Month: January 2022

Men who are newly diagnosed with prostate cancer have difficult choices to make about medical therapy, and the last thing any of them want is to regret their treatment decisions later. But unfortunately, treatment-related regrets are quite common, according to a new study.

After looking into the experiences of 2,072 men diagnosed with prostate cancer between 2011 and 2012, the investigators found that more than one in 10 were unhappy with their chosen treatment.

The men were all younger than 80, with an average age of 64. Nearly half of them had slow-growing cancers with a low risk of recurrence or spread after treatment. The rest were in intermediate- or higher-risk categories.

All the men were treated in one of three different ways: surgery to remove the prostate (a procedure called radical prostatectomy); radiation therapy; or active surveillance, which entails monitoring prostate tumors with routine PSA checks and imaging, and treating only when, or if, the cancer progresses. More than half the men chose surgery regardless of their cancer risk at the time of diagnosis. Most of the others chose radiation, and about 13% of the men — the majority of them in low- or intermediate-risk categories — chose active surveillance. Then, at periodic intervals afterwards, the men filled out questionnaires asking if they felt they might have been better off with a different approach, or if the treatment they had chosen was the wrong one.

What the results showed

Results showed that after five years, 279 of the men (13% of the entire group) had regrets about what they had chosen. The surgically-treated men were most likely to voice unhappiness with their decision; 183 of them (13%) felt they would have been better off with a different approach. By contrast, regrets were expressed by 76 (11%) of the radiation-treated men and 20 (7%) of men who chose active surveillance. Men in the low-to intermediate-risk categories were more likely to regret having chosen immediate treatment with surgery or radiation instead of active surveillance. The men with high-risk cancer, however, did not regret being treated immediately.

The study was led by Dr. Christopher Wallis, a urologic oncologist at Mount Sinai Hospital in Toronto, Canada. Wallis and his team didn’t explore which specific disease outcomes or complications led to the regrets associated with particular treatments. However, the study did find that sexual dysfunction was significantly associated with treatment regrets in general. “And patients on active surveillance may develop regret if their disease progresses and they then come to believe that they may have been better suited by getting treatment earlier,” Wallis wrote in an email.

The study’s key finding, according to the investigators, is that regrets arise from discrepancies between what men expect from a particular approach and their actual experiences over time. “That’s the important take-away,” Wallis said.

In an accompanying editorial, Randy Jones, PhD., RN, a professor at the University of Virginia School of Nursing, emphasized that improved treatment counseling at the time of diagnosis can help to minimize the likelihood of regret later. This communication, he wrote, should consider the patient’s personal values, stress shared decision-making between patients and doctors, and aim for an “understanding of realistic expectations and adverse effects that are possible during treatment.”

“This study underscores the importance of not rushing into a decision, and fully understanding the time course of side effects and what can be expected from them,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org. “Only when these consequences of treatment(s) or surveillance are fully understood is the patient able to make a truly informed decision.” All too often, newly diagnosed patients respond by “wanting to take care of this as soon as emergently possible.” But with prostate cancer, patients have the time to fully understand what is at stake. “I urge my patients to speak with members of prostate support groups and other prostate cancer patients about the issues they are likely to face, not necessarily in the immediate future, but years later. The fact that this study evaluated individuals 10+ years following their decision is an important feature in helping us better understand the time course during which regrets may be experienced.”

Migraine is a common and disabling headache disorder. Painful migraine headaches frequently affect people between the ages of 18 and 44. Many common medication treatments for migraine may cause side effects that are difficult to tolerate, and can lead people to not take their medications as recommended, or to stop taking them altogether. A recent study suggests that up to 20% of patients with migraine have used opioids to treat their pain in the past year. Therefore, there is a great need for better and more tolerable treatments for people who have migraines.

Research has shown that combining behavioral treatments with preventive medication treatments works better for preventing headaches than medications alone. Mindfulness practice has also been associated with improvements in individuals with chronic pain, including migraine. Mindfulness is the mind-body treatment that involves purposely focusing one’s attention on the present momentary awareness and accepting it without judgment.

Stress is a well-known trigger for migraine. Moreover, stressful events have been associated with people experiencing more frequent or chronic migraines versus having them occasionally. Mindfulness can result in stress reduction, reduced emotional response to stress, and improved general happiness. In patients with migraine, pain severity and unpleasant symptoms can be reduced with this treatment.

Mindfulness can potentially strengthen emotional and cognitive control of pain by helping to train someone with migraine to reassess their pain in a nonjudgmental way and modify their evaluation of the pain. In addition, mindfulness practices can help to control depression, anxiety, and pain catastrophizing (an exaggerated negative feeling toward pain experiences), which can play a role in chronic migraine.

The study

In a recent study published in JAMA, a group of researchers investigated whether mindfulness-based stress reduction may provide benefit for people experiencing migraine. The study randomly assigned half of participants with migraine to the mindfulness treatment and the other half to only headache education.

The mindfulness-based stress reduction treatment incorporated eight weeks of two-hour, in-person classes, which included sitting and walking meditation, body scanning (sequential attention to parts of the body), and mindful movement (bodily awareness during gentle stretching using hatha yoga), bringing attention back to the natural rhythm of the breath. In addition, the study participants were encouraged to build their capacity to address physical and mental perceptions of their pain, and they were provided audio files for at-home practice.

The headache education treatment included a standardized protocol of eight weeks of two-hour, in-person classes that contained education about the biological, psychological, and environmental processes associated with migraines, headache triggers, and stress. The patients were also given time for questions, answers, and discussion during each class.

The results

The researchers demonstrated that mindfulness-based stress reduction treatment significantly improved people’s disability, quality of life, self-efficacy, pain catastrophizing, and depression compared to patients who only had headache education. Reductions in monthly migraine days were observed in those with mindfulness-based stress reduction treatment, but were not significantly different from those receiving headache education. The authors of the study explain that the reason they could not demonstrate improvement in the headache frequency could be the use of an active control group such as headache education, which itself may result in improvement of headache frequency.

Most importantly, the study demonstrated that mindfulness-based treatments can reduce the burden of migraine. With mindfulness, the participants of the study may have learned a new way of processing pain that may have a significant effect on their long-term health. The results of this study have major implications for both patients and clinicians, and the research can support a holistic, integrative treatment plan for patients with migraine, with less emphasis on nonmedical treatments.

What you can do

Many healthcare providers, including headache specialists, pain specialists, neurologists, and primary care physicians, have started to incorporate mindfulness-based treatment in their practices, or they have sought mindfulness-based programs or specialists for their patients.

There are also many ways for patients with migraine to practice mindfulness at home. Patients with migraine can integrate some of the following mindfulness-based practices in their daily life, including during a migraine headache:

• Accept yourself, your present moment.
• Lie on your back or in a comfortable position with no distractions, and direct your awareness to your body and breathing. Scan your body and observe your feet, legs, hands, arms, and other parts of your body.
• Try to sit down in a comfortable and quiet place, close your eyes, take a deep breath. Try to do breathing exercises, paying attention to the sensations of your breath while inhaling and exhaling.
• Sitting or walking meditation done outside in nature may be very relaxing. Focus on the experience of walking, being aware of the sensations of standing and the subtle movements that keep your balance.

Resources

There many are apps and quality resources for mindfulness and migraine learning and practice. Here are few online resources to explore:

Body scan mindfulness exercise for pain (Harvard Health Publishing)

Mindfulness Meditation for Migraine (American Migraine Foundation)

Mindfulness series for Migraine & Headache Disorders (Miles for Migraine)

Mindfulness and Migraine (National Headache Foundation)

Some things are not debatable. Rain falls from the sky. Elevators go up and down. Orange traffic cones are orange. But because we interpret the world through our experiences, a lot isn’t so definitive.

The boss might say, “Good job,” and we wonder why they didn’t say, “Great job.” We see someone looking in our direction and they seem angry, so we believe that they’re mad at us, and no other explanation makes sense.

What’s happening is that we’re distorting our experience, jumping to conclusions, mind reading, and going to the worst-case scenario. When we do this, we shrink our successes and maximize our “failures,” and because it can be an automatic process, it’s hard to tell when it’s happening. “You don’t know you’re wearing magnifying glasses,” says Dr. Luana Marques, associate professor of psychology at Harvard Medical School.

So what can you do to see things more clearly and with a more balanced perspective? It takes practice and a willingness to tolerate discomfort, but as with addressing any problem, it starts with awareness.

What’s happening when we magnify failures and jump to negative conclusions?

We like to process information quickly, and we use filters to help do that. If we believe, “I’m no good,” all words and behaviors that support that contention just make everything easier.

“The brain doesn’t want to spend energy trying to fight that,” Marques says. And the brain responds depending on the distortion. If something causes anxiety, say from a curious look or comment, the limbic system is activated and we’re in fight-or-flight mode, hyper-focused on the threat, not thinking creatively or considering alternative, less threatening options.

But sometimes, there’s no threat in play. We’re just thinking, probably overthinking, when we question our abilities and minimize our accomplishments.

So what can you do about it?

Label the type of thinking distortion

It helps to define our distortions, the common ones being:

• Catastrophizing: Taking a small incident and going to the worst-case scenario.
• Black-and-white thinking: Seeing only all-or-nothing possibilities.
• Jumping to conclusions: Assuming what will happen rather than waiting to see what will actually happen.
• Mind reading: Assuming what someone is thinking without much evidence.

When you label it, you can better understand and recognize what your go-to distortion is, because “we tend to do one more than another,” Marques says.

After that, it helps to take your emotional temperature by asking: Am I stressed? Am I sweating? Is my heart pounding or my breathing shallow? It brings you more into the moment and it allows you to think about what you were doing that brought on the response, such as, “I was trying to guess the outcome.” It’s another way to pinpoint the distortion you tend to favor, she says.

Challenge the distortion

Whichever distortion it is, you want to examine your assumption by looking for other evidence. If you question your boss’s reaction to you, ask yourself: What does my boss really say? What does this person say about other people? Have I received raises and promotions? Am I given good projects?

An easy trap with distortions is that they’re plausible. A person who is mad at me would give me a look. A person who hated me wouldn’t text me back. Maybe so, but think of five other possible explanations, Marques says. This exercise engages the prefrontal cortex, which takes you out of the fight-or-flight mode and expands your thinking. You’re then problem-solving and not solely keyed on one option.

You also want to ask an essential question: is this thinking helpful? You might realize that all your thinking/wondering/worrying does is make you anxious. Gaining that presence might be enough to get you off the path of distorted thinking. “Asking and answering the question about your thinking pauses the brain, and you potentially see the world differently,” she says.

Being balanced and kind to ourselves

As you examine and attempt to control your distortions, be mindful of how you treat yourself. Self-criticism is a really easy trap to fall into, but try talking to yourself as you would a friend. Better yet, imagine you’re speaking to a child. Your language would be considerate, supportive, and you wouldn’t use words such as “stupid” or “dumb.” This approach also shifts you into the detached, third person. “You get out of your head,” Marques says. “We’re cleaning our magnifying glasses a little bit.”

Lastly, realize that you’re not looking to switch your attitude from “I’m unworthy” to “I’m super-great.” That’s just trading one extreme for another. All you want is to counterbalance your distortion, then let it go. Countering thinking distortions is a lot like meditation, where you practice acknowledging your thoughts without getting hooked onto them.  “You don’t have to magnify or minimize.” Marques says.