Michael Hoerger

Values and options in cancer care (VOICE): study design and rationale for a patient-centered communication and decision-making intervention for physicians, patients with advanced cancer, and their caregivers

BackgroundCommunication about prognosis and treatment choices is essential for informed decision making in advanced cancer. This article describes an investigation designed to facilitate communication and decision making among oncologists, patients with advanced cancer, and their caregivers.Methods/designThe Values and Options in Cancer Care (VOICE) Study is a National Cancer Institute sponsored randomized controlled trial conducted in the Rochester/Buffalo, NY and Sacramento, CA regions. A total of 40 oncologists, approximately 400 patients with advanced cancer, and their family/friend caregivers (one per patient, when available) are expected to enroll in the study. Drawing upon ecological theory, the intervention uses a two-pronged approach: oncologists complete a multifaceted tailored educational intervention involving standardized patient instructors (SPIs), and patients and caregivers complete a coaching intervention to facilitate prioritizing and discussing questions and concerns. Follow-up data will be collected approximately quarterly for up to three years.DiscussionThe intervention is hypothesized to enhance patient-centered communication, quality of care, and patient outcomes. Analyses will examine the effects of the intervention on key elements of physician-patient-caregiver communication (primary outcomes), the physician-patient relationship, shared understanding of prognosis, patient well-being, and health service utilization (secondary outcomes).Trial registrationClinical Trials Identifier: NCT01485627

Impulsive responses to positive mood and reward are related to mania risk

Bipolar disorder is characterised by impulsivity, and recent research suggests it is important to consider more specific forms of impulsivity. In two student samples, we examined associations of self-reported impulsivity with mania risk (Hypomanic Personality Scale, HPS). We hypothesised that mania risk would relate to impulsivity in the context of opportunities for rewarding activities (Delaying Gratification Inventory, DGI), reward pursuit (Fun-Seeking subscale of the Behavioural Activation Scale, BAS), and when experiencing positive affect (Positive Urgency Measure, PUM). In Study 1 (N=823), the HPS was uniquely related to Fun-Seeking and PUM scores. Study 2 (N=482) replicated the correlation of HPS scores with PUM while documenting positive associations between PUM and trait-like responses to positive affect. Findings across both studies stress the importance of considering the role of positive emotion in driving the impulsivity among persons at risk for mania. These findings have implications for refining our understanding of the aetiology of bipolar disorder and for treatment development.

Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer: The VOICE Randomized Clinical Trial.

Importance Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported. Objective To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life. Design, Setting, and Participants Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers. Interventions Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training. Main Outcomes and Measures The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life. Results Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant. Conclusions and Relevance A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes. Trial Registration clinicaltrials.gov Identifier: NCT01485627

Toward Identifying the Effects of the Specific Components of Mindfulness-Based Stress Reduction on Biologic and Emotional Outcomes Among Older Adults

OBJECTIVES The objectives of this study were to examine the effects of specific Mindfulness-Based Stress Reduction (MBSR) activities (yoga, sitting and informal meditation, body scan) on immune function, circulating insulin-like growth factor (IGF)-1 concentrations, and positive affect among older adults. DESIGN The study design comprised longitudinal analyses of data from subjects in an 8-week MBSR program. SETTING The study was conducted at a University-affiliated health center. SUBJECTS This study involved 100 community-dwelling older adults. Inclusion criteria were as follows: ≥65 years of age and English-speaking. INTERVENTION This was an 8-week MBSR program. OUTCOME MEASURES Interleukin (IL)-6 and IGF-1 levels were assayed from blood collected at postintervention assessments. Participants were immunized postintervention with keyhole limpet hemocyanin (KLH), and immunoglobulin (Ig)M and IgG KLH-specific antibody responses were measured prior to immunization as well as 3 weeks and 24 weeks postintervention. Participants completed a 10-item measure of positive affect at study entry and postintervention. RESULTS Participants maintained weekly practice logs documenting participation in yoga, sitting meditation, informal meditation, and body scan. More practice of yoga was associated with higher post-treatment IGF-1 levels and greater improvement in positive affect from study entry to postintervention. Sitting meditation was positively associated with post-treatment IGF-1. Greater use of body scanning was associated with reduced antigen-specific IgM and IgG 3 weeks postintervention but not 24 weeks. No associations were found between MBSR activities and IL-6 levels. CONCLUSIONS Practice of MBSR activities, particularly yoga, could provide benefits for specific aspects of physiologic function and positive affect. Changes in adaptive immunity in older adult MBSR practitioners warrant further study.

Emotional benefits of mindfulness-based stress reduction in older adults: the moderating roles of age and depressive symptom severity.

Objectives: To examine the effects of age and depressive symptom severity on changes in positive affect among older adults randomly assigned to a Mindfulness-Based Stress Reduction (MBSR) program or a Waitlist Control group. Drawing from the Motivational Theory of Life-Span Development, we hypothesized that lower levels of depressive symptom severity and older age would be associated with greater positive affect in response to the MBSR intervention. Methods: Data were collected from a sample of community-dwelling English-speaking adults (n = 200) aged ≥ 65, randomly assigned to an eight-week MBSR program or a Waitlist Control group. Our main outcome variable was a five-item measure of positive affect, which was measured at study entry as well as eight weeks and six months later. Results: At the six-month follow-up, we observed group by baseline depressive symptom severity (β = −.17, p = .02) and group by baseline depressive symptom severity by age (β = −.14, p = .05) interactions. Among MBSR participants, greater baseline depressive symptom severity was also associated with less improvement in positive affect at the six-month follow-up (β = −.30, p = .003). Findings were qualified by a significant depressive symptom severity by age interaction (β = −.25, p = .01), such that MBSR participants who were 70 and over with lower baseline depressive symptom severity having the greatest improvement in positive affect at the six-month follow-up. Conclusion: MBSR improves positive affect for older adults with lower depressive symptom severity, perhaps because it capitalizes on naturalistic changes in control strategies.

Affective forecasting and medication decision making in breast-cancer prevention.

OBJECTIVE Over 2 million American women at elevated risk for breast cancer are eligible to take chemoprevention medications such as tamoxifen and raloxifene, which can cut in half the risk of developing breast cancer, but which also have a number of side effects. Historically, very few at-risk women have opted to use chemoprevention medications. Affective forecasting theory suggests that people may avoid these medications if they expect taking them to increase their health-related stress. METHOD After receiving an individually tailored decision aid that provided personalized information about the risks and benefits of these medications, 661 women at elevated risk of breast cancer were asked to make 3 affective forecasts, predicting what their level of health-related stress would be if they took tamoxifen, raloxifene, or neither medication. They also completed measures of decisional preferences and intentions, and at a 3-month follow-up, reported on whether or not they had decided to use either medication. RESULTS On the affective forecasting items, very few women (<10%) expected the medications to reduce their health-related stress, relative to no medication at all. Participants with more negative affective forecasts about taking a chemoprevention medication expressed lower preferences and intentions for using the medications (Cohens ds from 0.74 to 0.79) and were more likely to have opted against using medication at follow-up (OR range = 1.34-2.66). CONCLUSION These findings suggest that affective forecasting may explain avoidance of breast-cancer chemoprevention medications. They also highlight the need for more research aimed at integrating emotional content into decision aids. (PsycINFO Database Record

Personality Change Pre- to Post- Loss in Spousal Caregivers of Patients With Terminal Lung Cancer

Personality is relatively stable in adulthood but could change in response to life transitions, such as caring for a spouse with a terminal illness. Using a case–control design, spousal caregivers (n = 31) of patients with terminal lung cancer completed the NEO Five-Factor Inventory (NEO-FFI) twice, 1.5 years apart, before and after the patient’s death. A demographically matched sample of community controls (n = 93) completed the NEO-FFI on a similar time frame. Based on research and theory, we hypothesized that bereaved caregivers would experience greater changes than controls in interpersonal facets of extraversion (sociability), agreeableness (prosocial and nonantagonistic), and conscientiousness (dependability). Consistent with hypotheses, bereaved caregivers experienced an increase in interpersonal orientation, becoming more sociable, prosocial, and dependable (Cohen’s d = .48–.67), though there were no changes in nonantagonism. Changes were not observed in controls (ds ≤ .11). These initial findings underscore the need for more research on the effect of life transitions on personality.

Distress, delay of gratification and preference for palliative care in men with prostate cancer.

Patient‐centered cancer care standards include routine psychosocial distress screening and referral for supportive care services. Although many cancer patients report psychosocial distress that could be alleviated by supportive services including palliative care, patients often decline such services for reasons that are poorly understood. Research on decision‐making suggests that during periods of acute distress, individuals have more difficulty prioritizing long‐term over immediate gains. Thus, distressed cancer patients may prioritize immediate gains (e.g., avoidance of palliative care discussions in the moment) over longer‐term gains (e.g., improved quality of life in the future).

Right-to-try laws and individual patient “compassionate use” of experimental oncology medications: A call for improved provider-patient communication

ABSTRACT The U.S. Food and Drug Administration’s Expanded Access program allows patients with life-threatening diagnoses, such as advanced cancer, to use experimental medications without participating in clinical research (colloquially, “Compassionate Use”). Sixteen U.S. states recently passed “right-to-try” legislation aimed at promoting Expanded Access. Acknowledging popular support, Expanded Access could undermine clinical trials that benefit public health. Moreover, existing norms in oncologic care, for example, often lead patients to pursue intense treatments near the end of life, at the expense of palliation, and improved communication about the risks and benefits of Expanded Access would more often discourage its use.

Agreement between informant and self-reported personality in depressed older adults: what are the roles of medical illness and cognitive function?

In a sample of 77 dyads, involving depressed patients at least 50 years of age and their family or friends (informants), patient illness burden and cognitive decline were associated with self-informant rating discrepancies for facets of Revised NEO Personality Inventory (NEO-PI-R) Openness and Extraversion. Informant judgments about Neuroticism and Conscientiousness were not associated with illness burden or cognitive function, underscoring the potential utility of risk-detection strategies that rely on informant-report in these two domains. Findings suggest the need for research on how patient illness severity and cognitive function affect how friends and family use or misuse information when making judgments about older depressed patients.