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Objective: To determine the prevalence of clinical significance reporting in contemporary comparative effectiveness research (CER)., Background: In CER, a statistically significant difference between study groups may or may not be clinically significant. Misinterpreting statistically significant results could lead to inappropriate recommendations that increase health care costs and treatment toxicity., Methods: CER studies from 2022 issues of the Annals of Surgery , Journal of the American Medical Association , Journal of Clinical Oncology , Journal of Surgical Research , and Journal of the American College of Surgeons were systematically reviewed by 2 different investigators. The primary outcome of interest was whether the authors specified what they considered to be a clinically significant difference in the "Methods.", Results: Of 307 reviewed studies, 162 were clinical trials and 145 were observational studies. Authors specified what they considered to be a clinically significant difference in 26 studies (8.5%). Clinical significance was defined using clinically validated standards in 25 studies and subjectively in 1 study. Seven studies (2.3%) recommended a change in clinical decision-making, all with primary outcomes achieving statistical significance. Five (71.4%) of these studies did not have clinical significance defined in their methods. In randomized controlled trials with statistically significant results, sample size was inversely correlated with effect size ( r = -0.30, P = 0.038)., Conclusions: In contemporary CER, most authors do not specify what they consider to be a clinically significant difference in study outcome. Most studies recommending a change in clinical decision-making did so based on statistical significance alone, and clinical significance was usually defined with clinically validated standards., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Cancer "curvivors" (completed initial curative intent treatment with surgery, radiation, chemotherapy, and/or other novel therapies) and "metavivors" (living with metastatic or chronic, incurable cancer) experience unique stressors, but it remains unknown whether these differences impact benefits from mind-body interventions. This study explored differences between curvivors and metavivors in distress (depression, anxiety, worry) and resiliency changes over the course of an 8-week group program, based in mind-body stress reduction, cognitive-behavioral therapy (CBT), and positive psychology., Methods: From 2017-2021, 192 cancer survivors (83% curvivors; 17% metavivors) completed optional online surveys of resiliency (CES) and distress (PHQ-8, GAD-7, PSWQ-3) pre- and post- participation in an established clinical program. Mixed effect regression models explored curvivor-metavivor differences at baseline and in pre-post change., Results: Compared to curvivors, metavivors began the program with significantly more resilient health behaviors (B = 0.99, 95% CI[0.12, 1.86], p = .03) and less depression (B = -2.42, 95%CI[-4.73, -0.12], p = .04), with no other significant differences. Curvivors experienced significantly greater reductions in depression (curvivor-metavivor difference in strength of change = 2.12, 95% CI [0.39, 3.83], p = .02) over the course of the program, with no other significant differences. Neither virtual delivery modality nor proportion of sessions attended significantly moderated strength of resiliency or distress change., Conclusion: Metavivors entering this mind-body program had relatively higher well-being than did curvivors, and both groups experienced statistically comparable change in all domains other than depression. Resiliency programming may thus benefit a variety of cancer survivors, including those living with incurable cancer., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Medication adherence is critical for optimal health outcomes in patients with hematologic malignancies who have undergone allogeneic hematopoietic stem cell transplants (HSCT). However, this population struggles with medication nonadherence. Research that comprehensively describes the complex patient- and medication-related factors which impact medication adherence in this population is lacking. Hence, we used semistructured qualitative interviews to explore the diverse and complex factors contributing to medication adherence in HSCT recipients. We conducted 30 in-depth interviews with patients who were more than 180 days post-allogeneic HSCT at the Dana-Farber Cancer Institute. The interviews explored the physical, social, psychological, and sociodemographic factors that facilitate or discourage adherence to the post-transplantation medication regimen. Interviews were audio-recorded, transcribed, and coded using NVivo software. Two themes emerged that characterized the barriers patients face with their medication regimen. Patients reported factors outside of their control, such as managing multiple pharmacies, health insurance difficulties, and dosage timing, as significant barriers to medication adherence. Patients also reported barriers within their control, such as familial responsibilities. Important facilitators for medication adherence included caregiver and clinician support, previous experience managing a medication regimen, and tools that aid pill organization and timing. Furthermore, patients reported that although medication side effects and quantity of pills did not directly impact medication adherence, it increased their psychological distress. Facilitators and barriers to medication adherence can be physical, psychological, organizational, and social. There are many aspects of medication regimens that significantly increase patient distress. Hence, supportive interventions to improve medication adherence in patients undergoing HSCT may need to incorporate strategies to manage medication side effects and skills to improve psychological well-being and social support., (Copyright © 2023 The American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc. All rights reserved.)

Background: Although patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) experience low levels of positive psychological well-being (PPWB), interventions that specifically boost PPWB in this population are lacking., Objective: To describe the methods of a randomized controlled trial (RCT) designed to assess the feasibility, acceptability, and preliminary efficacy of a positive psychology intervention (PATH) tailored to the unique needs of HSCT survivors and aimed to decrease anxiety and depression symptoms and boost quality of life (QOL)., Methods: We will conduct a single-institution RCT of a novel nine-week phone-delivered manualized positive psychology intervention compared to usual transplant care in 70 HSCT survivors. Allogeneic HSCT survivors at 100 days post-HSCT are eligible for the study. The PATH intervention, tailored to the needs of HSCT survivors in the acute recovery phase, focuses on gratitude, strengths, and meaning. Our primary aims are to determine feasibility (e.g., session completion, rate of recruitment) and acceptability (e.g., weekly session ratings). Our secondary aim is to test the preliminary efficacy of the intervention on patient-reported outcomes (e.g., anxiety symptoms, QOL)., Discussion: If the PATH intervention is feasible, a larger randomized, controlled efficacy trial will be indicated. Additionally, we anticipate that the results from this RCT will guide the development of other clinical trials and larger efficacy studies of positive psychology interventions in vulnerable oncological populations beyond HSCT., Competing Interests: Declaration of Competing Interest HSLJ reports consulting to SBR Bioscience and grant funding from Kite Pharma. All other authors report no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Although most patients with cancer prefer to know their prognosis, prognostic communication between oncologists and patients is often insufficient. Targeted therapies for lung cancer improve survival yet are not curative and produce variable responses. This study sought to describe how oncologists communicate about prognosis with patients receiving targeted therapies for lung cancer., Methods: This qualitative study included 39 patients with advanced lung cancer with targetable mutations, 14 caregivers, and 10 oncologists. Semistructured interviews with patients and caregivers and focus groups or interviews with oncologists were conducted to explore their experiences with prognostic communication. One oncology follow-up visit was audio-recorded per patient. A framework approach was used to analyze interview transcripts, and a content analysis of patient-oncologist dialogue was conducted. Themes were identified within each source and then integrated across sources to create a multidimensional description of prognostic communication., Results: Six themes in prognostic communication were identified: Patients with targetable mutations develop a distinct identity in the lung cancer community that affects their information-seeking and self-advocacy; oncologists set high expectations for targeted therapy; the uncertain availability of new therapies complicates prognostic discussions; patients and caregivers have variable information preferences; patients raise questions about progression by asking about physical symptoms or scan results; and patients' expectations of targeted therapy influence their medical decision-making., Conclusions: Optimistic patient-oncologist communication shapes the expectations of patients receiving targeted therapy for lung cancer and affects their decision-making. Further research and clinical guidance are needed to help oncologists to communicate uncertain outcomes effectively., (© 2022 American Cancer Society.)

This is the seventh entry in the Psychological Elements of Palliative Care (PEPC) series. Previous articles have focused on the psychological elements of the care we provide patients and the relationships we build with our referring clinician colleagues. In this entry, we focus on how the PEPC also impact clinician well being. The PEPC are bidirectional: we impact patients, but patients also impact us. The reactions that we have to patients and the boundaries we set around the care we provide are two examples of psychological factors of care that can influence our well being. Creating spaces to explore and reflect on the psychological impact of the clinical care we provide is a key component of wellness. Such spaces vary in their configuration, but all share the opportunity to self-reflect and to experience emotional validation, normalization, and reality testing from peers or mentors. In mental health training, clinical supervision is one common format for creating such a space. While this can be replicated in the palliative care setting, other strategies include integrating a psychological orientation into interdisciplinary team meetings, creating peer support or process groups, and creating small groups within teams for longitudinal self-reflection.

Background: Healthcare policies have focused on centralizing care to high-volume centers in an effort to optimize patient outcomes; however, little is known about patients' and caregivers' considerations and selection process when selecting hospitals for care. We aim to explore how patients and caregivers select hospitals for complex cancer care and to develop a taxonomy for their selection considerations., Methods: This was a qualitative study in which data were gathered from in-depth interviews conducted from March to November 2019 among patients with hepatopancreatobiliary cancers who were scheduled to undergo a pancreatectomy (n = 20) at a metropolitan, urban regional, or suburban medical center and their caregivers (n = 10)., Results: The interviews revealed six broad domains that characterized hospital selection considerations: hospital factors, team characteristics, travel distance to hospital, referral or recommendation, continuity of care, and insurance considerations. The identified domains were similar between participants seen at the metropolitan center and urban/suburban medical centers, with the following exceptions: participants receiving care specifically at the metropolitan center noted operative volume and access to specific services such as clinical trials in their hospital selection; participants receiving care at urban/suburban centers noted health insurance considerations and having access to existing medical records in their hospital selection., Conclusions: This study delineates the many considerations of patients and caregivers when selecting hospitals for complex cancer care. These identified domains should be incorporated into the development and implementation of centralization policies to help increase patient access to high-quality cancer care that is consistent with their priorities and needs.

Objective: This study simulates the regionalization of pancreatectomies to assess its impact on spatial access in terms of patient driving times., Background: Although policies to regionalize complex procedures to high-volume centers may improve outcomes, the impact on patient access is unknown., Methods: Patients who underwent pancreatectomies from 2005 to 2014 were identified from California's statewide database. Round-trip driving times between patients' home ZIP code and hospital addresses were calculated via Google Maps. Regionalization was simulated by eliminating hospitals performing <20 pancreatectomies/yr, and reassigning patients to the next closest hospital that satisfied the volume threshold. Sensitivity analyses were performed for New York and Medicare patients to assess for influence of geography and insurance coverage, respectively., Results: Of 13,317 pancreatectomies, 6335 (47.6%) were performed by hospitals with <20 cases/yr. Patients traveled a median of 49.8 minutes [interquartile range (IQR) 30.8-96.2] per round-trip. A volume-restriction policy would increase median round-trip driving time by 24.1 minutes (IQR 4.5-53.5). Population in-hospital mortality rates were estimated to decrease from 6.7% to 2.8% (P < 0.001). Affected patients were more likely to be racial minorities (44.6% vs 36.5% of unaffected group, P < 0.001) and covered by Medicaid or uninsured (16.3% vs 9.8% of unaffected group, P < 0.001). Sensitivity analyses revealed a 17.8 minutes increment for patients in NY (IQR 0.8-47.4), and 27.0 minutes increment for Medicare patients (IQR 6.2-57.1)., Conclusions: A policy that limits access to low-volume pancreatectomy hospitals will increase round-trip driving time by 24 minutes, but up to 54 minutes for 25% of patients. Population mortality rates may improve by 1.5%., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patients with acute myeloid leukemia (AML) receiving intensive chemotherapy face a life-threatening illness, isolating hospitalization, and substantial physical and psychological symptoms. However, data are limited regarding risk factors of posttraumatic stress disorder (PTSD) symptoms in this population., Methods: The authors conducted a secondary analysis of data from 160 patients with high-risk AML who were enrolled in a supportive care trial. The PTSD Checklist-Civilian Version was used to assess PTSD symptoms at 1 month after AML diagnosis. The Brief COPE and the Functional Assessment of Cancer Therapy-Leukemia were to assess coping and quality of life (QOL), respectively. In addition, multivariate regression models were constructed to assess the relation between PTSD symptoms and baseline sociodemographic factors, coping, and QOL., Results: Twenty-eight percent of patients reported PTSD symptoms, describing high rates of intrusion, avoidance, and hypervigiliance. Baseline sociodemographic factors significantly associated with PTSD symptoms were age (B = -0.26; P = .002), race (B = -8.78; P = .004), and postgraduate education (B = -6.30; P = .029). Higher baseline QOL (B = -0.37; P ≤ .001) and less decline in QOL during hospitalization (B = -0.05; P = .224) were associated with fewer PTSD symptoms. Approach-oriented coping (B = -0.92; P = .001) was associated with fewer PTSD symptoms, whereas avoidant coping (B = 2.42; P ≤ .001) was associated with higher PTSD symptoms., Conclusions: A substantial proportion of patients with AML report clinically significant PTSD symptoms 1 month after initiating intensive chemotherapy. Patients' baseline QOL, coping strategies, and extent of QOL decline during hospitalization emerge as important risk factors for PTSD, underscoring the need for supportive oncology interventions to reduce the risk of PTSD in this population., (© 2021 American Cancer Society.)

Purpose: Molecularly targeted therapies have revolutionized non-small cell lung cancer (NSCLC) treatment. Many patients with metastatic NSCLC receiving targeted therapy may live several years with incurable cancer. We sought to describe how these metastatic cancer survivors and their caregivers experience uncertainty about the future and identify their unmet supportive care needs., Methods: We conducted semi-structured interviews with patients with metastatic NSCLC receiving targeted therapy (n = 39) and their caregivers (n = 16). We used a framework approach to code and analyze the qualitative data., Results: Metastatic lung cancer survivors described awareness of their mortality and the possibility that their cancer could progress at any time. Though some found ways to cope, many felt inadequately supported to manage their distress, especially since they were "doing fine medically." Survivors struggled with decisions about working and managing their finances given their uncertain life expectancy and sought trustworthy lung cancer information in plain language. They wished to compare experiences with other patients with their molecular subtype of NSCLC. Participants desired comprehensive cancer care that includes psychosocial support, preparation for the future, and ways to promote their own health, such as through lifestyle changes., Conclusions: Patients with metastatic NSCLC receiving targeted therapy and their caregivers experience distress related to living with uncertainty and desire more coping support, connection with peers, information, and healthy lifestyle guidance., Implications for Cancer Survivors: Patients living with treatable yet incurable cancer and their caregivers are a growing population of cancer survivors. Recognition of their unmet needs may inform the development of tailored support services to help them live well with cancer.

Objectives: Asynchronous virtual learning communities provide learners with the ability to enhance their learning and contribute to their peers' learning in a safe environment. However, the tone and content of learner comments, the level of engagement among learners, and the role of moderators have not been well studied within non-course-related virtual learning communities. Therefore, we sought to explore these characteristics using the NEJM Knowledge+ Question of the Week (NEJM Knowledge+ QoW) forum, a web-based asynchronous virtual learning community. Methods: We reviewed 73 NEJM Knowledge+ questions posted on the QoW forum between 2015 and 2016. We then selected three QoWs to analyze through a multistep coding process based on three broad criteria that aligned with our study aims. Results: Learner comments reflected both positive and critical tones, with learners sharing their own clinical practice and local experiences to contextualize their perspectives and reactions to both the QoW answer and the responses of other learners. Learners also commonly requested moderators to act as expert referees. Conclusion: Asynchronous virtual learning communities can engage learners by providing the opportunity to enhance their knowledge through responding to proposed medical scenarios and sharing their experiences in a discussion forum. Future work should examine the impact that geographic region has on asynchronous virtual learning communities and the role of moderators in shaping the learning experience.

Background: Little is known about the process by which inpatient teams document and convey goals of care (GOC) for critically ill surgical patients. We sought to explore clinician perspectives on the barriers and facilitators to clinician-to-clinician communication and delivery of goal-concordant patient care., Methods: Purposive and snowball sampling were used to recruit a multidisciplinary sample of clinicians who held roles in a surgical intensive care unit at a single tertiary care facility. Semistructured interviews with clinicians were conducted between September and December 2017 to assess clinician experiences with communicating and honoring patient GOC. Two independent coders performed qualitative coding in an iterative fashion using a framework approach. Inter-rater agreement was measured by kappa coefficient., Results: Thirty-three clinicians from multiple disciplines including surgery, anesthesiology, nursing, and social work, were interviewed. Analysis revealed that clinicians in all disciplines felt responsible for honoring patient GOC. Conflicts over patient GOC and how to honor them arose between clinicians with longitudinal patient relationships (preoperative and postoperative) and those with single-phase relationships (postoperative). Barriers to clinician-to-clinician communication and delivery of goal-concordant care included inaccessible records, lack of protocols, and difficulty in documenting complex conversations. Facilitators included recognition of a patient's unique treatment priorities and family members with a unified understanding of a patient's GOC., Conclusions: Differences in the clinician-patient relationships and difficulty accessing information about patient preferences contribute to clinician conflicts and concerns with the goal concordance of patient care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Patients with cancer often prefer to avoid time in the hospital; however, data are lacking on the prevalence and predictors of potentially avoidable readmissions (PARs) among those with advanced cancer., Methods: We enrolled patients with advanced cancer from September 2, 2014, to November 21, 2014, who had an unplanned hospitalization and assessed their patient-reported symptom burden (Edmonton Symptom Assessment System) at the time of admission. For 1 year after enrollment, we reviewed patients' health records to determine the primary reason for every hospital readmission and we classified readmissions as PARs using adapted Graham's criteria. We examined predictors of PARs using nonlinear mixed-effects models with binomial distribution., Results: We enrolled 200 (86.2%) of 232 patients who were approached. For these 200 patients, we reviewed 277 total hospital readmissions and identified 108 (39.0%) of these as PARs. The most common reasons for PARs were premature discharge from a prior hospitalization (30.6%) and failure of timely follow-up (28.7%). PAR hospitalizations were more likely than non-PAR hospitalizations to experience symptoms as the primary reason for admission (28.7% v 13.0%; P = .001). We found that married patients were less likely to experience PARs (odds ratio, 0.30; 95% CI, 0.15 to 0.57; P < .001) and that those with a higher physical symptom burden were more likely to experience PARs (odds ratio, 1.03; 95% CI, 1.01 to 1.05; P = .012)., Conclusion: We observed that a substantial proportion of hospital readmissions are potentially avoidable and found that patients' symptom burdens predict PARs. These findings underscore the need to assess and address the symptom burden of hospitalized patients with advanced cancer in this highly symptomatic population.

Positive psychological constructs (eg, optimism, positive affect) have been independently associated with superior health outcomes across many medical populations. However, there has been little synthesis of the literature examining these associations among patients with hematologic malignancies receiving hematopoietic stem cell transplantation (HSCT). To address this gap we completed a systematic review, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, of studies examining relationships between positive psychological constructs and health-related outcomes (eg, psychiatric symptoms, function, health-related quality of life [HRQoL], or treatment compliance) after HSCT. Eighteen eligible studies (N = 4201; 47% women; mean age, 47.1) were identified. Optimism (n = 12 studies) was the most frequently studied positive construct and HRQoL (examined in n = 11 studies) the most common outcome. All 17 studies with quantitative analyses found a significant (P < .05) association between a positive psychological construct and a health outcome; most but not all controlled for 1 or more relevant covariates. Among patients with hematologic malignancies who receive HSCT, positive psychological constructs appear to be associated with improved HRQoL and other health outcomes. Further work is warranted to more comprehensively understand the independent effects of positive psychological constructs on a variety of health outcomes and to develop interventions to promote well-being that are adapted to the needs of this population., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: ASCO recommends early involvement of palliative care for patients with advanced cancers on the basis of evidence from 18 randomized trials. We examined racial and ethnic minority representation in these trials and the role of race and ethnicity in the statistical analyses. The goal was to identify specific gaps in the palliative care evidence base for these individuals and potential strategies to address them., Methods: We reviewed the 18 trials cited in the 2012 and 2017 ASCO clinical statements on integrating palliative care into oncology. We extracted data on the reporting and categorization of race and ethnicity, on the enrollment of specific racial and ethnic minority groups, and on how race and ethnicity were addressed in the analyses., Results: One third of patient trials reported representation of specific racial and ethnic minority groups, one third reported rates of "white" versus "other," and one third did not report race or ethnicity data. Among the patient trials with race and ethnicity data, 9.9% of participants were Asian, 8.8% Hispanic/Latino, and 5.7% African American. Analyses that used race and ethnicity were primarily baseline comparisons among randomized groups., Conclusion: Race and ethnicity were inconsistently reported in the trials. Among those that provided race and ethnicity data, representation of specific racial and ethnic minority groups was low. In addition to more research in centers with large minority populations, consistent reporting of race and ethnicity and supplementary data collection from minority patients who participate in trials may be strategies for improvement.

Purpose Patients with advanced cancer experience potentially burdensome transitions of care after hospitalizations. We examined predictors of discharge location and assessed the relationship between discharge location and survival in this population. Methods We conducted a prospective study of 932 patients with advanced cancer who experienced an unplanned hospitalization between September 2014 and March 2016. Upon admission, we assessed patients' physical symptoms (Edmonton Symptom Assessment System) and psychological distress (Patient Health Questionnaire-4). The primary outcome was discharge location (home without hospice, postacute care [PAC], or hospice [any setting]). The secondary outcome was survival. Results Of 932 patients, 726 (77.9%) were discharged home without hospice, 118 (12.7%) were discharged to PAC, and 88 (9.4%) to hospice. Those discharged to PAC and hospice reported high rates of severe symptoms, including dyspnea, constipation, low appetite, fatigue, depression, and anxiety. Using logistic regression, patients discharged to PAC or hospice versus home without hospice were more likely to be older (odds ratio [OR], 1.03; 95% CI, 1.02 to 1.05; P < .001), live alone (OR, 1.95; 95% CI, 1.25 to 3.02; P < .003), have impaired mobility (OR, 5.08; 95% CI, 3.46 to 7.45; P < .001), longer hospital stays (OR, 1.15; 95% CI, 1.11 to 1.20; P < .001), higher Edmonton Symptom Assessment System physical symptoms (OR, 1.02; 95% CI, 1.003 to 1.032; P < .017), and higher Patient Health Questionnaire-4 depression symptoms (OR, 1.13; 95% CI, 1.01 to 1.25; P < .027). Patients discharged to hospice rather than PAC were more likely to receive palliative care consultation (OR, 4.44; 95% CI, 2.12 to 9.29; P < .001) and have shorter hospital stays (OR, 0.84; 95% CI, 0.77 to 0.91; P < .001). Patients discharged to PAC versus home had lower survival (hazard ratio, 1.53; 95% CI, 1.22 to 1.93; P < .001). Conclusion Patients with advanced cancer who were discharged to PAC facilities and hospice had substantial physical and psychological symptom burden, impaired physical function, and inferior survival compared with those discharged to home. These patients may benefit from interventions to enhance their quality of life and care.

Background: Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown., Methods: We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes that led to code status order transitions from full code to DNR., Results: In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of "presumed full." In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of "presumed full" at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005)., Conclusions: One-half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895-902. © 2017 American Cancer Society., (© 2017 American Cancer Society.)

Background: Current national cancer screening recommendations include the potential risk of psychological harm related to screening. However, data on the relation of psychological distress to cancer screening is limited. The authors conducted a systematic review to assess psychological distress associated with cancer screening procedures., Methods: Studies that administered measures of psychological distress between 2 weeks before and 1 month after the screening procedure were included., Results: In total, 22 eligible studies met criteria for review, including 13 observational trials and 9 randomized controlled trials. Eligible studies used a broad range of validated and unvalidated measures. Anxiety was the most commonly assessed construct and was measured using the State Trait Anxiety Inventory. Studies included breast, colorectal, prostate, lung, and cervical screening procedures. Distress was low across procedures, with the exception of colorectal screening. Distress did not vary according to the time at which distress was measured. None of the studies were conducted exclusively with the intention of assessing distress at the time of screening., Conclusions: Evidence of low distress during the time of cancer screening suggests that distress might not be a widespread barrier to screening among adults who undergo screening. However, more studies are needed using validated measures of distress to further understand the extent to which screening may elicit psychological distress and impede adherence to national screening recommendations. Cancer 2017;123:3882-94. © 2017 American Cancer Society., (© 2017 American Cancer Society.)

Objective: Our aim was to assess quality of life (QOL) and functionality in a large cohort of patients ≥5-years after pancreaticoduodenectomy (PD)., Background: Long-term QOL outcomes after PD for benign or malignant disease are largely undocumented., Methods: We administered the EORTC QLQ-C30 questionnaire to patients who underwent PD for neoplasms from 1998 to 2011 and compared their scores with an age- and sex-matched normal population. Clinical relevance (CR) of differences was scored as small (5-10), moderate (10-20), or large (>20) based on validated interpretation of clinically important differences., Results: Of 305 PD survivors, 245 (80.3%) responded, of whom 157 (64.1%) underwent PD for nonmalignant lesions. Median follow-up was 9.1 years (range 5.1 -21.2 yrs). New-onset diabetes developed in 10.6%; 50.4% reported taking pancreatic enzymes; 54.6% reported needing antacids. Compared with the age- and sex-adjusted controls, PD survivors demonstrated higher global QOL (78.7 vs 69.7, CR small, P < 0.001), physical (86.7 vs 77.9, CR small, P < 0.001) and role-functioning scores (86.3 vs 74.1, CR medium, P < 0.001). Using linear regression and adjusting for socioeconomic variables, there were no differences in QOL or functional scores in the benign versus malignant subgroups. Older age at operation was associated with worse physical-functioning (-0.4/yr, P = 0.008). Taking pancrelipase (-6.8, P = 0.035) or antacids (-6.3, P = 0.044) were both associated with lower social-functioning scores., Conclusions: Patients who had a PD demonstrated better global QOL, physical- and role-functioning scores at 5-years when compared with age- and sex-matched controls. Approximately half of the patients required pancreatic enzyme replacement, while only 11% developed new-onset diabetes.

Background: A minimum-volume policy restricting hospitals not meeting the threshold from performing complex operation may increase travel burden and decrease spatial access to operation. We aim to identify vulnerable populations that would be sensitive to an added travel burden., Methods: We performed a retrospective analysis of the database of the California Office of Statewide Health Planning and Development for patients undergoing pancreatectomy from 2005 to 2014. Number of hospitals bypassed was used as a metric for travel. Patients bypassing fewer hospitals were deemed to be more sensitive to an added travel burden., Results: There were 13,374 patients who underwent a pancreatectomy, of whom 2,368 (17.7%) were nonbypassers. On unadjusted analysis, patients >80 year old travelled less than their younger counterparts, bypassing a mean of 10.9 ± 9.5 hospitals compared with 14.2 ± 21.3 hospitals bypassed by the 35-49 year old age group (P < .001). Racial minorities travelled less when compared with non-Hispanic whites (P < .001). Patients identifying their payer status as self-pay (8.9 ± 15.6 hospitals bypassed) and Medicaid (10.1 ± 17.2 hospitals bypassed) also travelled less when compared with patients with private insurance (13.8 ± 20.4 hospitals bypassed, P < .001). On multivariate analysis, advanced age, racial minority, and patients with self-pay or Medicaid payer status were associated independently with increased sensitivity to an added travel burden., Conclusion: In patients undergoing pancreatectomy, the elderly, racial minorities, and patients with self-pay or Medicaid payer status were associated with an increased sensitivity to an added travel burden. This vulnerable cohort may be affected disproportionately by a minimum-volume policy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: During hospitalization for hematopoietic stem cell transplantation (HCT), patients experience a steep deterioration in quality of life (QOL) and mood. To our knowledge, the impact of this deterioration on patients' QOL and posttraumatic stress disorder (PTSD) symptoms after HCT is unknown., Methods: We conducted a prospective longitudinal study of patients hospitalized for HCT. They assessed QOL using the Functional Assessment of Cancer Therapy-Bone Marrow Transplantation (FACT-BMT) and depression and anxiety symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at the time of admission for HCT, during hospitalization, and 6 months after HCT. We also used the Hospital Anxiety and Depression Scale (HADS) to measure patients' anxiety and depression symptoms at baseline and during HCT hospitalization. The PTSD Checklist was used to assess for PTSD symptoms. Multivariable linear regression models were used to identify predictors of QOL and PTSD symptoms at 6 months., Results: We enrolled 90 of 93 consecutively eligible patients (97%) undergoing autologous and allogeneic HCT. Data at 6 months were available for 67 participants. At 6 months, 28.4% of participants met the criteria for PTSD and 43.3% had clinically significant depression. On multivariable regression analyses adjusting for significant covariates, changes in QOL and depression scores from week 2 of HCT hospitalization to baseline predicted worse QOL (changes in scores between week 2 and baseline [Δ] QOL: β, 0.94 [P<.0001] and Δ PHQ-9: β, -2.59 [P = 0.001]) and PTSD symptoms (Δ QOL: β, -0.40 [P<.0001] and Δ PHQ-9: β, 1.26 [P<.0001]) at 6 months after HCT., Conclusions: Six months after HCT, a significant percentage of patients met the criteria for PTSD and depression. A decline in QOL and an increase in depressive symptoms during hospitalization for HCT were found to be the most important predictors of 6-month QOL impairment and PTSD symptoms. Therefore, managing symptoms of depression and QOL deterioration during HCT hospitalization may be critical to improving QOL at 6 months and reducing the risk of PTSD. Cancer 2016;122:806-812. © 2015 American Cancer Society., (© 2015 American Cancer Society.)

Background: We conducted a study to investigate the impact of hospitalization for hematopoietic stem cell transplantation (HCT) on the quality of life (QOL) and mood of patients and family caregivers (FC)., Methods: We conducted a longitudinal study of patients who were hospitalized for HCT and their FC. We assessed QOL (using the Functional Assessment of Cancer Therapy-Bone Marrow Transplantation) and mood (using the Hospital Anxiety and Depression Scale) at baseline (6 days before HCT), day +1, and day +8 of HCT. We administered the Medical Outcomes Study Health Survey Short Form-36 to examine FC QOL (Physical Component Scale and Mental Component Scale). To identify predictors of changes in QOL, we used multivariable linear mixed models., Results: We enrolled 97% of eligible patients undergoing autologous (30 patients), myeloablative (30 patients), or reduced intensity (30 patients) allogeneic HCT. Patients' QOL markedly declined (mean Functional Assessment of Cancer Therapy-Bone Marrow Transplantation score, 109.6 to 96.0; P<.0001) throughout hospitalization. The percentage of patients with depression (Hospital Anxiety and Depression Scale-Depression score of >7) more than doubled from baseline to day +8 (15.6% to 37.8%; P<.0001), whereas the percentage of patients with anxiety remained stable (22.2%; P = .8). These results remained consistent when data were stratified by HCT type. Baseline depression (β, -2.24; F, 42.2 [P<.0001]) and anxiety (β, -0.63; F, 4.4 [P =.03]) were found to independently predict worse QOL throughout hospitalization. FC QOL declined during the patient's hospitalization (physical component scale: 83.1 to 79.6 [P =.03] and mental component scale: 71.6 to 67.4 [P =.04])., Conclusions: Patients undergoing HCT reported a steep deterioration in QOL and substantially worsening depression during hospitalization. Baseline anxiety and depression predicted worse QOL during hospitalization, underscoring the importance of assessing pre-HCT psychiatric morbidity., (© 2014 American Cancer Society.)

Significant disparities exist in both access to and quality of mental health care for Latino Americans with depression compared to Caucasians, resulting in a greater burden of disability in this underserved population. Our aim is to evaluate participant acceptability of a Culturally Focused Psychiatric (CFP) consultation program for depressed Latino Americans. Latino American adult primary care patients endorsing depressive symptoms on a screening questionnaire were targeted in their primary care clinic. The intervention addressed participants' depressive symptoms using culturally adapted clinical assessments and toolkits. Acceptability was evaluated using a treatment satisfaction scale and in-depth semi-structured interviews. Overall, 85% of participants responded positively to all questions of the satisfaction scale. In in-depth interviews, the vast majority of participants reported the program met expectations, all stated providers were culturally sensitive, and most stated recommendations were culturally sensitive. The CFP program was found to be acceptable to a group of depressed Latino American primary care patients. Further research is needed to evaluate if the CFP intervention can improve depressive symptoms and outcomes.

Background: Uncontrolled pain remains prevalent in patients with advanced cancer and has been associated with worse quality of life and greater health care utilization. Poor adherence to analgesics may represent a modifiable barrier to pain management., Objective: This pilot study aimed to establish feasibility/utility of evaluating self-reported adherence to long-acting (LA) opioids in patients with advanced lung cancer, and to explore rates and correlates of adherence., Methods: Consecutive patients attending an ambulatory thoracic oncology clinic with a diagnosis of advanced lung cancer and a current LA opioid regimen were approached to complete a brief questionnaire during their clinic visit. Participants reported LA opioid adherence during the past 4 weeks (0%-100%) and knowledge of their LA opioid regimen, and completed the Patient Health Questionnaire-2 (PHQ-2) depression screen. Demographic and clinical information were confirmed via electronic health record review., Results: Fifty-four eligible patients were approached to reach our target sample (n=50; enrollment=92.6%). Self-reported adherence to LA opioids was 85.4% (standard deviation [SD]=21.0). Twenty-eight percent reported a frequency of medication use that did not match the prescribed daily frequency. Lower adherence was associated with inaccurate frequency (p=0.004), positive depression screen (p=0.005), and older age (p=0.04)., Conclusions: Our results demonstrate the feasibility of integrating self-report assessments of LA opioid adherence into a thoracic oncology clinic. Patients reported high adherence, but more than one-quarter did not accurately report the prescribed frequency of daily doses. Understanding of LA opioid regimens may be a critical indicator of adherence in patients with advanced cancer.

Poor social support in the aftermath of a traumatic event is a well-established risk factor for posttraumatic stress disorder (PTSD) among adult trauma survivors. Yet, a great deal about the relationship between social support and PTSD remains poorly understood. In this study, we analyzed data from 102 survivors of a serious motor vehicle accident (MVA) at 4 weeks (Time 1) and 16 weeks (Time 2) post-MVA. We assessed the role of perceived dyadic social support, positive dyadic interaction, and negative dyadic interaction in the development and maintenance of PTSD. In addition, we examined how these social support constructs work together with negative post-trauma cognitions to affect the maintenance of PTSD. Neither perceived social support nor the quality of social interaction (i.e., positive or negative) was associated with PTSD symptom severity at Time 1. However, among those with elevated PTSD symptom severity at Time 1, greater social support and positive social interaction and lower negative social interaction were each associated with reductions in PTSD symptom severity from Time 1 to Time 2. For social support and negative social interaction, this association ceased to be significant when jointly assessed with negative post-trauma cognitions, suggesting that perceived social support and negative dyadic interaction were associated with maintenance of PTSD symptom severity because of their association with negative post-trauma cognitions. These results provide support to models and treatments of PTSD that emphasize the role of negative post-trauma cognitions in maintenance of PTSD., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Differences in the presentation of clinical features of body dysmorphic disorder (BDD) across ethnic groups have received little investigation. The current study assessed BDD symptoms in an ethnically diverse sample of adults (n=401) using an online survey. Participants completed self-report measures assessing BDD symptoms, body parts of concern and BDD behaviors. Compared to Caucasian participants, no significant differences were found in body parts or behaviors reported by Latino or African American participants. Significant group differences did emerge between Asian and Caucasian participants. Specifically, Asians reported more concern with straight hair and dark skin and fewer body shape concerns than Caucasians. Asians also endorsed lower rates of grooming, touching body parts, and camouflaging and higher rates of exercise compared to Caucasians. Although most clinical features of BDD appear similar across ethnic groups, results showed some differences in body parts and behaviors between Caucasians and Asian Americans with BDD symptoms., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The frequency of mood and anxiety disorders is elevated among individuals with a history of intravenous drug abuse and among those with human immunodeficiency virus (HIV), and these disorders are associated with continued substance use despite treatment. The present study examined rates of mood and anxiety disorders, and recent heroin use, among HIV-infected and HIV-noninfected patients receiving methadone maintenance therapy. Participants were 160 (80 HIV-infected, 80 HIV-noninfected) methadone patients. Clinician-administered, semistructured interviews were used to identify unipolar and bipolar depression, and four major anxiety disorders (panic disorder with agoraphobia [PDA], generalized anxiety disorder [GAD], post-traumatic stress disorder [PTSD], and social anxiety disorder [SAD]). Toxicology screens and self-reporting were used to assess heroin, cocaine, marijuana, and alcohol use over the past month. The entire sample met criteria for at least one psychiatric disorder other than substance dependence. Substantial proportions of participants met criteria for major depressive disorder (55.6%), bipolar I, bipolar II, or cyclothymia (6.4%), PDA (34.4%), GAD (22.5%), SAD (16.9%), and PTSD (34.4%). A greater proportion of HIV-infected participants met criteria for SAD (χ 2 = 5.03), and a greater proportion of HIV-noninfected participants met criteria for GAD (χ 2 = 5.39, P < 0.01). About 14% of participants continued to use heroin over the past month, a significantly greater proportion of whom were HIV-infected. In adjusted analyses, none of the mood or anxiety disorders emerged as significant predictors of recent heroin use, but being HIV-infected did. This study highlights the high rate of psychopathology and continued heroin use despite substance abuse treatment, and underscores the need for interventions that help mitigate these problems among methadone patients.

Objective: Treatment for localized prostate carcinoma (PCa) is frequently associated with decrements in sexual functioning and satisfaction. Given the highly interpersonal nature of these decrements, interpersonal problems (such as interpersonal sensitivity) may affect recovery of sexual functioning after PCa treatment through interference with physician and partner communication and through distorted cognitions surrounding sexual dysfunction. The objective of the present study was to determine the effect of interpersonal sensitivity on several treatment indicators, including response to a group-based psychosocial intervention., Methods: Participants were 101 older men recovering from radical prostatectomy who were enrolled in a randomized controlled trial of a 10-week group-based cognitive-behavioral stress management (CBSM) intervention. Measures included the Inventory of Interpersonal Problems and the sexual functioning subscale of the University of California-Los Angeles quality-of-life measure., Results: At baseline, interpersonal sensitivity was related to a belief linking sexual dysfunction to core male identity (r=.29, P<.05). Using hierarchical regression, we found that (a) the CBSM intervention was effective in promoting sexual recovery in all participants, and (b) this effect was moderated by interpersonal sensitivity, such that individuals with higher levels of interpersonal sensitivity made larger improvements in sexual functioning in response to CBSM., Conclusions: CBSM was effective in improving sexual function after radical prostatectomy. Individuals with higher levels of interpersonal sensitivity were more likely to perceive sexual dysfunction as a threat to masculine identity and made larger gains in the CBSM intervention. Results and relevance to the older male cancer patients are discussed from the perspective of interpersonal theory.