Anxiety, Depression, and Coping Strategies during Chemotherapy Treatment: A Comparison of Older and Younger Adults with Advanced Cancer in Brazil.

We sought to examine differences in anxiety, depression and coping strategies among younger (<64-year old) and older (≥65-year old) patients. Patients were assessed at baseline (T1), mid-point (T2) and on the last day of treatment (T3) using the Hospital Anxiety and Depression Scale and the Ways of Coping. A linear mixed modeling approach was used. The study included 200 patients (gender: 70% women; diagnosis: 30% breast, 22% hematological, 18% gastrointestinal; disease stage: 60% advanced). Older patients who used an emotion-focused coping strategy had a greater decrease in anxiety at T3 compared to those that used problem-focused coping (p = .002).

Association between requests for supportive care assistance and patients' characteristics, prior to treatment in a comprehensive cancer center.

PURPOSE: Patients with cancer experience a wide array of distress symptoms (emotional, practical, physical, and functional), which often hinders their quality of life and survival. Unfortunately, only a small proportion of these patients request assistance for these problems. This study explored the relationship between requests for supportive care assistance and distress of patients newly diagnosed with cancer. METHODS: This study was conducted at city of hope, an NCI-designated comprehensive cancer center, and included 2658 patients treated between 2009 and 2017. Patients were asked to complete a 30-item biopsychosocial problem-related distress survey via SupportScreen® , prior to any treatment. Correlations between requests for assistance and distress domains were evaluated. Primary types of requests were examined for all patients, and general linear modeling was used to determine the significant predictors of requests for assistance. p-values <0.05 were considered significant. RESULTS: Strong correlations were observed between distress subscales and requests for assistance (r ranging from 0.67 to 0.69). The primary types of requests varied by domain: items such as feeling anxious or fearful, finances, and sleep ranked first within the emotional, practical, and physical-functional domains respectively (∼20% requests for each item). Verbal assistance was generally preferred to the written form of assistance, with the exception of a few items, including finances. Overall, household income of <$100,000 and completing the survey in Spanish were significant predictors of requests for assistance. Regarding the practical and physical-functional domains, having an advanced stage of disease was significantly related to an increase in demands for assistance. Being older was associated to a decrease in requests for assistance vis-à-vis both the emotional and physical functional subscales. CONCLUSION: We demonstrated that distress levels were strongly correlated with requests for assistance. Patients' clinical and demographic characteristics such as age, household income, disease stage and survey language were associated with inquiries for psychosocial support, highlighting the importance of targeting interventions towards those most likely to need them, to better aim patients' needs. Therefore, tailoring supportive care assistance to patients' characteristics could help boost the frequency of requests, reduce distress burden, and improve health outcomes.

Emotional problem-related distress screening and its prevalence by cancer type: Assessment by patients' characteristics and level of assistance requested.

OBJECTIVE: Emotional problem-related distress is a common issue faced by patients with cancer. However, patients suffering with this emotional burden do not typically seek assistance. This study sought to determine the prevalence of emotional problem-related distress by cancer type, and identify factors correlated with the level of assistance requested. METHODS: Using the SupportScreen®, patients were screened for emotional problem-related distress at their first or second visit to an NCI designated Comprehensive Cancer Center. General Linear Model was used to test the association between emotional problem-related distress and type of cancer, and the relationship between level of assistance requested and patients' characteristics. RESULTS: A total of 2,421 patients were included in this analysis. Patients were mostly female (62%), diagnosed with breast (24%), gynecological (16%) or gastrointestinal (15%) cancers. Highest levels of emotional problem-related distress were reported by patients diagnosed with lung, gynecological, breast and gastrointestinal cancers. Level of assistance requested were significantly associated with problem-related distress scores (p < 0.001), which were higher among patients with lower household incomes (p < 0.001) and Spanish as primary language (p = 0.001). CONCLUSION: Our study found an association between Level of assistance requested and emotional problem-related distress, which were heightened by lower income and Spanish-speaking. Intervention strategies should be considered to increase access to psychosocial support services.

Association between chemotherapy toxicity risk scores and physical symptoms among older Brazilian adults with cancer.

OBJECTIVE: Utilizing the Cancer and Aging Research Group (CARG) chemotherapy toxicity risk score before starting treatment in older adults with cancer is guideline-recommended. However, this has not been tested in most developing countries. We investigated the use of a Portuguese version of the CARG score, including the association between this score and physical symptoms, among older Brazilian adults with cancer. PATIENTS AND METHODS: We enrolled patients aged ≥65 starting chemotherapy at a public Brazilian hospital. A Portuguese version of the CARG tool was created and linguistically validated. Patients were assessed for chemotherapy toxicity risk using the CARG score, and physical symptoms were evaluated using the Functional Assessment of Cancer Treatment-General (FACT-G) scale. Multivariable logistic regression was used to identify physical symptoms associated with high CARG scores, including pain, nausea, and fatigue. RESULTS: Older patients (65+) with cancer were enrolled (n = 117). Patients were mostly female (57.3%), white (52.1%), married (52.1%), and had less than high school education (75.2%). Breast, gastrointestinal and lung cancers were the most common diagnosis, and 66.7% had metastatic disease. Elevated pain scores (P < .01) were associated with higher chemotherapy toxicity risk scores, even after adjusting for potential confounders. CONCLUSION: We created and implemented a Portuguese language version of the CARG tool. We found that, although physical symptoms are not included in the CARG model, elevated pain was strongly associated with having a high CARG score. As a modifiable risk factor, pain should be addressed among older patients with cancer considering chemotherapy, to help mitigate their risks for toxicity.

Biopsychosocial distress and clinical outcome in metastatic renal cell carcinoma.

OBJECTIVE: Limited research exists examining the biopsychosocial experience of patients diagnosed with metastatic renal cell carcinoma (mRCC), a disease commonly associated with a poor prognosis. The purpose of this study was to describe rates and types of distress in mRCC patients and explore the relationship between distress and overall survival. METHOD: A cohort of 102 patients with mRCC treated at a single institution was assessed by a touch screen-based instrument comprising 22 core items spanning physical, practical, functional, and emotional domains. Association between biopsychosocial distress and clinicopathologic criteria was interrogated. Overall survival was compared between patients with low distress versus high distress.ResultHigh rates of distress (20.7%) were found among patients newly diagnosed with mRCC. Among those domains contributing to distress, pain, fatigue, and financial comorbidity were the most commonly reported by patients with mRCC. A trend toward poorer overall survival in those patients with high distress versus low distress was observed among mRCC patients.Significance of resultsBased on data from a relatively large sample of patients, this study provides the first specific insights into the potential impact of biopsychosocial distress and outcomes among patients with mRCC.

Breast and gynecological cancer patients' risk factors associated with biopsychosocial problem-related distress.

OBJECTIVES: Inequalities exist between breast and gynecological cancer patients' experiences, leading to high levels of distress throughout the cancer journey. The present study aims to identify differences in source of biopsychosocial problem-related distress between women diagnosed with breast or gynecological cancers. METHODS: From 2009 to 2016, women with breast (n = 2111) and gynecological (n = 641) cancers were screened using the core items of the instrument You, Your Family, and City of Hope are a Team. This is a touch screen-based instrument that assess problem-related distress due to physical, practical, functional, emotional, and other problems and identifies types of assistance requested. Data were analyzed using the linear regression model. RESULTS: A significant difference in overall biopsychosocial problems rated as high distress was found between breast (M = 5.0) and gynecological (M = 6.2) cancer patients (P < .001). Gynecological cancer patients endorsed a greater number of problems to talk with a member of the team (alone or with written information), while both cancer groups requested written information equally. Gynecological cancer was associated with higher physical, functional, emotional, and total distress. Younger patients, non-Asian, and those with lower education and lower household income also reported greater distress. CONCLUSIONS: Gynecological cancer patients represent a high-risk group, reporting greater problem-related distress and higher levels of requested assistance. Age, education, race/ethnicity, and income were found to be potential risk factors. Findings highlight the importance of considering characteristics and special needs related to specific types of cancer to assist in the effective treatment of distress throughout the continuum of care.

Development and implementation of a comprehensive psychosocial screening program in a Brazilian cancer center.

OBJECTIVE: International guidelines recommend routine screening for distress as part of care practices. Accordingly, a Brazilian cancer center developed and implemented a distress screening program (DS) in 2007, which was enhanced in 2009 through the inclusion of a psychosocial care meeting group (DS + PCM) regarding patients' psychosocial needs. The current paper will provide an overview of the development and pilot implementation of this program and initial analyses to assess patient outcomes and report initial results to extend international research on this key aspect of cancer care. METHOD: Patients were assessed for distress, anxiety and depression, and in the DS+PCM phase for quality of life at the first day of chemotherapy infusion, at midpoint, and at treatment end. We compared data from program phases (DS vs DS + PCM), with a sequential cohort design and mixed effects modeling. RESULTS: Clinical and demographic characteristics were similar between groups. Patients receiving DS + PCM showed significantly lower distress and depression/anxiety upon chemotherapy initiation (Ps < .001). While both groups reported significantly lowered distress and total depression/anxiety scores across time (Ps < .003), patients receiving DS + PCM maintained the lowest distress and total anxiety/depression at all assessments. Patients from DS + PCM group also reported improvements in quality of life over time. CONCLUSIONS: The current study provides preliminary evidence that a multidisciplinary structured screening program utilizing validated measures and team meetings is associated with reduced impairment in patients' psychological well being. This program provided more opportunities for collaboration among providers with increased multidisciplinary meetings, enabled patients to more easily report problems, and ensured rapid access to relevant resources.

Course of distress, anxiety, and depression in hematological cancer patients: Association between gender and grade of neoplasm.

OBJECTIVE: The aim of our study was to explore the impact of gender and hematological cancer grade on distress, anxiety, and depression in patients receiving chemotherapy. METHODS: A prospective study was done in a cohort of 104 patients with hematological cancer. We employed the (1) Distress Thermometer (DT) and the Problem List (PL) and (2) the Hospital Anxiety and Depression Scale (HADS) for assessments at baseline (T1), the halfway timepoint (T2), and completion of chemotherapy (T3). RESULTS: The proportion of patients experiencing significant distress (DT ≥ 4) decreased from the first to the last timepoint; the proportion experiencing anxiety and depression (as assessed by HADS) also decreased. Specifically, 50% of participants reported significant distress levels, 47.1% anxiety, and 26% depression at T1. At T2, the proportion of patients experiencing distress was reduced by 60.8%, by 76% for anxiety, and by 48.5% for depression; at T3, the reduction was close to 80% for all assessments compared with T1. Emotional and physical problems were most commonly reported. Significant reductions were discovered for distress and problem-related distress levels over time, and a significant interaction was found between gender and practical and physical problems (p < 0.05). SIGNIFICANCE OF RESULTS: Our findings suggest that female patients reported more distress, anxiety, and depression than male patients. Gender differences were related to problem-related distress but not to grade of neoplasm. We observed that, over the course of chemotherapy, the distress levels of patients with hematological cancer decrease over time.

Successful strategies for implementing biopsychosocial screening.

OBJECTIVE: This commentary integrates successful screening implementation strategies applied in four institutions in the United States and the accumulated knowledge from international leaders about how to engage key professionals and administration in partnering to create a culture of screening. METHODS: As in clinical practice, it is first necessary to know the patient's story, potential resources and what motivates them to coordinated meaningful action. Introducing a comprehensive program of screening shares similarities with clinical care but also requires additional insights and an understanding of what motivates institutions to make resources available. Specific behaviors that are tailored to the values of particular professions and the institution are described to increase the likelihood of program uptake. Once key professionals and administration understand the value of screening and not before, a screening implementation plan is put into place. RESULTS: Since the 1990s our screening programs have been successfully implemented in four settings: three NCI Designated Comprehensive Cancer Centers and one community hospital. It is estimated that more than 15,000 cancer outpatients have been screened for distress and cancer-related problems. These programs have demonstrated that biopsychosocial screening programs can be integrated into busy outpatient cancer clinics as part of standard clinical care. CONCLUSIONS: Screening involves an intervention that impacts patients, clinical systems, the institution and staffing levels of psychosocial providers. Provision of scarce resources, active engagement of key professionals and administration will only occur if the stakeholders have a clear sense of the benefits for them. Implementing a screening program creates culture change and culture change not only takes time, but active engagement, patience and persistence.