Daniel C. McFarland

Early Childhood Adversity and its Associations With Anxiety, Depression, and Distress in Women With Breast Cancer

BACKGROUND Certain vulnerability factors have been found to place patients at risk for depression and anxiety, especially within the context of medical illness. OBJECTIVES We sought to describe the relationships among early childhood adversity (ECA) and anxiety, depression and distress in patients with breast cancer. METHODS Patients with breast cancer (stages 0-IV) were assessed for ECA (i.e., the Risky Families Questionnaire subscales include Abuse/Neglect/Chaotic Home Environment), distress (i.e., Distress Thermometer and Problem List), anxiety (Hospital Anxiety and Depression Scale-Anxiety), depression (Hospital Anxiety and Depression Scale-Depression), meeting standardized cut-off thresholds for distress (Distress Thermometer and Problem List ≥4 or ≥7)/anxiety (Hospital Anxiety and Depression Scale-Anxiety ≥8)/depression (Hospital Anxiety and Depression Scale-Depression ≥8) and demographic factors. RESULTS A total of 125 participants completed the study (78% response rate). ECA was associated with depression (p <0.001), anxiety (p = 0.001), and distress (p = 0.006), meeting cut-off threshold criteria for distress (p = 0.024), anxiety (p = 0.048), and depression (p = 0.001). On multivariate analysis, only depression (p = 0.04) and emotional issues (i.e., component of Distress Thermometer and Problem List) (p = 0.001) were associated with ECA. Neglect, but not Abuse and Chaotic Home Environment, was associated with depression (β = 0.442, p < 0.001), anxiety (β = 0.342, p = 0.002), and self-identified problems with family (β = 0.288, p = 0.022), emotion (β = 0.345, p = 0.004), and physical issues (β = 0.408, p < 0.001). CONCLUSION ECA and neglect are associated with multiple psychologic symptoms, but most specifically depression in the setting of breast cancer. ECA contributes to psychologic burden as a vulnerability factor. ECA may help to explain individual patient trajectories and influence the provision of patient-centered care for psychologic symptoms in patients with breast cancer.

Predictors of patient satisfaction with inpatient hospital pain management across the United States: A national study

Satisfactory pain management of hospitalized patients remains a national unmet need for the United States. Although prior research indicates that inpatient pain management may be improving nationally, not all populations of patients rate pain management as equally satisfactory. County-level predictors, such as demographics and population density, and hospital-level predictors (eg, hospital-bed number), are understudied determinants of pain management patient satisfaction. We created a multivariate regression model of pain management patient satisfaction scores as indicated by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results based on county and hospital level predictors. Number of hospital beds (β = -0.16), percent foreign-born (β = -0.16), and population density (β = -0.08) most strongly predicted unfavorable ratings, whereas African American (β = 0.23), white (β= 0.23), and younger population (β = 0.08) most strongly predicted favorable ratings. Greater attention should be placed on pain management in larger hospitals that serve foreign-born patients in population-dense areas. Journal of Hospital Medicine 2016;11:498-501.

Signaling pathways in lymphoma: pathogenesis and therapeutic targets

Lymphoma is the fifth most common cancer in the USA. Most lymphomas are classified as non-Hodgkins lymphoma, and nearly 95% of these cancers are of B-cell origin. B-cell receptor (BCR) surface expression and BCR functional signaling are critical for survival and proliferation of both healthy B cells, as well as most B-lymphoma cells. Agents that inhibit various components of the BCR signaling pathway, as well as parallel signaling pathways, are currently in clinical trials for the treatment of various lymphoma subtypes, including those targeting isoforms of PI3K, mTOR and BTK. In this review, we describe the signaling pathways in healthy mature B cells, the aberrant signaling in lymphomatous B cells and the rationale for clinical trials of agents targeting these pathways as well as the results of clinical trials to date. We propose that the entry into a kinase inhibitor era of lymphoma therapy will be as transformative for our patients as the advent of the antibody or chemotherapy era before it.

Prevalence of physical problems detected by the distress thermometer and problem list in patients with breast cancer

Patients with breast cancer have high rates of physical symptoms that negatively impact their quality of life. The relationship between womens perceptions of these physical symptoms and patient demographic and breast cancer characteristics is less well known. This study describes physical symptoms of patients with breast cancer and their relationship with patient characteristics.

Resilience of internal medicine house staff and its association with distress and empathy in an oncology setting

Resilience is a beneficial trait for resident physicians who are exposed to adversity through their work with patients. Inpatient hematology–oncology produces vicarious trauma for physicians in training. Physician distress and empathy influence patient care and may be associated with respectively lower and greater levels of resilience.

Acute empathy decline among resident physician trainees on a hematology-oncology ward: an exploratory analysis of house staff empathy, distress, and patient death exposure.

A reason for empathy decline during medical training has not been fully elucidated. Empathy may decrease acutely during an inpatient hematology–oncology rotation because of the acuity of death exposures. This study aimed to explore physician trainee empathy, distress, death exposures, and their attributed meaning for the trainee.

Predictors of Satisfaction With Doctor and Nurse Communication: A National Study

ABSTRACT Prior research indicates that effective communication between medical providers and patients is associated with a number of positive patient outcomes, yet little research has examined how ecological factors (e.g., hospital size, local demographics) influence patients’ reported satisfaction with doctor and nurse communication. Given the current emphasis on improving patient satisfaction in hospitals across the United States, understanding these factors is critical to interpreting patient satisfaction and improving patient-centered communication, particularly in diverse and dense populations. As such, this study examined county-level data including population density, population diversity, and hospital structural factors as predictors of patient satisfaction with doctor and nurse communication. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), U.S. Census data, and number of hospital beds were obtained from publicly available Hospital Compare, U.S. Census, and American Hospital Directory websites, respectively. Multivariate regression modeling was performed for the individual dimensions of HCAHPS scores assessing doctor and nurse communication. Standardized partial regression coefficients were used to assess strengths of county-level predictors. County-level factors accounted for 30% and 16% of variability in patient satisfaction with doctor and nurse communication, respectively. College education (β = 0.45) and White ethnicity (β = 0.25) most strongly predicted a favorable rating of doctor and nurse communication, respectively. Primary language (non-English speaking; β = −0.50) most strongly predicted an unfavorable rating of doctor communication, while number of hospital beds (β = −0.16) and foreign-born (β = −0.16) most strongly predicted an unfavorable rating of nurse communication. County-level predictors should be considered when interpreting patient satisfaction with doctor and nurse communication and designing multilevel patient-centered communication improvement strategies. Discordant findings with individual-level factors should be explored further.

ReCAP: Would Women With Breast Cancer Prefer to Receive an Antidepressant for Anxiety or Depression From Their Oncologist?

PURPOSE Patient treatment preferences for the management of anxiety and depression influence adherence to treatment and treatment outcomes, yet the preferences of patients with breast cancer for provider-specific pharmacologic management of anxiety and depression is unknown. This study examined the antidepressant prescriber preferences of patients with breast cancer and their preferences for treatment by a mental health professional. METHODS Patients with breast cancer (stages 0 to IV) were asked two questions: “Would you be willing to have your oncologist treat your depression or anxiety with an antidepressant medication if you were to become depressed or anxious at any point during your treatment?” and “Would you prefer to be treated by a psychiatrist or mental health professional for problems with either anxiety or depression?” In addition, the Distress Thermometer and Problem List, Hospital Anxiety and Depression Scale, Risky Families Questionnaire, and demographic information were assessed. RESULTS One hundred twenty-five participants completed the study. A total of 60.4% were willing to accept an antidepressant from an oncologist, and 26.3% preferred treatment by a mental health professional. The 77.3% who were willing to receive an antidepressant from their oncologist reported either no preference or that treatment by a mental health professional did not matter (P = .01). Participants taking antidepressants (P = .02) or reporting high chronic stress (P = .03) preferred a mental health professional. CONCLUSION The majority of patients accepted antidepressant prescribing by their oncologist; only a minority preferred treatment by a mental health professional. These findings suggest that promoting education of oncologists to assess psychological symptoms and manage anxiety and depression as a routine part of an outpatient visit is beneficial

Changes in Pathological Complete Response Rates after Neoadjuvant Chemotherapy for Breast Carcinoma over Five Years.

Historically, neoadjuvant chemotherapy (NACT) was extrapolated from adjuvant regimens. Dual HER2 blockade and the introduction of carboplatin for triple negative breast cancers (TNBC) emerged by December 2013 and have improved pathological complete response (pCR) rates. The objective of this study was to assess the pCR rates before and after the introduction of these new neoadjuvant regimens. Materials and Methods. Stage I–III breast cancer patients who received NACT were analyzed for rates of pCR by clinical characteristics (i.e., age, BMI, axillary lymphadenopathy, and histologic subtype), by time period (1 = 3/2010–11/2013, 2 = 12/2013–3/2015), and by type of chemotherapy (e.g., anthracycline/taxane only, carboplatin-containing, and HER2 blockade). Results. 113 patients received NACT. Overall pCR rate was 26.5 percent (n = 30). The pCR rate increased from 14% to 43.1% (p = 0.001) from time period 1 to time period 2 and were associated with HER2 positivity (p = 0.003), receiving treatment during time period 2 (p = 0.001) and using an anthracycline/taxane plus additional agent type of regimen (p = 0.004). Conclusions. Our study revealed a significant difference in rates of pCR over five years. Window of opportunity trials and other trials that utilize pCR analysis should be encouraged.

Neoadjuvant Therapy in Differentiated Thyroid Cancer.

Objectives. Invasion of differentiated thyroid cancer (DTC) into surrounding structures can lead to morbid procedures such as laryngectomy and tracheal resection. In these patients, there is a potential role for neoadjuvant therapy. Methods. We identified three studies involving the treatment of DTC with neoadjuvant chemotherapy: two from Slovenia and one from Japan. Results. These studies demonstrate that in selected situations, neoadjuvant chemotherapy can have a good response and allow for a more complete surgical resection, the treatment of DTC. Additionally, the SELECT trial shows that the targeted therapy lenvatinib is effective in the treatment of DTC and could be useful as neoadjuvant therapy for this disease due to its short time to response. Pazopanib has also demonstrated promise in phase II data. Conclusions. Thus, chemotherapy in the neoadjuvant setting could possibly be useful for managing advanced DTC. Additionally, some of the new tyrosine kinase inhibitors (TKIs) hold promise for use in the neoadjuvant setting in DTC.