CAPO Digest

LAST THREE DAYS TO REGISTER!

CAPO Conference Social & Networking event

Thursday, June 6, 2024, 7 to 10 p.m., National 10th Avenue, 341 10 Ave SW, Calgary AB.

Come join us for a special meet up of friends and colleagues at National 10th Avenue. Pack your best western accessory and get ready to eat, laugh and dance!

National is a restaurant & entertainment venue inspired by North American tastes, with games and events, extraordinary food, and select craft beers. A place filled with Calgarians who embrace being Calgarian, National is the ideal place to unwind with friends or host a private event.

Registration to the social includes light food to suit all tastes, and two drink tickets.

Advanced registration is required.

Fees: $65 (Open to all)

REGISTER HERE: https://www.capo.ca/event-5725513

Digest commentator: Tori Langmuir, BSc, clinical research coordinator at the Ottawa Hospital Research Institute and the University of Ottawa

Background

The impact of the COVID-19 pandemic on the health care system needs no introduction; it has been unprecedented. During the early months of the pandemic, Canada, the Netherlands, and the United Kingdom reported sharp decreases in cancer diagnoses, screening, and surgeries, leading many experts to express concern about “a tsunami of cancer” after the pandemic. Delayed appointments due to increased real or perceived barriers to accessing health care may negatively affect a patient’s psychosocial and physical wellbeing, as well as their prognosis. Among cancer patients and survivors, symptoms of anxiety and/or depression have been shown to negatively affect health care consumption, particularly during a health threat as significant as COVID-19. The present study measured the prevalence of anxiety and depression among a large cohort of breast cancer survivors during the early months of the COVID-19 pandemic, as well as the association between the presence of these symptoms and health care consumption impacted by COVID-19.

Method

This cross-sectional study was conducted with a large prospective observational multi-centre cohort of ex-breast cancer patients called the “Utrecht cohort for Multiple BREast cancer intervention studies and Long-term evaLuAtion” (UMBRELLA). All participants completed self-report questionnaires including the Hospital Anxiety and Depression Scale (HADS) at regular time points during and after their breast cancer treatment. Active participants who enrolled in the UMBRELLA cohort between October 2013 and April 2020 were sent an online survey on April 7, 2020 that included the HADS and COVID-19-related questionnaires.

Results

Of the 3239 participants enrolled in the UMBRELLA cohort, 1595 met the inclusion criteria. Of those, 1051 (66.0%) completed the COVID-19-specific questionnaire. Overall, 284 (27.0%) of participants experienced clinically relevant symptoms of anxiety and/or depression during COVID-19. Of the participants who experienced symptoms of anxiety and/or depression during COVID-19, 62.7% (n = 156) had experienced these symptoms prior to the COVID-19 pandemic. During the pandemic, a total of 18.2% (n = 191) of all participants reported symptoms of anxiety and 16.0% (n = 168) reported symptoms of depression. The reported rates of anxiety and/or depression were slightly but significantly lower than before the pandemic (23.4%, n = 220). Factors associated with anxiety and/or depression during COVID-19 were lower age, higher stage of cancer, receipt of systemic therapy or radiotherapy and pre-existing symptoms of anxiety or depression.

Participants with anxiety and/or depression reported significantly higher barriers to contacting their general practitioner (GP; 47.5% vs. 25.0%, resp.) and their oncologists (26.8% vs. 11.2%, resp.) compared to patients without these symptoms. A higher proportion of participants with anxiety and/or depression reported that their current treatment (or follow-up treatment) was affected by COVID-19 compared to those without symptoms (32.7% vs. 20.5%, resp.).

Why I liked this article

This study has two important findings. First, breast cancer survivors experienced increased barriers to accessing important health care services during the COVID-19 pandemic, and those who have reported symptoms of depression and/or anxiety were more likely to report barriers. Second, survivors with pre-existing anxiety and/or depression were more likely to report increased symptoms of anxiety and depression during the COVID-19 pandemic. These survivors may have a higher risk of not only experiencing increased distress during the pandemic [relative to their non-anxious and/or depressed counterparts], but of not accessing health care services. These two groups may benefit from psychosocial support to improve their mental well-being and decrease perceived barriers to accessing health care.

I also would like to acknowledge the use of the phrase “(ex-)breast cancer patients” used throughout this article. In my interactions with cancer survivors, some have expressed disdain or frustration with the term “survivor”; it seems to trigger the occasional emotional reaction. Consequently, in some of our research, we have replaced the term with “patients who have completed cancer treatment”. The phrase “ex-breast cancer patients” could be a useful alternative.

Caution:

The data collection for this study began on April 7, 2020 and it is unclear when data collection ended. The article was submitted to the journal in late October, so one could estimate that data collection lasted no longer than a few months. It is worth considering that symptoms of anxiety and/or depression in ex-breast cancer patients (including those with pre-existing symptoms) may have been higher during the early spring months of the COVID-19 pandemic, which were marked by global uncertainty and fear, compared to the later summer months, when case numbers decreased, or the fall months, when vaccines were announced. It is possible that symptoms of anxiety and/or depression may have continued to decrease throughout the course of the pandemic, impacted by factors such as habituation, coping, and increased public knowledge/preventative measures (masks, social distancing, lockdowns). This of course would be mediated by several factors including employment, social support, financial support, diagnosis, and severity of pre-existing symptoms.

Additionally, this study was conducted with breast-cancer patients only, therefore generalization to men, or other cancer diagnoses, is not direct.

Original Article

Mink van der Molen, D. R., Bargon, C. A., Batenburg, M., Gal, R., Young-Afat, D. A., van Stam, L. E., van Dam, I. E., van der Leij, F., Baas, I. O., Ernst, M. F., Maarse, W., Vermulst, N., Schoenmaeckers, E., van Dalen, T., Bijlsma, R. M., Doeksen, A., Verkooijen, H. M., & UMBRELLA study group (2021). (Ex-)breast cancer patients with (pre-existing) symptoms of anxiety and/or depression experience higher barriers to contact health care providers during the COVID-19 pandemic. Breast cancer research and treatment, 186(2), 577–583. https://doi.org/10.1007/s10549-021-06112-y

Other articles mentioned:

Hogan, S., & Glanz, M. (2020, December 17). Oncologist fears ‘tsunami of cancer’ after COVID-19 lockdowns limited screening. CBC News. https://www.cbc.ca/news/health/cancer-tsunami-screening-delays-covid-1.5844708

St. Philip, E., Favaro, A., & Cousins, B. (2020, August 13). 'Collateral damage': Doctors worry patients diagnosed with more advanced cancers because of delays. CTV News. https://www.ctvnews.ca/health/coronavirus/collateral-damage-doctors-worry-patients-diagnosed-with-more-advanced-cancers-because-of-delays-1.5063815

Digest Commentator: David Mackay, MD Student, Cumming School of Medicine Class of 2021, University of Calgary

Digest Editor: 

Jacob E. Berchuck, MD; Craig S. Meyer, PhD, MPH; Ning Zhang, MS; Caroline M. Berchuck, MD; Neil N. Trivedi, MD; Beth Cohen, MD; SunnyWang, MD

Background:

The link between mental and physical health is an important aspect of health outcomes. Numerous studies have explored this fundamental connection. Researchers have long established a relationship between pre-existing mental health disorders and poorer health outcomes. In psychosocial oncology, studies have found higher rates of cancer-related mortality among individuals with pre-existing mental health disorders than in the general population. Lung cancer is the leading cause of cancer related death in Canada and the US. In Canada, in 2020, it was the cause of 1 in 4 cancer related deaths. Roughly half of all lung cancers diagnosed in Canada are diagnosed at stage 4. Non-small cell lung cancer is the most common type of lung cancer diagnosed. Studies have shown that preexisting mental health disorders in patients diagnosed with lung cancer are associated with increased mortality. This study asks the question “Is mental health treatment associated with improved outcomes for people with pre-existing mental health disorders after they are diagnosed with cancer?” It evaluates the association of participation in mental health treatment programs, housing support programs, or employment support programs associated with stage at non-small cell lung cancer diagnosis, receipt of stage-appropriate treatment, and mortality among patients with a pre-existing mental health disorder.

Methods:

This retrospective, population-based cohort study looked at data on 55,315 veterans using the Veterans Affairs Central Cancer Registry. This group of veterans all had newly diagnosed non–small cell lung cancer (diagnosed between September 30, 2000, to December 31, 2011). This cohort was separated into three groups: mental health disorder, other mental health disorder, and no mental health disorder. Data were analyzed from January 15, 2017, to March 17, 2020.

Mental health disorders were identified using ICD-9 Codes. To fall in to the mental health disorder category, participants had to have an ICD-9 Code for schizophrenia, bipolar disorder, depressive disorder, anxiety disorder, posttraumatic stress disorder, or substance use disorder linked to their name and listed twice in an outpatient setting or once in an inpatient setting. Researchers also included an other mental health disorder group for participants with diagnoses not specified in the mental health disorder group. These included ICD-9 diagnosis codes 290 to 310 – organic psychotic conditions, other psychoses, neurotic disorders, personality disorders, and other nonpsychotic mental disorders – (except for dementia and tobacco use disorder).

Researchers then determined which participants in the mental health disorder and other mental health disorder groups participated in evidence based programs designed to address mental health needs, substance use, housing and employment needs. Specific programs looked at in this study were mental health intensive case management for schizophrenia and bipolar disorder, psychotherapy for depressive and anxiety disorders, PTSD therapy, and substance use treatment programs. To ascertain participation in these programs, researchers used Current Procedural Terminology codes and Veteran Affairs stop codes (this is a Veteran Affairs coding system used to capture workload data).

As outcome variables, researchers in this study compared (1) the hazard of mortality between patients with individual mental health disorders versus those with no mental health disorder; and (2) patients with individual mental health disorders who participated in evidence-based mental health treatment programs specific to that mental health disorder versus those that did not. Patients with multiple ICD-9 codes associated with their name, and thus multiple mental health disorders, were included in the analysis for each individual mental health disorder.

Results:

Of 55,315 veterans with a new diagnosis of non-small cell lung cancer included in the analysis (98.1% men; mean [SD] age, 68.1 [9.8] years), 18,229 had a preexisting mental health disorder. Patients with any mental health disorder had increased all-cause mortality (adjusted hazard ratio [AHR], 1.03; 95% CI, 1.01-1.06; P = .008) and lung cancer–specific mortality (AHR,1.03; 95% CI, 1.01-1.06; P = .02). Schizophrenia and other mental health disorders were the only individual mental health disorders that were associated with an increased hazard of all-cause mortality (AHRs, 1.09 [95% CI, 1.03-1.16; P = .047] and 1.09 [95% CI, 1.04-1.13; P < .001], respectively) and lung cancer–specific mortality (AHRs, 1.10 [95% CI, 1.02-1.18; P = .01] and 1.07 [95% CI, 1.02-1.13; P = .006], respectively).

Among individuals with both a diagnosis of non-small cell lung cancer and a pre-existing diagnosis of a mental health disorder, participation in mental health treatment programs was associated with a lower likelihood of being diagnosed in a late stage (odds ratio [OR], 0.62; 95%CI, 0.58-0.66; P < .001), a higher likelihood of receiving stage-appropriate treatment (OR, 1.55; 95%CI, 1.26-1.89; P < .001), lower all-cause mortality (AHR, 0.74; 95%CI, 0.72-0.77; P < .001), and lower lung cancer-specific mortality (AHR, 0.77; 95%CI, 0.74-0.80; P < .001). Participation in housing and employment support programs was also associated with similar improvements in all of the outcomes listed above.

Why I Like This Article:

The link between physical and mental health is a fascinating and important one. Systemic hurdles in accessing care and delayed treatment affect mortality outcomes for patients with mental health disorders. This article highlights how mental health support and treatment programs can have a positive impact on health and mortality outcomes for a specific disease.

Evidently, discrepancies in access to mental health resources continue to affect outcomes for patients. This is concerning and an area of research and policy change that I think we will continue to see grow over the coming years. The bottom line of this research is that the association between mental health disorders and an increased risk of mortality due to non-small cell lung cancer is a notable one; participation in programs that support mental health and social needs can improve health outcomes for this group. 

Caution:

The strong association between mental health disorders and increased mortality does not mean that this is the sole, or even the greatest contributing factor.

In this study, multivariate models were adjusted for age, sex, race, marital status, Charlson comorbidity score, smoking status (never, former, or current), substance

use (except for patients with substance use disorder), and year of diagnosis. Understandably, not all variables can be controlled for in this type of research. Factors possibly predictive of outcomes, such as education, socioeconomic status, severity of mental health disorder, and urban vs rural residency were not controlled for.

Of note, the population studied here consists almost entirely of men, so generalization of the results to women is not direct or clear. Patients who participated in mental health treatment programs in this study were younger and had fewer comorbidities. This study also did not include participants who were diagnosed with a mental health disorder after their cancer diagnosis. Finally, treatment outside of the Veterans Health Administration may not have been captured.

Citation of Original Article:

Berchuck JE, Meyer CS, Zhang N, et al. Association of Mental Health Treatment With Outcomes for US Veterans Diagnosed With Non–Small Cell Lung Cancer. JAMA Oncol. 2020;6(7):1055–1062. doi:10.1001/jamaoncol.2020.1466

(https://jamanetwork.com/journals/jamaoncology/article-abstract/2766567)

Other Research Mentioned:

Kisely S, Crowe E, Lawrence D. Cancer-Related Mortality in People With Mental Illness. JAMA Psychiatry. 2013;70(2):209–217. doi:10.1001/jamapsychiatry.2013.278

Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics: A 2020 special report on lung cancer. Toronto, ON: Canadian Cancer Society; 2020. Available at: cancer.ca/Canadian-Cancer-Statistics-2020-EN

Arrieta O, Angulo LP, Núñez-Valencia C, et al. Association of Depression and Anxiety on Quality of Life, Treatment Adherence, and Prognosis in Patients with Advanced Non–Small Cell Lung Cancer. Ann Surg Oncol. 2013;20(6):1941-1948. doi:10.1245/s10434-012-2793-5

Lin J, McGlynn KA, Carter CA, et al. The Impact of Preexisting Mental Health Disorders on the Diagnosis, Treatment, and Survival Among Lung Cancer Patients in the US Military Health System. Cancer Epidemiol Biomarkers Prev. 2016;25(12): 1564-1571. doi:10.1158/1055-9965.EPI-16-0316

Digest Commentator: Dr. Violet D'Souza, PhD, MS, MSc, BDS. Research Associate, Faculty of Dentistry, University of Toronto

Background:

Cancer disparity continues to exist worldwide, affecting those with limited access to care, especially those living in rural areas. Compared to those living in urban areas, rural cancer survivors are less informed and experience higher levels of anxiety and distress, non-cancer-related comorbidities, and mortality. The study described the common health information needs of breast, prostate, and colorectal cancer survivors living in rural areas.

Methods:

This cross-sectional study was conducted with breast, prostate, and colorectal cancer survivors who received treatment at the Wake Forest Baptist Comprehensive Cancer Center in North Carolina. Participants were between two to five years post-diagnosis, at least 40 years of age, spoke English, and lived in a small town or rural area. The rurality was defined based the Zip code. The data were collected through a mailed/telephone-administered survey, which included 23 health information needs questions (binary outcomes) on follow-up care topics under eight domains: tests and treatment, side effects and symptoms, emotional and interpersonal needs, health promotion, fertility, occupation, and insurance. A large proportion of the questions were taken from a National Cancer Institute study on health information needs in adult cancer survivors.

Results:

Of the contacted 345 cancer survivors, 170 with complete data were included in the analyses. Of them, 74 had prostate cancer, 69 had breast cancer, and 27 had colorectal cancers. The most common information needs were about side effects and symptoms (58%), health promotion (54%), tests and treatment (41%), decreasing the risk of future cancers (36%), nutrition and diet (30 %), weight (26 %), and physical fitness (25 %). Furthermore, over 25% reported needing more information about symptoms, late and long-term side effects, how to deal with fatigue, and when to seek medical attention. The number of endorsed needs were significantly higher for younger participants, those belonging­­­­ to an ethnic minority, the less educated, and the financially stressed when compared with older participants who were not a member of an ethnic minority, possessed higher levels of education, and were not financially stressed.

Why I like this article:

The findings of this study are valuable given the paucity of literature on rural cancer survivors. Indeed, this is one of the largest studies ever conducted on rural cancer survivors. This study helps to identify vulnerable survivors among those living in rural areas: those with a younger age, lower education, lower income, and ethnic minority members. The side-effect-related questions were endorsed by 20-30% of participants, suggesting their value in exploring the unmet informational needs of cancer survivors. Given the differences in the healthcare system and demographics between the US and Canada, it might be interesting to explore them in Canadian cancer survivors.

Caution:

Even though risk cannot be estimated in cross-sectional studies, the authors of this study used risk ratios as the measure of effects.  

Original article:

Palmer NR, Avis NE, Fino NF, Tooze JA, Weaver KE. Rural cancer survivors' health information needs post-treatment. Patient Educ Couns. 2020;103(8):1606-14.

Journal website: https://www.sciencedirect.com/journal/patient-education-and-counseling/vol/103/issue/8

Digest Commentator: Georden Jones, Ph.D. Student in Clinical Psychology, University of Ottawa, supervised by Dr. Sophie Lebel

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

Background:
Cancer survivors are faced with multiple physical and psychological symptoms which significantly impact their quality of life. Rehabilitation programs including physical and psychological components have demonstrated effectiveness to improve patients’ function and return to normal lives, however little is known about optimal duration of rehabilitation programs and factors associated with clinically relevant change. This study aimed to assess outcomes (health-related quality of life (HRQOL), fatigue, and level of physical activity) following a one-week Inpatient Educational Program (IEP) and investigate factors associated with clinically relevant change. 

Methods: 
Breast, prostate and gastrointestinal patients who were diagnosed within the past ten years and referred to the IEP at The Norwegian Resource Center for Coping with Cancer (Montebello-Center) were invited to participate in the study. A Norwegian general population sample (NORMS) was used as a comparison group. The IEP was offered over 6 days for a total of 30 hours and aimed to improve participants’ level of coping with cancer-specific health problems and to motivate the participants to adopt a healthy lifestyle. The IEP was facilitated by a multidisciplinary healthcare team and was comprised of lectures (50-55%), guided group physical activity (20-25%), and group sessions (25%). Topics included: cancer and its treatment, risk of adverse effects, work, social resources and support, sexuality, psychological reactions, and lifestyle.

Participants completed questionnaires prior to the IEP (T0) and three months post-IEP (T1). The questionnaire package included sociodemographic and medical questions, the Fatigue Questionnaire, the Medical Outcomes Study Short Form 36 (SF-36), and the Nord-Trondelag Health Study Physical Activity Questionnaire (HUNT 1 PA-Q).

Results:
Of the 482 patients who were invited to participate, 332 (69%) agreed. At T1 235/482 (49%) participants completed pre and post measures. The median age of participants was 59.4 y, 63% of participants were female, 57% were diagnosed with breast cancer, 32% prostate cancer, and 11% gastrointestinal cancer. At both time points, participants had higher levels of fatigue and lower levels of HRQOL than the NORMS. Females showed significant changes in physical and total fatigue and in general health and vitality. Males showed improvement in role limitations due to physical problems. No changes were found in level of physical activity. Clinically relevant improvements on significant outcomes ranged from 30-36% and higher education and relapse or progression before T0 were associated with higher improvement in total fatigue scores for females. Study limitations include the lack of a control group, low participation rates at T1 (49%), and the sample may be more representative of females diagnosed with breast cancer.

Why I liked this article:
This study demonstrated that short-term rehabilitation programs may be effective in improving psychosocial outcomes for cancer survivors and that tailoring content and activities by gender may be needed to target specific outcomes.

Health rehabilitation programs are available in Canada for diverse chronic illnesses such as cardiac illnesses, stroke, and acquired brain injuries whereas such programs are less common in oncology. However, oncology rehabilitation programs are more commonly offered in other Western countries such as Norway. This raises questions for me 1) Does the Canadian healthcare system perceive cancer more as an acute illness compared to other countries? 2) Could moving towards a rehabilitation model of cancer survivorship care improve survivors’ transition from tertiary to primary care in the Canadian healthcare system?

Citation of original article: Gjerset, G. M., Kiserud, C. E., Loge, J. H., Fosså, S. D., Wisløff, T., Gudbergsson, S. B., ... & Thorsen, L. (2019). Changes in fatigue, health-related quality of life and physical activity after a one-week educational program for cancer survivors. Acta Oncologica, 1-8.

Journal website: https://www.tandfonline.com/toc/ionc20/current

Digest Commentator(s): Jonathan Avery, Ph.D., Post-Doctoral Research Fellow, Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network, Toronto)

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

In caring for patients with advanced cancer, there may come a time when clinicians have to tell their patients that tumor-directed treatments are no longer effective, and the side-effects and complications outweigh the benefits. In such cases, a timely decision to stop this type of treatment is associated with better patient outcomes. However, empirical research has demonstrated a tendency towards more aggressive tumor directed therapy closer to end of life (EOL) particularly in the adolescent and young adult (AYA) population. In the article “Rather one more chemo than one less. . .”: Oncologists and Oncology Nurses’ Reasons for Aggressive Treatment of Young Adults with Advanced Cancer, Laryionava et al. explored the reasons as to why this tendency occurs. 

Twenty-nine qualitative face-to-face semi-structured interviews were conducted with oncologists (n= 22) and nurses (n= 7) working at the Department of Hematology & Oncology at the University Hospital of Munich, Germany. The sample consisted of fellows (n= 13; 45%), senior physicians (n= 9; 31%), and nurses (n= 7; 24%), who varied in their working experience from 8 months to 34 years. Their age range was 22–64 years.  An interview guide was developed that asked specific questions and probes about oncologists and oncology nurses’ views on treatment decisions with young adult patients with advanced cancer. Interviews were analyzed using the grounded theory approach.

The authors highlight three themes that explain the tendency for more aggressive treatments with AYA closer to EOL: 1) Patient’s preference for further treatment; 2) Oncologists and nurses’ perception of unfairness of dying at a young age; 3) Oncologist’s identification with patients.

Why I liked this article

What is most interesting about this article is how the results illustrate the decision to stop tumor-directed therapy with AYA is complicated and multi-factorial involving the consideration of patient preferences and, what the authors describe as, the “emotional entanglement” of clinicians. This entanglement emerges from the clinicians’ own thoughts and feelings from treating a young adult dying from cancer. Participant quotations highlight that not only does it feel unfair when young adult dies from cancer, there appears to be something inherent with the stage of life of the AYA that “we”, as health professionals, reflect fondly on. Falling in love, having a family, and establishing our lives are significant and meaningful life experiences that we value and cherish. Caring for young adults with advanced cancer and seeing their hopes and dreams ripped away is very difficult to witness because of our own experiences and fondness for that stage of life. This difficulty appears to be impacting the clinical judgement as to whether aggressive tumor-directed treatments close to end of life would be an appropriate or effective mode of therapy for AYA.

As a post-doctoral research fellow developing my own program of research, I find this type social dynamic between clinician and patient very interesting. For better or for worse, the emotional entanglement emerging from this study can at times impact how care is provided. I hope to explore this type of dynamism in my own research particularly in the area of AYA palliative care to ensure that both clinicians’ and patients’ well-being are considered when approaching difficult circumstances such as EOL care. 

Laryionava K, Heubner P, Hiddemann W, Winkler E. "Rather one more chemo than one less...":Oncologists and oncology nurses' reasons for aggressive treatment of young adults with advanced cancer. Oncologist. 2018;23(2):256-262.

https://www.ncbi.nlm.nih.gov/pubmed/29133515

Digest Commentator: Nicole Anna Rutkowski, PhD student in Clinical Psychology, School of Psychology, University of Ottawa

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

Digest Commentary

Returning to work is an important milestone and financial necessity for many cancer survivors, however many misperceptions and barriers preclude survivors from successfully transitioning back into a working environment. This article addresses an important gap in cancer survivorship, as little research has been done within the Canadian context on cancer survivors’ experiences returning to work. The Canadian Partnership Against Cancer launched a Return to Work Initiative to gain a better understanding of Canadian cancer survivors’ needs as they transition back into the work force.  The purpose of this study was to determine survivors’ and caregivers’ concerns related to working, challenges employers face accommodating survivors, and ways to better support employees, managers, and caregivers.  

In order to gain a comprehensive understanding, the Return to Work Initiative examined the perspectives of survivors, caregivers, and workplace representatives. During the preliminary phase, the researchers conducted a literature review, an environmental scan, and conducted key informant interviews. The findings suggested a shortage of services available to survivors experiencing challenges resuming work activities. With a greater understanding of the lack of resources and programs available for survivors, the researchers turned their focus to trying to understand the individual experience of survivors and their caregivers. A national online survey captured cancer survivors’ (n=410) and caregivers’ (n=60) challenges when returning to work. To gain the perspective of employers, in-depth interviews were conducted with 41 workplace representatives (i.e. managers, union leaders, insurers). After the initial analysis, results were reviewed and discussed with cancer survivors and employers through separate focus groups to develop solutions for identified challenges. Recommendations were developed on how to better meet the needs of cancer survivors returning to work.       

Despite many survivors reporting feeling supported by employers, concerns remained. Major concerns for survivors included decreased income, an inability to resume previous work activities, a lack of accommodations, difficulties negotiating with employers, and a lack of information on assistive programs. Interestedly, many similar concerns were raised amongst employers, survivors, and caregivers. All expressed a need for more education on workplace accommodations, improved communication, and a need for additional community resources and supports. Additionally, receiving more information on how to access financial supports was deemed to be important by survivors and caregivers.  Employers expressed interested in addressing survivors’ return to work concerns, however they also encountered difficulties navigating insurance and government sponsored benefits for employees. Unfortunately, survivors re-entering the workplace were not seen as a priority due to the relatively low numbers of cases and an absence of re-entry policies for cancer survivors. Importantly, survivors expressed fears of informing employers of their diagnosis due to perceived negative repercussions on job duties, promotions, and possible termination. Limitations of the study included convenience sampling which likely contributed to a well-educated, predominately female sample and a high portion of breast cancer survivors (46%). Further, employers may have over emphasized the support provided to employees and minimized weaknesses.   

Why I liked this article:

This article provides insight into some of the barriers cancer survivors, caregivers, and employers face regarding return to work. By understanding the challenges and unique experiences of these groups we can begin to develop and implement adequate re-entry policies and programs to ensure cancer survivors receive appropriate support as they transition back to the work place.

Fitch MI & Nicoll I. (2019). Returning to work after cancer: Survivors’, caregivers’ and employers’ perspectives. Psycho‐Oncology; 1-7. doi.org/10.1002/pon.5021

Journal website: https://onlinelibrary.wiley.com/journal/10991611

website: http://www.ccsrc.ca/AboutUs/our-team/margaret_fitch

Digest Commentator: Breanna Lane, B.A. (Hons), Department of Psychology, Faculty of Science, Memorial University of Newfoundland

Digest Editor: Mary Ann O'Brien, Ph.D., Department of Family and Community Medicine, University of Toronto

Digest Commentary

Fear of cancer recurrence (FCR) is one of the most prevalence, high priority and lasting psychosocial implications of a cancer diagnosis. Researchers have begun to examine the cognitive mechanisms that perpetuate FCR. Exploration of avoidance and cognitive appraisal as moderating factors for FCR and functioning has been unsuccessful. Rumination plays a disruptive role in cognitive functioning and emotional distress associated with anxiety and depression, and therefore may provide insight into the development of psychological illness for individuals with cancer. Liu et al. reported data from a cross-sectional study that examined potential interactions between FCR and rumination in relation to self-reported symptoms of anxiety and depression.

Of the 927 approached to participate in the study, 388 eligible adults diagnosed with cancer were recruited following service utilization at the National University Cancer Institute Singapore. Eligible participants could understand English or Mandarin, were currently in remission, and completed treatment at least one year ago. Participants had a mean age of 55.6y(SD = 11.6y), 80.2% identified as female, and 70.7% reported being diagnosed with Stage I/II cancer. Participants completed a series of outcome measures including the Fear of Cancer Recurrence Inventory (FCRI), Ruminative Response Scale (RRS), and the Hospital Anxiety and Depression Scale (HADS). The FCRI severity scale, which has been validated independently as the FCRI Short Form, was also used in subsequent analysis.

An interaction between FCR and rumination was associated with depression symptoms. When rumination was high in individuals with high FCR, rumination was associated with more severe depression symptoms compared to those with high FCR and low rumination. Independent of rumination, a significant relationship between high FCR and more severe depression symptoms remained. These relationships suggest that individuals with high FCR may ruminate or fixate on cancer fears, which contribute to low mood, negative thoughts, and distress. Using anxiety as the outcome the interaction between FCR and rumination was not replicated; individually FCR and rumination were associated with anxiety. Body-checking is a frequent behavioural reaction to FCR which can perpetuate fears and compulsive checking, and therefore it is possible that FCR could contribute to anxiety without individuals engaging in rumination. Finally, the significant association between rumination and anxiety suggests that anxious thoughts and feelings can create a cognitive cycle that contributes to anxiety symptoms. The cross-sectional design and symptom self-report limits the ability to determine causal factors contributing to mental health symptoms. However, overall, this study provides crucial insights into the relationships between essential psychological concerns often experienced by cancer survivors and illustrates the potential implications of maladaptive cognitive coping styles.

Why I liked this article:

With the development of novel treatments to target psychological symptoms associated with coping with cancer, greater insight into the mechanisms of change is essential for enhancing the efficacy and effectiveness of interventions. Individuals with high FCR and maladaptive coping strategies, like rumination, may be particularly vulnerable for developing severe symptoms of depression. Therefore, this study provides preliminary evidence for the use of interventions that disrupt rumination and teach alternative skills to assist with positive coping and reduce the risk for the development of psychopathology.

Liu, J., Peh, C.-X., Simard, S., Griva, K. &  Mahendran R. (2018). Beyond the fear that lingers: The interaction between fear of cancer recurrence and rumination in relation to depression and anxiety symptoms. Journal of Psychosomatic Research, 111, 120-126. DOI: https://doi.org/10.1016/j.jpsychores.2018.06.004.

Journal of Psychosomatic Research website: https://www.journals.elsevier.com/journal-of-psychosomatic-research

Author Website: http://nusmedicine.nus.edu.sg/pcm/faculty-staff/expert-team-physicians-psychologist/rathi-mahendran/

Digest Commentator(s): David Michael Langelier MD, FRCPC, Dip CSCN (EMG), Cancer Rehabilitation Fellow, Princess Margaret Hospital, University of Toronto

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

Digest Commentary

Background: The expectation of health care providers to understand and appropriately prescribe complimentary therapies (CT) to cancer patients increases on an annual basis. Unfortunately, this increasing demand for physician competency in complimentary services have not yet been appropriately reflected in the way physicians are trained. Therefore, when confronted with a patient inquiring about various CTs, clinicians often look to clinical practice guidelines in order to safely and effectively prescribe outside their scope of knowledge. This article highlights areas of CT interest to patients and suggests particular CTs for future research and guideline development based on patient preferences.

Research Design: In April 2018, Qureschi et al. published a more extensive analysis into survivor’s interest and use of CTs in the journal of Integrative Cancer Therapies. This involved a cross-sectional survey of 212 ambulatory cancer patients with no restrictions on tumor type, stage, or current treatment status. The study’s goals were to gather a more comprehensive picture of which CTs were being used, which were of highest interest, and whether particular physical symptoms, perceived stress, and spirituality were related to certain interests. The authors also examined barrier perception and whether clinical practice guidelines were available for CTs with the highest interest.

Results: Overall, 75% of patients had used or were currently using CTs. The most frequently reported CTs were biologic (e.g. vitamins B12 and D, calcium) followed by mind/body (e.g. yoga, massage, mindfulness-based stress reduction), then energy-based (e.g. acupuncture) and alternative CTs (e.g. naturopathy). The largest perceived barriers were a lack of CT awareness and insufficient evidence on the CTs effectiveness. Lack of support from health providers contributed only minimally to CT participation. In all CTs except cannabinoids, higher levels of perceived stress corresponded to higher levels of CT interest.

Importance: In the era of patient-centered-care, health care practitioners must acknowledge the high use of CTs and be attune to which CTs are important to the patient. This article highlights the specific CTs requiring a research focus and this corresponds to the gap in available clinical practice guidelines. To fill this gap, guidelines are needed particularly in the areas of biologic (i.e. vitamin B12, vitamin D) and mind-body (i.e. breathing/relaxation) CTs. Additionally, as a health care provider this article flags awareness and further education as two specific barriers to CT involvement. Health care providers in oncology have a shared responsibility to know and share the evidence behind various CTs with patients, even if the evidence is limited.

Citation: Qureshi M, Zelinski E, Carlson LE. Cancer and Complimentary Therapies: Current Trends in Survivors’ Interest and Use. Integrative Cancer Therapies. 2018 Apr 1:1534735418762496. DOI: 101177/1534735418762496.

Journal website: http://journals.sagepub.com/home/ict

Author Website: https://lindacarlson.ca/about

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