Anxiety and Depression in Metastatic Cancer: A Critical Review of Negative Impacts on Advance Care Planning and End-of-Life Decision Making With Practical Recommendations.

PURPOSE: Providers treating adults with advanced cancer increasingly seek to engage patients and surrogates in advance care planning (ACP) and end-of-life (EOL) decision making; however, anxiety and depression may interfere with engagement. The intersection of these two key phenomena is examined among patients with metastatic cancer and their surrogates: the need to prepare for and engage in ACP and EOL decision making and the high prevalence of anxiety and depression. METHODS: Using a critical review framework, we examine the specific ways that anxiety and depression are likely to affect both ACP and EOL decision making. RESULTS: The review indicates that depression is associated with reduced compliance with treatment recommendations, and high anxiety may result in avoidance of difficult discussions involved in ACP and EOL decision making. Depression and anxiety are associated with increased decisional regret in the context of cancer treatment decision making, as well as a preference for passive (not active) decision making in an intensive care unit setting. Anxiety about death in patients with advanced cancer is associated with lower rates of completion of an advance directive or discussion of EOL wishes with the oncologist. Patients with advanced cancer and elevated anxiety report higher discordance between wanted versus received life-sustaining treatments, less trust in their physicians, and less comprehension of the information communicated by their physicians. CONCLUSION: Anxiety and depression are commonly elevated among adults with advanced cancer and health care surrogates, and can result in less engagement and satisfaction with ACP, cancer treatment, and EOL decisions. We offer practical strategies and sample scripts for oncology care providers to use to reduce the effects of anxiety and depression in these contexts.

A Systematic Review and Meta-Analysis of Interventions to Promote Adjuvant Endocrine Therapy Adherence Among Breast Cancer Survivors.

PURPOSE: Adjuvant endocrine therapy (AET) adherence among breast cancer survivors is often suboptimal, leading to higher cancer recurrence and mortality. Intervention studies to promote AET adherence have burgeoned, more than doubling in number since this literature was last reviewed. The current aim is to provide an up-to-date systematic review and meta-analysis of interventions to enhance AET adherence and to identify strengths and limitations of existing interventions to inform future research and clinical care. METHODS: Systematic searches were conducted in three electronic databases. Studies were included in the systematic review if they examined an intervention for promoting AET adherence among breast cancer survivors. Studies were further included in the meta-analyses if they examined a measure of AET adherence (defined as compliance or persistence beyond initiation) and reported (or provided upon request) sufficient information to calculate an effect size. RESULTS: Of 5,045 unique records, 33 unique studies representing 375,951 women met inclusion criteria for the systematic review. Interventions that educated patients about how to manage side effects generally failed to improve AET adherence, whereas policy changes that lowered AET costs consistently improved adherence. Medication reminders, communication, and psychological/coping strategies showed varied efficacy. Of the 33 studies that met the inclusion criteria for the systematic review, 25 studies representing 367,873 women met inclusion criteria for the meta-analysis. The meta-analysis showed statistically significant effects of the adherence interventions overall relative to study-specified control conditions (number of studies [k] = 25; odds ratio, 1.412; 95% CI, 1.183 to 1.682; P = .0001). Subgroup analyses showed that there were no statistically significant differences in effect sizes by study design (randomized controlled trial v other), publication year, directionality of the intervention (unidirectional v bidirectional contact), or intervention type. CONCLUSION: To our knowledge, this is the first known meta-analysis to demonstrate a significant effect for interventions to promote AET adherence. The systematic review revealed that lowering medication costs and a subgroup of psychosocial and reminder interventions showed the most promise, informing future research, policy, and clinical directions.

A randomized controlled trial of a multi-modal palliative care intervention to promote advance care planning and psychological well-being among adults with advanced cancer: study protocol.

BACKGROUND: Up to half of adults with advanced cancer report anxiety or depression symptoms, which can cause avoidance of future planning. We present a study protocol for an innovative, remotely-delivered, acceptance-based, multi-modal palliative care intervention that addresses advance care planning (ACP) and unmet psychological needs commonly experienced by adults with metastatic cancer. METHODS: A two-armed, prospective randomized controlled trial (RCT) randomizes 240 adults with Stage IV (and select Stage III) solid tumor cancer who report moderate to high anxiety or depression symptoms to either the multi-modal intervention or usual care. The intervention comprises five weekly two-hour group sessions (plus a booster session one month later) delivered via video conferencing, with online self-paced modules and check-ins completed between the group sessions. Intervention content is based on Acceptance and Commitment Therapy (ACT), an acceptance, mindfulness, and values-based model. Participants are recruited from a network of community cancer care clinics, with group sessions led by the network's oncology clinical social workers. Participants are assessed at baseline, mid-intervention, post-intervention, and 2-month follow-up. The primary outcome is ACP completion; secondary outcomes include anxiety and depression symptoms, fear of dying, and sense of life meaning. Relationships between anxiety/depression symptoms and ACP will be evaluated cross-sectionally and longitudinally and theory-based putative mediators will be examined. DISCUSSION: Among adults with advanced cancer in community oncology settings, this RCT will provide evidence regarding the efficacy of the group ACT intervention on ACP and psychosocial outcomes as well as examine the relationship between ACP and anxiety/ depression symptoms. This trial aims to advance palliative care science and inform clinical practice. TRIAL REGISTRATION: Clinicaltrials.gov NCT04773639 on February 26, 2021.

Cancer survivors' cancellations of healthcare appointments during the COVID-19 pandemic: Associations with anxiety and depression.

OBJECTIVE: Though it is well-documented that cancer survivors experienced healthcare delays during the COVID-19 pandemic, who initiated those delays has not been examined. This longitudinal study distinguishes rates of patient-from provider-cancelled healthcare appointments at three timepoints during the pandemic, and examines psychosocial factors associated with patient-cancelled appointments. METHODS: Cancer survivors (N = 147) in the United States completed psychosocial and health behavior measures three times between May and December 2020. We examined rates of patient- and provider-cancelled healthcare appointments, including cancer screening appointments, at each timepoint and change between timepoints. Logistic regression was used to determine if anxiety symptoms, depression symptoms, and COVID-19 fears were associated with self-cancelled healthcare appointments. RESULTS: In May 2020, one third (33.79%) of participants reported one or more self-cancelled appointments within the prior 2 months and nearly half (45.89%) reported one or more provider-cancelled appointments. Rates of provider-cancelled appointments decreased to 35.71% in June/July 2020 and to 9.24% in November/December 2020 (both reflected p < 0.05 reductions compared to the previous timepoint). Rates of self-cancelled appointments, however, remained more stable (ps > 0.144). In June/July and November/December 2020, higher depression and anxiety symptoms, but not COVID-19 fears, were associated with greater likelihood of self-cancelled appointments. CONCLUSIONS: Cancer survivors cancelled their healthcare appointments at a stable rate even as provider-cancelled appointments declined. Depression and anxiety symptoms, but not COVID-19 concerns, were associated with patient cancellations. Interventions that address anxiety and depression symptoms may help to promote adherence to cancer survivorship care during the pandemic.

A mixed-methods study of the technical feasibility and patient acceptability of a real-time adherence monitor in breast cancer survivors taking adjuvant endocrine therapy.

PURPOSE: Oral anti-cancer medications are increasingly common and endocrine therapies represent the most common oral anti-cancer medications in breast cancer. Adjuvant endocrine therapies reduce the likelihood of recurrence and mortality in the approximately 80% of women diagnosed with hormone-receptor-positive breast cancer, thus rendering adherence essential. Real-time medication adherence monitors, such as the Wisepill electronic pillbox, transmit adherence data remotely, allowing for early intervention for non-adherence. However, their feasibility and acceptability have yet to be examined among breast cancer survivors taking endocrine therapies. METHODS: This study presents quantitative patient-report and technical support data and qualitative patient acceptability data on Wisepill, a common real-time adherence monitor, among 88 breast cancer survivors prescribed adjuvant endocrine therapy. RESULTS: This mixed-methods study of a common real-time adherence monitor, among the first in breast cancer survivors taking adjuvant endocrine therapy, demonstrates its technical feasibility and patient acceptability. CONCLUSION: The use of wireless medication monitors that transmit real-time adherence data is uniquely promising for maximizing the benefits of adjuvant endocrine therapy by allowing for continuous tracking, ongoing communication with oncologic or research teams, and early intervention. This study demonstrates the feasibility and patient acceptability of one such real-time adherence monitor.

Randomized Controlled Pilot Trial of a Low-Touch Remotely-Delivered Values Intervention to Promote Adherence to Adjuvant Endocrine Therapy Among Breast Cancer Survivors.

BACKGROUND: Oral anti-cancer treatments such as adjuvant endocrine therapies (AET) for breast cancer survivors are commonly used but adherence is a challenge. Few low-touch, scalable interventions exist to increase ET adherence. PURPOSE: To evaluate the acceptability, feasibility, and initial efficacy of a low-touch, remotely-delivered values plus AET education intervention (REACH) to promote AET adherence. METHODS: A mixed-methods trial randomized 88 breast cancer survivors 1:1 to REACH or Education alone. Wisepill real-time electronic adherence monitoring tracked monthly AET adherence during a 1-month baseline through 6-month follow-up (FU) (primary outcome). Patient-reported outcomes were evaluated through 3- and 6-month FU (secondary). Multiple indices of intervention feasibility and acceptability were evaluated. Qualitative exit interviews (n = 38) further assessed participants' perceptions of feasibility/acceptability and recommendations for intervention adaptation. RESULTS: The trial showed strong feasibility and acceptability, with an eligible-to-enrolled rate of 85%, 100% completion of the main intervention sessions, and "good" intervention satisfaction ratings on average. For Wisepill-assessed AET adherence, REACH outperformed Education for Month 1 of FU (p = .027) and not thereafter. Participants in REACH maintained high adherence until Month 4 of FU, whereas in Education, adherence declined significantly in Month 1. Conditions did not differ in self-reported adherence, positive affective attitudes, future intentions, or necessity beliefs. REACH trended toward less negative AET attitudes than Education at 3-month FU (p = .057) reflecting improvement in REACH (p = .004) but not Education (p = .809). Exploratory moderator analyses showed that average to highly positive baseline AET affective attitudes and oncologist-patient communication each predicted higher adherence following REACH than Education; low levels did not. Participants identified recommendations to strengthen the interventions. CONCLUSIONS: REACH, a low-touch values intervention, showed good feasibility and acceptability, and initial promise in improving objectively-assessed AET adherence among breast cancer survivors (relative to education alone). Future research should target improving REACH's tailoring and endurance.

Transitions in coping profiles after breast cancer diagnosis: implications for depressive and physical symptoms.

The objective of this study was to determine whether: (a) cancer-related coping profiles change across time; (b) coping profile transition types predict changes in depressive and physical symptoms. Latent transition analysis was conducted with repeated measures of seven cancer-related coping processes from 460 women recently diagnosed with breast cancer. In multilevel models, coping profile transition groups were entered as predictors of symptoms across 12 months. Three coping profiles emerged at study entry, with two profiles at later assessments. Forty-eight percent of women maintained high-moderate approach-oriented coping over time. Specific factors (e.g., age, acceptance of emotions) differentiated the transition groups. Women who increased and then maintained high-moderate approach-oriented coping had relatively high initial depressive symptoms that declined steeply. When cancer-related acceptance predominated, women experienced increasing physical symptoms. Distinct cancer-related coping patterns are related to the level of and change in depressive and physical symptoms longitudinally. Early intervention to increase approach-oriented coping strategies could yield favorable outcomes.

Correspondence Between Objective and Self-reported Endocrine Therapy Adherence Among Women With Breast Cancer.

BACKGROUND: Among the approximately 70% of women with hormone receptor-positive breast cancer, endocrine therapies lower the likelihood of recurrence. Nonadherence to endocrine therapy predicts lower survival. PURPOSE: We examined concordance between self-reported and objective indicators of adherence and predictors of over-reporting endocrine therapy adherence among survivors of breast cancer. METHODS: Women with breast cancer (N = 112) receiving their initial endocrine therapy prescription completed three assessments at prescription initiation (Time 1), 1 month (Time 2), and 4 months later (Time 3). At Time 1, participants were provided a medication event monitoring system (MEMS) cap to assess adherence; it was collected at Time 3. Women completed items regarding self-reported adherence, depressive symptoms, cancer-related coping processes, and the patient-physician relationship. RESULTS: MEMS was significantly negatively correlated with the self-reported nonadherence measurements of occasionally forgetting (Time 2, ρ = -.29, p < .01; Time 3, ρ = -.24, p < .01), nonadherence in the past week (Time 2, ρ = -.53, p < .01; Time 3, ρ = -.45, p < .01), and nonadherence in an average week in the past month (Time 2, ρ = -.38, p < .01; Time 3, ρ = -.39, p < .01). Concordance in objective and self-reported adherence measures was evident in 83% of women at Time 2 and 73% at Time 3. Older age was significantly associated (p < .01) with discordance. CONCLUSIONS: Findings reveal moderate correspondence between objective and self-report measures, with self-report overestimating objective adherence. Clinicians should be aware when treating older breast cancer survivors that they are more likely to over self-report their endocrine therapy adherence.

Quality of Life in Patients With Pancreatic Cancer and Their Caregivers: A Systematic Review.

Little is known about quality of life (QOL) of patients with pancreatic cancer and their caregivers compared with adults with other cancers. This systematic review summarizes the available evidence base, identifies its limitations, and recommends directions for research and clinical application. A systematic review was conducted of research on QOL in adults with pancreatic cancer and their caregivers. Quality of life was examined in the following specific domains: psychological, physical, social, sexual, spiritual, and general. Of the 7130 articles reviewed, 36 studies met criteria for inclusion. Compared with healthy adults or population norms, adults with pancreatic cancer had worse QOL across all domains. Compared with patients with other cancer types, patients with pancreatic cancer evidenced worse psychological QOL. Physical and social QOL were either similar or more compromised than in patients with other cancers. Limited data preclude conclusions about sexual, spiritual, and caregiver QOL. Patients with pancreatic cancer evidence decrements in multiple QOL domains, with particular strain on psychological well-being. Methodological limitations of available studies restrict definitive conclusions. Future research with well-defined samples, appropriate statistical analyses, and longitudinal designs is needed. Findings from this review support the merits of distress screening, integration of mental health professionals into medical teams, and attention to caregiver burden.

Prospective investigation of social support, coping, and depressive symptoms: A model of adherence to endocrine therapy among women with breast cancer.

OBJECTIVE: Nonadherence reduces the effectiveness of behavioral change regimens for promoting health and decreasing morbidities and mortality. Such is the case with endocrine therapies, which lower the likelihood of recurrence in the approximately 70% of women with hormone receptor-positive breast cancers. This investigation tests a model of contributors to objective adherence. METHOD: Women with breast cancer receiving their 1st endocrine therapy prescription (N = 130) were recruited from a large community oncology breast clinic. Participants completed three interview and questionnaire sessions at prescription initiation, one month and four months later. Questionnaires addressed patients' experience with cancer and included measures of coping (COPE and Emotional Approach Coping), social support (Interpersonal Support Evaluation List), and depressive symptoms (Center for Epidemiologic Studies Depression Scale). At the initial appointment, participants were provided a Medication Event Monitoring System (MEMS) cap to assess adherence; the MEMS cap was collected at the 4-month follow-up appointment. RESULTS: Structural equation modeling offered partial support for a mediational model, χ2(68, N = 130) = 77.47, p = .202, root-mean-square error of approximation = .03, comparative fit index = .97, standardized root-mean-square residual = .06. Greater social support at prescription initiation was associated with lower depressive symptoms 1 month later, which in turn were associated with higher objective adherence (MEMS) four months after study entry, controlling for significant covariates (p < .05). Use of avoidance-oriented coping was not statistically significantly related to depressive symptoms (p > .05). CONCLUSIONS: This model informs theory regarding medication adherence as well as intervention development for women prescribed adjuvant endocrine therapy. (PsycINFO Database Record

Barriers to and facilitative processes of endocrine therapy adherence among women with breast cancer.

The treatment of chronic illness, and the prevention of disease progression and recurrence, often involve long-term adherence to prescription medications in breast cancer. Despite the survival benefit of endocrine therapies, nonadherence remains high. In this study, we examined barriers to and facilitators of endocrine therapy adherence among women with breast cancer (n = 1371). Participants currently taking tamoxifen or aromatase inhibitors were recruited from Dr. Susan Love Research Foundation's Army of Women(®) Registry. Participants responded online to open-ended and close-ended questions about thoughts, feelings, and behaviors relevant to endocrine therapy. Two weeks later, women were invited to complete a second online questionnaire regarding current endocrine therapy adherence. Approximately one-third (36 %) of participants reported the presence of factors that make endocrine therapy difficult; reporting any barrier to medication adherence was significantly associated with nonadherence (P < 0.001). In addition, 31 % of women used one or more strategies to maintain their motivation to adhere and the use of cognitive self-talk (e.g., thoughts regarding endocrine therapy efficacy) was related to higher adherence. Hierarchical linear regressions revealed a significant behavioral barrier × behavioral facilitator interaction (P < 0.05); participants who endorsed a behavioral barrier in the absence of a behavioral facilitator reported the lowest adherence. Findings suggest that a sizeable minority of women face barriers to taking endocrine therapy, which are associated with nonadherence.