Moriah J. Brier

Screening for psychosocial risk in pediatric cancer.

Major professional organizations have called for psychosocial risk screening to identify specific psychosocial needs of children with cancer and their families and facilitate the delivery of appropriate evidence‐based care to address these concerns. However, systematic screening of risk factors at diagnosis is rare in pediatric oncology practice. Subsequent to a brief summary of psychosocial risks in pediatric cancer and the rationale for screening, this review identified three screening models and two screening approaches [Distress Thermometer (DT), Psychosocial Assessment Tool (PAT)], among many more articles calling for screening. Implications of broadly implemented screening for all patients across treatment settings are discussed. Pediatr Blood Cancer 2012; 59: 822–827.

Psychosocial, health-promotion, and neurocognitive interventions for survivors of childhood cancer: a systematic review.

OBJECTIVE Survivors of childhood cancer must contend with a number of medical and psychosocial vulnerabilities after their cancer treatment ends. Interventions have been developed to alleviate or prevent adverse outcomes among this population. This systematic review summarizes the efficacy of psychosocial, health behavior, and neurocognitive interventions for survivors of pediatric cancer. METHOD Multiple databases were searched for studies published between January 1970 and June 2013. Studies were coded by 2 raters for methodological quality using the Effective Public Health Practice Project quality assessment tool. RESULTS Twenty-four interventions were identified (7 psychosocial, 10 health behavior, and 7 neurocognitive). Eleven were controlled trials, of which 7 achieved medium to large effect sizes. Survivor interest, as demonstrated by consent rates, was high for interventions that did not require travel. CONCLUSIONS Interventions using delivery methods varying from traditional counseling to computers achieved moderate to strong efficacy and merit replication. Survivor needs related to transition to adult-oriented health care and school reentry were not addressed by existing interventions. This review also revealed the absence of health behavior interventions for survivors in middle childhood and late adolescence. Intervention formats that are cost-effective and reduce participant burden should be prioritized for further testing. To broaden the reach and appeal of interventions, alternative delivery methods, such as mobile phone software applications, should be evaluated.

Promoting Recovery After War in Northern Uganda: Reducing Daily Stressors by Alleviating Poverty

Findings from a representative survey of youth in northern Uganda suggest that former female child soldiers experience a range of distress symptoms, have initial problems reintegrating, and have fewer education and employment opportunities than males. Given the multiple layers of needs, the findings pose a question of where best to intervene. Would broad-based economic programs address this populations poverty while also indirectly addressing mental health symptoms by reducing stress and improving social capital? This article describes how these findings led to the development and evaluation of an economic and social program designed to reduce daily stressors and improve this populations economic, social, and psychological outcomes through livelihoods training, a cash grant for small business development, and follow-up support.

Association between self-report adherence measures and oestrogen suppression among breast cancer survivors on aromatase inhibitors

PURPOSE Poor adherence to oral adjuvant hormonal therapy for breast cancer is a common problem, but little is known about the relationship between self-report adherence measures and hormonal suppression. We evaluated the relationship of three self-report measures of medication adherence and oestrogen among patients on aromatase inhibitors (AIs). MATERIALS AND METHODS We recruited 235 women with breast cancer who were prescribed AI therapy. Participants self-reported AI adherence by completing the following: (1) a single item asking whether they took an AI in the last month, (2) a modified Morisky Medication Adherence Scale-8 (MMAS-8) and (3) the Visual Analog Scale (VAS). Serum estrone and estradiol were analysed using organic solvent extraction and Celite column partition chromatography, followed by radioimmunoassay. RESULTS Ten percent of participants reported they had not taken an AI in the last month and among this group, median estrone (33.2 pg/ml [interquartile range (IQR)=22.3]) and estradiol levels (7.2 pg/mL [IQR=3.3]) were significantly higher than those in participants who reported AI use (median estrone=11.5 pg/mL [IQR=4.9]; median estradiol=3.4 pg/mL [IQR=2.1]; p<0.001). This relationship held when controlling for race and AI drug type. CONCLUSIONS A single-item monthly-recall adherence measure for AIs was associated with oestrogen serum levels. This suggests that patient-reported monthly adherence may be a useful measure to identify early non-adherence behaviour and guide interventions to improve patient adherence to hormonal treatment.

Development and validation of the Penn Arthralgia Aging Scale among breast cancer survivors.

Breast cancer survivors on aromatase inhibitors often experience joint pain as a side effect of their treatment; qualitative investigations suggest that this arthralgia may cause women to feel that they are aging faster than they should be. To facilitate further study of this experience, the Penn Arthralgia Aging Scale (PAAS) was developed. This report describes the development and validation of the PAAS in a racially diverse sample of breast cancer survivors suffering from joint pain.

Attributions and perceptions of criticism: An examination of patients with anxiety and normal control participants.

Perceived criticism from relatives predicts poor clinical outcomes for patients with a variety of psychological disorders. Research indicates the attributions individuals make about motives for relatives’ criticism are linked to perceived criticism from this relative. Accordingly, attributions may be an important target of intervention to reduce perceived criticism and improve clinical outcomes, but this association requires testing in a clinical sample. We examined relationships among attributions of criticism, perceived criticism, and upset due to criticism among individuals with anxiety disorders (n = 53) and with no psychopathology (n = 52). Participants completed measures of global attributions, perceived criticism, and upset due to criticism regarding criticism from a romantic partner/spouse or parent. After a 10-min problem-solving interaction with their relative, they completed measures of attributions, perceived criticism, and upset with regard to this relative’s critical behavior during the interaction, and observers reliably coded interactions for relatives’ criticism. Results showed that negative attributions were related to greater perceived criticism and upset for both global and interaction-specific measures. In analyses of interaction-specific measures, negative attributions added to prediction of perceived criticism and upset over and above the contribution of observed criticism. Positive attributions were not significantly related to global or interaction-specific upset in any analyses. Relationships were consistent across patients and normal controls. Our findings suggest that negative attributions of relatives’ motives for their criticism are important predictors of perceived criticism and upset. Thus, interventions targeting these attributions may be helpful in mitigating the negative effect of perceived criticism for individuals with psychopathology.

Abstract P5-13-16: Arthralgia-associated aging perceptions predict adherence to aromatase inhibitors among women with breast cancer

Background: Aromatase inhibitors (AIs) are associated with reduced risk of breast cancer recurrence, yet many women discontinue their treatment prematurely, often due to arthralgia. Empirically, breast cancer survivors who experience AI-associated arthralgia often report that they have aged quickly over a short period of time. Objective: We aimed to determine whether survivors with a heightened sense of aging due to arthralgia were more likely to non-adhere to their AI regimen. Methods: We conducted a prospective cohort study in an urban academic cancer center among post-menopausal women with hormone receptor positive breast cancer who were within the first two years of their aromatase inhibitor therapy. Perceptions of aging due to arthralgia were measured by the previously validated Penn Arthralgia Aging Scale. Non-adherence was defined as interrupting treatment or discontinuing the AI before the prescribed treatment length was over. Trained raters abstracted adherence data from medical charts. We performed Cox proportional hazards regression to evaluate the relationship between perceptions of aging due to arthralgia and time to non-adherence while adjusting for potential confounders. Results: Among 509 participants, most were White (81.2%) and had at least some college education (77.9%). The majority had been prescribed anastrozole (88.0%), followed by letrozole (9.0%), and exemestane (3.0%). During the follow up period, 144 (28.3%) did not adhere to the AIs as originally prescribed. In univariate analysis, women with a heightened sense of aging due to arthralgia were at more than twice the risk of non-adherence compared to women with low levels of aging perceptions (Hazard Ratio [HR], 2.20; 95% CI, 1.50 – 3.21; p p = 0.02). Depression status also uniquely predicted non-adherence risk (HR, 1.63; 95% CI, 1.03 – 2.59; p = 0.04). Arthralgia pain severity, which predicted adherence in univariate analysis, was not a significant predictor in the final model (HR, 1.21; 95% CI, 0.84 – 1.75; p = .30). Conclusions: Breast cancer survivors on AIs who have a heightened sense of aging due to arthralgia are at greater risk of non-adhering to their AI regimen. Interventions are needed to help survivors reduce arthralgia and develop adaptive appraisals of their AI experience to achieve optimal adherence. Citation Format: Mao JJ, Chambless DL, Chen J, Bao T, Brier MJ. Arthralgia-associated aging perceptions predict adherence to aromatase inhibitors among women with breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-16.

Abstract PD4-02: Health beliefs predict adherence to aromatase inhibitors

Background: Post-menopausal breast cancer survivors are often prescribed aromatase inhibitors (AIs) to decrease the chance of cancer recurrence. Despite their efficacy, many survivors do not fully adhere to their AI regimen. To improve adherence rates, it is important to understand which patient factors are associated with adherence. Current research has mostly focused on demographic, cancer, and symptom variables, most of which cannot be modified. One relevant factor that may be modifiable is health beliefs, which include perceived susceptibility of cancer recurrence, perceived benefits of treatment, and perceived barriers to treatment. Among breast cancer patients, each of these has been found to be associated with adherence behaviors, such as mammography and tamoxifen adherence. In this study, we explored whether health beliefs also play a role in adherence to AIs. Objective: The purpose of this longitudinal study was to determine whether patients with lower perceived susceptibility to cancer recurrence, higher perceived barriers to taking AIs, and lower perceived benefits of AIs were more likely to non-adhere to their AI regimen. Method: Four hundred and thirty-seven breast cancer survivors who were currently on an AI completed a survey that included the Health Beliefs and Medication Adherence in Breast Cancer (HBMABC) scales (a measure adapted from the Champion Health Belief Model Scales (CHBMS) for Mammography Screening), as well as questions about their demographics and symptoms. Exploratory and confirmatory factor analysis of the HBMABC yielded a 3-factor solution: perceived susceptibility, perceived benefits, and perceived barriers. Adherence data, including drug holidays (taking breaks from AI treatment) and premature discontinuation (stopping AI treatment early), were collected from physicians9 notes in patients9 medical charts dating from the day they completed the survey through the end-date of their prescribed AI treatment. Bivariate analyses were conducted to determine variables that were predictive of non-adherence. Variables found to be associated with non-adherence were entered into multiple logistic regression analyses. Results: Eighty-five patients (20.6%) exhibited some form of non-adherence (premature discontinuation, drug holiday, or both). Joint pain severity and the number of years a patient was on an AI at the time of the survey were both associated with non-adherence. After adjusting for these covariates, perceived barriers to AI treatment was significantly associated with non-adherence (OR 1.76, 95% CI: 1.03 – 3.00, p = 0.04). No relationship was found between perceived susceptibility or perceived benefits, and AI adherence. Conclusions: Breast cancer patients on AIs who perceive greater barriers to AI treatment are more likely to non-adhere to their AI regimen. This finding suggests that clinicians can intervene to help modify patients9 negative beliefs and ultimately help improve patients9 adherence levels. Citation Format: Brier MJ, Stricker CT, Chambless DL, Chen J, Ahluwalia K, Mao JJ. Health beliefs predict adherence to aromatase inhibitors. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD4-02.

Abstract P5-17-01: Development and validation of the Penn arthralgia aging scale among breast cancer survivors on aromatase inhibitors

Background: Aromatase inhibitors (AIs) have been shown to decrease the recurrence rate and increase the overall survival rate of hormone receptor positive breast cancer among post-menopausal women. Unfortunately, arthralgia is a frequently experienced side effect of AIs, leading some women to discontinue AIs prematurely. Qualitative investigations suggest that joint pain may cause women on AIs to feel they are aging faster than they should be. Since general perceptions of aging have been shown to predict important health outcomes, such as adherence and mortality, aging perceptions related to joint pain are worth further exploration. Objective: The purpose of this study was to develop and validate a measure that captures perceptions of aging related to joint pain. A psychometrically validated tool will advance our ability to quantify and further understand the importance of this construct. Method: We developed the eight-item Penn Arthralgia-Aging Scale (PAAS) from interviews with 67 patients on AIs. The scale was pilot-tested, and changes to items were made based on patient feedback, as well as feedback from oncologists, nurses, and physical therapists. To validate the scale, participants suffering from joint pain were selected from a larger study examining the genetic determinants of symptom distress and disease outcomes among women on AIs. Five hundred and fifty-six breast cancer survivors completed the PAAS, as well as the Hospital Anxiety and Depression Scale, the pain interference and pain intensity subscales of the Brief Pain Inventory, and a demographic questionnaire. Exploratory factor analysis using oblique rotation was conducted to examine the factor structure of the scale. Convergent validity was assessed by correlating the PAAS with joint-pain severity. To determine whether the scale provides important information beyond existing measures, we used hierarchical regressions to calculate whether it predicted incremental variance in anxiety, depression, and pain interference outcomes. Results: The resulting scale had a one-factor structure (eigenvalue = 6.21), high internal consistency (Cronbach’s alpha = 0.94), and strong convergent validity (Spearman r = .55, p Citation Format: Moriah J Brier, Dianne L Chambless, Laura Lee, Angela DeMichele, Jun J Mao. Development and validation of the Penn arthralgia aging scale among breast cancer survivors on aromatase inhibitors [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-17-01.