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This study examined the dynamic, real-time associations between partner involvement in diabetes self-care and continuous glucose monitor (CGM) metrics in adults with type 2 diabetes.For 1 week, 63 participants wore Dexcom G4 CGMs and provided momentary reports of partner involvement in diabetes self-care five times per day. Dynamic structural equation models were used to estimate the reciprocal lagged effects of partner involvement on next-hour CGM metrics (and vice versa).Partner involvement predicted improved next-hour glucose control for five of six CGM metrics in analyses adjusted for time-varying covariates. The hour after partner involvement, the model predicted a 26.34 mg/dl decrease in glucose level (standardized β = -0.19), 30% greater odds of meeting target time in target range ( β = 0.07), 48% higher odds of target time below target range (TBR; β = 0.04; the only nonsignificant effect), 47% greater odds of target time above target range (β = 0.11), a 4.20 unit decrease in glucose standard deviation ( β = -0.19), and a 0.01 unit decrease in glucose coefficient of variation ( β = -0.08; all p values.05). There was less consistent support for the reverse pathway, with only two metrics significantly related to next-hour partner involvement: glucose level ( β = 0.15) and TBR ( β = 0.21), such that having higher levels and meeting target TBR were significantly predictive of next-hour partner involvement.This is the first study showing that partner involvement in daily diabetes management predicts short-term glucose control. More research is needed to understand how partners influence glycemic control and evaluate interventions that promote their involvement in diabetes care.

Background Fear of cancer recurrence (FCR) and sleep disturbance are common in cancer survivors. Yet, little research has examined their relationship, and even less is known about what links may exist between these variables among the intimate partners of cancer survivors. Purpose This study examines the relationship between FCR and sleep disturbance in breast cancer survivors and their partners. Using daily sleep data collected at two distinct periods early in survivorship—the completion of adjuvant treatment and the first post-treatment mammogram—higher survivor and partner FCR was hypothesized to predict greater sleep disturbance. Methods Breast cancer survivors and intimate partners (N = 76 couples; 152 individuals) each reported sleep duration, sleep quality, sleep onset latency, and wake after sleep onset each morning of two 21-day sleep diary bursts during the first year post-diagnosis. Three validated measures formed latent FCR factors for survivors and partners, which were used to predict average daily sleep. Results Across both sleep diary bursts, survivor FCR was associated with their own reduced sleep duration, reduced sleep quality, and greater sleep onset latency. Survivor FCR was also associated with their partners’ reduced sleep quality and greater sleep onset latency. Partner FCR was associated with their own reduced sleep duration, reduced sleep quality, and greater sleep onset latency. Partner FCR was also associated with survivors’ reduced sleep quality. Conclusions Findings revealed intrapersonal and interpersonal associations between FCR and sleep disturbance, addressing gaps in knowledge on FCR and an outcome with known short- and long-term implications for health and mortality.

Although fear of cancer recurrence (FCR) has been conceptualized as a multidimensional construct with emotional and cognitive components, little work has distinguished or assessed both components. Further, most existing research has not included intimate partners of cancer patients, although they also experience FCR. This study aimed to (1) determine whether FCR is better conceptualized as a singular or multidimensional construct at the within-person level over time and (2) model the corresponding trajectories in patients and their partners.Female early stage breast cancer patients and their partners (N = 78 couples) completed up to five assessments over the first year post-diagnosis tapping both emotional and cognitive elements of FCR. Multilevel confirmatory factor analysis was used to evaluate FCR's factor structure, and multivariate latent growth curve modeling was used to estimate trajectories of emotional and cognitive FCR.FCR was best conceptualized as two distinct but related emotional and cognitive factors. In patients and partners, emotional FCR decreased over the first year post-diagnosis on average, while cognitive FCR did not change over time.Findings support the conceptualization of FCR as a multidimensional construct and underscore the potential importance of distinguishing emotional and cognitive components of FCR in future research.

Background:The NCI requires designated cancer centers to conduct catchment area assessments to guide cancer control and prevention efforts designed to reduce the local cancer burden. We extended and adapted this approach to a community cancer center catchment area with elevated rates of triple-negative breast cancer (TNBC).Methods:Cancer registry data for 462 TNBC and 2,987 “Not-TNBC” cases diagnosed between 2012 and 2020 at the Helen F. Graham Cancer Center & Research Institute (HFGCCRI), located in New Castle County, Delaware, were geocoded to detect areas of elevated risk (hot spots) and decreased risk (cold spots). Next, electronic health record (EHR) data on obesity and alcohol use disorder (AUD) and catchment area measures of fast-food and alcohol retailers were used to assess for spatial relationships between TNBC hot spots and potentially modifiable risk factors.Results:Two hot and two cold spots were identified for TNBC within the catchment area. The hot spots accounted for 11% of the catchment area but nearly a third of all TNBC cases. Higher rates of unhealthy alcohol use and obesity were observed within the hot spots.Conclusions:The use of spatial methods to analyze cancer registry and other secondary data sources can inform cancer control and prevention efforts within community cancer center catchment areas, where limited resources can preclude the collection of new primary data.Impact:Targeting community outreach and engagement activities to TNBC hot spots offers the potential to reduce the population-level burden of cancer efficiently and equitably.

Cigarette use remains the leading preventable cause of premature mortality in the US, with declines in smoking rates slowing in recent years. One promising target for improved tobacco control is the expanded regulation of tobacco retailers. Evaluations of such policy attempts have largely produced mixed results to date. The objective of this study was to the assess the potential of using a novel, residentially-focused zoning approach to produce a more targeted and equitable reduction in tobacco retailers in high-risk urban settings. We focused on Wilmington, Delaware, a city characterized by high poverty rates, a majority Black population, a disparate number of tobacco retailers, and an elevated smoking prevalence. Through the use of geospatial analyses, we observed disproportionately higher counts of convenience store tobacco retailers in medium- and high-density residential zones in Wilmington relative to the surrounding county. By linking electronic health record (EHR) data from a local health care system and US Census Bureau data, we further found that approximately 80% of Wilmington smokers and 60% of Wilmington youth lived in these residential zones. These findings highlight the potential to more equitably reduce tobacco retailer exposure through a residentially-focused zoning approach. Tobacco control policy and research implications are considered.

To highlight and recommend policies that can be projected to reduce disproportionate tobacco exposure for youth and adults in Wilmington, Delaware's densest and most disadvantaged neighborhoods. Four policy options were drawn from the literature: pharmacy tobacco bans, zoning-based tobacco retailer reductions, residential density caps, and buffers around K-12 schools.Changes in tobacco retailer density and resident-to-retailer distance in Wilmington's medium- and high- density residentially zoned neighborhoods were projected using GIS analysis of current conditions and projections for each of the four policies.Banning tobacco sales in pharmacies was found to be least effective, while 500-meter buffers around K-12 schools was projected to have the greatest impact on both retailer density and resident-to-retailer distance.As a result of these findings, the authors recommend a ban of tobacco sales with a 500-meter radius of all K-12 schools in the City of Wilmington.

Background Spouses often attempt to influence patients' diabetes self-care. Spousal influence has been linked to beneficial health outcomes in some studies, but to negative outcomes in others. Purpose We aimed to clarify the conditions under which spousal influence impedes glycemic control in patients with type 2 diabetes. Spousal influence was hypothesized to associate with poorer glycemic control among patients with high diabetes distress and low relationship quality. Methods Patients with type 2 diabetes and their spouses (N = 63 couples) completed self-report measures before patients initiated a 7-day period of continuous glucose monitoring. Mean glucose level and coefficient of variation (CV) were regressed on spousal influence, diabetes distress, relationship quality, and their two- and three-way interactions. Results The three-way interaction significantly predicted glucose variability, but not mean level. Results revealed a cross-over interaction between spousal influence and diabetes distress at high (but not low) levels of relationship quality, such that spousal influence was associated with less variability among patients with low distress, but more among those with high distress. Among patients with high distress and low relationship quality, a 1 SD increase in spousal influence predicted a difference roughly equivalent to the difference between the sample mean CV and a CV in the unstable glycemia range. Conclusions This was the first study to examine moderators of the link between spousal influence and glycemic control in diabetes. A large effect was found for glucose variability, but not mean levels. These novel results highlight the importance of intimate relationships in diabetes management.

Background Triple negative breast cancer (TNBC) is an aggressive subtype of invasive breast cancer that disproportionately affects Black women and contributes to racial disparities in breast cancer mortality. Prior research has suggested that neighborhood effects may contribute to this disparity beyond individual risk factors. Methods The sample included a cohort of 3316 breast cancer cases diagnosed between 2012 and 2020 in New Castle County, Delaware, a geographic region of the US with elevated rates of TNBC. Multilevel methods and geospatial mapping evaluated whether the race, income, and race/income versions of the neighborhood Index of Concentration at the Extremes (ICE) metric could efficiently identify census tracts (CT) with higher odds of TNBC relative to other forms of invasive breast cancer. Odds ratios (OR) and 95% confidence intervals (CI) were reported; p-values Results The ICE-Race, -Income-, and Race/Income metrics were each associated with greater census tract odds of TNBC on a bivariate basis. However, only ICE-Race was significantly associated with higher odds of TNBC after adjustment for patient-level age and race (most disadvantaged CT: OR = 2.09; 95% CI 1.40–3.13), providing support for neighborhood effects. Higher counts of alcohol and fast-food retailers, and correspondingly higher rates of unhealthy alcohol use and obesity, were observed in CTs that were classified into the most disadvantaged ICE-Race quintile and had the highest odds of TNBC. Conclusion The use of ICE can facilitate the monitoring of cancer inequities and advance the study of racial disparities in breast cancer.

Background: Triple negative breast cancer (TNBC) is an aggressive subtype of invasive breast cancer that disproportionately affects Black women and contributes to racial disparities in breast cancer mortality. Prior research has found evidence of a link between TNBC risk and neighborhood/area-level measures of disadvantage, including socioeconomic status and racial segregation. This study evaluated additional area-level exposures as potential mediators of the relationship between neighborhood disadvantage and TNBC risk in New Castle County, DE, a region with elevated rates of TNBC. Methods: The study population included 3,316 Black and White adult female residents of New Castle County who were diagnosed with invasive breast cancer at the Helen F. Graham Cancer Center & Research Institute (HFGCCRI) in Newark, DE from 2012-2020. Patient addresses were geocoded, and demographic and clinical measures were abstracted from the HFGCCRI cancer registry. Neighborhood and environmental exposure measures were generated from electronic health records (EHR), the US Census Bureau American Community Survey, and Environmental Protection Agency (EPA) Risk-Screening Environmental Indicator (RSEI) data; these measures were aggregated to the census tract and linked to patient geocodes. Included neighborhood exposure measures were factors that may influence patient-level exposure to well-known breast cancer risk factors, including alcohol use disorder (AUD) and diabetes prevalence, breastfeeding (assessed with the proxy measure ‘% single female-headed households with children’), and toxic environmental indicators (e.g., toxic release inventory sites). The relationships between these exposures and the odds of TNBC (relative to other subtypes of invasive breast cancer) were first evaluated on a univariate basis. Next, to estimate the relationship between cumulative exposure and TNBC odds, census tract risk scores were calculated by dichotomizing each exposure into low- and high-risk categories and summing the total of high-risk exposures. A multilevel logistic regression model was used to test the association between this risk score and TNBC odds while adjusting for patient-level age and race.Results: TNBC cases accounted for 14% (n = 453) of invasive breast cancer cases. Significantly higher odds of TNBC were observed for patients who reside in census tracts characterized by higher rates of AUD, diabetes, % single female-headed households with children, and RSEI scores. In the multilevel logistic regression model that adjusted for patient demographics, the cumulative exposure risk score was significantly associated with greater odds of TNBC. Conclusion: Results provide preliminary support for a link between TNBC odds and cumulative, area-level exposure to disordered alcohol use, metabolic disorders, lower breastfeeding rates, and toxic environmental indicators. Additional research evaluating the cumulative exposure risk score as a potentially modifiable mediator of the relationship between neighborhood disadvantage and TNBC risk will be presented. Citation Format: Scott D. Siegel, Madeline M. Brooks, Jesse D. Berman, Shannon M. Lynch, Jennifer Sims-Mourtada, Zachary T. Schug, Frank C. Curriero. Deconstructing the link between neighborhood disadvantage and triple negative breast cancer: Preliminary evidence in support of cumulative exposure to area-level risk factors [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr C095.

Introduction COVID-19 exemplifies the spatial nature of infectious disease in both its mechanism of transmission and the community-level conditions that facilitate its spread. With a long history of use for infectious disease applications, maps and geographic information systems (GIS) have been widely used in recent months for surveillance and risk prediction mapping. The Value Institute’s Geospatial Analytics Core applied spatial methodologies to inform ChristianaCare’s pandemic response around telehealth, testing disparities, and test site prioritization. Methods Descriptive data related to disparities in telehealth utilization were mapped to identify areas in which intervention is needed to increase telehealth access. Cluster detection methodology was used to identify “hot” and “cold” spots for COVID-19 testing by place and race across New Castle County, DE. A composite risk score was created to prioritize communities for testing sites. All analyses took place in Delaware from March-June 2020, with particular emphasis on New Castle County. Results Parts of northeastern New Castle County and western Sussex County were highlighted for intervention to increase broadband internet access for telehealth utilization. “Cold” spots for COVID-19 testing were found in New Castle County, indicating neighborhoods in which testing levels were significantly lower than expected. Data for testing levels, disease positivity, and socioeconomic risk factors were used to identify communities in northeastern New Castle County that warranted new test sites to mitigate disease spread. Public Health Implications Geospatial methodologies can be used to combine electronic health record data and population-level spatial data for pandemic response efforts. This allows health systems to confidently identify areas of need while mitigating disparities in resource allocation.

As a framework, population health emphasizes health outcomes for entire populations, the broad range of determinants of these outcomes, and the comparative effectiveness of medical and public health interventions. In practice, however, many contemporary population health programs instead focus on small subsets of patients who account for a disproportionate share of health care utilization, often with disappointing results. The authors proposed a new approach to operationalize population health in clinical settings, with the example of tobacco use. Electronic health record (EHR) data from a mid-Atlantic health system were used to: (1) define and describe a hospital-based population of current smokers, (2) analyze the demographic characteristics of the population to consider how the social context may impact treatment, and (3) join EHR data with public licensing data on tobacco retail locations to assess the relationship between the built environment and smoking status. Out of a total of 20,310 unique adult admissions to the health system, 3749 (18.5%) were current smokers. Compared to never smokers, current smokers were significantly younger, more likely to be male, more likely to be Black/African American, less likely to be Hispanic/Latino/a, and more likely to be on Medicaid or be self-pay. Current vs. former smokers had significantly higher exposure to tobacco retail locations, even after adjusting for demographic and other covariates. By defining populations around leading modifiable medical determinants of health, and accounting for the larger context of sociodemographic factors and the built environment, health systems can invest in comprehensive programs designed to produce the greatest population health returns.

Tobacco and alcohol use are leading causes of premature mortality in the US and concurrent use is associated with even greater health risks. A cross-sectional study of 20,310 patients admitted to a Mid-Atlantic acute health care system between July 1, 2018 and June 30, 2019 were categorized according to smoking and alcohol use disorder (AUD) status. Of the total admissions, 1,464 (7.2%) were current smokers with an AUD. These patients were younger (52.4 vs. 63.9), more likely to be male (64.1% vs. 38.0%) and covered by Medicaid (46.9% vs. 11.6%), and resided in proximity to higher counts of tobacco (10.3 vs. 4.72) and alcohol (2.24 vs. 1.14) retailers than never smokers without an AUD. Clinically, these patients had higher rates of other substance use disorders (60.4% vs. 6.1%), depression (64.6% vs. 34.8%), HIV/AIDS (3.3% vs. 0. 6%), and liver disease (40.7% vs. 13.2%) than never smokers without an AUD. Patients who concurrently smoke and have an AUD face unique and serious health risks. A multimorbidity framework can guide clinical and community-based interventions for individuals with concurrent psychiatric and chronic medical conditions, complex social needs, and adverse environmental exposures.

Background Fear of cancer recurrence (FCR) is a top ongoing concern of breast cancer (BC) survivors and thus the focus of recent intervention development. The Self-Regulation Model of FCR (Lee-Jones C, Humphris G, Dixon R, Hatcher MB. Fear of cancer recurrence–a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psychooncology. 1997;6:95–105.) states that everyday cancer-related events trigger FCR, which, in turn, leads to specific behavioral responses, including checking the body for signs or symptoms of cancer. Links between triggering events, FCR, and checking behavior have not yet been studied in the context of daily life or at the within-person level. Purpose The goal of this study was to examine whether FCR has a within-person link with daily checking behavior and whether FCR mediates the link between triggering events and checking behavior. Methods Seventy-two early-stage BC survivors completed daily diaries over a 21-day period approximately 5 months after BC surgery. FCR, checking behavior, and triggering events were assessed each evening. Results Multilevel modeling results indicated that FCR predicted greater odds of same-day, but not next-day, checking behavior. We found that daily FCR significantly mediated the same-day effect of triggering events on checking behavior. These average within-person effects varied substantially between patients and were not explained by momentary negative affect. Conclusions Findings support the within-person relationship between triggering events, FCR, and checking behavior posited by guiding theory, and can inform FCR intervention development.

Public health decision-makers need to consider geographic differences in rates of chronic disease risk factors and outcomes in order to focus intervention efforts on populations exhibiting the greatest burden of disease. Increasingly, public health agencies are using geographic information systems (GIS) to analyze area-based variations and identify geographic priority areas for health promoting interventions. The articles in this issue are descriptive studies presenting the geographic distribution of select chronic disease risk factors and outcomes among Delaware communities. These studies emerged from a collaboration between the Christiana Care Value Institute and the Jefferson College of Population Health. These studies show that the burden of chronic diseases is not distributed evenly among communities in Delaware. The results of these studies add to the evidence base about public health in Delaware, and should inform public health practitioners working to improve the health of Delaware communities.

The nicotine metabolite ratio (NMR), a genetically informed biomarker of rate of nicotine metabolism, has been validated as a tool to select the optimal treatment for individual smokers, thereby improving treatment outcomes. This review summarizes the evidence supporting the development of the NMR as a biomarker of individual differences in nicotine metabolism, the relationship between the NMR and smoking behavior, the clinical utility of using the NMR to personalize treatments for smoking cessation, and the potential mechanisms that underlie the relationship between NMR and smoking cessation. We conclude with a call for additional research necessary to determine the ultimate benefits of using the NMR to personalize treatments for smoking cessation. These future directions include measurement and other methodologic considerations, disseminating this approach to at-risk subpopulations, expanding the NMR to evaluate its efficacy in predicting treatment responses to e-cigarettes and other noncigarette forms of nicotine, and implementation science including cost-effectiveness analyses. See all articles in this Special Collection Honoring Paul F. Engstrom, MD, Champion of Cancer Prevention

Tobacco retail density and smoking prevalence remain elevated in marginalized communities, underscoring the need for strategies to address these place-based disparities. The spatial variation of smokers and tobacco retailers is often measured by aggregating them to area-level units (e.g., census tracts), but spatial statistical methods that use point-level data, such as spatial intensity and K-functions, can better describe their geographic patterns. We applied these methods to a case study in New Castle County, DE to characterize the cross-sectional spatial relationship between tobacco retailers and smokers, finding that current smokers experience greater tobacco retail exposure and clustering relative to former smokers. We discuss how analysis at different geographic scales can provide complementary insights for tobacco control policy.

Background Tobacco use disorder (TUD) rates are 2–3 times higher among people with serious mental illness (SMI) than the general population. Clinicians working in outpatient community mental health clinics are well positioned to provide TUD treatment to this group, but rates of treatment provision are very low. Understanding factors associated with the provision of TUD treatment by mental health clinicians is a priority. Methods This study used baseline data from an ongoing cluster-randomized clinical trial evaluating two approaches to training clinicians to increase TUD treatment. Following a psychometric assessment of our assessment tool, the Smoking Knowledge, Attitudes, and Practices (S-KAP) instrument, a new factor structure was evaluated utilizing confirmatory factor analysis. Structural equation modeling was then used to examine the associations between TUD treatment practices and clinician, setting, and patient characteristics in a sample of 182 mental health clinicians across 10 mental health clinics. Results Clinician but not setting or patient characteristics emerged as significant correlates of providing TUD treatment. Specifically, clinicians’ general ethical commitment to providing TUD services and perceptions of their skills in providing this type of care were associated with providing TUD treatment. In contrast, clinician perceptions of patient motivation, anticipated quit rates, or available setting resources were not significantly associated with providing TUD treatment. Conclusions Enhancing community mental health clinician TUD treatment skills and commitment to providing such services may reduce TUD rates among people with SMI. Future studies should evaluate interventions that target these factors.

BACKGROUND There has been little attention paid to the role of therapeutic processes in group therapy outcomes for cancer patients participating in group. The goal was to evaluate the contribution of 3 group processes-group climate (conflict, engagement, and avoidance) working alliance and therapeutic realizations-to the outcomes of 2 couple-focused approaches to group treatment. METHODS Three hundred and two women with early stage breast cancer and their partners were randomized to one of 2 conditions: an 8-session enhanced couple-focused group (ECG) intervention or a couples' support group participated. Couples completed measures of depressive symptoms and well-being before and 6 months after group. Group process measures were completed after sessions 4 and 8. RESULTS Support group participants (both patients and partners) perceived higher engagement and less avoidance than ECG participants. Conflict, working alliance, and therapeutic realizations did not differ. Group engagement, working alliance, and therapeutic realizations increased, and group conflict decreased over the course of both treatments. Greater conflict was associated with more posttreatment anxiety and lower well-being, and engagement was associated with higher posttreatment well-being. Patients whose partners reported higher conflict reported greater posttreatment anxiety. Working alliance was associated with posttreatment anxiety for ECG patients and with well-being among participants whose partners reported higher working alliance. CONCLUSIONS Fostering a positive group environment bolsters treatment efficacy for women with early stage breast cancer and their partners attending couple-focused groups. Facilitating the leader-member alliance bolsters treatment efficacy. Improving engagement with one member of a couple impacts the other member.

Objective The aims of this study were to evaluate the efficacy of the 2 types of couple-focused group interventions on couples' psychological and relationship functioning, and to examine possible moderators for each intervention. Method Three hundred and two women with early stage breast cancer who were recruited within 1 year of diagnosis and their spouses were randomly assigned to either an 8 session enhanced couple-focused group intervention (ECG) or a couples' support group (SG). Couples completed surveys at 4 time points: preintervention, 1 week postgroup, 6 months, and 1 year. Results Analyses indicated that anxiety, depressive symptoms, and cancer-specific distress declined and positive well-being improved for couples enrolled in both ECG and SG. Thus, neither treatment was superior in terms of reduction of distress or improvements in positive well-being. Moderator effects indicated that, among patients reporting higher levels of cancer-specific preintervention distress, anxiety, depression, and well-being over the 1-year postintervention time period were significantly lower among SG couples than ECG couples. When patient cancer-specific preintervention distress was low, these 3 outcomes were more positive in ECG relative to SG. A similar pattern with regard to anxiety was illustrated when the moderator effects for perceived partner unsupportive behavior was examined, and a similar pattern was seen for anxiety and well-being for preintervention marital satisfaction. Conclusions A couple-focused supportive group therapy may be more effective for distressed patients, whereas a structured, skills-based couples' group therapy may be more effective for less distressed patients. (PsycINFO Database Record

Background There is increasing recognition of the unique physical and psychosocial concerns of the growing population of cancer survivors. An emerging literature demonstrates that fear of cancer recurrence (FCR) is a problematic long-term and late effect for cancer survivors. In fact, FCR is a top concern, and this article provides a necessary synthesis of the extant research evidence and theory. Methods Literature searches were conducted using databases including MEDLINE and PsychINFO using specified search terms including ‘fear of recurrence’ and ‘worry about recurrence’. A comprehensive narrative review summarizes early empirical findings on FCR including current definitions, assessment tools, clinical presentations, quality of life impact, prevalence, trajectory and risk factors. This paper also critically reviews the relevant theoretical frameworks to best understand these findings and considers multiple psychosocial treatment models that may have relevance for addressing FCR in the clinical setting. Results There is evidence of substantial prevalence and quality of life impact of FCR. Several theories (e.g. self-regulation model of illness, a family-based model, uncertainty in illness theory, social-cognitive processing theory, terror management theory) directly or indirectly help conceptualize FCR and inform potential treatment options for those with clinically significant distress or impairment resulting from FCR. Conclusions Further investigation into FCR is warranted to promote evidence-based care for this significant cancer survivorship concern.

OBJECTIVES: Fear of cancer recurrence (FCR) is a top concern of breast cancer (BC) survivors and their spouses, yet little is known about responses to FCR triggers in daily life. We examined whether a biologically-based individual difference—threat sensitivity—predicted FCR in couples facing the first post-diagnosis mammogram (MMG). We hypothesized that threat sensitivity would predict greater FCR reactivity before the MMG and higher peak FCR on the MMG day, controlling for global anxiety. We also explored the link between threat sensitivity and FCR recovery after MMG. DESIGN AND SAMPLE: Fifty-seven early-stage BC patients and their spouses completed cross-sectional measures of threat sensitivity and global anxiety. Couples then reported daily FCR during a three-week diary period that began two weeks before the patient’s MMG appointment. METHODS: Multilevel actor-partner interdependence modeling was used to estimate within-person random slopes of FCR before (reactivity) and after (recovery) the MMG. Random intercepts captured individual differences in peak FCR on the MMG day. Patient and spouse threat sensitivity and anxiety were entered as predictors of reactivity, peak, and recovery. FINDINGS: FCR increased leading to MMG; however, inconsistent with hypotheses, this reactivity was not significantly predicted by threat sensitivity. Actor, but not partner, effects for peak FCR emerged, such that patients and spouses with greater threat sensitivity had greater FCR on the MMG day. FCR decreased after the MMG, and spouse, but not patient, threat sensitivity predicted slower recovery for both partners. CONCLUSIONS: Findings lend preliminary support for the role of threat sensitivity in the experience of FCR as couples confront threatening events in BC survivorship. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: MMGs can be a triggering event for couples. Threat sensitivity may help identify those who are likely to experience elevations in FCR during this stressful period.

Objective Patient and spouse/partner mutual self-disclosure is central for maintaining intimacy and cognitive processing when transitioning to life after cancer. Protective buffering inhibits self-disclosure and is defined as efforts to protect one's partner from upset and burden by hiding or denying cancer-related concerns. Intimacy and fear of cancer recurrence (FCR) are important determinants of individual and couple adaptation following cancer. Links between protective buffering and intimacy have not been examined in the context of daily life, and links with FCR have not been studied. We hypothesized that protective buffering is associated with decreased intimacy and increased FCR at a daily, within-person level. Methods Sixty-nine early-stage breast cancer (BC) survivors and their spouses completed electronic diaries for 21 consecutive days at the end of adjuvant treatment. Patients and spouses reported on daily protective buffering, intimacy, and FCR. Dyadic multilevel path modeling was used to estimate within-person effects. Patient and spouse protective buffering on one's own as well as one's partner's same-day intimacy and FCR were examined, controlling for previous levels of intimacy and FCR. Results Protective buffering was associated with decreased intimacy and increased FCR for the individual reporting buffering that same day. Patient and spouse protective buffering was also linked to decreased intimacy for her/his partner that same day. Moreover, patient protective buffering predicted increased spouse FCR that same day. Conclusions Findings supported a daily, within-person link between buffering, intimacy, and FCR, suggesting open disclosure of cancer-related concerns may be a relevant target for interventions for adaptation to BC.

Objective The purpose was to evaluate whether patient and spouse cancer-specific distress mediated the association between cancer severity and occupational functioning among employed spouses of women diagnosed with breast cancer. We examined whether sociodemographic characteristics, lower spouse-reported marital quality, and lower spouse self-rated health were associated with poorer spouse occupational functioning. Methods One hundred forty-three currently employed spouses of women diagnosed with breast cancer were administered measures of socioeconomic status, occupational functioning (work absenteeism, low productivity, and poor performance), cancer-specific distress, marital quality, and self-rated health. Patients completed measures of cancer-related distress and functional impairment and cancer stage were collected from medical charts. Results In the model evaluating work absenteeism, greater patient functional impairment was associated with more absenteeism, but there was no evidence of a mediating effect for either partners' cancer-specific distress. Higher cancer stage and more functional impairment were associated with higher spouse cancer-specific distress, which in turn predicted poorer work productivity. Patient cancer-specific distress did not mediate the association between patient functional impairment or cancer stage and spouse work productivity. Finally, higher cancer stage was associated with more spouse cancer-specific distress, which in turn predicted poorer work performance. There were no direct or indirect effects of the patient's functional impairment on spouse work performance. Conclusions Distressed spouses are more likely to have poorer work productivity after their partners' breast cancer diagnosis. These spouses may need assistance in managing their distress and the patient's functional impairment to ensure that their work productivity is not adversely affected. Copyright © 2015 John Wiley & Sons, Ltd.

Objective The core of fear of cancer recurrence (FCR)-a top concern of couples after successful breast cancer (BC) treatment-is fear of death. Daily relationship processes may be instrumental in regulating FCR as triggers of existential distress are encountered. We tested the hypothesis that daily capitalization, the process of sharing good news (capitalization attempts) to a partner perceived as responsive (responsiveness), buffers patient and spouse FCR as they confront the first mammogram post-diagnosis. Methods Fifty-seven early-stage BC survivors and their spouses reported daily FCR, capitalization, and positivity of the disclosed event during a 3-week diary period beginning 2 weeks before the first annual mammogram post-diagnosis. Dyadic multilevel path models estimated within-person effects of patient and spouse capitalization on same-day FCR, controlling for event positivity. Results Before the mammogram, capitalization attempts were unrelated to FCR, but for patients, responsiveness was predictive of greater same-day FCR. After the mammogram, for both partners, attempts were predictive of greater same-day FCR, yet responsiveness was predictive of lower FCR. Conclusions Findings were largely inconsistent with the hypothesis that capitalization buffers existential distress. However, results revealed novel insights about daily dyadic processes that may characterize within-person adaptation to existential threat. Potential explanations for the differential links between capitalization and FCR based on timing (before versus after threat) and capitalization component (attempts versus responsiveness) are discussed.

The purpose of this study was to determine whether fear of cancer recurrence (FCR) is associated with greater health care utilization (HCU) in early-stage breast cancer survivors. Three hundred early-stage breast cancer survivors diagnosed within the past 7 years reported on FCR as well as calls and visits to oncology providers and primary care providers during the preceding 3 months. Participants also reported on use of mental health services and psychotropic medications since diagnosis. Structural equation modeling was used to create a latent FCR factor and evaluate this factor as a predictor of various HCU outcomes controlling for age at diagnosis, years since diagnosis, generalized anxiety, objective risk of recurrence, and number of comorbidities. FCR predicted more visits to both oncology providers (RR = 1.53, p = .002) and primary care providers (RR = 1.31, p = .013), as well as more phone calls to oncology providers (RR = 2.08, p = .007). FCR was not a significant predictor of phone calls to primary care providers (RR = 1.39, p = .054), utilization of mental health treatment (OR = 1.27, p = .362), or use of psychotropic medications (OR = 1.37, p = .178). FCR was associated with increases in some types of HCU, which may reflect excessive medical reassurance-seeking and lead to unnecessary medical costs. FCR is a serious concern that warrants greater attention to reduce distress-related health care utilization. Utilization of mental health services to address FCR may represent higher-value health care.

If couples can maintain normalcy and quality in their relationship during the cancer experience, they may experience greater relational intimacy. Cancer-specific relationship awareness, which is an attitude defined as partners focusing on the relationship and thinking about how they might maintain normalcy and cope with cancer as a couple or “team”, is one factor that may help couples achieve this goal. The main aim of this study was to evaluate the associations between cancer-specific relationship awareness, cancer-specific communication (i.e., talking about cancer’s impact on the relationship, disclosure, and responsiveness to partner disclosure), and relationship intimacy and evaluate whether relationship communication mediated the association between relationship awareness and intimacy. In the current study, a total of 254 women diagnosed with early-stage breast cancer and their partners were recruited. Participants completed measures of cancer-specific relationship awareness, relationship talk, self- and perceived partner-disclosure, perceived partner responsiveness, and relationship intimacy. Results indicated that patients and spouses who were higher in cancer-specific relationship awareness engaged in more relationship talk, reported higher levels of self-disclosure, and perceived that their partner disclosed more. Their partners reported that they were more responsive to disclosures. Relationship talk and perceived partner responsiveness mediated the association between cancer-specific relationship awareness and intimacy. Helping couples consider ways they can maintain relationship normalcy and quality during the cancer experience and framing coping with cancer as a “team” effort may facilitate better communication and ultimately enhance relationship intimacy.

Women with breast cancer (BC) who perceive social constraints on their disclosure of cancer-related concerns are more likely to experience distress and have difficulty adjusting after diagnosis. Much of the existing research on psychosocial adjustment is cross-sectional in nature and an important area of concern that has received little attention is psychosexual adjustment to cancer surgery and treatment. This study examined whether perceived partner social constraints were associated with psychosexual adjustment over time in 108 BC survivors. Early-stage BC patients completed measures of partner social constraints, psychosexual adjustment, and relationship dissatisfaction approximately 1 month, 8 months, and 4 years after initial surgery. Latent growth curve modeling revealed partner social constraints to be a significant time-varying, within-person predictor of psychosexual adjustment at each time point after controlling for relationship dissatisfaction. BC surgery type, reconstructive surgery, cancer stage, chemotherapy, or antihormonal adjuvant treatment did not moderate this effect. Findings point to a long-term link between social constraints and psychosexual outcomes in BC patients and clinical implications for women coping with BC. (PsycINFO Database Record

Objective Although the Institute of Medicine provided a vision for effective psychosocial care for cancer survivors, limited guidance exists regarding the essential components of comprehensive care or progressive steps for implementing each component. This paper describes the development of a unique tool for assessing capacity to provide quality psychosocial care to cancer survivors and the results of the first implementation of this tool in community settings. Methods The psychosocial working group of the National Cancer Institute Community Cancer Centers Program (NCCCP) developed the Cancer Psychosocial Care Matrix assessment tool. All NCCCP sites (n = 30, enrolled in 2007 and 2010) completed the matrix indicating their capacity for providing psychosocial care at entry into NCCCP (‘baseline’) after 2 years of NCCCP participation (2007 sites only) and within the coming year (‘future aspirations’). Results At baseline, matrix responses reflected few or no systematic processes in place for most components of comprehensive psychosocial care. However, reported capacity to deliver specific components improved at 2 years post-NCCCP entry for the 2007 sites and in all NCCCP sites' future aspirations. Conclusions With growing demand on cancer centers to meet new metrics of quality care, the psychosocial matrix can help centers systematically identify and develop steps to address gap areas in their capacity to meet these new standards. The Cancer Psychosocial Care Matrix appears to enable evaluation of psychosocial programs, may promote intentions to improve psychosocial services, and can facilitate communication of ‘best practices’ among cancer centers. Copyright © 2013 John Wiley & Sons, Ltd.

Objective Recent work has identified intimacy as a potentially important determinant of psychological adjustment in couples coping with cancer. Little work has examined specific social support processes within the context of the everyday life of couples' cancer experience. Specifically, we examined the links between breast cancer patient reports of receiving support from one's spouse/partner (support receipt) and spouse reports of providing support to the patient (support provision) with daily intimacy outcomes. We hypothesized that both patient and spouse would benefit from support receipt and support provision. Method Forty-five women with early stage breast cancer and their spouses independently completed an Internet-based electronic diary assessing support receipt, support provision, and relationship intimacy for seven consecutive evenings shortly after surgery. Study outcomes consisted of daily relationship intimacy reported by each partner. Results As hypothesized, when controlling for patient report of support receipt, spouse report of support provision was uniquely associated with a significant additional increase in feelings of relationship intimacy for patients. Moreover, the independent effects of support receipt and support provision were also found to be beneficial for nonpatient spouses' daily feelings of intimacy. Conclusion Findings highlight the use of dyadic diary methods and corresponding modeling to uncover the unique benefits of support provision that may sometimes occur outside the awareness of the recipient. Results are discussed in terms of conceptualizing the cancer experience in a shared interpersonal context, whereby patients and their spouses can both benefit from support as they adjust to cancer together.

Prostate carcinoma (PC) is the most commonly diagnosed cancer in men. Treatments for localized PC are associated with side effects including sexual dysfunction, which has been linked to decrements in health-related quality of life and elevated distress levels. In this study, we examined the relationship between 2 personality traits, interpersonal sensitivity and lack of sociability, assessed by the Inventory of Interpersonal Problems (IIP; Pilkonis, Kim, Proietti, & Barkham, 1996) and recovery of sexual functioning in 121 men (M age = 60.6 years) recently treated with radical prostatectomy. Interpersonal sensitivity refers to the predisposition to perceive and elicit criticism and rejection from others; lack of sociability refers to chronic difficulties taking the initiative in interpersonal situations. After adjusting for relevant covariates, interpersonal sensitivity, but not sociability, was significantly associated with lower levels of sexual functioning. Patient-physician communication and partner perceived social support were explored as mediators of this relationship. Although interpersonal sensitivity was significantly associated with both poorer patient-physician communication and lower levels of partner support, the results did not support mediation. This study provides preliminary evidence that certain IIP-assessed interpersonal styles may complicate the recovery of sexual functioning after surgical treatment for PC.

There is increasing recognition of the unique physical and psychosocial concerns of the growing population of cancer survivors. An emerging literature demonstrates that fear of cancer recurrence (FCR) is a problematic long-term and late effect for cancer survivors. In fact, FCR is a top concern, and this article provides a necessary synthesis of the extant research evidence and theory.Literature searches were conducted using databases including MEDLINE and PsychINFO using specified search terms including 'fear of recurrence' and 'worry about recurrence'. A comprehensive narrative review summarizes early empirical findings on FCR including current definitions, assessment tools, clinical presentations, quality of life impact, prevalence, trajectory and risk factors. This paper also critically reviews the relevant theoretical frameworks to best understand these findings and considers multiple psychosocial treatment models that may have relevance for addressing FCR in the clinical setting.There is evidence of substantial prevalence and quality of life impact of FCR. Several theories (e.g. self-regulation model of illness, a family-based model, uncertainty in illness theory, social-cognitive processing theory, terror management theory) directly or indirectly help conceptualize FCR and inform potential treatment options for those with clinically significant distress or impairment resulting from FCR.Further investigation into FCR is warranted to promote evidence-based care for this significant cancer survivorship concern.

Stressors have a major influence upon mood, our sense of well-being, behavior, and health. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. However, if the threat is unremitting, particularly in older or unhealthy individuals, the long-term effects of stressors can damage health. The relationship between psychosocial stressors and disease is affected by the nature, number, and persistence of the stressors as well as by the individual's biological vulnerability (i.e., genetics, constitutional factors), psychosocial resources, and learned patterns of coping. Psychosocial interventions have proven useful for treating stress-related disorders and may influence the course of chronic diseases.

Objective This paper provides an introduction to latent growth curve (LGC) modeling, a modern method for analyzing data resulting from change processes such as cardiovascular recovery from stress. LGC models are superior to traditional approaches such as repeated measures analysis of variance and simple change scores. Methods The basic principles of LGC modeling are introduced and applied to data from 167 men and women whose systolic blood pressure was assessed before, during, and after the cold pressor and evaluated speech stressors and who had completed the Cook-Medley Hostility Inventory. Results The LGC models revealed that systolic blood pressure recovery follows a different nonlinear trajectory after speech relative to the cold pressor. The difference resulted not from the initial decline at the completion of the stressor, but from higher levels at the end of the stressor and slower rate of change in decline for the speech. Hostility predicted the trajectory for speech but not for cold pressor. This relationship did not differ as a function of gender, although men had larger systolic blood pressure responses than women to both stressors. Conclusions LGC modeling yields an understanding of the processes and predictors of change that is not attainable through traditional statistical methods. Although our application concerns cardiovascular recovery from stress, LGC modeling has many other potential applications in psychosomatic research.

Capitalization is the relational process of savoring positive life events by sharing them with responsive relationship partners. The purpose of the present study was to use dyadic intensive longitudinal methods to examine novel hypotheses regarding links between capitalization processes and daily intimacy and well-being in women with breast cancer and their intimate partners. Although couples coping with cancer often experience an increase in negative daily life events, we hypothesized that it would be important for them to share and capitalize on positive events in addition to sharing negative events. Female patients with early stage breast cancer and their intimate partners (99 couples) completed electronic daily diaries for 7 to 10 consecutive days tapping everyday processes of sharing negative and positive events with each other. Dyadic multilevel process modeling revealed that on days when capitalization attempts (i.e., sharing the best event of the day) occurred, daily feelings of intimacy in the sharer were higher for both patients and partners. Moreover, greater perceived partner responsiveness to capitalization attempts was associated with increases in the sharer's daily feelings of intimacy and decreases in the sharer's daily negative affect. When the patient's partner was the sharer, perceived partner responsiveness also was associated with increased daily positive affect. More important, all effects of capitalization were observed above and beyond the effects of event positivity and sharing negative events (i.e., social support attempts). Findings suggest that, even in the midst of significant life adversity, sharing daily good news with intimate partners enhances relationship well-being independently of sharing bad news.

This study examined associations between partner unsupportive behaviors, social and cognitive processing, and adaptation in patients and their spouses using a dyadic and interdependent analytic approach. Women with early stage breast cancer (N = 330) and their spouses completed measures of partner unsupportive behavior, maladaptive social (holding back sharing concerns) and cognitive processing (mental disengagement and behavioral disengagement), and global well-being and cancer distress. Results indicated that both individuals' reports of unsupportive partner behavior were associated with their own holding back and their partners' holding back. Similar actor and partner effects were found between unsupportive behavior and behavioral disengagement. However, both patients' and partners' mental disengagement were associated only with their own unsupportive behavior. Together, holding back, mental disengagement, and behavioral disengagement accounted for one third of the association between partner unsupportive behavior and well-being and one half of the association between partner unsupportive behavior and intrusive thoughts. These results suggest that couples' communication and processing of cancer should be viewed from a dyadic perspective because couples' perceptions of one another's unsupportive behaviors may have detrimental effects on both partners' social and cognitive processing as well as their adaptation.