Stress Management for Cancer Patients - Dr. Antoni

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Dr. Michael Antoni of Sylvester Comprehensive Cancer Center discussed stress management for cancer patients at the 2011 WellBeingWell Conference in Miami.

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Stress Management for Cancer Patients - Dr. Antoni

  1. 1. Stress Management for Patients Undergoing Treatment: Effects, Biobehavioral Mechanisms, and Next Steps in Research WellBeingWell April 26, 2011 Miami, FL <ul><li>Michael H. Antoni, Ph.D. </li></ul><ul><li>Department of Psychology </li></ul><ul><li>Div of Health Psychology </li></ul><ul><li>Director, Co-Leader UM/Sylvester Biobehavioral Oncology and Cancer Epidemiology Program </li></ul>NCI 84944-P50 M. Antoni, P.I. NCI 064710-R01 M. Antoni, P.I.
  2. 2. Empirical Support for the Mind-Body Connection: The Case of Stress Management <ul><li>Stress is prevalent in many aspects of the cancer experience (diagnosis  treatment  recovery  survivorship) </li></ul><ul><li>Optimal disease adjustment is reflected in lower distress and greater positive life experiences </li></ul><ul><li>Interventions (relaxation) that reduce stress may help patients adjust optimally to demands of disease (from diagnosis  long-term survivorship) </li></ul><ul><li>Optimal psychosocial adjustment  physical health status via biobehavioral “stress” pathways that influence disease (e.g., stress hormone reduction) </li></ul>
  3. 3. Family of Stress Management Studies at UM (1986-2011) TELE CBSM TELE- CBSM Community-based CBSM HIV MSM Hetero Men Inner-City Women Asymp Dx Notif Symp Pre-HAART HAART Asymp. HIV+ AIDS HAART Eng Lang Spa Lang Spa Lang Eng Lang HPV + SIL Post- Adj Stage I-IIla BRCA Pre- Adj Stage I-II Stage I-IIIa Dismantle CBSM Abbrev CBSM PRCA Post Surg Post Radiation Advanced Disease Eng Lang Spa Lang Eng Lang Spa Lang Eng Lang CFS SMART ENERGY
  4. 4. A CASE FOR STRESS MANAGEMENT: Does Cognitive Behavioral Stress Mgmt (CBSM) affect psychosocial, neuroendocrine and immune functioning? <ul><li>HIV+ persons </li></ul><ul><li>Breast Cancer </li></ul><ul><li>HIV: Antoni et al., 1991, 2000a, b, 2002, 2005, 2006, 2008 </li></ul><ul><li>Breast Cancer: Antoni et al., 2000, 2001, 2006a, b, 2009; Cruess et al., 2000 </li></ul>
  5. 5. Theory Testing in Biobehavioral Oncology Across the Cancer Continuum Prevention Detection Diagnosis & Treatment Early Survivorship Late Efects Longer-term Survivorship Cancer Continuum Target Populations Patients/ Survivors Family Community Methodology Observational Assessment Randomized Controlled Trials Community-Participatory PREDICTORS Person Factors Socio-cultural Factors QOL /HEALTH OUTCOMES Behavioral Psychological Physical MEDIATORS Behavioral Processes Biological Processes
  6. 6. How Are Psychological Processes Related to Cancer Adaptation and Health Outcomes? <ul><ul><ul><li>What are the psy/behavioral predictors of quality of life (QoL)/adjustment and cancer health outcomes? </li></ul></ul></ul><ul><ul><ul><li>Are biobehavioral processes relevant? </li></ul></ul></ul><ul><ul><ul><li>How can these associations be used to create effective psychosocial interventions ? </li></ul></ul></ul>
  7. 7. E.g., Stress Management for Women with Breast Cancer <ul><li>Rationale </li></ul><ul><ul><li>Breast Cancer (BCa) is a stressor </li></ul></ul><ul><ul><li>Challenges of surgery and adjuvant tx </li></ul></ul><ul><ul><li>Patient assets can facilitate adjustment </li></ul></ul><ul><ul><li>CBSM can fortify these assets </li></ul></ul><ul><ul><li>CBSM may improve Psychosocial Adaptation and Physiological Adaptation </li></ul></ul>
  8. 8. CBSM Breast Cancer Studies at U.Miami (1992-2011) Community-Based Post- Adj Stage I-IIla BRCA Pre- Adj Stage I-II Stage I-IIIa Dismantle CBSM Abbrev CBSM
  9. 9. CBSM <ul><li> Awareness </li></ul><ul><li> Cognitive Appraisals </li></ul><ul><li>Emot Processing </li></ul><ul><li>Relaxation </li></ul><ul><li> Arousal </li></ul><ul><li> Social Support </li></ul> Physical Health  QOL Normalize endocrine and immune regulation <ul><li>+ Health Beh. </li></ul><ul><li> Negative Adapt </li></ul><ul><li>Positive Adapt </li></ul><ul><li> Physical Funct </li></ul>Theoretical Model for Using Cognitive Behavioral Stress Management during Cancer Treatment Antoni, M.H. (2003) Stress Management Intervention for Women with Breast Cancer . Washington DC: APA Press.
  10. 11. What is involved in Stress Management? <ul><li>Relaxation, Deep Breathing and Meditation </li></ul><ul><li>Cognitive Restructuring </li></ul><ul><li>Coping Skills </li></ul><ul><li>Interpersonal Skills </li></ul>
  11. 12. Anger Management Social Support Assertiveness Stress Response Cognitive Restructuring (challenging thoughts) YES NO Automatic Thought Cognitive Emotion Focused Softening (If still distressed) Coping Social Physical Behavioral Emotional Distorted? Problem Focused Uncontrollable Controllable <ul><li>Reframing </li></ul><ul><li>Venting </li></ul><ul><li>Making behavioral changes </li></ul><ul><li>Practicing relaxation </li></ul><ul><li>Making decision </li></ul><ul><li>Seeking information </li></ul><ul><li>Seeking advice </li></ul><ul><li>Setting goals </li></ul>Stressful Event Antoni, Ironson, Schneiderman 2007
  12. 13. Week Relaxation Stress Management 1 PMR 7 Stress & Awareness 2 PMR 4/D.B. Stress & Awareness/Stress Appraisals 3 D.B./PMR Disease-Specific , Automatic Thoughts 4 Autogenics Auto. Thghts, Distortions, Thght Rep. 5 D.B./Visualiz. Cognitive Restructuring 6 Sunlight Med. Effective Coping I 7 Color Meditation Effective Coping II 8 Meditation Social Support 9 Mindfulness Anger Management 10 Part. Choice Assertion Training & Program Review Topics of CBSM (Antoni et al., 2003, 2007; Penedo et al., 2008)
  13. 14. Assessment Time Points T1 surgery T4 One year post surgery T3 T2 2-8 wks post B SMART-10 wks. 3 months post 6 months post
  14. 15. CBSM Intervention after Surgery for Breast Cancer: <ul><li>Psychological adaptation: </li></ul><ul><li>increased benefit finding and optimism </li></ul><ul><li>decreased anxiety, depression, soc disruption, fatigue, sleep disruption </li></ul><ul><li>increased perceived relaxation skills and emotion processing important </li></ul><ul><li>Pattern of effects suggest a faster recovery after adjuvant therapy in CBSM pts vs controls </li></ul><ul><li>Antoni et al (2001) Health Psychology , 20 , 20-32; </li></ul><ul><li>Cruess, Antoni et al (2000) Psychosomatic Medicine, 61 , 94. </li></ul><ul><li>McGregor et al., (2004 ) J. Psychosom Res, 56, 1 – 8; </li></ul><ul><li>Antoni et al. (2006) Amer J. Psychiatry </li></ul><ul><li>Antoni et al . (2006) JCCP; </li></ul>
  15. 16. 1980s 1990s 2000- Study 1: Psychosocial processes in adaptation to breast cancer treatment History of BREAST CANCER RESEARCH Study 2: CBSM Effects on Psy Adaptation to Breast cancer treatment <ul><li>Study 3: CBSM Effects on Psy and Physiol Adaptation to breast cancer treatment </li></ul><ul><li>Cortisol reduction </li></ul><ul><li>Increased cellular immune function </li></ul>
  16. 17. <ul><li>Autonomic nervous system </li></ul><ul><ul><li>NE </li></ul></ul><ul><ul><li>Epinephrine </li></ul></ul><ul><ul><li>Other neuropeptides </li></ul></ul><ul><li>DNA Repair </li></ul><ul><li>Proliferation </li></ul><ul><li>Migration & invasion </li></ul><ul><li>Proteases (MMPs) </li></ul> Angiogenesis / Pro-angiogenic cytokines (VEGF, IL-6) ACTH Cortisol NE/Epi CRF / Locus Coeruleus  Dopamine  Oxytocin Oncogenic viruses <ul><li>Oncogene transcription </li></ul><ul><li>Viral replication </li></ul><ul><li>Host cell cycling </li></ul><ul><li>Immune response </li></ul><ul><li>Activity </li></ul>Optimism Perceived Stress Depression External Events Psychological Reactions Neuroendocrine Activity Peripheral Tissue Antoni et al. (2006). Nature Reviews Cancer, 6, 240-248. Adrenal Gland Cancer cells Immune cells (will need to show different types of cells – NK, T, Macroph, etc.) Endothelial cells (or a blood vessel) Social Isolation Negative Life Events Environmental stressors (SES)
  17. 18. Does CBSM also affect cellular immunity in Women with BCa? <ul><li>Prior work had shown Psy Intervention effects on lymphocyte proliferation in women with BCa </li></ul><ul><ul><li>Patients with lower T lymphocyte counts and T-cell responsivity @ surgery  higher risk for recurrent disease </li></ul></ul><ul><ul><li>(Andersen et al., J.NCI 2004) </li></ul></ul>
  18. 19. <ul><li>C BSM Effects on PM Cortisol and Immune Indicators in BCa </li></ul><ul><li>Reductions in PM plasma cortisol levels </li></ul><ul><ul><li>Pre-post 10wk CBSM (Cruess et al., 2000 Psychosom Med ) </li></ul></ul><ul><ul><li>12 mo follow-up (Phillips et al., 2008 Psychosom Med ) </li></ul></ul>
  19. 20. CBSM Intervention after Surgery for Breast Cancer: <ul><li>Psychological adaptation: </li></ul><ul><li>increased benefit finding and optimism </li></ul><ul><li>decreased anxiety, depression, soc disruption, fatigue, sleep disruption </li></ul><ul><li>increased perceived relaxation skills and emotion processing important </li></ul><ul><li>Physiological adaptation : </li></ul><ul><li>decreases in PM cortisol levels </li></ul><ul><li>increased LPR to anti-CD3 challenge </li></ul><ul><li>increased  -IFN and IL-2 production during LPR </li></ul><ul><li>Pattern of effects suggest a faster recovery after adjuvant therapy in CBSM pts vs controls </li></ul><ul><li>Antoni et al (2001) Health Psychology , 20 , 20-32; </li></ul><ul><li>Cruess, Antoni et al (2000) Psychosomatic Medicine, 61 , 94. </li></ul><ul><li>McGregor et al., (2004 ) J. Psychosom Res, 56, 1 – 8; </li></ul><ul><li>Antoni et al. (2006) Amer J. Psychiatry </li></ul><ul><li>Antoni et al . (2006) JCCP; </li></ul><ul><li>Phillips et al. (2008 ) Psychosom Medicine </li></ul><ul><li>Antoni et al. (2009) Brain Beh Immunity </li></ul>
  20. 21. Examining Biobehavioral Processes Associated with CBSM in Cancers <ul><li>PNI Processes </li></ul><ul><ul><li>Immune surveillance (CMI and innate)  monitoring metastatic growth </li></ul></ul><ul><ul><li>Inflammation (circulating cytokines/CRP)  relevant for symptom management and disease progression </li></ul></ul><ul><li>Other Biobehavioral Processes </li></ul><ul><ul><li>Tumor growth promoters </li></ul></ul><ul><ul><ul><li>Invasion, angiogenesis, metastasis </li></ul></ul></ul><ul><li>Technological advances in readout systems </li></ul><ul><ul><li>Expression measures for cellular activation of key pathways mediating stress effects on cancer (IRFs, STAT, NFkB, CREB, ELK1) </li></ul></ul>
  21. 22. Biobehavioral Pathways Associated with Stress and Cancer Pathogenesis (Miller & Cole, 2009 Ann Rev Psychol .) CREB/ATF GR NFkB/ IL-1 <ul><li>STRESS </li></ul><ul><li>Chronic stress </li></ul><ul><li>Depression </li></ul><ul><li>Social Adversity </li></ul><ul><li>CANCER PATHOGENESIS </li></ul><ul><li>Apoptosis/Anoikis </li></ul><ul><li>Angiogenesis </li></ul><ul><li>Growth & Metastasis </li></ul><ul><li>BIOBEHAVIORAL </li></ul><ul><li>MEDIATORS </li></ul><ul><li>SNS Activation </li></ul><ul><li>HPA dysregulation </li></ul><ul><li>Inflammation </li></ul><ul><li>Cellular Immune Suppression </li></ul>Type I IFN
  22. 23. What about changes in Gang Activity? <ul><ul><li>TELiS-generated Transcriptional-factor binding motifs (TFBMs) </li></ul></ul><ul><ul><li>Collections of logically related genes with common missions: </li></ul></ul><ul><ul><ul><li>SNS-related cAMP binding CREB </li></ul></ul></ul><ul><ul><ul><li>HPA axis signal receipt via GC receptor GCS </li></ul></ul></ul><ul><ul><ul><li>NFkB-mediated inflammation signaling NFkB/rel </li></ul></ul></ul><ul><ul><ul><li>Type I Interferon response signaling IRFs 1/2 </li></ul></ul></ul>
  23. 24. Examining Leukocyte Transcription Changes after CBSM in BCa <ul><li>Can CBSM modulate gene expression in PBMCs for : </li></ul><ul><ul><li>Type I IFN signaling? – up </li></ul></ul><ul><ul><li>SNS activation? (CREB) - down </li></ul></ul><ul><ul><li>GC receptor resistance? - down </li></ul></ul><ul><ul><li>Inflammation? (NFkB, STAT) - down </li></ul></ul><ul><ul><li>Disease progression promoters? MMP-9 - down </li></ul></ul><ul><li>$$$ Questions: Are these changes in expression tied to: </li></ul><ul><ul><li>QOL and symptom management? </li></ul></ul><ul><ul><li>Faster recovery from surgery or adjuvant therapy? </li></ul></ul><ul><ul><li>Ability to tolerate larger dosage of adjuvant tx? </li></ul></ul><ul><ul><li>Success of cancer treatments vs resistance? </li></ul></ul><ul><ul><li>Clinical disease outcomes (recurrence, mortality)? </li></ul></ul>
  24. 25. Lutgendorf, Sood & Antoni, J. Clin Onc , 2010 Tracking Gene Gangs in the Hood………
  25. 26. Other Areas of Current Interest <ul><li>Best Timing for Delivering CBSM in the context of care? </li></ul><ul><li>Briefer Forms Effective? What are essential ingredients? </li></ul><ul><li>Does it work in Spanish? </li></ul><ul><li>Alternative Methods Effective for Delivering to Underserved Populations? </li></ul><ul><ul><li>Community-based participatory research </li></ul></ul><ul><ul><li>Telehealth (videophones and SKYPE) </li></ul></ul>
  26. 27. Can Stress Management Intervention Facilitate Positive Adjustment after Adjuvant Therapy for Breast Cancer has ended? NCI grant P50CA84944. M. Antoni, P.I. Examining the effects of CBSM at 3 - 12 months after adjuvant therapy has been completed
  27. 28. Assessment Time Points T1 surgery T4 One year post surgery T3 T2 2-8 wks post B SMART-10 wks. 3 months post 6 months post
  28. 29. Ongoing Work In CBSM <ul><li>Can CBSM be delivered effectively: </li></ul><ul><ul><li>In abbreviated components? </li></ul></ul><ul><ul><li>In the community? </li></ul></ul><ul><ul><li>In different languages? </li></ul></ul><ul><ul><li>Over the telephone? </li></ul></ul>
  29. 30. 5wk RT vs 5wk CBT vs 5wk Educ grp grp grp <ul><li>Psychosocial adaptation (BF, FACT-B, PSS, FSI, PSQI) </li></ul><ul><li>HPA axis regulation (sal cortisol output & regulation) </li></ul><ul><li>Pro-inflammatory cytokines (IL-1, TNF-  and IL-6) </li></ul><ul><li>Health behaviors (exercise) </li></ul><ul><li>Intervention processes (CBT-specific and non-specific) </li></ul><ul><li>( 2R01 CA064710-10A1) </li></ul>
  30. 31. Delivering CBSM in the Community: Project CARE (Lechner, P.I., Antoni, co-PI, Kobetz, co-PI) NCI R01CA131451 <ul><li>Partnered with Community Organizations in Overtown and other Miami regions of minority and underserved populations </li></ul><ul><li>Formative research to tailor CBSM-based intervention </li></ul><ul><li>Community-Based Participatory Research methods used to train assessors to collect physiologic and psychosocial measures in home </li></ul><ul><li>CBSM groups conducted in community (church & community centers) </li></ul><ul><li>Pre-post-F/U of psychosocial, physiological and symptom cluster outcomes </li></ul><ul><ul><li>PSS, Mood, QOL </li></ul></ul><ul><ul><li>Fatigue, sleep, symptoms </li></ul></ul><ul><ul><li>Salivary cortisol, HRV </li></ul></ul>
  31. 32. Hey what about the men? CBSM Prostate Cancer Studies at U.Miami (2000-2011) Tele-Phone CBSM PRCA Post Surg Post Radiation Advanced Disease Eng Lang Spa Lang Eng Lang Spa Lang Eng Lang
  32. 33. CBSM and Prostate Cancer (Penedo, Schneiderman, Antoni-NCI-P50) <ul><li>Early stage patients assigned to CBSM after surgery/radiation showed: </li></ul><ul><li>Increased quality of life </li></ul><ul><li>Increased stress management skills </li></ul><ul><li>Increased urinary functioning </li></ul><ul><li>Increased sexual functioning </li></ul><ul><li>Effects established in Spanish Translation </li></ul><ul><li>Penedo et al. (2004) Cancer, 100 , 192 – 200. </li></ul><ul><li>Dahn, Penedo et al (2004) Urology. 63, 273 – 277 </li></ul><ul><li>Dahn, Penedo et al. (2005). Urology, 65 (5), 953-958. </li></ul><ul><li>Kinsinger, Penedo, Antoni et al. (in press).  Psycho-Oncology. </li></ul>
  33. 34. Stress Reduction Materials for Persons with Cancer Antoni, M.H. (2003) Stress Management Intervention for Women with Breast Cancer . Washington DC: APA Press. Penedo, F., Antoni, M.H. & Schneiderman, N. (2008) Cognitive-Behavioral Stress Management for Prostate Cancer Recovery. N.Y.: Oxford Press.
  34. 35. Can You Hear Me Now?: Can CBSM groups be Delivered Over the Phone? <ul><li>Patients with advanced disease not able to attend groups </li></ul><ul><li>Some patients have transportation issues </li></ul><ul><li>Some prefer to maintain anonymity </li></ul><ul><li>Worked with Psychiatry and Engineering to develop Telecare-based technology with conference calling to allow access to CBSM via phone: “TELEPHONE GROUPS” </li></ul><ul><li>NCI-R21 (Penedo, Czaja, Antoni, Soloway): RCT of Telecare-CBSM in advanced Prostate Cancer </li></ul><ul><li>NIH-R01 (Antoni, Klimas, Penedo, Czaja, Fletcher): RCT of Telecare-CBSM in patients with Chronic Fatigue Syndrome </li></ul>
  35. 36. Developing and Testing Psychosocial Interventions in Clinical Disease: “Drilling Down and Reaching Out” <ul><li>Combining “Mechanism Research” with “Clinical Efficacy Research” is Efficient </li></ul><ul><li>Stress Management may produce molecular “footprints” in leukocytes pursuant to changes in neuroendocrine regulation over sustained periods </li></ul><ul><li>Using Community-based Approaches and Telecommunication Technology Reaches Populations Most in Need </li></ul>
  36. 37. Acknowledgments NCI (R01 CA64710/ P50CA84944/ R01CA131451) NIMH (P01 NIMH49548) NINDS (1R01NS072599-01; 1R01 NS055672-01) <ul><li>Charles S. Carver, PhD </li></ul><ul><li>Suzanne Lechner, Ph.D. </li></ul><ul><li>Sharlene Weiss, RN, PhD </li></ul><ul><li>Robert Derhagopian, MD </li></ul><ul><li>Frederick L. Moffat, MD </li></ul><ul><li>Jodeen E. Powell, MD </li></ul><ul><li>Dido Franceschi, MD </li></ul><ul><li>Alan Livingstone, MD </li></ul><ul><li>Tammy Enos Sifre, PhD </li></ul><ul><li>Kristin Kilbourn, PhD </li></ul><ul><li>Susan Alferi Fox, PhD </li></ul><ul><li>Patti Arena, PhD </li></ul><ul><li>Jessica Lehman, PhD </li></ul><ul><li>Amy Boyers, PhD </li></ul><ul><li>Jennifer Culver, PhD </li></ul><ul><li>Susan Yount, PhD </li></ul><ul><li>Suzanne Harris, PhD </li></ul><ul><li>Dean Cruess, Ph.D. </li></ul><ul><li>Sara Czaja, Ph.D. </li></ul><ul><li>Stefan Gluck, MD, Ph.D. </li></ul><ul><li>Bonnie McGregor, PhD </li></ul><ul><li>Alicia Price, PhD </li></ul><ul><li>Vida Petronis, PhD </li></ul><ul><li>Roselyn Smith-Gonas, PhD </li></ul><ul><li>Kurrie Wells, MS </li></ul><ul><li>Cassy Vaughn, MS </li></ul><ul><li>Kenya Urcuyo, MS </li></ul><ul><li>Sophie Guellati, PhD </li></ul><ul><li>Sarah Wimberly, Ph.D. </li></ul><ul><li>Aisha Kazi, Ph.D. </li></ul><ul><li>Kristin Phillips, Ph.D. </li></ul><ul><li>Janny Rodriguez, MEd </li></ul><ul><li>Nicole Whitehead, Ph.D. </li></ul><ul><li>Lynne Hudgins </li></ul><ul><li>Linda Cahan </li></ul><ul><li>Jarrard Goodwin, M.D. </li></ul><ul><li>Bonnie Blomberg, Ph.D. </li></ul><ul><li>Rich Shultz, Ph.D. </li></ul><ul><li>Neil Schneiderman, PhD </li></ul><ul><li>MaryAnn Fletcher, PhD </li></ul><ul><li>Nancy Klimas, MD </li></ul><ul><li>Mahendra Kumar, Ph.D. </li></ul><ul><li>Frank Penedo, PhD, </li></ul><ul><li>Gail Ironson, MD, PhD. </li></ul><ul><li>Maria Llabre, Ph.D. </li></ul><ul><li>Susan Lutgendorf, PhD. </li></ul><ul><li>Steve Cole, PhD. </li></ul><ul><li>Stacy Cruess, Ph.D. </li></ul><ul><li>Kristin Kilbourn, PhD </li></ul><ul><li>Adam Carrico, PhD </li></ul><ul><li>Ron Duran, Ph.D. </li></ul><ul><li>Barry Hurwitz, PhD </li></ul><ul><li>Deidre Pereira, PhD </li></ul><ul><li>Corina Lopez, M.S. </li></ul><ul><li>Kevin Maher, PhD </li></ul><ul><li>Erin Fekete, PhD. </li></ul><ul><li>Kate Weaver, Ph.D. </li></ul><ul><li>Jeffrey Gonzalez, Ph.D. </li></ul>

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