Tatiana D. Starr

Substance Abuse in Cancer Pain

In the oncology community, opioids recently have become the cornerstone of cancer pain management. This has led to a rapid increase in opioid prescribing in an effort to address the growing public health problem of chronic pain. A new paradigm in noncancer pain management has emerged, that of risk assessment and stratification in opioid therapy. Techniques foreign to cancer pain management have now become commonplace in the noncancer pain setting, such as the use of monitoring compliance via urine drug screens. Amidst these strides in opioid use for pain management, cancer has been changing. The survival rate has increased, and a group of these patients with chronic pain were treated with opioid therapy. With opioid exposure being longer and against the backdrop of prescription drug abuse, the question is how much of the adaptation of the risk management paradigm in chronic pain management is to be imported to cancer pain management?

Psychological Correlates of Sexual Dysfunction in Female Rectal and Anal Cancer Survivors: Analysis of Baseline Intervention Data

INTRODUCTION Sexual dysfunction represents a complex and multifactorial construct that can affect both men and women and has been noted to often deteriorate significantly after treatment for rectal and anal cancer. Despite this, it remains an understudied, underreported, and undertreated issue in the field of cancer survivorship. AIM This study examined the characteristics of women enrolled in an intervention trial to treat sexual dysfunction, and explored the relationship between sexual functioning and psychological well-being. METHODS There were 70 female posttreatment anal or rectal cancer survivors assessed as part of the current study. Participants were enrolled in a randomized intervention trial to treat sexual dysfunction and completed outcome measures prior to randomization. MAIN OUTCOMES MEASURES The main outcome measures are quality of life (QOL) (European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire [EORTC-QLQ-C30] and Colorectal Cancer-Specific Module [QLQ-CR38]), sexual functioning (Female Sexual Functioning Index), and psychological well-being (Brief Symptom Inventory Depression/Anxiety, Impact of Events Scale-Revised, CR-38 Body Image). RESULTS Women enrolled in the study intervention were on average 55 years old, predominantly Caucasian (79%), married (57%), and a median of 4 years postprimary treatment. For those reporting sexual activity at baseline (N=41), sexual dysfunction was associated with a range of specific measures of psychological well-being, all in the hypothesized direction. The Sexual/Relationship Satisfaction subscale was associated with all measures of psychological well-being (r=-0.45 to -0.70, all P<0.01). Body image, anxiety, and cancer-specific posttraumatic distress were notable in their association with subscales of sexual functioning, while a global QOL measure was largely unrelated. CONCLUSIONS For sexually active female rectal and anal cancer survivors enrolled in a sexual health intervention, sexual dysfunction was significantly and consistently associated with specific measures of psychological well-being, most notably Sexual/Relationship Satisfaction. These results suggest that sexual functioning may require focused assessment by providers, beyond broad QOL assessments, and that attention to Sexual/Relationship Satisfaction may be critical in the development and implementation of interventions for this cohort of patients.

Frequency, characteristics, and correlates of pain in a pilot study of colorectal cancer survivors 1-10 years post-treatment.

OBJECTIVE The long-term effects of disease and treatment in colorectal cancer (CRC) survivors are poorly understood. This study examined the prevalence and characteristics of pain in a sample of CRC survivors up to 10 years post-treatment. DESIGN One hundred cancer-free CRC survivors were randomly chosen from an institutional database and completed a telephone survey using the Brief Pain Inventory, Neuropathic Pain Questionnaire-Short Form, Quality of Life Cancer Survivor Summary, Brief Zung Self-Rating Depression Scale, Zung Self-Rating Anxiety Scale, and Fear of Recurrence Questionnaire. RESULTS Participants were primarily Caucasian (90%) married (69%) males (53.5%) with a mean age of 64.7 years. Chronic pain was reported in 23% of CRC survivors, with a mean moderate intensity rating (mean = 6.05, standard deviation = 2.66) on a 0-10 rating scale. Over one-third (39%) of those with pain attributed it to their cancer or treatment. Chi-square and t-test analyses showed that survivors with pain were more likely to be female, have lower income, be more depressed and more anxious, and show a higher endorsement of suicidal ideation than CRC survivors without chronic pain. On average, pain moderately interfered with daily activity. CONCLUSIONS Chronic pain is likely a burdensome problem for a small but not inconsequential minority of CRC survivors requiring a biopsychosocial treatment approach to improve recognition and treatment. Open dialogue between clinicians and survivors about physical and emotional symptoms in long-term follow-up is highly recommended.

Screening for abuse risk in pain patients.

As opioid prescribing has dramatically expanded over the past decade, so too has the problem of prescription drug abuse. In response to these now two major public health problems - the problem of poorly treated chronic pain and the problem of opioid abuse - a new paradigm has arisen in pain management, namely risk stratification. Once a prescriber has determined that opioids will be used (a medical decision based on how intense the pain is, what has been tried and failed and, to some extent, what type of pain the patient has), he/she must then decide how opioid therapy is to be delivered. Different models of delivery of opioid therapy can be utilized, beginning the process with a risk assessment that is highly individualized to each patient. Recently, researchers have produced a wide variety of literature regarding assessment tools to be used for this purpose. And while there remains a need for larger prospective studies to examine the ability of each tool to predict aberrant drug-taking behaviors, clinicians can and should utilize one or more of these screening tools and understand their benefits and limitations. This chapter will describe the nature of current screening assessments, their potential for use in the pain population in various settings, past clinical observations and suggestions for moving forward.

Barriers to recruitment in psycho-oncology: Unique challenges in conducting research focusing on sexual health in female survivorship

Patient participation in research is crucial for advancing knowledge and improving care. Barriers to successful recruitment can potentially hinder the feasibility of conducting psycho-oncology clinical trials [1]. Age has proven to be a consistent barrier to recruitment. Although older patients make up the largest proportion of those diagnosed with cancer, they remain under-represented in clinical trials [2]. Recruitment to psycho-oncology research may also be hampered by stigma surrounding mental health care [3], as well as the discussion of research concerning sensitive topics, such as sexual health. Despite this, there is a dearth of research regarding barriers to recruitment and alternative strategies in the domain of psycho-oncology. The current report examines recruitment data from a clinical trial of a sexual health intervention for female anal and rectal cancer survivors. Sexual function represents a complex and multifactorial construct that has been noted to deteriorate after treatment for a number of cancers, including rectal, rectosigmoid, and anal cancer [4]. Sexual dysfunction is also reported to be one of the most common and distressing consequences of cancer treatment [5] and is associated with impaired quality of life [4]. A four-session educational intervention was developed entitled: Cancer Survivorship Intervention-Sexual Health (CSI-SH), to address sexual dysfunction in female rectal, rectosigmoid, and anal cancer survivors and piloted at a large urban cancer center. In this brief report, study recruitment will be examined, and strategies for enhancing recruitment discussed in the context of this unique, challenging, and important domain of psychosocial oncology.

Ethnic disparities in colonoscopy use among colorectal cancer survivors: a systematic review

PurposeAfter curative treatment for colorectal cancer (CRC), routine colonoscopies are recommended. We aimed to identify all studies of ethnic disparities in CRC surveillance and examine any association between race/ethnicity and colonoscopy use.MethodsWe conducted a systematic literature review to address the association between race/ethnicity and colonoscopy use among CRC survivors. We searched Medline for relevant articles. Two authors reviewed titles, abstracts, and articles based on pre-determined inclusion/exclusion criteria.ResultsOf the 1,544 titles reviewed, eight studies published since 2001 investigated racial/ethnic disparities in colonoscopy use. Four articles showed a small significant ethnic disparity in the receipt of timely colonoscopy, and the remaining four articles showed a nonsignificant trend in the same direction. The effect did not vary by time of diagnosis or proportion of minorities in each study, though studies with larger samples showed somewhat greater racial/ethnic disparities in colonoscopy use.ConclusionsWe found at least a small disparity in the use of colonoscopy among CRC survivors, suggesting that ethnic disparities continue beyond prevention, detection, and treatment of CRC. It is important to identify areas of unequal care in CRC survivorship and to promote timely surveillance among CRC survivors who belong to racial/ethnic minorities to decrease disparities in mortality.Implications for Cancer SurvivorsCRC survivors who belong to racial/ethnic minorities may be less likely to receive follow-up colonoscopies on time, which could contribue to higher rates of death from CRC among minorities.

Polysomnographic Study of Sleep in Survivors of Breast Cancer.

STUDY OBJECTIVE Insomnia is a frequent complaint in breast cancer patients during and after treatment. Breast cancer survivors, 1-10 years posttreatment, underwent in-lab polysomnography (PSG) to objectively define the insomnia in those patients with such a complaint. METHODS Twenty-six breast cancer survivors (aged 39-80, mean 54.0 months posttreatment) spent 2 nights in the sleep laboratory. Sleep on Night 2 was scored for sleep stages, sleep onset latency, REM sleep onset latency, wake time, apneas and hypopneas, periodic limb movements and arousals. Subjects were allocated into 2 groups by their scores on the Pittsburgh Sleep Quality Index (PSQI): no/ mild sleep disturbance (PSQI score ≤ 9, n = 15) or moderate/ severe sleep disturbance (PSQI ≥ 10, n = 11). RESULTS Standard PSG/EEG parameters failed to differentiate insomniacs from non-insomniacs. The single variable that distinguished the insomnia group was periodic limb movements in sleep (PLMS). PLMS were significantly correlated (r ≅ 0.7, p < 0.02) with subjective report of insomnia on PSQI and insomnia severity index. Log[Number of PLMS] was higher in the moderate/severe insomnia group (p = 0.008). Five of 11 patients in the moderate/severe insomnia group had a PLMS index ≥ 15, compared to only one of 15 patients in the none/mild insomnia group (p = 0.02). Menopausal symptoms and use of caffeine, hypnotics, and antidepressants were unrelated to insomnia severity or PLMS. CONCLUSIONS PLMS was the sole PSG variable that separated breast cancer survivors with moderate/severe insomnia from those with no/mild sleep disturbance. Further study of the incidence and significance of PLMS in breast cancer survivors with the complaint of insomnia is merited.

Optimism and barriers to colonoscopy in low-income Latinos at average risk for colorectal cancer.

Colorectal cancer (CRC) screening continues to be underused, particularly by Latinos. CRC and colonoscopy fear, worry, and fatalism have been identified as screening barriers in Latinos. The study purpose was to examine the relationship of optimism, fatalism, worry, and fear in the context of Latinos referred for CRC screening.

Prevalence and predictors of depression, pain, and fatigue in older- versus younger-adult cancer survivors

As the number of older adults in the United States continues to grow, there will be increasing demands on health care providers to address the needs of this population. Cancer is of particular importance, with over half of all cancer survivors older than 65 years. In addition, depression, pain, and fatigue are concerns for older adults with cancer and have been linked to poorer physical outcomes.

Abstract B68: Assessing screening disparities for CRC by race across states

Background: Recent research suggests that there are geographic “hotspots” in the United States which have higher colorectal cancer (CRC) mortality rates [1]. These regions are characterized by high poverty, wherein individuals with lower socioeconomic status are less likely to undergo CRC screening tests, leading to a later stage of diagnosis and increased risk of mortality [1]. Additionally, significant racial disparities have been identified regarding CRC screening rates, although not always consistent, with the lowest rates amongst Blacks [2]. Furthermore, Hispanics over age 50 (the recommended age to begin screening at risk individuals) are less likely to have had a recent CRC screening than non-Hispanic Whites (29.9 vs. 44.3%) [3]. This study aims to identify geographic and racial disparities for CRC screening rates within the U.S. so that future interventions can be targeted according to geographic location and population demographics. Method: Analysis was conducted using available data published through the Behavioral Risk Factor Surveillance System (BRFSS) on the Centers for Disease Control and Prevention (CDC) website. The data were published on the “BRFSS: Table of Colorectal Cancer Screening,” and were open and available to the public [4]. While we recognize that these data were already published, we have analyzed it in a novel way, allowing us to formulate new research. Visual maps showing the ratios of screening rates for both fecal occult blood tests (FOBT) and colonoscopies were generated using SAS software. Additional maps were also created to display the overall screening rates for both screening tests according to race by state. Based on previous literature, states with screening data were grouped into five geographic regions: Northeast, Southeast, Midwest, West, and Southwest [5]. After data were weighted by population for each state, average screening rates were found for each race by test type and region. Ratios of Black to White and Hispanic to White screening rates for each test by region were also calculated in order to better understand the current disparities between the races by geographic location. Results: The lowest overall screening rates were found within the Hispanic population in the Southwest (10% for FOBT, 47% colonoscopy). The highest rates were within the White population in the Southeast (17% FOBT, 70% colonoscopy). The largest racial disparities were found between Hispanics and Whites in the West (ratio of 0.72 FOBT, 0.68 colonoscopy) and Southwest (ratio of 0.75 FOBT, 0.69 colonoscopy). Overall, Blacks had higher rates of FOBT screenings than Whites, with the largest disparity found in the Southwest (ratio of 1.57); colonoscopy rates were generally lower than Whites, with the largest disparity found in the Midwest (ratio of .91). Screening rates were most similar between Blacks and Whites in the Northeast (ratio of 1.20 FOBT, 0.98 colonoscopy). Conclusion: Future interventions should be targeted at increasing CRC screening rates for Hispanics, particularly in the West and Southwest regions of the U.S. Four of the states in these regions (New Mexico, Alaska, Texas, and Oklahoma) rank in the top ten states with the highest poverty levels [6]. Six states in these regions (Texas, Nevada, Arizona, Wyoming, New Mexico, and Alaska) are also in the top ten for the greatest percentage of the population without health insurance [7]. Due to these high poverty levels and subsequent lack of health insurance, individuals experience more obstacles to accessing benefits of healthcare such as CRC screening. Citation Format: Rachel Cooper, Noah Cohen, Elizabeth Schofield, Tatiana Starr, Chris Nelson, Lina Jandorf, Katherine Duhamel. Assessing screening disparities for CRC by race across states. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B68.