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1.  The role of posttraumatic growth and timing of quitting smoking as moderators of the relationship between stigma and psychological distress among lung cancer survivors who are former smokers 
Psycho-oncology  2014;24(6):683-690.
Patients diagnosed with lung cancer report high levels of stigma and psychological distress. This study examined posttraumatic growth among lung cancer survivors as a potential buffer against this relationship between stigma and psychological distress and examined how these relationships differed by the timing of quitting smoking (pre versus post-diagnosis).
Stages IA and IB non-small-cell lung cancer survivors (N= 141) who were former smokers, 1–6 years post-treatment, and had no evidence of disease completed standardized questionnaires assessing stigma, posttraumatic growth, timing of quitting smoking history, and psychological distress.
Hierarchical linear regression and simple slope analyses indicated that among those who quit smoking prior to diagnosis (pre-diagnosis quitters), stigma had a positive association with psychological distress at high levels of posttraumatic growth (p = 0.003) and had a positive (but non-significant) association with psychological distress among those with low levels of posttraumatic growth (p = 0.167). Among those who quit smoking after diagnosis (post-diagnosis quitters), stigma had a positive association with psychological distress among those with low levels of posttraumatic growth (p = 0.004) but had no relationship among those with high levels of posttraumatic growth (p = 0.880).
Findings indicate that posttraumatic growth buffers against the negative effects of stigma on psychological distress but only among post-diagnosis quitters. Future interventions could focus on fostering posttraumatic growth as a way to decrease the negative effects of stigma.
PMCID: PMC4515573  PMID: 25345591
2.  Patient-mediated factors predicting early- and late-stage presentation of breast cancer in Egypt 
Psycho-oncology  2011;20(5):532-537.
Breast cancer fatality rates are high in low- and middle-income countries because of the late stage at diagnosis. We investigated patient-mediated determinants for late-stage presentation of breast cancer in Egypt.
A case–case comparison was performed for 343 women with breast cancer, comparing those who had been initially diagnosed at Stage I or II with those diagnosed at Stage III or IV. Patients were recruited from the National Cancer Institute of Cairo University and Tanta Cancer Center in the Nile delta. Patients were either newly diagnosed or diagnosed within the year preceding the study. Interviews elicited information on disease history and diagnosis, beliefs and attitudes toward screening practices, distance to treatment facility, education, income, and reproductive history.
Forty-six per cent of the patients had presented at late stage. Women seen in Cairo were more likely to present at late stages than patients in Tanta (OR = 5.05; 95% CI = 1.30, 19.70). Women without any pain were more likely to present at later stage (OR = 2.68; 95% CI = 1.18, 6.08). Knowledge of breast self-examination increased the likelihood of women to present in early stages significantly (OR = 0.24; 95% CI = 0.06, 0.94).
Despite increasing numbers of cancer centers in Egypt during the past 20 years, additional regional facilities are needed for cancer management. In addition, increasing awareness about breast cancer will have significant long-term impact on breast cancer prevention.
PMCID: PMC4511958  PMID: 21456061
patient factors; late stage; breast cancer; oncology; Egypt; global health
4.  Psychosocial issues related to sexual functioning among African-American prostate cancer survivors and their spouses† 
Psycho-oncology  2011;20(1):106-110.
Focus on cancer survivorship and quality of life (QOL) is a growing priority. The aim of this study was to identify and describe the most salient psychosocial concerns related to sexual functioning among African-American (AA) prostate cancer survivors and their spouses.
Twelve AA prostate cancer survivors and their spouses participated in semi-structured individual interviews. The interviews assessed couples’ experiences with psychosocial adjustment and sexual functioning posttreatment for localized prostate cancer. The data were analyzed using the constant comparison method and content analysis.
In this qualitative study of couples surviving prostate cancer, there were divergent views between the male prostate cancer survivors and their female partners, particularly regarding sexual functioning. For the males, QOL issues emerged as the primary area of concern, whereas survival of their husbands was considered most important among the female spouses. The male respondents expressed unease with the sexual side effects of their cancer treatment, such as erectile dysfunction and decreased sexual desire and satisfaction. Female spouses recognized decreased sexual desire in their partners following treatment, but this was not considered a primary concern.
Patients and their spouses may have differing perceptions regarding QOL and the impact of sexual functioning on survivorship. This study points to the need for further research and intervention development to address these domains with a goal to improve QOL.
PMCID: PMC4509592  PMID: 20187071
prostate cancer; cancer survivorship; psychosocial; sexual functioning; African-Americans; quality of life
5.  Quantifying the Recruitment Challenges with Couple-Based Interventions for Cancer: Applications to Early Stage Breast Cancer 
Psycho-oncology  2009;18(6):667-673.
Despite mounting evidence supporting the use of psychosocial interventions to promote adaptation to cancer, enrolling participants into these interventions is challenging. This is particularly salient for couple-based interventions, and newer, more targeted recruitment strategies to increase enrollment are needed. However, there have been few published empirical studies focused specifically on recruitment–related variables associated with enrollment into these types of interventions. To better understand how to encourage participation in couple-based psychosocial interventions for cancer, we examined facilitating and impeding factors to enrollment into a couple-based intervention for women with early stage breast cancer.
In this sample of 99 women diagnosed with early stage breast cancer, patient demographic variables and method of approaching eligible patients were examined as predictors of enrollment into a randomized controlled trial comparing Couple-Based Relationship Enhancement with treatment-as-usual.
Results indicated that women were more likely to enroll if they were contacted at home or at a follow-up medical appointment rather than when first diagnosed at a busy multidisciplinary clinic; they were also more likely to enroll the closer they lived to the research facility.
In addition to decreasing participant burden, timing and setting of recruitment efforts may have important implications for enhancing participation rates in couple-based intervention studies for cancer.
PMCID: PMC4506748  PMID: 19061201
cancer; oncology; couples and breast cancer; psychosocial; recruitment
6.  Evaluating the quality of psychosocial care in outpatient medical oncology settings using performance indicators 
Psycho-oncology  2010;20(11):1221-1227.
An American Psychosocial Oncology Society workgroup has developed indicators of the quality of psychosocial care that can be measured through review of medical records. The present report describes the first large-scale use of these indicators to evaluate psychosocial care in outpatient medical oncology settings.
Medical records of 1660 colorectal, breast and non-small cell cancer patients first seen by a medical oncologist in 2006 at 11 practice sites in Florida were reviewed for performance on indicators of the quality of psychosocial care.
Assessment of emotional well-being was significantly less likely to be documented than assessment of pain (52 vs 87%, p<0.001). A problem with emotional well-being was documented in 13% of records and evidence of action taken was documented in 58% of these records. Ten of eleven practice sites performed below an 85% threshold on each indicator of psychosocial care. Variability in assessment of emotional-well being was associated (p<0.02) with practice site and patient gender and age while variability in assessment of pain was associated (p<0.001) with practice site and cancer type.
Findings illustrate how use of the psychosocial care indicators permits identification of specific practice sites and processes of care that should be targeted for quality improvement efforts. Additionally, findings demonstrate the extent to which routine assessment of emotional well-being lags behind routine assessment of pain in cancer patients.
PMCID: PMC4497369  PMID: 20878724
quality of care; psychosocial oncology
7.  Social Support, Self-Efficacy for Decision Making, and Follow-up Care Use in Long-term Cancer Survivors 
Psycho-oncology  2014;23(7):788-796.
Cancer survivors play an important role in coordinating their follow-up care and making treatment-related decisions. Little is known about how modifiable factors like social support are associated with active participation in follow-up care. This study tests associations between social support, cancer-related follow-up care use, and self-efficacy for participation in decision making related to follow-up care (SEDM). We also identified sociodemographic and clinical factors associated with social support among long-term survivors.
The FOllow-up Care Use among Survivors (FOCUS) study is a cross-sectional, population based survey of breast, prostate, colon, and gynecologic cancer survivors (n=1522) 4 to 14 years post-diagnosis. Multivariable regression models were used to test associations between perceived social support (tangible and emotional/informational support modeled separately), follow-up care use (past two years), and SEDM, as well as to identify factors associated with perceived support.
Neither support type was associated with follow-up care use (all p>0.05), although marital status was uniquely, positively associated with follow-up care use (p<0.05). Both tangible support (B for a standard deviation increase (SE)=9.75(3.15), p<0.05) and emotional/informational support (B(SE)=12.61(3.05), p<0.001) were modestly associated with SEDM. Being married, having adequate financial resources, history of recurrence, and better perceived health status were associated with higher perceived tangible and emotional support (all p<0.05).
While perceived social support may facilitate survivor efficacy for participation in decision making during cancer follow-up care, other factors, including marital satisfaction, appear to influence follow-up care use. Marital status and social support may be important factors to consider in survivorship care planning.
PMCID: PMC4082440  PMID: 24481884
cancer; social support; follow-up care; decision-making
8.  Barriers to Mental Health Service Use and Preferences for Addressing Emotional Concerns among Lung Cancer Patients 
Psycho-oncology  2014;23(7):812-819.
This study examined barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients (N=165) at two medical centers in the midwestern United States.
Lung cancer patients completed an assessment of anxiety and depressive symptoms, mental health service use, barriers to using these services, and preferences for addressing emotional concerns.
Only 45% of distressed patients received mental health care since their lung cancer diagnosis. The most prevalent patient-reported barriers to mental health service use among non-users of these services (n=110) included the desire to independently manage emotional concerns (58%) and inadequate knowledge of services (19%). In addition, 57% of distressed patients who did not access mental health services did not perceive the need for help. Seventy-five percent of respondents (123/164) preferred to talk to a primary care physician if they were to have an emotional concern. Preferences for counseling, psychiatric medication, peer support, spiritual care, or independently managing emotional concerns also were endorsed by many patients (range=40%–50%). Older age was associated with a lower likelihood of preferring to see a counselor.
Findings suggest that many distressed lung cancer patients underuse mental health services and do not perceive the need for such services. Efforts to increase appropriate use of services should address patients' desire for autonomy and lack of awareness of services.
PMCID: PMC4082441  PMID: 24493634
lung cancer; oncology; mental health service use; barriers; psychological; distress
9.  How language affects peer responsiveness in an online cancer support group: Implications for treatment design and facilitation 
Psycho-oncology  2014;23(7):766-772.
Little is known about how positive group interactions develop in online support groups. Previous research suggests that message content, self-disclosure, and emotional expression may be central to this process. The purpose of this study was to identify linguistic and qualitative characteristics of participants' messages that predict how other participants respond in an asynchronous discussion board for cancer-related distress.
525 discussion board messages posted by 116 participants in the trial were collected. Linguistic Inquiry and Word Count (2001) was used to identify linguistic markers of emotional expression and pronoun use. Message topics were identified using qualitative analysis. Logistic regression and chi-square analyses were used to evaluate whether linguistic characteristics and message topics predicted receiving a response from other survivors in the online group.
Messages were more likely to receive a reply if they had higher word count, OR=1.30, p=.001, or fewer second person pronouns, OR=.923, p=.040. Messages with high levels of positive emotion were less likely to receive a reply, OR=.94, p=.03. Common message topics related to self-disclosure (51%), the support group (38.5%), medical experiences (30.9%,), and experiences with the website (30.1%). Several message topics were associated with greater likelihood of a reply: self-disclosure (p<.001), medical experiences (p=.01), relationship issues (p=.05), and introductory posts (p<.01).
Informing participants how to introduce themselves to the group (i.e., detailed and self-focused messages discussing personal issues such as the effects of illness on life and relationships) could promote cohesion and enhance overall engagement with Internet-based support groups or interventions.
PMCID: PMC4082444  PMID: 24519856
Cancer; oncology; online support groups; social-support; linguistic; emotions
10.  Attachment Style and Respiratory Sinus Arrhythmia Predict Post-Treatment Quality of Life in Breast Cancer Survivors 
Psycho-oncology  2014;23(7):820-826.
Breast cancer is the most frequent malignant tumor among women in the industrialized world. The vast majority of these tumors can now be successfully treated. A subset of breast cancer survivors report quality of life (QOL) difficulties well after treatment is completed. The current study examined how individual differences in attachment style and self-regulatory capacity (as indexed by RSA) were associated quality of life among post-treatment breast cancer survivors.
Women who had completed treatment for stage 0-IIIA breast cancer within the past two years participated in the study (N = 96). RSA was assessed using Electrocardiography (ECG) data that was continuously measured non-invasively for 10 minutes. Attachment orientation was measured using a modified version of the Experiences in Close relationships Scale, and Overall QOL by the Functional Assessment of Cancer Therapy-Breast scale.
Breast cancer survivors with more attachment anxiety reported poorer QOL than those with less attachment anxiety. Women who were more avoidantly attached also reported poorer QOL compared with those who were less avoidantly attached. Furthermore, attachment avoidance interacted with RSA to predict QOL such that those with higher attachment avoidance were only vulnerable to poorer QOL if they also had lower self-regulatory capacity, as indexed by lower RSA.
A better understanding of how attachment style and RSA contribute to breast cancer survivor QOL will help identify people at risk for QOL problems after treatment completion.
PMCID: PMC4082446  PMID: 24532423
Cancer survivorship; Psycho-oncology; Attachment Theory; Quality of Life; Respiratory Sinus Arrhythmia; Self-regulation
11.  Objective burden, resources, and other stressors among informal cancer caregivers: a hidden quality issue?† 
Psycho-oncology  2011;20(1):44-52.
A great deal of clinical cancer care is delivered in the home by informal caregivers (e.g. family, friends), who are often untrained. Caregivers' context varies widely, with many providing care despite low levels of resources and high levels of additional demands.
Changes in health care have shifted much cancer care to the home, with limited data to inform this transition. We studied the characteristics, care tasks, and needs of informal caregivers of cancer patients.
Caregivers of seven geographically and institutionally defined cohorts of newly diagnosed colorectal and lung cancer patients completed self-administered questionnaires (n = 677). We combined this information with patient survey and chart abstraction data and focused on caregivers who reported providing, unpaid, at least 50% of the patient's informal cancer care.
Over half of caregivers (55%) cared for a patient with metastatic disease, severe comorbidity, or undergoing current treatment. Besides assisting with activities of daily living, caregivers provided cancer-specific care such as watching for treatment side effects (68%), helping manage pain, nausea or fatigue (47%), administering medicine (34%), deciding whether to call a doctor (30%), deciding whether medicine was needed (29%), and changing bandages (19%). However, half of caregivers reported not getting training perceived as necessary. In addition, 49% of caregivers worked for pay, 21% reported poor or fair health, and 21% provided unpaid care for other individuals. One in four reported low confidence in the quality of the care they provided.
Much assistance for cancer patients is delivered in the home by informal caregivers, often without desired training, with a significant minority having limited resources and high additional demands. Future research should explore the potentially high yield of addressing caregiver needs in improving quality of cancer care and both survivors' and caregivers' outcomes.
PMCID: PMC4479404  PMID: 20201115
cancer; oncology; caregivers; burden; stress; informal care
12.  Sexual dysfunction and spousal communication in couples coping with prostate cancer† 
Psycho-oncology  2009;18(7):735-746.
To characterize the sexual function of both prostate cancer patients and their partners, and to examine whether associations between sexual dysfunction and psychosocial adjustment vary depending on spousal communication patterns.
In this cross-sectional study, 116 prostate cancer patients and their partners completed psychosocial questionnaires.
Patients and partners reported high rates of sexual dysfunction. Within couples, patients’ and their partners’ sexual function was moderately to highly correlated (r = 0.30–0.74). When patients had poor erectile function, their partners were more likely to report that the couple avoided open spousal discussions; this in turn was associated with partners’ marital distress (Sobel's Z = 12.47, p = 0.001). Patients and partners who reported high levels (+1SD) of mutual constructive communication also reported greater marital adjustment, regardless of their own sexual satisfaction. In contrast, greater sexual dissatisfaction was associated with poorer marital adjustment in patients and partners who reported low levels (−1SD) of mutual constructive communication (p<0.05).
Our findings underscore the need for psychosocial interventions that facilitate healthy spousal communication and address the sexual rehabilitation needs of patients and their partners after prostate cancer treatment. Although some couples may be reluctant to engage in constructive cancer-related discussions about sexual problems, such discussions may help alleviate the negative impact that sexual problems have on prostate cancer patients’ and their partners’ marital adjustment.
PMCID: PMC4476400  PMID: 19061199
prostate cancer; sexual function; marriage; couples; communication patterns
13.  Post-traumatic stress symptoms in cancer survivors: relationship to the impact of cancer scale and other associated risk factors† 
Psycho-oncology  2014;24(6):643-652.
The purpose of this study was to determine the prevalence of post-traumatic stress symptoms in a sample of cancer survivors and to investigate their association with the impact of cancer, depressive symptoms, and social support.
We administered a survey to participants in a cancer survivor registry. It included: Post-Traumatic Stress Disorder Checklist-Civilian version (PCL-C), Impact of Cancer Scale (IOC) v.2, and measures of social support, income, and long-term effects of cancer. We performed multivariate analyses to estimate associations between PCL-C and other variables. PCL-C score was examined as a continuous dependent variable and categorically.
Responses were available from 162 cancer survivors. Mean age was 51 years (standard deviation (SD) 16); mean time since diagnosis was 11 years (SD 10). Mean PCL-C score was 27 (SD 9, range 17–64); 29% of the sample scored 30 and above, 13% scored 38 and above, 7% scored 44 and above. Linear regression indicated that PCL-C scores were significantly associated with the IOC negative impact summary scale (NIS) (p <0.001), depressive symptoms (p = 0.003), less social support (p = 0.02), and lower income (p = 0.03). NIS subscale analyses showed that two subscales, life interference (LI) and worry (W), were significantly correlated with PCL-C score (LI: p <0.001; W: p = 0.02).
In this study, the IOC NIS was associated with endorsement of PTSD symptoms. Assessing survivors for PTSD symptoms with the PCL-C could detect those individuals in need of psychosocial support. The IOC may be useful for identifying target areas for interventions to reduce these symptoms among cancer survivors.
PMCID: PMC4400255  PMID: 25059888
14.  Bladder and Bowel Symptoms in Cervical and Endometrial Cancer Survivors 
Psycho-oncology  2014;23(6):672-678.
Previous studies likely underestimate the prevalence of bowel and bladder symptoms in gynecologic cancer survivors. We sought to estimate the prevalence of these symptoms in cervical and endometrial cancer survivors who had completed treatment one year previously compared to non-cancer controls, and to examine factors associated with more severe symptoms in survivors.
As part of a larger quality of life study, survivors who were one-year post-treatment for cervical or endometrial cancer (n = 104) completed measures of bladder and bowel symptoms. An age- and race/ethnicity-matched sample of women with no history of cancer was recruited for comparison purposes.
Survivors reported a higher prevalence of bladder symptoms, specifically storage and incontinence symptoms, than non-cancer controls. Prevalence rates for bowel symptoms in survivors were higher than those reported in previous studies. Greater symptom severity was associated with younger age, lower annual incomes and less education. Other correlates included higher body mass index and history of smoking. As hypothesized, more severe symptoms were associated with radical hysterectomy and pelvic radiation.
Bladder and bowel symptoms are more prevalent in cervical and endometrial cancer survivors than non-cancer controls. Future research should replicate these findings in a larger, prospective study.
PMCID: PMC4043946  PMID: 24481859
cervical cancer; endometrial cancer; bladder symptoms; bowel symptoms; survivorship
15.  A prospective study of cognitive function in men with non-seminomatous germ cell tumors 
Psycho-oncology  2013;23(6):626-633.
Longitudinal neuropsychological assessments were performed to determine if adjuvant chemotherapy was associated with cognitive dysfunction in men with non-seminomatous germ cell tumors (NSGCT).
Patients with NSGCT status post orchiectomy that either received adjuvant chemotherapy (n=55) or did not (n=14) were recruited. Patients were tested before chemotherapy, one week post chemotherapy (or three months later in the surveillance group) and 12 months after the baseline evaluation.
Compared to the surveillance group, patients treated with chemotherapy had higher rates of cognitive decline at 12 months (overall cognitive decline: 0%, 52% and 67% in the surveillance, LE and HE group, respectively), greater number of tests that declined (mean of 0.1, 1.4 and 2.0 in the surveillance, LE and HE group, respectively), and more frequent worsening in motor dexterity (0%, 48% and 46% in the surveillance, LE and HE group, respectively). Compared to the surveillance group, patients receiving more cycles of chemotherapy demonstrated worse psychomotor speed and learning and memory. Younger age was associated with greater incidence of overall cognitive decline at 12 month follow-up.
Men with NSGCT that received chemotherapy demonstrated greater rates of cognitive decline in a dose-response manner. Reductions in motor dexterity were most common. Decline in learning and memory also was evident particularly at later follow up time points and in men receiving more chemotherapy. Men that receive chemotherapy for NSGCT are at risk for cognitive decline and may benefit from monitoring and referral for psychosocial care.
PMCID: PMC4066616  PMID: 24339329
Chemotherapy; Cognitive Function; Neurotoxicity; Quality of Life; Testicular Cancer; Oncology
16.  Couple-Based Tibetan Yoga Program for Lung Cancer Patients and their Caregivers 
Psycho-oncology  2014;24(1):117-120.
PMCID: PMC4437691  PMID: 24890852
Non-small cell lung cancer; family caregivers; dyadic mind body intervention; feasibility; quality of life
17.  Quality of life and diet intervention in individuals at risk for recurrence of colorectal adenomas 
Psycho-oncology  2005;14(2):85-93.
The effect of participation in a diet intervention study on self-reported quality of life (QOL) with subjects at risk of recurrence of colorectal adenomas was explored in 77 men and women, aged 18-80 years, with a history of adenomatous polyps. Participants were randomly assigned to intervention and control groups and followed for one year. Dietary goals for the intervention group included reduced intake of fat and increased intakes of fiber, calcium, and vegetables and fruit. Diet counseling was provided by telephone. Anthropometric measurements were obtained and dietary intakes were assessed at baseline, six and 12 months. The Quality of Life Factors questionnaire (QF), designed to explore the absolute effects of the diet intervention on participants’ perceived QOL, was administered at baseline and study end. Based on repeated 24-hour dietary recalls, the intervention group reported significantly higher consumption of vegetables, fruit, low-fat dairy products, fiber, and calcium at 12 months. There were no significant differences in total QF scores for the two groups at study end, and no significant changes within groups between baseline and study end. Findings suggest that even though the intervention participants made significant modifications in their eating behavior, these changes did not impact their perceived QOL negatively.
PMCID: PMC4428563  PMID: 15386785
18.  Sexual Problems, Communication Patterns, and Depressive Symptoms in Couples Coping with Metastatic Breast Cancer 
Psycho-oncology  2012;22(4):814-822.
The treatment of breast cancer tends to result in physical side effects (e.g., vaginal dryness, stomatitis, and atrophy) that can cause sexual problems. Although studies of early-stage breast cancer have demonstrated that sexual problems are associated with increased depressive symptoms for both patients and their partners, comparatively little is known about these associations in metastatic breast cancer (MBC) and how patients and partners cope together with sexual problems. We examined the links between sexual problems, depressive symptoms, and two types of spousal communication patterns [mutual constructive (MC) and demand-withdraw (DW)] in 191 couples in which the patient was initiating treatment for MBC.
Patients and partners separately completed paper-pencil surveys.
Multilevel models indicated that high levels of sexual problems were significantly associated with more depressive symptoms only for patients who reported low levels of MC communication (p<0.01) and high levels of DW communication (p<0.0001). In contrast, for partners, greater sexual problems were associated with more depressive symptoms regardless of the type of communication pattern reported. These associations remained significant when we controlled for patients’ reports of average pain and functional and physical well-being and couples’ dyadic adjustment.
Sexual problems were associated with depressive symptoms for both MBC patients and their partners. The way in which patients and partners talk to one another about cancer-related problems appears to influence this association for patients. MBC patients may benefit from programs that teach couples how to minimize DW communication and instead openly and constructively discuss sexual issues and concerns.
PMCID: PMC4428564  PMID: 22565300
metastatic breast cancer; sexual problems; depression; communication patterns; couples
19.  A meta-analysis of prevalence rates and moderating factors for cancer-related post-traumatic stress disorder 
Psycho-Oncology  2014;24(4):371-381.
Systematic reviews highlight a broad range of cancer-related post-traumatic stress disorder (CR-PTSD) prevalence estimates in cancer survivors. This meta-analysis was conducted to provide a prevalence estimate of significant CR-PTSD symptoms and full diagnoses to facilitate the psychological aftercare of cancer survivors.
A systematic literature search was conducted for studies using samples of cancer survivors by using validated clinical interviews and questionnaires to assess the prevalence of CR-PTSD (k = 25, n = 4189). Prevalence estimates were calculated for each assessment method using random-effects meta-analysis. Mixed-effects meta-regression and categorical analyses were used to investigate study-level moderator effects.
Studies using the PTSD Checklist—Civilian Version yielded lower event rates using cut-off [7.3%, 95% confidence intervals (CI) = 4.5–11.7, k = 10] than symptom cluster (11.2%, 95% CI = 8.7–14.4, k = 9). Studies using the Structured Clinical Interview for Diagnostic and Statistical Manual, Fourth Edition (SCID), yielded low rates for lifetime (15.3%, 95% CI = 9.1–25, k = 5) and current CR-PTSD (5.1%, 95% CI = 2.8–8.9, k = 9). Between-study heterogeneity was substantial (I2 = 54–87%). Studies with advanced-stage samples yielded significantly higher rates with PTSD Checklist—Civilian Version cluster scoring (p = 0.05), and when assessing current CR-PTSD on the SCID (p = 0.05). The effect of mean age on current PTSD prevalence met significance on the SCID (p = 0.05). SCID lifetime prevalence rates decreased with time post-treatment (R2 = 0.56, p < 0.05).
The cancer experience is sufficiently traumatic to induce PTSD in a minority of cancer survivors. Post-hoc analyses suggest that those who are younger, are diagnosed with more advanced disease and recently completed treatment may be at greater risk of PTSD. More research is needed to investigate vulnerability factors for PTSD in cancer survivors.
© 2014 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.
PMCID: PMC4409098  PMID: 25146298
cancer; oncology; PTSD; prevalence; meta-analysis; DSM-5
20.  Depressive Symptomatology in Men Receiving Androgen Deprivation Therapy for Prostate Cancer: A Controlled Comparison 
Psycho-oncology  2014;24(4):472-477.
Prostate cancer patients who receive androgen deprivation therapy (ADT) often experience many physical and psychological side effects. ADT may be associated with increased risk for depression, but the relationship between ADT and depression is not fully understood. This study used a longitudinal design to assess depressive symptomatology in patients receiving ADT compared to two groups of matched controls.
Participants were men initiating ADT treatment (ADT+ group; n = 61) and their matched controls: prostate cancer patients treated with radical prostatectomy (ADT− group; n = 61) and no-cancer controls (CA− group; n = 61). Depressive symptomatology was assessed using the Center for Epidemiological Studies Depression Scale at ADT initiation and again six months later. Differences in depressive symptomatology and rates of clinically-significant depressive symptomatology were analyzed between groups at each time point and within groups over time. Results: Between baseline and follow-up, ADT+ participants demonstrated increased depressive symptomatology and increased rates of clinically-significant depressive symptomatology (ps < .05). ADT+ participants also reported greater depressive symptomatology than both control groups at follow-up (ps < .001). Rates of clinically-significant depressive symptomatology were higher in the ADT+ group than the ADT− and CA− groups at both time points (baseline: 28%, 5%, 12%; follow-up: 39%, 9%, 11%).
Findings support the hypothesis that ADT administration yields increases in depression and suggest that the mechanism behind ADT’s association with depression should be explored and that prostate cancer patients treated with ADT should receive particular focus in depression screening and intervention.
PMCID: PMC4265307  PMID: 24924331
prostate cancer; oncology; androgen deprivation therapy; depression; quality of life
21.  Emotions and social relationships for breast and gynecologic patients: A qualitative study of coping with recurrence 
Psycho-oncology  2013;23(4):382-389.
In contrast to the large literature on patients’ coping with an initial diagnosis of cancer, there have been few quantitative or qualitative studies of patients coping with recurrence. A qualitative study was undertaken to aide in the development of a tailored intervention for these patients. Individuals (N=35) receiving follow-up care for recurrent breast or gynecologic cancer at a university-affiliated cancer center participated in an individual or a group interview. Transcripts of interviews were analyzed using a coding format with two areas of emphasis. First, we focused on patients’ emotions, as there is specificity between emotions and the corresponding ways in which individuals choose to manage them. Secondly, we considered the patients’ social environments and relationships, as they too appear key in the adjustment to, and survival from, cancer. Patients identified notable differences in their responses to an initial diagnosis of cancer and their current ones to recurrence, including the following: 1) depressive symptoms being problematic; 2) with the passing years and the women’s own aging, there is shrinkage in the size of social networks; and, 3) additional losses come from social support erosion, arising from a) an intentional distancing by social contacts; b) friends and family not understanding that cancer recurrence is a chronic illness, and/or c) patients’ stemming their support requests across time. The contribution of these findings to the selection of intervention strategies is discussed.
PMCID: PMC3975664  PMID: 24123502
Cancer; oncology; emotions; social support; recurrence
22.  “It's Not Like You Just Had a Heart Attack”: Decision-Making about Active Surveillance by Men with Localized Prostate Cancer 
Psycho-oncology  2013;23(4):467-472.
Growing recognition that active surveillance (AS) is a reasonable management option for many men diagnosed with localized prostate cancer led us to describe patients’ conceptualizations of AS and reasons for their treatment decisions.
Men were patients of a multidisciplinary prostate cancer clinic at a large tertiary cancer center where patients are routinely briefed on treatment options, including AS. We conducted a thematic analysis of interviews with 15 men who had chosen AS and 15 men who received radiation or surgery.
Men who chose AS described it as an organized process with a rigorous and reassuring protocol of periodic testing, with potential for subsequent and timely decision making about treatment. AS was seen as prolonging their current good health and function with treatment still possible later. Rationales for choosing AS included trusting their physician's monitoring, “buying time” without experiencing adverse effects of treatment, waiting for better treatments, and seeing their cancer as very low risk. Men recognized the need to justify their choice to others because it seemed contrary to the impulse to immediately treat cancer. Descriptions of AS by men who chose surgery or radiation were less specific about the testing regimen. Getting rid of the cancer and having a cure were paramount for them.
Men fully informed of their treatment options for localized prostate cancer have a comprehensive understanding of the purpose of AS. Slowing the decision-making process may enhance the acceptability of AS.
PMCID: PMC3983844  PMID: 24243777
Cancer; Oncology; Prostate Neoplasms; Decision Making; Qualitative Research
23.  Randomized Trial of Print Messaging: The Role of the Partner and Monitoring Style in Promoting Provider Discussions about Prostate Cancer Screening Among AA Men 
Psycho-oncology  2013;23(4):404-411.
Although AA men are at elevated risk for prostate cancer (Pca), medical guidelines do not present consistent screening recommendations for this group. However, all guidelines stress the need for screening decision making with a provider. This study evaluated the effectiveness of a brochure designed for the female partners of AA men, designed to help promote such discussion on the part of their mates. We also explored the effect of the partner's monitoring style (i.e., the extent to which the partner typically attends to health threats) on promoting discussion.
Female partners of AA men (N=231) were randomized to receive either a Pca screening CDC brochure for AA men, combined with a “partner” brochure containing strategies to promote men's initiation of a provider visit to discuss screening, or the CDC brochure only, and completed pre- and post-intervention surveys online.
The message groups did not differ on taking active steps to engage in provider discussion: relative risk ratio (RRR) = 0.99, p = .98; thinking about it: RRR= 1.13, p = .74. However, among partners who received the partner brochure, monitoring style was associated with “thinking about initiating a provider visit” on the part of the mate (RRR = 1.74, p<.01). Across conditions, monitoring style was also associated with “taking active steps to initiate a provider visit” on the part of the mate (RRR = 1.38, p < .05).
High monitoring partners may be effective in influencing their AA mates to initiate provider discussion, particularly when tailored messaging is provided.
PMCID: PMC4091779  PMID: 24130097
prostate cancer; partner; communication messages; monitoring style; AA men
24.  Internet-based interventions for cancer-related distress: exploring the experiences of those whose needs are not met 
Psycho-oncology  2013;23(4):452-458.
Low levels of engagement in Internet-based interventions are common. Understanding users' experiences with these interventions is key to improving efficacy. Although qualitative methods are well-suited for this purpose, few qualitative studies have been conducted in this area. In the present study, we assessed experiences with an Internet-based intervention among cancer survivors who made minimal use of the intervention.
Semi-structured interviews were conducted with 25 cancer survivors who were minimally engaged (i.e., spent around 1 hour total on website) with the online intervention, The intervention was a 12-week, facilitated support group with social and informational components. Interviews were analyzed using an interpretive descriptive design.
Three broad categories, consisting of 18 specific themes, were identified from the interviews, which included connecting with similar others, individual expectations, and problems with the site (K= 0.88). The “similar others” category reflected the significance of interacting with relatable survivors (i.e., same cancer type), the “individual expectations” category reflected the significance of participants' expectations about using online interventions (i.e., personally relevant information), and the “problems with the site” category reflected the significance of study procedures (i.e., website structure).
The data indicate that minimally-engaged participants have high variability regarding their needs and preferences of Internet-based interventions. Using qualitative methodologies to identify and incorporate these needs into the next generation of interventions has the potential to increase engagement and outcomes. The current study provides a foundation for future research to characterize survivors' needs and offer suggestions for better meeting these needs.
PMCID: PMC4167707  PMID: 24243756
cancer; oncology; distress; Internet; engagement; support
25.  Spiritual beliefs near the end of life: a prospective cohort study of people with cancer receiving palliative care† 
Psycho-Oncology  2013;22(11):2505-2512.
Despite growing research interest in spirituality and health, and recommendations on the importance of spiritual care in advanced cancer and palliative care, relationships between spiritual belief and psychological health near death remain unclear. We investigated (i) relationships between strength of spiritual beliefs and anxiety and depression, intake of psychotropic/analgesic medications and survival in patients with advanced disease; and (ii) whether the strength of spiritual belief changes as death approaches.
We conducted a prospective cohort study of 170 patients receiving palliative care at home, 97% of whom had a diagnosis of advanced cancer. Data on strength of spiritual beliefs (Beliefs and Values Scale [BVS]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), psychotropic/analgesic medications, daily functioning, global health and social support were collected at recruitment then 3 and 10 weeks later. Mortality data were collected up to 34 months after the first patient was recruited.
Regression analysis showed a slight increase in strength of spiritual belief over time approaching statistical significance (+0.16 BVS points per week, 95% CI [−0.01, 0.33], p = 0.073). Belief was unrelated to anxiety and depression (−0.15 points decrease in HADS for 10 points increased in BVS (95% CI [−0.57, 0.27], p = 0.49) or consumption of psychotropic medication). There was a non-significant trend for decreasing analgesic prescription with increasing belief. Mortality was higher over 6 months in participants with lower belief at recruitment.
Results suggest that although religious and spiritual beliefs might increase marginally as death approaches, they do not affect levels of anxiety or depression in patients with advanced cancer. © 2013 The Authors. Psycho-Oncology published by John Wiley & Sons, Ltd.
PMCID: PMC4350444  PMID: 23775823
cancer; oncology; end-of-life; spirituality; religion; wellbeing

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