Trends in Endometrial Cancer Incidence in the United States by Race/Ethnicity and Age of Onset from 2000 to 2019.

Endometrial cancer is one of few cancers that has continued to rise in incidence over the past decade with disproportionate increases in adults younger than 50 years old. We used data from the Surveillance, Epidemiology, and End Results Registry (2000-2019) to examine endometrial cancer incidence trends by race/ethnicity and age of onset among women in the United States. Case counts and proportions, age-adjusted incidence rates (per 100,000), and average annual percent changes were calculated by race/ethnicity, overall and stratified by age of onset (early vs late). We found a disproportionate increase in endometrial cancer incidence among women of color, for both early and late onset endometrial cancer. The highest increases in early onset endometrial cancer (<50 years old) were observed among American Indian/Alaska Native women (4.8), followed by Black (3.3), Hispanic/Latina (3.1), and Asian and Pacific Islander women (2.4), whereas white women (0.9) had the lowest increase. Late onset (>50 years old) endometrial cancer incidence followed a similar pattern, with the greatest increases for women of color. The increasing burden of endometrial cancer among women of color, particularly those younger than 50 years old, is a major public health problem necessitating further research and clinical efforts focused on health equity.

Clinical, demographic factors, and substance use among Hispanic and non-Hispanic young adult childhood cancer survivors.

PURPOSE: The purpose of this study is to examine the protective and risk factors of substance use behaviors (tobacco, marijuana, e-cigarette, and alcohol) among young adult childhood cancer survivors. The study focused on clinical (receipt of cancer-related follow-up care, treatment intensity, late effects, depressive symptoms, self-rated health) and demographic (race/ethnicity, neighborhood socioeconomic status) factors and their associations with substance use. METHODS: Participants were from the Project Forward cohort, a population-based study of young adult survivors of childhood cancers. Participants (N = 1166, Mage = 25.1 years) were recruited through the Los Angeles Cancer Surveillance Program (Cancer Registry covering Los Angeles County, California). Multivariate path analyses were performed with substance use as the outcome variables and clinical and demographic factors as independent variables. Covariates included age and sex. FINDING: Substance use was positively associated with depressive symptoms, and inversely associated with cancer-related follow-up care, female sex, age, Hispanic ethnicity, treatment intensity, and self-rated health. Neighborhood SES was inversely associated with tobacco use, while being positively associated with binge drinking and e-cigarette use. The results highlight the interrelationship between the clinical and demographic variables and their associations with different substance use. CONCLUSION: Findings support the need for effective interventions targeting substance use behavior among CCS. This will help improve long-term outcomes and mitigate the risk for early morbidity.

Goal-Focused Emotion-Regulation Therapy (GET) in Young Adult Testicular Cancer Survivors: A Randomized Pilot Study.

BACKGROUND: Young adult testicular cancer survivors experience adverse impacts after treatment. We developed Goal-focused Emotion-regulation Therapy (GET) to improve distress symptoms, emotion regulation, and goal navigation skills. PURPOSE: This pilot study examined GET versus an active control intervention in young adult survivors of testicular cancer. METHODS: Seventy-five eligible survivors treated with chemotherapy were randomized to receive GET or Individual Supportive Listening (ISL). Study acceptability, engagement, and tolerability were examined, and intervention fidelity and therapeutic alliance were compared between arms. Preliminary efficacy was evaluated by effect sizes for between-group changes in primary (anxiety and depressive symptoms) and secondary (career confusion, goal navigation, and emotion regulation) outcomes from baseline to immediately and 3-month post-intervention. RESULTS: Among the 38 men randomized to GET, 81.1% completed all study sessions compared with 82.4% of the 37 men assigned to ISL. Fidelity to the intervention was 87% in GET. Therapeutic alliance wassignificantly higher among those receiving GET versus ISL. Participants exhibited a medium group-by-time effect size with greater reductions in depressive (d = 0.45) and anxiety (d = 0.29) symptoms for those in GET versus ISL, with a similar pattern at 3 months for depressive (d = 0.46) and anxiety (d = 0.46) symptoms. CONCLUSIONS: GET is a feasible and acceptable intervention for reducing adverse outcomes after testicular cancer for young adults. Observed effect sizes preliminarily suggest meaningful change, though should be interpreted with caution in small samples. GET may be a developmentally-matched behavioral approach to improve psychosocial function in this cancer group. CLINICAL TRIAL INFORMATION: Clinicaltrials.gov, NCT04150848. Registered on October 28, 2019.

Young adult testicular cancer survivors experience adverse impacts after treatment. Goal-focused Emotion-regulation Therapy (GET) was developed to improve distress symptoms, emotion regulation, and goal navigation skills. The aim of this pilot study was to examine GET versus a control intervention in young adult survivors of testicular cancer. Seventy-five survivors were randomly assigned to GET or Individual Supportive Listening (ISL). Indictors of acceptability, engagement, and tolerability were examined, and intervention fidelity and therapeutic alliance were compared between groups. Between-group changes in primary (anxiety and depressive symptoms) and secondary (career confusion, goal navigation, and emotion regulation) outcomes from baseline to immediately and 3-month post-intervention were examined. Among GET participants, 81.1% completed all study sessions compared with 82.4% of those receiving ISL. Fidelity to the intervention was 87% in GET. Therapeutic alliance scores were significantly higher among those receiving GET. Participants exhibited greater reductions in depressive and anxiety symptoms for those in the GET versus ISL, with a similar pattern observed for changes at 3 months for depressive and anxiety symptoms. GET is a feasible and acceptable intervention for reducing adverse outcomes after testicular cancer for young adults.

Peer victimization and relationships to approach and avoidance coping to health and health behaviors.

Peer victimization during high school is a common experience associated with engagement in risky health behaviors and elevated depressive symptoms. Mechanisms linking peer victimization to health outcomes remain inadequately understood. In the current study, latent class analysis was used to identify latent subclasses of college students who display similar patterns of responses to frequent peer victimization experiences during high school. We also examined moderating and mediating effects of coping (approach/avoidance) on relationships between victimization class and health outcomes (i.e., binge drinking, current smoking, depressive symptoms). College students completed questionnaire measures of peer victimization, approach and avoidance coping, binge drinking, smoking, and depressive symptoms. Four distinct patterns of peer victimization were identified among college students (Low, High, Moderate, and Social/Verbal). Moderation models revealed significant interactions of moderate victimization x approach coping on depressive symptoms and high victimization x avoidance coping on binge drinking. Mediation models revealed a significant indirect effect of avoidance coping on depressive symptoms for those in the high victimization class. Findings provide a greater understanding of the complex patterns of peer victimization. Coping efforts among varying peer victimization classes had different relationships with health outcomes during the college years. Interventions aimed at reducing health-risk and depressive symptoms among college student might benefit from increased attention to high school victimization experiences and current coping processes.Supplemental data for this article is available online at https://doi.org/10.1080/08964289.2021.1946468 .

Disparities in health-related quality of life among lesbian, gay, and bisexual cancer survivors.

OBJECTIVE: This study compared health-related quality of life (HRQOL) among lesbian, gay, and bisexual (LGB) cancer survivors and their heterosexual counterparts in a US population-based sample of cancer survivors. METHODS: The study utilized data from the All of Us research program. LGB survivors (n = 885) were matched for age, gender identity, marital status, income, education, and cancer site with heterosexual survivors (n = 885) using 1:1 propensity matching. Physical, mental, and social HRQOL were assessed with items from the Patient-Reported Outcomes Measurement Information System (PROMIS). RESULTS: Relative to heterosexuals, LGB cancer survivors reported lower HRQOL in mental and social domains, but not in physical HRQOL. Older age was associated with higher HRQOL across domains. LGB survivors identifying as Black/African American were more likely to experience lower social HRQOL than White survivors. CONCLUSIONS: This study highlights several disparities in HRQOL that exist between LGB and heterosexual cancer survivors.

Social constraints and cancer-related quality of life in single and partnered young adult testicular cancer survivors: a contextual approach.

To examine the context of relationship status on the link between friends/family social constraints (SCff) and cancer-related quality-of-life (QOL) among young adult testicular cancer survivors.Participants completed the Functional Assessment of Cancer Therapy (general version), the Social Constraints Scale (friends/family), and demographic questions.The sample included 162 young adult testicular cancer survivors.SCff, but not relationship status, significantly predicted QOL when controlling for age, time since diagnosis, education, and income. The SCff X relationship status interaction was significant such that SCff were more strongly related to lower QOL for single survivors than for partnered survivors.Focusing on friends and family support of young adult survivors, findings highlight the vulnerability of single survivors to social constraints within their diffuse social network. Interventions that target supportive exchanges in friends and family networks may be useful in improving QOL in single young adult cancer survivors.

Emotional approach coping among young adults with cancer: Relationships with psychological distress, posttraumatic growth, and resilience.

OBJECTIVE: Cancer, particularly, during young adulthood, can evoke difficult emotions, interfere with normative developmental activities, and challenge coping responses. Emotion-regulating coping efforts aimed at active emotional processing (EP) and emotional expression (EE) can be beneficial to cancer adjustment and perceptions of positive growth. However, it may be that EP and EE work differently to influence well-being. This study examines relationships of EP and EE with psychological distress, posttraumatic growth (PTG), and resilience. We expect that EP will be positively associated with PTG and resilience, whereas EE will be negatively associated with psychological distress. METHODS: Young adults with cancer (M age  = 34.68, N = 57) completed measures of emotional; approach coping (EP and EE), psychological distress (depressive symptoms, fear of cancer; recurrence [FCR]) and indicators of positive adjustment and growth (resilience and PTG). RESULTS: Greater use of EP was associated with higher resilience (ß = 0.48, p = 0.003) and PTG (ß = 0.27, p = 0.05), whereas greater use of EE was associated with lower resilience (ß = -0.33, p = 0.04). The EE × EP interaction was significant for FCR (ß = 0.29, p = 0.04) such that low EE was associated with lower FCR in those with high EP. Interaction effects were not significant for depressive symptoms, resilience, or PTG. CONCLUSIONS: Findings highlight differing relationships between EP and EE among young adults with cancer. Interventions aimed at increasing emotion-regulating coping strategies may prove useful in facilitating positive adjustment and growth, strengthening young adults' ability to cope with the diverse effects of disease, treatment, and survivorship.

American Cancer Society prostate cancer survivorship care guidelines.

Prostate cancer survivors approach 2.8 million in number and represent 1 in 5 of all cancer survivors in the United States. While guidelines exist for timely treatment and surveillance for recurrent disease, there is limited availability of guidelines that facilitate the provision of posttreatment clinical follow-up care to address the myriad of long-term and late effects that survivors may face. Based on recommendations set forth by a National Cancer Survivorship Resource Center expert panel, the American Cancer Society developed clinical follow-up care guidelines to facilitate the provision of posttreatment care by primary care clinicians. These guidelines were developed using a combined approach of evidence synthesis and expert consensus. Existing guidelines for health promotion, surveillance, and screening for second primary cancers were referenced when available. To promote comprehensive follow-up care and optimal health and quality of life for the posttreatment survivor, the guidelines address health promotion, surveillance for prostate cancer recurrence, screening for second primary cancers, long-term and late effects assessment and management, psychosocial issues, and care coordination among the oncology team, primary care clinicians, and nononcology specialists. A key challenge to the development of these guidelines was the limited availability of published evidence for management of prostate cancer survivors after treatment. Much of the evidence relies on studies with small sample sizes and retrospective analyses of facility-specific and population databases.

Furthering the Focus on Translational Sleep Science in Behavioral Medicine.

Translational sleep science has become a critical and fundamental focus in the field of behavioral medicine. This is the second issue in the special series of the International Journal of Behavioral Medicine focused on the physiological, psychological, social, and environmental concomitants of sleep and human health. The articles included in this issue draw further attention to the range and significance of sleep as a marker of health status and as a target of behavioral intervention. The research included in this series highlights the pervasive manner in which sleep health is intrinsically connected to health risk, behavior, and outcomes. The next decade promises to further behavioral medicine approaches to improving the provision of care and the overall public health through the implementation of translational sleep science research.

Sleep Quality in Young Adult Informal Caregivers: Understanding Psychological and Biological Processes.

BACKGROUND: Providing informal care for a relative or friend with medical or mental needs can extol a physical burden on the caregiver, including impaired aspects of sleep quality such as suboptimal sleep duration, lengthened sleep latency, frequent awakenings, daytime sleepiness, and poor self-rated sleep quality. Diminished sleep quality can worsen the health in the caregiver, including dysregulation of hypothalamic-pituitary-adrenal axis (HPA) activity. Few studies have attempted to describe sleep in young adults who provide regular informal care. This study examines subjective and objective indicators of sleep quality and diurnal cortisol rhythms among young adult caregivers relative to non-caregiving peers. We expect that caregivers will exhibit poorer objective and subjective sleep quality and greater dysregulation in diurnal cortisol indices, than demographically similar non-caregivers, and that caregivers with poorer sleep will exhibit pronounced cortisol dysregulation. METHODS: Participant self-reported sleep quality over the prior month via the Pittsburgh Sleep Quality Index and objective sleep quality was observed via wrist actigraph for three consecutive days. Diurnal salivary cortisol was also measured across the three days of actigraph monitoring. RESULTS: Informal caregivers exhibited more self-reported sleep disturbance and greater sleep latency than non-caregivers, as well as more objectively measured sleep fragmentation. Caregivers with a shorter sleep duration were observed to have flatter diurnal cortisol slopes than caregivers with a relatively longer sleep duration. CONCLUSIONS: Young adult caregivers appear to be at risk for impairment in sleep quality, which in turn might impact health through HPA axis dysregulation. Longitudinal research is needed to identify these relationships across time.

Emotional processing writing and physiological stress responses: understanding constructive and unconstructive processes.

Writing about emotions related to a life stressor is thought to promote coping via emotional processing. However, all styles of emotional processing may not be beneficial to managing stress. Such styles can include constructive (planning/problem-solving, meaning-making) and unconstructive (rumination, worry) forms. This study utilised a randomised experimental design to examine the physiological impact (as indexed by heart rate variability, salivary cortisol reactivity and recovery) of expressive writing with guidance to promote constructive and discourage unconstructive styles (EP+) versus expressive writing with no guidance (EP). Participants (N = 151) engaged in three sessions of expressive writing anchored to a self-nominated stressor over three days. Stress reactivity was measured two weeks later in response to a stress recall task. There was no effect of group on cortisol reactivity, cortisol recovery, or HRV reactivity. However, there was a significant interaction of group and subjective stressfulness of the nominated stressor was observed, such that EP+ was associated with greater cortisol recovery. Those with more taxing stressors may be better equipped to process emotions with guidance on emotional processing styles.

Using a Biopsychosocial Model to Understand Long-Term Outcomes in Persons With Burn Injuries.

OBJECTIVE: To determine the importance of preburn adjustment, injury-related variables, and selection of coping style in various outcome measures using a biopsychosocial model. DESIGN: Longitudinal study. SETTING: Outpatient burn clinics. PARTICIPANTS: Burn survivors (N=231) who participated in this study as part of a larger burn model system study of 645 patients with major burn injuries. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 36-Item Short-Form Health Survey was used to assess preburn adjustment. Other outcome measures entered into the model included the Ways of Coping Checklist Revised, the Brief Symptom Inventory, the Beck Depression Inventory-II, and the Davidson Trauma Scale. RESULTS: Correlational and mediational analyses revealed that preburn emotional health predicted better adjustment at year 1 and more posttraumatic stress disorder symptoms at year 2. Better preburn emotional health was also related to less use of avoidance coping strategies, which was found to be a mediator of the effect of preburn emotional health and posttraumatic stress disorder symptoms. Burn injury characteristics were not significantly associated with psychological adjustment at either year 1 or year 2. CONCLUSIONS: The results indicate that there is a complex relation between premorbid mental health and the selection of coping strategies that affect long-term adjustment in persons recovering from a burn injury. This relation seems to have greater effect on long-term outcomes than does preburn emotional or physical health alone or the severity of the burn.

Salivary Bioscience and the Future of Behavioral Medicine.

Behavioral medicine research from across the globe has been catalyzed by the quest to understand the interactions between psychological, social, and physiological factors underlying disparities in human health. A more complete biopsychosocial model increasingly integrates advanced clinical and laboratory assessments of relevant environmental chemicals, biological mediators of inflammation, cardiometabolic and endocrine markers, infectious disease exposure, and genetic polymorphisms determined from saliva specimens. The overarching aims are to identify mechanisms, decode moderating processes that translate adversity into risk, and verify the impact of clinical intervention. This special issue of the International Journal of Behavioral Medicine highlights novel contributions of salivary bioscience with emphasis on research utilizing varied research designs (i.e., experimental, longitudinal, dyadic), incorporating a broad array of salivary analytes, and investigating the influence of psychological and social factors on human health.

The experience of financial stress among emerging adult cancer survivors.

Objective: The experience of cancer-related financial stress was examined within the developmental context of emerging adulthood.Methodological approach: This study is a secondary analysis of data drawn from two samples of testicular or hematologic cancer survivors. In-depth interviews from 52 emerging adult (EA) cancer survivors, ages 18-29, were coded by combining thematic analysis with an abductive approach.Findings: Emergent themes included some common to most age groups, including worries about medical costs and availability of health insurance, as well as specific age-related concerns, such as fertility preservation. Financial stress appeared to interrupt developmental tasks of emerging adulthood, including completing an education, establishing independence, and managing relationships. Surprisingly, financial stress was experienced as a benefit for some participants.Conclusion: Financial stress affects EA cancer survivors in unique ways. To provide support, health professionals should consider survivors' developmental life stage to understand their financial stress, and ultimately, to improve quality of life.

Feasibility and acceptability of cognitive behavioral therapy for insomnia (CBT-I) or acupuncture for insomnia and related distress among cancer caregivers.

OBJECTIVE: Insomnia is a common, distressing, and impairing psychological outcome experienced by informal caregivers (ICs) of patients with cancer. Cognitive behavioral therapy for insomnia (CBT-I) and acupuncture both have known benefits for patients with cancer, but such benefits have yet to be evaluated among ICs. The purpose of the present study was to evaluate the feasibility, acceptability and preliminary effects of CBT-I and acupuncture among ICs with moderate or greater levels of insomnia. METHOD: Participants were randomized to eight sessions of CBT-I or ten sessions of acupuncture. RESULTS: Results highlighted challenges of identifying interested and eligible ICs and the impact of perception of intervention on retention and likely ultimately outcome. SIGNIFICANCE OF THE RESULTS: Findings suggest preliminary support for non-pharmacological interventions to treat insomnia in ICs and emphasize the importance of matching treatment modality to the preferences and needs of ICs.

Relational processes and psychological adjustment among young adults with cancer: The role of technology-related communication.

OBJECTIVE: Little attention has been paid to understanding how engaging in cancer-related interpersonal exchanges via varying modes of communication influences psychological well-being among young adults with cancer. This study explored the moderating role of communication mode on the relationship of relational processes of disclosure and responsiveness with psychological well-being. METHODS: 61 young adults with cancer (Mage = 34.59, SD = 4.82) completed a questionnaire about their most recent cancer-related conversation. Participants reported on communication mode (ie, face-to-face, text message, and phone call) and relational processes of self- and support member- disclosure of thoughts, information, and feelings and how accepted, cared for, and understood they felt within the cancer-related conversation. Cancer adjustment measures included functional well-being and depressive symptoms. RESULTS: There were no main effects of communication mode or relational processes. However, communication mode did moderate the relationship between relational processes and cancer adjustment. Greater relational processes of disclosure and responsiveness were associated with better functional well-being and lower depressive symptoms only among those who engaged in their most recent cancer-related conversation through technology-related communication and not for those engaged in face-to-face communication. CONCLUSION: Relational processes that are likely to benefit psychological adjustment after cancer appear to be particularly advantageous over technology-based communication. Young adults commonly report feelings of social isolation and psychological distress after cancer. These findings suggest that technology-related communication holds promise as a way to strengthen support-related communication and protect against distress.

Benefit finding and diurnal cortisol after prostate cancer: The mediating role of positive affect.

OBJECTIVE: Benefit finding (BF) has exhibited a salutary effect on psychological adjustment to cancer. However, few studies have examined its relationship with physiology or have examined BF in men with cancer. This study investigated whether BF is associated with hypothalamic-pituitary-adrenal axis activity (ie, diurnal salivary cortisol) in men treated for prostate cancer. Positive affect (PA) is proposed as a potential pathway linking BF to diurnal salivary cortisol. METHODS: A sample of 66 men treated for localized prostate cancer within the prior 2 years completed questionnaires and collected salivary cortisol 3 times per day over 3 consecutive days. Hierarchical linear modeling was used for estimating the effects of BF and PA on cortisol responses as measured by diurnal slope and area under the curve (AUCg). Confidence intervals for indirect effects were estimated using the Monte Carlo method for mediation testing. RESULTS: BF was significantly associated with diurnal cortisol slope, controlling for body mass index and age (B = -.12, P = .03), such that greater BF was associated with steeper cortisol slope. Analyses revealed that PA mediated the effect of BF on cortisol slope (Monte Carlo estimation 95% CI = -0.087, -0.001); negative affect did not mediate this relationship. BF was not significantly associated with AUCg. CONCLUSIONS: Deriving more benefit from one's experience with prostate cancer is associated with a healthier diurnal cortisol rhythm. Through its potential to enhance PA, the relationship of BF and physiological processes underscores the health relevant value of BF in prostate cancer survivors.

Mechanisms of navigating goals after testicular cancer: meaning and emotion regulation.

OBJECTIVE: The navigation of major life goals can be challenging to cancer survivors, particularly during young adulthood. This study examined the relationships of goal navigation skills (e.g., goal identification, goal clarification, and goal adjustment) with having a sense of life meaning, emotion regulation coping processes, and physical and psychological health indicators in young adult survivors of testicular cancer. METHODS: Men ages 18 to 29 years (N = 171; M age = 25.2, SD = 3.32) with a history of testicular cancer were recruited via the California State Cancer Registry and completed questionnaire measures including assessments of goal navigation, sense of meaning, emotional approach coping, and indicators of physical and psychological well-being. RESULTS: Goal navigation skills were negatively related to depressive symptoms (r = -0.41, p < 0.01) and positively related to physical functioning (r = 0.28, p < 0.01). Controlling for participant age and months since diagnosis, mediation models revealed significant indirect effects of sense of meaning on depressive symptoms (-0.50, p < 0.05) and physical functioning (0.34, p < 0.05). Similarly, emotion-regulating coping had significant indirect effects on depressive symptoms (-0.08, p < 0.05) and physical functioning (0.11, p < 0.05) CONCLUSIONS: Consistent with a self-regulation framework, goal navigation skill is related to physical and psychological well-being via its association with maintenance of a sense of meaning as well as successful attempts at regulation of emotions. The study provides preliminary evidence that these skill-based processes relate to adjustment to cancer in young adults. Copyright © 2016 John Wiley & Sons, Ltd.

Masculine norms about emotionality and social constraints in young and older adult men with cancer.

Beliefs that men should restrict their display of emotions, or restrictive emotionality, might contribute to adjustment to cancer and this might be sensitive to social receptivity to disclosure. The present research examined relationships of restrictive emotionality, social constraints, and psychological distress in young adults with testicular cancer (N = 171; Study 1) and older men with prostate cancer (N = 66; Study 2). Study 1: positive associations were observed for social constraints and restrictive emotionality with depressive symptoms. Social constraints moderated the relationship, such that high restrictive emotionality was associated with higher depressive symptoms in those with high constraints. Study 2: only social constraints (and not restrictive emotionality) was positively associated with depressive symptoms and cancer-related intrusive thoughts. The social constraints × restrictive emotionality interaction approached significance with depressive symptoms, such with high social constraints low restrictive emotionality was associated with higher depressive symptoms compared to those with less constraints. No significant associations were found for intrusive thoughts in either study. Findings demonstrate unique relationships with psychological distress across the lifespan of men with cancer given perception of constraints and adherence to masculine norms about emotionality.

An emotional processing writing intervention and heart rate variability: the role of emotional approach.

Expressing and understanding one's own emotional responses to negative events, particularly those that challenge the attainment of important life goals, is thought to confer physiological benefit. Individual preferences and/or abilities in approaching emotions might condition the efficacy of interventions designed to encourage written emotional processing (EP). This study examines the physiological impact (as indexed by heart rate variability (HRV)) of an emotional processing writing (EPW) task as well as the moderating influence of a dispositional preference for coping through emotional approach (EP and emotional expression (EE)), in response to a laboratory stress task designed to challenge an important life goal. Participants (n = 98) were randomly assigned to either EPW or fact control writing (FCW) following the stress task. Regression analyses revealed a significant dispositional EP by condition interaction, such that high EP participants in the EPW condition demonstrated higher HRV after writing compared to low EP participants. No significant main effects of condition or EE coping were observed. These findings suggest that EPW interventions may be best suited for those with preference or ability to process emotions related to a stressor or might require adaptation for those who less often cope through emotional approach.