offering brief interventions to minimize Anxious Preoccupation could be one way to reduce overall side effect burden, perhaps in the case of many medical interventions.

The multidimensionality of spiritual wellbeing: peace, meaning, and faith and their association with quality of life and coping in oncology.

OBJECTIVE: This study explored associations between the recently proposed three-factor structure of the 12-item Functional Assessment of Chronic Illness Therapy-Spiritual Well-being (FACIT-Sp) subscale (Peace, Meaning, and Faith), quality of life (QoL), and coping in an oncology population. METHODS: A total of 999 newly diagnosed, study eligible, consecutive cancer patients completed the FACIT-Sp and the Mental Adjustment to Cancer (MAC) scale. RESULTS: Hierarchical multiple regressions revealed that Peace alone added 3% to the prediction of QoL and accounted for 15.8% of the overlap in Total Functional Assessment of Cancer Therapy--General (FACT-G) scores (both p<0.001). Meaning alone added 1.3% to QoL prediction and accounted for 5.8% in overlap (both p<0.001). Faith did not significantly contribute to the unique prediction or overlap of QoL. Correlational analyses revealed that Peace was most prominently associated with the QoL subscales of Functional (r = 0.64) and Emotional Wellbeing (r = 0.61) and the coping styles of Helpless/Hopeless (r = -0.53), Fighting Spirit (r = 0.47), and Anxious Preoccupation (r = -0.34). Meaning was also highly associated with Functional Wellbeing (r = 0.56), Helpless/Hopeless (r = -0.53), and Fighting Spirit (r = 0.54), but in addition, Social Wellbeing (r = 0.49). CONCLUSIONS: The three-factor model of spiritual wellbeing appears psychometrically superior to previous models as it further discriminates between which components are most highly associated with improved QoL facets and coping styles. This study provides normative data on newly diagnosed patients with cancer and further highlights the clinical contribution of such detailed assessment.

Gynecological cancer survivors: assessment of psychological distress and unmet supportive care needs.

This study highlights psychosocial needs of gynecological cancer survivors, contributing to evaluation of the Cancer Survivors Unmet Needs measure. Of the 45 participants, 28.9% reported clinical anxiety, 20.0% mild-to-severe depression, and 15.6% had probable posttraumatic stress disorder. Strength of unmet needs was associated with anxiety, depression, posttraumatic stress, poorer quality of life, younger age, and greater time since diagnosis. Linear regressions showed clinical measures, quality of life, optimism, and self-blaming coping style explained 56.4% of strength of unmet needs. Anxiety, functional well-being, posttraumatic stress, and emotional well-being accounted for 40.7% of variance in fear of recurrence, with emotional well-being the strongest predictor.

The long-term effects of mindfulness-based cognitive therapy as a relapse prevention treatment for major depressive disorder.

BACKGROUND: Mindfulness-based Cognitive Therapy (MBCT) is a relapse prevention treatment for major depressive disorder. METHOD: An observational clinical audit of 39 participants explored the long-term effects of MBCT using standardized measures of depression (BDI-II), rumination (RSS), and mindfulness (MAAS). RESULTS: MBCT was associated with statistically significant reductions in depression from pre to post treatment. Gains were maintained over time (Group 1, 1-12 months, p = .002; Group 2, 13-24 months, p = .001; Group 3, 25-34 months, p = .04). Depression scores in Group 3 did begin to worsen, yet were still within the mild range of the BDI-II. Treatment variables such as attendance at "booster" sessions and ongoing mindfulness practice correlated with better depression outcomes (p = .003 and p = .03 respectively). There was a strong negative correlation between rumination and mindful attention (p < .001), consistent with a proposed mechanism of metacognition in the efficacy of MBCT. CONCLUSION: It is suggested that ongoing MBCT skills and practice may be important for relapse prevention over the longer term. Larger randomized studies of the mechanisms of MBCT with longer follow-up periods are recommended.

Mindfulness-based cognitive therapy: an efficacious community-based group intervention for depression and anxiety in a sample of cancer patients.

OBJECTIVE: To assess the impact of an 8-week structured mindfulness-based cognitive therapy (MBCT) program on individuals experiencing distress as a consequence of cancer. DESIGN, SETTING AND PARTICIPANTS: Prospective study of 16 participants with a history of cancer and five carers of people with cancer recruited from August 2008 to February 2009 through calls to the Cancer Council South Australia Helpline. Participants were assessed for anxiety and depression before and after undergoing a course in MBCT between 30 September and 18 November 2008 and 20 February and 10 April 2009. MAIN OUTCOME MEASURES: Depression, anxiety and mindfulness as measured by the Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory (STAI), and Freiburg Mindfulness Inventory (FMI), respectively, and a consumer-centred evaluation. RESULTS: There were significant reductions in depression (F[1,24] = 6.37; P = 0.012; partial-eta2 = 0.27) and anxiety (F[2,34] = 9.43; P = 0.001, partial-eta2 = 0.36) and mindfulness (F[2,32] = 8.36; P = 0.001; partial-eta2 = 0.34) following the intervention, and these effects were sustained at the 3-month follow-up. Reliable change indices further support these findings. Participants' scores on measures of depression and anxiety decreased as a function of increased mindfulness, as reflected by significant (P < 0.05) negative correlations between FMI scores and BDI-II scores (ranging from r = -0.46 to r = -0.79) and STAI scores (ranging from r = -0.46 to r = -0.50) scores at all time points. CONCLUSION: The MBCT program appears to be an efficacious intervention for use among people affected by cancer who also experience symptoms of depression and anxiety.

Improving informed consent to chemotherapy: a randomized controlled trial of written information versus an interactive multimedia CD-ROM.

OBJECTIVE: This randomized controlled trial aimed to determine whether an interactive CD-ROM improved cancer patients' recall of chemotherapy treatment information over standard written information, and whether demographic, cognitive, and psychological factors better predicted recall than this format of delivery. METHODS: One-hundred-and-one new patients about to commence chemotherapy were randomized to receive written information or a CD-ROM containing treatment information before giving informed consent. Patients' recall, concentration, short-term memory, reading comprehension, anxiety, depression, and coping styles were assessed with standardized measures pre-treatment. Seventy-seven patients completed tests for recall of treatment information before their second chemotherapy session. RESULTS: Intention-to-treat analyses indicated no significant differences between the written information and CD-ROM groups across recall questions about number of drugs received (p=.43), treatment length (p=.23), and treatment goal (p=.69). Binary logistic regressions indicated that for groups combined different variables predicted each of the recall questions. CONCLUSION: An interactive CD-ROM did not improve cancer patients' recall of treatment information enough to warrant changes in consent procedures. PRACTICE IMPLICATIONS: Different variables predicted recall of different treatment aspects highlighting the complex nature of attempting to improve patient recall. Attending to the effect of depression on patient knowledge and understanding appears paramount.

Spirituality as a core domain in the assessment of quality of life in oncology.

OBJECTIVES: This study investigated including spiritual wellbeing as a core domain in the assessment of quality of life (QOL) in an Australian oncology population. METHODS: Four hundred and ninety consecutive cancer patients with mixed diagnoses completed the Functional Assessment of Chronic Illness Therapy--Spiritual Well-Being (FACIT-Sp) and the Mental Adjustment to Cancer (MAC) scale. RESULTS: Overall, 449 patients completed assessments. Spiritual wellbeing demonstrated a significant, positive association with QOL (r=0.59), fighting spirit (r=0.49) and a significant, negative relationship with helplessness/hopelessness (r=-0.47) and anxious preoccupation (r=-0.26). A hierarchical multiple regression showed spiritual wellbeing to be a significant, unique contributor to QOL beyond the core domains of physical, social/family, and emotional wellbeing (R(2) change=0.08, p=0.000). However, high levels of meaning/peace or faith did not appear to significantly impact patients' ability to enjoy life despite chronic symptoms of pain or fatigue, making the current results inconsistent with other findings. CONCLUSION: Results lend further support to the biopsychosocialspiritual model. By failing to assess spiritual wellbeing, the 'true' burden of cancer is likely to be miscalculated. However, at this stage, the exact clinical utility of spirituality assessment is unclear.

Relationships between patients' pre-treatment expectations of toxicities and post chemotherapy experiences.

A lack of adequate pharmacological explanations for side effect variation following chemotherapy suggests psychological factors may contribute to toxicity experience. This research aimed to determine if patients' expectations were associated with perceived toxicities for a wider range of chemotherapy toxicities than previously researched, including subjective and objective side effects. Eighty-seven chemotherapy-naive patients rated their expectations of 20 common side-effects before treatment, and then rated their experiences following their first chemotherapy dose. Hierarchical multiple regression analyses revealed that expectations of the inability to concentrate, hair loss, and diarrhoea prior to treatment had the strongest associations with the experience of symptoms. Expectations of encountering problems with sleep and sex, changes in taste or appetite, weakness, and nervousness, all showed moderate associations, and expectations of mood changes, feelings of tiredness, and nausea all showed weak associations with experience. These outcomes suggest that subjective side effects may be more prone to influence by expectation given their ambiguous nature. However, further research needs to be conducted into the effect expectations have on the treatment process, including the impact of other psychological factors. The current overriding emphasis placed on personal autonomy and fully informed consent may set up negative expectations which translate into adverse experiences to the detriment of the patient.