Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series

CBPRA-00800; No of Pages 15: 4C

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Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series Chelsea G. Ratcliff, Sam Houston State University, Huntsville, Texas, USA, VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA, Baylor College of Medicine, Houston, Texas, USA Frances Deavers, Michael E. DeBakey VA Medical Center, Houston, Texas, USA Emily A. Tullos, Maxwell R. Christensen, Mia M. Ricardo, Sam Houston State University, Huntsville, Texas, USA Lilian Dindo and Jeffrey A. Cully, VA South Central Mental Illness Research, Education and Clinical Center, Houston, Texas, USA, Baylor College of Medicine, Houston, Texas, USA, VA HSR&D Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA

Preoperative distress is associated with poor postoperative outcomes, such as increased risk of surgical site infection and readmission, and brief psychosocial interventions delivered during the perioperative period may improve postoperative mental and physical health. However, there are few protocols for screening and treating distress in the surgical oncology setting. The current article describes the development and feasibility pilot testing of a four-session intervention (Behavioral Intervention for Wellness and Engaged Living [Be-WEL]) that combines behavioral and self-management strategies to manage preoperative distress and improve postoperative recovery. Data from three patients who participated in an ongoing open clinical trial are reviewed to illustrate the feasibility, acceptability, and potential strengths and limitations of this intervention.

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N estimated one in three women and one in two men in the United States will develop cancer in his or her lifetime, and the majority of these individuals will undergo surgery as their first line of treatment (Siegel et al., 2012). Considerable efforts have been made in the last decade to improve postoperative outcomes by improving surgical procedures (Nguyen et al., 2008; Stulberg et al., 2010). However, patient outcomes following some surgical oncology procedures, including malignant colorectal, liver, pancreas, and esophageal procedures, remain far from ideal. For example, an estimated 20–40% of colorectal surgery patients experience early postsurgical complications, such as surgical site infection or prolonged ileus (Balentine et al., 2011; Bingener et al., 2015). Additionally, the average hospital stay following colorectal surgery is 6–8 days, several days longer than most other surgeries (DeBarros & Steele, 2013; Harrison et al., 2014; Krell et al., 2013). Furthermore, nearly half of colorectal

Keywords: behavioral medicine; psychotherapy integrated care; telemedicine; distress management; surgical oncology

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surgery patients are discharged to skilled nursing or home health (Balentine et al., 2014; Hyder, 2014), and close to 10% of patients are readmitted to the hospital within 30 days of surgery and 20% are readmitted within 90 days (Harrison et al., 2014; Krell et al., 2013). Not surprisingly, these indices of protracted, costly recovery are associated with less routinely measured patientcentered outcomes, including compromised quality of life (QOL), poorly controlled postoperative pain, and functional dependence (Artinyan et al., 2015; Stitzenberg et al., 2015; Tiefenthal et al., 2015). In light of calls to improve patient-centered outcomes while decreasing healthcare cost (DeBarros & Steele, 2013; Institute of Medicine, 2001), it is imperative to identify who is at greatest risk of poor postoperative outcomes, and examine new methods to reduce these patients’ risk of postoperative problems. Depression and anxiety before surgery are common and appear to be important predictors of postoperative recovery. In a recent prospective study of veterans undergoing general elective surgery, over 40% of patients report clinically significant preoperative depression or anxiety, and these patients were 60% more likely to experience infection after surgery compared to their nondistressed counterparts (Lo et al., 2017). Similarly, studies using large databases indicate that patients

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

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diagnosed with depression prior to colorectal surgery stay in the hospital an average of 1 day longer, are less likely to be functionally independent (i.e., discharged home), and are 11% more likely to be readmitted to the hospital within 30 days of surgery compared to patients without a diagnosis of depression (Balentine et al., 2011). In light of the underdocumentation of depression and anxiety in medical records (Cully et al., 2009; Ratcliff et al., 2017), the impact of preoperative mental health on postoperative outcomes is likely much greater than currently understood. Furthermore, even subclinical depression symptoms and self-reported poor QOL have been associated with greater functional dependence, increased risk of complication, and mortality following GI surgery (Barsevick et al., 1994; Stucky et al., 2011). Additionally, although few studies have examined anxiety, one study found higher preoperative anxiety predicts greater postoperative pain following a wide variety of surgical procedures (Ip et al., 2009). Thus, identifying patients at increased risk of poor outcomes due to anxiety or depression, and providing brief behavioral intervention prior to surgery, may be a critical, and ultimately costeffective, step to improve both patient-centered and health-service-related surgical outcomes. Promising research suggests that preoperative behavioral interventions may improve postoperative outcomes. For example, patients who screened positive for depression prior to cardiac surgery, and participated in four sessions of cognitive behavioral therapy, experienced a clinically meaningful reduction in depressive symptoms and stayed in the hospital 1 day less than their counterparts in usual care (Dao et al., 2011). Similarly, two sessions of stress management prior to surgery for breast (Garssen et al., 2013) and prostate cancer (Parker et al., 2009) improved postoperative healthrelated QOL and immune functioning critical to wound healing (Cohen et al., 2011; Larson et al., 2000), particularly for patients with elevated preoperative distress (Gilts et al., 2013). In light of the consequences of distress and benefits of intervention, national guidelines (Institute of Medicine; Page & Adler, 2008), American College of Surgeons (ACOS, 2012), American Society of Clinical Oncology (ASCO; Lazenby et al., 2015)) recommend routine screening of distress (i.e., depression and/or anxiety) and subsequent triage to psychosocial treatment for cancer patients reporting distress above recommended cutoffs. However, only 14% of ASCO members reported that their hospital routinely screens for distress (Pirl et al., 2007), and up to half of patients who report distress to their oncology team do not receive any psychosocial treatment (Detmar et al., 2000; Passik et al., 1998; Van Ryn et al., 2014). This article describes the process of developing and pilot testing a behavioral intervention for patients who report clinically significant distress in the weeks leading up to surgery for GI cancer. The intervention was

designed to provide a brief, straightforward approach to managing patient distress prior to surgery for GI cancer, and to facilitate uptake by front-line providers (e.g., psychologists, counselors, social workers, nurses) working in real-world surgical oncology clinics. In addition to describing the process of intervention development, this article describes an open pilot study of the intervention (N = 10) and presents three representative case examples.

Method Section 1: Intervention Development Diverse stakeholders were asked to participate in the development of the intervention to increase its acceptability, feasibility, and, ultimately, likelihood of contributing to sustained practice change and improved postoperative outcomes for GI cancer surgery patients at risk for poor postoperative outcomes (Johnson et al., 2018). First, the authors conducted a process evaluation with 10 patients who had recently undergone surgery for GI cancer to assess need and interest in a brief behavioral intervention around the time of surgery (Stetler et al., 2006). The process evaluation consisted of individual, face-to-face, semistructured interviews lasting 20–30 minutes immediately following patients’ postoperative follow-up appointment (typically 4 weeks postoperation). The interview guide included open-ended questions about participants’ experience and concerns during the weeks before and after surgery, their interest in additional supportive care before and after surgery, and their impressions of telephone-delivered supportive care. This process evaluation confirmed the need and desire for behavioral intervention prior to surgery (i.e., 7/10 patients reported that increased supportive care in the form of phone calls before and after surgery would have been helpful or very helpful). Additionally, the process evaluation indicated that patients desired supportive care during the weeks following surgery, in addition to the weeks leading up to surgery (i.e., 8/10 reported experiencing surprising emotional distress in the weeks following surgery). Finally, in response to open-ended questions about their pre- and postoperative experiences, patients indicated a desire for support surrounding managing (a) anxiety related to the surgical procedure itself (reported by 7/10), (b) mood in the context of postoperative recovery (i.e., when mobility is limited) (reported by 6/10), (c) postoperative pain (reported by 6/10), and (d) communication with their treatment team (reported by 4/10). In response to feedback gathered in the process evaluation, we adapted a six-session cognitive behavioral intervention previously developed to be delivered in primary care for Veterans with chronic illness and depression or anxiety (“Adjusting to Chronic Conditions Using Education Support and Skills [ACCESS]” (Cully

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

Behavioral Intervention for Cancer Surgery Patients et al., 2017; Cully & Teten, 2008) to meet the needs of patients with GI cancer during the pre- and postoperative period. We then shared the initial adaptation of the intervention, along with a summary of the findings from the process evaluation, with surgical providers (three surgical oncologists and one physician assistant), behavioral medicine providers embedded in surgical or oncology clinics (two psychologists), a local Patient Advisory Board consisting of VA patients, medical providers, leaders, as well as representatives from the National Alliance for Mental Illness and public health leaders, and experts in intervention development and evaluation (co-authors). Each stakeholder group was asked to provide recommendations to improve the intervention, drawing on their own perspectives and in light of the process evaluation outcomes. Intervention development was iterative, with each stakeholder group reviewing and providing feedback on materials through multiple meetings. The resulting intervention, called BeWEL (Behavioral Intervention for Wellness and Engaged Living), focused on concrete skills and goal-setting with an easy-to-follow patient workbook to allow for delivery by professionals from a variety of disciplines, thereby increasing accessibility and adaptability to settings where a psychologist may not be present. The final treatment development process led to the creation of the Be-WEL intervention, which included a four-session (two preoperative, two postoperative) multicomponent telephone-delivered intervention that blends behavioral therapy and surgical self-care to reduce preoperative distress (e.g., anticipatory anxiety) and contribute to improved postoperative quality of life and recovery. Section 2: Open Pilot Study Procedures All procedures for the Be-WEL open trial were approved by the Baylor College of Medicine Institutional Review Board and the Michael E. DeBakey VA Medical Center Office of Research and Development. All eligible patients were offered the Be-WEL intervention. All included participants provided informed consent, including consent to the use of quotes. Treatment consisted of four telephone psychotherapy sessions (two before and two after surgery) delivered by a clinical psychology postdoctoral fellow, predoctoral intern, or master’s student, under the supervision of a licensed clinical psychologist. Session 1 was typically 45 minutes, and subsequent sessions were 20–30 minutes. The two preoperative sessions took place during the 1–2 weeks before the surgery, and the postoperative sessions took place 1–3 weeks after the surgery (typically, the first postoperative session occurred 10–14 days postoperative-

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ly, and the second occurred 16–28 days postoperatively, depending on participant availability). Assessments were conducted at baseline and 4 weeks after surgery (within 1 week of completing the second postoperative session). Patients were compensated for completing baseline ($10) and postoperative ($15) assessments. Participants Participants were recruited from two study sites (surgical oncology clinics at the Michael E. DeBakey VA Medical Center and the Baylor College of Medicine). Study staff regularly communicated with clinic staff to identify patients on the preoperative clinic schedule who were likely to be scheduled for a cancer-related gastrointestinal surgery. After the surgeon met with the patient, and determined the type and date of surgery, a study research assistant met with the patient to assess initial eligibility. Patients were included in the open trial if they were scheduled for a cancer-related gastrointestinal surgery (malignant colorectal, liver, pancreas, or esophageal procedure) in b 13 days and reported elevated depression or anxiety symptoms (PHQ-8 N 10 and/or GAD-7 N 10) in the case of patients recruited from the VA hospital, or elevated distress (Distress Thermometer N 4) in the case of patients recruited from the private hospital. Patients were excluded if they were cognitively impaired (b 3 on the Mini Cog, 6-item cognitive screener), or had a diagnosis of bipolar or psychotic disorder noted in their medical record. All other co-occurring psychiatric and physical conditions were included. Of the 32 patients scheduled for GI cancer surgery approached, 4 declined screening. Of the 28 screened patients, 19 (68%) reported elevated distress and were eligible for the intervention. Of these, 18 (95%) consented. However, 4 of the 18 (22%) consented patients did not receive the intervention because their operations were cancelled. Of the 13 patients who began the intervention, 3 (23%) did not complete the intervention or provide follow-up data, and 1 (8%) completed all four sessions of the intervention but did not provide follow-up data. Thus, 10 patients completed all four sessions of the intervention and provided 1 month follow-up data. For this report, 3 patients were selected as case examples based on their variation in clinical symptoms (i.e., mild, moderate, severe) and therapeutic experiences (e.g., challenges to treatment engagement), which generally represent the overall concepts of the intervention. Measures All participants completed the below measures at the time of consent. Distress was measured using the Distress Thermometer (DT; NCCN, 2008), a screening tool that measures a global level of distress using a visual analogue scale from 0 to 10 in the shape of a thermometer, with 0 identified as

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

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“no distress” and 10 labeled as “extreme distress,” and nature of distress via a checklist of common emotional, family, physical, practical, and spiritual concerns with instructions for the patient to indicate which of those concerns contributed to the distress they experienced within the past week. Participant recruited from the private hospital were considered eligible for the study if they reported a score N 4, based on previous studies (NCCN, 2013). Higher scores reflect greater distress. Depressive symptoms were measured using the 8-item Patient Health Questionnaire (PHQ-8; Spitzer et al., 1999). Participant recruited from the VA hospital were considered eligible for the study if they reported a score N 10 (Kroenke et al., 2001). Scores range from 0 to 24, with higher scores indicating greater depression. Anxiety symptoms were measured by the 7-item Generalized Anxiety Disorder questionnaire (GAD-7; Spitzer et al., 2006), which assesses anxiety symptoms on a 4-point scale. Participant recruited from the VA hospital were considered eligible for the study if they reported a score N 10. Scores range from 0 to 21, with higher scores indicating greater anxiety. Health-related QOL was assessed using the Short Form 36 (SF-36; Ware, 2000), a popular generic measure of healthrelated QOL that taps into eight dimensions: physical functioning, role limitations due to physical problems, bodily pain, general health, energy/vitality, social functioning, role limitations due to emotional problems, and mental health, within the time frame of the past 4 weeks. It also includes overall physical and mental health component scales (PCS and MCS), which were used in the present study. PCS and MCS norms for the general United States population are a mean of 50 and standard deviation of 10 (Maglinte et al., 2012). Higher scores reflect higher QOL. Satisfaction was measured using the Client Satisfaction Questionnaire (CSQ), an 8-item, empirically derived, selfreport measure that is widely used to assess patient satisfaction with services (Attkisson & Zwick, 1982; Larsen et al., 1979). Scores range from 8 to 34, with higher scores indicating greater satisfaction. Additionally, patients completed a semistructured exit interview to provide qualitative feedback on the benefits and barriers to the treatment program and delivery. Treatment The intervention was guided by a patient workbook that was developed with input from diverse stakeholders, as described above. The workbook was either provided to patients by study staff at their preoperative appointment or mailed to the patient within 1 week of their preoperative appointment. The workbook included an outline for each session, information and handouts for each skill (described below), and an information section

to help patients prepare for surgery, including what to expect on the day of surgery (logistics), typical inpatient recovery time and tasks, and typical outpatient recovery time and guidelines. Patients were encouraged to read this material between Sessions 1 and 2, and discussed any questions with their Be-WEL counselor during Session 2 of the Be-WEL intervention.

Skill Modules. In each session, patients selected one of four skills to help them emotionally and physically prepare for a smooth surgery and recovery. Using Relaxation to Manage Stress. Within this module, patients could select one of three relaxation procedures: diaphragmatic breathing, guided imagery, and mindfulness. Be-WEL counselors provided a rationale for relaxation exercises, highlighting the impact of stress/ tension on physical pain. Be-WEL counselors then gave an overview of the three relaxation options, and the patient selected one. The counselor then guided patients in an insession demonstration of their chosen exercise, using a script from the patient workbook. In the case of imagery, patients were encouraged to develop their own calm, safe space, and counselors worked with patients to develop an image of this place that incorporated as many sensory details as possible. In the case of mindfulness, patients practiced mindful breathing in session, and discussed other ways to practice mindfulness during the week, including mindfully eating, bathing, walking, or brushing their teeth. At the conclusion of the session, patients set a specific, measurable, attainable, relevant, and timed (SMART) goal and an action plan to practice their chosen relaxation skill using the SMART goal handout (see below for more thorough description of SMART goal setting). Doing Meaningful Activities to Stay Healthy. This module consisted of behavioral-activation techniques. Counselors described the relation between activity (what we do) and emotions (how we feel), eliciting examples from the patient. Counselors highlighted the importance of doing pleasant or meaningful activities (even, or especially, when one does not want to) as a way to avoid the downward spiral of inactivity (i.e., inactivity leads to worse mood, which leads to greater inactivity). Patients then reported some pleasant or meaningful activities in which they currently engage, and some in which they are no longer engaging. The patient workbook included a list of 35 low-cost activities to help patients struggling to identify such activities (adapted from Lejuez et al., 2001). At the conclusion of the session, patients used the SMART goal handout to set a goal and action plan to engage in one or two pleasant or meaningful activities. Staying Physically Active to Speed Recovery. In this module, counselors remind patients that physical activity is essential to postoperative recovery (indeed, it is often a

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

Behavioral Intervention for Cancer Surgery Patients requirement for discharge from the hospital). Additionally, research indicates that even small increases in physical activity during the weeks before surgery can substantially improve postoperative recovery. Though some individuals may see physical activity as “meaningful” (and thus may set a goal for being physically active in the “Doing Meaningful Activities to Stay Healthy”), this module was kept distinct in response to surgical oncology stakeholders’ suggestion that the importance of physical activity before and after surgery be emphasized for all patients. In this module, counselors acknowledge that, in the face of pain, stress, and physical limitations, being physically active can seem daunting. The value of small, manageable physical activity goals is stressed. Patients then reported any physical activities in which they are currently engaging, or in which they engaged in the past, and identified an activity they would like to do. The patient workbook included a list of ideas, including walking (with a partner or pet), biking, swimming, gardening, stretching, light weight lifting, yoga, or tai chi. At the conclusion of the session, patients used the SMART goal handout to set a goal and action plan to increase their physical activity. Special attention was given postoperatively to work around physical limitations (for example, pacing activities to avoid “over working”). Being an Active Part of Your Medical Team. This module introduced the concept of adherence (i.e., “following your doctor’s recommendations of the timing, dosage and frequency of taking your medications or of caring for your surgical wound”). The benefits of adherence were discussed, and patients chose whether to focus the session on medication adherence or wound care adherence. Patients who chose medication adherence reviewed possible goals to increase adherence, including creating a medication list, monitoring benefits and side effects, using a pillbox, and setting reminders. Patients who chose wound care adherence discussed their specific recommendations for wound care (frequency and method of cleaning/dressing changes). At the conclusion of the session, patients used the SMART goal handout to set a goal and action plan to increase adherence in their selected domain. If patients reported barriers that involved a lack of knowledge or confidence to administer their medications or wound care appropriately, Be-WEL counselors helped patients get in touch with their surgical clinical provider (i.e., nurse or physician assistant).

Session 1: Getting Started. This session provided information about the program’s purpose (“to teach strategies to help you prepare for a smooth surgery and quick recovery”) and structure (frequency and duration of sessions). Patients were encouraged to discuss their

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concerns or expectations about their surgery and recovery. The four skill modules were then introduced, and, where possible, related to the patients’ concerns (e.g., using relaxation strategies to manage preoperative anxiety). Patients then selected one of the four skills on which to focus first. Material specific to the chosen skill was then reviewed, and, when possible, the skill was practiced in session. The importance of setting “SMART” goals was then discussed (i.e., a goal that is Specific, Measurable, Attainable, Relevant, and Timed), and the patient and counselor collaboratively set a SMART goal. Finally, patients completed a SMART goal handout, in which they (1) documented their goal, (2) listed steps needed to reach that goal (i.e., developed an action plan), (3) when possible, identified a person (or pet) that may support them in reaching their goal, (4) noted possible obstacles to completing their goal and ways to overcome those obstacles, and (5) rated their goal’s importance and confidence on a 1–10 scale (Rollnick et al., 2008). While completing the SMART goal handout, Be-WEL counselors used motivational interviewing strategies to facilitate patients’ commitment to their goal.

Session 2: Keeping It Up. This session reviewed any questions that arose when reading the “Information to Help You Prepare for Surgery and Recovery” section, and, when necessary, counselors helped connect patients to their surgical treatment team for additional information. This session also reviewed contact information for additional hospital resources, including social work, chaplaincy, peer support, smoking cessation, weight management, and Primary Care–Mental Health Integration (PC-MHI), and general mental health care services. The Be-WEL counselor also discussed the importance of assertively communicating with medical providers. Specifically, patients were encouraged to think (and write) questions, concerns, or preferences to share with their medical providers before or after surgery. Patients then reviewed their progress on their previous SMART goal, and chose whether to focus on a new skill or continue working on the skill selected in Session 1. Material for patients’ selected skill was reviewed and, when possible, the skill was practiced in session. Just as in Session 1, patients completed a SMART goal handout. Session 3: Beginning Recovery. This was the first postoperative session, and typically took place 2 weeks after surgery. During this session, Be-WEL counselors reviewed the patient’s surgery experience, inquired about patients’ physical and emotional well-being, and reinforced the importance of assertively communicating questions, concerns, and preferences with their medical providers.

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

Ratcliff et al.

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The session then focused on “Using Your Be-WEL Skills After Surgery,” including a review of the downward spiral (i.e., inactivity leads to worse mood, which leads to greater inactivity) and the importance of using the previously discussed skills even in the face of new barriers, such as pain or immobility. Patients then selected one skill on which to focus during session, and material specific to the chosen skill was reviewed, with attention given to any adjustments necessary for the postoperative period. When possible, the skill was practiced in session. Just as in preoperative sessions, patients completed a SMART goal handout.

Session 4: Continuing Recovery. The final Be-WEL session was essentially identical to Session 3. The session concluded with a review of the skill(s) that the patient found particularly useful and a discussion about what the patient felt he gained/learned from his work in the BeWEL program. Maintenance of gains was achieved through continued SMART goal setting and application of skills to challenging situations that may come up in the future (e.g., through adjuvant chemotherapy). The importance of continued practice was reviewed, and patients identified ways in which they planned to continue using skills. Finally, patients reflected on supportive individuals in their lives who could continue to offer support.

Results All 10 patients who completed the intervention and provided follow-up data elected to focus at least one session on Using Relaxation to Manage Stress. Six out of 10 elected to focus at least one session on Doing Meaningful

Activities to Stay Healthy; four elected to focus at least one session on Staying Physically Active to Speed Recovery; three elected to focus at least one session on Being an Active Part of Your Medical Team. Baseline and follow-up sample means for depression, anxiety, and health-related QOL outcomes are presented Figures 1 and 2. Participants reported mild depression symptoms at baseline (PHQ-8 M = 8.54, SD = 5.91), which remained mild at the 4-week follow-up (M = 9.00, SD = 6.31). Participants reported moderate-to-severe anxiety symptoms at baseline (GAD-7 M = 14.77, SD = 3.96), which decreased slightly at the 4week follow-up (M = 12.58, SD = 5.58). Participants reported average physical and mental health-related QOL at baseline (SF-36 PCS M = 49.76, SD = 21.00; MCS M = 51.25, SD = 12.72), which decreased considerably at the 4week follow-up (PCS M = 33.07, SD = 15.31; MCS M = 39.98, SD = 11.27). Participants reported being satisfied with the intervention (CSQ M = 28.09, SD = 3.59). Most (8/10) reported being mostly or very satisfied with their overall surgical experience and their overall experience of Be-WEL, 9/10 indicated that they would refer a friend to the program, and 9/10 reported they would come back to the program. Below we present quantitative and qualitative data for three representative cases to describe Be-WEL feasibility, patient satisfaction, and potential strengths and weaknesses of the intervention. Participant names have been changed and details regarding their case have been slightly altered to obscure the identity of each participant. Demographic information for the three cases is provided in Table 1, and treatment information (i.e., timing of sessions and skills chosen) is provided in Table 2.

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13

11

PHQ-8 GAD-7

9

7

5 Baseline

Postoperave Follow Up

Figure 1. Sample Means of Anxiety and Depression Symptoms Before and After InterventionNote: PHQ-8 = Patient Health Questionnaire -8 item; GAD-7 = General Anxiety Disorder Questionnaire – 7 item Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

Behavioral Intervention for Cancer Surgery Patients

7

55 50 45 PCS

40

MCS 35 30 25

Baseline

Postoperave Follow Up

Figure 2. Sample Means of Health-Related Quality of Life Before and After InterventionNote: PCS = SF-36 Physical Component Summary; MCS = SF-36 Mental Component Summary

Bill Bill was a 59-year-old Caucasian male seen in the VA hospital’s Surgical Oncology clinic 1 week after being diagnosed with colon cancer following his first colonoscopy. He consented and completed baseline measures 21 days prior to undergoing laparoscopic right hemicolectomy to remove the tumor and stage his disease. Bill also had a longstanding history of hypertension, hepatitis C, rheumatoid arthritis, and chronic low back pain. He lived with his wife, whom he described as his “top priority.” Bill did not have any mental health diagnoses in his medical record, and reported moderate distress (DT = 7), mild depression (PHQ8 = 6) and moderate anxiety (GAD-7 = 10). He worked in manual labor throughout his life, noting “I love the work. It’s very physical.” He reported feeling worried about how he would make ends meet during the months following his surgery, as his surgeon had informed him that he would likely not be able to return to work for several months. Bill admitted a tendency to “overwork,” injure himself further, and be out of work longer. He shared that being physically active was not only important for his income, but also for his mood, noting that being “physically fit is very important to me. It’s the kind of person I am.” Additionally, Bill shared that his wife was scheduled to undergo surgery 1 week after his procedure, and expressed concern about his ability to care for her. He shared that “worrying is useless unless you can do something about it,” but noted that, nevertheless, he finds himself preoccupied about how he will manage after the surgery. Over the course of treatment, Bill’s distress reduced, his depressive symptoms remained mild, and his anxiety symptoms dropped below the clinical cutoff from baseline to 1 month follow-up. His mental-health-related QOL also remained relatively constant. In contrast, he reported a

significant decrease in physical-health-related QOL (see Table 3). He indicated high satisfaction with the treatment (see Table 4). During Session 1, Bill indicated feeling worried about “making ends meet” after surgery due to being unable to return to work; that being sedentary may increase his existing chronic back pain; and about his ability to care for his wife after her upcoming surgery. Bill elected to focus on “Using Relaxation to Manage Stress” during his first session, specifically on practicing mindfulness. He noted that the concept of “mindlessness” resonated with him as it might counter his usual “always in a hurry” approach to life, which he perceived as incompatible with postoperative down time. Bill set the SMART goal of walking mindfully with his wife for 15 minutes twice a week at the YMCA or in his neighborhood (depending on weather). He identified “not doing it the first time” as a possible barrier to this goal; therefore, he planned to take the first walk immediately after session. Session 2 was brief (15 minutes) due to Bill’s multiple preoperative medical appointments. He reported that he did walk mindfully with his wife on two occasions, and noted that he felt close to his wife and less anxious during the walks. Bill remained concerned about his finances after surgery and expressed interest in continuing to focus on “Using Relaxation to Manage Stress,” and wanted to learn a new strategy, diaphragmatic breathing, to help manage worry. Bill set the SMART goal of practicing diaphragmatic breathing for 5 minutes each morning leading up to his surgery. Session 3 took place 2 weeks after Bill’s surgery. Bill reported that he did not practice diaphragmatic breathing, but continued to employ mindfulness skills. For example, he shared that he intentionally “turned on my 5

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

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Descriptive Data for Three Patients Completing the Be-WEL Treatment ⁎ Site ⁎

Age

Education

Race

Occupation

Marital Status

Income

Psychotropic Medications

Psychiatric Diagnoses

Reason for Surgery

Surgery

Bill

VA

59

Caucasian

20k30k

None

None

55

Divorced, Lives Alone

b 10k

MDD

Marcus

BCM

84

Married

N 60k

Trazodone (took 1-2x/ week after surgery) None

Stage 1 Colon Cancer Stage IIIB Rectal adenocarcinoma

Laparoscopic hemicolectomy

VA

Employed, manual labor Employed, manual labor

Married

Lee

H i g h school graduate Some College

College graduate

African American

Caucasian

Employed, office work

None

Pancreatic Cancer

Colorectal resection with ileostomy Pancreatectomy, Splenectomy, and Transverse colon resection

Note: VA = Michael E. DeBakey VA Medical Center; BCM = Baylor College of Medicine.

Ratcliff et al.

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

Table 1

Table 2

Treatment Data for Three Patients Completing the Be-WEL Treatment Preop 1 Skill

Bill

Days Preop

Using Relaxation to Manage Stress: 13 Mindfulness (45 minutes) Lee Using Relaxation to Manage Stress: 5 Diaphragmatic Breathing (55 min) Marcus Using Relaxation to Manage Stress: 13 Diaphragmatic Breathing (30 min)

Preop 2 Skill

Days Preop

Using Relaxation to Manage Stress: 1 Diaphragmatic Breathing (15 min) Using Relaxation to Manage Stress: 3 Guided Imagery (20 min) Using Relaxation to Manage Stress: 7 Mindfulness (20 min)

Postop 1 Skill

Days Postop

Being an Active Part of Your 19 Medical Team (30 min) Being an Active Part of Your 9 Medical Team (35 min) Staying Active to Speed 8 Recovery (20 min)

Postop 2 Skill

Days Postop

Engaging in Meaningful 33 Activities (30 min) Being an Active Part of 16 Your Medical Team (40 minutes) Engaging in Meaningful 21 Activities (20 min)

Behavioral Intervention for Cancer Surgery Patients Table 3

Scores Baseline, 1-Month Follow-up for Three Patients Completing the Be-WEL Treatment DT

PHQ-8

GAD-7

PCS

MCS

Bill Baseline 1 Month Post-Op

7 6

6 5

10 5

44 25

43 41

Lee Baseline 1 Month Post-Op

9 9

19 21

20 21

43 25

42 25

Marcus Baseline 1 Month Post-Op

5 0

2 0

2 0

42 -

45 -

Note: DT = National Comprehensive Cancer Network’s Distress Thermometer; PHQ-8 = Patient Health Questionnaire-8 item; GAD7 = General Anxiety Disorder Questionnaire – 7 item; PCS = SF-36 Physical Component Summary; MCS = SF-36 Mental Component Summary

senses” when dining with his wife, rather than dwelling on his financial concerns. The counselor noted that Bill had cancelled his follow-up appointments with his surgical oncology treatment team. Bill indicated that he was not able to make the long commute to the hospital during his wife’s postoperative recovery, as he was her primary caregiver. In light of this, Bill and his counselor focused on the “Being an Active Part of Your Medical Team” module. Bill set the SMART goal of calling his surgery oncology team to discuss options for follow-up, including telehealth or visiting a local outpatient clinic affiliated with the hospital. Session 4 took place 3 weeks after Bill’s surgery. Bill shared that he completed his SMART goal of contacting his surgical oncology team, and arranged follow-up care at his local outpatient clinic. Bill noted that he continued to use mindfulness skills during mealtimes with his wife. However, he shared that not working and limited physical activity negatively affected his mood, so Bill elected to focus on the “Engaging in Meaningful Activities” module. Bill set the SMART goal of spending 2 hours per day over the next week cleaning his home in 20-minute increments, followed by 10 minutes of rest, to avoid re-injuring himself.

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Over the course of the treatment, Bill spent more time in the “here and now” with his wife through brief but regular mindfulness practice. He became more actively involved in managing his medical treatment, and identified ways of engaging in meaningful activities with his limited mobility. A major challenge during Bill’s treatment was maintaining consistent contact. Preoperatively, he took many extra shifts of work and postoperatively, he experienced temporary halt in his phone connection due to his financial difficulties. In his exit interview, Bill stated that talking with his counselor “helped motivate me. A lot of time I can get down, depressed, and don’t want to do anything. But, making goals through all this helped me stay out of that situation.” Though he experienced some bumps in his postoperative recovery (e.g., delayed postoperative follow-up care, and one instance of readmission due to urine retention), he expressed satisfaction with his care experience: “I can remember [surgeries] here where it didn’t seem like people care that much. This time, the hospitality and concern and care I felt from talking to everyone in the Be-WEL program was really great … having someone take the time to touch base with me built my self-esteem.”

Lee Lee was a 55-year-old African American male seen in the VA Surgical Oncology clinic 6 months after being diagnosed with stage IIIB rectal adenocarcinoma. He was scheduled for colorectal resection with ileostomy 13 days after consenting and completing baseline measures. He had already undergone 2 months of neoadjuvant chemoradiation to reduce his tumor to an operable size. Lee’s baseline distress (DT = 9), depressive (PHQ-8 = 19) and anxiety (GAD-7 = 20) symptoms were severe, and his medical record indicated that he had been diagnosed with major depressive disorder by a psychiatrist within the past year. He was prescribed Trazodone for sleep 2 months prior to consenting to the present study, but shared that he planned to begin the medication after his surgery, stating “I don’t want to mess anything else up in my body right now.” He was not prescribed any other psychiatric medications. He was divorced, lived alone, and had a supportive romantic partner. He reported that he lost

Table 4

Patient Satisfaction

Bill Lee Marcus

Overall Surgical Experience

Overall Be-WEL experience

Refer to a friend

Come back to the program

Mostly satisfied Very dissatisfied ⁎ Satisfied

Very satisfied Very satisfied Mostly satisfied

Definitely Definitely Definitely

Definitely Definitely Definitely

Lee reported being “very dissatisfied” with the “overall surgical experience,” adding that this was largely due to the impact his surgery had on his financial and employment status. Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

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his full-time “decent paying” job in the oil industry 2 years prior, and had since worked part time as an escort in a local hospital, transporting patients and equipment. Since being laid off, he shared that he had experienced considerable financial strain, unstable housing, and depressed mood. He indicated that his mood worsened since his cancer diagnosis, and attributed this to the increase in financial strain he faced due to restricted ability to work. He stated, “I need some financial means to keep going. That is why I’m depressed. When you’re working with very little money, you think about it all the time. Even more than the cancer. Because if you die, you die. But if you’re living and you don’t have any money, it’s hard.” Though finances were his top concern, he also reported worry about managing “pain and my nerves” immediately after surgery. Over the course of treatment, Lee reported consistent levels of distress, depression, and anxiety. His mental and physical-health-related QOL declined from baseline to 1month follow-up (see Table 3). Lee reported high satisfaction with the treatment (see Table 4). During Session 1, Lee expressed concern about pain and anxiety immediately after surgery. He stated, “Soon as I wake up, I’m going to be nervous … I don’t know what I’ll do to handle myself.” He also described being in a dire financial situation, which he anticipated worsening after surgery if he was not allowed to return to work. Lee became agitated, noting, “I can’t think straight with all this worrying [about finances]. It makes me stress about every little thing. I try to relax, but I can’t do anything because I don’t have the money.” Lee and his counselor chose to focus on “Using Relaxation to Manage Stress,” specifically diaphragmatic breathing, for the first session. He set the goal of practicing diaphragmatic breathing for 10 minutes before bed each night leading up to his surgery. In Session 2, Lee reported practicing diaphragmatic breathing for 10 minutes before bed each night. He continued to feel anxious about finances, but added, “the main thing I’m thinking about is opening my eyes after that surgery, and then concentrating on what I need do to get up out of that bed.” Lee decided to continue focusing on “Using Relaxation to Manage Stress,” and added guided imagery to his diaphragmatic breathing practice. Lee set the SMART goal of using imagery of fishing on a peaceful lake (a favorite activity) and diaphragmatic breathing for 10 minutes before bed each night leading up to his surgery. Session 3 took place 1 week after Lee’s surgery. He shared, “I used the breathing right after surgery. I thought I was dying! Not just the pain, when I looked down and saw all those holes and tubes, that’s when I needed to really calm down. I laid there, and I breathed. And it calmed my thoughts. That helped out a whole lot.” Lee had not found imagery helpful, but continued to practice diaphragmatic breathing each night before bed. During the third session, Lee expressed anxiety about wound care

and changing his ostomy bag. He stated, “I don’t have the confidence that I’m taking care of it right.” The counselor suggested they discuss “Being a Part of Your Medical Team” to help Lee get the support he needed from his providers. Lee set the SMART goal of asking the home health nurse to provide feedback after watching him change his ostomy bag and clean his wound. Lee also expressed concerns about returning to work. He stated that his surgeon instructed him to only do “light duty” for 8 weeks following surgery, but his employer indicated light duty was not available. Lee and his counselor used problem solving to discuss possible solutions to this, and Lee set the goal of talking with his supervisor the next day about his options for returning to work. Session 4 took place 2 weeks after surgery. Lee shared that his home health nurse watched him perform wound care, and reported he felt more comfortable caring for his wound. He indicated that he continued to use diaphragmatic breathing before falling asleep. Lee also reported that he spoke with his supervisor, but was told the employer did not have any light duty work. He shared concerns about being evicted from his apartment if he could not pay rent. Lee elected to focus again on “Being a Part of Your Medical Team” in order to elicit additional support from his primary care team. Specifically, he set the SMART goal of contacting his primary care provider to see if he could meet with a social worker about his employment and housing concerns. Over the course of treatment, Lee made diaphragmatic breathing a part of his daily routine and used it to manage his anxiety immediately after surgery. He gained practice setting goals to elicit support from his medical providers. Lee experienced several challenges during treatment. His financial strain worsened, causing anxiety that at times became overwhelming. Though he successfully used relaxation skills to manage his stress, the program was not designed to directly address difficulties with finances, employment, or unstable housing. A followup interview with Lee revealed that he had gotten in contact with a primary care social worker, who helped him become involved in several VA housing and employment assistance programs. He also indicated that he continued to use diaphragmatic breathing after the program ended. He reported that the program was “very helpful at teaching me the breathing, and making sure I really practice it” and “it helped me figure out who I could talk to hopefully figure out how to get back to work.” Marcus Marcus was an 84-year-old Caucasian male seen in Baylor College of Medicine Surgical Oncology clinic 1 month after a mass on his pancreas was identified during a CT scan for a persistent cough. He subsequently

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

Behavioral Intervention for Cancer Surgery Patients received a diagnosed of stage III pancreatic cancer, and was scheduled for pancreatectomy, splenectomy, and transverse colon resection 23 days after consenting and completing baseline measures. Though Marcus’s baseline distress (DT = 5) was above the cutoff for clinical significance, his scores on measures of depression (PHQ-8 = 2) and anxiety (GAD-7 = 1) were in the minimal range and did not indicate clinically significant impairment. He had not been previously diagnosed with any mental health disorder or prescribed any psychiatric medications, and reported being happily married for over 40 years. He reported that since the shock of his initial diagnosis he had been feeling “pretty good,” but noted he was in the process of retiring his high-stress job of 30 years, and expressed some concerned about the many adjustments he would face after his surgery. Marcus expressed interest in learning new skills that had the potential to help him with recovery from surgery. Over the course of treatment, Marcus reported reduced distress, and minimal depressive and anxiety symptoms throughout the study period. He reported relatively high mental- and physical-health-related QOL at baseline, but did not provide QOL follow-up data, due to an administrative error (Table 3). He indicated high satisfaction with the treatment in a post-intervention debriefing (Table 4). During Session 1, Marcus mentioned his upcoming retirement from his job as a stressor and shared that though he initially experienced considerable distress upon receiving his diagnosis, he felt hopeful concerning his prognosis after doctors had reassured him that his stage of cancer was treatable. Marcus chose to focus on “Using Relaxation to Manage Stress,” specifically diaphragmatic breathing, as he believed that it would be helpful for him just before and after surgery. Marcus set a SMART goal of completing 3 minutes of diaphragmatic breathing upon waking up in the morning. He noted forgetting as a possible barrier, so Marcus set a reminder in his calendar immediately after session. In Session 2, Marcus shared that he accomplished his SMART goal of practicing diaphragmatic breathing each morning, and described the practice as very relaxing. He elected to continue to focus on “Using Relaxation to Manage Stress,” and chose to incorporate mindfulness into his breathing exercises. He set a SMART goal of mindful breathing for 3 minutes each morning. Session 3 took place 8 days after Marcus’ surgery. He appeared in good spirits and stated that he was “feeling better every day,” despite discomfort from the surgical incision. Marcus shared that he used diaphragmatic breathing throughout the day of surgery, and that it was “simple, but effective.” Marcus shared that he would begin chemotherapy in several weeks and “was not looking forward to it,” but accepted it as part of his postoperative

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treatment. Marcus shared that he preferred the simple diaphragmatic breathing to the mindful breathing, and planned to continue his daily morning diaphragmatic breathing. He shared that his surgeon had encouraged him to incorporate physical activity into his day, but was unsure of how to be active while recovering from surgery. He decided to focus on “Staying Active to Speed Recovery.” After a discussion of his typical activity level and his current pain level, he set the SMART goal of walking around his neighborhood at a slower than usual pace for 10 minutes each afternoon. In Session 4, Marcus expressed confidence in going forward after surgery, as well as satisfaction with retirement thus far. He shared that he had taken several short walks during the week, though not every day. Marcus reported that his postoperative recovery was going as planned, although not as quickly as he might have liked. He set an open-ended goal of using diaphragmatic breathing whenever stressful situations arose in his life, including during his upcoming chemotherapy treatment. During treatment, Marcus learned and used the skills of diaphragmatic breathing and being physically active postsurgery. During his exit interview, Marcus noted that the Be-WEL program provided “good support” around surgery, stating, “just the idea of someone other than your family being concerned about you is big. I appreciate all the calls from the whole group! Appreciated talking to the counselor, the surgeon, everyone was great.” However, he noted that patients may be better served if the program continued through postoperative treatments such as chemotherapy or radiation. He shared, “the news from the oncologist is not always as sunny as the news from the surgeon. I just heard I have a 60% chance of recurrence in the next 5–10 years. That is not something anyone wants to hear. It may be useful to follow patients through chemo. That can be pretty uncertain.”

Discussion The Be-WEL intervention implements behavioral techniques (e.g., behavioral activation, guided relaxation) alongside illness self-management strategies (e.g., being active, communicating with medical team) to reduce preoperative distress and improve postoperative quality of life and recovery in patients with gastrointestinal cancer. The association of preoperative distress with poorer postoperative outcomes (Balentine et al., 2011; Barsevick et al., 1994; Ip et al., 2009; Lo et al., 2017) and the promising mental and physical health-related outcomes of brief interventions delivered during the perioperative (Dao et al., 2011; Garssen et al., 2013; Parker et al., 2009) have contributed to the rise of national calls to integrate psychosocial care into oncology care (ACoS, 2012; Lazenby et al., 2015; Page & Adler, 2008). However, there is a dearth of protocols for screening and treating of

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

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distress in the surgical oncology setting (Pirl et al., 2014). The absence of such protocols is particularly concerning because oncology providers often do not recognize patients’ mental health needs (Gouveia et al., 2015; Okuyama et al., 2011) and patients do not typically discuss their mental health with their oncology providers (KadanLottnick et al., 2005). Additionally, oncology patients with mental health symptoms rarely receive appropriate treatment (Walker et al., 2014). Indeed, mounting evidence suggests that mental health screening and treatment are much more likely when a mental health provider is embedded or co-located in the medical clinic (Fann et al., 2012; Pirl et al., 2014). For example, the presence of a mental health clinical nurse specialist in one primary care clinic nearly doubled the rate of depression diagnoses detected by primary care providers (Dobscha et al., 2001). Furthermore, patients who met with a mental health provider embedded in their primary care clinic were twice as likely to receive mental health treatment compared to patients who were referred to mental health services outside their clinic (Bohnert et al., 2013; Szymanski et al., 2013). Similar results have been found in oncology care settings (Sharpe et al., 2014). In light of this, mental health providers’ inclusion in oncology care teams is essential to caring for the whole patient (Fann et al., 2012; Institute of Medicine, 2008). However, even when mental health specialists are a part of the treatment team, guidance on what to deliver during the acute time before or after surgery is lacking. This intervention was developed in an effort to help fill that gap. The Be-WEL protocol is designed to be delivered by mental health providers working as a part of a surgical oncology team. To facilitate implementation in an integrate care context, the Be-WEL protocol is brief to account for the limited time available to mental health specialists and to accommodate the many appointments and psychosocial concerns patients are coping with during the perioperative period. Additionally, in keeping with the integrated approach to care used by interdisciplinary teams, the protocol addresses both the physical and mental health needs of patients, and increases the connection of the patient to the surgical oncology team as a whole. Additionally, the intervention was delivered via telephone to increase access and minimize burden of travel, which is often reported as a barrier to cancer care (Charlton et al., 2015). Previous research suggests that telephone delivery of behavioral interventions embedded as a part of medical care (e.g., in the context of primary care mental health) decreases attrition and results in similar mental-health-related outcomes compared to face-to-face delivery (Mohr et al., 2012), and has achieved promising outcomes in a presurgical (Cassin et al., 2016) and oncology care (Kroenke et al., 2010) contexts. Thus, this delivery method shows great promise for this population. Finally, the Be-WEL intervention is patient-

centered and flexible, allowing the mental health specialist and patient to collaboratively select skills that fit with the values and goals of the individual. These features allow for the intervention to be delivered by mental health specialists from a variety of disciplines (e.g., nursing, social work, psychology, case management) in real-world settings where time to provide supportive care is limited. This pilot study highlights the feasibility, acceptability, and potential outcomes of the Be-WEL intervention using three cases. The treatment had high rates of participation and completion, with 94% of eligible patients consenting to participate and over 84% of those who consented and received their operation completing the intervention. Exit interviews with participants revealed a high degree of satisfaction with the Be-WEL treatment, and importantly, with their healthcare experience as a whole. For example, Bill and Marcus noted their satisfaction “with the whole group.” Interventions that improve patient satisfaction may translate to increased revenue for hospitals, via increased patient volume or increased reimbursement rates from payers (Ratcliff et al., 2018). Therefore, the high degree of patient satisfaction with this intervention may have implications for hospital performance metrics. Though the 10 participants included in the study and three cases presented in detail here are not a sufficient sample from which to draw conclusions about effectiveness, this preliminary data suggests the potential for the Be-WEL intervention to have a positive impact on distress. Data from the full sample (N = 10) suggest that, overall, Be-WEL participants’ anxiety and depression remained fairly stable from before to after surgery and health-related quality of life declined during the postoperative period. Patients’ decline in quality of life from baseline to follow-up was expected based on previous studies in this population (Bingener et al., 2015), and this open trial leaves the impact of the intervention on QOL unknown. Detailed data from cases presented highlights the impact the sequela of surgery can have on mental and physical health. For example, though Lee’s distress, depression, and anxiety symptoms did not decrease, they remained at a consistent level from baseline to follow-up. Given that his financial circumstances were poor at the outset of treatment and worsened after surgery, the skills he learned and services with which he was connected during Be-WEL may have prevented an increase in distress. In contrast, both Marcus and Bill reported reduced distress at follow-up, and Bill also experienced a decrease in anxiety symptoms from baseline to follow-up. To draw conclusions about the effectiveness of this intervention, further study with a control group is necessary. Patients’ feedback in exit interviews raised several important elements of the program that will be revised in future studies. First, as illustrated by our three case examples, diaphragmatic breathing was the most popular skill among patients. Indeed, all 10 patients who completed the trial

Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002

Behavioral Intervention for Cancer Surgery Patients elected to focus on “Using Relaxation to Manage Stress” during one of their preoperative sessions. Thus, it may be ideal to standardize the first session to focus on diaphragmatic breathing. However, as illustrated by the case examples, each of the other three skills played an important role in patients’ recovery as well, so maintaining the flexibility of choice in the last three sessions may be ideal. Second, 3 out of the 10 patients who completed the intervention noted they would have liked to meet their provider once face-to-face, though all 10 patients reported they appreciated the ability to participate remotely. Future testing of the intervention may incorporate video telehealth to improve patient-counselor rapport. Third, as in the case of Lee, 5 out of the 10 patients indicated that the Be-WEL program would benefit from a stronger referral system to other providers, such as social work, primary care, and specialty mental health care. Similarly, Marcus expressed an interest in continued support from the Be-WEL program during postoperative chemotherapy. In response to this, future versions of the program will place greater emphasis on the interdisciplinary treatment team (e.g., connecting patients to appropriate member of their treatment team when necessary) and will incorporate additional information on how to contact providers for care that falls outside the surgical oncology treatment team (e.g., referrals to mental health providers after the program concludes). There were several limitations to this open feasibility pilot study. The threshold for inclusion was relatively low and screening took place within 1 week of patients receiving news of their upcoming surgeries. Screening for distress shortly after a surgery is scheduled may have led to false positives, as may have been the case for Marcus. However, the approach to screening used in the present study is consistent with the American College of Surgeons Commission on Cancer’s (ACoS CoC) accreditation requirement to screen for distress at critical junctures in patients’ oncology treatment, including surgery (ACoS, 2012; Pirl et al., 2014) and the screening cutoffs used in the present study are consistent with those recommended by the National Comprehensive Cancer Network (NCCN, 2013) and the American Society of Clinical Oncology (Andersen et al., 2014). Furthermore Marcus, though not highly distressed, reported high satisfaction with the program and expressed a desire for the program to extend into postoperative chemotherapy. Additionally, due to the lack of a control group, the utility of the program for patients experiencing severe distress is not clear. As noted above, Lee, who reported severe distress at baseline, did not report a reduction in his distress at follow-up. Though the program may have prevented a worsening of symptoms, it is not clear from the current study. Additionally, the program may be less feasible for patients with severe compared to moderate or mild distress. Out of the 13 patients who began the intervention, 6 had a diagnosis of depression or anxiety documented in their medical record, but 3 of those were lost

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to follow-up. It is possible that patients experiencing severe distress may find the program less useful or may be less motivated to complete the program compared to patients with moderate distress. However, as most surgical oncology clinics have no mental health available for patients (Detmar et al., 2000; Pirl et al., 2014), a brief program such as Be-WEL may be a step in the right direction, particularly if referrals to specialty mental health providers are provided. Finally, the present study is unable to determine the potential effect of the Be-WEL intervention on health service use outcomes. Of the 13 patients who began the intervention, 5 were readmitted to the hospital within 30 days of surgery, including one of the case examples (Bill, readmitted within 24 hours of discharge). These findings highlight the need among this population for assistance in managing their health postoperatively. Previous research suggests that improving patients’ mental health during perioperative time period may have important implications for patient’s health, health service use, and satisfaction with care. Despite national guidelines calling for the provision of and/or linkage to psychosocial care in oncology settings, few surgical oncology clinics have a protocol for addressing mental health needs during the pre- and postoperative period. The present study describes a process of developing a brief intervention suitable for delivery by a member of a surgical oncology team to patients experiencing preoperative distress. Surgical oncology patients and providers who participated in the iterative development of the intervention expressed a desire increased psychosocial support during the weeks before and after surgery. The resulting Be-WEL intervention holds promise as a brief, standardized, patient-centered intervention for managing preoperative distress and possibly for improving postoperative recovery. The findings warrant revision and further investigation of this intervention.

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Please cite this article as: Ratcliff et al., Brief Behavioral Intervention for Distressed Patients Undergoing Cancer Surgery: A Case Series, (2020), https://doi.org/10.1016/j.cbpra.2020.02.002