Screening for Distress

This area of research acknowledges the high rates of distress in cancer patients and families throughout the spectrum of diagnosis and treatment. The goal of the research is to integrate results regarding how best to treat distress into a complete system of identification of distress, triage and referral to evidence-based treatments. The system involves advanced and personalized technology, rapid and timely identification of problems, and evaluation of different methods of intervention for identified distress. The system developed through the Chair program will be used as a template for developing screening for distress programs throughout Canada. Dr. Carlson has been involved in this area for over 10 years, and her group has published early work documenting the impact of integrating real-time Quality of Life assessment on patient care in lung (Psycho-Oncology, 2000) and pain (J. Pain and Symptom Management, 2001) clinics. Her current distress screening program began with a survey of over 3,000 cancer patients (BJC, 2004), and since 2006 her team received over $1 million in funding for three large-scale studies which are currently underway (Carlson PI). These trials involve evaluating the best form of computerized distress screening and triage to appropriate services for newly diagnosed cancer patients, and over 7,000 patients have been accrued to date. She has published a number of editorials publicizing distress as the “6th Vital Sign” in cancer care (JCO, 2005; Psycho-Oncology, 2006), a review paper on distress screening methods (JPR, 2004) and hosted two international research and policy workshops on distress screening (March 2008; October 2008) sponsored by the Canadian Partnership Against Cancer (CPAC). CPAC is now funding an initiative to bring screening for distress to cancer centres across Canada.

Studies Underway:

1. Online Distress Screening for Newly Diagnosed Oncology Outpatients: Randomized Controlled Trial of Three Levels of Screening and Triage. In this study, three versions of the computerized distress screening program were being compared. Newly diagnosed lung and breast cancer patients were screened at their first appointment and 3 months later for a variety of concerns including distress, common problems such as finances and drug coverage, as well as coping, fatigue, pain, and nutrition. A total of 1215 (88%) patients agreed to participate in this study and 3 month follow-up is available on 1071 (88%) patients. The data is currently being analyzed for this study and much of this work will be published in 2010.
2. Distress and Resource use in Cancer Patients: A Longitudinal Study of Usual Care. This study of usual care tracked newly diagnosed patients with a range of different types of cancer over a year period to investigate the natural course of distress over time without distress screening. 1328 patients agreed to participate in this study and 3, 6, and 12 month follow-up assessments were recently completed with those patients. The data for this study is currently being analyzed for publication and much of this work will be published in 2010.
3. Online Distress Screening for Newly Diagnosed Oncology Outpatients: Trial of Computerize vs. Personalized Triage. This study examined computerized Screening for Distress comparing triage to specific resources by a trained professional to computerized referral suggestions to be pursued by the patient. 3377 patients were accrued to this study. Those patients who agree to participate are screened at their first appointment and at 3, 6, and 12 months later for psychosocial, practical, and physical concerns.

Integrative Oncology (mind-body interventions)

Another focus of the chair is the broad category of integrative oncology interventions for cancer patients. This area of focus investigates the usefulness of a broad range of popular complementary interventions for cancer patients, focusing on both quality of life, stress reduction, psychological and biological outcomes such as immune function and stress hormones. Mind-body and complementary interventions offered to patients through this program include meditation, yoga, exercise, acupuncture, Reiki, nutritional counseling and support groups.

An area of particular expertise within this focus is in mindfulness-based stress reduction (MBSR; a group intervention based upon principles of mindfulness meditation and yoga). Dr. Carlson’s group was the first to publish on the effects of MBSR in cancer patients. Two early papers appeared in Psychosomatic Medicine (2000), and Supportive Care in Cancer (2001), detailing the results of a randomized controlled trial that demonstrated benefits from the program of improved mood and fewer symptoms of stress in cancer patients, which were maintained over a 6-month follow-up period. Following on this work, Dr. Carlson’s team were also the first to investigate the effects of MBSR on possible biological mechanisms of action in cancer patients, including immune cell counts and function, and stress hormone levels. These results appeared in Psychosomatic Medicine (2003), Psychoneuroendocrinology (2004) and Brain, Behaviour and Immunity (2007). The results indicated possible effects of MBSR on enhancing production of cytokines with tumour-killing properties, and decreasing levels of immune-killing stress hormones, which persisted over a year of follow-up. Her team also replicated earlier results of improvements in quality of life and reduced stress symptoms, and saw enhanced quality of sleep. Separate papers on MBSR effects on sleep (International Journal Behavioural Medicine, 2005); spirituality and post-traumatic growth (Supportive Care in Cancer, 2007) and several review papers and book chapters have also followed. Dr. Carlson has been invited to present this work internationally on many occasions, most recently at the Mayo Clinic in 2008 in an audience with His Holiness the Dalai Lama. Six ongoing studies in this area have been funded for over $800,000. In addition, Dr. Carlson recently published a book in 2009 with co-author Dr. Shauna Shapiro from the American Psychological Association Press entitled: The art and science of mindfulness: integrating mindfulness into psychology and the helping professions http://books.apa.org/books.cfm?id=4317196

Studies Underway:

1. MINDSET: A randomized trial comparing mindfulness-based stress reduction to supportive expressive therapy in women completed treatment for breast cancer. Women are compared on both psychological and biological outcomes of these therapies. This study is currently being conducted in both Calgary and Vancouver and has currently recruited over 180 women.
2. MASTER: The effects of mindfulness-based stress reduction on acute stress reactivity and blood pressure in a laboratory setting. This study is completed with 38 women in each of an intervention and comparison control group and results will be published in 2010.
3. MINDMAP: This study compares radiation therapy alone to radiation therapy plus acupuncture and radiation therapy plus meditation for the treatment of pain in women with breast cancer which has spread to the bone.

Survivorship

The third area of focus of the Chair is the growing field of cancer survivorship research.

Given that the majority of people now survive the scourge of cancer treatment (over 65% of all patients will now live beyond 5 years post-diagnosis), there is a clear need to study and understand issues that arise well after the acute life threat of cancer has passed. Examples of areas of study within this stream are assessing issues around increased risk for future malignancies, fears of recurrence, effects of treatments on neurocognitive function and learning ability, relationships, sexuality and fertility issues, fatigue, disability and return to work issues. This encompasses all the issues relevant to cancer survivors who have completed primary cancer treatments. In this area, Dr. Carlson’s team was the first to report on monetary cost savings as a result of participation in a 6-week psychosocial group support program for breast cancer survivors (Cancer Practice, 2001). We demonstrated in a randomized controlled trial that women with breast cancer randomized to the treatment group billed 25% less to Alberta Health and Wellness over two years of follow-up than those in the control condition, the first ever report of medical cost offset as a result of psychosocial intervention in cancer patients. Dr. Carlson’s group have followed this line of inquiry and published two reviews on the efficacy of psychosocial interventions and medical cost offset in cancer survivors (Oncology Exchange, 2002; Health and Quality of Life Outcomes, 2003; Psycho-oncology, 2004).

A major objective in this research stream was to recruit a senior scientist to lead this area; as such we successfully recruited Dr. Janine Giese-Davis from Stanford University, who joined our team in Sept 2008. She has since coalesced a provincial CancerBRIDGES survivorship team, submitted several grants relevant to the needs of cancer survivors. been awarded a summer research student funded by AHFMR and received donor support. Future plans are to create a survivors network and test out discharge care plans across the province.

Studies Underway:

1. A Randomized Controlled Trial Testing Efficacy of Professionally and Peer-led Online Support Groups for Young Canadian Breast Cancer Survivors. Janine Giese-Davis’ newly funded Canadian Breast Cancer Research Alliance project.
2. The Alberta CancerBRIDGES Care Plan Implementation for Breast and Head and Neck Cancers funded by the Canadian Partnership Against Cancer, Cancer Journey Action Group. This pilot project will be evaluating the implementation of detailed post-discharge care plans for a group of breast and head and neck cancer survivors over a year following discharge from the cancer centre.