Steven K. Sutton

Course and Predictors of Cognitive Function in Patients With Prostate Cancer Receiving Androgen-Deprivation Therapy: A Controlled Comparison

PURPOSE Men receiving androgen-deprivation therapy (ADT) for prostate cancer may be at risk for cognitive impairment; however, evidence is mixed in the existing literature. Our study examined the impact of ADT on impaired cognitive performance and explored potential demographic and genetic predictors of impaired performance. PATIENTS AND METHODS Patients with prostate cancer were assessed before or within 21 days of starting ADT (n = 58) and 6 and 12 months later. Age- and education-matched patients with prostate cancer treated with prostatectomy only (n = 84) and men without prostate cancer (n = 88) were assessed at similar intervals. Participants provided baseline blood samples for genotyping. Mean-level cognitive performance was compared using mixed models; cognitive impairment was compared using generalized estimating equations. RESULTS ADT recipients demonstrated higher rates of impaired cognitive performance over time relative to all controls (P = .01). Groups did not differ at baseline (P > .05); however, ADT recipients were more likely to demonstrate impaired performance within 6 and 12 months (P for both comparisons < .05). Baseline age, cognitive reserve, depressive symptoms, fatigue, and hot flash interference did not moderate the impact of ADT on impaired cognitive performance (P for all comparisons ≥ .09). In exploratory genetic analyses, GNB3 single-nucleotide polymorphism rs1047776 was associated with increased rates of impaired performance over time in the ADT group (P < .001). CONCLUSION Men treated with ADT were more likely to demonstrate impaired cognitive performance within 6 months after starting ADT relative to matched controls and to continue to do so within 12 months after starting ADT. If confirmed, findings may have implications for patient education regarding the risks and benefits of ADT.

Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations.

This article provides an overview of the current literature on seven cancer sites that may disproportionately affect lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. For each cancer site, the authors present and discuss the descriptive statistics, primary prevention, secondary prevention and preclinical disease, tertiary prevention and late‐stage disease, and clinical implications. Finally, an overview of psychosocial factors related to cancer survivorship is offered as well as strategies for improving access to care. CA Cancer J Clin 2015;65:384–400.

Expectancies for Cigarettes, E-Cigarettes, and Nicotine Replacement Therapies Among E-Cigarette Users (aka Vapers)

INTRODUCTION Use of e-cigarettes has been increasing exponentially, with the primary motivation reported as smoking cessation. To understand why smokers choose e-cigarettes as an alternative to cigarettes, as well as to US Food and Drug Administration (FDA)--approved nicotine replacement therapies (NRT), we compared outcome expectancies (beliefs about the results of drug use) for the three nicotine delivery systems among vapers, i.e., e-cigarette users, who were former smokers. METHODS Vapers (N = 1,434) completed an online survey assessing 14 expectancy domains as well as perceived cost and convenience. We focused on comparisons between e-cigarettes and cigarettes to determine the attraction of e-cigarettes as a smoking alternative and between e-cigarettes and NRT to determine perceived advantages of e-cigarettes over FDA-approved pharmacotherapy. RESULTS Participants believed that e-cigarettes, in comparison to conventional cigarettes, had fewer health risks; caused less craving, withdrawal, addiction, and negative physical feelings; tasted better; and were more satisfying. In contrast, conventional cigarettes were perceived as better than e-cigarettes for reducing negative affect, controlling weight, providing stimulation, and reducing stress. E-cigarettes, compared to NRT, were perceived to be less risky, cost less, cause fewer negative physical feelings, taste better, provide more satisfaction, and be better at reducing craving, negative affect, and stress. Moderator analyses indicated history with ad libitum forms of NRT was associated with less positive NRT expectancies. CONCLUSIONS The degree to which expectancies for e-cigarettes differed from expectancies for either tobacco cigarettes or NRT offers insight into the motivation of e-cigarette users and provides guidance for public health and clinical interventions to encourage smoking-related behavior change.

Predictors of smoking relapse in patients with thoracic cancer or head and neck cancer.

Cancer patients who continue smoking are at increased risk for adverse outcomes including reduced treatment efficacy and poorer survival rates. Many patients spontaneously quit smoking after diagnosis; however, relapse is understudied. The goal of this study was to evaluate smoking‐related, affective, cognitive, and physical variables as predictors of smoking after surgical treatment among patients with lung cancer and head and neck cancer.

Self-Help Booklets for Preventing Postpartum Smoking Relapse: A Randomized Trial

OBJECTIVES We tested a series of self-help booklets designed to prevent postpartum smoking relapse. METHODS We recruited 700 women in months 4 through 8 of pregnancy, who quit smoking for their pregnancy. We randomized the women to receive either (1) 10 Forever Free for Baby and Me (FFB) relapse prevention booklets, mailed until 8 months postpartum, or (2) 2 existing smoking cessation materials, as a usual care control (UCC). Assessments were completed at baseline and at 1, 8, and 12 months postpartum. RESULTS We received baseline questionnaires from 504 women meeting inclusion criteria. We found a main effect for treatment at 8 months, with FFB yielding higher abstinence rates (69.6%) than UCC (58.5%). Treatment effect was moderated by annual household income and age. Among lower income women (< 

The importance of disclosure: lesbian, gay, bisexual, transgender/transsexual, queer/questioning, and intersex individuals and the cancer continuum.

30 000), treatment effects were found at 8 and 12 months postpartum, with respective abstinence rates of 72.2% and 72.1% for FFB and 53.6% and 50.5% for UCC. No effects were found for higher income women. CONCLUSIONS Self-help booklets appeared to be efficacious and offered a low-cost modality for providing relapse-prevention assistance to low-income pregnant and postpartum women.

Decline in cue-provoked craving during cue exposure therapy for smoking cessation.

The Lesbian, Gay, Bisexual, Transgender/Transsexual, Queer/Questioning, Intersex (LGBTQI) population is one of the most understudied and underserved populations in health disparities research.1, 2 Previous studies have reported approximately 1 to 10 percent of the US population are lesbian, gay and/or bisexual and approximately 1 to 3 percent are transgender.3, 4 LGBTQI populations experience health disparities due to reduced access to health care and health insurance (when partnerships and marriages are not recognized) and are considered to be at elevated risk for multiple types of cancer compared to non-LGBTQI populations. These increased risks are related to high rates of smoking and substance use, high fat diet, anal intercourse, and positive HIV status.5 In addition, low rates of early detection, lack of access to screening, and low uptake of cancer screening can result in poor outcomes and patient survival for LGBTQI populations.6–8 Low screening uptake is linked to several factors: lack of knowledge about need for screening; lack of insurance; limited access to (or perception of) health care providers who will not discriminate based on LGBTQI status or who have knowledge of the specific health care needs of the populations; gender identity mismatch (e.g., a person born a biological female who feels male will not participate in cervical cancer screening); and the general perception of homophobia in health care.7 Negative experiences and medical encounters reported by LGBTQI individuals range from institutional and societal issues to negative interpersonal interactions with healthcare providers perceived as discriminatory by patients.9, 10 Traditionally, males and females were characterized by sex according to reproductive organs and biologic functions assigned by chromosomal complement. The vast majority of medical forms provide two options for sex: male or female. Gender traditionally referred to behaviors, characteristics, or socially constructed roles that a culture considered applicable for males and females.11 Moving beyond sex and gender as dichotomous constructs, gender identity refers to an individual’s sense of self that currently includes the following categories: male, female, transgender, Intersex (individuals born with both female and male genitalia or a variant chromosomal pattern from XX or XY), and two-spirit (having both masculine and feminine components12). As in the past, sexual orientation refers to attraction, behavior, and identity. However, there has been an expansion of self-descriptive categories, e.g., heterosexual/straight, gay, lesbian, bisexual, queer, questioning, transspectrum and other terms which may resonate with the individual.12 Presently there is no universally agreed upon acronym for the Lesbian, Gay, Bisexual, Transgender/Transsexual, Queer/Questioning, and Intersex community which includes the variations of LGB, LGBT, GLBT, LGBTQ, LGBTQI, to name a few. Collectively, these terms are self-reported and refer to gender identity and sexual orientation.5 Recognizing the unique health needs for specific populations within the LGBTQI umbrella, a 2013 report from the NIH Director cites “gaps and opportunities in LGBTQI research include depression, suicide, obesity, cancer risk, long-term hormone use, HIV/AIDS and sexually transmitted infections, and substance use and abuse including alcohol, smoking, and other drugs.”3, 13 A better understanding of how LGBTQI health needs change throughout the lifespan and how they are affected by other factors such as race, ethnicity, and socioeconomic status is needed. Understanding and improving the health, safety, and well-being of this diverse community is a growing public health concern and is a goal for the Centers for Disease Control and Prevention Healthy People 2020.14, 15 This commentary stresses the importance of the at-risk status of the LGBTQI community for cancer health disparities across the continuum of cancer care and the need for providers and institutions to create environments that encourage disclosure. Cancer Healthcare Experiences Research concerning LGBTQI and cancer health care perceptions and experiences is relatively sparse, particularly for transgender populations. Literature about LGBTQI experiences specific to cancer care is even more limited. There is a growing trend for research involving overall health care experiences and barriers among sexual minorities. Outside of HIV/AIDS work, this research is in its infancy. Negative healthcare experiences have been reported by LGBTQI individuals and their loved ones. These range from institutional and societal issues to negative interpersonal interactions perceived as discriminatory by patients.5, 9 Perceptions of discrimination lead to social stigma. Social stigma is a stressor with profound mental health consequences, producing inwardly-directed feelings of shame and self-loathing. These internalized feelings may result in low self-esteem, suicidal ideation, depression, anxiety, substance abuse, tobacco use, and feelings of powerlessness and despair.11 For LGBTQI patients with cancer, the usual challenges of diagnosis and treatment are further complicated by the need to disclose sexual orientation and gender identity, which may be difficult based on previous negative healthcare experiences.2 Some individuals choose not to disclose their sexual orientation or gender identity to health care providers as a logical decision, given the frequency of LGBTQI experience of negative attitudes through both overt and covert forms of discrimination.5 LGBTQI cancer survivors may also experience isolation more than heterosexual survivors. For example, counseling to address erectile dysfunction and coping skills may be geared to heterosexual relationships.16 Not only may a gay man feel vulnerable for disclosing this to his oncologist but there may be no resources geared to his sexual orientation. Lesbian women surviving breast cancer report traditional resources for women involving hair loss from chemotherapy and coping skills for dealing with partners are created for heterosexual women and these situations have different meanings within their community.17

Risk factors for depression and fatigue among survivors of hematopoietic cell transplantation

INTRODUCTION Based on the principles of Pavlovian learning and extinction, cue exposure therapy (CET) involves repeated exposure to substance-associated cues to extinguish conditioned cravings and reduce the likelihood of relapse. The efficacy of CET is predicated on successful extinction, yet the process of extinction in CET trials has rarely been demonstrated. This study explored the extinction process using a cue-reactivity paradigm in smokers undergoing multiple CET sessions as part of a comprehensive smoking cessation treatment. METHODS The sample comprised 76 moderately dependent, treatment-seeking smokers who completed at least 4 CET sessions and 6 counseling sessions. The CET and counseling sessions were scheduled twice weekly, and participants began using transdermal nicotine replacement therapy on their quit day, which occurred prior to initiation of CET. Each CET session consisted of presentation of 140 images on a computer screen, with self-reported craving as the primary measure of cue reactivity. RESULTS Mixed-model analyses revealed a progressive decline in cue-provoked craving both within and across 6 sessions of CET. Moderator analyses showed that the decline in craving was greatest among those who displayed initial cue reactivity. CONCLUSIONS These data are consistent with the premise that CET can produce extinction of laboratory-based cue-provoked smoking cravings and highlight important individual differences that may influence extinction. Implications for conducting cue exposure research and interventions are discussed.

Prepartum and Postpartum Predictors of Smoking

Patients treated with hematopoietic cell transplantation (HCT) often experience depression and fatigue but analyses to determine risk factors have typically lacked statistical power. The current study examined sociodemographic and clinical risk factors for depression and fatigue in a large cohort of survivors of HCT.

7 mg nicotine patch fails to enhance P300 neural indices of cognitive control among nonsmokers.

INTRODUCTION Reduction of smoking during pregnancy and in the postpartum period remains a public health priority. This study tested whether variables (demographic, pregnancy related, emotional, and smoking related) assessed in abstinent women during their pregnancy predicted resumed smoking at 1 month and 1 year postpartum. Additionally, pregnancy-related and smoking-related variables obtained in the immediate postpartum period were examined as predictors of smoking at 1 year postpartum. METHODS Participants were pregnant women in their second and third trimester (N = 504) who enrolled in a randomized controlled trial of a smoking relapse-prevention intervention. Multivariate regression analyses were conducted with baseline data collected during pregnancy and follow-up assessments completed at 1 month and 12 months postpartum. RESULTS Independent predictors of smoking at 1 month postpartum included not intending to remain abstinent, lower quitting confidence, the presence of other household smokers, and not planning to breast feed. Smoking at 12 months postpartum was predicted by only not intending to remain abstinent and having a partner who maintained his or her smoking rate. In contrast, when assessed at 1 month postpartum, smoking at 12 months was predicted by current smoking status and lower quitting confidence. CONCLUSIONS Baseline variables measured during pregnancy differentially predicted early versus late smoking status. After delivery, the best predictor of later smoking status was current smoking status, reinforcing the need to focus on preventing early postpartum relapse. The importance of quitting confidence, or self-efficacy, was also reinforced. Findings may be useful for screening women at risk of relapse and targeting interventions to key variables.