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Cancer-related disability is a complex problem for older breast cancer survivors. One aspect of cancer-related disability is a survivor's inability to complete meaningful daily activities and engage in life roles, referred to as activity limitations and participation restrictions respectively. There is a limited understanding of how interventions influence activity limitations and participation restrictions in this population. A scoping review was undertaken to identify and characterize nonpharmacological interventions developed to address activity limitations and participation restrictions. A systematic search of electronic databases (Ovid Medline, Embase, EBSCO CINAHL, and Ovid PsycINFO) was conducted in April 2020 and updated October 2020. Eleven studies met inclusion criteria. Most frequently observed delivery features were in-person and one-on-one format. Six interventions incorporated telehealth delivery components. Interventions were often complex and varied in content. Exercise and behavioral strategies were among the most frequently used active ingredients. Activity limitations and participation restrictions were often secondary outcomes, and measures of these outcomes were varied in content and assessment method. Study samples were not representative of the current population of older adult breast cancer survivors. Future intervention research should clarify intervention delivery, content, and dose, prioritize comprehensive measurement of activity limitations and participation restrictions, as well as recruit and involve representative study samples to enhance generalizability of findings.

Purpose Many older breast cancer survivors experience long-term disability due to cancer and cancer-related treatments. However, less than 20% of older breast cancer survivors utilize cancer rehabilitation services to address cancer-related disability. Further understanding of survivor experiences may reveal strategies to improve uptake cancer rehabilitation services in the USA. Methods Older breast cancer survivors were recruited from university-based registries, previous breast cancer research studies at our institution, community support groups, and geriatric oncology clinics. Participants completed a brief online survey to capture demographic and clinical characteristics. Semi-structured telephone-based interviews were recorded, transcribed, and thematically analyzed. Interviews facilitated conversation about access to rehabilitation and indications for cancer rehabilitation. Results Participants (n = 14) were, on average, 71 years old, primarily White, and an average of 36.5 months post-diagnosis. Five participants had formally received rehabilitation for a cancer-related concern. Participants described seven factors that influenced utilization of cancer rehabilitation services: (1) emerging awareness of disability; (2) coping styles; (3) comparison of cancer experience with others; (4) provider interaction; (5) perceptions of cancer diagnosis; (6) social support; and (7) cost of rehabilitation. Conclusions Older breast cancer survivors consider multiple factors when determining utilization of cancer rehabilitation services. Development of shared decision-making tools addressing the seven described factors may enhance communication and referral to cancer rehabilitation services. Intervention research should adopt frameworks that enhance healthcare accessibility to improve relevance of intervention content and delivery features for older breast cancer survivors.

Background Virtual Learning Collaboratives (VLC), learning communities focused on a common purpose, are used frequently in healthcare settings to implement best practices. Yet, there is limited research testing the effectiveness of this approach compared to other implementation strategies. This study evaluates the effectiveness of a VLC compared to Technical Assistance (TA) among community oncology practices implementing ENABLE (Educate, Nurture, Advise, Before Life Ends), an evidence-based, early palliative care telehealth, psycho-educational intervention for patients with newly diagnosed advanced cancer and their caregivers. Methods Using Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Proctor’s Implementation Outcomes Frameworks, this two-arm hybrid type-III cluster-randomized controlled trial (RCT) will compare two implementation strategies, VLC versus TA, among the 48 National Cancer Institute Community Oncology Research Program (NCORP) practice clusters that have not historically provided palliative care to all patients with advanced cancer. Three cohorts of practice clusters will be randomized to the study arms. Each practice cluster will recruit 15–27 patients and a family caregiver to participate in ENABLE. The primary study outcome is ENABLE uptake (patient level), i.e., the proportion of eligible patients who complete the ENABLE program (receive a palliative care assessment and complete the six ENABLE sessions over 12 weeks). The secondary outcome is overall program implementation (practice cluster level), as measured by the General Organizational Index at baseline, 6, and 12 months. Exploratory aims assess patient and caregiver mood and quality of life outcomes at baseline, 12, and 24 weeks. Practice cluster randomization will seek to keep the proportion of rural practices, practice sizes, and minority patients seen within each practice balanced across the two study arms. Discussion This study will advance the field of implementation science by evaluating VLC effectiveness, a commonly used but understudied, implementation strategy. The study will advance the field of palliative care by building the capacity and infrastructure to implement an early palliative care program in community oncology practices. Trial registration Clinicaltrials.gov. NCT04062552; Pre-results. Registered: August 20, 2019. https://clinicaltrials.gov/ct2/show/NCT04062552?term=NCT04062552&draw=2&rank=1

INTRODUCTION: Isolated and confined environments (ICEs), such as spaceflight, are challenging psychologically. We have been evaluating self-directed tools to sustain and improve psychological well-being in these settings. The Expedition Application for Peak Psychological Performance (Expedition-APPP) is an interactive media-based set of self-directed tools that address conflict resolution, stress management, and depression treatment. Virtual reality (VR) of nature scenes is a tool to improve attention and relieve stress by providing users with an immersive nature experience. We evaluated both Expedition-APPP and VR in an ICE.METHODS: The Expedition-APP was evaluated during three, and nature VR during two, deployments at the HI-SEAS habitat, where crews of six were isolated for 812 mo. Participants used both the Expedition-APPP and VR and shared their feedback and experiences after the deployments in semistructured interviews. These interviews were evaluated using qualitative analysis techniques to gather generalizable insights into implementing autonomous mental health programs for people living and working in ICEs.RESULTS: Expedition-APPP modules provided a shared culture, language, and tools for working through challenges. VR allowed for access to emotions and experiences that were unavailable in the habitat. Suggestions for improvement included making refresher training easily available and providing a wider range of content to address different individuals coping styles.DISCUSSION: Both the Expedition-APPP and VR were appreciated and used, although a wider range of content and experiences was desired by participants.Lyons KD, Slaughenhaupt RM, Mupparaju SH, Lim JS, Anderson AA, Stankovic AS, Cowan DR, Fellows AM, Binsted KA, Buckey JC. Autonomous psychological support for isolation and confinement. Aerosp Med Hum Perform. 2020; 91(11):876885.

Guidelines promote high quality cancer care. Rehabilitation recommendations in oncology guidelines have not been characterized and may provide insight to improve integration of rehabilitation into oncology care. This report was developed as a part of the World Health Organization (WHO) Rehabilitation 2030 initiative to identify rehabilitation-specific recommendations in guidelines for oncology care. A systematic review of guidelines was conducted. Only guidelines published in English, for adults with cancer, providing recommendations for rehabilitation referral and assessment or interventions between 2009 and 2019 were included. 13840 articles were identified. After duplicates and applied filters, 4897 articles were screened. 69 guidelines were identified with rehabilitation-specific recommendations. Thirty-seven of the 69 guidelines endorsed referral to rehabilitation services but provided no specific recommendations regarding assessment or interventions. Thirty-two of the 69 guidelines met the full inclusion criteria and were assessed using the AGREE II tool. Twenty-one of these guidelines achieved an AGREE II quality score of ≥ 45 and were fully extracted. Guidelines exclusive to pharmacologic interventions and complementary and alternative interventions were excluded. Findings identify guidelines that recommend rehabilitation services across many cancer types and for various consequences of cancer treatment signifying that rehabilitation is a recognized component of oncology care. However, these findings are at odds with clinical reports of low rehabilitation utilization rates suggesting that guideline recommendations may be overlooked. Considering that functional morbidity negatively affects a majority of cancer survivors, improving guideline concordant rehabilitative care could have substantial impact on function and quality of life among cancer survivors.

Introduction Caregivers of patients undergoing hematopoietic stem cell transplantation need encouragement to maintain their own wellbeing. This feasibility study explored a six-session wellness intervention for caregivers entitled Ready to CARE (Connect, Actively Relax, and Exercise). Method This study used a single-arm pre–post design to explore the feasibility and acceptability of the intervention and study procedures. The individual, participant-directed intervention was initiated at hospitalization for stem cell reinfusion. Caregivers completed telephone surveys on four occasions and engaged in one semi-structured interview to share their perceptions of the intervention. Results Twenty participants enrolled and completed the baseline survey, with 50%, 90%, and 80% completing the subsequent three surveys, respectively. Seventy-four percent completed all six sessions of the intervention. Caregivers most often used the sessions to set goals related to physical activity (36%), stress management (14%), sleep (13%), and caregiving tasks (11%). Caregivers reported appreciation of the intervention’s focus on supporting caregivers, taking action with goal-setting, and allowing caregivers to determine the focus of the goals. Scheduling the sessions was the most problematic aspect of the intervention. Conclusion While caregivers were open to a wellness intervention, a high degree of flexibility and tailoring is needed to engage and support busy caregivers. Clinical Trial Registration: NCT03210727

IntroductionThe purpose of this research was to assess the feasibility, acceptability and potential effectiveness of a program to support the occupational performance of urban breast cancer survivo...

COVID-19 strained our nation's hospitals and exposed gaps in care. As COVID-19 surged in Boston in March 2020, we worked to rapidly create a Palliative Care Compassion Unit (PCCU) to care for those dying of COVID-19 or non-COVID-19-related illnesses. The PCCU provided interdisciplinary end-of-life care, supported families, and enabled surge teams to focus on patients needing life-sustaining treatments. In this study, we describe the creation of the PCCU, including opportunities and challenges, in hopes of lending insight to other palliative care teams who may need to rapidly craft new care models during a crisis.

Objectives Pre-operative exercise may improve functional outcomes for lung cancer patients, but barriers associated with cost, resources, and burden make it challenging to deliver pre-operative exercise programs. The goal of this proof-of-concept study was to determine level of moderate-vigorous physical activity (MVPA) and change in aerobic capacity after participation in a home-based pre-operative exercise intervention. Materials and methods Eighteen patients scheduled for surgery for suspected stage I-III lung cancer received an exercise prescription from their surgeon and wore a commercially-available device that tracked their daily MVPA throughout the pre-operative period. Descriptive statistics were used to calculate adherence to the exercise prescription. A one-sample t-test was used to explore change in aerobic capacity from baseline to the day of surgery. Results Participants exhibited a mean of 20.4 (sd = 46.2) minutes of MVPA per day during the pre-operative period. On average, the sample met the goal of 30 min of MVPA on 16.4% of the days during the pre-operative period. The mean distance achieved at baseline for the 6-min walk test was 456.7 m (sd = 72.9), which increased to 471.1 m (sd = 88.4) on the day of surgery. This equates to a mean improvement of 13.8 m (sd = 37.0), but this difference was not statistically different from zero (p = 0.14). Eight of the 17 participants (47%) demonstrated a clinically significant improvement of 14 m or more. Conclusion A surgeon-delivered exercise prescription plus an activity tracker may promote clinically significant improvement in aerobic capacity and MVPA engagement among patients with lung cancer during the pre-operative period, but may need to be augmented with more contact with and support from practitioners over time to maximize benefits. Trial registration The study protocol was registered with ClinicalTrials.gov prior to initiating participant recruitment (NCT03162718).

Background Occupational exposure to agrochemicals, some of which are known or suspected carcinogens, is a major health hazard for subsistence agricultural workers and their families. These impacts are more prevalent in low-and-middle income countries (LMIC) due to weak regulations, lack of awareness of the risks of contamination, predominant use of handheld backpack style spraying equipment, general lack of personal protective equipment (PPE), and low literacy about proper agrochemical application techniques. Reducing exposure to agrochemicals was identified as a paramount concern by rural Hondurans working with a community-engaged research initiative. Fluorescent tracer dyes have been described as a means of visualizing and quantifying dermal exposure to agricultural chemicals, and exposure models adapted for LMIC have been developed previously. Tracer dyes have also been used in educational simulations to promote pesticide safety. However, studies evaluating the effectiveness of these educational dye interventions in reducing future exposure have been lacking. Aim To evaluate whether observing one's own chemical contamination after applying agrochemicals changed the amount of occupational dermal exposure during a subsequent chemical application. Methods We employed a multi-modal community intervention in a rural village in Honduras that incorporated chemical safety education and use of a fluorescent tracer dye during pesticide application on two consecutive occasions, and compared dermal exposure between the intervention group (previous dye experience and safety education, n = 6) and the control group (safety education only, n = 7). Results Mean total visual score (TVS) of the tracer dye, which accounts for both extent and intensity of whole-body contamination, was lower among those who had previously experienced the dye intervention (mean TVS = 41.3) than among participants who were dye-naive (mean TVS = 78.4), with a difference between means of −37.10 (95% CI [-66.26, −7.95], p = 0.02). Stratifying by body part, contamination was significantly lower for the anterior left lower extremity and bilateral feet for the dye-experienced group vs. dye-naive, with most other segments showing a trend toward decreased contamination as well. Conclusion Participants who had previously experienced the dye intervention were significantly less contaminated than the dye-naive control group during a subsequent spraying event. The findings of this small pilot study suggest that a multi-modal, community-based approach that utilizes fluorescence-augmented contamination for individualized learning (FACIL) may be effective in reducing dermal exposure to carcinogenic agrochemicals among subsistence farmers in Honduras and other LMIC.

Purpose: To build consensus around an optimal patient-reported outcome measure of cancer symptoms and patient needs to facilitate patient-provider communication and trigger referrals to supportive ...

Evidence-based interventions often need to be adapted to maximize their implementation potential in low-to middle-income countries. A single-arm feasibility study was conducted to determine the feasibility and acceptability of a telephone-delivered, nurse-led, symptom management intervention for adults undergoing chemotherapy in Honduras. Over the course of 6 months, nurses engaged 25 patients undergoing chemotherapy in the intervention. Each participant received an average of 16.2 attempts to contact them for telephone sessions ( SD = 8.0, range = 2-28). Collectively, the participants discussed 24 different types of symptoms. The most commonly discussed symptoms were pain (12%), nausea (7%), and constipation (5%). Qualitative and quantitative data were used to identify treatment manual modifications (i.e., adding content about different symptoms and addressing scheduling of treatment) and workplace modifications (i.e., dedicated nurse time and space) that are needed to optimize implementation of the intervention.

Objective The purpose of this study was to explore the feasibility, acceptability and perceived utility of the provision of a wearable fitness device and an exercise prescription from a surgeon, prior to surgery for lung cancer. Methods A single-arm, pre-post feasibility study was conducted with 30 participants scheduled for surgery to treat stage I, II or III lung cancer. Participants were given a Garmin Vivoactive HR device and a prescription for 150 min of moderately to vigorous exercise per week. Participants completed assessments on four occasions and completed a semi-structured interview on two occasions. Descriptive statistics were used to assess the feasibility and acceptability of study procedures, including synchronising the Garmin device and engaging in study assessments. Results Seventy-nine per cent of enrolled participants completed the pre-operative study activities. Seventy-one per cent of enrolled participants successfully synchronised their device during the pre-operative period. Data were transmitted from the device to the study team for an average of 70% of the pre-operative days. Conclusion This pilot study demonstrated the feasibility and acceptability of a pre-operative exercise program for patients scheduled to undergo surgery for lung cancer. Trial registration The study protocol was registered with ClinicalTrials.gov prior to the initiation of participant recruitment (NCT03162718).

PURPOSE To evaluate the feasibility of brigade-style, multiphasic cancer screening in Honduras, exploring data from 3 screening events that each tested for multiple cancers on single occasions. METHODS This series of 3 studies each used a single-arm, post-test–only design to explore the feasibility of implementing multiphasic, community-based cancer screening at the same rural location in 2013, 2016, and 2017. The 2013 event for women screened for 2 cancers (breast and cervix), and the 2016 event for women screened for 3 cancers (breast, cervix, and thyroid). The 2017 event for men screened for 5 cancers (skin, prostate, colorectal, oropharynx, and testes). RESULTS Totals of 473 and 401 women participated in the 2013 and 2016 events, respectively, and 301 men participated in the 2017 event. Staffing for each event varied from 33 to 44 people and relied primarily on in-country medical students and local community members. High rates (mean, 88%) of compliance with referral for follow-up testing at clinics and primary care facilities were observed after the screening events. CONCLUSION The multiphasic, community-based approach proved feasible for both women and men and resulted in high rates of compliance with follow-up testing. This approach appears highly replicable: it was conducted multiple times across the years with different screening targets, which could be further scaled elsewhere using the same technique.

Purpose Cervical cancer is a leading cause of cancer-related mortality in low- and middle-income countries (LMICs) and screening in LMICs is extremely limited. We aimed to implement on-site high-risk human papillomavirus (hrHPV) DNA testing in cohorts of women from an urban factory and from a rural village. Methods A total of 802 women were recruited for this study in partnership with La Liga Contra el Cancer through the establishment of women’s health resource fairs at two locations in Honduras: a textile factory (n = 401) in the city of San Pedro Sula and the rural village of El Rosario (n = 401) in Yoro. Participants received a routine cervical examination during which three sterile cytobrushes were used to collect cervical samples for testing. hrHPV genotyping was performed using a hrHPV genotyping assay and a real-time polymerase chain reaction instrument. Results hrHPV status across all participants at both sites was 13% hrHPV positive and 67% hrHPV negative. When hrHPV status was compared across all three testing sites, hrHPV-positive rates were approximately equal among the factory (13%), village (12%), and confirmatory testing at Dartmouth-Hitchcock Medical Center (Lebanon, NH; 14%). hrHPV genotype was compared across sites, with HPV16 showing the highest infection rate (15%), followed by HPV59 (12%), and HPV68 (11%). There was a low prevalence of HPV18 observed in both populations compared with the hrHPV-positive population in the United States. Conclusion In collaboration with oncologists and pathologists from La Liga Contra el Cancer, we were able to provide a continuum of care once health-fair testing was performed. We established a method and implementation plan for hrHPV testing that is sustainable in LMICs.

Despite research explicating the benefits of cancer rehabilitation interventions to optimize physical, social, emotional, and vocational functioning, many reports document low rates of referral to and uptake of rehabilitation in oncology. Cancer rehabilitation clinicians, researchers, and policy makers could learn from the multidisciplinary specialty of palliative care, which has benefited from a growth strategy and has garnered national recognition as an important and necessary aspect of oncology care. The purpose of this article is to explore the actions that have increased the uptake and integration of palliative care to yield insights and multimodal strategies for the development and growth of cancer rehabilitation. After examining the history of palliative care and its growth, the authors highlight 5 key strategies that may benefit the field of cancer rehabilitation: 1) stimulating the science in specific gap areas; 2) creating clinical practice guidelines; 3) building clinical capacity; 4) ascertaining and responding to public opinion; and 5) advocating for public policy change. Coordinated and simultaneous advances on these 5 strategies may catalyze the growth, utilization, and effectiveness of patient screening, timely referrals, and delivery of appropriate cancer rehabilitation care that reduces disability and improves quality of life for cancer survivors who need these services.

This study investigated the supportive care needs of a sample of low-income Latina breast cancer survivors. Ninety-nine Spanish-speaking breast cancer survivors who self-identified as Latina and reported an income below the US Census Bureau low-income threshold were recruited from the oncology clinic of a major public safety net hospital. Eligible participants completed the supportive care needs survey (SCNS-SF34) and a demographic questionnaire. Ninety-three percent of respondents had unmet needs. The majority of frequently reported unmet needs involved (1) access to and delivery of health-related information and (2) physical function. These findings appear to contrast with those of other studies of supportive care needs in heterogeneous cancer survivors, most of which describe psychological concerns as most urgent. Participants espoused information-related needs with a higher frequency than many other samples of cancer survivors. This study population may also require a particularly high level of assistance with overcoming participation restrictions. Further research is needed to understand these discrepancies and to address unmet needs across all domains.

Background We aim to address palliative care workforce shortages by teaching clinicians how to provide primary palliative care through peer coaching. Intervention We offered peer coaching to internal medicine residents and hospitalists (attendings, nurse practioners, and physician assistants). Measures An audit of peer coaching encounters and coachee feedback to better understand the applicability of peer coaching in the inpatient setting to teach primary palliative care. Outcomes Residents and hospitalist attendings participated in peer coaching for a broad range of palliative care–related questions about pain and symptom management (44%), communication (34%), and hospice (22%). Clinicians billed for 68% of encounters using a time-based billing model. Content analysis of coachee feedback identified that the most useful elements of coaching are easy access to expertise, tailored teaching, and being in partnership. Conclusion/Lessons Learned Peer coaching can be provided in the inpatient setting to teach primary palliative care and potentially extend the palliative care work force.

BACKGROUND: Many older adult cancer survivors reduce their activity level during and after cancer treatment. Occupational therapy interventions need to flexibly address various obstacles to occupational engagement that survivors may face. OBJECTIVE: To describe the content of a participant-directed occupational therapy intervention for older adults with cancer. METHODOLOGY: Content analysis was used to describe the treatment session data from the experimental arm of a pilot randomized controlled trial in terms of activities addressed, obstacles reported, and treatment strategies utilized. RESULTS: Participants predominantly used the intervention to increase exercise engagement or address instrumental activities of daily living. The most common obstacles to occupational engagement included fatigue, finding time, weather, and pain. Regarding treatment strategies, 77% of participants chose to practice the activity with the occupational therapist, 42% requested a piece of equipment, and 11% modified the environment in order to increase activity engagement. CONCLUSION: Overall, the participant-directed intervention appears flexible enough to address various activities and obstacles to occupational engagement.

Individuals with cancer are at high risk for restricted participation in meaningful life activities such as work, school, and social activities. Evaluating participation in life activities is identified as a critical component of rehabilitation referral and triage systems. This scoping review investigates what assessments are used to measure participation in life activities in individuals with cancer. Six databases were systematically searched using keywords and controlled vocabulary through February 2020. Eligible studies used the term participation in the context of life situations and had an assessment with at least 5 participation-specific questions. A total of 4604 unique articles were identified and screened for eligibility. Thirty-two studies were included; 20 unique assessments of participation were identified. Assessments were developed with the primary purpose of measuring participation (n = 8); global or physical function (n = 9); community integration (n = 1); social activity (n = 1); or occupational gaps (n = 1). Most assessments (12/20) were not developed with the purpose of measuring participation and only 4 assessments measured key components of participation other than frequency. Measuring participation in life activities is a developing area in oncology research. Most studies do not accurately or comprehensively measure this construct. The heterogeneity in assessments used indicates no clear consensus on a gold-standard participation measure for use among cancer survivors. Comprehensively measuring participation will help identify individuals in need of rehabilitation services and is an essential first step to inform the development of targeted interventions to enhance participation.

Background Acute respiratory failure survivors experience depression symptoms and new impairments in physical function. Behavioural activation, an evidence-based nonpharmacological treatment for depression, combined with physical rehabilitation, is a promising intervention. Notably, mHealth applications (Apps) are potentially effective methods of delivering home-based interventions. Objectives The objective of this study was to evaluate the usability and acceptability of a prototype App to deliver a combined, home-based behavioural activation and rehabilitation intervention to acute respiratory failure survivors. Methods A prospective user-preference study was conducted with acute respiratory failure survivors and self-designated care partners. Survivors were adults with at least mild depression symptoms before hospital discharge who received mechanical ventilation in the intensive care unit for ≥24 h. Survivors and care partners reviewed the App during a single in-person home visit and completed the System Usability Scale (range: 0–100; score >73 considered “good”) and a semistructured interview. Results Ten patient/care partner dyads completed study. The median [interquartile range] patient age was 50 [40–64] years, and 50% were female. The median System Usability Scale scores among patients and care partners were 76 [68–83] and 88 [75–94], respectively. Qualitative feedback supported usability and acceptability of the App, with three themes reported: (1) stigma associated with depression, (2) App as a motivator for recovery, and (3) App providing multidisciplinary support for survivor and care partner. Conclusions A mobile App prototype designed to deliver a combined behavioural activation and rehabilitation intervention was usable and acceptable to survivors of acute respiratory failure and their care partners. Given the reported stigma associated with depression, the self-directed App may be particularly valuable for motivation and multidisciplinary support.

Background Stiff-Knee gait (SKG) after stroke is often accompanied by decreased knee flexion angle during the swing phase. The decreased knee flexion has been hypothesized to originate from excessive quadriceps activation. However, it is unclear whether hyperreflexia plays a role in this activation. The goal of this study was to establish the relationship between quadriceps hyperreflexia and knee flexion angle during walking in post-stroke SKG. Methods The rectus femoris (RF) H-reflex was recorded in 10 participants with post-stroke SKG and 10 healthy controls during standing and walking at the pre-swing phase. In order to attribute the pathological neuromodulation to quadriceps muscle hyperreflexia and activation, healthy individuals voluntarily increased quadriceps activity using electromyographic (EMG) feedback during standing and pre-swing upon RF H-reflex elicitation. Results We observed a negative correlation (R = − 0.92, p = 0.001) between knee flexion angle and RF H-reflex amplitude in post-stroke SKG. In contrast, H-reflex amplitude in healthy individuals in presence (R = 0.47, p = 0.23) or absence (R = − 0.17, p = 0.46) of increased RF muscle activity was not correlated with knee flexion angle. We observed a body position-dependent RF H-reflex modulation between standing and walking in healthy individuals with voluntarily increased RF activity (d = 2.86, p = 0.007), but such modulation was absent post-stroke (d = 0.73, p = 0.296). Conclusions RF reflex modulation is impaired in post-stroke SKG. The strong correlation between RF hyperreflexia and knee flexion angle indicates a possible regulatory role of spinal reflex excitability in post-stroke SKG. Interventions targeting quadriceps hyperreflexia could help elucidate the causal role of hyperreflexia on knee joint function in post-stroke SKG.

Nipple-sparing mastectomies (NSMs) are accepted as safe oncologic procedures for select patient populations, but objective evaluation of aesthetic outcomes has not been clearly established. The purpose of this study was to utilize BCCT.core computer software to objectively evaluate NAC malposition following bilateral NSM with implant reconstruction and compare the analysis to an expert panel. Postoperative photographs of 43 patients who underwent bilateral NSM were analyzed with the BCCT.core and by an expert panel of plastic surgery residents and attendings. The panel was asked to only evaluate nipple asymmetry and position. The intraclass correlation coefficient (ICC) was used to determine interrater reliability (n = 12) and between expert panel ratings and BCCT.core ratings. Statistics were performed using SPSS statistical package version 24.0. The ICC for the expert panel interrater reliability was excellent (ICC = 0.941, 95% CI: 0.912-0.964). The analysis between BCCT.core individual parameters, specifically the breast retraction assessment (ie, BRA score = the difference in nipple position between the two breasts assessing breast symmetry) and expert panel, showed statistically significant positive correlation. The parameters provided by the BCCT.core software were correlated with both the mean expert panel rating and BCCT.core ratings. Therefore, it is plausible that BCCT.core parameters could be used to objectively quantify NAC malposition/asymmetry and guide treatment in patients undergoing bilateral NSM with implant reconstruction.

Stiff-knee gait (SKG) after stroke is often accompanied by decreased knee flexion angle during the swing phase. The decreased knee flexion has been hypothesized to originate from excessive quadriceps activation. However, it is unclear whether this activation is due to poor timing or hyperreflexia, both common post-stroke impairments. The goal of this study was to investigate the relation between quadriceps hyperreflexia in post-stroke SKG with knee flexion angle during walking. The rectus femoris (RF) H-reflex was recorded in eleven participants with post-stroke SKG and ten healthy controls during standing and walking during toe-off. In order to separate the effects of poorly timed quadriceps muscle activation from hyperreflexia, healthy individuals voluntarily increased quadriceps activity using RF electromyographic (EMG) biofeedback during standing and pre-swing upon H-reflex stimulation. We observed a negative correlation (R = −0.92, p=0.001) between knee flexion angle and RF H-reflexes in post-stroke SKG. In contrast, H-reflex amplitude in healthy individuals in presence (R = 0.47, p = 0.23) or absence (R = −0.17, p = 0.46) of increased RF activity had no correlation with knee flexion angle. The RF H-reflex amplitude differed between standing and walking in healthy individuals, including when RF activity was increased voluntarily (d = 2.86, p = 0.007), but was not observed post-stroke (d =0.73, p = 0.296). Thus, RF reflex modulation is impaired in post-stroke SKG. Further, RF hyperreflexia, as opposed to overactivity, may play a role in knee flexion kinematics in post-stroke SKG. Interventions targeting self-regulated quadriceps hyperreflexia may be effective in promoting better neural control of the knee joint and thus better quality of walking post-stroke.

Date Presented 03/28/20 HSCT is a lengthy and debilitating cancer treatment. Caregivers of HSCT recipients report distress and reductions in their own self-care. A caregiver wellness intervention based on behavioral activation was developed and implemented in order to assess its feasibility and acceptability. Future research will explore the efficacy of the intervention, which is well-suited for delivery by OTs working in cancer rehabilitation. Primary Author and Speaker: Jamme Morency Additional Authors and Speakers: Kathleen Lyons Contributing Authors: Lynn Root, Kate Caldon, Christi Hayes, Susan Brighton

The physical and psychological side effects of breast cancer therapies can have substantial impact on survivors' physical and social functioning. Roughly half of the more than 3 million Americans alive with a history of breast cancer report adverse, function-degrading sequelae related to their oncologic treatments. Care delivery models for the timely delivery of rehabilitation services have been proposed yet limitedly vetted or implemented. These include the prospective surveillance model, procedure-linked referrals, survivorship care plans, and risk stratification. Patients' capacity to engage in the rehabilitative process varies during cancer therapy and into survivorship. Perioperative attention generally focuses on managing premorbid impairments and normalizing shoulder function. In contrast, during chemotherapy and radiation therapy, symptom control, constructive coping, and role preservation may become more salient. Risk-stratified, individualized screening and prevention activities for specific impairments have become increasingly feasible through predictive models and analytics. Impairments' severity deleterious impact can be mitigated, as has been established for lymphedema, shoulder dysfunction, chemotherapy-induced peripheral neuropathy, cognitive dysfunction, fatigue, and sexual side effects. Integrated rehabilitative programs, often initiated after the completion of cancer treatment, are available in some countries outside of the United States and may offer survivors vital vocation- and avocation-directed services.

Purpose: Determine correlations between health-related quality of life (HRQOL), supportive care need, and sociodemographic factors in low-income Latina breast cancer survivors.Methods: A descriptiv...

We conducted a randomized controlled trial (RCT) of an early palliative care intervention (ENABLE: Educate, Nurture, Advise, Before Life Ends) for persons with advanced cancer and their family caregivers. Not all patient participants had a caregiver coparticipant; hence, we explored whether there were relationships between patient survival, having an enrolled caregiver, and caregiver outcomes prior to death. One hundred and twenty‐three patient‐caregiver dyads and 84 patients without a caregiver coparticipant participated in the ENABLE early versus delayed (12 weeks later) RCT. We collected caregiver quality‐of‐life (QOL), depression, and burden (objective, stress, and demand) measures every 6 weeks for 24 weeks and every 3 months thereafter until the patient's death or study completion. We conducted survival analyses using log‐rank and Cox proportional hazards models. Patients with a caregiver coparticipant had significantly shorter survival (Wald = 4.31, HR = 1.52, CI: 1.02–2.25, P = 0.04). After including caregiver status, marital status (married/unmarried), their interaction, and relevant covariates, caregiver status (Wald = 6.25, HR = 2.62, CI: 1.23–5.59, P = 0.01), being married (Wald = 8.79, HR = 2.92, CI: 1.44–5.91, P = 0.003), and their interaction (Wald = 5.18, HR = 0.35, CI: 0.14–0.87, P = 0.02) were significant predictors of lower patient survival. Lower survival in patients with a caregiver was significantly related to higher caregiver demand burden (Wald = 4.87, CI: 1.01–1.20, P = 0.03) but not caregiver QOL, depression, and objective and stress burden. Advanced cancer patients with caregivers enrolled in a clinical trial had lower survival than patients without caregivers; however, this mortality risk was mostly attributable to higher survival by unmarried patients without caregivers. Higher caregiver demand burden was also associated with decreased patient survival.

Purpose Randomized controlled trials have supported integrated oncology and palliative care (PC); however, optimal timing has not been evaluated. We investigated the effect of early versus delayed PC on quality of life (QOL), symptom impact, mood, 1-year survival, and resource use. Patients and Methods Between October 2010 and March 2013, 207 patients with advanced cancer at a National Cancer Institute cancer center, a Veterans Affairs Medical Center, and community outreach clinics were randomly assigned to receive an in-person PC consultation, structured PC telehealth nurse coaching sessions (once per week for six sessions), and monthly follow-up either early after enrollment or 3 months later. Outcomes were QOL, symptom impact, mood, 1-year survival, and resource use (hospital/intensive care unit days, emergency room visits, chemotherapy in last 14 days, and death location). Results Overall patient-reported outcomes were not statistically significant after enrollment (QOL, P = .34; symptom impact, P = .09; mood, P = .33) or before death (QOL, P = .73; symptom impact, P = .30; mood, P = .82). Kaplan-Meier 1-year survival rates were 63% in the early group and 48% in the delayed group (difference, 15%; P = .038). Relative rates of early to delayed decedents' resource use were similar for hospital days (0.73; 95% CI, 0.41 to 1.27; P = .26), intensive care unit days (0.68; 95% CI, 0.23 to 2.02; P = .49), emergency room visits (0.73; 95% CI, 0.45 to 1.19; P = .21), chemotherapy in last 14 days (1.57; 95% CI, 0.37 to 6.7; P = .27), and home death (27 [54%] v 28 [47%]; P = .60). Conclusion Early-entry participants' patient-reported outcomes and resource use were not statistically different; however, their survival 1-year after enrollment was improved compared with those who began 3 months later. Understanding the complex mechanisms whereby PC may improve survival remains an important research priority.

Objective Randomized controlled trials (RCTs) of early palliative care interventions in advanced cancer have positively impacted patient survival, yet the mechanisms remain unknown. This secondary analysis of 2 RCTs assessed whether an early palliative care intervention moderates the relationship between depressive symptoms and survival. Method The relationships among mood, survival, and early palliative care intervention were studied among 529 advanced cancer patients who participated in 2 RCTs. The first (N = 322) compared intervention versus usual care. The second (N = 207) compared early versus delayed intervention (12 weeks after enrollment). The interventions included an in-person consultation, weekly nurse coach-facilitated phone sessions, and monthly follow-up. Mood was measured using the Center for Epidemiologic Studies-Depression (CES-D) scale. Cox proportional hazard analyses were used to examine the effects of baseline CES-D scores, the intervention, and their interaction on mortality risk while controlling for demographic variables, cancer site, and illness severity. Results The combined sample was 56% male (M = 64.7 years). Higher baseline CES-D scores were significantly associated with greater mortality risk (hazard ratio [HR] = 1.042, 95% confidence interval [CI] [1.017, 1.067], p = .001). However, participants with higher CES-D scores who received the intervention had a lower mortality risk (HR = .963, CI [0.933, 0.993], p = .018) even when controlling for demographics, cancer site, and illness-related variables. Conclusion This study is the first to demonstrate that patients with advanced cancer who also have depressive symptoms benefit the most from early palliative care. Future research should be devoted to exploring the mechanisms responsible for these relationships. (PsycINFO Database Record

This chapter offers a close reading of selected scenes and details in the novella as they relate to the themes of fashion, competing models of femininity, the embodiment of modernity and self-determination within love relationships, topics which can be familiar to readers acquainted with Burgos's repertoire of concerns. It considers the implications of the work's use of biblical images and language, which consistently refer to loss and redemption in terms reminiscent of the archetypal story of Adam and Eve. In Carmen de Burgos's novella, the protagonist Adela's desire for an updated hairstyle is a matter of relatively minor significance that takes on grandiose proportions, and she reflects that despite "being such a small thing, it was going to cost her hole life's happiness". In employing religious language for mundane matters, Burgos certainly calls attention to the seemingly inescapable gender dynamics of patriarchal authority and feminine rebellion so central to the archetypal story of Adam and Eve.

Background Active surveillance is a management strategy for men diagnosed with early-stage, low-risk prostate cancer in which their cancer is monitored and treatment is delayed. This study investigated the primary coping mechanisms for men following the active surveillance treatment plan, with a specific focus on how these men interact with their social network as they negotiate the stress and uncertainty of their diagnosis and treatment approach. Methods Thematic analysis of semi-structured interviews at two academic institutions located in the northeastern US. Participants include 15 men diagnosed with low-risk prostate cancer following active surveillance. Results The decision to follow active surveillance reflects the desire to avoid potentially life-altering side effects associated with active treatment options. Men on active surveillance cope with their prostate cancer diagnosis by both maintaining a sense of control over their daily lives, as well as relying on the support provided them by their social networks and the medical community. Social networks support men on active surveillance by encouraging lifestyle changes and serving as a resource to discuss and ease cancer-related stress. Conclusions Support systems for men with low-risk prostate cancer do not always interface directly with the medical community. Spousal and social support play important roles in helping men understand and accept their prostate cancer diagnosis and chosen care plan. It may be beneficial to highlight the role of social support in interventions targeting the psychosocial health of men on active surveillance.

OBJECTIVE. The objective of this study was to assess the feasibility of conducting a future full-scale trial to test the efficacy of an in-home occupational therapy intervention designed to reduce disability in older adult cancer survivors. METHOD. Participants reporting activity limitations during or after cancer treatment were enrolled in a Phase 1 pilot randomized controlled trial comparing the 6-wk intervention (n = 30) to usual care (n = 29). Descriptive data on retention rates were collected to assess feasibility of intervention and study procedures. Potential efficacy was explored through participants’ self-reported disability, quality of life, activity level, and behavioral activation at 0, 8, and 16 wk after enrollment. RESULTS. Retention rates were high regarding completion of the intervention (90%) and outcome assessments (90% of usual-care participants and 80% of intervention participants). Outcomes consistently favored the intervention group, although group differences were small. CONCLUSION. The procedures were feasible to implement and acceptable to participants.

Objective: To describe the clinical and personal factors associated with work status, distress regarding work status, and the desire to resume employment and receive help to address work challenges reported by women living with advanced breast cancer. Design: Descriptive statistics and univariate and multivariate logistic regression were used to explore factors related to employment challenges in this secondary analysis of an existing dataset. Setting: Participants were recruited from an outpatient oncology clinic specializing in breast cancer at a free-standing comprehensive cancer center. Participants: English-speaking women older than 18 years living with metastatic breast cancer with intact mental status and Karnofsky Performance Scale scores between 40 and 90 (N=163). Intervention: Not applicable. Main Outcome Measures: Dependent variables included (1) continued employment if working at the time of cancer diagnosis; (2) interest in resuming employment if working at the time of cancer diagnosis and now no longer working; (3) distress regarding vocational limitations; and (4) interest in receiving help to resume work. Results: Seventy percent of the sample was working before their cancer diagnosis (n=114), yet only 21% (n=35) was working when surveyed. Lower functional status and higher symptom burden were strongly and consistently associated with lack of work retention, distress related to vocational role limitations, and desire for help in addressing limitations (all P values

Benefits of early diagnosis and treatment remain debatable for men with low-risk prostate cancer. Active surveillance (AS) is an alternative to treatment. The goal of AS is to identify patients whose cancer is progressing rapidly while avoiding treatment in the majority of patients. The purpose of this study was to explore cognitive and affective representations of AS within a clinical environment that promotes AS a viable option for men with low-risk prostate cancer. Participants included patients for whom AS and active treatment were equally viable options, as well as practitioners who were involved in consultations for prostate cancer. Data were generated from semistructured interviews and audits of consultation notes and were analyzed using thematic analysis. Nineteen patients and 16 practitioners completed a semistructured interview. Patients generally viewed AS as a temporary strategy that was largely equated with inaction. There was variation in the degree to which inaction was viewed as warranted or favorable. Patient perceptions of AS were generally malleable and able to be influenced by information from trusted sources. Encouraging slow deliberation and multiple consultations may facilitate greater understanding and acceptance of AS as a viable treatment option for low-risk prostate cancer.

Objective To solicit expert opinions and develop consensus around the research that is needed to improve cancer rehabilitation for older adults. Design Delphi methods provided a structured process to elicit and prioritize research questions from national experts. Setting National, Web-based survey. Participants Members (N=32) of the American Congress of Rehabilitation Medicine completed at least 1 of 3 investigator-developed surveys. Interventions Not applicable. Main Outcome Measures In the first survey, participants identified up to 5 research questions that needed to be answered to improve cancer rehabilitation for older adults. In 2 subsequent surveys, participants viewed the compilation of questions, rated the importance of each question, and identified the 5 most important questions. This generated priority scores for each question. Consensus scores were created to describe the degree of agreement around the priority of each question. Results Highest priority research concerns the epidemiology and measurement of function and disability in older adult cancer survivors; the effects of cancer rehabilitation interventions on falls, disability, participation, survival, costs, quality of care, and health care utilization; and testing models of care that facilitate referrals from oncology to rehabilitation providers as part of coordinated, multicomponent care. Conclusions A multipronged approach is needed to fill these gaps, including targeted funding opportunities developed with an advisory panel of cancer rehabilitation experts, development of a research network to facilitate novel collaborations and grant proposals, and coordinated efforts of clinical groups to advocate for funding, practice change, and policy change.

Context Little is known about whether early palliative care (EPC) support for family caregivers (CGs) impacts depressive symptoms and grief after care recipients die. Objectives To assess after-death CG depressive symptom and grief scores for early compared to delayed group CGs. Methods We conducted a randomized controlled trial (10/2010–9/2013) of an EPC telehealth intervention for CGs (n = 123) initiated at the time of care recipients' advanced cancer diagnosis (early group) or 12 weeks later (delayed group) in a rural comprehensive cancer center, affiliated clinics, and a Veterans Administration medical center. The ENABLE [Educate, Nurture, Advise, Before Life Ends] CG intervention consisted of three weekly sessions, monthly follow-up, and a bereavement call. CGs completed the Center for Epidemiological Study–Depression (CES-D) scale and the Prigerson Inventory of Complicated Grief-Short Form (PG13) 8–12 weeks after care recipients' deaths. Crude and covariate-adjusted between-group differences were estimated and tested using general linear models. Results For care recipients who died (n = 70), 44 CGs (early: n = 19; delayed: n = 25) completed after-death questionnaires. Mean depressive symptom scores (CES-D) for the early group was 14.6 (SD = 10.7) and for the delayed group was 17.6 (SD = 11.8). Mean complicated grief scores (PG13) for the early group was 22.7 (SD = 4.9) and for the delayed group was 24.9 (SD = 6.9). Adjusted between-group differences were not statistically significant (CES-D: d = 0.07, P = 0.88; PG13: d = −0.21, P = 0.51). Conclusion CGs' depressive symptom and complicated grief scores 8–12 weeks after care recipients' deaths were not statistically different based on the timing of EPC support. The impact of timing of CG EPC interventions on CGs bereavement outcomes requires further investigation.

Family caregivers of persons with advanced cancer often take on responsibilities that present daunting and complex problems. Serious problems that go unresolved may be burdensome and result in negative outcomes for caregivers' psychological and physical health and affect the quality of care delivered to the care recipients with cancer, especially at the end of life. Formal problem-solving training approaches have been developed over the past several decades to assist individuals with managing problems faced in daily life. Several of these problem-solving principles and techniques were incorporated into ENABLE (Educate, Nurture, Advise, Before Life End), an "early" palliative care telehealth intervention for individuals diagnosed with advanced cancer and their family caregivers. A hypothetical case resembling the situations of actual caregiver participants in ENABLE that exemplifies the complex problems that caregivers face is presented, followed by presentation of an overview of ENABLE's problem-solving key principles, techniques, and steps in problem-solving support. Though more research is needed to formally test the use of problem-solving support in social work practice, social workers can easily incorporate these techniques into everyday practice.

Background: ENABLE (Educate, Nurture, Advise Before Life Ends) II was one of the first randomized controlled trials (RCTs) examining the effects of a concurrent oncology palliative care intervention on quality of life, mood, and symptom control for advanced cancer patients and their caregivers. However, little is known about how participants experience early palliative care and the benefits and burdens of participating in a palliative care clinical trial. Aim: To gain a deeper understanding of participants’ perspectives of the intervention and palliative care trial participation. Design: A qualitative descriptive study using thematic analysis to determine benefits and burdens of a new palliative care intervention and trial participation. Setting/participants: Of the 72 participants who were alive when the study commenced, 53 agreed to complete an in-depth, semi-structured interview regarding the ENABLE II intervention and clinical trial participation. Results: Participants’ perceptions of intervention benefits were represented by four themes: enhanced problem-solving skills, better coping, feeling empowered, and feeling supported or reassured. Three themes related to trial participation: helping future patients and contributing to science, gaining insight through completion of questionnaires, and trial/intervention aspects to improve. Conclusions: The benefits of the intervention and the positive aspects of trial participation outweighed trial “burdens”. This study raises additional important questions relevant to future trial design and intervention development: when should a palliative care intervention be initiated and what aspects of self-care and healthy living should be offered in addition to palliative content for advanced cancer patients when they are feeling well?

A cross sectional survey was performed to obtain the characteristics of specialized inpatient psychiatry units exclusively serving children with autism and other developmental disorders in the United States. Identified units were surveyed on basic demographic characteristics, clinical challenges and therapeutic modalities. Average length of stay was 42.3 days, children with autism spectrum disorders constituted the majority of the inpatient population (62.5-87.5%), and obtaining adequate post-discharge services was identified as the greatest challenge. Health policy implications and future research directions are suggested.

UNLABELLED: PRPOSE/OBJECTIVES: to describe the natural pace and pattern of activity resumption in the first six months after stem cell transplantation (SCT). DESIGN: longitudinal, descriptive survey. SETTING: bone marrow transplantation program of a National Cancer Institute-designated comprehensive cancer center in the northeastern United States. SAMPLE: 18 men and 18 women who underwent either autologous (83%) or allogeneic (17%) transplantation. METHODS: participants were surveyed 30 days, 100 days, and six months after SCT. Descriptive statistics were followed by exploratory linear mixed modeling with factors of time, gender, and the interaction between time and gender. MAIN RESEARCH VARIABLES: a modified checklist version of the Activity Card Sort was used to measure activity retention. FINDINGS: participants generally were performing 49% of their usual activities 30 days after transplantation, 70% of their premorbid activities 100 days after transplantation, and 77% of their premorbid activities six months after transplantation. Level of activity engagement increased over time, with the greatest changes observed from 30-100 days after SCT. Men retained more of their activities than women in the domains of low physical-demand leisure and social activities. CONCLUSIONS: rehabilitation screening may be most helpful in the period from 100 days to six months, when activity levels begin to plateau. Activity recovery may differ for men and women; future research should explore how this could affect rehabilitation needs. IMPLICATIONS FOR NURSING: nurses can use structured surveys to explore and promote patients' satisfaction with and ability to engage in daily activities and ensure appropriate referrals to rehabilitation during recovery from SCT.

Background: Cervical cancer is one of the most prevalent cancers in Honduran women. Lacking national or population-based registries, we rely on hospital registries to establish incidence: San Felipe General Hospital in 2012 diagnosed 38% of 998 women and The League against Cancer Hospital (LCC) in 2016 diagnosed 54.4% of 695 women with cervical cancer CC. According to PAHO's Honduras Profile 2013, screening coverage with Pap was 48.1%. Bruni in 2010 reported a prevalence of high risk HPV (hrHPV) infection for Central America of 13%, identifying genotypes 16, 18, 52, 31 and 58 as most frequent. Information about pathogenesis of hrHPV to induce cervical lesions is based on models of genotypes 16 and 18 only. Aim: Inform evidence of hrHPV genotypes collected in Honduras from an urban and a rural population, generate discussion and subsequent improvement of cervical cancer control strategies in our country. Methods: In 2016, 2 clinical studies funded by Norris Cotton Cancer Center at Dartmouth College and the LCC accrued 913 women: 401 in Locomapa Valley (rural), 111 in La Mosquitia (remote rural), and 401 in a textile factory in San Pedro Sula (urban). Women were consented, to obtain 3 cervical samples, during a cervical cancer screening brigade. One sample for conventional cytology, and 2 for hrHPV by PCR genotyping. One local with our customized PCR device and the second at Dartmouth. An educational component and survey were included. Positive patients identified with hrHPV, pre or invasive cancer were referred to LCC for treatment and follow-up. Results: In Locomapa and the factory (rural and urban sites) 13% of participants were positive for hrHPV. Only 15% had HPV 16. The following common genotypes varied by location: urban factory HPV 59, 12% in rural location HPV 58, 10%; HPV 31, 9%; HPV 39 8%; HPV 35 and 66, 7%; HPV 45 and 51, 6%; HPV 18 and 56, 3%; HPV 33 and 52, 1%. 17% of women had multiple hrHPV coinfection. 7.7% had abnormal Pap tests. In La Mosquitia (remote rural), 24% of women were positive for hrHPV: HPV 52, 29%; HPV 16, 23%; HPV 39, 10%; HPV 68, 6%; HPV 58, 6%; HPV 45, 6%; HPV 51 and HPV 31, 18, 66, 59 and 35, 3% each. 1.8% had abnormal Pap tests; all participants identified with hrHPV were referred for follow-up. The average age was 40.3 years, parity, 3 children, education 6.0 years; and 15% were first-time users of a cervical screening program. Conclusion: Associate the burden of disease, with risk factors, will help us to generate models of prevention and care that are reproducible and effective to reduce morbi-mortality. Brigade-type screening models, with trained providers working at a community location over a single day, can offer improved access for women at risk and facilitate educational activities for health promotion. Introducing tests as hrHPV DNA detection, effectively reduces the volume of women to follow. Strengthening the capacity of primary care with novel screening techniques and ensure diligent follow-up is essential.

Background: Occupational exposure to agrochemicals, some of which are known or suspected carcinogens, is a major health hazard for subsistence agricultural workers and their families. These impacts are more prevalent in low-and-middle income countries (LMICs) due to weak regulations, lack of awareness of the risks of contamination, general lack of personal protective equipment (PPE), and low literacy about proper agrochemical application techniques. Fluorescent tracer dyes have been described as a means of visualizing and quantifying dermal exposure to agricultural chemicals, and dye techniques adapted for LMICs have been developed previously. These tracer dyes have also been used in educational demonstrations about pesticide safety. However, studies evaluating the efficacy of these educational dye interventions in reducing exposure have been lacking. Aim: To evaluate whether observing one's own chemical contamination after applying agrochemicals changed the amount of occupational dermal exposure during a subsequent chemical application. Methods: We used a multimodal community intervention in a rural village in Honduras that incorporated chemical safety education and use of a fluorescent tracer dye during pesticide application and compared dermal exposure between the intervention group (previous dye experience and safety education) and the control group (safety education only). Results: Mean total visual score (TVS) of the tracer dye, which accounts for both extent and intensity of contamination, was lower among those who had previously experienced the dye intervention (mean TVS=41.3) than among participants who were dye-naïve (mean TVS=78.4), with a difference between means of -37.10 (95% CI [-66.26, -7.95], P = 0.02). Conclusion: That workers who had experienced the dye demonstration once before were significantly less contaminated on average when compared with the dye-naïve group indicates that a multimodal community intervention that utilizes fluorescent dye visualization may be effective in reducing dermal exposure to carcinogenic agrochemicals among subsistence farmers in LMICs.

The American Cancer Society estimates that 11.1 million Americans were living with cancer in 2005, and that 1.5 million new cases of cancer were diagnosed in 2009 (American Cancer Society, 2009). Because of the debilitating nature of advanced cancers and their treatment, many persons with advanced cancer require the assistance of an informal caregiver, defined as an unpaid individual who assists someone else who has functional impairment with activities of their daily living (Scott, 2006). Over 22 million Americans (with estimates running as high as 52 million) are involved in informal caregiving (Scott, 2006), and a nationally representative survey of older Americans revealed that end-of-life caregivers provide an average of 43 hours of assistance per week (Wolff, Dy, Frick, & Kasper, 2007). Unfortunately, there is substantial evidence documenting deleterious caregiver physical and mental health effects, often referred to as caregiver burden. As people live longer with cancer, the negative effects of caregiver burden will only continue to grow. A meta-analysis of 84 caregiver burden studies across all types of chronic disease showed that caregivers exhibit higher levels of stress and depression, lower subjective well-being, and worse physical health compared to non-caregiver controls (Pinquart & Sorenson, 2003a). Caregiver burden has also been identified as an independent risk factor for mortality: controlling for demographics and co-morbid disease, caregivers were 63% more likely to die within a 4-year span than non-caregiver controls (Schulz & Beach, 1999). Although the negative effects of caregiving are most pronounced in caregivers of patients with dementia, informal caregivers of patients with cancer also report worse mental health (Ringdal et al., 2004; Braun, Mikulincer, Rydall, Walsh, & Rodin, 2007; Janda et al., 2007; Rhee et al., 2008). In addition, caring for someone with a slow-developing cancer, such as colon or lung cancer, has been shown to increase 9-year mortality rates versus caregivers of patients with ‘quick’ cancers (Elwert & Christakis, 2008). Even hospitalization for cancer may increase the risk of spouse mortality within 1 year (Christakis & Allison, 2006). The evidence seems clear that informal caregiving can exact a heavy toll. Because of the significant effect of caregiving on health outcomes, various interventions to alleviate caregiver burden have been tested, but these have produced equivocal results (Harding & Higginson, 2003). A meta-analysis of 78 caregiver interventions across a wide array of chronic ailments found only marginal effects (0.14 < d < 0.41) (Sorenson, Pinquart, & Duberstein, 2002). A review of end-of-life palliative care studies concluded that the evidence for interventions improving outcomes for caregivers of patients with cancer was weak (Lorenz et al., 2008). Psychoeducational interventions that teach caregivers about symptom management, self-care, and coordination of resources have been shown to improve caregivers’ physical health, distress, and depression relative to controls, but these effects appeared short-lived as group differences disappeared shortly after the interventions ceased (McCorkle, Robinson, Nuamah, Lev, & Benoliel, 1998; Jepson, McCorkle, Adler, Nuamah, & Lusk, 1999). Caregiver interventions designed to improve problem-solving and coping skills have been shown to improve physical and social functioning (Toseland, Blanchard, & McCallion, 1995). The benefits of both types of intervention, however, were most evident for those caregivers that entered the study with the highest impairment (Toseland et al., 1995; Jepson et al., 1999). One exception was a problem-solving and coping skills intervention that successfully improved caregiver quality of life and reduced caregiver burden at 30 days post-intervention compared to both a usual care condition and an emotional support intervention (McMillan et al., 2005). Unfortunately, this intervention failed to change the proposed mediators (e.g. problem-focused coping), leaving the mechanism behind this success unknown. In a disheartening statement, a review of interventions for caregivers of patients with cancer concluded that “no intervention can be recommended for nursing practice as an evidence-based strategy to reduce strain and burden in caregivers” (Honea et al., 2008) One explanation for the ineffectiveness of earlier caregiver interventions is that these programs neglected the deteriorating health of caregivers’ loved ones (Hebert, Arnold, & Schulz, 2007). Cancer patients’ physical health (e.g. functional impairment, experience of pain) and quality of life have been found to predict caregiver burden, distress, depression, and quality of life (Miaskowski, Kragness, Dibble, & Wallhagen, 1997; Beach, Schulz, Yee, & Jackson, 2000; Fang, Manne, & Pape, 2001; Harding, Higginson, & Donaldson, 2003; Given et al., 2004). A meta-analysis showed that among couples in which one partner had cancer, each partner’s level of distress was significantly correlated (r = .29) and distress was not significantly different between partners (Hagedoorn, Sanderman, Bolks, Tuinstra, & Coyne, 2008). Additionally, a randomized controlled trial (RCT) of a caregiver intervention found that only a reduction in patient symptoms predicted decreases in caregiver depression (Kozachik et al., 2001). It was argued, therefore, that caregiver interventions will not be effective if the patient is suffering, and that patient-directed interventions might help caregivers indirectly by improving patient outcomes (Hebert et al., 2007). However, previous palliative care interventions for patients with cancer have failed to affect caregiver outcomes despite demonstrating improvements in patients’ quality of life (Clark et al., 2006). For example, a RCT of a psychoeducational intervention produced marked improvements in patient depression and symptom severity in the intervention condition but a non-significant trend that caregivers in the intervention showed higher depression scores than controls (Kurtz, Kurtz, Given, & Given, 2005). This finding indicates that certain interventions may inadvertently result in increased caregiver burden. Even a nursing intervention that increased longevity among patients with cancer only resulted in short-term benefits for caregiver stress and depression (Giarelli, Pisano, & McCorkle, 2000). The ENABLE II (Educate, Nurture, Advise Before Life Ends) palliative care intervention provided a prime opportunity to determine if an effective patient-directed intervention could alleviate caregiver burden. ENABLE II was designed to improve problem-solving skills, symptom management, and communication skills, as well as promote advance care planning (e.g., advanced directives and “do not resuscitate” orders) among patients with advanced cancer. Importantly, participants were recently diagnosed with cancer and the intervention occurred concurrently with cancer treatment, such as chemotherapy and radiation, in an effort to provide elements of palliative care to patients before death was imminent (Bakitas et al., 2009a). In this RCT, the intervention proved effective in improving patients’ quality of life, reducing symptom intensity, and lowering depressed mood compared to a usual care control condition in the 7 months following study enrollment (Bakitas et al., 2009b). Although the intervention did not directly involve caregivers, we hypothesized that the intervention would improve caregiver outcomes indirectly through improvements in patient outcomes (Hebert et al., 2007).

Introduction: Poverty, poor health infrastructure, and rurality contribute to lack of cancer screening for most residents of Honduras (HN). We hypothesized that if community-identified barriers were mitigated, rural Hondurans would participate in cancer screening; initial low-tech screening methods would be useful in identifying high-risk individuals in a large group; and that we could operationalize an acceptable and effective multiorgan screening program. Our objective was to test multiorgan cancer-screening strategies for challenging rural environments such as our site in rural El Rosario, Honduras and develop a strategy that would be generalizable to rural sites in other low-income countries. Methods: We conducted three cancer-screening projects (2013/n=449 women, 2016/n=389 women, 2017/n=299 men) by developing relationships with rural community leaders and Honduran oncologists. Together, we launched multiorgan screening events via a brigade-style medical outreach model designed to mitigate barriers to early detection of cancers. Key strategies: 1) a screening cascade system and low-tech methods to identify high-risk individuals for further screening; 2) triage for findings requiring additional workup, rather than focusing on making a definitive cancer diagnosis; 3) inserting cancer education into the participants' experience; and 4) multiorgan screening to maximize cancer prevention with little additional use of resources. Community-identified barriers were transportation, cost, fear, and inconvenience; we negotiated an array of minimalist and highly effective community-based strategies to mitigate the barriers. In 2013 and 2016 we screened women for cancers including cervix, breast, oropharynx, and thyroid, and in 2017 screened men for testicular, oropharynx, skin, prostate, and colon cancers. Post-study, participants with suspicious findings were connected with follow-up care at a cancer center in HN. On-site screening methods ranged from no-tech, including surveys, clinical breast exams, throat palpation for thyroid, digital rectal exam for prostate, physical exam of testes, and visual skin inspection for skin cancer; to mid-tech, including telepathology for oral cancer, fecal occult blood test for colon cancer, and PSA for prostate; and high-tech PCR screening for high-risk HPV (hrHPV). Well-trained HN medical students staffed the screening areas; their participation is intended to increase long-term screening capacity in HN. Community leaders were responsible for promoting the screening clinic by training teens who traveled to villages to introduce the opportunity. Results: Participants came via a free bus, horse, motorbike, and on foot from 31 (2013), 40 (2016), and 38 (2017) different communities. Median age and years of education were 38/5 (2013), 40/6 (2016), and 47/4 (2017). Almost every participant completed all screenings. We found 11 types of hrHPV; in 2013/8.4% and 2016/12.5% were positive for 1 or more types. Referrals for breast follow-up were 2013/2.7% and 2016/4.4%. In 2017 (men), 26 referrals were: skin screening/2; testicular exams/2; colon/2; oropharynx/0; and 20 men for clinical prostate follow-up by a screening cascade of survey, digital rectal exam, and PSA. 249 men self-identified based on ASCO colon standards and brought stool samples for FOBT/4 tested positive. We used oral consent and focus groups for post-event evaluation. Comments reflected satisfaction with the medical students, convenience of a free bus, and protection of participants' privacy. Conclusion: With community engagement and attention to planning for organized and rapid throughput, large-scale multiorgan cancer screening is feasible in low-income rural communities. Despite low expectation of male participation because it is “common knowledge” that Honduran males avoid clinics, our experience demonstrates that with mitigation of barriers, men will participate. Citation Format: Linda Skewes Kennedy, Kayla A. Marra, Ethan Phillip Marshall LaRochelle, Mary D. Chamberlin, Kathleen D. Lyons, Suyapa A. Bejarano, Gregory J. Tsongalis. Cancer screening in rural Honduras: Maximizing impact with a multiorgan screening approach [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B20.

Stem cell transplantation is an aggressive therapy for hematological malignancies in which a damaged immune system is essentially destroyed and replaced with healthy stem cells. This article reports the results of semi-structured interviews with 18 survivors of either autologous or allogeneic stem cell transplantation. Participants were interviewed after they had reached 100 days post-transplant and asked to discuss their activities, daily routines, and experiences since being discharged from the hospital. Activity engagement was mentioned by participants as a way to promote health, help reconnect one with his or her pre-transplant identity and lifestyle, and measure progress toward improved stamina. Although many participants reported a gradual resumption of previous routines, some participants described a more complicated process of reconstructing their daily routine in response to changes in their environment or career.

The Functional Assessment of Chronic Illness Therapy (FACIT) system provides a general, multidimensional measure of health-related quality of life (FACT-G) that can be augmented with disease or symptom-specific subscales. The 19-item palliative care subscale of the FACIT system has undergone little psychometric evaluation to date. The aim of this paper is to report the internal consistency, factor structure, and construct validity of the instrument using the palliative care subscale (FACIT-Pal). Two hundred fifty-six persons with advanced cancer in a randomized trial testing a palliative care psychoeducational intervention completed the 46-item FACIT-Pal at baseline. Internal consistency was greater than 0.74 for all subscales and the total score. Seventeen of the 19 palliative care subscale items loaded onto the four factor solution of the established core measure (FACT-G). As hypothesized, total scores were correlated with measures of symptom intensity (r = −0.73, P < 0.001) and depression (r = −0.75, P < 0.001). The FACIT-Pal was able to discriminate between participants who died within three months of completing the baseline and participants who lived for at least one year after completing the baseline assessment (t = −4.05, P