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1.  Prevalence, Predictors, and Characteristics of Off-Treatment Fatigue in Breast Cancer Survivors 
Cancer  2010;116(24):5740-5748.
Lack of consensus regarding how to identify cancer patients with significant fatigue has hampered research regarding cancer-related fatigue (CRF).
Specific criteria were used to identify CRF cases in women with stage 0-II breast cancer (BC group, n = 304). Women completed assessments before adjuvant therapy (baseline), end of adjuvant therapy (Post-Tx), and 6 and 42 months after end of adjuvant therapy (6 and 42 Month Post-Tx). At each, women completed a clinical interview and questionnaires assessing physical and mental health. A healthy control (HC) group with no history of BC (n = 337) completed 2 similar assessments 36 months apart.
Off-treatment CRF prevalence was 9% and 13% at the 6 and 42 Month Post-Tx assessments, respectively. Thus, 15% of the sample evidenced off-treatment CRF with 7% evidencing delayed onset CRF. CRF at the 6 Month Post-Tx assessment was associated only with CRF at baseline (OR = 3.2) and Post-Tx assessments (OR = 3.9). CRF at the 42 Month Post-Tx assessment was associated with CRF at the Post-Tx assessment (OR = 6.1), obesity at baseline, and several baseline measures of coping in response to fatigue. Off-treatment CRF cases differed markedly from CRF noncases and healthy controls on a spectrum of health status indices (mean effect size >1.0 SD).
Results document the prevalence of off-treatment and delayed onset CRF, suggest the utility of a cognitive-behavioral model of CRF, and support NCCN guidelines recommending monitoring fatigue across the cancer trajectory.
PMCID: PMC4048855  PMID: 20734399
fatigue; survivorship; assessment; outcomes; late effects
2.  Physical and Mental Health Status of Female Adolescent/Young Adult Survivors of Breast and Gynecological Cancer: A National, Population-Based, Case-Control Study 
Each year nearly 21,000 adolescents and young adults (AYA) ages 15 to 29 years are diagnosed with cancer. Breast and gynecological cancers account for 25% of the cancers seen in AYA females. The purpose of this study was to compare the current physical and mental health status of female AYA cancer survivors with non-cancer female controls.
Using data from the population-based 2009 National Health Interview Survey, 100 cases of female AYA survivors of breast and gynecological cancers were identified (FCS group). FCS cases were matched with 300 female respondents without a history of cancer on age, education, marital status, and minority status (NCC group). The FCS and NCC groups were compared on a range of physical and mental health status indices using analysis of covariance and binary logistic regression.
FCS group reported significantly poorer physical and mental health status than the matched controls. Relative to the NCC group, FCS survivors had significantly poorer scores on 7 of 8 mental health outcomes and were more likely to meet criteria for serious psychological distress (OR = 4.23, p ≤ 0.001). FCS group also reported greater lifetime and current prevalence of various medical conditions; more health-related disabilities; and greater functional limitations than the NCC group.
Diagnosis of breast and gynecological cancer during adolescence and young adulthood is associated with clinically important deficits in physical and mental health status. Given the young age of this cancer survivor cohort, increased attention should be devoted to minimizing these deficits.
PMCID: PMC3644006  PMID: 23306935
cancer; adolescent/young adult; survivorship; breast; gynecological
3.  Prolonged Impact of Chemotherapy on Fatigue in Breast Cancer Survivors 
Cancer  2011;118(15):3833-3841.
In this study, the authors examined the influence of prior treatment on the course of fatigue in breast cancer survivors. Patients who received chemotherapy were expected to have greater fatigue than patients who received radiotherapy and noncancer controls 6 months after the completion of treatment, but they were expected to recover to levels similar to those of the other 2 groups 3 years later.
Patients with stage 0 through II breast cancer completed the Fatigue Symptom Inventory (FSI) and the Profile of Mood States Fatigue Scale (POMS-FAT) 6 months (T1) and 42 months (T2) after completing chemotherapy with or without radiotherapy (the CT group; n = 103) or radiotherapy only (the RT group; n = 102). An age-matched group of women with no history of cancer (the NC group; n = 193) was assessed over a similar interval.
A significant (P = .041) group × time effect for FSI severity scores revealed that fatigue worsened over time in the CT group but remained stable and lower in the RT and NC groups. There also were significant group effects for FSI days (P < .001) and POMS-FAT (P = .010) scores, indicating that fatigue was significantly greater across time in the CT group than in the NC group (POMS-FAT) or the RT and NC groups (FSI days).
Contrary to expectations, fatigue did not diminish over time in patients with breast cancer who received chemotherapy. This finding has important implications for patient education and for fatigue monitoring during follow-up. The authors concluded that future research should seek to examine possible mechanisms to explain the apparent prolonged impact of chemotherapy on fatigue in breast cancer survivors.
PMCID: PMC4007757  PMID: 22086766
fatigue; breast cancer; chemotherapy; radiotherapy
4.  Factors associated with breast cancer worry three years after completion of adjuvant treatment 
Psycho-oncology  2012;22(4):936-939.
Although many survivors continue to worry about cancer years after completing treatment, little is known about factors associated with cancer worry. This study examined associations between breast cancer worry and demographic and clinical variables, as well as fatigue, symptom burden, and risk perception in a sample of breast cancer survivors three years post-adjuvant treatment. We hypothesized that after controlling for demographic and treatment factors, a significant proportion of variance in cancer worry would be explained by greater fatigue severity, more symptom burden, and greater perceived risk of recurrence.
Stage 0–II breast cancer patients (N = 202) completed measures of risk perception, cancer worry (modified Lerman's Cancer Worry Scale), symptom burden (Memorial Symptom Assessment Scale), and fatigue severity (Fatigue Symptom Inventory) three years after completing adjuvant treatment. Multiple regression analyses were used to determine the proportion of variance in cancer worry accounted for by fatigue, symptom burden, and risk perception after controlling for demographic and clinical variables.
Age, fatigue, symptom burden, and risk perception each explained a significant proportion of variance in cancer worry (p < .05). Fatigue, symptom burden, and risk perception together accounted for 27% of the variance in cancer worry after controlling for demographic and clinical factors (p < .01).
The hypothesis was supported that fatigue, symptom burden, and risk perception are associated with cancer worry among breast cancer survivors. It is possible that lingering fatigue and other symptoms may remind breast cancer survivors of their disease.
PMCID: PMC3392435  PMID: 22419546
breast cancer; worry; fatigue; symptom burden; risk perception; survivorship
5.  Physical and Mental Health Status and Health Behaviors of Childhood Cancer Survivors: Findings from the 2009 BRFSS Survey 
Pediatric blood & cancer  2011;58(6):964-970.
The growing number of childhood cancer survivors makes examination of their current physical and mental health status and health behaviors an important concern. Much of what is known about the long-term outcomes of childhood cancer survivors comes from the Childhood Cancer Cohort Study (CCSS) which uses sibling controls.
Using data from the 2009 Behavioral Risk Factor Surveillance System survey, 651 childhood cancer survivors and 142,932 non-cancer peer controls were identified. The two groups were compared on a variety of physical and mental health status and health behavior variables using ANCOVA and binary logistic regression.
While controlling for differences in age, sex, and minority status, survivors significantly (p ≤0.001) had poorer socioeconomic outcomes, more comorbid conditions, lower life satisfaction, less social and emotional support, poorer general health, and reported more days per month of poor physical and mental health than non-cancer individuals. Survivors were more likely to report being a current smoker (odds ratio [OR] = 2.33; 95% confidence interval [CI], 1.98 to 2.73; p<0.001); tested for human immunodeficiency virus (HIV) (OR = 1.79; 95% CI, 1.52 to 2.11; p<0.001); and that at least one HIV situation applied to them (OR = 2.06; 95% CI, 1.55 to 2.74; p<0.001). No significant differences were found between groups in regards alcohol use and diet.
Results support and extend previous findings reported by the CCSS. New findings regarding survivors’ increased likelihood to engage in risky behaviors proposes new directions for future research.
PMCID: PMC3332525  PMID: 22012636
childhood cancer survivors; physical health; mental health; health behaviors
6.  History of Major Depressive Disorder Prospectively Predicts Worse Quality of Life in Women with Breast Cancer 
Data are scarce about whether past history of major depressive disorder in the absence of current depression places breast cancer patients at risk for worse quality of life.
The current study prospectively examined quality of life during chemotherapy in breast cancer patients with a history of resolved major depressive disorder (n=29) and no history of depression (n=144).
Women with Stages 0–II breast cancer were assessed prior to and at the completion of chemotherapy. Major depressive disorder was assessed via structured interview and quality of life with the SF-36.
Patients with past major depressive disorder displayed greater declines in physical functioning relative to patients with no history of depression (p≤0.01).
Findings suggest that breast cancer patients with a history of resolved major depressive disorder are at increased risk for declines in physical functioning during chemotherapy relative to patients with no history of depression.
PMCID: PMC3424106  PMID: 22167580
7.  Breast Cancer Recurrence Risk Reduction Beliefs in Breast Cancer Survivors: Prevalence and Relation to Behavior 
Psycho-Oncology  2011;21(4):427-435.
There is a growing body of evidence suggesting breast cancer (BC) recurrence risk might be linked to behavioral factors. However, little is known about BC survivors' beliefs regarding the link between their behavior and recurrence risk. The objective of this study was to describe BC survivors' beliefs regarding performance of behaviors potentially associated with BC recurrence risk reduction, and to examine the link between these behaviors and BC recurrence risk reduction beliefs, worry, and risk perception.
200 female BC survivors (age, years: mean = 57.7, standard deviation = 9.2) completed a questionnaire assessing beliefs about the effectiveness of 14 potential BC recurrence risk reduction behaviors, their performance of these potential risk reduction behaviors, recurrence worry, and perception of personal lifetime BC recurrence risk.
The behaviors most frequently endorsed as potentially reducing BC recurrence risk included avoiding tobacco use (84%), exercising at least three times per week (74%), eating an average of five servings a day of fruits and vegetables (72%), and limiting food intake to maintain current weight or lose weight (70%). Multivariate logistic regression analyses predicting behavioral performance showed that beliefs were consistently associated with behavior while worry and risk perception were largely unrelated to behavior.
BC survivors' beliefs about the effectiveness of potential BC recurrence risk reduction behaviors are largely consistent with empirical findings and relate strongly to actual behavioral performance. Misconceptions about the effects of behavior to reduce BC recurrence risk are important targets for clinical and public health efforts.
PMCID: PMC3116938  PMID: 21312312
cancer; oncology; recurrence; prevention and control; behavior; survivors
8.  Cognitive Functioning After Cancer Treatment: A Three-Year Longitudinal Comparison of Breast Cancer Survivors Treated with Chemotherapy or Radiation and Non-cancer Controls 
Cancer  2011;118(7):1925-1932.
This study examined the influence of prior treatment on the course of cognitive functioning in breast cancer survivors. Changes in cognitive functioning over time were compared in breast cancer survivors treated with chemotherapy plus radiotherapy, breast cancer survivors treated with radiotherapy only, and women with no history of cancer.
Stage 0-II breast cancer patients treated with chemotherapy plus radiotherapy (CT group; n=62) or radiotherapy only (RT group; n=67) completed neuropsychological assessments 6 months after completing treatment (T1) and again 36 months later (T2). Women with no history of cancer (NC group; n=184) were assessed over a similar interval. RESULTS: A significant group X time effect was found for processing speed (p=.009) that reflected a tendency for the NC group but not the RT and CT groups to improve over time. There was also a significant group effect for executive functioning (p=.006) that reflected the NC group performing better than the CT and RT groups. Additional analyses found the administration of hormonal therapy was not associated with change over time in cognitive performance.
Findings provided limited support for the view that changes in cognitive functioning in cancer survivors are attributable to chemotherapy administration and illustrate the importance of including a radiotherapy comparison group. Future research should seek to examine possible mechanisms that could explain the apparent prolonged impact of both chemotherapy and radiotherapy on cognitive functioning in breast cancer survivors.
PMCID: PMC3305821  PMID: 22161750
cognitive function; breast cancer; chemotherapy; radiotherapy; survivorship
9.  Physical and Mental Health Status and Health Behaviors of Survivors of Multiple Cancers: A National, Population-Based Study 
Annals of Behavioral Medicine  2011;42(3):304-312.
Little is known about the unique experience of adults with a history of multiple cancer diagnoses (i.e, survivors of multiple cancers).
This research assessed the health status and health behaviors of survivors of multiple cancers.
The health status and health behaviors of 8734 survivors of multiple cancers, 47562 survivors of a single cancer, and 348229 non-cancer controls were compared using weighted data from the 2009 Behavioral Risk Factor Surveillance System.
Survivors of multiple cancers reported poorer physical and mental health status outcomes (e.g., more mental distress and greater activity limitations) than survivors of a single cancer (all p’s < .001) who reported poorer outcomes than controls (all p’s < .001). Survivors of multiple cancers reported unhealthier behaviors than survivors of a single cancer and healthier behaviors than controls on most health behavior outcomes (e.g., alcohol use, tobacco use, and diet) (all p’s < .001).
Data suggest the need for clinical interventions to enhance physical and mental health status, and to increase adoption of healthier behaviors in survivors of multiple cancers.
PMCID: PMC3319008  PMID: 21732227
Behavioral Risk Factor Surveillance System; Centers for Disease Control and Prevention; multiple neoplasms; quality of life; health behaviors; survivorship
10.  Cancer Recurrence Worry, Risk Perception, and Informational-Coping Styles among Appalachian Cancer Survivors 
Despite a growing literature on the psychosocial impact of the threat of cancer recurrence, underserved populations, such as those from the Appalachian region, have been understudied. To examine worry and perceived risk in cancer survivors, cancer patients at an ambulatory oncology clinic in a university hospital were surveyed. Appalachians had significantly higher worry than non-Appalachians. Cancer type and lower need for cognition were associated with greater worry. Those with missing perceived risk data were generally older, less educated, and lower in monitoring, blunting, and health literacy. Additional resources are needed to assist Appalachians and those with cancers with poor prognoses to cope with worry associated with cancer recurrence. More attention to prevention of cancer is critical to improve quality of life in underserved populations where risk of cancer is greater.
PMCID: PMC3322407  PMID: 21240722
Appalachian region; cancer; health disparities; oncology; perceived risk; psychosocial factors
11.  Psychological Health in Cancer Survivors 
Seminars in Oncology Nursing  2008;24(3):193-201.
The prevalence of both negative (distress) and positive responses (growth, well-being) to the cancer experience is examined and difficulties in establishing the prevalence of these responses discussed. A conceptual framework for understanding factors associated with psychological health in cancer survivors is presented. Finally, strategies for promoting psychological health in cancer survivors are examined.
Data Sources
Review of the literature.
Psychological health in cancer survivors is defined by the presence or absence of distress as well as the presence or absence of positive well-being and psychological growth. Furthermore, psychological health in cancer survivors is determined by the balance between two classes of factors: the stress and burden posed by the cancer experience and the resources available for coping with this stress and burden.
Implications for nursing practice
In general, promotion of psychological health is based upon the prevention or treatment of distress as well as the encouragement of growth and well-being. Periodic screening for psychological distress across the cancer trajectory is critical to appropriate management of distress.
PMCID: PMC3321244  PMID: 18687265
12.  Cancer Risk Assessment by Rural and Appalachian Family Medicine Physicians 
The Journal of Rural Health  2009;25(4):372-377.
Challenges to the identification of hereditary cancer in primary care may be more pronounced in rural Appalachia, a medically underserved region.
To examine primary care physicians’ identification of hereditary cancers.
A cross-sectional survey was mailed to family physicians in the midwestern and southeastern United States, stratified by rural/non-rural and Appalachian/non-Appalachian practice location (N=176). Identification of hereditary breast-ovarian cancer (BRCA1/2), hereditary non-polyposis colon cancer (HNPCC), and other hereditary cancers was assessed.
Less than half of physicians (45%) reported having patients with cancer genetic testing. Most (70%) correctly identified the BRCA1/2-relevant scenario; 49% correctly identified the HNPCC-relevant scenario. Factor analysis of psychosocial variables revealed 2 factors: Confidence (knowledge, comfort, confidence) and Importance (responsible, important, effective, need) of identifying hereditary cancer. Greater confidence was associated with use of 3 generation pedigree in taking family history. Greater knowledge and access to genetic services were associated with use of genetic testing. More recent graduation year, greater knowledge, and greater confidence were associated with identifying the BRCA1/2-relevant scenario. Greater knowledge and confidence were associated with identifying the HNPCC-relevant scenario.
Although rural Appalachian physicians do not differ in ability to identify high risk individuals, access barriers may exist for genetic testing. Interventions are needed to boost physician confidence in identifying hereditary cancer and to improve availability and awareness of availability of genetic services.
PMCID: PMC3319913  PMID: 19780917
hereditary cancer; physicians; primary care; psychosocial factors; Appalachian region
13.  Clinical, Demographic, and Situational Factors Linked to Distress Associated with Benign Breast Biopsy 
Few studies have examined the magnitude of distress associated with specific aspects of the benign breast biopsy (BBB) or distress risk factors. Women (n=51) completed questionnaires regarding distress associated with a recent BBB experience. Clinical and demographic risk factors for distress were also examined. All women reported distress associated with BBB; one-third reported it as “very stressful.” Biopsy-specific events were rated most distressing. Younger age, less education, non-surgical biopsy, and absence of family history of breast cancer were identified as risk factors for distress. The identified factors provide an efficient and potentially cost-effective means of stratifying risk for BBB-related distress.
PMCID: PMC3319914  PMID: 21240724
14.  Posttraumatic Growth and PTSD Symptomatology among Colorectal Cancer Survivors: A Three-Month Longitudinal Examination of Cognitive Processing 
Psycho-Oncology  2009;18(1):30-41.
The experience of cancer can be understood as a psychosocial transition, producing both positive and negative outcomes. Cognitive processing may facilitate psychological adjustment.
Fifty-five post-treatment, colorectal cancer survivors (M=65.9 years old; SD=12.7), an average of thirteen months post-diagnosis, were recruited from a state cancer registry and completed baseline and three-month questionnaires assessing dispositional (social desirability), cognitive processing (cognitive intrusions, cognitive rehearsal) and psychological adjustment variables (posttraumatic growth (PTG), posttraumatic stress disorder (PTSD) symptomatology, depression, anxiety, positive affectivity).
PTSD symptomatology was positively associated with depression, anxiety and negatively associated with positive affectivity. In contrast, PTG scores were unrelated to PTSD symptomatology, depression, anxiety, and positive affectivity. In addition, PTG was independent of social desirability. Notably, after controlling for age at diagnosis and education, multiple regression analyses indicated cognitive processing (intrusions, rehearsal) was differentially predictive of psychological adjustment. Baseline cognitive intrusions predicted three-month PTSD symptomatology and there was a trend for baseline cognitive rehearsal predicting three-month PTG.
Additional research is needed to clarify the association between PTG and other indices of psychological adjustment, further delineate the nature of cognitive processing, and understand the trajectory of PTG over time for survivors with colorectal cancer.
PMCID: PMC3319916  PMID: 18481837
posttraumatic growth; PTSD symptomatology; cognitive processing; psychological adjustment; cancer; oncology
15.  Beliefs About Cancer Causation and Prevention As a Function of Personal and Family History of Cancer: A National, Population-Based Study 
Psycho-Oncology  2008;17(10):967-974.
Research suggests individuals possess multifaceted cognitive representations of various diseases. These illness representations consist of various beliefs, including causal attributions for the disease, and are believed to motivate, guide, and shape health-related behavior. As little research has examined factors associated with beliefs about cancer causation, the present study examined the relationship between personal and family history of cancer and beliefs about the causes and prevention of malignant disease. Data was obtained from 6369 adult respondents to the 2003 Health Information National Trends Survey (HINTS), a national population-based survey. Information about personal and family history of cancer and beliefs regarding cancer causation and prevention was obtained. Results showed both a personal and family history of cancer were associated with differences in beliefs about the causes of cancer. In general, a personal history of cancer was not significantly linked to causal attributions for cancer relative to those without a personal history. In contrast, a family history of cancer tended to increase the likelihood a respondent viewed a particular cause as increasing cancer risk. Thus, personal and vicarious experience with cancer had dramatically diverging influences on attributions of cancer causation, which may be due to differing self-protection motives. Results support the belief that illness representations, in this case the causal belief component, are influenced by both personal and vicarious experience with a disease and also suggest illness representations may influence receptivity to messages and interventions designed to increase appropriate cancer risk reduction behavior.
PMCID: PMC3319087  PMID: 18203236
cancer; oncology; causal attributions; attribution theory; illness representations; prevention
16.  Receipt of a False Positive Test Result During Routine Screening for Ovarian Cancer: A Teachable Moment? 
The term "teachable moment" (TM) has been used to describe a life transition or event which motivates an individual to change a behavior or presents an opportunity to intervene to prompt behavior change. We examined whether receipt of a false positive ovarian cancer (OC) screening result may represent a TM.
403 women participating in an OC screening program completed questionnaires assessing demographic, clinical, behavioral, and psychosocial information. The TM was operationalized as expressed interest in receiving health-related information. We hypothesized that among women receiving a false positive screening test result, those women who had experienced greater personal perceived risk for OC as well as distress would be more interested in receiving health-related information than women receiving a normal result.
Analyses revealed that women receiving a false positive screening result were less interested in receiving health-related information than women receiving a normal screening result. For women receiving a false positive result, expressed interest in receipt of health-related information was only modestly related to distress and related even less to perceptions of OC risk.
Our data do not support viewing a false positive OC screening result as a TM. Potential explanations for the current findings as well as recommendations for future research investigating the TM are discussed.
PMCID: PMC3319350  PMID: 21373852
teachable moment; ovarian cancer screening; normal/false positive cancer screening result; cancer risk
17.  Response to an Abnormal Ovarian Cancer Screening Test Result: Test of the Social Cognitive Processing and Cognitive Social Health Information Processing Models 
Psychology & health  2010;26(4):383-397.
All cancer screening tests produce a proportion of abnormal results requiring follow-up. Consequently, the cancer screening setting is a natural laboratory for examining psychological and behavioral response to a threatening health-related event. This study tested hypotheses derived from the Social Cognitive Processing and Cognitive-Social Health Information Processing models in trying to understand response to an abnormal ovarian cancer (OC) screening test result. Women (n=278) receiving an abnormal screening test result a mean of 7 weeks earlier were assessed prior to a repeat screening test intended to clarify their previous abnormal result. Measures of disposition (optimism, informational coping style), social environment (social support and constraint), emotional processing, distress, and benefit finding were obtained. Regression analyses indicated greater distress was associated with greater social constraint and emotional processing and a monitoring coping style in women with a family history of OC. Distress was unrelated to social support. Greater benefit finding was associated with both greater social constraint and support and greater distress. The primacy of social constraint in accounting for both benefit-finding and distress was noteworthy and warrants further research on the role of social constraint in adaptation to stressful events.
PMCID: PMC2911487  PMID: 20419561
Distress; cancer screening; adjustment; psychosocial; coping; health behavior theory
18.  Differences in Cancer Information Seeking Behavior, Preferences, and Awareness Between Cancer Survivors and Healthy Controls: A National, Population-Based Survey 
Journal of Cancer Education  2009;24(1):73-79.
No research has examined how cancer diagnosis and treatment might alter information source preferences or opinions.
Data from 719 cancer survivors (CS group) and 2012 matched healthy controls (NCC group) regarding cancer-related information seeking behavior, preferences, and awareness from the population-based 2003 Health Information National Trends Survey (HINTS) was examined.
The CS group reported greater consumption of cancer-related information but the CS and NCC groups did not differ in information source use or preferences. The CS group was more confident of their ability to get cancer information, reported more trust in health care professionals and television as cancer information sources, but evaluated their recent cancer information seeking experiences more negatively than the NCC group. Awareness of cancer information resources was surprisingly low in both the CS and NCC groups.
Cancer diagnosis and treatment subtly alters cancer information seeking preferences and experience. However awareness and use of cancer information resources was relatively low regardless of personal history of cancer.
PMCID: PMC3315685  PMID: 19259869
19.  Retrospective analysis of high-dose intrathecal morphine for analgesia after pelvic surgery 
The effectiveness of intrathecal opioids (ITOs) for postoperative analgesia has been limited by reduced opioid dosing because of opioid-related side effects, most importantly respiratory depression. To overcome these limitations, high-dose intrathecal morphine was combined with a continuous intravenous (IV) postoperative naloxone infusion. The aim of the present chart analysis was to investigate the safety and efficacy of high-dose ITOs combined with IV naloxone compared with IV opioid analgesia alone.
A retrospective chart analysis was performed on 121 female patients requiring major pelvic surgery. Ninety-eight patients received a single injection of high-dose ITOs before administration of typical general anesthesia, followed by an IV naloxone infusion at 5 μg/kg/h started post-ITO and continued for 22 h postoperatively. Twenty-three patients were given IV morphine (IVM) for postoperative analgesia and served as a reference group. Postoperative pain relief, analgesic consumption and ability to ambulate were assessed for 48 h postoperatively. Treatment safety was assessed by monitoring opioid-related side effects and vital signs. Data are presented as mean ± SD.
Mean ITOs given were morphine 1.1±0.2 mg combined with fentanyl 49±6 μg. The mean worst pain visual analogue scale score in the first 12 h postoperatively was 0.2±0.90 in the ITO group versus 4.3±3.0 in the IVM group (P<0.05). On postoperative day 2, the mean worst pain visual analogue scale score was only 1±1.8 in the ITO group versus 4.1±2.6 in the IVM group (P<0.05). Analgesic requirements were reduced in the ITO group. In the first 24 h, the ITO group used 6.8±10.2 morphine equivalents (mg IV) versus 76.1±44.4 in the IVM group (P<0.05). All patients in the ITO group were able to ambulate in the first 12 h postoperatively compared with 17/23 in the IVM group. There was a higher incidence of opioid-related sedation in the IVM group. Other opioid-related side effects were infrequent and minor in both groups.
High-dose ITOs combined with a postoperative IV naloxone infusion provided excellent analgesia for major pelvic surgery. The IV naloxone infusion combined with high-dose ITOs appeared to control opioid side effects without affecting analgesia.
PMCID: PMC3052403  PMID: 21369537
Intrathecal opioids; Morphine; Naloxone; Spinal analgesia
20.  Factors associated with Self-reported Physical and Mental Health after Hematopoietic Cell Transplantation 
Hematopoietic cell transplantation (HCT) is an intensive treatment for hematologic malignancies that has the potential to cure disease or prolong life, but also to impair quality of life for survivors. Earlier studies have suggested a variety of factors to be associated with physical and mental health after HCT. In this study we evaluated demographic and clinical factors before and after transplant and selected psychosocial factors after transplant, to explore their association with self-reported physical and mental health. We studied a cohort of 662 survivors at a median of 6.6 years after HCT. Pre-HCT demographic and clinical factors accounted for only a small amount of the variance in physical and mental health post-transplant (3% and 1%, respectively). Adding post-HCT clinical variables to the pre-transplant factors accounted for 32% and 7% of physical and mental outcomes, respectively. When both clinical and psychosocial factors were considered, better physical health after HCT was associated with younger age, race other than white, higher current family income, currently working or being a student, less severe transplant experience (not having GVHD), fewer current comorbidities, higher Karnofsky status, less social constraint, less social support, and less trait anxiety. This multivariate model accounted for 36% of the variance in physical health with the psychosocial variables contributing very little. When both clinical and psychosocial factors were considered, better mental health after HCT was associated with more severe transplant experience, less social constraint, greater spiritual well-being, and less trait anxiety. This multivariate model accounted for 56% of the variance in mental health, with the psychosocial factors accounting for most of the variance. These data suggest that clinical factors are explanatory for much of the post-HCT physical health reported by HCT survivors but for very little of self-perceived mental health. These observations provide insights into identification of factors that would allow recognition of at-risk patients as well as factors amenable to intervention.
PMCID: PMC2975785  PMID: 20685400
21.  Use of Formal and Informal Mental Health Resources by Cancer Survivors: Differences Between Rural and Nonrural Survivors and a Preliminary Test of the Theory of Planned Behavior 
Psycho-oncology  2010;19(11):1148-1155.
Previous research has identified rural residence as a risk factor for poorer mental health (MH) outcomes in cancer survivors. This may be due to less use of various MH resources due to poorer access and less favorable attitudes and social norms related to MH resource utilization. The present study sought to examine use of MH resources in rural and nonrural survivors and identify factors associated with MH resource use.
Cancer survivors (n=113, 1 to 5 years post-diagnosis) completed a questionnaire packet and telephone interview. Accessibility and post-diagnosis use of various formal and informal MH resources was assessed along with constructs potentially linked to use of MH resources by the Theory of Planned Behavior (TPB; personal attitude, social norm, perceived behavioral control).
Results indicated no widespread differences between rural and nonrural cancer survivors in MH resource use although some evidence suggested poorer accessibility and less use of mental health professionals and cancer support groups among rural survivors. In general, rural survivors reported less favorable personal attitudes and social norms regarding MH resource use. TPB constructs accounted for a significant portion of variance in use of most MH resources with personal attitudes generally being the strongest predictor of MH resource use.
Additional research is needed to expand the search for factors, particularly modifiable factors, which might account for disparities in MH outcomes between rural and nonrural survivors.
PMCID: PMC2889207  PMID: 20017114
cancer; survivorship; health disparities; mental health; rural health; health behavior
22.  Attitudes Toward Information About Genetic Risk for Cognitive Impairment After Cancer Chemotherapy: Breast Cancer Survivors Compared With Healthy Controls 
Journal of Clinical Oncology  2010;28(21):3442-3447.
The trend toward personalized medicine will involve cancer treatment increasingly being tailored to the genetic characteristics of individuals. However, the availability of genetic information does not imply this information is desired or would impact treatment decision making.
One hundred sixty breast cancer survivors (BC group) and 205 healthy controls (HC group) were randomly assigned to respond to two different clinical scenarios varying in genetic-related risk of cognitive impairment (CI; little v very likely) and severity of CI (little v moderate problem) after chemotherapy. Ratings of the importance of being told this genetic information (information importance) and the likelihood this information would affect their decision to receive chemotherapy (information impact) were obtained.
Results indicated the importance ascribed to genetic information was greatest when CI likelihood and severity were both high or low (P < .05). Information impact ratings were not sensitive to differences in CI likelihood or severity; the BC group was less likely to indicate genetic information would affect their decision to receive chemotherapy than the HC group (P < .001).
Results suggest lessened enthusiasm for genetic information that maintains or increases uncertainty about a specific course of action and highlight the importance of including clinically relevant groups in treatment decision-making research that employs hypothetical scenarios. Although women generally believe it is important to receive genetic information, they might benefit from assistance (eg, decision aid) in the difficult task of integrating information about survival and risk for adverse late effects from cancer treatment.
PMCID: PMC2917210  PMID: 20498392
23.  Disparities in Mental Health between Rural and Nonrural Cancer Survivors: A Preliminary Study 
Psycho-oncology  2010;19(6):637-645.
While much research has sought to identify disparities in cancer incidence, survival, and treatment, little research has sought to identify disparities in mental health outcomes among cancer survivors. The present study aimed to identify disparities in mental health outcomes between rural and nonrural cancer survivors.
Cancer survivors who met eligibility criteria were identified through the Kentucky SEER Cancer Registry. Rural status was determined by 2003 USDA Rural-Urban Continuum Codes. 116 (n = 54 rural, 62 nonrural) survivors with diagnoses of breast (n=42), hematologic (n=39) or colorectal (n=35) cancer completed mail-back questionnaires and/or a telephone interview.
Rural cancer survivors reported poorer mental health functioning (Effect size; ES = .45 SD), greater symptoms of anxiety (ES = .70) and depression (ES = .47), greater distress (ES = .41), and more emotional problems (ES = .47) than nonrural cancer survivors. Rural and nonrural cancer survivors did not differ consistently in regard to positive mental health outcomes, such as benefit finding. The pattern of results was maintained when adjusted for education and physical functioning.
Clinically important disparities in mental health outcomes were evident between rural and nonrural cancer survivors. Interventions aimed at raising access and utilization of mental health services may be indicated for cancer survivors in rural areas.
PMCID: PMC2880195  PMID: 19582800
cancer; oncology; healthcare disparities; mental health; rural health
24.  The Preventive Health Behaviors of Long-Term Survivors Cancer and Hematopoietic Stem Cell Transplantation Compared to Matched Controls 
Little is known about the health promotion, prevention, and disease screening behaviors of cancer survivors treated with hematopoietic cell transplantation (HCT), who undergo arduous treatment and may be at particular risk for late effects and secondary malignancies. The purpose of this study was to examine the current health and secondary prevention behaviors of long-term HCT survivors compared to noncancer matched controls and to identify sociodemographic and clinical factors associated with appropriate prevention practices.
HCT survivors (n=662) were drawn from 40 North American transplant centers. Peer-nominated acquaintances of survivors matched on sex, age, education, and marital status, served as controls (n=158). Data were collected a mean of 6.7 years post-HCT (range 1.8 – 22.6 years).
Despite greater frequency of physical exams, HCT survivor health and screening behaviors were similar to matched controls. Sociodemographic factors were associated with health prevention behaviors in expected ways. Some differences between disease group and type of transplant were found, with survivors of acute leukemia less likely to report regular exercise, autologous transplant survivors more likely than allogeneic to report screenings for breast and cervical cancer, and allogeneic survivors more likely than autologous to report a skin exam in the last year.
Despite higher levels of engagement with health care providers, HCT survivor health behaviors were no different than matched controls and comparable to those reported by non HCT cancer survivors. There remains considerable room for improvement. These findings support the need for further education of both HCT survivors and health practitioners.
PMCID: PMC2819641  PMID: 19781657
Cancer; hematopoietic stem cell transplant; bone marrow transplant; health behaviors; cancer survivorship
25.  Exploring the differential experience of breast cancer treatment-related symptoms: a cluster analytic approach 
Cancer patients experience multiple concurrent symptoms. This exploratory analysis assessed symptom burden among patients undergoing chemotherapy for breast cancer to identify distinct subgroups of patients who experience differential symptom burden and assessed whether the patient subgroups were associated with deleterious quality of life (QOL) outcomes.
Materials and methods
Women (N=133) with stage I and II breast cancer undergoing adjuvant chemotherapy after primary surgery were evaluated at baseline and at the end of chemotherapy using the Memorial Symptom Assessment Scale (MSAS) and the SF-36 QOL questionnaire. Post treatment MSAS symptoms were included in hierarchical cluster analysis. Two patient subgroups were identified that corresponded to a high-symptom prevalence group and a low-symptom group.
Results and discussion
No marked, statistically significant differences were found between groups on demographic, symptoms, QOL, or treatment variables at baseline. Patients in the high-symptom cluster were more likely to have stage I disease (p<0.05). The two groups of patients showed significant differences in end-of-treatment symptoms and QOL scores (p<0.05). The high-symptom burden group was more likely to report greater symptom prevalence and poorer QOL.
Future research needs to examine why these differences occur despite similarities in treatment and how symptom burden can be reduced for the high-symptom prevalence group.
PMCID: PMC2892385  PMID: 18043948
Breast cancer; Cluster analysis; Symptom clusters; Symptom management; Quality of life

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