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Uncontrolled chemotherapy-induced nausea and vomiting (CINV) can reduce patients’ quality of life and may result in premature discontinuation of chemotherapy. Although nausea and vomiting are commonly grouped together, research has shown that antiemetics are clinically effective against chemotherapy-induced vomiting (CIV) but less so against chemotherapy-induced nausea (CIN). Nausea remains a problem for up to 68% of patients who are prescribed guideline-consistent antiemetics. Despite the high prevalence of CIN, relatively little is known regarding its etiology independent of CIV. In this review paper, we summarize a metagenomics approach to the study and treatment of CIN with the goal of encouraging future research. Metagenomics focuses on genetic risk factors, encompassing both human (i.e., host) and gut microbial genetic variation. Little work to date has focused on metagenomics as a putative biological mechanism of CIN. Metagenomics has the potential to be a powerful tool in advancing scientific understanding of CIN by identifying new biological pathways and intervention targets. Investigation of metagenomics in the context of well-established demographic, clinical, and patient-reported risk factors may help to identify patients at risk and facilitate prevention and management of CIN.

Background Cyclin‐dependent kinase 4 and 6 (CDK4/6) inhibitor targeted therapies dramatically improve survival outcomes for metastatic breast cancer (MBC), but they are associated with significant symptom burden that can impact patients’ health‐related quality of life (HRQOL) and treatment outcomes. This study is the first to describe CDK4/6 inhibitor symptoms from the lived perspectives of MBC patients taking CDK4/6 inhibitors and healthcare providers involved in MBC care. This study also explored patients’ symptom management and HRQOL concerns, and gathered feedback about developing supportive interventions for MBC. Methods MBC patients taking CDK4/6 inhibitors (N = 20) and MBC healthcare providers (N = 12) participated in semi‐structured interviews that were analyzed for qualitative themes. MBC patients completed surveys about HRQOL, symptoms, and unmet needs. Results Patient and provider perceptions of CDK4/6 inhibitor symptoms did not align with patients perceiving symptoms as more burdensome. Patients reported that supportive resources (e.g., support groups, blogs) that are not specific to MBC do not adequately meet their needs. Patients and providers were enthusiastic about developing supportive interventions specifically for MBC and offered considerations for designing such interventions. Conclusions Findings highlight differences in perceptions of CDK4/6 inhibitor symptom burden between MBC patients and providers. Results will inform the development of supportive interventions to assist MBC patients in managing CDK4/6 inhibitor symptom burden and maintaining HRQOL. Such interventions could also improve treatment outcomes., Metastatic breast cancer (MBC) patient and provider perceptions of symptoms associated with CDK4/6 inhibitor did not align, with patients perceiving symptoms as more burdensome. Patients reported that supportive resources (e.g., support groups, blogs) that are not specific to MBC do not adequately meet their needs, however patients and providers were enthusiastic about developing supportive interventions specifically for MBC and offered considerations for designing such interventions. Results will inform the development of supportive interventions to assist MBC patients in managing CDK4/6 inhibitor symptom burden and maintaining health‐related quality of life.

OBJECTIVE: Informal family caregivers provide critical support for patients receiving chimeric antigen receptor (CAR) T-cell therapy. However, caregivers' experiences are largely unstudied. This study examined quality of life (QOL; physical functioning, pain, fatigue, anxiety, and depression), caregiving burden, and treatment-related distress in caregivers in the first 6 months after CAR T-cell therapy, when caregivers were expected to be most involved in providing care. Relationships between patients' clinical course and caregiver outcomes were also explored. METHODS: Caregivers completed measures examining QOL and burden before patients' CAR T-cell therapy and at days 90 and 180. Treatment-related distress was assessed at days 90 and 180. Patients' clinical variables were extracted from medical charts. Change in outcomes was assessed using means and 99% confidence intervals. Association of change in outcomes with patient clinical variables was assessed with backward elimination analysis. RESULTS: A total of 99 caregivers (mean age 59, 73% female) provided data. Regarding QOL, pain was significantly higher than population norms at baseline but improved by day 180 (p < .01). Conversely, anxiety worsened over time (p < .01). Caregiver burden and treatment-related distress did not change over time. Worsening caregiver depression by day 180 was associated with lower patient baseline performance status (p < .01). Worse caregiver treatment-related distress at day 180 was associated with lower performance status, intensive care unit admission, and lack of disease response at day 90 (ps < 0.01). CONCLUSIONS: Some CAR T-cell therapy caregivers experience pain, anxiety, and burden, which may be associated patients' health status. Further research is warranted regarding the experience of CAR T-cell therapy caregivers.

Background Systemic therapy (ST) can be deferred in patients who have metastatic renal cell carcinoma (mRCC) and slow-growing metastases. Currently, this subset of patients managed with active surveillance (AS) is not well described in the literature. Methods This was a prospective observational study of patients with mRCC across 46 US community and academic centers. The objective was to describe baseline characteristics and demographics of patients with mRCC initially managed by AS, reasons for AS, and patient outcomes. Descriptive statistics were used to characterize demographics, baseline characteristics, and patient-related outcomes. Wilcoxon 2-sample rank-sum tests and χ2 tests were used to assess differences between ST and AS cohorts in continuous and categorical variables, respectively. Kaplan-Meier survival curves were used to assess survival. Results Of 504 patients, mRCC was initially managed by AS (n = 143) or ST (n = 305); 56 patients were excluded from the analysis. Disease was present in 69% of patients who received AS, whereas the remaining 31% had no evidence of disease. At data cutoff, 72 of 143 patients (50%) in the AS cohort had not received ST. The median overall survival was not reached (95% CI, 122 months to not estimable) in patients who received AS versus 30 months (95% CI, 25-44 months) in those who received ST. Quality of life at baseline was significantly better in patients who were managed with AS versus ST. Conclusions AS occurs frequently (32%) in real-world clinical practice and appears to be a safe and appropriate alternative to immediate ST in selected patients.

Background Increases in fatigue, depressive symptomatology, and cognitive impairment are common after the initiation of androgen deprivation therapy (ADT) for prostate cancer. To date, no studies have examined the potential role of inflammation in the development of these symptoms in ADT recipients. The goal of the current study was to examine circulating markers of inflammation as potential mediators of change in fatigue, depressive symptomatology, and cognitive impairment related to the receipt of ADT. Methods Patients treated with ADT for prostate cancer (ADT+; n = 47) were assessed around the time of the initiation of ADT and 6 and 12 months later. An age- and education-matched group of men without a history of cancer (CA-; n = 82) was assessed at comparable time points. Fatigue, depressive symptomatology, and cognitive impairment were assessed with the Fatigue Symptom Inventory, the Center for Epidemiological Studies Depression Scale, and a battery of neuropsychological tests, respectively. Circulating markers of inflammation included interleukin 1 receptor antagonist (IL-1RA), interleukin 6 (IL-6), soluble tumor necrosis factor receptor II (sTNF-RII), and C-reactive protein (CRP). Results Fatigue, depressive symptomatology, and serum IL-6 increased significantly over time in the ADT+ group versus the CA- group; rates of cognitive impairment also changed significantly between the groups. No significant changes in IL-1RA, sTNF-RII, or CRP over time were detected. Treatment-related increases in IL-6 were associated with worsening fatigue but not depressive symptomatology or cognitive impairment. Conclusions Results of this preliminary study suggest that increases in circulating IL-6, perhaps due to testosterone inhibition, may play a role in fatigue secondary to receipt of ADT. Additional research is needed to determine whether interventions to reduce circulating inflammation improve fatigue in this population.

Patient-generated health data (PGHD), or health-related data gathered from patients to help address a health concern, are used increasingly in oncology to make regulatory decisions and evaluate quality of care. PGHD include self-reported health and treatment histories, patient-reported outcomes (PROs), and biometric sensor data. Advances in wireless technology, smartphones, and the Internet of Things have facilitated new ways to collect PGHD during clinic visits and in daily life. The goal of the current review was to provide an overview of the current clinical, regulatory, technological, and analytic landscape as it relates to PGHD in oncology research and care. The review begins with a rationale for PGHD as described by the US Food and Drug Administration, the Institute of Medicine, and other regulatory and scientific organizations. The evidence base for clinic-based and remote symptom monitoring using PGHD is described, with an emphasis on PROs. An overview is presented of current approaches to digital phenotyping or device-based, real-time assessment of biometric, behavioral, self-report, and performance data. Analytic opportunities regarding PGHD are envisioned in the context of big data and artificial intelligence in medicine. Finally, challenges and solutions for the integration of PGHD into clinical care are presented. The challenges include electronic medical record integration of PROs and biometric data, analysis of large and complex biometric data sets, and potential clinic workflow redesign. In addition, there is currently more limited evidence for the use of biometric data relative to PROs. Despite these challenges, the potential benefits of PGHD make them increasingly likely to be integrated into oncology research and clinical care.

Objective Cancer-associated cognitive decline is a concern among cancer survivors. Survivors' memory lapses (eg, location of keys, names, and reason entered room) may negatively impact quality of life. This study used smartphone-based surveys to compare cancer survivors to those without cancer history on frequency of, severity of, and affective response to daily memory lapses. Methods For 14 evenings, breast cancer survivors (N = 47, M age = 52.9) and women without a cancer history (N = 105, M age = 51.8) completed smartphone-based surveys on memory lapse occurrence and severity and negative and positive affect. Results Survivors were nearly three times more likely to report a daily memory lapse but did not differ from comparison group on memory lapse severity. Negative affect was significantly higher on days with memory lapses associated with doing something in the future (eg, appointments) but this did not differ across groups. Positive affect was not significantly related to survivorship status or the occurrence of daily memory lapses. Conclusion Survivors may be at-risk for more frequent memory lapses. Both survivors and women without a history of cancer reported greater negative affect on days when memory lapses occurred, suggesting that daily cognitive functioning may have important implications for quality of life.

Despite high levels of stress, there are few empirically supported stress management interventions for caregivers of allogeneic hematopoietic stem cell transplant (HCT) cancer patients. This study examined the feasibility, acceptability, and various stress-related outcomes from pre- to post-treatment of a pilot, single-arm trial of a 6-week mindfulness-based intervention (FOCUS) for stress management. Caregivers (N = 21; 76% female; mean age = 57.43) were enrolled prior to patient transplant and received FOCUS during the first 90 days post-transplant. Findings indicated that FOCUS was highly feasible and acceptable (e.g., 71% attended at least four of six sessions; 100% reported using the skills learned at follow-up; high treatment engagement). Significant increases in mindfulness, post-traumatic growth, and general mental health were observed, along with significant decreases in negative affect (all ps < .05).

Racial and ethnic disparities are well-documented in cancer outcomes such as disease progression and survival, but less is known regarding potential disparities in symptom burden.The goal of this retrospective study was to examine differences in symptom burden by race and ethnicity in a large sample of cancer patients. We hypothesized that racial and ethnic minority patients would report greater symptom burden than non-Hispanic and White patients.A total of 5798 cancer patients completed the Edmonton Symptom Assessment Scale-revised (ESAS-r-CSS) at least once as part of clinical care. Two indicators of symptom burden were evaluated: (1) total ESAS-r-CSS score (i.e., overall symptom burden) and (2) number of severe symptoms (i.e., severe symptomatology). For patients completing the ESAS-r-CSS on multiple occasions, the highest score for each indicator was used. Zero-inflated negative binomial regression analyses were conducted, adjusting for other sociodemographic and clinical characteristics. Symptomology varied across race. Patients who self-identified as Black reported higher symptom burden (p = .016) and were more likely to report severe symptoms (p .001) than self-identified White patients. Patients with "other" race were also more likely to report severe symptoms than White patients (p = .032), but reported similar total symptom burden (p = .315). Asian and Hispanic patients did not differ from White or non-Hispanic patients on symptom burden (ps .05).This study describes racial disparities in patient-reported symptom burden during routine oncology care, primarily observed in Black patients. Clinic-based electronic symptom monitoring may be useful to detect high symptom burden, particularly in patients who self-identify their race as Black or other. Future research is needed to reduce symptom burden in racially diverse cancer populations.

BACKGROUND Sleep disturbance and genetic profile are risks for cognitive decline in noncancer populations, yet their role in cancer-related cognitive problems remains understudied. This study examined whether sleep disturbance was associated with worse neurocognitive outcomes in breast cancer survivors and whether sleep effects on cognition varied by genotype. METHODS Newly diagnosed female patients (n = 319) who were 60 years old or older and had stage 0 to III breast cancer were recruited from August 2010 to December 2015. Assessments were performed before systemic therapy and 12 and 24 months later. Neuropsychological testing measured attention, processing speed, executive function, learning, and memory; self-perceived cognitive functioning was also assessed. Sleep disturbance was defined by self-report of routine poor or restless sleep. Genotyping included APOE, BDNF, and COMT polymorphisms. Random effects fluctuation models tested associations of between-person and within-person differences in sleep, genotype, and sleep-genotype interactions and cognition and controlled for age, reading level, race, site, and treatment. RESULTS One-third of the patients reported sleep disturbances at each time point. There was a sleep-APOE e4 interaction (P = .001) in which patients with the APOE e4 allele and sleep disturbances had significantly lower learning and memory scores than those who were APOE e4-negative and without sleep disturbances. There was also a sleep disturbance-COMT genotype interaction (P = .02) in which COMT Val carriers with sleep disturbances had lower perceived cognition than noncarriers. CONCLUSIONS Sleep disturbance was common and was associated with worse cognitive performance in older breast cancer survivors, especially those with a genetic risk for cognitive decline. Survivorship care should include sleep assessments and interventions to address sleep problems.

OBJECTIVE: Cancer and its treatment are associated with long-term cognitive deficits. However, most studies of cancer patients have used traditional, office-based cognitive evaluations instead of assessing patients in their daily lives. Recent research in cognitive aging suggests that variability in performance may be a sensitive indicator of cognitive decline. Using Ecological Momentary Assessment (EMA), we examined cognitive variability among breast cancer survivors and evaluated whether ratings of fatigue and depressed mood were associated with cognition. METHODS: Participants were 47 women (M age = 53.3 years) who completed treatment for early stage breast cancer 6 to 36 months previously. Smartphones were preloaded with cognitive tests measuring processing speed, executive functioning and memory, as well as rating scales for fatigue and depressed mood. Participants were prompted five times per day over a 14-day period to complete EMA cognitive tasks and fatigue and depressed mood ratings. RESULTS: Cognitive variability was observed across all three EMA cognitive tasks. Processing speed responses were slower at times that women rated themselves as more fatigued than their average (p

Background Patient-reported outcomes for hematopoietic cell transplantation (HCT) survivors are well characterized with established measures; however, there is little experience with the new, freely available Patient-Reported Outcomes Measurement Information System (PROMIS) measures in this population. The aim of this study was to compare the performance of the PROMIS measures in the HCT setting with the performance of the commonly used 36-Item Short Form Health Survey (SF-36). Methods Adult HCT survivors from the Fred Hutchinson Cancer Research Center (n = 4446) were mailed a survey that included the following as part of an annual follow-up survey: the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH; 10 questions), the 29-Item Patient-Reported Outcomes Measurement Information System Profile (PROMIS-29), and the SF-36. Results Both the SF-36 and PROMIS measures were available for 1634 HCT recipients (503 autologous recipients and 1131 allogeneic recipients). The overall response rate was 46%. The median time after transplantation for allogeneic and autologous recipients was 12.0 years (range, 0.4-44.1 years) and 6.1 years (range, 0.4-30.1 years), respectively. With the SF-36 or PROMIS-GH, overall physical functioning was somewhat lower in comparison with the general population, but mental functioning was similar. Component and domain scores with similar contents were strongly correlated by Pearson correlation coefficients: the Global Health-Physical and SF-36 Physical Component Summary scores for autologous (r = 0.82) and allogeneic recipients (r = 0.83) and the PROMIS-29 and SF-36 physical function, pain, and vitality/fatigue scores for allogeneic (0.87, -0.82, and -0.82, respectively) and autologous recipients (0.84, -0.82, and -0.81, respectively). The correlation between the Global Health-Mental and SF-36 Mental Component Summary scores was lower (0.70 for autologous recipients and 0.72 for allogeneic recipients). Conclusions Physical and mental symptoms and function in autologous and allogeneic HCT survivors can be adequately assessed with PROMIS-29 and PROMIS-GH. Cancer 2018;124:841-9. © 2017 American Cancer Society.

BACKGROUND Patients with prostate cancer receiving androgen deprivation therapy (ADT) are at risk of sleep disturbance; however, to the authors' knowledge, the mechanisms by which ADT may affect sleep are not well understood. The current study compared objective and subjective sleep disturbance in ADT recipients and controls and examined whether sleep disturbance in ADT recipients is attributable to the influence of ADT on hot flashes and nocturia. METHODS Patients with prostate cancer were assessed before or within 1 month after the initiation of ADT as well as 6 months and 12 months later (78 patients). Patients with prostate cancer were treated with prostatectomy only (99 patients) and men with no history of cancer (108 men) were assessed at similar intervals. Participants self-reported their sleep disturbance (Insomnia Severity Index) and interference from hot flashes (Hot Flash Related Daily Interference Scale). One hundred participants also wore actigraphs for 3 days at the 6-month assessment to measure objective sleep disturbance and reported their nocturia frequency. RESULTS ADT recipients reported worse sleep disturbance, higher rates of clinically significant sleep disturbance, and greater hot flash interference than controls (Ps≤.03). In cross-sectional analyses among those with actigraphy data, ADT recipients had greater objective sleep disturbance and more episodes of nocturia (Ps

There is a growing literature on the effects of cancer caregiving on the well-being of informal family caregivers. However, there has been little longitudinal research on caregivers of patients with the complex, rapidly-changing disease of primary malignant brain tumor. Objective Our objective was to model longitudinal relationships between caregiver burden, social support, and distress within caregivers of patients with primary brain tumor. Methods Caregiver participants were recruited from a neuro-oncology clinic. Caregiver questionnaire data, including sociodemographics, social support, depression, anxiety, and caregiving burden, were collected at 4 time points (diagnosis, +4, +8, and +12 mo). Using the stress process model as a guide, we hypothesized that early burden would predict later depression and anxiety, and this would be mediated by social support. Results Using data from 147 participants, we found support for the stress process model in caregivers of patients with primary brain tumor. Greater burden at diagnosis was associated with lower social support at 4 months, and lower social support was related to higher depression and anxiety at 8 months, as well as to changes in anxiety between 8 and 12 months. Conclusion We found evidence of the stress process model in caregivers of primary brain tumor patients unfolding over the course of a year after diagnosis. Our findings emphasize the potential importance of early programs for caregivers to ensure low initial levels of burden, which may have a positive effect on social support, depression, and anxiety.

Patient‐reported outcomes regarding symptom burden may provide valuable information in addition to physician assessment. Systematic collection of patient‐reported outcomes may be an important metric to identify unmet needs and improve quality of patient care. To understand common symptoms of patients seen in radiation oncology clinic, we examined the prospectively collected modified Edmonton Symptom Assessment Scale (ESAS‐r) data to explore symptom clusters. Our clinic established use of a modified Edmonton Symptom Assessment Scale in August 2015. All outpatients presenting for radiation oncology services completed the form at each clinic visit. Symptom clusters are defined by two or more symptoms that are interrelated and occur simultaneously with a high degree of predictability. A sample of 916 de‐identified surveys was assessed statistically using principal component analysis (PCA) with varimax rotation to determine independent clustering between the symptoms queried. We found four major clusters of symptoms: Tiredness (tired, drowsiness; PC1), Loss of Appetite (nausea, lack of appetite; PC2), Low Well‐Being (overall & spiritual well‐being; PC3), and Depression (depression, anxiety; PC4). These accounted for 46%, 9.2%, 7.6%, and 7% of total variance, respectively. Internal consistency using Cronbach's alpha was 0.87, 0.7, 0.82, and 0.87, respectively. The most frequent write‐in item was itchiness, present in 24% of the 148 patients responding. Assessment of patients seen in a large radiation oncology clinic revealed several symptom clusters. {Tiredness and drowsiness} represents a major symptom cluster. Itchiness may be underrecognized.

BACKGROUND Routine monitoring of cancer-related distress is recognized as essential to quality care and mandated by a major accrediting organization. However, to the authors' knowledge, few cancer-specific measures have been developed to date to assess the multiple cancer-related factors contributing to this distress. In the current study, the authors examined the psychometric properties of the Cancer and Treatment Distress (CTXD) measure over time in hematopoietic cell transplantation (HCT) recipients. METHODS As a secondary analysis of a multicenter randomized controlled clinical trial, adult patients undergoing autologous or allogeneic HCT completed patient-reported outcomes including the CTXD and the Medical Outcomes Study Short Form-36 (SF-36) before transplantation and 100 days and 180 days after HCT. RESULTS Across 21 transplantation centers, a total of 701 patients consented, underwent transplantation, and were included in the current analyses, 645 of whom were alive at 100 days and 618 of whom were alive at 180 days. Internal consistency reliability was found to be strong for the overall CTXD at the 3 time points: Cronbach alphas (α) were .94, .95, and .95, respectively. Subscale reliability met hypothesized levels of an α>.70 across time, with the lowest reliability noted for the Identity subscale at 180 days (α = .77). Correlations with the SF-36 Mental Health subscale were higher than with the Physical Functioning subscale at each time point, thereby supporting convergent and discriminant validity. Strong correlations of the pretransplantation CTXD with the posttransplantation CTXD and SF-36 Mental Health subscale supported predictive validity. CONCLUSIONS The CTXD is reliable and valid as a measure of cancer distress both before and after HCT. It may be a useful tool for measuring dimensions of distress and for defining those patients requiring treatment for distress during and after transplantation. Cancer 2016. © 2016 American Cancer Society.

BACKGROUND Patients treated with hematopoietic cell transplantation (HCT) often experience depression and fatigue but analyses to determine risk factors have typically lacked statistical power. The current study examined sociodemographic and clinical risk factors for depression and fatigue in a large cohort of survivors of HCT. METHODS Measures of depression and fatigue were included in an annual survey of HCT recipients that also included self-reported sociodemographic and health information. Patient clinical characteristics were obtained from the clinical database. RESULTS The sample consisted of 1869 recipients (with a mean age of 56 years; 53% male) who were a mean of 13 years (allogeneic recipients) and 6 years (autologous recipients) from HCT. Moderate to severe depression was reported by 13% of participants; moderate to severe fatigue was reported by 42%. Among allogeneic recipients, female sex, younger age, current presence of chronic pain, and current patient-reported severity of chronic graft-versus-host disease were found to be independently associated with greater depression whereas female sex, current presence of chronic pain, and current severity of chronic graft-versus-host disease were independently associated with greater fatigue (P values

BACKGROUND In hematopoietic cell transplantation (HCT), current risk adjustment strategies are based on clinical and disease-related variables. Although patient-reported outcomes (PROs) predict mortality in multiple cancers, they have been less well studied within HCT. Improvements in risk adjustment strategies in HCT would inform patient selection, patient counseling, and quality reporting. The objective of the current study was to determine whether pre-HCT PROs, in particular physical health, predict survival among patients undergoing autologous or allogeneic transplantation. METHODS In this secondary analysis, the authors studied pre-HCT PROs that were reported by 336 allogeneic and 310 autologous HCT recipients enrolled in the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 0902 protocol, a study with broad representation of patients who underwent transplantation in the United States. RESULTS Among allogeneic HCT recipients, the pre-HCT Medical Outcomes Study Short Form-36 Health Survey (SF-36) physical component summary (PCS) scale independently predicted overall mortality (hazards ratio, 1.40 per 10-point decrease; P

Epithelial-mesenchymal transition (EMT) is a process whereby epithelial cells assume mesenchymal characteristics to facilitate cancer metastasis. However, EMT also contributes to the initiation and development of primary tumors. Prior studies that explored the hypothesis that EMT gene variants contribute to epithelial ovarian carcinoma (EOC) risk have been based on small sample sizes and none have sought replication in an independent population. We screened 15,816 single-nucleotide polymorphisms (SNPs) in 296 genes in a discovery phase using data from a genome-wide association study of EOC among women of European ancestry (1,947 cases and 2,009 controls) and identified 793 variants in 278 EMT-related genes that were nominally (P < 0.05) associated with invasive EOC. These SNPs were then genotyped in a larger study of 14,525 invasive-cancer patients and 23,447 controls. A P-value

Background Lung cancer has a commonly understood behavioral etiology. Thus, lung cancer patients are often blamed for their illness and may seek to avoid this blame by concealing their diagnosis from others. This study sought to determine the prevalence of concealment and identify demographic, clinical, and psychosocial correlates of concealment among lung cancer patients. Methods A sample of 117 lung cancer patients receiving chemotherapy for non-small cell or small cell lung cancer was recruited and completed self-report demographic questionnaires, a measure of diagnosis concealment designed and pilot tested for this study, and standard measures of psychosocial variables. Clinical factors were assessed via a medical chart review. Results Thirty participants (26%) reported concealing their diagnosis in the previous month, most frequently from casual friends and close friends. Reported reasons for concealment largely reflected concern for others. Univariate analyses indicated that those who concealed their lung cancer diagnosis reported more internalized shame related to their illness and use of positive reappraisal as a coping strategy (ps ≤ 0.02). In addition, those who concealed were more likely to have used alcohol in the previous month and have a more recent recurrence, among those who had a recurrence (ps ≤ 0.04). Multivariate analyses indicated that internalized shame and use of positive reappraisal accounted for significant unique variance in concealment above and beyond that accounted for by use of alcohol (ps

Objective The purpose of this study was to investigate the effects of mindfulness-based stress reduction for breast cancer survivors (MBSR(BC)) on multiple measures of objective and subjective sleep parameters among breast cancer survivors (BCS). Methods Data were collected using a two-armed randomized controlled design among BCS enrolled in either a 6-week MBSR(BC) program or a usual care (UC) group with a 12-week follow-up. The present analysis is a subset of the larger parent trial (ClinicalTrials.gov Identifier: NCT01177124). Seventy-nine BCS participants (mean age 57 years), stages 0–III, were randomly assigned to either the formal (in-class) 6-week MBSR(BC) program or UC. Subjective sleep parameters (SSP) (i.e., sleep diaries and the Pittsburgh Sleep Quality Index (PSQI)) and objective sleep parameters (OSP) (i.e., actigraphy) were measured at baseline, 6 weeks, and 12 weeks after completing the MBSR(BC) or UC program. Results Results showed indications of a positive effect of MBSR(BC) on OSP at 12 weeks on sleep efficiency (78.2% MBSR(BC) group versus 74.6% UC group, p = 0.04), percent of sleep time (81.0% MBSR(BC) group versus 77.4% UC group, p = 0.02), and less number waking bouts (93.5 in MBSR(BC) group versus 118.6 in the UC group, p

Objective Prostate cancer patients who receive androgen deprivation therapy (ADT) often experience many physical and psychological side effects. ADT may be associated with increased risk for depression, but the relationship between ADT and depression is not fully understood. This study used a longitudinal design to assess depressive symptomatology in patients receiving ADT compared to two groups of matched controls.

Dear Editor, Aromatase inhibitors (AIs) are used routinely as part of adjuvant therapy for postmenopausal women with estrogen receptor positive breast cancer. Although beneficial, AIs are not without side effects. In addition to increased risk of osteoporosis and bone fracture, their use is associated with an arthralgia syndrome characterized by joint pain and stiffness. Other common symptoms attributed to AIs include fatigue, sleep problems, hot flashes, and mood disturbance. There has been limited research, to date, on treatment of AI-associated arthralgia as demonstrated by the lack of evidence-based clinical practice guidelines for its management. The possibility of relieving AI-associated joint pain with yoga has drawn attention. Initial supportive evidence comes from a randomized trial of yoga for 37 early stage breast cancer patients experiencing hot flashes that included 22 women prescribed AIs [1]. Significant reductions in joint pain were reported post-intervention and three months later relative to a wait-list condition. Additional support comes from a trial focused on yoga for AI-associated joint pain [2]. Participants were 10 breast cancer patients who reported worst joint pain severity ≥3 on a 0–10 scale. In a single-arm study, significant improvements over time were evident on performance-based measures of balance and flexibility and patient-reported outcomes (PROs) of perceived disability, pain severity, and quality of life. This study sought to gather additional preliminary data about the acceptability, feasibility, and potential efficacy of yoga for relief of AI-associated joint pain and to address the lack in the previous single-arm study of PROs assessing other common symptoms attributable to AIs.

Background Research has shown that self-directed stress management training improves mental well-being in patients undergoing chemotherapy. The present study extends this work by evaluating separate and combined effects of stress management training and home-based exercise. Method Following assessment of mental and physical well-being, depression, anxiety, exercise, and stress reduction activity before chemotherapy started, patients were randomized to stress management training (SM), exercise (EX), combined stress management and exercise (SMEX), or usual care only (UCO). Outcomes were reassessed 6 and 12 weeks after chemotherapy started. Significance testing of group-by-time interactions in 286 patients who completed all assessments was used to evaluate intervention efficacy. Results Interaction effects for mental and physical well-being scores were not significant. Depression scores yielded a linear interaction comparing UCO and SMEX (p = 0.019), with decreases in SMEX but not UCO. Anxiety scores yielded a quadratic interaction comparing UCO and SMEX (p = 0.049), with trends for changes in SMEX but not UCO. Additional analyses yielded quadratic interactions for exercise activity comparing UCO and SMEX (p = 0.022), with positive changes in SMEX but not UCO, and for stress management activity comparing UCO and SM (p

As more people are living longer post-treatment for breast cancer (BC), there is a need to understand the worries of these individuals. Among survivors, cancer worry is broadly defined as the fear or worry that cancer will return or progress [1]. Worry is distinct from risk perception, as the former relates to an emotional reaction and the latter to a cognitive reaction [2]. Cancer worry is consistently endorsed by survivors as a lingering concern post-treatment [3–7]. One study found that over a third of BC survivors rated worrying about cancer as a dominant concern and nearly half reported unmet needs about addressing these fears [8]. Understanding characteristics associated with cancer worry can help target those who are likely to experience such fears. A model proposed by Deimling and colleagues [3] identified primary stressors (personal and cancer/treatment characteristics) and secondary stressors (current health factors) contributing to cancer worry. Regarding personal characteristics, younger age has been consistently related to greater cancer worry [1, 3–5, 7, 9–11]. Research has also shown evidence for ethnic differences in reported cancer worry, with African Americans reporting lower levels of worry than white women [3, 10] and Hispanic women who are low in acculturation reporting higher levels [10]. Lower education has been related to greater cancer worry in at least one study [12], but not others [1, 9]. Regarding cancer/treatment characteristics, studies have found relationships between cancer worry and more advanced disease among those with early-stage cancer [9, 13]. Research has also demonstrated associations between past mastectomy [13], radiation [3, 10], and chemotherapy [4] and greater cancer worry. Greater perceived risk of cancer recurrence has been related to greater cancer worry in BC survivors [9], though a study of colorectal cancer survivors found that long-term survivors (defined as having completed treatment more than 41 months prior) had significantly lower perceived risk than short term survivors [11]. Post-treatment symptoms have also been associated with cancer-related worry [3, 12]. Regarding fatigue, a recent study found associations between cancer worry and fatigue while on treatment [10]. However, a study of long-term survivors of testicular cancer found that correlations between cancer worry and fatigue were no longer significant in multivariate analyses [12]. Thus, more work is needed to understand the relationship between cancer worry and post-treatment fatigue, which may serve as a trigger of cancer-related thoughts and worries among survivors. The aim of the current study was to investigate associations among cancer worry and demographic and treatment variables, and secondary stressors (i.e., fatigue, symptom burden, and risk perception) three years after completion of adjuvant treatment for BC. We hypothesized after controlling for demographic and treatment variables, a significant proportion of variance in cancer worry would be explained by greater fatigue severity, more symptom burden, and greater risk perception.

Advances in hematopoietic cell transplant (HCT) technology over the past two decades have resulted in higher survival rates and an increased number of transplants performed.1, 2 The increased prevalence of transplanted patients is reflected in a growing interest in post-transplant quality of life.3–5 Post-transplant cognitive function is an area of particular concern. Impairment in cognitive function can have important consequences for quality of life, such as the ability to return to work or school, function socially, and attain career or educational goals.6–8 HCT is a physically demanding treatment that may result in neurotoxicities such as delirium, seizures, and significant impairment in cognitive function during and after the transplant process.9, 10 On average, acute cognitive changes improve over time.11–13 Nevertheless, a sizable number of patients display enduring cognitive deficits. It is estimated that 20–28% of HCT survivors experience long-term cognitive deficits that are moderate to severe (i.e., more than two standard deviations below population norms)14–16 and 51% experience mild long-term cognitive deficits (i.e., more than one standard deviation below population norms).17 It is important to be able to determine which patients are at greatest risk for long-term cognitive impairment. Early identification of these patients can enable effective clinical management through close monitoring and timely referrals for intervention and support. Cognitive function tends to vary over the course of the transplant process. Syrjala and colleagues18 reported that prior to allogeneic transplant, 71% of patients displayed impairment on one or more neuropsychological test. At 80 days post-transplant, this number increased to 94%, then declined to 74% at one year post-transplant and 41% at five years post-transplant.18, 19 The authors noted that pre-transplant impairment was predictive of impairment at one year follow-up; 88% of patients who were impaired at baseline also displayed later impairment, while 54% of patients who were unimpaired at baseline displayed later impairment.18 The cognitive domains most likely to be impaired were grip strength, motor dexterity, verbal fluency and verbal memory.18 A number of studies support Syrjala’s findings suggesting that cognitive impairments are common prior to transplant,13, 15–17, 20 remain stable or become worse during the acute transplant phase (i.e., within 100 days post-transplant),16, 21 then show modest recovery over time.13, 15, 17 Observed cognitive deficits in transplanted patients likely result from multiple disease and treatment factors. Patients with a history of total body irradiation or cranial irradiation,22, 23 intrathecal chemotherapy,24 or multiple standard-dose chemotherapy regimens25 may be at risk for greater cognitive impairment. During the acute transplant phase, length of hospital stay, days until engraftment, and severity of mucositis and enteritis, proxies for transplant-related toxicity, may predict cognitive function. Following transplant, allogeneic patients,21 patients with acute or chronic graft versus host disease (GVHD) at the time of assessment,17, 18, 21, 26 or those treated with steroids or narcotics may be at risk.17, 26, 27 We are aware of only one study examining the cumulative effects of clinical risk factors on cognition in HCT patients.23 The study examined cross-sectional relationships between cognitive function and four clinical variables: history of cranial irradiation, high-dose cytosine arabinoside (ara-C), central nervous system disease with intrathecal chemotherapy, and prophylactic intrathecal chemotherapy. Together, these risk factors accounted for 25% of variance in total neuropsychological performance. Existing literature regarding risk factors for cognitive deficits in patients treated with HCT is beset by methodological limitations. Most studies have small samples, which limits power to detect effects. Many are also cross-sectional, so it is unclear how clinical risk factors affect cognitive function over time. In addition, few studies take patient attrition into account. This is particularly problematic in longitudinal studies of HCT patients, which tend to experience high rates of attrition due to mortality and morbidity.28 As such, studies may overestimate cognitive function because patients who are more severely compromised may not remain in the study. The goal of the current study was to longitudinally examine the cumulative effects of clinical risk factors for cognitive deficits in hematologic cancer patients treated with HCT. Clinical risk factors included history of cancer treatment known to affect neuropsychological function (e.g., cranial irradiation, intrathecal chemotherapy), HCT-related risk factors (e.g., allogeneic transplant, unrelated donor), and post-HCT complications (e.g., severity of mucositis and enteritis, graft versus host disease). As described previously,11,12 a sequential longitudinal design was employed to statistically control for practice effects of repeated neuropsychological testing and sample attrition. Participants were randomly assigned to different groups that varied on the number of times they were evaluated. This enabled us to statistically partition changes in neuropsychological performance due to practice from true changes in neuropsychological performance over time.

Evidence suggests that fatigue is among the most common problems experienced by adult cancer survivors.1-3 For example, a survey of adults who had been diagnosed with cancer approximately 1 year previously found that 67% reported a problem with fatigue.2 Although frequently reported, questions arise about whether fatigue is a greater problem for cancer survivors than for people without cancer. The issue reflects the finding that fatigue is also common in the general population.4,5 One useful approach to determining whether fatigue is a greater problem for cancer survivors is to compare survivors with individuals who have no history of cancer. Consideration should be given to matching the samples on demographic characteristics associated with fatigue, such as age,4-6 because differences in these characteristics could confound interpretation of results. Consideration should also be given to recruiting samples of cancer survivors with similar disease and treatment histories because variability in these characteristics is likely to contribute to variability in fatigue.7-9 Comparisons of the type proposed have been conducted primarily with breast cancer patients treated with adjuvant therapy. In 1 study,10 88 women with stage 0-IIIa breast cancer were compared with an age-matched sample of 88 women who had benign breast problems but no history of breast cancer. Patients had completed treatment an average of 25 months previously (range, 2-54 months), with the majority (67%) having received adjuvant therapy (chemotherapy and/or radiotherapy). Findings showed that survivors reported greater fatigue on the Piper Fatigue Scale and the Medical Outcomes Study (MOS) Vitality Scale. In another study,11 61 women with stage I-III breast cancer were compared with an age-matched sample of 59 women with no cancer history nominated by the patients. All the patients had received chemotherapy and 48% also received radiotherapy. The average time since chemotherapy completion was 471 days (range, 108-875 days). Findings showed that survivors reported greater fatigue on the Profile of Mood States Fatigue Scale (POMS-F), the Multidimensional Fatigue Symptom Inventory (MFSI), and measures of current fatigue and fatigue interference from the Fatigue Symptom Inventory (FSI). In a study using a similar design,12 45 women with stage 0-III breast cancer were compared with an age-matched sample of 44 women with no cancer history nominated by the patients. All the patients had received radiotherapy and had completed treatment an average of 22 months previously (range, 5-88 months). No significant (P < .05) differences were found on any of the fatigue measures administered (POMS-F, MFSI, and FSI). In a study limited to individuals age 70 year and older,13 127 women who had been diagnosed with breast cancer at least 1 year previously were compared with 87 women without cancer participating in a longitudinal study of aging. Patients had been diagnosed an average of 5.1 years previously (range, 1-15 years), with 65% having received chemotherapy and 17% having received radiotherapy. Findings showed that survivors reported more severe fatigue on the MOS Vitality Scale and more frequent fatigue on the FSI. In 1 other study of this type,14 164 women with stage I-III breast cancer were compared with an ageand race-matched sample of 164 women with no history of cancer recruited using the neighborhood control method.15 The patients had all been diagnosed 5½ years previously and treated with chemotherapy. There was no significant (P < .05) difference on the 1 fatigue measure for which results were reported (MOS Vitality Scale). A subsequent report derived from the same study compared 267 disease-free survivors with 187 controls.16 There were no significant (P < .05) differences between patients and controls on the MOS Vitality Scale or the General and Physical Fatigue Scales of the MFSI. However, patients who had not previously received an educational intervention17 scored significantly higher on the MFSI Mental Fatigue Scale than both patients who had received the intervention and controls. The lack of consistent findings across studies can be attributed, in part, to differences in methodology. These include differences in fatigue measures administered and differences in the average time since treatment completion. Beyond this, several of the studies have methodological features that limit the conclusions that can be drawn. First, only 2 studies recruited comparison subjects without cancer directly from the community.13,14 The possibility that women with benign breast problems10 and women nominated by breast cancer patients11,12 may have problems with fatigue that could lead to biased findings cannot be ruled out. Second, only 1 study recruited patients who were all at a similar timepoint from the end of treatment.14 The wide intervals in time since treatment completion in the other studies10-12 preclude generalizability of the results to a specific timepoint in the survivorship period. Third, only 2 studies12,14 limited participation to breast cancer patients treated with the same adjuvant therapy modality. The other studies did not conduct analyses comparing the treatment subgroups with their respective matches, possibly because of small sample sizes. Consequently, it is unknown whether results from these studies are generalizable to all the different treatment modalities represented in the samples. The present study was designed to further an understanding of fatigue after treatment for early stage breast cancer by addressing several limitations of previous research. To this end, the study used an age- and geographically matched comparison sample recruited from the community to limit potential biases in reports of fatigue. The patient sample included only women with nonmetastatic breast cancer who received adjuvant therapy (radiotherapy alone or chemotherapy plus radiotherapy) to limit variability in disease and treatment status. Sufficient numbers of patients were recruited to permit meaningful comparisons of each treatment subgroup with their respective matched controls. Finally, all post-treatment assessments were conducted in the 6 months after completion of radiotherapy to provide information about fatigue at specific timepoints early in the course of cancer survivorship. These data were used to test the hypothesis that breast cancer survivors would report greater fatigue than women with no history of cancer. Differences between patients and comparison subjects were expected to be greatest at the initial patient assessment, diminishing over the 6-month follow-up period. Consistent with prior research directly comparing treatment subgroups,18,19 we also predicted that women treated with both chemotherapy and radiotherapy would report greater fatigue relative to comparison subjects than women treated with radiotherapy alone.