Kristen McCarter

Eating As Treatment (EAT) study protocol: a stepped-wedge, randomised controlled trial of a health behaviour change intervention provided by dietitians to improve nutrition in patients with head and neck cancer undergoing radiotherapy

Introduction Maintaining adequate nutrition for Head and Neck Cancer (HNC) patients is challenging due to both the malignancy and the rigours of radiation treatment. As yet, health behaviour interventions designed to maintain or improve nutrition in patients with HNC have not been evaluated. The proposed trial builds on promising pilot data, and evaluates the effectiveness of a dietitian-delivered health behaviour intervention to reduce malnutrition in patients with HNC undergoing radiotherapy: Eating As Treatment (EAT). Methods and analysis A stepped-wedge cluster randomised design will be used. All recruitment hospitals begin in the control condition providing treatment as usual. In a randomly generated order, oncology staff at each hospital will receive 2 days of training in EAT before switching to the intervention condition. Training will be supplemented by ongoing supervision, coaching and a 2-month booster training provided by the research team. EAT is based on established behaviour change counselling methods, including motivational interviewing, cognitive–behavioural therapy, and incorporates clinical practice change theory. It is designed to improve motivation to eat despite a range of barriers (pain, mucositis, nausea, reduced or no saliva, taste changes and appetite loss), and to provide patients with practical behaviour change strategies. EAT will be delivered by dietitians during their usual consultations. 400 patients with HNC (nasopharynx, hypopharynx, oropharynx, oral cavity or larynx), aged 18+, undergoing radiotherapy (>60 Gy) with curative intent, will be recruited from radiotherapy departments at 5 Australian sites. Assessments will be conducted at 4 time points (first and final week of radiotherapy, 4 and 12 weeks postradiotherapy). The primary outcome will be a nutritional status assessment. Ethics and dissemination Ethics approval from all relevant bodies has been granted. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. Trial registration number ACTRN12613000320752.

Smoking cessation care among patients with head and neck cancer: a systematic review

Objective To examine the effectiveness of smoking cessation interventions in improving cessation rates and smoking related behaviour in patients with head and neck cancer (HNC). Design A systematic review of randomised and non-randomised controlled trials. Methods We searched the following data sources: CENTRAL in the Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL up to February 2016. A search of reference lists of included studies and Google Scholar (first 200 citations published online between 2000 and February 2016) was also undertaken. The methodological quality of included studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). 2 study authors independently screened and extracted data with disagreements resolved via consensus. Results Of the 5167 studies identified, 3 were eligible and included in the review. Trial designs of included studies were 2 randomised controlled trials and 1 non-randomised controlled trial. 2 studies received a weak methodological rating and 1 received a moderate methodological rating. The trials examine the impact of the following interventions: (1) nurse delivered cognitive–behaviour therapy (CBT) via telephone and accompanied by a workbook, combined with pharmacotherapy; (2) nurse and physician brief advice to quit and information booklets combined with pharmacotherapy; and (3) surgeon delivered enhanced advice to quit smoking augmented by booster sessions. Only the trial of the nurse delivered CBT and pharmacotherapy reported significant increases in smoking cessation rates. 1 study measured quit attempts and the other assessed consumption of cigarettes per day and readiness to change. There was no significant improvement in quit attempts or cigarettes smoked per day among patients in the intervention groups, relative to control. Conclusions There are very few studies evaluating the effectiveness of smoking cessation interventions that report results specific to the HNC population. The 3 trials identified reported equivocal findings. Extended CBT counselling coupled with pharmacotherapy may be effective. Trial registration number CRD42016016421.

Interventions to improve screening and appropriate referral of patients with cancer for distress: systematic review protocol

Introduction It is estimated that 35–40% of patients with cancer experience distress at some stage during their illness. Distress may affect functioning, capacity to cope, treatment compliance, quality of life and survival of patients with cancer. Best practice clinical guidelines recommend routine psychosocial distress screening and referral for further assessment and/or psychosocial support for patients with cancer. However, evidence suggests this care is not provided consistently. Methods and analysis We developed our methods following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The review is registered with PROSPERO and any amendments to the protocol will be tracked. The primary aim of this systematic review is to examine the impact of interventions delivered in healthcare settings that are aimed at (1) improving routine screening of patients for psychosocial distress and (2) referral of distressed patients with cancer for further assessment and/or psychosocial support. The effectiveness of such interventions in reducing psychosocial distress, and any unintended adverse effect of the intervention will also be assessed in patients with cancer. Data sources will include the bibliographic databases Cochrane Central Register of Controlled trials (CENTRAL) in the Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL. Eligible studies must compare an intervention (or two or more interventions) in a healthcare setting to improve the rate of screening for psychosocial distress and/or referral for further assessment and/or psychosocial support for patients with cancer with no intervention or ‘usual’ practice. Two investigators will independently review titles and abstracts, followed by full article reviews and data extraction. Disagreements will be resolved by consensus and if necessary, a third reviewer. Where studies are sufficiently homogenous, trial data will be pooled and meta-analyses performed. Ethics and dissemination No ethical issues are foreseen. The findings of this study will be disseminated widely via peer-reviewed publications and conference presentations. Systematic review registration PROSPERO registration number CRD4 2015017518.

Effectiveness of clinical practice change strategies in improving dietitian care for head and neck cancer patients according to evidence-based clinical guidelines: a stepped-wedge, randomized controlled trial

Best practice guidelines make a number of recommendations regarding dietitian management of head and neck cancer (HNC) patients. Randomized trials assessing the effectiveness of clinical practice change strategies for improving the nutritional management of HNC patients have not previously been conducted. The purpose of this study was to evaluate the effect of practice change strategies on improving the implementation of best practice guideline recommendations for the nutritional management of HNC patients. Four Australian radiotherapy departments participated in a stepped-wedge, randomized controlled trial. Baseline data were collected across all sites simultaneously, and the intervention was then introduced to each site sequentially, in a randomly determined order. During the intervention phase, sites received a range of supportive clinical practice change strategies to facilitate dietitian adherence to clinical practice guidelines. To assess the associated practice change by dietetic staff, we evaluated the change in implementation of six guideline recommendations for dietitians from preintervention to postintervention periods. Adherence to the clinical practice guidelines during the preintervention period was generally very low. The clinical practice change strategies significantly improved the odds of provision of four of the six guideline recommendations. The study found the intervention significantly enhanced dietitian provision of recommended care for HNC patients during the postintervention period. This finding holds clinical importance for clinician and health service effective implementation of guideline recommendations as well as HNC patient treatment outcomes. Trial registration number ACTRN12613000320752, https://www.anzctr.org.au.

Associations between personality disorder characteristics and treatment outcomes in people with co-occurring alcohol misuse and depression.

BackgroundPersonality disorders are highly comorbid with alcohol misuse and depressive symptomatology; however, few studies have investigated treatment outcomes in this population. The aim of this study was to examine relationships between baseline personality disorder cluster profiles and overall and treatment-related changes for those with co-occurring alcohol misuse and depression.MethodsSecondary analysis was conducted using a subset of data (N = 290) from two randomised controlled trials of psychological interventions for co-occurring alcohol misuse and depression, which did not specifically target personality disorders. Baseline dimensional personality disorder cluster scores were derived from the International Personality Disorder Examination Questionnaire (IPDEQ). Four treatment conditions were compared: a brief integrated intervention, followed by no further treatment, or nine further sessions of integrated-, alcohol-, or depression-focused treatment. Associations between IPDEQ scores and changes in alcohol use, depressive symptoms and functioning from baseline to the 6- and the 12-month follow-ups were of primary interest.ResultsPersonality disorder cluster scores moderately negatively impacted on overall change (primarily Cluster C), as well as treatment-related outcomes (primarily Cluster A), particularly changes in depressive symptoms and psychosocial functioning. Longer interventions appeared to be more effective in the longer-term (e.g., at 12-month follow-up), with integrated interventions relatively more effective than single-focused ones for individuals with higher personality disorder cluster scores.ConclusionsGreater attention needs to be paid to particular personality disorder clusters during the assessment and treatment of individuals with co-occurring alcohol misuse and depression. Integrated interventions, incorporating motivational interviewing and cognitive behaviour therapy, may provide a useful therapeutic framework. Integrated interventions also provide opportunities for adjunctive components focussing on other issues and coping strategies (e.g., to offset negative affective states), potentially tailored to the characteristics and needs of individual participants.

Interventions to improve screening and appropriate referral of patients with cancer for psychosocial distress: systematic review

Objectives The primary aim of the review was to determine the effectiveness of strategies to improve clinician provision of psychosocial distress screening and referral of patients with cancer. Design Systematic review. Data sources Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched until July 2016. Inclusion criteria Population: adult patients with cancer and clinical staff members. Intervention: any strategy that aimed to improve the rate of routine screening and referral for detected distress of patients with cancer. Comparison: no intervention controls, ‘usual’ practice or alternative interventions. Outcome: (primary) any measure of provision of screening and/or referral for distress, (secondary) psychosocial distress, unintended adverse effects. Design: trials with or without a temporal comparison group, including randomised and non-randomised trials, and uncontrolled pre–post studies. Data extraction and analysis Two review authors independently extracted data. Heterogeneity across studies precluded quantitative assessment via meta-analysis and so a narrative synthesis of the results is presented. Results Five studies met the inclusion criteria. All studies were set in oncology clinics or departments and used multiple implementation strategies. Using the Grades of Recommendation, Assessment, Development and Evaluation, the overall rating of the certainty of the body of evidence reported in this review was assessed as very low. Three studies received a methodological quality rating of weak and two studies received a rating of moderate. Only one of the five studies reported a significant improvement in referrals. Conclusions The review identified five studies of predominantly poor quality examining the effectiveness of strategies to improve the routine implementation of distress screening and referral for patients with cancer. Future research using robust research designs, including randomised assignment, are needed to identify effective support strategies to maximise the potential for successful implementation of distress screening and referral for patients with cancer. PROSPERO registration number CRD42015017518.

Protocol for a systematic review of psychological treatment for methamphetamine use: an analysis of methamphetamine use and mental health symptom outcomes

Introduction People who use methamphetamine (MA) regularly, often experience symptoms of mental ill health associated with the use of the drug. These include symptoms of psychosis, depression, anxiety and also cognitive deficits. Accordingly, psychological treatments aim to reduce MA use and related problems, including symptoms of mental ill health. Although there has been a substantial body of research reporting on the evidence of effectiveness of psychological treatments for MA use, there is a paucity of research addressing the effectiveness of these treatments for coexisting symptoms of mental ill health. We aim to address this gap by providing a comprehensive overview of the evidence for psychological treatments for MA use and associated symptoms of mental ill health in experimental/controlled clinical studies. In addition, a critical evaluation of study methods and the outcomes of psychological interventions on MA use and symptoms of mental ill health will be conducted. Methods and analysis The Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement will be used to inform the methods of this review. Eight electronic peer-reviewed databases will be searched. Pilot searches have been conducted for MA literature considering controlled clinical trials only. Eligible articles will be independently assessed against inclusion criteria. Before final analyses are completed, searches will be rerun and if eligible, additional studies will be retrieved for inclusion. A quantitative synthesis of the findings will be reported where possible, and ‘summary of findings’ tables will be generated for each comparison. Risk ratios and 95% CI (dichotomous outcomes) will be calculated and/or effect size according to Cohen’s formula (continuous outcomes) for the primary outcome of each trial. Ethics and dissemination No ethical issues are foreseen. Findings will be disseminated widely to clinicians and researchers via journal publication and conference presentation(s). Trial registration number CRD42016043657.

Head and neck cancer patient experience of a new dietitian-delivered health behaviour intervention: 'you know you have to eat to survive'

PurposeThe aim of this study was to explore head and neck cancer (HNC) patient experiences of a novel dietitian delivered health behaviour intervention.MethodsThis study is a qualitative study which employed semi-structured individual interviews using open and axial coding and then final selective coding to organise the data. Patients with HNC who had participated in a dietitian delivered health behaviour intervention to reduce malnutrition were invited to discuss their experience of this intervention. Individual interviews were conducted, transcribed and analysed using grounded theory.ResultsNine patients participated in the interviews. Four dimensions were identified in the initial coding process: ‘information’, which described patients’ desire for tailored advice during their treatment; ‘challenges of treatment experience’, which described the difficulties related to treatment side effects; ‘key messages: importance of eating and maintaining weight’, which covered perceived integral messages delivered to patients by dietitians; and ‘dietitian’s approach’ describing patient experiences of empathic and compassionate dietitians. Two overarching themes resulted from examining the connections and relationships between these dimensions: ‘survival’, a connection between eating and living; and ‘support’, describing the valued working partnership between dietitian and patient.ConclusionsDimensions and themes overlapped with the qualitative literature on HNC patient experience of treatment. However, some themes, such as the empowerment of a message linking eating to survival, appeared unique to this study. Patients found this message to be delivered in a supportive manner that motivated change.

Smoking, drinking, and depression: comorbidity in head and neck cancer patients undergoing radiotherapy

We aimed to determine the prevalence and co‐occurrence of tobacco smoking, alcohol consumption, and depressive symptoms among a sample of head and neck cancer (HNC) patients undergoing radiotherapy. A total of 307 HNC patients participated in a multi‐site stepped‐wedge randomized controlled trial (RCT) evaluating the effectiveness of a dietitian‐delivered health behavior intervention in patients with HNC undergoing radiotherapy. During week one of radiotherapy patients completed measures of smoking, alcohol consumption, and level of depression. Approximately one‐fifth (21%) of patients had two or more co‐occurring problems: current smoking, hazardous alcohol use, and/or likely presence of a major depressive episode (MDE). Approximately one‐third (34%) of the sample were current smokers, one‐third (31%) were drinking hazardously and almost one‐fifth (19%) had likely cases of depression. Comorbidity of smoking, hazardous alcohol use, and MDE is high in HNC patients, and interventions need to address this cluster of cancer risk factors.

Eating as Treatment (EAT): improving treatment outcomes for head and neck cancer patients undergoing radiotherapy with a health behavior intervention

Genetic polymorphism of infl ammation response genes TNF-α -308g > A and TL-8 -251 T > A and their infl uence on colorectal cancer predisposition risk in mala y sian population MM AMINUDIN, MS SITINURFATIMAH, AA AHMADAIZAT, RN VENKATESH, BM BISWAL, Z ZAIDI, AMS SHANWANI, AH MOHAMMAD RADZI, R ANKATHIL Human Genome Centre, Department of Nuclear Medicine, Radiotherapy & Oncology, School of Medical Sciences, Department of Pathology, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia, Surgical Department, Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, Malaysia, Internal Medicine Department, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia