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1.  Spiritual quality of life in advanced cancer patients receiving radiation therapy 
Psycho-oncology  2013;23(2):216-221.
The aim of this randomized controlled trial for patients with advanced cancer receiving radiation therapy was to determine the effect of a multidisciplinary intervention on spiritual quality of life (QOL) at the end of the intervention (week 4) and at two follow-up time points (weeks 26 and 52).
One hundred thirty-one persons were randomized to either the intervention or control (forms only) groups. The intervention included six 90-min in-person sessions based on the physical, emotion, social, and spiritual domains of QOL. Three sessions included the spiritual component. Caregivers were present for four sessions, one which included a spiritual component. Ten follow-up phone calls were made to the patients in the intervention group during the 6-month follow-up period. Patients completed the Functional Assessment of Cancer Therapy: General Scale, the Linear Analog Self-Assessment which includes an assessment of spiritual QOL, and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) at enrollment, and weeks 4, 27, and 52.
Following the intervention, the intervention group demonstrated improved spiritual QOL on the FACIT-Sp, whereas the spiritual QOL of the control group decreased, resulting in significant mean changes between groups (total score: 1.7 vs. −2.9; p <0.01; meaning/peace subscale: 1.0 vs. −3.5; p <0.01; faith subscale: 3.1 vs. −1.7; p = 0.04).
The results indicate that a multidisciplinary intervention which includes a spiritual component can maintain the spiritual QOL of patients with advanced cancer during radiation therapy.
PMCID: PMC4332624  PMID: 24019196
2.  The Importance of Contextual Factors and Age in Association with Anxiety and Depression in Black Breast Cancer Patients 
Psycho-oncology  2013;23(2):143-150.
Limited research exists on correlates of psychosocial distress in Black breast cancer patients. The goals of the study were to describe the prevalence of distress (anxiety and depression) in Black women with breast cancer and to examine the influence of demographic, clinical, contextual (e.g. self-efficacy, medical mistrust), and process of care factors (e.g., patient satisfaction) on women’s level of anxiety and depression.
Eighty-two Black women diagnosed with invasive non- metastatic breast cancer were interviewed by phone. Collected data included demographics, clinical, contextual, and process of care factors. Bivariate correlations were used to examine relationships between those variables. Multiple linear regressions were used to examine predictors of anxiety and depression.
About one-third of the women (32%) met cut-off thresholds for distress. Medical mistrust and positive attitude had significant influences on anxiety levels while age and positive attitude were determinants of levels of depression. Participants with higher medical mistrust reported more anxiety (r=.379; p<.001) and depression (r=.337 p=.002) while women with higher self-efficacy reported less anxiety (r=−.401; p<.001) and depression (r=−.427; p < .001). Age was inversely related to both anxiety and depression (r=−.224, r=−.296, respectively; p<.05).
Findings support national recommendations for routine distress screening in the delivery of cancer care particularly in younger Black patients. Interventions targeted to boost self-efficacy or reduce medical mistrust through enhanced patient-provider interactions may decrease psychological distress. Psychosocial needs of younger patients warrant particular attention.
PMCID: PMC4144019  PMID: 24150907
3.  Stigma among patients with lung cancer: A patient-reported measurement model 
Psycho-oncology  2013;23(1):81-92.
Although stigma may have negative psychosocial and behavioral outcomes for patients with lung cancer, its measurement has been limited. A conceptual model of lung cancer stigma and a patient-reported outcome (PRO) measure is needed to mitigate these sequelae. This study identified key stigma-related themes to provide a blueprint for item development through thematic analysis of semi-structured interviews and focus groups with lung cancer patients.
Participants were recruited from two outpatient oncology clinics and included: a) 42 lung cancer patients who participated in individual interviews and, b) 5 focus groups (inclusive of 23 new lung cancer patients). Never smokers, long-term quitters, recent quitters, and current smokers participated. Individual interviews facilitated theme development and a conceptual model of lung cancer stigma, whereas subsequent focus groups provided feedback on the conceptual model. Qualitative data analyses included iterative coding and validation with existing theory.
Two main thematic elements emerged from interviews with lung cancer patients: perceived (felt) stigma and internalized (self) stigma. Discussions of perceived stigma were pervasive, while internalized stigma was more commonly endorsed among current and recently quit smokers. Participants also discussed maladaptive (e.g., decreased disclosure) and adaptive (e.g., increased advocacy) stigma-related consequences.
Results indicate widespread acknowledgment of perceived stigma among lung cancer patients, but varying degrees of internalized stigma and associated consequences. Next steps for PRO measure development are item consolidation, item development, expert input, and cognitive interviews before field testing and psychometric analysis. Future work should address stigma-related consequences and interventions for reducing lung cancer stigma.
PMCID: PMC3936675  PMID: 24123664
lung cancer; cancer; oncology; stigma; patient-reported outcomes
4.  Broadening the cancer and cognition landscape: The role of self-regulatory challenges 
Psycho-oncology  2013;23(1):10.1002/pon.3351.
The potentially detrimental effects of cancer and related treatments on cognitive functioning have emerged as key foci of cancer survivorship research, but little is known about how psychological variables other than depression influence these relationships. To illustrate the potential of social psychological perspectives, we examine how a self-regulatory analysis and specific self-regulatory challenges of contending with cancer-related expectancies and stereotypes provide conceptual frameworks for understanding some of the potential causes and consequences of cancer-related cognitive deficits.
Literatures on cancer-related cognitive deficits, self-regulatory ego depletion, expectancy-stereotypes and their points of convergence are briefly reviewed.
A review and conceptual integration of relevant literatures suggests that coping with cancer can impair self-regulatory capacity, there is overlap between cognitive deficits associated with self-regulatory challenge and with cancer and its treatment, and restoring self-regulatory resources can attenuate cancer-related cognitive deficits. Examination of specific regulatory challenges of contending with expectancies and stereotypes related to treatment suggest insights that can inform when and among whom cognitive deficits may most likely emerge.
Integrating social psychological ideas with a substantial knowledge base can illustrate novel research trajectories that can deepen our understanding of cancer-related cognitive deficits and their impact on psychosocial well-being.
PMCID: PMC3880400  PMID: 23839818
cancer; oncology; cognitive deficit; self-regulation; expectancies
5.  Comorbidity of common mental disorders with cancer and their treatment gap: Findings from the World Mental Health Surveys 
Psycho-oncology  2013;23(1):40-51.
To study the comorbidity of common mental disorders (CMDs) and cancer, and the mental health treatment gap among community residents with active cancer, cancer survivors and cancer-free respondents in 13 high- and 11 low-middle income countries.
Data were derived from the World Mental Health Surveys (N=66,387; n=357 active cancer, n=1,373 cancer survivors, n=64,657 cancer free respondents). The WHO/Composite International Diagnostic Interview was used in all surveys to estimate CMDs prevalence rates. Respondents were also asked about mental health service utilization in the preceding 12 months. Cancer status was ascertained by self-report of physician’s diagnosis.
Twelve month prevalence rates of CMDs were higher among active cancer (18.4% SE=2.1) than cancer free respondents (13.3%, SE=0.2) adjusted for socio-demographic confounders and other lifetime chronic conditions (Adjusted Odds Ratio (AOR)=1.44 95% CI 1.05–1.97). CMD rates among cancer survivors (14.6% SE=0.9) compared with cancer-free respondents did not differ significantly (AOR=0.95 95% CI 0.82–1.11). Similar patterns characterized high and low-middle income countries. Of respondents with active cancer who had CMD in the preceding 12 months 59% sought services for mental health problems (SE=5.3). The pattern of service utilization among people with CMDs by cancer status (highest among persons with active cancer, lower among survivors and lowest among cancer-free respondents) was similar in high- (64.0% SE=6.0, 41.2% SE=3.0, 35.6% SE=0.6) and low-middle income countries (46.4% SE=11.0, 22.5% SE=9.1, 17.4% SE=0.7).
Community respondents with active cancer have relatively higher CMD rates and relatively high treatment gap. Comprehensive cancer care should consider both factors.
PMCID: PMC3992888  PMID: 23983079
Cancer; Epidemiology; Mental health; Oncology; Treatment gap; World Mental Health Surveys
6.  It’s Out of My Hands: How Deferring Control to God Can Decrease Quality of Life for Breast Cancer Patients 
Psycho-oncology  2013;22(12):2747-2754.
PMCID: PMC4041193  PMID: 23913722
Breast cancer; oncology; religious coping; computer-mediated social support; quality of life
7.  Exercise and quality of life during and after treatment for breast cancer: results of two randomized controlled trials 
Psycho-oncology  2009;18(4):343-352.
To determine the effect of exercise on quality of life in (a) a randomized controlled trial of exercise among recently diagnosed breast cancer survivors undergoing adjuvant therapy and (b) a similar trial among post-treatment survivors.
Fifty newly diagnosed breast cancer survivors were recruited through a hospital-based tumor registry and randomized to a 6-month, home-based exercise program (n=25) or a usual care group (n=25). In a separate trial, 75 post-treatment survivors were randomized to a 6-month, supervised exercise intervention (n=37) or to usual care (n=38). Participants in both studies completed measures of happiness, depressive symptoms, anxiety, stress, self-esteem, and quality of life at baseline and 6 months.
Forty-five participants completed the trial for newly diagnosed survivors and 67 completed the trial for post-treatment survivors. Good adherence was observed in both studies. Baseline quality of life was similar for both studies on most measures. Exercise was not associated with quality of life benefits in the full sample of either study; however exercise was associated with improved social functioning among post-treatment survivors who reported low social functioning at baseline (p<0.05).
Exercise did not affect quality of life in either recently diagnosed or post-treatment breast cancer survivors; however this may be due in part to relatively high baseline functioning among participants in both studies. Strategies for future research include limiting enrollment to survivors who report reduced quality of life on screening questionnaires and targeting survivor subgroups known to be at particular risk for quality of life impairment.
PMCID: PMC4221990  PMID: 19242918
Cancer; oncology; physical activity; patient reported outcomes; quality of life
8.  Concordance of parent proxy report and child self-report of posttraumatic stress in children with cancer and healthy children: Influence of parental posttraumatic stress 
Psycho-oncology  2013;22(11):10.1002/pon.3321.
This study examined the relationships between parental posttraumatic stress symptoms (PTSS), child PTSS, and parent-child concordance for child PTSS.
Participants were children with cancer (n = 199) and healthy children (n = 108) and their parents. Children self-reported on PTSS and parents completed measures of child and parent PTSS.
In the cancer group, child and parent report of child PTSS were significantly correlated with no mean differences between reporters. In contrast, correlations were non-significant in the control group, and parents reported significantly lower levels of child PTSS than children. Increased parental PTSS was associated with better concordance in the cancer group, but not in the control group. In fact, in the cancer group, parent-child concordance was strongest at the highest level of parental PTSS.
Parents of children with cancer were found to be accurate reporters of their children’s distress, even with high levels of reported personal distress. In contrast, parents of healthy children appear primarily influenced by personal distress when reporting child PTSS. Although multiple informant assessments are always desirable, it appears that utilization of a single informant may be reasonable in the cancer setting when access to informants is limited.
PMCID: PMC3808492  PMID: 23723147
assessment; cancer; child; parent-child concordance; posttraumatic stress
9.  A Comparison of Cancer Survivors from the PROMIS Study Selecting Telephone Versus Online Questionnaires 
Psycho-oncology  2013;22(11):10.1002/pon.3330.
PMCID: PMC3808510  PMID: 23813785
cancer; oncology; data collection; surveys; internet; telephone
10.  Patients’ and Family Members’ Views on Patient-Centered Communication During Cancer Care 
Psycho-oncology  2013;22(11):10.1002/pon.3317.
To explore patients’ and family members’ views on communication during cancer care, and to identify those aspects of clinician-patient communication which were most important to patients and family members.
We conducted a secondary data analysis of qualitative data from 137 patients with cancer and family members of patients with cancer. We used a modified version of the constant comparative method and coding paradigm of grounded theory.
Patients want sensitive, caring clinicians who provide information that they need, when they need it, in a way that they can understand; who listen and respond to questions and concerns, and who attempt to understand the patient’s experience. Effective information exchange and a positive interpersonal relationship with the clinician were of fundamental importance to patients and family members. These were interrelated; for instance, failure to provide information a patient needed could damage the relationship, while excellent listening could foster the relationship. Information exchange and relationship were also integral to decision making, managing uncertainty, responding to emotions, and self-management. Clinicians who were responsive to patients’ needs beyond the immediate medical encounter were valued.
The complexity of cancer care today suggest that efforts to improve communication must be multi-level, acknowledging and addressing patient, clinician, organizational and policy barriers and facilitators. Measurement tools are needed to assess cancer patients’ and family members’ experiences with communication over the course of cancer care in order to provide meaningful, actionable feedback to those seeking to optimize their effectiveness in communicating with patients with cancer.
PMCID: PMC3808529  PMID: 23780672
Psycho-oncology  2013;22(11):2513-2521.
Spiritual well-being (SpWB) is integral to health-related quality of life (HRQOL). The challenges of colorectal cancer (CRC) and subsequent bodily changes can affect SpWB. We analyzed the SpWB of CRC survivors with ostomies.
Two-hundred-eight-three long-term (≥5 years) CRC survivors with permanent ostomies completed the modified City of Hope Quality of Life-Ostomy (mCOH-QOL-O) questionnaire. An open-ended question elicited respondents’ greatest challenge in living with an ostomy. We used content analysis to identify SpWB responses and develop themes. We analyzed responses on the 3-item SpWB sub-scale.
Open-ended responses from 52% of participants contained SpWB content. Fifteen unique SpWB themes were identified. Sixty percent of individuals expressed positive themes such as “positive attitude”, “I am fortunate”, “appreciate life more”, and “strength through religious faith”. Negative themes, expressed by only 29% of respondents, included “struggling to cope”, “not feeling ‘normal’”, and “loss”. Fifty-five percent of respondents expressed ambivalent themes including “learning acceptance”, “an ostomy is the price for survival”, “reason to be around despite suffering”, and “continuing to cope despite challenges”. The majority (64%) had a high SpWB sub-scale score.
While CRC survivors with ostomies infrequently mentioned negative SpWB themes as a major challenge, ambivalent themes were common. SpWB themes often were mentioned as a source of resilience or part of the struggle to adapt to an altered body after cancer surgery. Interventions to improve the quality of life of cancer survivors should contain program elements designed to address SpWB that support personal meaning, inner peace, inter-connectedness, and belonging.
PMCID: PMC4105015  PMID: 23749460
cancer; oncology; spiritual well-being; ostomy; stoma; survivorship; HRQOL
12.  Barriers to physical activity among African American breast cancer survivors 
Psycho-oncology  2014;23(11):1314-1317.
PMCID: PMC4167984  PMID: 24644092
13.  Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers 
Psycho-oncology  2009;18(1):62-70.
Women with gynecological cancers have reported poor health-related quality of life (QOL), with complex physical and psychological needs post-surgery and during chemotherapy treatment. There are no studies reporting interventions addressing these needs post-hospital discharge in this population.
Patients were randomized into two groups. The intervention group received 6 months of specialized care by an Advanced Practice Nurse (APN); in addition, women with high distress were evaluated and monitored by a psychiatric consultation–liaison nurse (PCLN). The attention control group was assisted with symptom management by a research assistant. The effects of the 6-month intervention were evaluated using self-report questionnaires at baseline (24–48 h after surgery), 1, 3, and 6 months post-surgery. QOL assessments included the Center for Epidemiological Studies–Depression Scale, the ambiguity subscale of the Mishel Uncertainty in Illness Scale, the Symptom Distress Scale, and the Short-Form Health Survey (SF-12). The sample for the longitudinal analysis included 123 who completed QOL outcome measures across three occasions post-surgery.
The APN intervention resulted in significantly less uncertainty than the attention control intervention 6 months after surgery. When the sub-group who received the APN plus PCLN intervention was compared with the total attention control group, the sub-group had significantly less uncertainty, less symptom distress, and better SF-12 mental and physical QOL over time.
Nurse tailored interventions that target both physical and psychological aspects of QOL in women recovering from cancer surgery and undergoing chemotherapy produce stronger outcomes than interventions that target solely one QOL aspect.
PMCID: PMC4186244  PMID: 18570223
gynecological cancers; post-surgical; advanced practice nurse; tailored intervention; quality of life
14.  Psychosocial Impact of Lymphedema: A Systematic Review of Literature from 2004–2011 
Psycho-oncology  2012;22(7):1466-1484.
This systematic review aimed to evaluate the level of evidence of contemporary peer-reviewed literature published from 2004–2011 on the psychosocial impact of lymphedema.
Eleven electronic databases were searched and 1,311 articles retrieved; 23 met inclusion criteria. Twelve articles utilized qualitative methodology and 11 employed quantitative methodology. An established quality assessment tool was used to assess the quality of the included studies.
The overall quality of the 23 included studies was adequate. A critical limitation of current literature is the lack of conceptual or operational definitions for the concept of psychosocial impact. Quantitative studies showed statistically significant poorer social well-being in persons with lymphedema, including perceptions related to body image, appearance, sexuality, and social barriers. No statistically significant differences were found between persons with and without lymphedema in the domains of emotional well-being (happy or sad) and psychological distress (depression and anxiety). All 12 of the qualitative studies consistently described negative psychological impact (negative self-identity, emotional disturbance, psychological distress) and negative social impact (marginalization, financial burden, perceived diminished sexuality, social isolation, perceived social abandonment, public insensitivity, non-supportive work environment). Factors associated with psychosocial impact were also identified.
Lymphedema has a negative psychosocial impact on affected individuals. The current review sheds light on the conceptualization and operationalization of the definitions of psychosocial impact with respect to lymphedema. Development of a lymphedema-specific instrument is needed to better characterize the impact of lymphedema and to examine the factors contributing to these outcomes in cancer and non-cancer-related populations.
PMCID: PMC4153404  PMID: 23044512
Lymphedema; Psychosocial; Systematic review; Psychological distress; Cancer; Oncology
15.  Slower Processing Speed after Treatment for Pediatric Brain Tumor and ALL 
Psycho-oncology  2013;22(9):1979-1986.
ALL and brain tumor (BT) survivors are at risk for post-treatment IQ declines. The extent to which lower scores represent global cognitive decline versus domain-specific impairment remains unclear. This study examined discrepancies between processing speed and Estimated IQ (EIQ) scores and identified clinical characteristics associated with score discrepancies in a sample of pediatric cancer survivors.
Survivors (50 ALL, 50 BT) ages 12–17 completed cognitive testing. The Wechsler Abbreviated Scale of Intelligence provided an untimed measure of general reasoning ability (EIQ). The age-appropriate Wechsler Intelligence Scale provided a Processing Speed Index (PSI) score. Scores were examined and compared.
Survivors’ PSI scores were lower than their EIQ scores (BT t(45)=6.3, p<0.001; ALL t(49)=6.9, p<0.001). For BT survivors, lower PSI scores were associated with history of craniospinal irradiation, t(44)=3.3, p<0.01. For ALL survivors, lower PSI scores were associated with male gender, grade retention, and time since diagnosis, F(3,46)=10.1, p<0.001. Clinically significant EIQ-PSI score discrepancies were identified in 41.3% of BT and 14.0% of ALL survivors.
Many pediatric BT and ALL survivors exhibit slower processing speed than expected for age while general reasoning ability remains largely intact. Risk factors associated with larger EIQ-PSI discrepancies include: BT diagnosis, craniospinal irradiation (BT only), male gender and younger age at diagnosis (ALL only). Grade retention was frequent and associated with lower EIQ scores (both groups) and PSI scores (ALL only). Describing post-treatment cognitive declines using global measures of intellectual ability may underestimate dysfunction or fail to isolate specific underlying deficits contributing to impairment.
PMCID: PMC3740073  PMID: 23447439
pediatric hematology/oncology; processing speed; intelligence; late effects of cancer treatment
16.  Elevated Peri-transplant Distress in Caregivers of Allogeneic Blood or Marrow Transplant Patients 
Psycho-oncology  2013;22(9):2064-2070.
A full-time 24/7 caregiver is required for 100 days or longer following an allogeneic blood or marrow transplant during which time caregivers have multiple demands. Although distress in caregivers is documented, generalization is limited by small sample sizes, restricted range of assessments, and lack of information as to which caregivers may be more vulnerable to distress. The purpose of this study was to describe the peri-transplant psychological status of a sample of caregivers of allogeneic transplant patients.
We assessed caregiver mood, stress, burden, and sleep using valid self-report measures in 109 caregivers of allogeneic transplant patients prior to stem cell transplantation. Caregivers’ scores were compared to norms or established cut-off scores for behavioral measures. Additionally, demographic characteristics such as age and sex were tested as predictors of distress.
Caregivers showed significant levels of anxiety, stress, intrusion and avoidance behaviors, and poor sleep at the start of transplant compared to established norms. Younger caregivers were more distressed than older caregivers. There were no differences in levels of distress between male and female caregivers.
The peri-transplant period is a time of heightened anxiety and distress for caregivers of allogeneic transplant patients. This study indicates that caregivers would benefit from support programs in the peri-transplant period. Recommendations for types of support that may be helpful to caregivers are provided but additional research is needed to validate that these programs would help caregivers providing care to patients receiving an allogeneic transplant in the peri-transplant period.
PMCID: PMC3696414  PMID: 23440998
Cancer; oncology; caregiver; allogeneic transplant; stress; distress
17.  Conveying genomic recurrence risk estimates to patients with early stage breast cancer: Oncologist perspectives 
Psycho-oncology  2013;22(9):2110-2116.
The development and increased use of genomic profiling has led to refinement of breast cancer treatment. This study sought to examine medical and surgical oncologists’ perceptions of factors related to the translation and integration of Oncotype DX® into routine clinical care.
Twenty oncologists (10 medical and 10 surgical oncologists) participated in qualitative interviews. Questions centered on the following themes: oncologists’ perceptions about the clinical utility of testing, the impact of patient preferences on the decision to test and use results to inform treatment decisions, methods of communicating risk associated with test results to patients, and benefits of and barriers to incorporating testing into multidisciplinary care settings.
Oncologists found Oncotype DX® test results useful in their practice, but had concerns as well. These included that some oncologists either used testing inappropriately or placed undue emphasis on the results at the expense of other clinical information. The use of intermediate test results, which have less clear clinical implications, incorporating results with patient treatment preferences, and the use of testing in multidisciplinary teams were noted as specific challenges.
Oncologists noted several benefits of testing, but also many challenges, despite wide dissemination and common use. Education for health providers should include specific training in how to interpret and communicate the uncertainty inherent in genomic tests while integrating patient preferences to inform treatment decision making.
PMCID: PMC3757108  PMID: 23447452
qualitative; physician; communication; 21-gene; breast cancer; oncology
Psycho-oncology  2008;17(8):831-843.
Prophylactic mastectomy (PM) offers 90% or greater reduction in risk of breast cancer to women at increased hereditary risk. Nonetheless, acceptance in North America has been low (0–36%). Most women report reduced cancer worry post-operatively, but up to 25–50% of women electing surgery also report psychological distress and/or difficulty adapting following PM. Psychological consultation to aid decision-making and improve post-surgical coping isn’t routinely offered. This retrospective, cross-sectional study explored, quantitatively and qualitatively, interest in and acceptability of psychological consultation for issues related to PM among 108 women who had undergone or were considering surgery. Of the 71 women who had undergone PM, more than half felt pre-surgical psychological consultation was advisable and nearly 2/3 felt post-surgical psychological consultation would be helpful. All 37 women (100%) currently considering PM believed psychological consultation would aid decision-making and preparation for surgery.
Narratives from the interviews illustrate the nature and intensity of the need for psychological support and describe preferences for the role of the psychologist. Suggestions are offered for the integration of psychological services for women deciding about or adapting to PM.
PMCID: PMC4133134  PMID: 18636423
19.  Working Memory Training in Survivors of Pediatric Cancer: A Randomized Pilot Study 
Psycho-oncology  2012;22(8):1856-1865.
Survivors of pediatric brain tumors and acute lymphoblastic leukemia (ALL) are at increased risk for neurocognitive deficits, but few empirically-supported treatment options exist. We examined the feasibility and preliminary efficacy of a home-based, computerized working memory training program, CogmedRM, with survivors of childhood cancer.
Survivors of brain tumors or ALL (n = 20) with identified deficits in attention and/or working memory were randomized to either the success-adapted computer intervention or a non-adaptive, active control condition. Specifically, children in the adaptive condition completed exercises that became more challenging with each correct trial, whereas those in the non-adaptive version trained with exercises that never increased in difficulty. All participants were asked to complete 25 training sessions at home, with weekly, phone-based coaching support. Brief assessments were completed pre- and post-intervention; outcome measures included both performance-based and parent-report measures of working memory and attention.
Eighty-five percent of survivors were compliant with the intervention, with no adverse events reported. After controlling for baseline intellectual functioning, survivors who completed the intervention program evidenced significant post-training improvements in their visual working memory and in parent-rated learning problems compared with those in the active control group. No differences in verbal working memory functioning were evident between groups, however.
Home-based, computerized cognitive training demonstrates good feasibility and acceptability in our sample. Children with higher intellectual functioning at baseline appeared to benefit more from the training, though further study is needed to clarify the strength, scope, and particularly the generalizability of potential treatment effects.
PMCID: PMC4131851  PMID: 23203754
intervention; survivors; pediatric cancer; cognitive training; working memory
20.  Parenting Stress and Neurocognitive Late Effects in Childhood Cancer Survivors 
Psycho-oncology  2012;22(8):1774-1782.
Surveillance of neurocognitive late effects has typically focused on the pediatric survivor alone and rarely has focused on the potential family burden. We investigated the impact of child neurocognitive effects on parenting stress, and hypothesized that parents of childhood cancer survivors with greater executive difficulties experience higher stress relative to parents of children with less adverse impact.
Parents of 44 children who survived cancer involving CNS-directed treatments and who had documented neurocognitive deficits completed standardized questionnaires assessing their perceived level of stress and perception of their child’s executive functioning abilities in daily life. Data from performance-based cognitive tests were obtained on the children. Multivariate regression models examined socio-demographic, clinical, and child’s executive functioning as predictors of parent stress. Differences in parenting stress based on child’s level of executive functioning were evaluated.
Parent stress was significantly associated with both performance-based and parent report measures of child executive functioning. Child executive functioning significantly predicted parent stress even after controlling for socio-demographic and clinical factors, and the final model accounted for 42% of variance in parent stress levels. Significant differences in parent stress were found when comparing higher versus lower levels of child executive functioning. The nature of the executive difficulties, however, appears important, as we found increased parenting stress among children with behavioral regulation problems rather than metacognitive difficulties.
The associations between parenting stress and neurocognitive problems found in this study suggests the need for further research, along with professional monitoring and appropriate intervention.
PMCID: PMC3721633  PMID: 23097416
childhood cancer; neurocognitive; parent; stress; survivor; pediatric cancer
21.  A Systematic Review and Meta-Analysis of Psychosocial Interventions for Couples Coping With Cancer 
Psycho-oncology  2012;22(8):1688-1704.
Quality of life (QOL) is a multidimensional construct that includes physical, psychological, and relationship well-being. We conducted a systematic review and meta-analysis of randomized controlled studies published between 1980 and 2012 of interventions conducted with both cancer patients and their partners that were aimed at improving QOL. Using bibliographic software and manual review, two independent raters reviewed 752 articles with a systematic process for reconciling disagreement, yielding 23 articles for systematic review and 20 for meta-analysis. Most studies were conducted in breast and prostate cancer populations. Study participants (N=2645) were primarily middle-aged (Mean = 55 years old) and white (84%). For patients, the weighted average effect size (g) across studies was 0.25 (95% CI = 0.12-0.32) for psychological outcomes (17 studies), 0.31 (95% CI = 0.11-0.50) for physical outcomes (12 studies), and 0.28 (95% CI = 0.14-0.43) for relationship outcomes (10 studies). For partners, the weighted average effect size was 0.21 (95% CI = 0.08-0.34) for psychological outcomes (12 studies), and 0.24 (95% CI = 0.6 - 0.43) for relationship outcomes (7 studies). Therefore, couple-based interventions had small but beneficial effects in terms of improving multiple aspects of QOL for both patients and their partners. Questions remain regarding when such interventions should be delivered and for how long. Identifying theoretically based mediators and key features that distinguish couple-based from patient-only interventions may help to strengthen their effects on patient and partner QOL.
PMCID: PMC3562417  PMID: 23045191
couples; interventions; meta-analysis; cancer; quality of life; randomized-control trial; systematic review; distress; relationship satisfaction; behavior
22.  Body image in recently diagnosed young women with early breast cancer 
Psycho-oncology  2012;22(8):1849-1855.
To assess body image concerns among young women following a breast cancer diagnosis.
419 women with recently diagnosed stage 0-III breast cancer were surveyed following enrollment as part of a prospective cohort study of women age 40 or younger at diagnosis. Body image was assessed using three items from the psycho-social scale of the Cancer Rehabilitation Evaluation System (CARES). CARES scores range from 0–4, with higher scores indicative of greater image concerns. Mean CARES scores were calculated and compared between treatment groups using t-tests and ANOVA. Multiple linear regression models were fit to evaluate the relationship between physical and psychological factors and body image.
Mean time from diagnosis to completion of the baseline survey was 5.2 months. The mean CARES score for all women was 1.28. Mean CARES scores in the mastectomy-only group (1.87) and in the mastectomy with reconstruction group (1.52) were significantly higher (p<0.0001) compared to the scores in the lumpectomy group (0.85), indicating that radical surgery was associated with more body image concerns. Radiation (p=0.01), anxiety (p=0.0001), depression (p<0.0001), fatigue (p=0.04), musculoskeletal pain symptoms (p<0.0001), weight gain (p=0.01) and weight loss (p=0.02), in addition to surgery type (p<0.0001), were all associated with more body image concerns in the multi-variable analysis.
This analysis highlights the impact of treatment, along with physical and psychological factors, on body image early in the survivorship period. Our findings provide targets for potential future intervention and may aid young women in the surgical decision-making process.
PMCID: PMC3594059  PMID: 23132765
Breast cancer; oncology; young women; body image; mastectomy
23.  Family Factors Associated with Academic Achievement Deficits in Pediatric Brain Tumor Survivors 
Psycho-oncology  2012;22(8):1731-1737.
To examine whether parental education, socioeconomic status (SES), or family environment moderate the extent of academic achievement deficits in pediatric brain tumor survivors (PBTS) relative to classmate case-controls. PBTS are known to be at risk for cognitive and academic impairment; however, the degree of impairment varies. Prior, research has focused on treatment risk and efforts to examine the protective role of family resources and relationships have been lacking.
PBTS (N = 164), ages 8–15 and 1–5 years post-treatment, were recruited at five treatment centers in the United States and Canada. A case-control classmate, matched for age, gender, and race, was recruited for each survivor. The Wide Range Achievement Test, a demographic form, and the Family Environment Scale were administered in families’ homes. Treatment data were abstracted from medical charts.
PBTS demonstrated lower achievement than classmate-controls in reading, spelling, and arithmetic. Parental education and SES were associated with levels of achievement demonstrated by PBTS, but did not account for discrepancies between PBTS and classmate-controls. Deficits in achievement relative to classmate-controls, across all academic domains, were greater for survivors in families lower in support and higher in conflict. These associations remained after controlling for age at diagnosis, time since treatment, and whether treatment had involved chemotherapy, focal or whole brain radiation.
These results support the development of interventions to enhance family functioning as well as educational resources as part of intervention and rehabilitation services to optimize academic progress in children who have been treated for brain tumors.
PMCID: PMC3574177  PMID: 23059621
24.  Body Image Screening for Cancer Patients Undergoing Reconstructive Surgery 
Psycho-oncology  2014;23(8):898-905.
Body image is a critical issue for cancer patients undergoing reconstructive surgery, as they can experience disfigurement and functional impairment. Distress related to appearance changes can lead to various psychosocial difficulties, and patients are often reluctant to discuss these issues with their healthcare team. Our goals were to design and evaluate a screening tool to aid providers in identifying patients who may benefit from referral for specialized psychosocial care to treat body image concerns.
We designed a brief 4-item instrument and administered it at a single time point to cancer patients who were undergoing reconstructive treatment. We used simple and multinomial regression models to evaluate whether survey responses, demographic, or clinical variables predicted interest and enrollment in counseling.
Over 95% of the sample (n = 248) endorsed some concerns, preoccupation, or avoidance due to appearance changes. Approximately one-third of patients were interested in obtaining counseling or additional information to assist with body image distress. Each survey item significantly predicted interest and enrollment in counseling. Concern about future appearance changes was the single best predictor of counseling enrollment. Sex, age, and cancer type were not predictive of counseling interest or enrollment.
We present initial data supporting use of the Body Image Screener for Cancer Reconstruction. Our findings suggest benefits of administering this tool to patients presenting for reconstructive surgery. It is argued that screening and treatment for body image distress should be provided to this patient population at the earliest possible time point.
PMCID: PMC4116641  PMID: 25066586
body image; distress screening; breast cancer; head and neck cancer; reconstructive surgery
25.  Beta-blockers May Reduce Intrusive Thoughts in Newly Diagnosed Cancer Patients 
Psycho-oncology  2012;22(8):1889-1894.
A cancer diagnosis provokes significant levels of emotional distress, with intrusive thoughts being the most common manifestation among breast cancer survivors. Cancer-related intrusive thoughts can take the form of emotional memories, flashbacks, nightmares, and intrusive images. Emotional arousal after a severe life stressor prolongs adrenergic activation, which in turn may increase risk for posttraumatic symptomatology. However, antihypertensive beta-blockers block adrenergic activation and are known to reduce traumatic memories and related psychological distress. Thus, the current study examined the association between beta-blocker use and the severity of cancer-related intrusive thoughts and related symptoms following a cancer diagnosis.
The 174 breast and 36 female colorectal cancer patients who had recently undergone diagnostic screening or biopsy included 39 beta-blocker users and 171 non-users. Prior to any cancer treatment including surgery, participants completed questionnaires that included the Impact of Events Scale (IES) and the Center for Epidemiological Studies Depression Scale (CES-D). Analyses controlled for age, education, cancer stage, cancer type, days since diagnosis, marital status, depression, and comorbidities.
Although the high rates of cancer-related distress in this sample were similar to those of other studies with recently diagnosed patients, beta-blocker users endorsed 32% fewer cancer-related intrusive thoughts than non-users.
Recently diagnosed cancer patients using beta-blockers reported less cancer-related psychological distress. These results suggest that beta-blocker use may benefit cancer patients’ psychological adjustment following diagnosis, and provide a promising direction for future investigations on the pharmacological benefits of beta-blockers for cancer-related distress.
PMCID: PMC3612565  PMID: 23255459
Stress; PTSD; propranolol; intrusions; cancer; oncology

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