Sarah M. Belcher

Introduction: Financial toxicity and poor mental health are common among lesbian, gay, bisexual, transgender, queer, and other non‐cisgender heterosexual (LGBTQ+) cancer caregivers. This study aimed to assess the relationship between financial toxicity and mental health among LGBTQ+cancer caregivers. Methods: We conducted a sequential explanatory mixed‐methods study (national survey and semi‐structured interviews with a subset of survey participants). Data were collected from April 2024 through December 2024. Bivariate and multivariable regression models were used to examine the association between financial toxicity (modified COmprehensive Score for financial Toxicity [mCOST]) and mental health outcomes (Mental Health Continuum‐SF [MHC‐SF] and Patient‐Reported Outcomes Measurement Information System [PROMIS] domains of anxiety, depression, sleep disturbance, and fatigue). Results: A total of N = 316 LGBTQ+cancer caregivers participated in the survey, and N = 14 participated in an interview. Among caregivers, 34.5% reported high financial toxicity (mCOST< 22). The average MHC‐SF score was 38.4 (SD: 16.9, range: 0–70). Mean PROMIS domain T‐scores were: anxiety 59.7 (SD: 10.0, range: 40.3–81.6), depression 56.2 (SD: 10.6, range: 41.0–79.4), sleep disturbance 54.2 (SD: 9.2, range: 32–73.3), and fatigue 54.8 (SD: 11.9, range: 33.7–75.8). In controlled multivariable models, high financial toxicity was significantly associated with poorer mental health (lower MHC‐SF scores [beta = −10.56, 95% CI: −14.47 to −6.65], and higher PROMIS anxiety [beta = 8.54, 95% CI: 6.33–10.74], depression [beta = 7.49, 95% CI: 5.07–9.91], sleep disturbance [beta = 6.33, 95% CI: 4.16–8.50], and fatigue [beta = 8.94, 95% CI: 6.26–11.63]. Qualitative analysis yielded two themes: (1) Financial Stress and Frustration and (2) Negative impacts of financial toxicity on health. Conclusion: LGBTQ+cancer caregivers experience high financial toxicity that is associated with poor mental health outcomes. Financial toxicity should be addressed in addition to general caregiving‐related stress in this at‐risk population.

At-home administration of oral anticancer medications (OAM) limits interactions with healthcare providers, therefore limiting opportunities for symptom management, posing threats to medication adherence. Individuals diagnosed with multiple myeloma (MM) experience symptoms from both disease- and treatment-related factors. Proteins Beta-2 Microglobulin (B2M) and Lactate Dehydrogenase (LDH) are routinely used in disease monitoring, yet their associations with symptoms and regulation via DNA methylation (DNAm) in individuals with MM have not been investigated. This study explored relationships among LDH and B2M proteins; DNAm of genes B2M, LDHA, LDHB ; and symptoms in patients prescribed OAMs for MM. This was a 6-month, longitudinal, exploratory analysis. Symptoms were assessed using self-reported measures. Protein levels were extracted from medical records. DNAm of B2M, LDHA, and LDHB promoter regions were quantified via pyrosequencing of peripheral blood samples. Linear mixed modeling explored cross-sectional and longitudinal associations. Significant cross-sectional associations were identified between fatigue, LDHA and B2M DNAm, and B2M protein ( p < .02); pain and LDHA and B2M DNAm ( p < .05); gastrointestinal disturbances and LDHA DNAm and LDH protein ( p < .05); shortness of breath and LDHA DNAm ( p < .04); and depression and LDH protein ( p < .04). Longitudinal interaction effects were significant for B2M DNAm and fatigue ( p < .05), LDHA and B2M DNAm and pain ( p < .04), and LDH protein and depression ( p < .04). Prognostic proteins B2M and LDH and their gene-level DNAm patterns were significantly associated with symptoms in individuals taking OAMs for MM. These preliminary findings support further exploration of multi-omics pathways underlying symptoms to inform symptom identification and management strategies.

Background: Oral anticancer medications are standard care for cancer. Medication adherence influences health outcomes, but valid, reliable measures assessing self-reported medication adherence are limited. Psychometric properties of the PROMIS ^® Medication Adherence Scale (PMAS) were evaluated in patients prescribed oral anticancer medications for multiple myeloma. Methodology: This was a secondary analysis from a longitudinal observational study examining medication adherence, symptoms, quality of life, and financial hardship among individuals prescribed oral anticancer medications for multiple myeloma. PMAS measured self-reported medication adherence. Self-report and medical record data assessed participant characteristics and adherence correlates. Objective medication adherence indices were generated from continuous electronic event monitored data. Internal consistency reliability was estimated using Cronbach’s alpha. Dimensionality was assessed with confirmatory factor analysis. Construct validity was assessed considering adherence correlates. Spearman rank-order correlations summarized associations between PMAS and electronic event monitored data. Results: PMAS items had limited variability, with high adherence over time. Reliability of PMAS scores was adequate (T1 α = 0.82, 95% CI: 0.75, 0.87; T2 α = 0.84, 95% CI: 0.78, 0.89). Confirmatory factor analysis fit was better for sub-scales (Medication Beliefs and Knowledge and Medication Taking Behaviors) than Total scale, particularly for the Medication Beliefs and Knowledge subscale. Adherence correlates were observed as expected between PMAS and age, self-reported cognitive function, symptom severity, and depression. Weak/moderate positive associations were found between PMAS and electronic event monitored data. Conclusions: Reliability, two-factor dimensionality, and construct validity were supported, with some evidence of concurrent criterion validity with electronic event monitored adherence data. Additional validation testing is needed to support findings. Evidence supports the feasibility of longitudinal oral anticancer medication adherence assessment monitoring using PMAS.

Social determinants of health (SDoH) impact health and wellness. The link between SDoH and adverse health outcomes, including symptom occurrence and severity, may be explained by an individual’s physiologic response to one or more SDoH. One potential mechanism underlying this physiologic response linking SDoH and symptoms is the dynamic epigenome. The purpose of this scoping review of the literature was to examine differential susceptibility for symptoms by identifying and summarizing research linking SDoH and symptoms through epigenomic mechanisms. PubMed was searched to identify empirical research where at least one SDoH was an independent or dependent variable, at least one symptom was investigated, and the investigation included an epigenomic measure. Of the 484 articles initially retrieved, after thorough vetting, 41 articles met eligibility. The most studied symptom was depressive symptoms followed by anxiety, cognitive function, sleep dysfunction, and pain. The most frequently studied SDoH were: 1) stress, particularly early life stress and acculturative stress; and 2) trauma, predominantly childhood trauma. DNA methylation and telomere length were the most studied epigenomic measures. Four genes ( SLC6A4, BDNF, NR3C1, OXTR) had evidence from multiple studies and across methodological approaches linking SDoH to symptoms. This review supports the inclusion of epigenomic approaches to better understand the link between SDoH and symptoms and provides evidence that SDoH impact telomere length and the methylation of genes involved in neurotransmitter signaling, neuronal survival, behavior, inflammation and stress response.

Background: Patients with advanced cancer are increasingly experiencing financial hardship (FH) and associated negative health outcomes. Objective: The aims of this study were to describe FH and explore its relationship to quality of life (QOL) in patients with advanced cancer receiving outpatient palliative care (PC). Methods: Validated questionnaires assessed FH, QOL dimensions, symptom burden, and sociodemographic and clinical characteristics. Descriptive statistics characterized the sample and described FH. Pearson correlation and linear regression assessed relationships between FH and QOL. Results: The average participant (n = 78) age was 56.6 (SD, 12.2) years. Most were female (56.4%), White (50%) or Black (46.2%), and had a range of education, partner statuses, and cancer diagnoses. Median time since cancer diagnosis was 35.5 months (interquartile range, 9-57.3 months). Highest mean symptom burden scores were for pain (2.5 [SD, 1.0]) and fatigue (2.0 [SD, 1.1]), on a 0- to 3-point scale (higher score representing worse symptom burden). The median COST (COmphrehensive Score for financial Toxicity) score was 15.0 (interquartile range, 9.0-23.0). Most (70%) had some (n = 43) or extreme (n = 9) difficulty paying for basic needs. Greater than 28% (n = 21) incurred cancer-related debt. Multivariate models indicated that FH negatively affected role limitations due to physical health (P = .008), pain (P = .003), and emotional well-being (P = .017) QOL dimensions. Conclusions: Financial hardship, QOL, and symptom burden scores demonstrate need for continued support for and research among patients with advanced cancer. Data support links between FH and important QOL dimensions. Larger, longitudinal studies are needed to understand how FH affects QOL in patients with advanced cancer. Implications for Practice: Proactive financial assessment and interventions are needed to support patients with advanced cancer experiencing the cumulative effects of cancer and its treatment.

Objectives: The purpose of this study was to explore social determinants of health (SDoH), and disease severity as predictors of sleep quality in persons with both Obstructive Sleep Apnea (OSA) and type 2 diabetes (T2D). Methods: Disease severity was measured by Apnea-Hypopnea Index [(AHI) ≥ 5] and HbA1c for glycemic control. SDoH included subjective and objective financial hardship, race, sex, marital status, education, and age. Sleep quality was measured by Pittsburgh Sleep Quality Index (PSQI). Results: The sample (N = 209) was middle-aged (57.6 ± 10.0); 66% White and 34% African American; and 54% men and 46% women. Participants carried a high burden of disease (mean AHI = 20.7 ± 18.1, mean HbA1c = 7.9% ± 1.7%). Disease severity was not significantly associated with sleep quality (all p >.05). Worse sleep quality was associated with both worse subjective (b = -1.54, p = .015) and objective (b = 2.58, p <.001) financial hardship. Characteristics significantly associated with both subjective and objective financial hardship included being African American, female, ≤ 2 years post high school, and of younger ages (all p < .01). Discussion: Financial hardship is a more important predictor of sleep quality than disease severity, age, sex, race, marital status, and educational attainment, in patients with OSA and T2D

Background: Although higher incidence and mortality of gynecological cancer (GynCa) are documented in black compared with white women, few studies have documented quality of life (QOL) or healthy control comparisons. Objective: This study compared depression, sexual function, and QOL between patients with GynCa and race-matched healthy controls. Methods: Patients with GynCa and healthy controls completed the Patient Health Questionnaire-9, Female Sexual Function Index, and Functional Assessment of Cancer Therapy–General measures at baseline; GynCa patients were assessed again at 6 months post–radiation therapy (RT). Results: Analyses included 84 participants (51% white, 49% black), including 28 GynCa patients and 56 controls with similar marital status. Compared with healthy controls, patients were younger, had a higher body mass index, and had more depression (P = .01); 82% of the patients and 71% of the healthy controls met criteria for sexual dysfunction at baseline (P = .29). Patients pre-RT had greater sexual dysfunction and lower QOL (P = .001) than controls did; patients at 6-month post-RT showed improved sexual function scores compared with pre-RT, with similar results to controls. White GynCa patients reported less sexual desire (P = .02), more pain (P = .05), and lower total Female Sexual Function Index scores (P = .01) than did black GynCa patients. Both black and white GynCa patients reported lower total QOL than their race-matched controls did (P = .07 and P = .002). Conclusions: Women with GynCa reported more depression and lower QOL than did healthy controls pre-RT. Among GynCa patients, white women had more sexual dysfunction than black women did. Implications for Practice: The differences in sexual dysfunction between white and black women with GynCa suggest developing guidelines directing routine sexual assessment and rehabilitation in women treated for GynCa.

Despite known disparities by race, studies to date have not focused on pain characterization among African American patients with multiple myeloma. This study aimed to characterize the pain experience, beliefs about pain and pain control, and additional symptoms among African American patients with multiple myeloma taking around-the-clock opioids. This study employed secondary analysis of baseline data from a completed longitudinal study of opioid adherence. Descriptive statistics were used to characterize the sample, pain experience, beliefs regarding pain and pain control, and related symptoms. Participants (N = 34) experienced everyday pain and additional symptoms, and half experienced depression. Pain management barriers included dislike of pills, fear of addiction, and bothersome side effects from pain and medication. Additional larger studies can incorporate multilevel factors contributing to high symptom burden.

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.

Objective: Survivors of multiple primary cancers (MPC) are at increased risk for poor health outcomes compared with survivors of single cancers. Using an adapted psychobehavioral stress‐response model, the study purpose was to identify pathways and individual risk factors associated with poor health outcomes in adults with MPC.Methods: Adult MPC survivors (N = 211) with first cancers (stages I‐III) diagnosed within 1 to 10 years were recruited via tumor registry. Employing a cross‐sectional design, established questionnaires were used to operationalize patient characteristics and theoretical constructs including perceived stress, psychological and behavioral responses, financial hardship, social role function, and physical health. Disease and treatment data were obtained via registry and medical records. Structural equation modeling (SEM) was performed to fit, test, and modify the hypothesized psychobehavioral model.Results: Following measurement model refinement, an SEM linking self‐management behaviors, distress, financial hardship, and functional health demonstrated a good fit:χ²(200, N = 206) = 332.06,P< .01; Tucker‐Lewis index (TLI) = .95, comparative fit index (CFI) = .96, standardized root mean residual (SRMR) = .06, root‐mean‐square error of approximation (RMSEA) = .06. Less use of self‐management behaviors predicted higher distress which, in turn, predicted higher financial hardship; higher distress and financial hardship predicted poorer functional health. Several sociodemographic and personal factors predicted self‐management behaviors and distress.Conclusions: The hypothesized stress‐response model was partially supported. Data supported pathways among self‐management behaviors, distress, financial hardship, and functional health. Self‐management and distress may represent modifiable intervention targets for MPC survivors. High body mass index (BMI), less education, greater neuroticism, and lower social support were associated with less use of self‐management behaviors and higher distress and should be further evaluated as potential markers of vulnerability.