Anne Moyer

Emotional Distress Following Genetic Testing for Hereditary Breast and Ovarian Cancer: A Meta-Analytic Review

OBJECTIVE Meta-analysis was used to synthesize results of studies on emotional consequences of predictive genetic testing for BRCA1/2 mutations conferring increased risk of breast and ovarian cancer. DESIGN Studies assessing anxiety or cancer-specific distress before and after provision of test results (k = 20) were analyzed using a random-effects model. Moderator variables included country of data collection and personal cancer history of study participants. MAIN OUTCOME MEASURES Standardized mean gain effect sizes were calculated for mutation carriers, noncarriers, and those with inconclusive results over short (0-4 weeks), moderate (5-24 weeks), or long (25-52 weeks) periods of time after testing. RESULTS Distress among carriers increased shortly after receiving results and returned to pretesting levels over time. Distress among noncarriers and those with inconclusive results decreased over time. Some distress patterns differed in studies conducted outside the United States and for individuals with varying cancer histories. CONCLUSION Results underscore the importance of time; changes in distress observed shortly after test-result disclosure frequently differed from the pattern of distress seen subsequently. Although emotional consequences of this testing appear minimal, it remains possible that testing may affect cognitive and behavioral outcomes, which have rarely been examined through meta-analysis. Testing may also affect understudied subgroups differently.

Pre-intervention distress moderates the efficacy of psychosocial treatment for cancer patients: a meta-analysis

This meta-analysis examined whether effects of psychosocial interventions on psychological distress in cancer patients are conditional upon pre-intervention distress levels. Published articles and unpublished dissertations between 1980 and 2005 were searched for interventions reporting the Hospital Anxiety and Depression Scale (HADS) or the Spielberger State-Trait Anxiety Inventory (STAI). Multilevel mixed-effects modeling was used to meta-analyze effect-sizes separately for the HADS (27 trials, 2,424 patients) and STAI (34 trials, 2,029 patients). Pre-intervention distress significantly moderated intervention effects, explaining up to 50% of the between-study effect-size variance: effects on anxiety and depression were generally negligible when pre-intervention distress was low and pronounced when it was high. These results could not be explained by differences in intervention type, setting, dose, and whether intervention was targeted at distressed patients. Psychosocial interventions may be most beneficial for cancer patients with elevated distress. Future research should identify which treatment components are most effective for these patients to facilitate optimal treatment tailoring and cost-effective health care.

Characteristics and methodological quality of 25 years of research investigating psychosocial interventions for cancer patients

The considerable amount of research examining psychosocial interventions for cancer patients makes it important to examine its scope and methodological quality. This comprehensive overview characterizes the field with as few exclusions as possible. A systematic search strategy identified 673 reports comprising 488 unique projects conducted over a 25 year time span. Although the literature on this topic has grown over time, the research was predominantly conducted in the United States (57.0%), largely with breast cancer patients (included in 70.5% of the studies). The intervention approach used most frequently was cognitive behavioral (32.4%), the treatment goal was often improving quality of life generally (69.5%), and the professionals delivering the interventions were typically nurses (29.1%) or psychologists (22.7%). Overall, there was some discrepancy between the types of interventions studied and the types of supportive services available to and sought by cancer patients. Strengths of this research include using randomized designs (62.9%), testing for baseline group equivalence (84.5%), and monitoring treatment, which rose significantly from being used in 48.1-64.4% of projects over time. However, deficiencies in such areas as examining treatment mechanisms and the adequacy of reporting of methodology, essential for useful syntheses of research on these interventions, remain to be addressed. Methodological challenges related to the complexity of this applied research, such as participants seeking treatment outside of research, contamination, and reactions to randomization, also were apparent. Future research could benefit from closer interactions between academic and voluntary sectors and expanding the diversity of participants.

Predictors of awareness of clinical trials and feelings about the use of medical information for research in a nationally representative US sample

Objective. We examined in a large, nationally representative sample, predictors of (1) awareness of clinical trials and (2) feelings about the use of medical information for research in order to better understand factors related to public participation in research. Design. We used data from 7011 adults included in the National Cancer Institutes Health Information National Trends Survey 2007. We examined demographics, including race and ethnicity, and history of clinically relevant disease as predictors for both outcomes. For the outcome, feelings about the use of medical information for research, we also examined awareness of clinical trials as a predictor. Results. Relative to White respondents, Black/African-American and Asian respondents were significantly less likely to have heard of clinical trials, as were Hispanic/Latino respondents relative to non-Hispanic/Latino respondents, those with lower incomes and education levels, and those who did not have a family history of cancer. Blacks/African-Americans, compared with Whites, and those with lower education levels felt significantly less positively about the use of medical information for research. Respondents who had heard of clinical trials felt significantly more positively about the use of medical information for research. Conclusion. Although some racial groups feel less positively about some aspects of research, it is also evident that awareness of clinical trials, a predictor of more positive feelings about research, is less prevalent in some groups. In addition to creative outreach efforts to foster more positive feelings about research and researchers, promoting awareness of clinical trials among the general public and among members of racial and ethnic minority groups may ameliorate low general rates of participation and the under-representation of particular groups in medical research.

Group vs. individual exercise interventions for women with breast cancer: a meta-analysis

Abstract Background. Both during and after treatment, cancer survivors experience declines in physical and psychosocial quality of life (QoL). Prior research indicates that exercise interventions alleviate problems in physical functioning and some aspects of psychological functioning. For survivors seeking social support, exercise programmes that are conducted in group settings may foster optimal QoL improvement (by addressing additional issues related to isolation and social support) over individually based exercise programmes. Methods. We reviewed literature on group cohesion in exercise studies, and conducted a meta-analysis to test the hypothesis that group as compared to individual exercise interventions for breast cancer survivors would show greater improvement in QoL. Results. As currently implemented, group exercise interventions showed no advantage. However, they typically did not provide any evidence that they capitalised upon potentially beneficial group processes. Conclusions. Future exercise intervention studies could investigate the effect on QoL of deliberately using group dynamics processes, such as team-building experiences and group goal setting to foster group cohesion.

Rating Methodological Quality: Toward Improved Assessment and Investigation

Assessing methodological quality is considered essential in deciding what investigations to include in research syntheses and in detecting potential sources of bias in meta-analytic results. Quality assessment is also useful in characterizing the strengths and limitations of the research in an area of study. Although numerous instruments to measure research quality have been developed, they have lacked empirically-supported components. In addition, different summary quality scales have yielded different findings when they were used to weight treatment effect estimates for the same body of research. Suggestions for developing improved quality instruments include: distinguishing distinct domains of quality, such as internal validity, external validity, the completeness of the study report, and adherence to ethical practices; focusing on individual aspects, rather than domains of quality; and focusing on empirically-verified criteria. Other ways to facilitate the constructive use of quality assessment are to improve and standardize the reporting of research investigations, so that the quality of studies can be more equitably and thoroughly compared, and to identify optimal methods for incorporating study quality ratings into meta-analyses.

Lessons to be learned from 25 years of research investigating psychosocial interventions for cancer patients.

Conducting rigorous psychosocial intervention research with cancer patients has many challenges including encouraging them to join studies, asking them to engage in interventions or be part of control conditions, and to provide data over follow-up assessments. Here, we highlight valuable insights regarding such challenges provided by investigators studying psychosocial interventions for cancer patients. Handling these skillfully has important implications for the internal and external validity of this research and the ethical treatment of participants. Challenges noted in research reports included in a systematic review of 25 years of research (comprising 488 unique projects) investigating interventions designed to enhance cancer patients’ quality of life were compiled. Among the difficulties mentioned was the fact that patients may not feel the need for psychosocial interventions and thus may not be interested in joining an intervention study. Patients who do feel the need for such interventions may be deterred from joining trials by the prospect of being randomized to a nonpreferred group; if they do join a trial, participants may be disappointed, drop out, or seek compensatory additional assistance when they are assigned to a control group. Apart from randomization, other aspects of research may be off-putting to participants or potential participants, such as the language of consent forms or the intrusiveness of questions being asked. Potential remedies, such as research awareness interventions, monetary incentives, partnering with cancer support organizations, and using designs that take preferences into account merit consideration and further research inquiry.

Mediators of Change in Psychosocial Interventions for Cancer Patients: A Systematic Review

Careful reviews and meta-analyses have made valuable contributions to understanding the efficacy of psychosocial interventions for cancer patients. An important next step is to determine the mediators that explain the influence of efficacious interventions on outcomes. This systematic review summarizes tests of mediating variables from twenty-two projects conducted from 1989–2010. Although all authors provided some type of rationale for considering particular mediating relationships, the investigations varied widely with respect to the extent to which formal theoretical constructs were tested, the type and goals of the interventions studied, and the broad types of outcomes and potential mediators examined. Although there was some evidence supporting selected mediating relationships, with positive findings often found when mediating variables represented behaviors targeted by an intervention, the findings were mixed. Expanding the focus of research to include mechanisms in psychosocial oncology intervention research is necessary for providing a unified picture of how mediating relationships may be operating in this field.

Depression as a predictor of disease progression and mortality in cancer patients: a meta-analysis.

We read with interest the skillful meta-analysis by Satin et al indicating that depression is predictive of all-cause mortality, but not disease progression, in cancer patients. We commend the authors for their thoughtful methodology and interpretations, and wish to highlight important questions raised by the article. How do the effects compare with effects in the general population? To put their findings in context, the authors noted that a comparable meta-analysis found a more robust effect of depression on mortality in patients with cardiac disease. Another meta-analysis (cited by Satin et al but not directly compared with their results) reported an 81% higher mortality rate among subclinically and clinically depressed individuals in community samples, whereas Satin et al found mortality rates to be higher by 39% (for clinical depression) and 25% (for depressive symptoms). Thus, the effect of depression on mortality may not be greater (and potentially somewhat smaller) in cancer patients compared with the general population. Does depression increase the risk of dying from cancer? Satin et al noted surprise that depression predicted allcause mortality but not disease progression. However, if depression is predictive of all-cause (not cancer-specific) mortality in cancer patients as it is in the general population, this effect may have little to do with the effect of depression on cancer-specific course or outcome (as is aptly pointed out by Satin et al). As such, the authors’ postulate that the nonsignificant link between depression and disease progression in cancer patients is due to the limited number of extant studies should remain speculative until more research has accrued. What are the implications of the assumed (but controversial) importance of mortality as a primary endpoint of psychosocial oncology interventions? Depression can be lifethreatening, and the findings of Satin et al support the notion that treating depression to prevent mortality is as important for cancer patients as for anyone else. However, the findings do not speak directly to the role of interventions for depression in facilitating survival from cancer. REFERENCES

Published versus unpublished dissertations in psycho-oncology intervention research.

Objective: There are conflicting views regarding whether gray literature, including unpublished doctoral dissertations, should be included in systematic reviews and meta‐analyses. Although publication status frequently is used as a proxy for study quality, some research suggests that dissertations are often of superior quality to published studies.