CAPO Digest

CAPO Digests are summaries of recent psychosocial oncology research which have published in peer-reviewed journals in and out of the main psychosocial oncology outlets that may be of interest to CAPO members. We hope you enjoy these Digests. If you are interested in submitting a CAPO Digest please contact the CAPO office at [email protected].


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  • 15 Aug 2018 2:10 PM | Brandon Davenport (Administrator)

    Digest Commentator: Julia Parrott, Undergraduate student, School of Psychology, University of Ottawa

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Adolescents and young adults (AYA) (ages 15-39) with long term illnesses present a unique challenge for the clinicians addressing their palliative care. Spirituality and religiosity have previously been identified as important parts of helping cancer patients increase their quality of life. Yet, there is a lack of research in exactly how to address AYA religious and spiritual perspectives. AYA are in the process of defining who they are; shaping their own opinions on the meaning of life, independence and identity. Being sick while in this transitional phase makes them vulnerable to decreased physical and mental health outcomes. The purpose of this study was to identify ways to address the spiritual and/or religious components of palliative care in AYA’s with long term illness.

    Methods: The “Resilience in Adolescence and Young Adults” study was used for a subset of the sample (n=17). The authors looked at one site from this multisite, prospective longitudinal study and only included individuals aged 14-25 years at the time of their cancer diagnosis. To be eligible, the diagnosis required immediate treatment with multi-agent systemic chemotherapy. Nervous-system tumors were excluded because of the difference in treatment protocol. Quantitative data were analyzed from questionnaires completed at enrollment and qualitative data were collected from one-on-one semi-structured interviews. These interviews were transcribed and analyzed in three steps at three different time points; six months, six to 12 months and 12 to 18 months post-diagnosis. Researchers focused on the participants’ self-reported “religiousness” and “spirituality” and categorized the participants according to how they self-identified and not according to their qualitative narratives. The participants were not provided with definitions of religiousness and spirituality. The theme of hope was included in the qualitative analysis due to the frequency with which it was mentioned.

    Results:  Collectively, participants completed 44 interviews. Participants were about 17 years old and most were non-Hispanic white. More participants self-identified as “spiritual” rather than “religious”. Those who identified as “spiritual” and not necessarily “religious” were more likely to look for meaning but struggled with articulating their needs. This group was also more likely to express hopeful statements. Most AYA expressed some existential questioning. There was no consistent definition of religion or spirituality, but there was a common theme of hope. The AYA used hope to discuss the lessons they have learned, how they are going to approach the future and reconcile with the diagnosis. Those who rejected “religion” and “spirituality” demonstrated a negative perception of the divine or were truly agnostic. In the development of palliative guidelines for AYA, the authors emphasized respecting the AYA developing autonomy, while encouraging the exploration of spirituality even if the AYA do not outwardly express this interest. They recommend doing this through discussing hopes, worries, meaning, and changing life perspectives.

    Why I liked the article: I liked how the authors focused on respecting the AYA self-identification and allowed them to explore their own interpretation of spirituality and religion. By focusing on constructs that relate to spirituality like hope, worries, and meaning, care providers can help make these existential concepts more accessible. This could lead to improved support for AYAs in their spiritual journeys while battling cancer.

    Citation: Barton, K. S., Tate, T., Lau, N., Taliesin, K. B., Waldman, E. D., & Rosenberg, A. R. (2018). “I’m Not a spiritual person.” How hope might facilitate conversations about spirituality among teens and young adults with cancer. Journal of Pain and Symptom Management. doi:10.1016/j.jpainsymman.2018.02.001

    Journal website: http://www.jpsmjournal.com/


  • 15 Aug 2018 2:10 PM | Brandon Davenport (Administrator)

    Digest Commentator: Maclean Thiessen MD MN BSc FRCPC, Breast and GI Medical Oncology Fellow, Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, Alberta; Scholar in Residence, The College, University of Calgary, Calgary, Alberta

    Digest Editor:  Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    In general, chemotherapy is administered for one of two reasons: 1) As part of a strategy to cure cancer or 2) as part of a strategy to control disease and improve survival and/or symptoms for patients whose malignancy cannot be cured. In many types of cancer, when chemotherapy is being used as part of a curative strategy, the most important part of the treatment strategy is surgery – with chemotherapy

    being given either before or after surgery to improve the chance that the cancer will not come back. Colon cancer patients who have disease limited to the colon, but have involvement of regional lymph nodes, are usually offered chemotherapy after surgery. Chemotherapy has been demonstrated to improve survival by about one third in patients with lymph node positive colon cancer (1, 2). Historically, chemotherapy is given for a total of six months to these patients. While chemotherapy can substantially reduce the risk of recurrence, receiving chemotherapy for half a year can have a substantial impact on a person’s life for many reasons including cumulative toxicity and prolonged time away from work.

    At the 2017 American Society of Clinical Oncology (ASCO) meeting, prospectively-designed pooled analysis of individual patient data from six large clinical trials was presented (3). In this analysis, patients with node positive, resected colon cancer had been randomized to receive either three or six months of standard post-surgical chemotherapy. At 39 months median follow-up, the shorter three-month treatment was found to be non-inferior(4) to the six-month treatment. In simple terms, non-inferiority means that, statistically, the three-month duration of treatment was found to be no worse than the six- month duration of treatment. In a subset analysis, three months of treatment was found to be inferior to six months, with three-year disease free survival decreased by 1.7% (95% CI = -4.3% to 0.9%) from 64.4% to 62.7% for patients who received three months of chemotherapy compared to those who received six months. Six months of treatment compared to three months of treatment was associated with higher rates of neurotoxicity, severe enough to interfere with activities of daily living.

    Why I liked the article: Less toxicity and faster completion of treatment will undoubtedly help to lessen the psycho-social impact of the colon cancer experience for many patients. While the results of this study have not matured, and other studies exploring three versus six months in this same population are underway, this report is exciting. These early results suggest that the biggest benefit of chemotherapy in this population occurs in the first three months, after which there may be an opportunity to further tailor treatment around patient’s pathological risk features and psycho-social needs.

    Citation:

    1. Andre T, de Gramont A, Study Group of Clinical Research in Radiotherapies Oncology OMRG. An overview of adjuvant systemic chemotherapy for colon cancer. Clin Colorectal Cancer. 2004;4 Suppl 1:S22-8.

    2. Andre T, de Gramont A, Vernerey D, Chibaudel B, Bonnetain F, Tijeras-Raballand A, et al. Adjuvant fluorouracil, leucovorin, and oxaliplatin in stage II to III colon cancer: Updated 10-year survival and outcomes according to BRAF mutation and mismatch repair status of the MOSAIC study. J Clin Oncol. 2015;33(35):4176-87.

    3. Shi Q, Sobrero A, Shields A, Yoshino T, Paul J, Taieb J, et al., editors. Prospective pooled analysis of six phase III trials investigating duration of adjuvant (adjuv) oxaliplatin-based therapy (3 vs 6 months)

    for patients (pts) with stage III colon cancer (CC): The IDEA (International Duration Evaluation of Adjuvant chemotherapy) collaboration. American Society of Clinical Oncology; 2017; Chicago, Illinois, USA. J Clin Oncol. 2017;35 (suppl; abstr LBA1).

    4. Mauri L, D&#39;Agostino RB, Sr. Challenges in thedesign and interpretation of noninferiority trials. N Engl J Med. 2017;377(14):1357-67.

    Journal website: http://ascopubs.org/doi/abs/10.1200/JCO.2017.35.18_suppl.LBA1

    Author Blog: http://macthiessen.weebly.com/


  • 15 Aug 2018 2:09 PM | Brandon Davenport (Administrator)

    Digest Commentator: Sophie Lebel, PhD, C.Psych, School of Psychology, University of Ottawa

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Fear of cancer recurrence is a growing area of research, now with its own IPOS Special Interest Group called FORWARDS. As a researcher and clinician working on fear of cancer recurrence, I frequently get asked this question: “Fear of cancer recurrence is present in almost all of my patients but how can I help them deal with this fear? I am not sure it is something that can be changed”. Until recently, this feeling was warranted as there was only one published trial of an intervention to address fear of cancer recurrence (Herschbach et al, 2009), which showed that both group Cognitive Behavioral Therapy and group supportive expressive therapy were efficacious in reducing this fear. In November 2017, Butow and colleagues published the results of their trial of an individual therapy to address fear of cancer recurrence in cancer survivors in the Journal of Clinical Oncology. The intervention is called ConquerFear and consists of five face-to face individual sessions that cover attention training, metacognitions, acceptance/mindfulness, screening behavior, and values-based goal setting. Specifically, the intervention teaches strategies for controlling worry and excessive threat monitoring, modifying unhelpful beliefs about worry, and developing appropriate monitoring and screening behaviors, educates about follow-up and strategies (e.g., exercise) to reduce risk of recurrence, addresses existential issues, and promotes goal setting. One of the interesting features of this trial is that the intervention was compared to a nonspecific attention control intervention (five sessions of face-to-face relaxation training). The effects of the therapy were also assessed at 3- and 6-months post therapy. Participants (95% female) were 222 stage 0 to III breast, Dukes’ stage A to C colorectal, and Stage IA to IIB melanoma survivors who were disease-free and who displayed elevated levels of fear of cancer recurrence before being enrolled in the trial (as defined as a score of ≥ 13 on the Fear of Cancer Recurrence Inventory). Participants had completed adjuvant treatment 2 months to 5 years previously. They were randomly assigned to either ConquerFear or the control group. Twenty-six therapists from 17 sites across Australia participated and delivered both interventions. ConquerFear participants had clinically and statistically greater improvements than control participants from baseline to completion of the intervention on their fear of cancer recurrence score and these differences were still statistically significant at 3- and 6-month post-intervention. There were also significantly greater improvements reported by ConquerFear participants in general anxiety, cancer-specific distress, and mental quality of life and metacognitions from baseline to end of the intervention, however few of these differences were significant at the subsequent follow-ups. Interestingly, ConquerFear was effective regardless of baseline fear of cancer recurrence levels, stage of disease, age, education, and country of birth.

    Why I liked the article: In conclusion, yes, it is possible to help patients deal with their fear of cancer recurrence. A next step will be to see how these interventions fare when implemented in clinical settings.

    Citation: Butow PN, Turner J, Gilchrist J, Sharpe L, Smith AB, Fardell JE, Tesson S,O’Connell R, Girgis A, Gebski VJ, Asher R, Mihalopoulos C, Bell ML, Zola KG, Beith J, Thewes B. Randomized Trial of ConquerFear: A Novel, Theoretically Based Psychosocial Intervention for Fear of Cancer Recurrence. J Clin Oncol. 2017 Nov 2:JCO2017731257. doi: 10.1200/JCO.2017.73.1257.

    Journal website: http://ascopubs.org/doi/full/10.1200/JCO.2017.73.1257


  • 15 Aug 2018 2:08 PM | Brandon Davenport (Administrator)

    Digest Commentator: Andrea Johnson, PhD (C), School of Social Work, University of British Columbia

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    As more adolescents and young adults (AYAs) (ages 15-39) are surviving a diagnosis of cancer, greater attention is being directed towards their psychosocial wellbeing as cancer survivors. Over the past decade, there has been increasing research and practice interest in the prevalence of mental health outcomes (eg. mood and anxiety disorders) experienced by this cohort after treatment. There is a small but robust literature base that has demonstrated peaks of psychological distress experienced by AYAs following treatment completion. However, what remains unknown are the associations between developmental life stage, cancer survivorship, and mental health outcomes for people diagnosed with cancer. Specifically, are AYAs at greater risk for adverse mental health outcomes when compared to cancer-free AYAs and older adult cancer survivors. This article reports on a study designed to answer this question.

    The Canadian Community Health Survey (CCHS) was used as a population-based instrument in this study. This survey collects annual health-related data from Canadians of different ages. The final sample size in this study was 239, 316 and this included four combined annual cycles (2007-2010) of respondents. This sample was dichotomized into AYAs (ages 15-39) and older adults (ages 40+). Outcomes of interest in this study were: self-perceived general health status, self-perceived mental health status, and self-reported mood and anxiety disorders diagnosed by a professional. Weighted logistic regression was used to analyze the relationships between age, cancer survivorship, and psychosocial outcomes of respondents.

    Cancer survivorship was found to be strongly associated with poor self-perceived mental health and mood and anxiety disorders among AYAs. AYA survivors of cancer were more likely to report mood and anxiety disorders than both AYAs without a history of cancer and older adults who were cancer survivors. This increased prevalence held for both self-perceptions of mental health and self-reported clinically diagnosed mood and anxiety disorders. Notably, 15.1% of AYA cancer survivors and 5.4% of AYAs without cancer reported a diagnosis of anxiety. 14.8% of AYA cancer survivors and 5.7% of AYAs without cancer reported a diagnosis of a mood disorder.

    This study advances understanding of the mental health outcomes of AYA cancer survivors. It clearly argues that it is the intersection between developmental stage and a history of cancer that leaves AYA cancer survivors vulnerable to distress.

    Why I liked the article: I really liked how this study compared psychological outcomes between AYAs with and without cancer. The psychological distress observed of AYA cancer survivors may be wrongly dismissed in practice as typical “storm and stress” expected of AYAs. The adverse mental health outcomes experienced by AYAs in this survey however surpassed those of AYAs without cancer. There remain significant gaps in AYA psychosocial oncology care. Greater efforts must be made to both understand and respond to the psychological distress experiences of AYAs.

    Article: Lang, M.J., Giese-Davis, J., Patton, S.B. & Campbell, J.T. (2017). Does age matter? Comparing post-treatment psychosocial outcomes in young adult and older adult cancer survivors with their cancer-free peers. Psycho-Oncology. Advance online publication. doi:10.1002/pon.4490.

    Journal website: http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1099-1611


  • 15 Aug 2018 2:07 PM | Brandon Davenport (Administrator)

    Digest Commentators: Chelsea Moran, BSc, MA (c) &amp; Adina Coroiu, MA, PhD (c), Department of Educational

    and Counselling Psychology, McGill University

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Early detection and timely treatment of melanoma improves survival. Given that most melanomas are self-detected (by individuals or their partners), skin self-examination (SSE) is an important adjunct to yearly skin examinations by a physician. Partners can help at-risk individuals check body areas that are more difficult to examine carefully, such as the scalp and back. Robinson and colleagues (2016) examined the long-term effect of a structured educational intervention on participant frequency of SSE conducted with a partner.

    This study analyzed data from a randomized controlled trial (RCT; NCT01432860), in which melanoma patients with stage 0 to IIB melanoma and their skin-checking partners were randomized to one of three active intervention conditions or a control. The three active conditions included identical content, which was delivered in three different formats: in-person education, workbook education, and electronic tablet education. The active intervention included monthly SSE recommendations, written materials about how to use the ABCDE (asymmetry, border, color, diameter and evolution) criteria to identify suspicious lesions, a diary and body maps to record SSE and track mole history, and reinforcement of skills by dermatologists at 4-month intervals. The control condition included customary education, as per usual care. The aim of the study was to assess the effect of the intervention compared to the control on three outcomes: 1) frequency of SSE (objective 1); 2) patient-detected and physician-detected new or recurrent melanomas (objective 2); and 3) number of unscheduled physician appointments (objective 3). The three outcomes of interest were assessed at 4, 12, and 24-months post-intervention.

    In total, 494 dyads were randomized with 59% completion by the 24-month follow-up. Since there were no significant differences in SSE frequency among the intervention groups, the three groups (in-person, workbook, tablet) were collapsed into one group. From baseline to 24-months post-intervention, participants in the intervention groups (in-person, workbook, tablet) performed SSE with a partner at a significantly higher frequency than participants in the control group (objective 1). From baseline to 24-months post-intervention, dyads in the intervention groups identified 43 melanomas compared to none identified in the control group (objective 2). Across the entire sample, approximately 13% of participants developed new melanomas. Finally, 28 participants in the intervention groups and 2 participants in the

    control group requested unscheduled appointments with the study physicians due to concerning lesions, accounting for only 1.0% of total physician visits (objective 3). The authors concluded that the interventions led to increased SSE performance and increased detection of melanoma in patient-partner dyads, without leading to unnecessary visits to the dermatologist.

    Why we liked this article: We liked this article because it underscored the importance of interventions for the early detection of melanoma, as well as the importance of partner assistance with skin self-examination among high-risk groups. Further, this trial is one of the first studies with a rigorous design to show that interventions targeting SSE did not actually increase the number of unscheduled medical visits lending some support to claims that SSE may be a cost-effective behaviour. This is valuable work that will generate further research on the effect of SSE interventions on melanoma early detection and melanoma-related mortality.

    This study is a step forward in melanoma prevention literature in that it shows that receiving education about monthly SSE using the ABCDE criteria and tools such as body maps and checking diaries is associated with an increase in SSE with the help of a partner when compared to customary education. The results of this study have important implications for psychosocial professionals working with melanoma cancer survivors, as they reaffirm the need for specific education to promote regular SSE performance. When possible, practitioners should also encourage patients to obtain assistance from their partners when checking their skin to ensure more complete self-exams.

    Article: Robinson, J. K., Wayne, J. D., Martini, M. C., Hultgren, B. A., Mallett, K. A., &amp; Turrisi, R. (2016). Early detection of new melanomas by patients with melanoma and their partners using a structured skin self-examination skills training intervention: A randomized clinical trial. JAMA Dermatology, 152(9), 979-985.

    Journal website: http://jamanetwork.com/journals/jamadermatology/

    Author website: http://www.feinberg.northwestern.edu/faculty-profiles/az/profile.html?xid=12499


  • 15 Aug 2018 2:07 PM | Brandon Davenport (Administrator)

    Digest Commentator: Marguerite Gollish, B.A., University of Ottawa

    Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Latino cancer patients present a higher risk for poor mental health outcomes than non-Latino whites, with higher rates of depressive symptoms for Latinas with breast cancer. Given these results, it is concerning that Latinos are also less likely than non-Latino whites to receive treatment and services to improve these outcomes. The study by Costas-Muniz and colleagues aimed to investigate interest in and self-reported use of psychosocial services before and after a breast cancer diagnosis, comparing groups of Latina and non-Latina white cancer survivors.

    Methods: A questionnaire was mailed to 409 Latina and 514 non-Latina white breast cancer survivors who were in remission and who had received treatment at a single comprehensive oncology centre in the United States. Ninety-seven Latinas and 168 non-Latina white patients returned the questionnaire with an overall response rate of 30%. The questionnaire contained demographic and medical items, and self-reported use of psychosocial services before and after the cancer diagnosis. The type of service and type of professional was assessed, as well as frequency of service use.

    Results: Both Latinas and non-Latina white breast cancer survivors had similar rates of contact with a psychological service provider prior to diagnosis (34%), except for religious counselling. Non-Latina whites were less likely (6%) to have had contact with a religious counsellor than Latinas (13%). After diagnosis, 43% of participants (49% Latinas and 40% non-Latina whites) reported needing or wanting psychosocial services, but of these only 61% reported using a psychosocial service. While Latinas were less likely to have had contact with social workers and to use psychotropic medication, there were no significant differences between the groups when it came to contact with psychologists or psychiatrists, or the use of psychotherapy or counselling. Although there were no significant differences in the proportion of Latinas and non-Latina whites who reported needing psychosocial services, non-Latina whites were overall more likely to have had more frequent contact with a mental health professional.

    Why I liked the article: The authors provided particularly interesting considerations of how cultural and linguistic issues could explain the differences in the use of religious counselling and the use of psychotropic medication. It demonstrated a need for interventions for breast cancer survivors that take these cultural and linguistic differences into account.

    Article: Costas-Muñiz, R., Hunter-Hernández, M., Garduño-Ortega, O., Morales-Cruz, J., & Gany, F. (2017). Ethnic differences in psychosocial service use among non-Latina white and Latina breast cancer survivors. Journal of Psychosocial Oncology, 1–14.  https://doi.org/10.1080/07347332.2017.1310167

    Journal website: http://www.tandfonline.com/toc/wjpo20/current

    Author website: http://vivo.med.cornell.edu/display/cwid-roc2032


  • 15 Aug 2018 2:06 PM | Brandon Davenport (Administrator)

    Digest Commentator: Keith Wilson, PhD, CPsych. Emeritus Clinician Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute

    Edited by: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    For most women undergoing chemotherapy for breast cancer, hair loss (alopecia) is a distressing side effect of treatment. It has been known for some time that cooling the scalp during chemotherapy sessions can reduce the extent of alopecia in some people. The mechanism seems to be that cooling the scalp reduces blood flow – and the corresponding delivery of toxic chemotherapy drugs – to the sensitive hair follicles. Commercial cooling machines have been developed, and are available for use in some centres. To date, however, the efficacy of scalp cooling for preventing chemotherapy-induced alopecia has never been evaluated in a large randomized controlled trial.

    Nangia et al (2017) conducted a multi-centre study of 182 women with Stage I-II breast cancer who were receiving adjunct taxane-based or anthracycline-based chemotherapy which typically cause marked alopecia. Participants were assigned randomly to a scalp-cooling protocol or to a control group that did not receive scalp cooling. The cooling protocol required patients to wear a helmet-like cap for 30 minutes before each chemotherapy session, during the session, and for 90 minutes after. A liquid coolant was circulated through the cap to reduce scalp temperature. The primary outcome for hair preservation was a standard grading system, in which a clinician rated the extent of the patient’s hair loss.

    The authors reported that 142 patients, 95 in the cooling group and 47 in the control were evaluable in a planned interim analysis. Of the 95 patients who received the cooling protocol, 5%  had no hair loss at all, and a further 45% had <50% loss: an overall response rate of 50%. None of the control participants achieved that degree of hair preservation. Furthermore, all of the control participants went on to wear a wig or head wrap in their daily lives, whereas 37% of the treatment group felt no need to do so.

    This study also examined whether broad domains of quality of life were improved with the scalp cooling intervention, but there was no evidence that depression, anxiety, or social functioning were different between the two groups. It was also noted that different sites of the multi-centre trial had different success rates; apparently, there are technical issues involved in fitting the cooling caps that require training. Interestingly, however, a companion article in the same issue of JAMA reported that in routine use, up to 66% of patients can be helped with this approach.

    Why I liked this article: There are individual differences in how people respond to chemotherapy-induced alopecia. Some women embrace their hair loss, some accept it with resignation, and others feel stigmatized. The value of scalp cooling in reducing this troubling side effect seems to be underestimated. As with most novel interventions, there are unanswered questions – including who will pay the estimated $2000 to $4000 cost per patient. Concurrent scalp cooling during a chemotherapy session can also be quite uncomfortable for some individuals. In general, however, it is remarkable that a cosmetically meaningful reduction in alopecia can be achieved in about 50% of women who are receiving chemotherapy for breast cancer, using such a low-tech concept. That’s pretty cool.

    Article. Nangia, J., Wang, T., Osborne, C., Niravath, P., Otte, K., Papish, S., Holmes, F., Abraham, J., Lacouture, M., Courtwright, J., Paxman, R., Rude, M., Hilsenbeck, S., Osborne, C.K., & Rimawi, M. (2017). Effect of a scalp cooling device on alopecia in women undergoing chemotherapy for breast cancer: the SCALP randomized clinical trial. Journal of the American Medical Association, 317, 596-605. doi:10.1001/jama.2016.20939

    Journal website: http://jamanetwork.com/

    Dr. Morris’ university webpage: http://surgery.med.umich.edu/general/patient/faculty/ammsurg.shtml


    CAPO Digests are summaries of recent psychosocial oncology research which have been published in peer-reviewed journals in and out of the main psychosocial oncology outlets that may be of interest to CAPO members. We hope you enjoy these Digests. If you are interested in submitting a Digest please contact the CAPO office at [email protected]


  • 15 Aug 2018 2:06 PM | Brandon Davenport (Administrator)

    Digest Commentator: Chad Hammond, PhD, Postdoctoral Fellow, School of Rehabilitation Sciences, University of Ottawa

    Edited by: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Indigenous peoples are often left behind other populations in terms of accessing quality healthcare. In the area of cancer care, for example, their survival rates have lagged behind those of non-Indigenous populations despite recent improvements in cancer screening techniques and treatments. A long, continuing history of institutional racism, dismissal, and mistreatment leaves many Indigenous peoples distrustful and fearful of ‘becoming a patient.’ In many ways, the article by Morris and colleagues captures the current status of Indigenous patient-provider relationships among American Indian and Alaskan Native (AI/AN) patients. Their investigation was sparked by a very appropriate and timely question: how do AI/AN patients and their surgeons perceive the decision-making process around cancer treatment?

    Over three years, Dr. Morris and colleagues recruited AI/AN patients (multiple cancer sites) and their surgeons to rate their exchanges with each other. Although somewhat vaguely stated, the authors mention they abided by research protocols developed for respectful engagement with Indigenous communities—an essential ingredient toward developing trust between communities and institutions of research as well as of healthcare. A total of 49 AI/AN patients (62% response rate) completed a host of surveys, among them the Collaboration and Satisfaction about Care Decision scale, Ethnic Identity scale, Everyday Discrimination scale, and the Wake Forest Trust scale. Fourteen surgeons (37% response rate) were also surveyed and interviewed.

    The results of this study presented a promising image of patient-provider collaboration. Several domains of trust in providers (including honesty, confidentiality, collaborative decision-making, etc.) were rated quite highly, especially the domain of competence with 78% of patients agreeing or strongly agreeing with a statement about physician competence. Provider fidelity (caring/advocating for patient) was rated the lowest with 53% of patients agreeing or strongly agreeing with a statement about physician fidelity. Without making any causal claims, the authors reported that patients’ higher satisfaction, perceived quality of care, and sense of collaboration were correlated with their adherence to treatment. Twenty-six percent of patients reported non-adherence to treatment and their reasons were mostly non-clinical, citing personal and socio-economic circumstances (e.g., poverty), lack of proper access, and mistrust as potential factors in reducing adherence. Importantly, in all domains providers rated the quality of interaction and collaboration higher than AI/AN patients.

    This article is a hopeful gem, asking hard questions around Indigenous participation in healthcare and discovering that the default patient-provider relationship is not adversarial—many AI/AN patients give a vote of confidence in their providers. There are, however, domains needing improvement toward more cooperative, coordinated planning of treatments. The stark difference in patient ratings of provider competence versus fidelity is a powerful one; it suggests that Indigenous patients usually see their healthcare providers as effective healers but not always as loyal allies. The authors suggest that for AI/AN patients trust may matter more than satisfaction. Many Indigenous peoples, bearing the memories of trust betrayed by settler institutions and governments, know this intuitively.

    Morris, A. M., Doorenbos, A. Z., Haozous, E., Meins, A., Javid, S., & Flum, D. R. (2016). Perceptions of cancer treatment decision making among American Indians/Alaska Natives and their physicians. Psycho‐Oncology 25,1050-6. doi: 10.1002/pon.4191. Epub 2016 Jul 6

    Psycho-Oncology website: http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1099-1611

    Dr. Morris’ university webpage: http://surgery.med.umich.edu/general/patient/faculty/ammsurg.shtml


    CAPO Digests are summaries of recent psychosocial oncology research which have been published in peer-reviewed journals in and out of the main psychosocial oncology outlets that may be of interest to CAPO members. We hope you enjoy these Digests. If you are interested in submitting a Digest please contact the CAPO office at [email protected]



  • 15 Aug 2018 2:05 PM | Brandon Davenport (Administrator)

    Digest Commentator: Stephanie Saunders, MA student, Jennifer Brunet PhD

    Edited by: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Medical advancement in cancer treatments have led to improved surgical outcomes and survival in locally advanced rectal cancer patients. In particular, neoadjuvant chemoradiation therapy (NACRT), followed by surgical resection, has become the standard regimen for rectal cancer patients, as it improves local control of cancer. Although this leads to enhanced prognosis, NACRT is associated with a host of adverse side effects that negatively impact patients’ wellbeing. Whereas many researchers have reported that exercise is an effective strategy to mitigate these negative treatment side effects in a range of cancers (e.g., breast, prostate, colon), few of these studies have been performed in patients with rectal cancer, and, to date, no studies have looked at the influence of exercise on NACRT side effects.

    The current study examined study feasibility and safety of an aerobic exercise intervention in 18 patients diagnosed with rectal cancer during and immediately after NACRT. Forty-five participants were screened for eligibility by their medical oncologist at the time of their first radiation consultation. The study coordinator followed-up with 32 patients who were deemed eligible to participate, and scheduled initial exercise assessment for 18 interested participants.

    Morielli and colleagues (2016) had participants engage in a supervised aerobic exercise program, consisting of warm up and cool down, and a tailored session on a variety of aerobic modalities (e.g., treadmill, upright bike, recumbent bike, elliptical, and rower). The program ran three times per week throughout their NACRT treatment (6 weeks). Upon completion of their NACRT treatment, participants were given an unsupervised aerobic exercise program, cumulating in 150 minutes per week, for 6-8 weeks until their surgical resection.

    The authors found a high study eligibility (32/45,71%), high recruitment rate (18/32, 56%), and high retention rate (14/18, 78%), all of which are comparable to rates of other Phase 1 exercise intervention studies in other commonly studied cancers (e.g., breast and lymphoma). Additionally, secondary findings suggest that while health-related fitness outcomes (i.e., cardiorespiratory fitness level, psychosocial functioning, quality of life) declined during NACRT, they recovered afterwards to baseline levels, and in some cases improved beyond pre-NACRT levels. These results provide early evidence that exercise training among eligible patients with rectal cancer undergoing NACRT is both safe and feasible. In addition, exercise may have potential protective health effects during NACRT, as health-related fitness outcomes increased upon completion of treatment of NACRT prior to surgery. As this was a feasibility study without a control group, more research is needed to determine the effectiveness of the intervention and the effect of exercise on health outcomes.

    What I liked about this article: The current literature has shown that exercise is beneficial to a range of cancer populations; however its effects on patients with rectal cancer are understudied. Morielli and colleagues’ (2016) article is among the first to provide an indication of the role exercise can play in ameliorating negative side effects of NACRT in patients with rectal cancer. Further, as the authors have shown eligibility and recruitment rates over 50%, patients with rectal cancer are both highly interested, and able, to participate in exercise training opportunities. As a result of this study, researchers have an exciting opportunity to further explore the relationship between exercise and NACRT side effects, as well as investigate the benefits of exercise training in a population that has shown interest in participating in exercise-based studies.

    Journal website: https://onf.ons.org

    Morielli, A. R., Usmani, N., Boulé, N. G., Tankel, K., Severin, D., Nijjar, T., … & Courneya, K. S. (2016). A phase I study examining the feasibility and safety of an aerobic exercise intervention in patients with rectal cancer during and after neoadjuvant chemoradiotherapy. Oncology Nursing Forum, 43(3), 352-362.


    CAPO Digests are summaries of recent psychosocial oncology research which have been published in peer-reviewed journals in and out of the main psychosocial oncology outlets that may be of interest to CAPO members.  We hope you enjoy these Digests. If you are interested in submitting a Digest please contact the CAPO office at [email protected]


  • 15 Aug 2018 2:05 PM | Brandon Davenport (Administrator)

    Digest Commentator: Joan L. Bottorff, PhD, RN, FCAHS, FAAN, School of Nursing and Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia’s Okanagan Campus

    Edited by: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto

    Tobacco use has been established as a causal factor for a number of cancers and has been a primary focus for cancer prevention efforts.  However, less attention has been given to the risks of tobacco use among patients with cancer who continue to smoke. The evidence presented in the article by Passarelli and colleagues adds to the growing body of literature that we need to address continued smoking among those with cancer to reduce mortality and morbidity.  In this observational study, the authors followed up a sample of 20,691 breast cancer survivors in the United States to evaluate the association between smoking status before and after a breast cancer diagnosis, and mortality from breast cancer and smoking-related disease. Persistent smoking among survivors in this study was associated with a statistically significant 25% increase in relative risk of breast cancer death.  Women who continued to smoke also had a higher risk of death from respiratory cancer, noncancer respiratory disease, and cardiovascular disease. Women who quit smoking post-diagnosis had a 33% lower relative risk of death from breast cancer and other causes compared to those who continued to smoke, although this was not statistically significant.

    What I liked about this article:  This is a large population based study that provides a solid evidence base for promoting smoking cessation.  Although the factors by which smoking effects tumor progression are not fully understood, the results not only point to the adverse outcomes for those with a history of breast cancer who continue to smoke but also obligate us all to offer smoking cessation to women with breast cancer.  Respectful, women-centred approaches to smoking cessation can serve as an important foundation for offering cessation support to women with breast cancer. This study suggests the time is now for prescribing and supporting smoking cessation with every woman with breast cancer who smokes at every visit in order to optimize survival and overall health. The findings of Passarelli et al. can help us advocate for the resources we need to augment resources for smoking cessation in clinical practice.

    Article:  Passarelli, M.N., Newcomb, P.A., Hampton, J.M., Trentham-Dietz, A., Titus, L.J., Egan, K.M., Baron, J.A., & Willett, W.C. (2016).  Cigarette smoking before and after breast cancer diagnosis: Mortality from breast cancer

    Journal website: http://jco.ascopubs.org/content/34/12/1315.full.pdf+html?sid=8fa86d13-4eaa-4135-8e87-2c87c6456da1

    Author website: http://profiles.ucsf.edu/michael.passarelli


    CAPO Digests are summaries of recent psychosocial oncology research which have been published in peer-reviewed journals in and out of the main psychosocial oncology outlets that may be of interest to CAPO members.  We hope you enjoy these Digests. If you are interested in submitting a Digest please contact the CAPO office at [email protected]



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