Tailoring mind-body therapies to individual needs: patients' program preference and psychological traits as moderators of the effects of mindfulness-based cancer recovery and supportive-expressive therapy in distressed breast cancer survivors.

BACKGROUND: Mindfulness-based cancer recovery (MBCR) and supportive-expressive therapy (SET) are well-validated psycho-oncological interventions, and we have previously reported health benefits of both programs. However, little is known about patients' characteristics or program preferences that may influence outcomes. Therefore, this study examined moderators of the effects of MBCR and SET on psychological well-being among breast cancer survivors. METHODS: A multi-site randomized controlled trial was conducted between 2007 and 2012 in two Canadian cities (Calgary and Vancouver). A total of 271 distressed stage I-III breast cancer survivors were randomized into MBCR, SET or a 1-day stress management seminar (SMS). Baseline measures of moderator variables included program preference, personality traits, emotional suppression, and repressive coping. Outcome measures of mood, stress symptoms, quality of life, spiritual well-being, post-traumatic growth, social support, and salivary cortisol were measured pre- and post intervention. Hierarchical regression analyses were used to assess moderator effects on outcomes. RESULTS: The most preferred program was MBCR (55%). Those who were randomized to their preference improved more over time on quality of life and spiritual well-being post-intervention regardless of the actual intervention type received. Women with greater psychological morbidity at baseline showed greater improvement in stress symptoms and quality of life if they received their preferred versus nonpreferred program. CONCLUSIONS: Patients' program preference and baseline psychological functioning, rather than personality, were predictive of program benefits. These results suggest incorporating program preference can maximize the efficacy of integrative oncology interventions, and emphasize the methodological importance of assessing and accommodating for preferences when conducting mind-body clinical trials.

Randomized controlled trial of Mindfulness-based cancer recovery versus supportive expressive group therapy for distressed survivors of breast cancer.

PURPOSE: To compare the efficacy of the following two empirically supported group interventions to help distressed survivors of breast cancer cope: mindfulness-based cancer recovery (MBCR) and supportive-expressive group therapy (SET). PATIENTS AND METHODS: This multisite, randomized controlled trial assigned 271 distressed survivors of stage I to III breast cancer to MBCR, SET, or a 1-day stress management control condition. MBCR focused on training in mindfulness meditation and gentle yoga, whereas SET focused on emotional expression and group support. Both intervention groups included 18 hours of professional contact. Measures were collected at baseline and after intervention by assessors blind to study condition. Primary outcome measures were mood and diurnal salivary cortisol slopes. Secondary outcomes were stress symptoms, quality of life, and social support. RESULTS: Using linear mixed-effects models, in intent-to-treat analyses, cortisol slopes were maintained over time in both SET (P = .002) and MBCR (P = .011) groups relative to the control group, whose cortisol slopes became flatter. Women in MBCR improved more over time on stress symptoms compared with women in both the SET (P = .009) and control (P = .024) groups. Per-protocol analyses showed greater improvements in the MBCR group in quality of life compared with the control group (P = .005) and in social support compared with the SET group (P = .012). CONCLUSION: In the largest trial to date, MBCR was superior for improving stress levels, quality of life and social support [CORRECTED] for distressed survivors of breast cancer. Both SET and MBCR also resulted in more normative diurnal cortisol profiles than the control condition. The clinical implications of this finding require further investigation.

Core areas of practice and associated competencies for nurses working as professional cancer navigators.

UNLABELLED: Fillion et al. (2012) recently designed a conceptual framework for professional cancer navigators describing key functions of professional cancer navigation. PURPOSE: Building on this framework, this study defines the core areas of practice and associated competencies for professional cancer navigators. METHODS: The methods used in this study included: literature review, mapping of navigation functions against practice standards and competencies, and validation of this mapping process with professional navigators, their managers and nursing experts and comparison of roles in similar navigation programs. FINDINGS: Associated competencies were linked to the three identified core areas of practice, which are: 1) providing information and education, 2) providing emotional and supportive care, and 3) facilitating coordination and continuity of care. CONCLUSION: Cancer navigators are in a key position to improve patient and family empowerment and continuity of care. IMPLICATIONS: This is an important step for advancing the role of oncology nurses in navigator positions and identifying areas for further research.

Trait mindfulness, repression, suppression, and self-reported mood and stress symptoms among women with breast cancer.

OBJECTIVE: This study sought to identify relationships between trait mindfulness, repressive, and suppressive emotional styles, and the relative importance of these traits in their association with self-reported psychological health among women with breast cancer. METHOD: Of the 277 women with breast cancer accrued in the study, 227 (81.9%) completed a set of questionnaires assessing personality traits, stress symptoms, and mood. RESULTS: High levels of mindfulness were associated with fewer stress-related symptoms and less mood disturbance, while high levels of suppression were associated with poorer self-reported health. CONCLUSION: Individuals' dispositional ways to manage negative emotions were associated with the experience of symptoms and aversive moods. Helping patients cultivate mindful insights and reduce deliberate emotional inhibition may be a useful focus for psycho-oncological interventions.

A structured approach to knowledge exchange: understanding the implementation of a cancer survivor program.

PURPOSE: The purpose of this research was to describe the application of a model of knowledge exchange, the Knowledge Exchange-Decision Support (KE-DS) Model, to the Canadian pilot of Cancer Transitions, a psychosocial program for cancer survivors. METHOD: We compared and contrasted the program planning and implementation processes across three diverse sites offering Cancer Transitions. The KE-DS Model guided the collection and analysis of observations and written data according to specific model components. RESULTS: The use of the KE-DS Model highlighted four pertinent factors that influenced knowledge exchange during planning and implementation processes of this psychosocial program. First, the geographic diversity of where these programs were offered affected strategies for program promotion, recruitment and means of access. Second, the variation of the professional and organizational capacity of the three sites was critical to program planning and delivery. Third, cultural values and norms shaped each site's approach. Fourth, the KE-DS Model identified populations who were included and excluded from participation. CONCLUSIONS: The KE-DS Model was useful in elucidating the processes of knowledge exchange during the planning and implementing of an intervention for survivor care. This process information will inform future offerings of Cancer Transitions.

Diagnosis and therapy of polycystic ovarian syndrome: results of a survey among German gynecologists with a review on literature.

OBJECTIVE: Polycystic ovarian syndrome is one of the most frequent endocrine dysfunctions in women in their fertile age. To date, a clear definition of the disease remains controversial among experts, partly because study results concerning diagnostics and therapy are incoherent. In this survey, we intend to give an insight into the diagnostics and treatment regimes of PCOS in Germany and subsequently compare these results to the current recommendations found in international literature. DESIGN: In 2005, 7,000 outpatient gynecologists received a questionnaire with questions on PCOS definition, diagnostics and treatment. RESULTS: The survey shows that it remains difficult for gynecologists to restrict themselves to the few definition criteria defined in the 2003 Rotterdam PCOS Consensus Workshop. Nevertheless, therapy and diagnosis of PCOS show a uniform treatment pattern. The current recommendations found in international literature have been widely implemented into clinical practice. Modern therapeutic approaches such as the use of metformin are increasingly acknowledged. CONCLUSION: Further studies dealing with the diagnosis and therapy of PCOS will be necessary in order to establish guidelines, especially when looking at patients without a desire for reproduction.

Professional navigation: a comparative study of two Canadian models.

For many cancer control programs, cancer navigation has emerged as a specific strategy to improve access to supportive care and the patients' experience of cancer care. This study contributes to a better understanding of professional navigation by comparing two Canadian models: Quebec's Pivot Nurse in Oncology (PNO) and Nova Scotia's Cancer Patient Navigator (CPN). Qualitative interviews were conducted with professional navigators, patients and family members, front-line staff, physicians and health administrators (interviews: n = 49; focus groups: n = 10). The two models were analyzed using the professional navigation framework (Fillion et al., 2012). Although the models are different, results show that professional navigators in both programs perform similar functions and face similar challenges. This study highlights the complexity and the value of cancer navigation and recommends relevant actions to optimize its management within the health care system.

Professional navigation framework: elaboration and validation in a Canadian context.

PURPOSE/OBJECTIVES: To elaborate, refine, and validate the professional navigation framework in a Canadian context. RESEARCH APPROACH: A two-step approach consisting of a qualitative evaluative design and formal consultations. SETTING: Two applications of professional navigators in Quebec and Nova Scotia, Canada. PARTICIPANTS: Patient navigators, medical oncology specialists, nurses and oncology staff, administrators, family physicians, patients with cancer, and patients' families and significant others. METHODS: Individual interviews (n = 49) and focus groups (n = 10) were conducted with professional navigators, patients and family members, front-line staff, family physicians, and health administrators. Formal consultations (n = 13) occurred with clinical experts, managers, and researchers from across Canada. MAIN RESEARCH VARIABLES: The interview guide was based on an evaluative conceptual framework integrating questions related to the implementation process of the role of professional navigators and their organizational and clinical functions. FINDINGS: Results support a bi-dimensional framework and define key role functions. The first dimension, health system-oriented, refers to continuity of care. The second dimension, patient-centered, corresponds to empowerment. For each dimension, related concepts were illustrated from data. Examples of outcomes also were suggested. CONCLUSIONS: The framework brings clarity to the role and functions of professional navigators and suggests relevant outcomes for program evaluations. INTERPRETATION: With a clear definition of their role, professional navigators may be more efficient and less challenged in terms of setting priorities and making decisions while having to face demands from the health system and patients. The integrative framework could improve the effectiveness of cancer navigation programs.

Professional patient navigation in head and neck cancer.

OBJECTIVES: To discuss professional cancer navigation roles, models, implementation process and outcomes of patients and families dealing with head and neck cancers. One specific research is presented as an illustration. DATA SOURCES: Published scientific papers, research review articles, implementations studies. CONCLUSION: Two independent cohorts of patients with head and neck cancers were compared according to the presence of the professional navigator (Exposed cohort n=83) or not (Historical cohort n=75). The Exposed cohort showed a better profile on several indicators of outcomes. The results clearly indicate an association between the presence of the professional navigator with continuity of care (higher satisfaction and shorter duration of hospitalization), and empowerment (fewer cancer-related problems, including body images concerns, and better emotional quality of life). IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses can not only play an important role in continuity of care but also in supportive care by helping patients to cope better with cancer treatments, recovery or cancer progression and death issues.

The psychosocial screen for cancer (PSSCAN): further validation and normative data.

BACKGROUND: We have previously reported on the development of a cancer-specific screening instrument for anxiety and depression (PSSCAN). No information on cut-off scores or their meaning for diagnosis was available when PSSCAN was first described. Needed were additional analyses to recommend empirically justified cut-off scores as well as data norms for healthy adult samples so as to lend meaning to the recommended cut-off scores. METHODS: We computed sensitivity/specificity indices based on a sample of 101 cancer patients who had provided PSSCAN data on anxiety and depression and who had completed another standardized instrument with strong psychometrics. Next, we compared mean scores for four samples with known differences in health status, a healthy community sample (n = 561), a sample of patients with a representative mix of cancer subtypes (n = 570), a more severely ill sample of in-patients with cancer (n = 78), and a community sample with a chronic illness other than cancer (n = 85). RESULTS: Sensitivity/specificity analyses revealed that an excellent balance of sensitivity/specificity was achievable with 92%/98% respectively for clinical anxiety and 100% and 86% respectively for clinical depression. Newly diagnosed patients with cancer were no more anxious than healthy community controls but showed elevations in depression scores. Both, patients with chronic illness other than cancer and those with longer-standing cancer diagnoses revealed greater levels of distress than newly diagnosed cancer patients or healthy adult controls. CONCLUSION: These additional data on criterion validity and community versus patient norms for PSSCAN serve to enhance its utility for clinical practice.

A functional genomic fingerprint of chronic stress in humans: blunted glucocorticoid and increased NF-kappaB signaling.

BACKGROUND: Chronic stressors are known to increase vulnerability to medical illness, but the mechanisms underlying this phenomenon are poorly understood. METHODS: To identify transcriptional control pathways that are modified by chronic stress, we conducted genomewide expression microarrays on familial caregivers of brain-cancer patients (n = 11) and matched control subjects (n = 10). Analyses were conducted on peripheral blood monocytes, which are cells that have the ability to initiate and maintain many inflammatory responses. Salivary cortisol was collected over the course of 3 days as volunteers went about normal activities. RESULTS: Caregivers' patterns of cortisol secretion were similar to those of matched control subjects. However, their monocytes showed diminished expression of transcripts bearing response elements for glucocorticoids, and heightened expression of transcripts with response elements for NF-kappaB, a key pro-inflammatory transcription factor. Caregivers also showed relative elevations in the inflammatory markers C-reactive protein and interleukin-1 receptor antagonist. CONCLUSIONS: These findings suggest that even in the absence of excess adrenocortical output, stress brings about functional resistance to glucocorticoids in monocytes, which enables activation of pro-inflammatory transcription control pathways. This persistent activation of inflammatory mechanisms may contribute to stress-related morbidity and mortality.

Understanding Canadian Punjabi-speaking South Asian women's experience of breast cancer: a qualitative study.

BACKGROUND: Knowledge of women's experience with breast cancer is based on studies on middle-class Caucasian women. Generalizations are drawn from the few studies of South Asian women such as lack of desire to discuss personal and family issues. The purpose of this qualitative study was to understand the experience of Canadian Punjabi-speaking South Asian women in order to inform health care practices. DESIGN: Twenty women were recruited mainly through the local cancer center and word of mouth to participate in four focus groups conducted in Punjabi. All women spoke Punjabi and/or English, were involved in/or had completed cancer treatment and lived within driving distance of the local Cancer Center. FINDINGS: The themes that emerged from focus group data were all psychosocial: spiritual beliefs, patient inclusion, family systems, psychosocial distress and emotional expression. All women: (1) formed a strong spiritual connection, believed that it was fate or karma and that their cancer diagnosis was the will of God and women used this strength of spirituality to help them cope and (2) women were distressed by the diagnosis and prior to being exposed to cancer believed that cancer equals death. There was in-group difference amongst the women with the remaining themes: being alone to hear the diagnosis alone versus having family members present and feeling supported by family members versus being stressed by family and degree of inclusion desired in the decision-making process. The key findings which are contrary to previous research, is the women's desire to discuss their experience openly and the variation in experience within the group. The implication for practice for all professionals is not to make assumptions regarding therapeutic interactions with patients but to individually assess the clients and learn about their specific values and beliefs and incorporate spirituality in health care delivery.

The impact of acculturation on the use of traditional Chinese medicine in newly diagnosed Chinese cancer patients.

GOALS OF WORK: This study assessed the impact of acculturation on the prevalence of traditional Chinese medicine and other complementary and alternative medicine (TCM/CAM) use in newly diagnosed Chinese cancer patients. The individual determinants of TCM/CAM use among patients were also investigated. MATERIALS AND METHODS: A consecutive sample of Chinese cancer patients treated at the British Columbia Cancer Agency was surveyed at admission using a 15-item questionnaire. Items included TCM/CAM use, sociodemographics, as well as medical and cultural factors. Data were analyzed using bivariate methods including Pearson's X (2) test and Student's t test. As well, multiple logistic regression was used to obtain the final causal model. MAIN RESULTS: Of the 230 respondents, 57% completed the survey in Chinese and 94% were immigrants. The average age was 59. Participants had a mean disease duration of approximately 2 months and 79% had already received at least one conventional treatment. Overall, TCM/CAM was used by 47% of respondents. Herbal remedies, vitamins/minerals, and prayer were the most commonly used therapies. Multivariable analysis showed that prior TCM/CAM use (p < 0.001), having received conventional treatment(s) (p = 0.029), and being less acculturated (p = 0.028) were associated with TCM/CAM use. CONCLUSIONS: Prevalence and type of use were found to vary as a function of the degree of acculturation. Health care practitioners would be well advised to discuss TCM/CAM use with their patients, especially those who are less acculturated to Western society, since they are the most likely users of TCM/CAM.

Residential radon and lung cancer--detailed results of a collaborative analysis of individual data on 7148 persons with lung cancer and 14,208 persons without lung cancer from 13 epidemiologic studies in Europe.

OBJECTIVES: Studies seeking direct estimates of the lung cancer risk associated with residential radon exposure lasting several decades have been conducted in many European countries. Individually these studies have not been large enough to assess moderate risks reliably. Therefore data from all 13 European studies of residential radon and lung cancer satisfying certain prespecified criteria have been brought together and analyzed. METHODS: Data were available for 7148 persons with lung cancer and 14,208 controls, all with individual smoking histories and residential radon histories determined by long-term radon gas measurements. RESULTS: The excess relative risk of lung cancer per 100 Bq/m3 increase in the observed radon concentration was 0.08 [95% confidence interval (95% CI) 0.03-0.16; P=0.0007] after control for confounding. The dose-response relationship was linear with no evidence of a threshold, and it remained significant when only persons with observed radon concentrations of <200 Bq/m3 were included. There was no evidence that the excess relative risk varied with age, sex, or smoking history. Removing the bias induced by random uncertainties related to radon exposure assessment increased the excess relative risk of lung cancer to 0.16 (95% CI 0.05-0.31) per 100 Bq/m3. With this correction, estimated risks at 0, 100, and 400 Bq/m3, relative to lifelong nonsmokers with no radon exposure, were 1.0, 1.2, and 1.6 for lifelong nonsmokers and 25.8, 29.9, and 42.3 for continuing smokers of 15-24 cigarettes/day. CONCLUSIONS: These data provide firm evidence that residential radon acts as a cause of lung cancer in the general population. They provide a solid basis for the formulation of policies with which to manage risk from radon and reduce deaths from the most common fatal cancer in Europe.

Development and validation of a psychosocial screening instrument for cancer.

BACKGROUND: We are reporting on the development of a psychosocial screening tool for cancer patients. The tool was to be brief, at a relatively low reading level, capture psychological variables relevant to distress and health-related quality-of-life in cancer patients, possess good reliability and validity, and be free of copyright protection. METHOD: Item derivation is described, data on reliability and validity as well as norms are reported for three samples of cancer patients (n = 1057; n = 570, n = 101). RESULTS: The resulting 21-item psychological screen for cancer (PSCAN) assesses perceived social support, desired social support, health-related quality-of-life, anxiety and depression. It has good psychometrics including high internal consistency (alpha averaging .83, and acceptable test-retest stability over 2 months (averaging r = .64). Validity has been established for content, construct and concurrent validity. CONCLUSION: PSCAN is considered ready for use as a screening tool and also for following changes in patient distress throughout the cancer care trajectory. It is freely available to all interested non-profit users.

Mortality of british radiologists: a lecture note.

The precautions introduced after the first 23 years experience of the use of x-rays for medical diagnosis proved adequate to eliminate the acute hazards of exposure, but it was much longer before it was realized that small doses that did not produce any acute effect could increase the risk of cancer. British radiologists who took up the specialty at different periods have, therefore, been studied to see if the risk has now been adequately controlled. Four groups have been studied starting respectively before 1921, in 1921-34, 1935-54, and 1955-77, corresponding approximately to periods when different limits of exposure were applied. Altogether 2698 male radiologists have been identified and all but 27 followed successfully to emigration, death, or survival to January 1st 1997. Of the 1198 who had died, 228 are known to have died of cancer. Two problems arise in evaluating the carcinogenic hazard to which they were exposed: the assessment of the doses received and the selection of an appropriate control group with which to compare their mortality. The most appropriate comparison group would seem to be medical practitioners in general. In comparison with them, radiologists entering in the first 3 periods had increased risks of death from cancer though appreciably less than would have been predicted from the expected effect of the radiation they had received. Those who joined in the latest period had a relatively reduced risk, irrespective of any effect of the small dose of radiation they are likely to have received. Independent evidence suggests, however, that since 1951 radiologists have smoked less than other doctors and the lower than predicted risk in the groups exposed since 1920 is limited to smoking related cancers, the mortality from other cancers being higher than in doctors generally. In assessing the risk of occupational exposure to radiation, life-style has to be taken into consideration, as well as dose of radiation.

Mortality in relation to alcohol consumption: a prospective study among male British doctors.

BACKGROUND: To relate alcohol consumption patterns to mortality in an elderly population. METHODS: We undertook a 23-year prospective study of 12 000 male British doctors aged 48-78 years in 1978, involving 7000 deaths. Questionnaires about drinking and smoking were completed in 1978 and once again in 1989-91. Mortality analyses are standardized for age, follow-up duration, and smoking, and (during the last decade of the study, 1991-2001) subdivide non-drinkers into never-drinkers and ex-drinkers. RESULTS: In this elderly population, with mean alcohol consumption per drinker of 2 to 3 units per day, the causes of death that are already known to be augmentable by alcohol accounted for only 5% of the deaths (1% liver disease, 2% cancer of the mouth, pharynx, larynx, or oesophagus, and 2% external causes of death) and were significantly elevated only among men consuming >2 units/day. Vascular disease and respiratory disease accounted for more than half of all the deaths and were both significantly less common among current than among non-drinkers; hence, overall mortality was also significantly lower (relative risk, RR 0.81, CI 0.76-0.87, P = 0.001). The non-drinkers, however, include the ex-drinkers, some of whom may have stopped recently because of illness, and during the last decade of the study (1991-2001) overall mortality was significantly higher in the few ex-drinkers who had been current drinkers in 1978 than in the never-drinkers or current drinkers. To avoid bias, these 239 ex-drinkers were considered together with the 6271 current drinkers and compared with the 750 men who had been non-drinkers in both questionnaires. Even so, ischaemic heart disease (RR 0.72, CI 0.58-0.88, P = 0.002), respiratory disease (RR 0.69, CI 0.52-0.92, P = 0.01), and all-cause (RR 0.88, CI 0.79-0.98, P = 0.02) mortality were significantly lower than in the non-drinkers. CONCLUSIONS: Although some of the apparently protective effect of alcohol against disease is artefactual, some of it is real.