Allison J. Applebaum

Objective: Cancer‐related posttraumatic stress disorder (PTSD) is prevalent among hematopoietic cell transplantation (HCT) survivors, yet access to evidence‐based care is limited. This study evaluated adaptive, stepped‐care treatment sequences for PTSD symptoms using a Sequential Multiple Assignment Randomized Trial (SMART), comparing digital and therapist‐delivered interventions. Methods: HCT survivors ( N = 477), 1–5 years post‐transplant, with probable or subthreshold PTSD, were randomized to the Cancer Distress Coach (CaDC) app or Usual Care. At Week 4, non‐responders (i.e., < 5‐point PCL‐5 reduction) were re‐randomized to CaDC + Coaching or therapist‐delivered cognitive behavioral therapy for PTSD (CBT‐PTSD). PTSD symptoms (primary outcome), depression, and anxiety were assessed at baseline, Week 4, Month 3 (primary endpoint), and Month 6. Results: Both initial treatment groups demonstrated symptom reductions at Week 4 with no significant between‐group differences; approximately 60% met early response criteria. By Month 3, outcomes reflected treatment escalation rather than direct comparison of initial interventions. Regimen‐level analyses demonstrated differences across adaptive sequences for PTSD at Months 3 and 6, and for depression and anxiety at Month 3 (global p ‐values ≤ 0.018). Regimens escalating to CBT‐PTSD were associated with greater and more sustained reductions than those escalating to CaDC + Coaching. The sequence initiating with CaDC and escalating to CBT‐PTSD produced the largest effects. Conclusions: Although a self‐guided digital intervention did not outperform Usual Care initially, adaptive stepped‐care strategies that triage early responders and escalate non‐responders to therapist‐delivered CBT‐PTSD were associated with the greatest reductions in symptoms. Digital tools may function as entry points within stepped‐care models to allocate higher‐intensity psychotherapy. Trials registration: ClinicalTrials.gov , NCT04058795, registered 8/16/2019

Meaning-Centered Psychotherapy (MCP) has shown significant promise in reducing existential distress and improving wellbeing in people with advanced cancer. Research is yet to explore the applicability and translation of MCP into an Indigenous Aotearoa New Zealand cultural context. Objectives: This research sought to explore the applicability of MCP within Aotearoa New Zealand. The objectives of this study were to investigate Indigenous patients’ experiences of an MCP trial and Indigenous therapists’ experiences of recruitment and MCP delivery within the trial. Methods: Semi-structured interviews were conducted with 2 Indigenous patients with advanced cancer receiving MCP, 1 Indigenous support person, and 4 Indigenous health psychologists delivering MCP about their experience in the research trial. Participants were also asked their views on recruiting Indigenous populations into research trials, and on the applicability of MCP in Aotearoa New Zealand. Reflective thematic analysis was utilized to analyze interview transcripts. Results: This study showed that trust is central to recruiting Indigenous populations into research trials and contributed to the overall success of MCP delivery. Participants highlighted community trust and organizational mistrust as potential contributors toward recruitment challenges. Trust in the self, in others, and in culture was central to finding meaning through MCP. When conducted in a safe patient-centered therapeutic space, MCP concepts and meaning-making can integrate effectively into Te Ao Māori and an Indigenous context. Significance of results: MCP concepts and delivery may integrate well into a Te Ao Māori framework. Care should be taken in future delivery of MCP within Aotearoa New Zealand, ensuring the patient-focused nature of the therapeutic modality is maintained, and the patient’s own connection with culture is the highest priority.

Background: Caregivers of patients with advanced cancer shoulder immense responsibilities as they care for patients, including symptom and medication management, providing emotional support, and navigating healthcare treatment and decision-making. Due to the heavy toll of these responsibilities, caregivers are at high risk for profound mental health challenges, including anxiety, depression, and posttraumatic stress disorder. A key driver of this heightened risk for psychopathology in caregivers is existential distress, manifesting as a loss of meaning and purpose, decreased spiritual well-being, and hopelessness. Historically, psychosocial interventions targeting distress in cancer caregivers have neglected to address existential distress. Meaning-Centered Psychotherapy for Cancer Caregivers, a seven-session structured intervention, was developed to address this gap. In a pilot randomized controlled trial, the approach led to enhancements in personal meaning, benefit finding, and spiritual well-being. Here, we present a large, multi-site trial that aims to definitively examine the efficacy of Meaning-Centered Psychotherapy for Cancer Caregivers in an adequately powered study. Method: This randomized controlled trial will evaluate the efficacy of Meaning-Centered Psychotherapy for Cancer Caregivers versus Supportive Psychotherapy for Cancer Caregivers on primary (personal meaning and spiritual well-being) and secondary (anxiety, depression, sense of meaning in caregiving, benefit finding, caregiver burden, social support) outcomes at baseline, posttreatment, and at 6- and 12- months follow-up. It will also evaluate the role of sense of meaning in life as a mediator of secondary outcomes, as well as the impact of Meaning-Centered Psychotherapy for Cancer Caregivers on pre- and post-loss bereavement outcomes. Caregivers ( N = 200) of patients with advanced (stage III/IV) solid tumor cancers from Memorial Sloan Kettering Cancer Center, Sylvester Comprehensive Cancer Center, and the community will be enrolled. Discussion: Meaning-Centered Psychotherapy for Cancer Caregivers has the potential to help alleviate existential suffering in caregivers as they manage the multifaceted demands of caring for patients with advanced cancer. This trial seeks to evaluate the efficacy of this intervention in a more robust and representative trial of cancer caregivers and extends prior research to explore mediators of improvement and the impact of the intervention on pre- and post-loss bereavement outcomes. Trial registration: ClinicalTrials.gov NCT06307535. Registered on 03/05/2024.

Background: Rising advanced cancer incidence globally places profound existential distress and psychological burden on family caregivers. We culturally adapted Meaning‐Centered Psychotherapy for Cancer Caregivers (MCP‐C) from Western to Chinese context, targeting existential distress through meaning‐making processes. Aims: This pilot randomized controlled trial aimed to examine the feasibility, acceptability, and preliminary effects of an online MCP‐C (eMCP‐C) among caregivers of patients with advanced cancer. Methods: Caregivers of patients with advanced cancer, experiencing distress related to caregiving, were randomly assigned (1:1) to eMCP‐C or enhanced usual care groups. Over 7 weeks, participants received weekly individual session of eMCP‐C focusing on meaning making and coping with caregiving, whereas enhanced usual care group received resources for mental health treatment and targeted referrals for specific distress problems. Feasibility outcomes were assessed through questionnaires and semi‐structured interviews at 7‐week. Efficacy outcomes were assessed by questionnaire at baseline, 7, and 19 weeks. Results: Forty‐six caregivers enrolled (26–79 years old), among which thirty‐seven (80%) completed the study. Intervention attendance, retention rates, and participant satisfaction were satisfactory. Depression, anxiety, meaning, peace, and self‐esteem improved from baseline to immediate and 3‐month post‐intervention in intervention group. Qualitative analysis revealed three key therapeutic mechanisms: (1) Therapeutic Alliance as a Catalyst for Intrapersonal and Interpersonal Healing, (2) Meaning‐making Through Acceptance and Action, and (3) Empowering Through Affirmation and Self‐Determined Action. Conclusions: For Chinese caregivers of patients with advanced cancer, eMCP‐C is feasible, well‐accepted, and showed preliminary benefits in psychological distress, meaning, peace, and self‐esteem, compared to an enhanced usual care group.

PURPOSE: Patient portals increase communication, but little is known about response rates or patient characteristics associated with patient responses to portal-enabled questionnaires about health-related values (HRVs). METHODS: We tested feasibility of sending seven HRV questions by portal to medical oncology patients, with responses automatically returned to clinicians. HRV questionnaires were sent 1 week in advance of scheduled follow-up visits. The primary feasibility measure was patient response rate. Secondarily, we assessed patient characteristics associated with responses, and oncology clinicians' impressions. RESULTS: One thousand five hundred fifty-six HRV questionnaires were sent by portal to as many individual patients of five total clinics between July 2023 and July 2024. Seven hundred thirty questionnaires were returned with at least one of the questions answered (47% response rate). Response rate increased significantly (45%-50%, P = .05) after April 2024 when the portal notification was updated with a personalized message from oncologists and two study clinics were added to the initial 3. Nonresponders either returned a blank questionnaire (133, 9%) or did not return anything (693, 45%). Response rates were significantly different by patient race ( P = .05): Asian (51%) and White (48%) versus Black (44%) and Hispanic (41%). Female patient responses were longer than males. Response time was associated with patients' oncology team and shorter after April 2024. Participating clinicians' impressions were consistently favorable. CONCLUSION: Automating a patient portal-driven process to broadly scale elicitation of medical oncology outpatients' HRVs and sending aggregated reports of HRVs to oncology teams are feasible and valued by clinicians. Patient characteristics appear to be associated with responses. Ongoing research will investigate technology-supported strategies to optimize response rates across diverse populations (including minoritized patients who may suffer digital health inequity), and measure effects on person-centered communication and care outcomes.

Family caregivers play a crucial role in supporting individuals with chronic and life-limiting illnesses, disabilities, age-related conditions, and mental health challenges. Yet taking on this role is often made without deliberation or consent. With over 63 million family caregivers in the United States, there is little discussion of how to engage current and future caregivers in a structured, informed decision-making process about the role and related responsibilities. While informed consent is a foundational principle in medicine designed to foster individual patient autonomy, it is seldom applied to caregiving decisions, leaving many unprepared for the role. Healthcare professionals are in a unique position to address this issue. This paper advocates for a shift toward informed decision-making in family caregiving, ensuring individuals can make choices that are informed and voluntary. This approach will lead to better-informed family caregivers and a more ethically focused healthcare system.

Background: Hematopoietic stem cell transplantation (HCT) is an intensive and invasive procedure used in cancer treatment that depends heavily on the involvement of caregivers and places them at high risk for posttraumatic stress disorder (PTSD) symptoms. These symptoms are frequently overlooked in oncology and general health care settings. The suitability and utility of the Primary Care PTSD Screen for DSM ‐ 5 (PC‐PTSD‐5) within cancer caregivers remains uncertain. This study sought to evaluate its performance as a brief (five‐item) case finding screening alternative to the longer (20‐item) PTSD Checklist for DSM‐5 (PCL‐5) in caregivers of survivors who received an HCT 1–5 years ago. Method: A total of 106 caregivers completed the PC‐PTSD‐5 and PCL‐5 during recruitment for a randomized clinical trial. Optimal cut scores for identifying probable PTSD and item performance were determined using indices correcting for chance and item response theory analyses. Results: Of the caregivers evaluated, 33% screened as positive for probable DSM‐5 PTSD using the PCL‐5. The PC‐PTSD‐5 exhibited acceptable internal consistency and significant associations with PCL‐5 scores (total, r = 0.79; items r [range] [0.60–0.69]). A cutoff score of 3 provided optimal sensitivity for screening (κ[Se] = 1). Item response theory analyses indicated the need for the complete PC‐PTSD‐5 items to provide the greatest information across varying levels of PTSD. Conclusion: Although not an instrument validation study, these findings provide preliminary support for using the PC‐PTSD‐5 as a succinct, effective screening tool among cancer caregivers in a clinical context.

Background Caregivers of patients with advanced cancer shoulder immense responsibilities as they care for patients, including symptom and medication management, providing emotional support, and navigating healthcare treatment and decision-making. Due to the heavy toll of these responsibilities, caregivers are at high risk for profound mental health challenges, including anxiety, depression, and posttraumatic stress disorder. A key driver of this heightened risk for psychopathology in caregivers is existential distress, manifesting as a loss of meaning and purpose, decreased spiritual well-being, and hopelessness. Historically, psychosocial interventions targeting distress in cancer caregivers have neglected to address existential distress. Meaning-Centered Psychotherapy for Cancer Caregivers, a 7-session structured intervention, was developed to address this gap. In a pilot randomized controlled trial, the approach led to enhancements in personal meaning, benefit finding, and spiritual well-being. Here, we present a large, multi-site trial that aims to definitively examine the efficacy of Meaning-Centered Psychotherapy for Cancer Caregivers in an adequately powered study. Method This randomized controlled trial will evaluate the efficacy of Meaning-Centered Psychotherapy for Cancer Caregivers versus Supportive Psychotherapy for Cancer Caregivers on primary (personal meaning and spiritual well-being) and secondary (anxiety, depression, sense of meaning in caregiving, benefit finding, caregiver burden, social support) outcomes at baseline, post-treatment, and at 6- and 12-months follow-up. It will also evaluate the role of sense of meaning in life as a mediator of secondary outcomes, as well as the impact of Meaning-Centered Psychotherapy for Cancer Caregivers on pre-and post-loss bereavement outcomes. Two hundred caregivers of patients with advanced (stage III/IV) solid tumor cancers from Memorial Sloan Kettering Cancer Center, Sylvester Comprehensive Cancer Center, and the community will be enrolled. Discussion Meaning-Centered Psychotherapy for Cancer Caregivers has the potential to help alleviate existential suffering in caregivers as they manage the multifaceted demands of caring for patients with advanced cancer. This trial seeks to evaluate the efficacy of this intervention in a more robust and representative trial of cancer caregivers, and extends prior research to explore mediators of improvement and the impact of the intervention on pre- and post-loss bereavement outcomes. Trial registration : This trial is registered at ClinicalTrials.gov, NCT06307535, registered on 03/05/2024

Background: Cognitive Behavioral Therapy (CBT) shows promise for addressing distress in cancer caregivers, though results are mixed. Traditional CBT may not fully address transdiagnostic processes underlying caregiver distress, such as attentional rigidity and perseverative thinking. Emotion Regulation Therapy (ERT), a contemporary CBT targeting these mechanisms, has promise for cancer caregivers (ERT-C). We compared ERT-C to caregiver-adapted CBT (CBT-C) on caregiver- and patient-reported outcomes. Methods: We conducted a multisite RCT (ERT-C vs. CBT-C) with distressed caregivers of patients with any cancer type or stage. Caregivers completed measures of anxiety, depression, worry, rumination, burden, and quality of life (QOL) at baseline, post-treatment, and 3- and 6-months follow-up. Patients reported outcomes at baseline and 3 months. Linear mixed-effects models with multiple imputation were used to assess group differences. Results: From March 2021 to April 2024, we randomized 253 caregivers, of whom 244 were analyzed (ERT-C = 124; CBT-C = 120), and enrolled 95 patients (ERT-C = 47; CBT-C = 48), of whom 87 were analyzed. From pre- to post-treatment and through 6 months follow-up, caregivers in ERT-C did not improve significantly more than in CBT-C. Although there were significant between-group differences in patient physical and mental health, these effects did not persist after multiplicity adjustment. However, caregivers overall demonstrated significant improvements over time in anxiety, depression, worry, and QOL, and patients demonstrated significant improvements in perceived stress and emergency room visits. Conclusions: Although ERT-C was not superior to CBT-C, caregivers showed meaningful psychosocial improvements overall, and patients improved on 2 outcomes. Future work will examine whether the 2 treatments differentially engage putative mechanisms leading to the observed clinical findings. Clinical trial registration: This trial is registered on ClinicalTrials.gov (identifier: NCT04802720).