Yuelin Li

Cancer survivors often experience multiple cooccurring symptoms such as insomnia, pain, fatigue, and anxiety; yet conventional analyses in symptom science typically analyze symptoms one at a time and thus overlook putative clusters of shared symptom experiences. We applied a novel machine learning approach to supporting tailored symptom management to cooccurring symptoms. Bayesian nonparametric (BNP) clustering was applied to discover unique subgroups of symptom profiles in cancer survivors diagnosed with insomnia (N = 160) and with cooccurring pain, fatigue, and anxiety, using secondary symptom data from a clinical trial (clinicaltrials.gov: NCT02356575) comparing cognitive-behavioral therapy for insomnia (CBT-I) and acupuncture. BNP identified survivor subgroups by recognizing shared features in symptoms that contributed to heterogeneous treatment responses at 8 weeks. Simulations evaluated sensitivity to model assumptions. BNP identified three patient subgroups: (1) “insomnia-predominant” (N = 84) with high severity insomnia alone; (2) “insomnia & pain” (n = 21) with high severity of both insomnia and pain; and (3) “high symptom burden” (n = 54) with high severity across all symptoms. CBT-I produced greater insomnia reduction among “insomnia-predominant” patients (posterior mean=-2.45, 95% Bayesian Highest Density Interval: − 4.38, − 0.35) and among “insomnia & pain” patients (− 2.66, 80% HDI: − 4.50, − 0.50). However, acupuncture produced greater pain reduction among “insomnia & pain” patients (− 1.47, 95% HDI: − 2.79, − 0.18). CBT-I and acupuncture were equally effective for all symptoms among the “high symptom burden” patients. Simulations showed that our main BNP settings accurately identified these subgroups. Unsupervised BNP learning supports interventions tailored to patients’ symptom burden and their main concerns. If further validated, BNP learning provides a roadmap for precision symptom management for cancer survivors, and broadly applicable in behavioral medicine data analysis.

Background: Alcohol use increases the risk of seven cancers, including breast and colorectal cancers. Awareness of this is low in the US population (34%), which impedes risk reduction efforts, support for alcohol regulation policies, and physician and family communication about this topic. Efforts to improve awareness of the cancer risks of alcohol will require multiple approaches, including the use of educational messages tailored to audience needs. There is a lack of evidence about how existing messaging influences awareness and characteristics associated with awareness that could guide future messaging. Methods: We recruited a nationally representative sample of N = 827 US adults aged ≥21 who reported alcohol use in the past month and were unaware that alcohol increases cancer risk. Participants viewed a publicly available educational video on this topic and subsequently reported cancer risk awareness. Results: After video exposure, 70% of participants reported awareness. Post-video awareness was lower among heavier drinkers, those with a cancer history, those with no family cancer history, and those who tend to avoid health information, perceive low cancer controllability, or feel cancer information overload. Those who reported inaccurate beliefs at baseline (responding “no” to the question of whether cancer can result from too much alcohol) reported lower awareness than those who initially reported that they “didn’t know” whether alcohol increased cancer risk. Conclusions: These findings provide groundwork to guide the development of adaptations to available alcohol and cancer risk messaging. Impact: Educational messages tailored to audience needs can help inform all sectors of the US public about the cancer harms of alcohol. See related In the Spotlight, p. 367

Background: Patients’ self-report of their symptoms can provide important data for the evaluation of treatment benefit and tolerability of oncology drugs. Contemporary treatment approaches, including immunotherapy and molecular targeted therapies, have unique toxicities based on their novel mechanisms of action. This scoping review aimed to summarize evidence from existing reviews and clinical practice guidelines to examine the type and prevalence of toxicities including symptomatic adverse events (sympAEs) for adult cancer patients to inform clinical care and therapeutic trials. Methods: A systematic search of PubMed, Web of Science, and Embase was performed using predefined eligibility criteria. Thirty-one literature reviews and 3 clinical practice guidelines met inclusion criteria and were selected for review and data abstraction. Results: Findings from this scoping review demonstrated several leading sympAEs that were reported across immunotherapy and targeted therapy drugs, including fatigue, diarrhea, and rash. In addition to these more prevalent sympAEs, there were some less frequently reported class-specific sympAEs, which had potential for significant harm or disability to the patient if not properly identified and treated. Many studies reported toxicities as AEs or syndromes solely using data reported by clinicians without additional self-report from patients. Conclusion: We identified several core sympAEs experienced by patients participating in oncology trials using immunotherapy and targeted therapy agents, which has implications for future trial design and drug labeling. Future cancer trials should assess patient-reported sympAEs based on the identified drug mechanism to inform the tolerability of these newer agents and enhance patient safety during trial participation and clinical care.

PURPOSE: The Anal Cancer/High-grade squamous intraepithelial lesions Outcomes Research (ANCHOR) trial demonstrated that treating precancerous anal HSIL reduces the incidence of anal cancer by 57% in people with HIV. It remains unclear how HSIL treatment or monitoring without treatment affects patient-reported health-related quality of life (HRQoL). We evaluated differences in HRQoL for individuals who were randomly assigned to active monitoring (AM) or treatment for anal HSIL. METHODS: Using an index designed and validated for use in ANCHOR, HRQoL was assessed before random assignment (T1), 2-7 days (+3 days) after random assignment/treatment (T2), and 28 days (±7 days) after random assignment/treatment (T3). RESULTS: ANCHOR participants living with HIV (N = 124; mean [standard deviation, SD] age, 52.6 years [10.3]; n = 101 [81.5%] men; n = 65 [52.4%] White; n = 95 [76.6%] non-Hispanic; treatment n = 70 [56.4%]; and AM n = 54 [43.6%]) were included. Treatment arm participants had significant mean worsening from T1-T2 in physical symptoms (mean [SD] difference, 0.31 [0.51]; P = .0001) and impact on psychological functioning (mean [SD] difference, 0.25 [0.64]; P = .022) that significantly improved to T1 levels from T2-T3 (ie, mean [SD] difference, –0.25 [0.52]; P = .003; and mean [SD] difference, –0.07 [0.23]; P = .039, respectively). AM arm participants experienced significant mean improvement in impact on psychological functioning from T1-T3 (mean [SD], difference, –0.20 [0.50]; P = .017). After adjusting for T1, treatment arm participants had a larger mean improvement than AM arm participants in physical symptoms from T2-T3 (mean [SD] difference, –0.25 [0.52]; P = .024); no between-arm differences were observed for impact on physical or psychological functioning. CONCLUSION: Treatment arm participants experienced significant worsening in physical symptoms and impact on psychological functioning from T1-T2 but returned to prerandomization levels by T3, indicating that any immediate anal HSIL treatment-related impacts to HRQoL are temporary. Further research is needed to determine long-term impacts of anal HSIL treatment on HRQoL.

Background: Remote symptom monitoring (RSM) is an evidence‐based strategy shown to mitigate postoperative morbidity; however, platform engagement is required to benefit from RSM. Patients who report current smoking are at high risk for postoperative complications, but it is unknown whether smoking status influences engagement with RSM, symptom severity, or unanticipated acute care visits.Methods: This observational case–control study was conducted in patients undergoing ambulatory oncologic surgery at a large cancer center. The authors examined the effect of current smoking status on adherence to an electronically delivered postoperative recovery‐assessment tool. Symptom severity and readmissions by smoking status were also analyzed.Results: In total, 19,481 patients who underwent surgery and were enrolled in RSM were included. The nonresponse rate (28%) in current smokers was significantly greater than the rate observed in never smokers (21%; odds ratio, 1.38; 95% confidence interval, 1.17–1.63; p < .0001). Current smokers reported higher symptom scores for pain, wound swelling, constipation, and anxiety. The observed 30‐day readmission rates were 3.6% for current smokers and 2.6% for never smokers, with overlapping confidence intervals.Conclusions: Current smokers report higher symptom burden after surgery yet are less likely to adopt proactive digital postoperative recovery strategies like RSM. Implementation strategies are needed to improve the engagement of current smokers in RSM if benefits are to be realized in this high‐risk population.

(1) Background: This pilot study evaluates the feasibility and preliminary effects of acupuncture for cancer-related cognitive dysfunction (CRCD) in cancer survivors. (2) Methods: A randomized trial comparing real acupuncture (RA) to sham acupuncture (SA) and waitlist control (WLC) among cancer survivors reporting cognitive difficulties. Interventions were delivered weekly over 10 weeks. Feasibility was evaluated by recruitment, treatment adherence, and assessment completion. Subjective CRCD was assessed by the Functional Assessment of Cancer Therapy-Cognitive Function—Perceived Cognitive Impairment subscale (FACT-Cog PCI) and objective CRCD was assessed by the Hopkins Verbal Learning Test—Revised (HVLT-R). (3) Results: 32 participants (57.1% of eligible patients) were enrolled. All participants in acupuncture groups completed ≥8 of 10 treatments. Assessment completion rate was 100% for all participants. From baseline to week 10, the RA group (n = 19) reported a clinically meaningful 17.3-point increase in FACT-Cog PCI (95% confidence interval [CI] 12.5 to 22.1), compared to 9.7 points (95% CI 2.8 to 16.7) in the SA group (n = 9), and 6.8 points (95% CI −3.7 to 17.2) in the WLC group (n = 4). In the subgroup analysis among patients with a below-average baseline HVLT-R (T-score < 50), the RA group (n = 8) increased FACT-Cog PCI scores by 20.4 (95% CI 13.6 to 27.3), compared to 11.1 points (95% CI 0.6 to 21.5) in the SA group (n = 5). The improvements from RA persisted through week 16 in both the total sample and the sub-group. Eleven mild adverse events were reported, with pain and bleeding at the needling sites being the most common. (4) Conclusions: The findings support the feasibility and safety of conducting a randomized, placebo-controlled trial to evaluate acupuncture for cognitive dysfunction in cancer survivors.

PURPOSE: Evidence suggests that oncology patients are satisfied with and sometimes prefer telemedicine compared with in-person visits; however, data are scarce on when telemedicine is appropriate for specific cancer populations. In this study, we aim to identify factors that influence patient experience and appropriateness of telemedicine use among a head and neck cancer (HNC) population. METHODS: We performed a mixed-methods study at a multisite cancer center. First, we surveyed patients with HNC and analyzed factors that may influence their telemedicine experience using multivariate regression. We then conducted focus groups among HNC oncologists (n = 15) to evaluate their perception on appropriate use of telemedicine. RESULTS: From January to December 2020, we collected 1,071 completed surveys (response rate 24%), of which 551 first unique surveys were analyzed. About half of all patients (56%) reported telemedicine as “same or better” compared with in-person visits, whereas the other half (44%) reported “not as good or unsure.” In multivariate analyses, patients with thyroid cancer were more likely to find telemedicine “same or better” (adjusted odds ratio, 2.08 [95% CI, 1.35 to 3.25]) compared with other HNC populations (mucosal/salivary HNC). Consistently, physician focus group noted that patients with thyroid cancer were particularly suited for telemedicine because of less emphasis on in-person examinations. Physicians also underscored factors that influence telemedicine use, including clinical suitability (treatment status, visit purpose, examination necessity), patient benefits (travel time, access), and barriers (technology, rapport-building). CONCLUSION: Patient experience with telemedicine is diverse among the HNC population. Notably, patients with thyroid cancer had overall better experience and were identified to be more appropriate for telemedicine compared with other patients with HNC. Future research that optimizes patient experience and selection is needed to ensure successful integration of telemedicine into routine oncology practice.

Analytics for behavioral habit typically model one behavior at a time, despite the fact that habit often involves multiple cooccurring behaviors, such as food choices and physical activities, where interrelated behaviors are often equally recommended. We propose a novel Mixed-Effects Dynamic hAbit model (MEDA) to simultaneously model multiple related, habitual behaviors. As an illustrative example, MEDA was applied to real-time assessments of sun protection (sunscreen, shade, hat, and protective clothing) reported twice daily by first-degree relatives of melanoma patients who are themselves at an elevated risk of skin cancer. MEDA aims to explicate habits in sun protection under varying environmental cues (e.g., sunny and hot weather). We found consistent between-group differences (e.g., men responding to weather cues more consistently than women) and interactions between cooccurring behaviors (e.g., being in shade discourages sunscreen wearing, more so in men than women). Moreover, MEDA transcends conventional methods to address longstanding challenges—how cue to action and volitional choices differ by groups or even by individual persons. Such nuances in interrelated habitual behaviors are relevant in numerous other applications, such as recommended dietary or physical activity behaviors. These methods best inform personalized behavioral interventions targeting individual preferences for precision behavioral intervention.

Background: Cancer and cancer treatments may affect aging processes, altering the trajectory of cognitive aging, but the extant studies are limited in their intervals of assessment (two–five years). We studied the cognitive performance of a cohort of survivors and controls aged from 60 to 89 years utilizing cross-sectional cognitive performance data as an indicator of potential aging trajectories and contrasted these trends with longitudinal data collected over two years. Methods: Female breast cancer survivors who had been diagnosed and treated at age 60 or older and were 5- to 15-year survivors (N = 328) and non-cancer controls (N = 158) were assessed at enrollment and at 8, 16, and 24 months with standard neuropsychological tests and comprehensive geriatric assessment. Results: A cross-sectional baseline analysis found the expected inverse association of age with cognition in both groups, with survivors performing lower overall than controls in learning and memory (LM). Younger survivors, i.e., those under 75 years of age, exhibited lower performance in both LM and attention, and processing speed and executive function (APE), compared to controls, with no differences being observed between older survivors and controls, which tracked with deficit accumulation trends. Conclusion: Cognitive differences between the survivors and controls for the LM and APE domains were prominent in younger survivors, as was deficit accumulation, suggesting a mediating effect on cognition. Deficit accumulation may represent a modifiable risk factor in cancer survivorship that may be targeted for prevention and intervention.