Conferencia: Late effects of cancer and cancer treatments: biobehavioral mechanisms and intervention

Conferencia: Late effects of cancer and cancer treatments: biobehavioral mechanisms and intervention


understand a word of that but that’s my
fault I don’t know how many almost I mean a billion people speak Spanish and
I don’t that’s my fault but I’m I’m very happy to be invited here and I’ll be
talking about psychological and sort of in and biobehavioral late effects of
cancer in cancer treatments because that’s what my research unit a lot of
our research is focusing on and rather than just covering the whole area I will
sort of focus on one example focusing on cancer related fatigue but I still think
that even though my talk will focus on cancer related fatigue we’ll cover some
of the other areas that are correlated with this late effect just you might not
know where OSes but it’s the second-largest city in Denmark and we
are situated where the red arrow is central region Denmark which is
approximately 1.5 million people and OHS is a small city of 350,000 so our unit
has existed in some form or other since 2000 was a very small research unit and
it was sort of financed by the Danish Cancer Society but later on after a
number of years we’re sort of we became a permanent sort of research unit
associated with the department of oncology and also the department of
psychology so it’s a sort of interdisciplinary research unit
and I don’t always have the right number but I think we are sort of 17 18 19
staff at the moment and and everybody is more or less focused on teaching and and
research a lot of our research is focused on cancer but there’s also other
health psychological research going on at our unit some of our people been
interested in fertility issues others have been working on dermatological
diseases like psoriasis in mainly but but most of our research is focused on
on cancer and our mission is that’s to produce scientific evidence about these
two psychological and social consequences of disease and treatment in
general but with specific emphasis on cancer and also a large part of our work
is to develop and to evaluate approaches and interventions aiming it sort of
minimizing these costs associated with illness and treatment and then in
general our I mean our task is to contribute to the development of a more
interdisciplinary perspective in in health so that’s our unit I’m also
involved in a very recently established center national Danish center called the
Danish breast cancer group centre and clinic for late effects and what we’re
doing and our mission is to develop sort of an app or sort of a program for
collecting patient reported outcomes mainly focusing on the late effects in
all women in Denmark treated for breast cancer and we’ll be collecting data
throughout their treatment and sort of survivorship trajectory so and all these
data will be sort of collected and subjected to artificial intelligence to
machine learning that’s the the the aim so we’ll try to be able to
identify who will who will be at risk of developing these light effects so we can
intervene earlier that’s the idea and then this knowledge will sort of will
signal sort of staff at the various alcohol oncology departments around the
Denmark about that this patient for instance has significant fatigue so and
then we’ll sort of the idea is to provide hospitals with treatment options
so that’s a long-term perspective but we’re still working on on this app we
are sort of testing a beta version at the moment right so we have a number of
projects research projects focusing on symptoms and late effects and some of
our projects have been focusing on cancer related distress both depression
anxiety and in in specific we’ve been focusing on fear of cancer recurrence
both how can we assess fear of cancer recurrence and how can we intervene and
we’ve been collaborating with psychologists and psychologists in
Sydney who have been developing developed and an intervention for fear
of cancer recurrence sort of a third wave act based intervention and right
now we’re sort of transforming it into a group based intervention in
collaboration with with Sydney we have some a number of projects that have
focused on pain both the prevalence of pain especially in in breast cancer
looking at what aren’t really the mechanisms because not everybody
develops pain some patients develop pain some develop of neuropathic pain others
don’t and their treatments are not sufficient predictors I mean there are
other factors as well that might be psychological predictors and so forth
and we’ve been trying to tease those apart
and then we’ve been testing a psychological intervention mindfulness
based cognitive therapy for pain and have sort of you know reasonable effects
and now we are sort of engaged in the task of implementing that intervention
into the hospital and that’s a bit uphill because there’s cuts all the time
sort of so resources it’s always a question of resources but hopefully we
can implement it as something that can be offered to all cancer patients and in
you know who’s a group of us are very interested in cognitive impairment
following cancer treatments and the old days it was called well that’s chemo
brain or chemo fog but as it turns out it’s it might to some degree be
associated with chemotherapy but it’s also associated with a number of other
factors so right now we have intervention we have studies looking at
how hormones like testosterone how that will affect or predict cognitive
impairment in in men with treated for prostate cancer and testicular cancer we
are looking at different genetic sort of variations like a pro e4 which is a
genetics or risk factor for dementia and how does that sort of work in the cancer
setting well it seems that if you have that genetic variation you’ll be much
much more vulnerable when receiving chemotherapy in terms of cognitive
impairment and then we have a number of projects focusing on sleep and fatigue
and I’ll talk more about that now but just in general I think you probably all
know that you know cancer and cancer treatments have a lot of consequences
for for patients and and not only patients in fact but also caregivers we
have projects looking at caregivers as well and because caregivers are
distressed caregivers have higher morbidity
hi immortality so we actually just completed a study focusing on helping
cancer caregivers informal caregivers and we’ll have well have published just
recently but all these different sort of sort of challenges associated with
cancer and cancer treatments they’re both psychological sort of general sort
of consequences there are the consequences directly or more or less
directly associated with the toxicity of the treatments and then there are some
some of these symptoms and late effects that are associated with the disease
itself because cancer also has a number of consequences so when you have a
cancer patient or cancer survivor who’s fatigued I mean a part of that fatigue
could be related to the cancer itself part of that fatigue could be related to
the treatment and so forth so all these factors affect the quality of life of
patients they affect also the their ability to return to work and that’s of
course of general interest in for society right now we have a PhD project
looking at you know what really predicts are the ability to return to work of
cancer patients we are looking at the self efficacy of return to work we are
looking at physical activity is physical activity a predictor of the ability to
return to work and it might be so that could be an argument for sort of
supporting patients with our sort of physical training physical exercise
interventions anyway okay but so there’s no doubt that Penn’s cancer patients and
cancer survivors of those who have completed treatment experienced a lot of
sort of different symptoms and late effects and when you look at the
literature it’s really varied I mean in some in some groups you will
see almost no late effects of symptoms in some groups you will see really
reported really high prevalences so there’s a huge variation and we still
really do not know exactly what the prevalence is at what time four
different cancers and cancer treatments but but these are some of the numbers
and so what I’ll be doing now is try to talk about some of the main sort of
consequences of cancer treatments and cancer and how they relate to each other
so I think what is really important when we’re looking at this is that all the
different cancer related symptoms and late effects they appear in correlated
clusters so when a patient experiences for instance pain on they are also more
likely to experience depression when you have sleep problems you are more likely
to be fatigued if you have pain you may be more likely to have sleep problems
when you have sleep problems you are more vulnerable in terms of anxiety fear
of cancer recurrence and if you have sort of chronic sleep problems you will
you will be more likely to develop cognitive impairment and so forth so
these are correlated but if you look at the research most studies look at one
symptom at a time and do not really take all this correlation into consideration
so but in recent recently there’s been research into it focused on on clusters
and there are sort of various clusters that have been identified this this
latter of this figure that’s um it shows of the network
graphic of how different symptoms that patients
talk about right about in on sort of on social media platforms about cancer how
they’re correlated so if you have a write about
chat about fatigue then you’re also more likely to chat about sort of cognitive
problems and so forth so that’s just one example of trying to to identify some of
these clusters and what’s important is that many of these associations are
likely to be bi-directional so if you have sleep problems you will have pain
that will increase a pain but pain will induce sleep problems and so forth and
what really seems to be behind is a common factor here is inflammation so it
seems many of these symptoms seem to be driven by what is termed sickness
behavior and I’ll return to that because what we know today is that the brains a
central nervous system and the immune system are closely related they there’s
bi-directional communication between these systems continuously and there’s
both sort of more dry hardwire connections between the brain and the
immune system and various immune related organs but also there are sort of more
humoral sort of communication paths as through various sort of cytokines and
and neuropeptides so there are receptors in both systems enabling sort of
communication between the brain and the immune system so we both have sort of
top-down associations and over the last maybe 25 years or so 30 years or so we
know that factors such as stress depression sleep disturbances will
affect various systems in in the body the sympathetic nervous system
and we’ll sort of release stress hormones these stress hormones will
affect the immune system and perhaps lead to immune suppression sort of
suppressing the cellular immune responses the adaptive immune response
increasing the risk for our susceptibility to to infections and and
cancers for instance but at the same time you will see activation in the
immune system in terms of a higher level of various pro-inflammatory cytokines
and these cytokines high levels of these cytokines are correlated and predict the
development of cardiovascular diseases autoimmune diseases a wide sort of array
of inflammatory diseases including cancer and also sort of depression and
what is called sort of sickness behavior so but of course it’s moderated by a
number of factors it depends on genetics it depends on age and and so forth right
but there’s also bottom-up sort of associations and and one example of a
bottom-up Association is the term is the concept of sickness behavior and what is
sickness behavior well is it’s an evolutionary conserved sort of bio
behavioral syndrome induced by pro-inflammatory cytokines it could be
like aisle one aisle six tnf-alpha so the common sort of cytokines of usual
suspects so to say released by activated immune cells and when these cytokines
are released are they pass the blood-brain barrier and they induce a
production of additional cytokines in the brain and these cytokines will then
induce what one could term a motivational state that promotes
adaptive responses during infection that’s you know that’s the evolutionary
part of this so it induces fatigue muscle pain reduced appetite fever and
depressed mood and that is an adaptive sort of condition adaptive state
especially I mean if you have a disease or infection you shouldn’t be running
around hunting for food you should you know rest and conserve energy you should
withdraw from the rest of of your tribe so as not to infect them and so forth
and so forth but the interesting part is that these various symptoms that are
induced by the immune system and are generally adaptive we see them also as
cancer and cancer treatment related symptoms they’re very very similar so
these are some of the same mechanisms and that’s really interesting another
important factor is that when you look at the research a lot of research is
cross-sectional and you will see maybe even in large studies you will see that
they’ve with questionnaires have measured maybe depression sort of in a
thousand patients but all these patients will be at different time points in the
disease trajectory so what is really important is that how these symptoms
really relate to each other they may change over the treatment trajectory and
this is an example from a study where we see how they are correlated at different
time points during the cancer treatment so in principle I mean here’s like the
possibilities when we look at data but we’re usually see published the means
and the standard deviations so across a whole group but that might not make
sense really because behind that mean might be very different trajectories the
blue one top blue one for example could be I mean some patients could be having
high levels of symptoms from the very start and continue to have so throughout
their treatment and the bottom some people may have very few symptoms and
continue to have the few symptoms throughout the treatment
some will start low and go high some will start high and improve and if you
just take an average you will end up with theoretically the gray line saying
okay nothing happens here but behind there are differential debt trajectory
x’ here’s just one example of a trajectory analysis sort of following
looking at mental health over a four to fifty-five month sort of trajectory in
after a breast cancer so that’s another major point we should look at different
trajectories in different patients because one size doesn’t fit all right
are you with me cool but good good good good it’s good to to get feedback and
just you know check you know maybe I was just way off sure sure sure okay well
and here’s another model and you might know this model when when you when we
try to figure out how does certain symptoms go from being acute to becoming
chronic or persistent I really don’t like the word chronic because that seems
so deterministic but say persistent symptoms at least and this model says
that if you have a certain people will have different predispositions to
develop various symptoms and I’ll return to this model when I’m talking about
sleep problems in a moment and but also and then some precipitating sort of
situation a factor will induce the symptom to a high level to a clinical
level and then over time when this problem sort of disappears then for most
people they will go back to their sort of normal state but in some patients are
these symptoms will be perpetuated they will be sort of strengthened and
maintained by various factors so what we really need to do when
we are looking to treat these various symptoms we need to look at not only the
predisposing factors but also the perpetuating factors and attack those
and target those in our treatment so what I will look at now is fatigue as an
example and and there’s no doubt that among cancer patients and cancer
survivors cancer related fatigue is is very prevalent it’s also among the most
distressing aside and light effects this is something that patients really
complain about that if they could sort of get rid of one of their symptoms then
it would be the fatigue and up to 70 to 90 percent of cancer patients experience
fatigue during chemo or radiotherapy and what’s really distressing is that even
years after completed treatment many patients continue to experience a
fatigue right so here again if we use this model and look at fatigue we can
look at their precipitating factors these are the cancer diagnosis and
treatment there’s some predisposing factors as shown in the literature like
childhood adversity if you have a history of depression if you have trade
anxiety and and so forth and if you have certain sort of genetic variations that
will sort of predispose you to develop fatigue or cancer related fatigue then
there are these perpetuating the maintaining factors so once you have
developed fatigue what sort of keeps the fatigue sort of even after you have
completed your treatment well one factor could be coping mechanisms like negative
coping mechanisms such as catastrophizing so if you think in a
negative catastrophizing sort of cognitive way about your fatigue that
will be a predictor of developing persistent fatigue loneliness sleep
disturbances physical inactivity is also a main factor so if you’re very
fatigued you become less physical active and when you’re less physical active you
become more fatigued so you have sort of an evil circle that we need to break but
also inflammation and viral infections and generally cellular aging how the
cancer in stress and distress affects our sort of basic DNA and how our
mitochondria works are some possible mechanisms right so so we’re maybe if we
should treat sort of fatigue how could we what should we do so we could target
some of the other symptoms in this sort of cluster and one possible intervention
could be like the sleep disturbance for instance what happens if we if we look
at these patients with fatigue and sleep disturbances what if we target their
sleep disturbances what how will that affect their fatigue or even their
depression and so forth so and we know from studies that poor sleep has been
prospectively associated both with increased pain it’s been and treating
sleep disturbances have been shown in chronic pain patients not only to reduce
their sleep disturbances but also their fatigue and their pain which is which is
interesting so the whole idea is that if you target one sort of core symptom it
will have positive effects in other symptoms yes so let’s look at some of
the mechanisms involved here let’s look at are the circadian system and and and
look at sleep but because generally what regulates our sleep is what is called
the dual process model as you may know there so sleep is regulated by the
balance between homeostatic sort of sleep drive mechanism and the circadian
processes and so it’s this balance that sort of
determines the degree to which we have sleep disturbances or even sort of
circadian disturbances the homeostatic sleep pressure is increased as soon as
we wake up in the morning we produce adenosine which is a hormone that sort
of that’s released when we when we are awake and broken down during sleep and
has adenosine levels sort of grow then we become more and more tired but at the
same time we have sort of waking mechanisms that keep us awake during the
daytime but then at nighttime are driven by the the light of most other things
melatonin will be released and that will sort of induce sleepiness and and in
that way we can sort of maintain also sleep during the night even when the
sleep pressure is is lowered the melatonin keeps us asleep during the
night so that’s sort of the basic sort of sleep regulating mechanism if we want
to sort of check and measure or assess our circadian activity and patients are
there that has been developed a number of sort of a tigress assessments and you
can see here’s an example the top example is is an example of a probably
circadian well structured person a well organized person and below you
see a more sort of dysregulated pattern and that can be sort of assist with
these actor graphs and and various are sort of algorithms
okay what about circadian disruption and sleep and inflammation and fatigue how
do they really relate to each other and I’ll just briefly present some some
results here we know there’s sort of communication between the cancer cells
and the central nervous system we know that
both tumors and the tumor associated macrophages the activate an inflammatory
cytokine network so when you have cancer you have more inflammation and when you
have more inflammation you will be more fatigued and you will also have be more
depressed so there’s an association by just having cancer and being depressed
so that’s a biological mechanism inducing fatigue and depression
in addition probably to the more mental psychological processes as well also we
have the HPA axis which is the axis responsible for our stress responses as
well and it works as negative feedback mechanisms for various inflammatory
processes I mean we need an intact valve regulated HPA axis in order to sort of
curb our inflammatory responses and when we have dysregulated HPA axis we get
chronic inflammation that influences sort of melatonin our production of
melatonin and so the diurnal rhythm is is an indicator of HPA accurate access
competence and when people are fatigued or fatigued cancer survivors we know
when we look at how how they produce their cortisol when we look at their
cortisol sort of diurnal sort of patterns they appear to be disrupted
right and when we look at sleep disturbances we find that cancer
patients may both have sleep disturbances before surgery and after
treatment and during treatment and but when they improve and sleep we see that
this is associated with reduced inflammation and when we have elevated
nocturnal cortisol we see higher levels of fatigue poor performance data status
more depression for a well being and so forth so there are all these sort of
associations between sleep or circadian disruption cortisol the inflammation
this all sort of works together okay let’s move on and look at sleep sort of
in general it’s estimated that 10 to 20 percent of the general population will
experience at least in the Western world will experience some level of insomnia
and six to ten percent meet sort of the diagnostic criteria but when we then
look at cancer patient there’s not that much research but the research there is
suggest that cancer survivors are two to three times more likely to to have
insomnia and here’s some some data from breast cancer lung cancer head and neck
cancer it seems by the way that prostate cancer patients seem to have fewer
problems in general they they they complain less than many of the other
cancer groups that could other factors could be at play here too but let’s look
at if what do we know from the literature and the research about
insomnia and its consequences well we know that insomnia sleep problems sleep
disturbances will affect a lot of physiological systems we know for
instance that we’ll see activation of the sympathetic nervous system we see
higher more release of catecholamines cortisol will see a ghrelin which is
sort of the hunger hormone levels there will be elevated so people have more
appetite they’re more hungry they consume more food we’ll see increased
inflammation and more increased oxidative stress and also we see
suppressed parasympathetic sort of activity in the parasympathetic system
we see decreased melatonin production we see decreased leptin function function
and leptin is the hormone that tells you that now you now you’re safe you don’t
need to eat more and also it you’ll see sort of decreased insulin sensitivity
and you’ll also see sort of this regulation of
of others or important aspects of the immune system this will lead short-term
to fatigue pain depression stress cognition problems and in the long run
this could develop into cardiovascular diseases obesity not the least cancer
type 2 diabetes and increased mortality so there’s a lot of interest in sleep
and its potential sort of health consequences right so let’s look at at
sleep how should we think about sleep in terms of I mean everybody experiences
sleep problems from time to other I think approximately 95% of the
population has at some time had difficulty falling asleep or been waking
up at night and having difficulty falling asleep again and so forth but
most people sort of get over it and and but some people seem to develop chronic
or sort of persistent sleep disturbances and let’s let’s look at this model again
we have the predisposing the precipitating and the perpetuating
factors and here’s some what we know from from from research people who are
sort of more anxious have a tendency to ruminate to worry they have they are
more sort of likely to develop sleep sort of to develop sort of persistent
sleep problems people who are a sort of sort of hyper aroused easily hyper
aroused and people who have late chronotype sort of the the night owl
people and people who have cancer I mean these are some of the physiological sort
of predisposing factors purposely problems if we look at their
precipitating of course periods with stress and anxiety that will keep people
awake of course because when you’re anxious when you’re afraid when there’s
a threat you shouldn’t sleep you should be aware right
so that’s stress keeps us awake and physically I mean pain and and we know
hormone therapy will you know induce hot flashes and and will sort of will be
factors that can increase li problems but then the they’re perpetuating the
maintaining factors we know from research that once people have devolved
easily problems some people will develop maladaptive beliefs they will start to
catastrophize about their sleep saying if I don’t get at least eight hours of
sleep I will you know I will die I’ll be sick I won’t be able to function at all
tomorrow and I won’t close an eye tonight when I go to bed I will be
completely unable to sleep that kind of sort of catastrophizing that’s really
not helpful that’s a sort of very sort of serious perpetuating factor all this
sort of affects people’s attention they’ll be selectively attending
everything that has was to do with sleep and that will make it harder to sleep
they will start to develop various safety behaviors like napping in the
afternoon maybe several times that is not very helpful because that relieves
the sleep pressure they will start to go back to bed very early so they can get
as many hours in bed as possible hoping that they will sleep more that’s not the
case so that’s not a very good behavior either and then fear recurrence
cancer recurrence depressive symptoms are all sort of factors that give people
something to worry about and will make that harder for them to sleep
and if they’ll be aroused by all these stressful thoughts and these are the the
maintaining factors so the treatments should target these maintaining factors
what do we know about the consequences well we know that when when people have
insomnia they have reduced emotion regular regular
flexibility I’m it’s probably due to that the sleepless problem sort of
affect our frontal prefrontal structures that will sort of make it less easy for
us to control our sort of sort of urges so we’ll be less flexible in our emotion
regulation and we have higher levels of fear of cancer recurrence we see that’s
been shown in research in some days is a prospective predictor of depressive
symptoms and breast cancer survivors so if you have depressive if you have
insomnia then you will have a higher levels of inflammation that will induce
and maintain depression over time and we know that pain affects sleep but
insomnia is in itself a prospective predictor of worsening of chronic pain
so actually it seems that sleep is probably is a better predictor of pain
than pain is a predictor of sleep at least in the studies we have so far and
and and and in fatigue we have sort of perpetuating dynamics so you have cancer
and treatment will lead to fatigue that will reduce physical activity that will
alter sleep patterns that will increase fatigue and so forth so we have some
some very negative dynamics being produced here and cognitive impairment
we know from from studies that insomnia in breast cancer survivors is associated
with poor executive function and and verbal memory and there’s no doubt that
these factors will also affect health behaviors so when you have sort of sleep
problems if you have insufficient sleep then your sort of executive function
will diminished that will make it harder to maintain sort of sort of healthy
health behaviors like avoiding fatty foods and so forth so and it seems it’s
still more difficult to stop smoking when you have insomnia because again you
have difficulty sort of regulating your emotions your stress you have poor
executive function that will make it more difficult right so and but again
these directions are bi-directional and finally how can we intervene well I mean
so we have the sleep we have sleep problems we have the circadian
disruption we have the fatigue so in general
tiredness and fatigue differ and usually just one good night’s sleep generally
does not you know relieve cancer related fatigue but I’ve said targeting some of
these aspects could be helpful so let’s see well how could we if we target sleep
for instance could we use sleep medication is that a good idea well no
really not it could be for one night sort of limited use of sleep medication
is okay but longtime use is has limited efficacy it’s not curative tolerance P
patients develop tolerance dependence and various side effects and also a
longtime use of sleep medication is associated with cognitive impairment and
has even been associated with mortality as you can see from from this example
here so it is really not recommended for long-term use so what should we do well
another approach if we want to target for instance are the the circadian sort
of aspect of this then light therapy could be an option we know that light is
the central site giver regulating their circadian rhythmicity we know that these
Pro inflammatory mediators they’re sort of associated with melatonin production
so when you have acute inflammation then melatonin is suppressed so if we
could sort of counter this effect on melatonin that would be interesting and
we know from other research that life therapy has been known to alleviate
seasonal affective disorder and so given the associations between circadian
regulation inflammation fatigue in cancer then it might also alleviate cats
related fatigue here are sort of three studies I mean that very few studies so
far we also have one study we’re right on the verge of publishing it but here
are three studies that seem promising there’s one study showing that bright
white light would buffer the development of fatigue in women undergoing
chemotherapy so those who had bright light therapy during chemotherapy they
they sort of maintain a certain level of fatigue but those who did not haven’t
had an increase in fatigue here’s another study of chronically fatigued
survivors of mixed cancers had sort of a very large effect of a bright white
light compared to a placebo of dim red light and here we have a Canadian study
which the effects are not really that great in the third study and there’s a
Dutch study that has been published recently I think where the effects are
not really great either but you know we never know it seems promising but what
about behavioral sleep interventions well we know that a lot of sort of non
pharmacological interventions have been developed over the years we know
relaxation in itself has some effect on insomnia we know that our sleep
restriction where you tell people you know to change their sleep habits to for
instance if you sleep six hours but spend ten hours in bed you have a sleep
efficiency of 60% then you tell people to go
four hours later to bed that means they become very tired they have trouble
keeping awake but and that’s sort of a different problem than trying to fall
asleep right and then when the you know finally are allowed to go to bed they
fall asleep faster and maintain their sleep better and then they can gradually
sort of increase the number of minutes or hours in bed until they reach sort of
the the sort of the desired number of hours so it’s kind of resetting this
whole sort of sleep pattern we know stimulus control is really telling
people do not do anything that is associated with activity being awake and
so forth in bed the only thing that is allowed in bed is sleeping and sex and
that’s it if you are awake more than 15 minutes you have to leave the bedroom
and go into your to another room and read a book listen to music or something
do not go to bed until you’re sleepy again and then we have the whole sleep
hygiene sort of education that really looks at all the factors that will
influence sleep like stimulants caffeine and so forth and and you make sure that
people tell people that they should be physically active and and so forth and
so forth and finally there’s the cognitive therapy aspect addressing all
the maladaptive cognitions about sleep like the catastrophizing for instance
and when you sort of group all these different approaches together it’s
usually called cognitive behavioral therapy for insomnia and is this
effective five minutes more oh shit sorry sorry here’s I’m just collected
sort of a number of meta-analysis here and in general when you look at the
individual components you see that they are effective but even more effective
when you look at them as combined CBT eyes
and what is interesting is it’s not only effective in patients who have insomnia
as a primary problem but also in patients with comorbid insomnia so if
you have chronic pain and insomnia it works if you have cancer and insomnia it
works and finally also I’ll just talk a bit about the problem here because while
cbt-i is recommended as first choice there’s a huge challenge meeting the
needs there’s a limited availability of trained therapists there are costs
associated with face-to-face therapy and there’s limited accessibility so one
approach could be to provide this over the internet and first of all we looked
at some years ago a couple years ago we looked at the different studies there
were 11 studies like 2 years ago that looked at different internet delivered
programs delivering cognitive behavioral therapy for insomnia and we found some
really really good effects these are huge effect sizes they’re like very
large effect sizes so we tried a program for women treated for breast cancer with
insomnia and we used an American program called shut-eye at the time and we
developed it into a Danish version and we we had a an RCT with 255 breast
cancer survivors randomized to a waitlist or to this program which is a
fully automated program there’s no therapist involvement at all it’s fully
automated and it’s based on feedback so you you you fill out a sleep Diaries and
based on your sleep Diaries you’re instructed to restrict your sleep and it
addresses the cognitive issues and so forth and we find some really nice
effects not only at post intervention but also at follow-up and what is really
interesting in this in this instance is that it also we also
measured cancer related fatigue in these women and had really nice effects really
prominent effects on on fatigue finally there’s exercise could one treat
fatigue with exercise here’s a meta-analysis of 72 studies looking at
the effect of exercise on cancer related fatigue and it does suggest that there’s
some some some decent effects here it seems like a relevant intervention
it also has effects on depression and there’s also some effect on sleep
disturbance so but what what types of exercises some exercise forms better
than others well not really there are no differences between the different
exercise types so in general it seems that you know regardless of delivery
method and so forth there seems to be a good affair really some decent effects
of exercise what about pharmacological interventions for fatigue well there
aren’t that many studies but there are some trials in cancer in and
transplantation and Transplant studies looking for instance at Ipoh and there
seems to be a nice effect of Ipoh but that of course relates to that you need
to have sort of anemia or something like that they need to you need to have some
certain problems that explain your fatigue so here’s another study just
looking generally at pharmacological and non-pharmacological treatments for
fatigue cancer related fatigue and we see that exercise and psychological
interventions have similar effects but the pharmacological effects sort of in
general when you look across cancer ah seems to be relatively poor so this is
my last slide so I think to take-home messages
late effects of cancer and cancer treatments are really we need to look at
them as clusters and inflammation is really sort of an underlying mechanism
we need to be thinking about all the time and the late effect should be
understood in terms of directories over time and and I think the model
describing the biobehavioral sort of predisposing precipitating and
perpetuating factors is a really good model for thinking about how to deal
with late effects so targeting key symptoms may have positive effects and I
think there’s a really good argument for behavioral interventions as promising
candidates yes that was what I had in mind today thank you so much Bobby and
please if you have any question please expand your intent re-mose intra todos
there are a conclusion isn’t a chef a a Cinco minutos C 15 minutes for questions
and I’ll be available afterwards questions Leticia is coming ha t okay thank you so much it’s a
pleasure to hear to you and thank you so much for say today with us sorry because
my English is not so try to make the question in English
sure sure great you can’t cure me oh yeah I understand you you come across
clearly it’s very interested conference and I think sometimes cognitive
impairment and fatigue is present and when the patient have a central nervous
system more than when the term is not very of the same time is judgment
limitation patience Excel treat an hour with us all day
fatigue attention this you in your experience do you think we can be now in
a chain and we are chained treatments to attain the target we have now results and dates to talk
about the new charger capital of intervation interface sorry target of
treatments and we can take this take-home message now and in future late
future change the treatments of quality patients yeah what I hear you’re saying
well first of all you mentioned of course that brain tumors will affect
cognition and we do have some studies also looking at that but I was sort of
talking about general sort of cognitive impairment not related to tumors but so
in those studies we just exclude those patients but we have other studies we
just started a proton sort of radiation Center in OHS and we’re trying to
compare the effects on sort of cognition broadly from the old radiation therapy
and proton therapy to see if it sort of is will induce a fewer cognitive
problems and it seems it will well anyway but what I hear you’re saying is
that we know a lot about effects of various interventions there’s much to be
learned I think there’s a lot to be learned about how we can optimize our
treatments so we can be more cost effective because I think
cost-effectiveness is necessary for these interventions to be implemented in
healthcare and that’s the next big big big hurdle is how I mean knowing that a
lot of these interventions actually work how can we make sure that they’re
implemented that patients actually who are in need are actually treated and
that’s a political question economical and political question and it needs
pressure groups so and I don’t think psychologists are necessarily the best
pressure groups or most powerful pressure groups but
cancer patients could be so I think we need to Alan you know align ourselves
with the cancer patients and the cancer societies in Denmark the Danish Cancer
Society’s a pretty powerful organization and it has large influence on the
politicians so yeah I think it’s a political discussion yeah okay I hope I
answered your question or comments in cognition my question is about the
information how my question is why the light effects on cognition are related
to inflammation it’s because all of these factors that oh it’s related also
with the cancer yes yeah what you’re saying is how much of it is related to
the cancer as such and how much is related to other factors secondary
factors and of course that’s always not you know easy to tell apart but if we
look at for instance we have have a large cohort of women a national court
of women treated for breast cancer and we’ve been following these women for
like almost 10 years and a lot of them still have fatigue or have some have
cognitive problems not too many though but some have cognitive problems like 9
years 10 years after and then these are other factors right
so you see some of these this inflammation for instance that’s been
induced during cancer it should actually drop when there’s no cancer anymore
right but other issues like sleep problems and obesity etc etc may
contribute to maintain high levels of of inflammation so it might not necessarily
be related directly to the cancer anymore but that be something that has
been maintained over time so we’ve looked we did a meta-analysis recently
where we looked at do psychotherapy does psychotherapy have any effect on
inflammatory parameters and I how many studies I think I don’t remember maybe
16 studies something like that and we looked at any study where they had
measured pro-inflammatory cytokines and there was any type of psychological
intervention and it could be for depression or whatever and we found some
effect on CRP and which is a very general measure and some effect on aisle
six which is correlated with CRP so there
were small effects but they were statistically significant service I
think that we should think of therapy also as something we should you know try
to target inflammation there were there very few studies so we couldn’t really
do any sort of meta analysis of that parameter okay so thank you very much and now the
closing remarks from our detectors dos minutos creo que es necesario sir are
los Actos cuando los in ec ahmo’s en algo momento yes si di intention en este
momento en esta hora del viernes después de una conferencia consistent a poor
Otto Grassi me ento primero a los Parente’s conference e on tape o
supuesto también y todos los participantes kane algo momento tambien
abyss participate Oh agoura cimento sobre todo supported el
de los mesa TiVo’s técnicos si trade el Consejo no soy
que también sino en todos los momentos para que Haga sir possible a este act o
OE sierra meant a NOS quiero un trabajo que sill de hacer una diffusion potent a
de lo que aqui há carido que como hemos dicho en algo momento a es donde a veces
FEA Mo’s pour tanto conclusion s propuestas cancer sido a key innovation
s ew todo ESO NOS comienza fun dear Lodi fundido la sol entre nosotros que esta
bien si no más allá de ESO es el acuerdo con
la macchina ria del consejo las luces en espanol van de algún ser yatras a socio
Mophie folk a la gaitana saenko probity o tambien a de fun dear
Tobi’s estás usted o indica Sione’s decir que co2 interess lo que se ex post
o ik e yq area sur un matisse no para para tener controversy associate sen el
futuro que tiene que ver con una cuestión que si des Lunada nalboon
momento sobre la especially da y la specialization es decir que la cycle
osya yeah no voy para todo es algo suscribe emos bastante smiles de Cicco
lagos en españa y no solo en Espana see you know en el mundo por que bueno por
que son conocimiento chakra sido y por tanto alguien que pretend a con cuatro
años de grado una medio de Mysterio hacer de todo pues no tiene que hacer
algo una cosa mass tiene que estudiar alguna cosas más yo SNS estudiar algunas
cosas más avid una una una participation yo yo con lo que se no que seguro que es
mucho puedo hacer muchas cosas

Leave a Reply

Your email address will not be published. Required fields are marked *