Positive Feedback on Psychosocial Intervention
Women being treated for cancer appear to benefit from a psychological intervention aimed at counseling them on fertility preservation, judging by the high level of participation and positive feedback in a recent study reported at the National Comprehensive Cancer Network (NCCN) 21st Annual Conference in Hollywood, FL.1
The greatest barriers to participation so far have been scheduling and logistic constraints, said Terri L. Woodard, MD, of MD Anderson Cancer Center, Houston, TX, and coauthors.
Deciding among the options for fertility preservation is stressful when dealing with cancer, and patients are often so focused on their illness and treatment that it may be difficult for them to concentrate on future concerns about fertility. The NCCN Guidelines for Adolescent and Young Adult Oncology recommend referral to a mental health professional to help cancer patients make complex decisions about preserving fertility.2
As a matter of routine, all women aged 18 to 40 years at risk for treatment-related infertility are referred to the Fertility Preservation Service at MD Anderson Cancer Center.
The study reported on the first 21 women randomized to either usual care (consultation with a reproductive endocrinologist and advanced practice nurse) or intervention (usual care plus 3 sessions of psychological assessment and counseling with a licensed clinical psychologist).
As part of usual care, women receive medical consultation and counseling about the fertility-related risks of their treatment and options for fertility preservation. The team also provides fertility treatment if the patient desires it. The psychological intervention occurs at the time of the fertility preservation consult and includes brief psychosocial assessment, clarification of values specific to parenthood, and skills training in mindfulness and acceptance-based coping. Participants receive 1 face-to-face consultation for up to 75 minutes plus 2 follow-up phone calls of up to 75 minutes approximately 1 week and 1 month later.
Mean age of participants was 32 years and the majority were non-Hispanic whites. The majority were married or were partnered or dating; about a third of participants were single and 10% were divorced. Approximately 53% had breast cancer, 15% had hematologic cancer, 19% had gynecologic cancer, and 14% had other cancers.
Four patients dropped out of the study: 2 because of scheduling difficulties, 1 because of geographic location, and 1 because of worsening health status.
After 6 months of participation, patients in the intervention group had reduced depression and anxiety scores compared with those offered usual care.
Of the 12 participants with available data at the 6-month assessment, 4 patients in the usual care group and 3 in the intervention group received some form of medical intervention for fertility preservation.
Participants in the intervention group provided positive feedback about their experience and mainly were grateful that they had been given the time and space to discuss their values and goals related to fertility, learned new coping exercises, and benefited from mindfulness exercises, and experienced emotional support from their teachers. Participants suggested incorporating peer support from other cancer survivors of child-bearing age and including intimate partners in counseling.
The study was funded by a grant from NCCN, in recognition of the psychological distress about treatment-related fertility that often occurs among cancer survivors, particularly young women.
References 1. Woodard TL, Bradford A, Covarrubias L, et al. Poster presented at: National Comprehensive Cancer Network 21st Annual Conference; March 31-April 2, 2016; Hollywood, FL. 2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Adolescent and Young Adult (AYA) Oncology. Version 1.2016. www.nccn.org/professionals/physician_gls/pdf/aya.pdf. Published September 3, 2015. Accessed April 20, 2016.
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Educational Campaign Improves CRC Screening Compliance
Colorectal cancer (CRC) is the only cancer with a mortality rate that can be significantly reduced by screening; thus, following recommended guidelines for fecal occult blood testing, sigmoidoscopy, or colonoscopy is essential. Nevertheless, many patients fail to be screened for CRC at appropriate intervals or even screened at all.
A new study has shown that an educational campaign consisting of letters that encourage screening or correction of noncompliance records resulted in improved screening compliance in a Medicare Advantage population with a 2-year history of CRC screening noncompliance.
The study, presented at a poster session during the NCCN 21st Annual Conference, was conducted over a 3-year period and led by M. Jhaveri, Humana Inc, Louisville, KY. All participants were enrolled in a Medicare Advantage program and were nonresponsive to screening reminders sent in 2012 and 2013. Reminder letters were sent in September 2014, and people were followed for up to 4 months.
There were some subpopulations with a low response, in particular, those living in a small rural area, and these require further study, the authors said.
The study included 38,675 participants, who were randomized either to a provider group (n = 20,085) or to no physician (those without an attributed provider) but offered a free fecal immunochemical test (FIT) kit (n = 18,590). These 2 groups were then rerandomized to an outreach letter group (17,602 in the provider group and 15,939 in the FIT group) or control group (2483 in the provider group and 2651 in the FIT group).
A total of 414 screenings were attributed to the educational campaign, resulting in a compliance increase of 1.2% to 1.3% for each form of the outreach. In the provider group, CRC screening rates were 6.1% for the outreach letter intervention versus 4.9% in the control group, and 5.6% for the outreach letter versus 4.3% for control in the FIT group.
The provider and FIT groups had similar participant characteristics: age, sex, and geographic location. Overall, the letters were effective. A stratified analysis suggests that the campaign was consistently effective among individuals aged 67 years and older and in those who were not dual eligible (ie, qualified for both Medicare and Medicaid).
Reference
Jhaveri M, Cambon J, Cordier T, et al. Effectiveness of colorectal cancer screening messaging among individuals non-compliant with guidelines. Poster presented at: National Comprehensive Cancer Network 21st Annual Conference; March 31-April 2, 2016; Hollywood, FL.
Physical Activity and Prostate Cancer
A moderate to high level of physical activity before and after diagnosis may improve survival among patients with prostate cancer, according to a large epidemiologic study presented at the American Association for Cancer Research (AACR) 2016 Annual Meeting. The amount of sedentary time—that is, sitting and not being physically active—was not associated with prostate cancer–specific mortality (PCSM).
“Our results support evidence that prostate cancer survivors should adhere to physical activity guidelines, and suggest that physicians should consider promoting a physically active lifestyle to their prostate cancer patients,” said lead author Ying Wang, PhD, Senior Epidemiologist in the Epidemiology Research Program at the American Cancer Society (ACS) in Atlanta, GA.
She explained that previous research showed that vigorous exercise could reduce the risk of PCSM. The present study showed that the reduced risk of PCSM is associated with moderate to vigorous physical activity both before and after a prostate cancer diagnosis.
The study was based on 10,067 men who participated in the Cancer Prevention Study II Nutrition Cohort. All participants received a diagnosis of nonmetastatic prostate cancer from 1992 or 1993 to June 2011, and age at diagnosis ranged from 50 to 93 years; 600 prostate cancer deaths were recorded during the study.
Participants recorded the amount of time they spent involved in recreational physical activity (including walking, dancing, bicycling, aerobics, jogging or running, swimming laps, playing tennis or racquetball), as well as the amount of time spent sitting. Based on these reports, the researchers calculated the metabolic equivalent (MET) hours per week of activity both before and after receiving a prostate cancer diagnosis.
Results showed that moderate to vigorous exercise both before and after diagnosis yielded benefits. In an adjusted analysis, exercising for more than 17.5 MET hours per week before diagnosis was associated with a 30% lower risk of PCSM compared with exercising for fewer than 3.5 MET hours per week. The cutoff of 17.5 MET hours per week represents twice the recommended minimum of physical activity, while that of 3.5 MET hours per week is equivalent to less than 1 hour of moderate walking per week.
Looking at the level of physical activity postdiagnosis using these MET values, the researchers found that men who exercised the most had a 34% lower risk of dying of prostate cancer compared with those who exercised the least. The benefits were also seen in patients who increased their prediagnostic level of physical activity after their diagnosis.
Dr Wang noted that the ACS recommends a minimum of 150 minutes of moderate or 75 minutes of vigorous physical activity per week. “These results indicate that following these guidelines might be associated with better prognosis,” she said.
About 40% of participants said that walking was their only form of physical exercise, so the authors evaluated the benefit of walking. Walking for 4 to 6 hours per week before diagnosis was associated with a 33% reduced risk of PCSM, and walking for 7 or more hours per week before diagnosis was associated with a 37% lower risk. No statistically significant association was found for walking after diagnosis.
Some limitations of the study include self-reports instead of objective determinations of activity level and sitting time. Additionally, the effect of vigorous exercise was not analyzed separately, although other studies have suggested that vigorous exercise lowers the risk of PCSM.
Wang Y, Jacobs EJ, Gansler T, et al. Physical activity, sitting time and prostate cancer specific mortality: the Cancer Prevention Study II Nutrition Cohort. Presented at: American Association for Cancer Research 2016 Annual Meeting; April 16-20, 2016; New Orleans, LA. Abstract 1736.
Don’t Delay Radiation for DCIS
The risk of developing invasive breast cancer was higher among women with ductal carcinoma in situ (DCIS) if they delayed radiation therapy or did not receive it, according to a study presented at the AACR 2016 Annual Meeting.
More than 60,000 women are diagnosed with DCIS each year. Although only a proportion of women with DCIS will go on to develop invasive breast cancer, at present it is not possible to predict which women are at risk for more serious cancer. Thus, NCCN guidelines suggest the following primary treatment options for women with DCIS: breast-conserving surgery plus radiation, or total mastectomy, or breast-conserving surgery alone.
“This study shows that it is important for women to understand the benefits of timely receipt of radiation therapy after breast-conserving surgery,” said lead author, Ying Liu, MD, PhD, instructor of surgery at Washington University School of Medicine and researcher at Siteman Cancer Center in St. Louis, MO.
The study was based on 5916 women in the Missouri Cancer Registry who were diagnosed with first primary DCIS between 1996 and 2011. All women were treated with breast-conserving surgery; 1053 (17.8%) received radiation 8 or more weeks after surgery, which was defined as delayed radiation; another 1702 (28.8%) women did not receive any radiation as part of therapy for DCIS; and the remaining 53.4% received “timely” radiation (ie, within 8 weeks of surgery).
During 72 months of follow-up, 3.1% of women developed an ipsilateral breast tumor (invasive or in situ). An analysis adjusted for propensity scores based on age, race, tumor size, and tumor grade showed that the risk of developing an ipsilateral breast tumor was 26% higher for women who delayed radiation and 35% higher for those who did not receive radiation therapy as treatment for DCIS.
Radiation delays were significantly more common among African American women, single women, Medicaid recipients, those with larger DCIS tumors, and patients who were diagnosed more recently.
Dr Liu said that African American women, those on Medicaid, and those with larger DCIS tumors are at higher risk of recurrence. “Therefore, timeliness of radiation therapy should be improved,” she noted.
She suggested that access to healthcare and the quality of healthcare could be a possible factor leading to delayed radiation therapy.
One limitation of the study is the small number of study participants who developed ipsilateral breast tumors. These findings need to be confirmed in a larger group of patients with longer follow-up.
“Future studies should also address the contributions of patient choice, healthcare providers, facilities, and neighborhoods to therapy delay,” Dr Liu stated.
Liu Y, Yun S, Lian M, et al. Radiation therapy delay and risk of ipsilateral breast tumors in women with ductal carcinoma in situ. Presented at: American Association for Cancer Research 2016 Annual Meeting; April 16-20, 2016; New Orleans, LA. Abstract 2576.
Biologic Agents and Cardiac Toxicity
Early findings from an ongoing study show that targeted therapies used to treat hematologic malignancies can cause unintended cardiac toxicity in some patients, and can lead to cardiac-related mortality.
“Unanticipated cardiac toxicity occurred in about 4% of patients with hematologic malignancies over a 10-year period. This was not dose-dependent. It was caused by the targeted therapy. For most patients, the cardiac toxicity was reversible,” said lead author Jan Moreb, MD, University of Florida, Gainesville.
“Most patients [who develop cardiac toxicity on targeted therapy] do well with cardiac drug regimens that lead to stable compensated cardiac function with objective improvement in LVEF [left ventricular ejection fraction] seen in about 25%. Two patients had non-ST-segment elevated myocardial infarction without coronary artery disease or significant drop in left ventricular ejection fraction,” he continued.
The retrospective study, which is being conducted by hematologists/oncologists, cardiologists, and pharmacists, looked at 820 patients with hematologic malignancies and cardiac problems treated between 2005 and 2014 at the University of Florida, Gainesville.
Fifty-three patients received any of the following drugs: tyrosine kinase inhibitors, such as imatinib, dasatinib, ponatinib, and nilotinib; proteasome inhibitors, such as bortezomib and carfilzomib; immunomodulatory drugs, such as thalidomide, pomalidomide, and lenalidomide; monoclonal antibodies, such as rituximab and alemtuzumab; and hypomethylating agents such as azacitidine and decitabine.
Cardiac toxicity was confirmed in 44 of these patients. Cardiac toxicity was defined as LVEF <50%, arrhythmias, or ischemic cardiovascular event. Ten patients were excluded from the study because they had preexisting cardiac disease.
In the 34 remaining patients, the distribution of hematologic malignancies was as follows: multiple myeloma (n = 16), B-cell non-Hodgkin lymphoma (n = 10), follicular non-Hodgkin lymphoma (n = 4), Philadelphia chromosome–positive acute lymphoblastic leukemia (n = 3), and myelodysplastic syndrome (n = 1).
Median age was 66 years; there were 19 males and 15 females, 26 were Caucasian, and 15 patients were alive at the time the study was conducted.
Median time from exposure to drug and development of cardiac toxicity was 120 days (range, <1-300 days).
Unanticipated cardiac toxicity was reported in 4%, and among this 4%, 17.6% of patients died of cardiac causes.
These findings are in contrast to cardiac toxicity with anthracyclines, which is anticipated and dose-dependent, Dr Moreb said.
The authors of this study are attempting to identify clinical and genetic factors that can be used in advance to predict which patients are at risk for this complication.
In the meantime, patients taking these drugs should have their cardiac function assessed as part of a clinical visit.
Moreb JS, Mohammad H, McCullough L, et al. Incidence and natural history of cardiovascular toxicity associated with biologic agents used in hematologic malignancies. Poster presented at: American Association for Cancer Research 2016 Annual Meeting; April 16-20, 2016; New Orleans, LA.
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