Donna M. Posluszny’s research while affiliated with University of Pittsburgh and other places

Simple Summary After cancer diagnosis and treatment, many patients report difficulty with cognitive functions such as learning, memory, and attention. Cancer-related cognitive impairment (also known as CRCI) can lead to problems in work, social life, and other daily activities. Research on the treatment of CRCI is ongoing, and one approach, cognitive-behavioral therapy or CBT, may be helpful. This article describes how to track symptoms with patient-reported outcome measures for individual cancer survivors who engage in CBT or other CRCI treatments in clinical practice. This system may help determine if treatments are effective and improve real-world patient outcomes. Abstract Cancer-related cognitive impairment (CRCI) affects a large proportion of cancer survivors and has significant negative effects on survivor function and quality of life (QOL). Treatments for CRCI are being developed and evaluated. Memory and attention adaptation training (MAAT) is a cognitive-behavioral therapy (CBT) demonstrated to improve CRCI symptoms and QOL in previous research. The aim of this article is to describe a single-case experimental design (SCED) approach to evaluate interventions for CRCI in clinical practice with patient-reported outcome measures (PROs). We illustrate the use of contemporary SCED methods as a means of evaluating MAAT, or any CRCI treatment, once clinically deployed. With the anticipated growth of cancer survivorship and concurrent growth in the number of survivors with CRCI, the treatment implementation and evaluation methods described here can be one way to assess and continually improve CRCI rehabilitative services.

Transplant candidates and recipients rely on lay caregivers to provide significant emotional and practical support during the transplant process and in the years thereafter. These caregivers, who are most often family members with close emotional ties to the patient, may experience significant burden related to caregiving. Although they may feel gratified that they can help their loved one, caregivers may also experience psychological distress and adverse physical health and quality of life consequences arising from their caregiving role. In this chapter, we review literature documenting the costs and consequences of caregiving in transplantation. We present a case involving a patient and his caregiver, with a focus on the caregiver’s role and reactions both before and after transplantation. We then pose a series of questions regarding when and how transplant teams might intervene to support caregivers, followed by a general discussion of recommendations to promote caregiver well-being during the transplant process.

276,000 Americans will be diagnosed with invasive breast cancer, lobular carcinoma in situ, or ductal carcinoma in situ this year and most will undergo breast surgery as part of their care. Although prognosis is excellent, many patients experience persistent post-surgical pain (PSP), which has no satisfactory pharmacological treatment. The causal contributions of pain-associated psychological factors (e.g., catastrophic thoughts about pain, psychological flexibility, self-efficacy) to the continuing burden of PSP have not yet been determined and may be opportune intervention targets. The randomized trial described here will compare the benefits of three manualized behavioral interventions for individuals with PSP. Participants will receive either: 1) self-guided health education (SGHE); 2) interventionist-guided health education (IGHE); or 3) interventionist-guided pain coping skills training with elements of acceptance and commitment therapy that specially target catastrophic thoughts about pain, self-efficacy, and psychological flexibility (CST-PSP). Participants will prospectively complete validated assessments of primary outcomes (PSP severity and interference) at baseline (pre-intervention) and 3-, 6-, and 12-months later. Validated measures of emotional distress and cancer-specific distress will be assessed as secondary outcomes. To test their roles as drivers of PSP, catastrophic thoughts about pain, self-efficacy, and psychological flexibility, will be assessed and statistically analyzed as mediators of hypothesized beneficial effects. The interventions' impacts on pain sensitivity and central sensitization will be investigated to test these physiological pathways as proximal drivers of PSP. To better characterize the patient experience, additional validated measures will be explored for associations with PSP, along with demographic and clinical factors. Trial registration: https://clinicaltrials.gov/ct2/show/NCT04225585, registered January 13, 2020

Background: Survival into the second decade after cardiothoracic transplantation (CTX) is no longer uncommon. Few data exist on any health-related quality of life (HRQOL) impairments survivors face, or whether they may even experience positive psychological outcomes indicative of "thriving" (e.g., personal growth). We provide such data in a long-term survivor cohort. Methods: Among 304 patients prospectively studied across the first 2 years post-CTX, we re-interviewed patients ≥15 years post-CTX. We (a) examined levels of HRQOL and positive psychological outcomes (posttraumatic growth related to CTX, purpose in life, life satisfaction) at follow-up, (b) evaluated change since transplant with mixed-effects models, and (c) identified psychosocial and clinical correlates of study outcomes with multivariable regression. Results: Of 77 survivors, 64 (83%) were assessed (35 heart, 29 lung recipients; 15-19 years post-CTX). Physical HRQOL was poorer than the general population norm and earlier post-transplant levels (p's<0.001). Mental HRQOL exceeded the norm (p<0.001), with little temporal change (p = 0.070). Mean positive psychological outcome scores exceeded scales' midpoints at follow-up. Life satisfaction, assessed longitudinally, declined over time (p<0.001) but remained similar to the norm at follow-up. Recent hospitalization and dyspnea increased patients' likelihood of poor physical HRQOL at follow-up (p≤0.022). Lower sense of mastery and poorer caregiver support lessened patients' likelihood of positive psychological outcomes (p's≤0.049). Medical comorbidities and type of CTX were not associated with study outcomes at follow-up. Conclusions: Despite physical HRQOL impairment, long-term CTX survivors otherwise showed favorable outcomes. Clinical attention to correlates of HRQOL and positive psychological outcomes may help maximize survivors' well-being. This article is protected by copyright. All rights reserved.

Background: Racial/ethnic minorities face known disparities in likelihood of kidney transplantation. These disparities may be exacerbated when coupled with ongoing substance use, a factor also reducing likelihood of transplantation. We examined whether race/ethnicity in combination with ongoing substance use predicted incidence of transplantation. Methods: Patients were enrolled between March 2010 and October 2012 at the time of transplant evaluation. Substance use data were retrieved from transplant evaluations. Following descriptive analyses, the primary multivariable analyses evaluated whether, relative to the referent group (White patients with no substance use), racial/ethnic minority patients using any substances at the time of evaluation were less likely to receive transplants by the end of study follow-up (August 2020). Results: Among 1152 patients, 69% were non-Hispanic White, 23% non-Hispanic Black, and 8% Other racial/ethnic minorities. White, Black, and Other patients differed in percentages of current tobacco smoking (15%, 26%, and 18%, respectively; P = 0.002) and illicit substance use (3%, 8%, and 9%; P < 0.001) but not heavy alcohol consumption (2%, 4%, and 1%; P = 0.346). Black and Other minority patients using substances were each less likely to receive transplants than the referent group (hazard ratios ≤0.45, P ≤ 0.021). Neither White patients using substances nor racial/ethnic minority nonusers differed from the referent group in transplant rates. Additional analyses indicated that these effects reflected differences in waitlisting rates; once waitlisted, study groups did not differ in transplant rates. Conclusions: The combination of minority race/ethnicity and substance use may lead to unique disparities in likelihood of transplantation. To facilitate equity, strategies should be considered to remove any barriers to referral for and receipt of substance use care in racial/ethnic minorities.

Background Allogeneic hematopoietic cell transplant (HCT) requires a complex, multicomponent medical regimen after hospital discharge. Patients must manage multiple medications, care for their catheter, minimize exposure to sources of potential infection, follow diet, exercise, and self-care guidelines, and attend frequent follow up medical appointments. Their caregivers are tasked with helping them manage the regimen. Despite its importance in preventing adverse clinical outcomes, there has been little study of regimen nonadherence and its predictors. Objectives We sought to prospectively determine rates and predictors of nonadherence to components of the post-HCT medical regimen during the first 8 weeks after hospital discharge. Study Design Patients (n=92) and their caregivers (n=91) (total N=183) completed interview assessments pre-HCT, and 4- and 8-weeks after hospital discharge post-HCT. Sociodemographic factors (e.g., age, sex); patient clinical status (e.g., disease type, donor type); patient and caregiver self-reported health-related factors (e.g., medical comorbidities); and patient and caregiver psychosocial factors (e.g., anxiety, depression, HCT task specific and general self-efficacy, relationship quality) were assessed pre-HCT. Nonadherence to each of 17 regimen tasks was assessed at 4- and 8-weeks post hospital discharge via self- and caregiver collateral report. Results Nonadherence rates varied among tasks, with 11.2-15.7% of the sample reporting nonadherence to immunosuppressant medication, 34.8-38.6% to other types of medications, 14.6-67.4% to required infection precautions, and 27.0-68.5% to lifestyle-related behaviors (e.g., diet/exercise). Nonadherence rates were generally stable but worsened over time for lifestyle-related behaviors. The most consistent nonadherence predictors were patient and caregiver pre-HCT perceptions of lower HCT task efficacy. Higher caregiver depression, caregiver perceptions of poorer relationship with the patient, having a non-spousal caregiver, and having non-AML disease also predicted greater nonadherence in one or more areas. Conclusions Rates of nonadherence vary across tasks and both patient and caregiver factors, particularly self-efficacy, predicted nonadherence. The findings highlight the importance of considering not only patient but caregiver factors in post-HCT regimen nonadherence.

Purpose: Caregivers of people with cancer represent a large, overburdened, and under-recognized part of the cancer care workforce. Research efforts to address the unmet needs of these caregivers are expanding with studies focused on caregivers' skill sets, physical and psychological health, and integration into healthcare delivery. As this field of research continues to expand, integrating caregivers' input is vital to studies to ensure that research aligns with their experiences. Methods: This is a focus group study of 15 cancer caregivers conducted during a cancer caregiving workshop at the University of Pittsburgh in February 2020. During the workshop, caregivers reviewed, critiqued, and proposed priorities to support caregivers of adults with cancer. We used a multistage consensus building approach to identify priority areas of research and clinical practice to address caregivers' experiences and needs. We used descriptive content analysis to summarize caregivers' priorities. Results: Caregiver-identified priorities included (1) training and information about cancer and treatment, (2) caregiver integration into the patient's healthcare delivery, (3) assistance with navigating the healthcare system, (4) focus on caregiver health and well-being, and (5) policy reform to address caregiver needs. We identified ways in which these priorities can inform cancer caregiving research and practice. Conclusion: These recommendations should be considered by researchers, clinicians, cancer center leadership, and policymakers interested in creating caregiver-focused research protocols, interventions, and support systems.

Objectives This study examines the associations of cancer death and aspects of the 24-h circadian rest-activity rhythm (RAR) on depression symptoms in older spouses. Methods Participants included 46 adults aged 60–94 years (M = 73 years) who experienced the death of a spouse. We tested a multivariate model using cancer death (vs. non-cancer death) and RAR variables as correlates of depression symptoms while controlling for age, sex, physical illness burden, and preparedness for death. We also present a case example to describe the behavioral activity patterns of a participant bereaved by cancer. Results Cancer death was associated with elevated levels of depression symptoms. However, the timing of the RAR moderated this association. Cancer bereavement was associated with depression symptoms when participants “settled-down” after 11:00 PM. The case example illustrates how intrusive thoughts about death quality impacts a widower’s drive to stay busy with daily activities. Conclusions Settling down earlier in the evening is important for older spouses bereaved by cancer, in terms of fewer symptoms of depression. Clinical implications Objectively specifying the activity patterns of older spouses bereaved by cancer is a promising avenue for interventions that aim to reduce depression symptoms.

Purpose Growing numbers of patients are entering the very late term period (15+ yrs) of survivorship after cardiothoracic transplant (CTx). Their health-related quality of life (HRQOL) is unknown. We examined (a) degree of late-term HRQOL impairment in multiple domains, (b) HRQOL benefit in areas of personal growth and life satisfaction, and (c) demographic, psychosocial, and clinical correlates of HRQOL. Methods Among 178 lung and 126 heart recipients from a single-site prospective study during the first 2 yrs post-CTx, we recontacted survivors 15-19 yrs post-CTx. We used validated scales to assess HRQOL impairments (SF-36) and benefits (personal growth from transplant experience [Post-Traumatic Growth Inventory]; having new life goals [Life Engagement Scale]; global life satisfaction rating). We examined HRQOL outcomes’ associations with other patient characteristics using multivariable regression. Results Of 82 survivors, 64 (84%) were assessed (n=29 lung, 35 heart recipients; M±SD=16±1 y post-CTx, range 15-19; 61% male; age 66±11). They were impaired in physical functional HRQOL domains, relative to norms (Fig 1). Mean mental health and social functioning were similar to or better than norms. Personal growth, and life engagement and satisfaction averaged higher than the scales’ midpoints (p<.05) and exceeded norms. More concurrent dyspnea symptoms, poorer family caregiver support, and low feelings of self-efficacy were associated (p<.05) with greater HRQOL impairment and less HRQOL benefit. Other factors (eg, demographics, lung v heart transplant, chronic graft rejection) did not predict these outcomes. Conclusion Despite physical functional HRQOL impairments in the late years after CTx, mental and social HRQOL is strikingly high and other HRQOL benefits are prominent. Because patients with more dyspnea and poorer psychosocial resources appear at risk for more HRQOL impairment and less HRQOL benefit, interventions targeting such individuals may help to maximize their HRQOL.

Background: In a randomized controlled trial (RCT), lung transplant recipients (LTRs) using a mobile health intervention, Pocket Personal Assistant for Tracking Health (Pocket PATH), showed better adherence to the medical regimen than LTRs receiving usual care during the first year posttransplant. We examined whether these effects were maintained beyond the trial's end, and evaluated other potential risk factors for long-term nonadherence. Methods: Adherence in eight areas was evaluated at follow-up in separate LTR and family caregiver (collateral) assessments. Pocket PATH and usual care groups' nonadherence rates were compared; multivariable regression analyses then examined and controlled for other patient characteristics' associations with nonadherence. Results: 105 LTRs (75% of survivors) were assessed (M=3.9 years posttransplant, SD=0.8). Nonadherence rates in the past month were 23%-81% for self-care and lifestyle requirements (diet, exercise, blood pressure monitoring, spirometry), 13%-23% for immunosuppressants and other medications, and 4% for tobacco use, with 31% clinic appointment nonadherence in the past year. In multivariable analysis, the Pocket PATH group showed lower risk of nonadherence to lifestyle requirements (diet/exercise) than the usual care group (p<.05). Younger age and factors during the first year posttransplant (acute graft rejection, chronically elevated anxiety, less time rehospitalized, nonadherence at the final RCT assessment) were each associated with nonadherence in at least one area at follow-up (p's<.05). Conclusion: Pocket PATH did not have sustained impact on most areas of the regimen, although we identified other risk factors for long-term nonadherence. Future work should explore strategies to facilitate sustained effects of mobile health interventions.