Michael Stefanek

The influence of bio-behavioural factors on tumour biology: pathways and mechanisms

Epidemiological studies indicate that stress, chronic depression and lack of social support might serve as risk factors for cancer development and progression. Recent cellular and molecular studies have identified biological processes that could potentially mediate such effects. This review integrates clinical, cellular and molecular studies to provide a mechanistic understanding of the interface between biological and behavioural influences in cancer, and identifies novel behavioural or pharmacological interventions that might help improve cancer outcomes.

National Institutes of Health State-of-the-Science Conference Statement: Family History and Improving Health

The role of obtaining family history information in the primary care setting, the validity of such information, and whether the information affects health outcomes must be clarified. Accordingly, t...

Cancer Risk Elicitation and Communication: Lessons from the Psychology of Risk Perception

Cancer risk perceptions are a key predictor of risk‐reduction practices, health behaviors, and processing of cancer information. Nevertheless, patients and the general public (as well as health care providers) exhibit a number of errors and biases in the way they think about risk, such that their risk perceptions and decisions deviate greatly from those prescribed by normative decision models and by experts in risk assessment. For example, people are more likely to engage in screening behaviors such as mammography when faced with loss‐based messages than gain‐framed messages, and they often ignore the base rate of a given disease when assessing their own risk of obtaining this disease. In this article, we review many of the psychological processes that underlie risk perception and discuss how these processes lead to such deviations. Among these processes are difficulties with use of numerical information (innumeracy), cognitive processes (eg, use of time‐saving heuristics), motivational factors (eg, loss and regret aversion), and emotion. We conclude with suggestions for future research in the area, as well as implications for improving the elicitation and communication of personal cancer risk.

Psychotherapy and Survival in Cancer: The Conflict Between Hope and Evidence

Despite contradictory findings, the belief that psychotherapy promotes survival in people who have been diagnosed with cancer has persisted since the seminal study by D. Spiegel, J. R. Bloom, H. C. Kramer, and E. Gottheil (1989). The current authors provide a systematic critical review of the relevant literature. In doing so, they introduce some considerations in the design, interpretation of results, and reporting of clinical trials that have not been sufficiently appreciated in the behavioral sciences. They note endemic problems in this literature. No randomized clinical trial designed with survival as a primary endpoint and in which psychotherapy was not confounded with medical care has yielded a positive effect. Among the implications of the review is that an adequately powered study examining effects of psychotherapy on survival after a diagnosis of cancer would require resources that are not justified by the strength of the available evidence.

Rethinking the Objectives of Decision Aids: A Call for Conceptual Clarity

Health decision aids are a potentially valuable adjunct to patient-physician communication and decision making. Although the overarching goal of decision aids— to help patients make informed, preference-sensitive choices—is widely accepted, experts do not agree on the means to achieve this end. In this article, the authors critically examine the theoretical basis and appropriateness of 2 widely accepted criteria used to evaluate decision aids: values clarification and reduction of decisional conflict. First, they argue that although clarifying values is central to decision making under uncertainty, it is not clear that decision aids—as they have been conceived and operationalized so far—can and should be used to achieve this goal. The pursuit of clarifying values, particularly values clarification exercises, raises a number of ethical, methodological, and conceptual issues, and the authors suggest research questions that should be addressed before values clarification is routinely endorsed. Second, the authors argue that the goal of reducing decisional conflict is conceptually untenable and propose that it be eliminated as an objective of decision aids.

Perceived Ambiguity about Screening Mammography Recommendations: Association with Future Mammography Uptake and Perceptions

Conflicting expert recommendations regarding cancer screening and prevention are growing in number, visibility, and importance, but their impact are not well understood. In this study, we examined the impact of conflicting recommendations about mammography screening on womens mammography behavior and perceptions. We conducted a secondary analysis of longitudinal data from the 1995 Maximizing Mammography Participation Trial, a large randomized interventional trial examining the effectiveness of patient reminders in increasing mammography utilization among women ages 50 to 79. Using the decision theory concept of “ambiguity” as an analytic framework, we tested several predictions about the effects of conflicting recommendations regarding mammography recommendations on behavior, cognitions, and emotions related to mammography screening. We found high perceived ambiguity about mammography recommendations to be associated with both diminished uptake of mammography over time [odds ratio (OR), 0.42; 95% confidence interval (95% CI), 0.23-0.76; P < 0.0001] and lower intentions for future mammography (OR, 0.34; 95% CI, 0.20-0.55; P < 0.0001). High perceived ambiguity also predicted greater mammography-related worry over time (OR, 2.60; 95% CI, 1.79-3.78; P < 0.0001). These findings suggest that conflicting recommendations regarding cancer screening and prevention have important effects, and we discuss the implications of these findings for future research. (Cancer Epidemiol Biomarkers Prev 2007;16(3):458–66)

Finding what is not there: unwarranted claims of an effect of psychosocial intervention on recurrence and survival.

In a recently published randomized trial, Andersen et al. claimed to observe a reduced risk of recurrence and improved survival among women with early stage breast cancer who were assigned to a psychological intervention versus an assessment‐only group. Anderson et al. concluded that “psychological intervention, as delivered and studied here, can improve survival.” The current commentary challenges that conclusion on methodological and statistical grounds, noting that the study by Andersen et al. was not designed to assess survival and used methods that capitalized on chance, making it highly unlikely that their claims could be replicated. No other study designed to assess whether psychosocial intervention provides a survival benefit for cancer patients has ever demonstrated such an effect; and, currently, there is no support for the hypothesis that survival benefits can be attributed to psychosocial intervention. The authors of this commentary argue that much needs to be learned at the more basic biobehavioral level about the impact of stress or psychological factors on tumor biology before even considering whether large clinical trials are warranted. In addition, making the claim that psychological interventions improve survival is not evidence‐based, is potentially harmful, and detracts from the potential significant benefits of psychological interventions related to quality of life. Cancer 2009.

A systems model for adaptation to somatic distress among cancer survivors

Applied coping research has generally failed to fulfill its goal of providing an empirical basis for clinical interventions, and research on coping with cancer is no exception. This can be attributed in large measure to the wide gap between coping theory and coping research. Theories of stress and adaptation are complex systems formulations that present conceptual and methodological challenges and thus make testing comprehensive models difficult. The present paper reviews arguments for a microanalytic strategy through which researchers can increase coverage of relevant variables from broad systems models of stress and coping by concentrating their resources on selected, high‐frequency, high‐stress problems. The utility of this approach for formulating problem‐specific systems models is illustrated using the example of coping with somatic distress among cancer survivors. Copyright

Current Research Promises and Challenges in Behavioral Oncology: Report from the American Society of Preventive Oncology Annual Meeting, 2002

The Behavioral Oncology Interest Group of the American Society of Preventive Oncology held a Roundtable session on March 10, 2002, at the American Society of Preventive Oncology annual meeting in Bethesda, Maryland, to discuss the current state-of-the-science in behavioral approaches to cancer prevention and control and to delineate priorities for additional research. Four key areas were considered: (a) behavioral approaches to cancer genetic risk assessment and testing; (b) biological mechanisms of psychosocial effects on cancer; (c) the role of risk perceptions in cancer screening adherence; and (d) the impact of tailored and targeted interventions on cancer prevention and control research. The evidence reviewed indicates that behavioral approaches have made significant contributions to cancer prevention and control research. At the same time, there is a need to more closely link future investigations to the underlying base of behavioral science principles and paradigms that guide them. To successfully bridge the gap between the availability of effective new cancer prevention and control technologies and the participants they are meant to serve will require the development of more integrative conceptual models, the incorporation of more rigorous methodological designs, and more precise identification of the individual and group characteristics of the groups under study.

Inflammation‐induced activation of the indoleamine 2,3‐dioxygenase pathway: Relevance to cancer‐related fatigue

Cancer‐related fatigue (CRF) is a common complication of cancer and its treatment that can significantly impair quality of life. Although the specific mechanisms remain poorly understood, inflammation is now considered to be a distinct component of CRF in addition to effects of depression, anxiety, insomnia, and other factors. One key biological pathway that may link inflammation and CRF is indoleamine 2,3‐dioxygenase (IDO). Induced by inflammatory stimuli, IDO catabolizes tryptophan to kynurenine (KYN), which is subsequently converted into neuroactive metabolites. Here we summarize current knowledge concerning the relevance of the IDO pathway to CRF, including activation of the IDO pathway in cancer patients and, as a consequence, accumulation of neurotoxic KYN metabolites and depletion of serotonin in the brain. Because IDO inhibitors are already being evaluated as therapeutic agents in cancer, the elucidation of the relationship between IDO activation and CRF in cancer patients may lead to novel diagnostic and clinical approaches to managing CRF and its debilitating consequences. Cancer 2015;121:2129–2136.