Financial burden for caregivers of adolescents and young adults with cancer.

OBJECTIVE: Adolescent and young adult (AYA) cancer survivors are vulnerable to cancer-related financial burden, which is likely shared by their caregivers. This study aims to enhance an existing conceptual model of financial burden by conducting concept elicitation interviews with caregivers to generate knowledge that can be translated to inform instrumental and psychosocial support in cancer care. METHODS: Qualitative concept elicitation interviews were conducted with 24 caregivers of AYA cancer survivors (caregivers of adolescents, n = 12; caregivers of emerging adults, n = 12) recruited from four sites. Constant comparative methods were used to identify themes, and results were interpreted and organized into domains of the conceptual model. We also explored COVID-19 related financial impacts among a subset (n = 12) of caregivers. RESULTS: Seven themes emerged, which varied by age group and strengthened the conceptualization of the model. Themes centered on: (1) direct and indirect costs of cancer; (2) impact of socioeconomic status on financial burden; (3) caregiver desire to shield AYAs from distress due to financial burden; (4) strategies to manage cancer-related costs; (5) worries about AYAs' financial future; (6) seeking and receiving financial support; and (7) navigating the healthcare system. Findings also revealed that COVID-19 exacerbates financial burden for some caregivers. CONCLUSIONS: Building upon our prior work, we have adapted the conceptual model of financial burden to reflect perspectives of AYAs, oncology providers, and now, caregivers. An important next step is to develop a reliable and valid self-report measure of financial burden among caregivers of AYA cancer survivors.

Psychosocial and Biological Outcomes of Immersive, Mindfulness-Based Treks in Nature for Groups of Young Adults and Caregivers Affected by Cancer: Results from a Single Arm Program Evaluation from 2016-2021.

The COVID-19 pandemic has left many individuals suffering from "connection deficit disorder" given changes to the way we work, go to school, socialize, and engage in daily activities. Young adults affected by cancer between the ages of 18-39 have known this connection deficit long before the pandemic. Being diagnosed and treated for cancer during this time can significantly disrupt engagement in important educational, career, social, and reproductive pursuits, and contribute to increased stress, anxiety, depression, and other negative outcomes. Experiencing meaningful connection-with nature, with peers who understand, and with oneself, may help assuage this adverse effect of disconnect. A single arm within-subjects program evaluation was conducted to examine outcomes following participation in immersive, multi-night, mindfulness-based treks in nature in a sample of young adults (n = 157) and caregivers (n = 50) affected by cancer from 2016-2021. Pre to post-trek changes included significant (p < 0.001) self-reported improvements in feeling connected to nature (d = 0.93-0.95), peers (d = 1.1-1.3), and oneself (d = 0.57-1.5); significant (p < 0.001) improvements on PROMIS Anxiety (d = 0.62-0.78), Depression (d = 0.87-0.89), and Sleep Disturbance (d = 0.37-0.48) short forms; and significant (p < 0.05) changes in pro-inflammatory biomarkers (d = 0.55-0.82). Connection-promoting experiences like this have the potential to improve health and wellbeing in this population and serve as a model for others.

Targeted eHealth Intervention to Reduce Breast Cancer Survivors' Fear of Recurrence: Results From the FoRtitude Randomized Trial.

BACKGROUND: Fear of recurrence (FoR) is a prevalent concern among breast cancer survivors (BCS), yet few accessible interventions exist. This study evaluated a targeted eHealth intervention, "FoRtitude," to reduce FoR using cognitive behavioral skills training and telecoaching. METHODS: BCS (N = 196) were recruited from an academic medical center and 3 National Cancer Institute Community Oncology Research Program community sites, had stage 0-III breast cancer, were 1-10 years postprimary treatment, with moderate to high FoR and familiarity with the internet. Using the Multiphase Optimization Strategy, participants were independently randomly assigned to 3 cognitive behavioral skills (relaxation, cognitive restructuring, worry practice) vs an attention control condition (health management content [HMC]) and to telecoaching (motivational interviewing) vs no telecoaching. Website content was released across 4 weeks and included didactic lessons, interactive tools, and a text-messaging feature. BCS completed the Fear of Cancer Recurrence Inventory at baseline and at 4 and 8 weeks. Fear of Cancer Recurrence Inventory scores over time were compared using mixed-effects models. All statistical tests were 2-sided. RESULTS: FCRI scores [SD] decreased statistically significantly from baseline to postintervention (T0 = 53.1 [17.4], T2 = 41.9 [16.2], P < .001). The magnitude of reduction in FCRI scores was comparable across cognitive behavior therapy (CBT) and attention control HMC conditions and was predicted by increased self-efficacy. Telecoaching was associated with lower attrition and greater website use (mean adherence score [SD] = 26.6 [7.2] vs 21.0 [10.5], P < .001). CONCLUSIONS: BCS experienced statistically significant reductions in FoR postintervention, but improvements were comparable between CBT and attention controls. Telecoaching improved adherence and retention. Future research is needed on optimal integration of CBT and HMC, dose, and features of eHealth delivery that contributed to reducing FoR. In the COVID-19 era, remote delivery has become even more essential for reaching survivors struggling with FoR.

Covid-19 related oncologist's concerns about breast cancer treatment delays and physician well-being (the CROWN study).

PURPOSE: To examine how treatment delays brought on by the COVID-19 pandemic impacted the physical and emotional well-being of physicians treating these patients. METHODS: A cross-sectional survey of physician breast specialists was posted from April 23rd to June 11th, 2020 on membership list serves and social media platforms of the National Accreditation Program for Breast Centers and the American Society of Breast Surgeons. Physician well-being was measured using 6 COVID-19 burnout emotions and the 4-item PROMIS short form for anxiety and sleep disturbance. We examined associations between treatment delays and physician well-being, adjusting for demographic factors, COVID-19 testing and ten COVID-19 pandemic concerns. RESULTS: 870 physicians completed the survey, 61% were surgeons. The mean age of physicians was 52 and 548 (63.9%) were female. 669 (79.4%) reported some delay in patient care as a result of the COVID-19 pandemic. 384 (44.1%) and 529 (60.8%) of physicians scored outside normal limits for anxiety and sleep disturbance, respectively. After adjusting for demographic factors and COVID-19 testing, mean anxiety and COVID-19 burnout scores were significantly higher among physicians whose patients experienced either delays in surgery, adjuvant chemotherapy, radiation, breast imaging or specialty consultation. A multivariable model adjusting for ten physician COVID-19 concerns and delays showed that "delays will impact my emotional well-being" was the strongest concern associated with anxiety, sleep disturbance and COVID-19 burnout factors. CONCLUSIONS: Breast cancer treatment delays during the initial surge of the COVID-19 pandemic in the United States were associated with a negative impact on physician emotional wellness.

Nature As Medicine: Mind, Body, and Soil.

Editor's Note: Debate over the evidence supporting integrative care interventions not infrequently references the challenges funding research on natural agents and practices that are not patentable. The subject of this column goes to the mother of all such interventions, nature herself. Yet in this case, the authors report an awakening of research that affirms nature's power in health and well-being. This is the eighth commentary through JACM's column partnership with the Osher Collaborative for Integrative Medicine through which we seek to stimulate critical conversations via perspectives from the leaders of the Collaborative's seven prominent academically based integrative centers. The author team came together from three of the centers: David Victorson, PhD, at the Northwestern University Feinberg School of Medicine, Christina Luberto, PhD, at the Harvard Medical School, and Karen Koffler, MD, at the University of Miami Miller School of Medicine. While providing readers an understanding of how to examine nature as medicine, they propose a "goodness of fit" between the precepts of the integrative field and the natural world.-Editor-in-Chief, John Weeks (johnweeks-integrator.com).