A specialized home care intervention improves survival among older post-surgical cancer patients.

CONTEXT: Changes in the healthcare system have resulted in shortened hospital stays, moving the focus of care from the hospital to the home. Patients are discharged post-operatively with ongoing needs, and whether they receive nursing care post-hospitalization can influence their recovery and survival. Little information is available about the factors that influence outcomes, including the survival of older cancer patients after cancer surgery. OBJECTIVE: To compare the length of survival of older post-surgical cancer patients who received a specialized home care intervention provided by advanced practice nurses (APNs) with that of patients who received usual follow-up care in an ambulatory setting. We also assessed potential predictors of survival in terms of depressive symptoms, symptom distress, functional status, comorbidities, length of hospital stay, age of patient, and stage of disease. DESIGN: A randomized controlled intervention study. SETTING: Discharged older cancer patients after surgery at a Comprehensive Cancer Center in southeastern Pennsylvania. PATIENTS: Three hundred seventy-five patients aged 60 to 92, newly diagnosed with solid cancers, were treated surgically between February 1993 and December 1995. One hundred ninety patients were randomized to the intervention groups and 185 to the usual care group. INTERVENTION: The intervention was a standardized protocol that consisted of standard assessment and management post-surgical guidelines, doses of instructional content, and schedules of contacts. The intervention lasted 4 weeks and consisted of three home visits and five telephone contacts provided by APNs. Both the patients and their family caregivers received comprehensive clinical assessments, monitoring, and teaching, including skills training. MAIN OUTCOME MEASURE: Time from enrollment of patients into the study until death or last date known alive at the end of November 1996. RESULTS: During the 44-month follow-up period, 93 (24.8%) of 375 patients died. Forty-one (22%) of those who died were patients in the specialized home care intervention group, compared with 52 (28%) in the usual care group. Stage of disease at diagnosis differed between the two groups at baseline (38% late stage patients in the intervention group compared with 26% in the control group, P = .01), so stratified analysis was performed. Overall, the specialized home care intervention group was found to have increased survival (P = .002 using stratified log-rank test). Among early stage patients only, there was no difference in survival between the intervention and control groups. Among late stage patients, there was improved survival in the intervention group. For example, 2-year survival among late stage intervention group cases was 67% compared with 40% among control cases. When Cox's proportional hazard model was used to adjust for significant baseline covariates, the relative hazard of death in the usual care group was 2.04 (CI: 1.33 to 3.12; P = .001) after adjusting for stage of disease and surgical hospitalization length of stay. CONCLUSIONS: This is the first empirical study of post-surgical cancer patients to link a specialized home care intervention by advanced practice nurses with improved survival. Additional research is needed to test home care interventions aimed at maintaining quality of life outcomes and their effects on survival of post-surgical cancer patients.

Popliteal artery aneurysms: current management and outcome.

PURPOSE: Thrombosis of popliteal artery aneurysms can produce limb-threatening ischemia. In this setting we have found preoperative thrombolytic therapy to be beneficial. METHODS: Thirty-three patients with 54 popliteal artery aneurysms were studied (mean follow-up 62 months). Twenty-one patients (62%) had bilateral popliteal artery aneurysms, and 20 patients (61%) had extrapopliteal arterial aneurysms. Thirty-three (61%) aneurysms had symptoms of compression or ischemia, and 21 (39%) aneurysms had thrombosis. A trend toward thrombosis for larger aneurysms was noted (p < 0.068). RESULTS: Forty-five aneurysms were treated with bypass grafting. Five-year graft patency and limb salvage rates were 71% and 90%, respectively. Factors favoring graft patency and limb salvage included presence of two- or three-vessel runoff compared with patients with single- or no-vessel runoff (p < 0.025 graft patency; p < 0.003 limb salvage) and presence of a patent aneurysm (p < 0.005 graft patency and limb salvage). Seven patients diagnosed with thrombosis of their aneurysm and all runoff vessels were treated with preoperative thrombolytic therapy. Complete clearing of thrombus from these arteries was achieved in six of these patients (and from two of these runoff vessels in the remaining patient). These patients had better graft patency (p < 0.005) and limb salvage (p < 0.01) than comparable patients treated with emergency operations. Six amputations were performed in the follow-up interval, none of which were performed in patients having undergone thrombolytic therapy. CONCLUSIONS: It is concluded that popliteal aneurysms are managed best by elective repair of patent aneurysms with good runoff. In that difficult situation of the thrombosed popliteal artery aneurysm associated with acute leg ischemia, thrombolytic therapy safely and effectively provides patients with a more favorable alternative than emergency surgery.

In vitro sensitivity of human hematopoietic progenitor cells to 4-hydroperoxycyclophosphamide.

Protracted engraftment and prolonged thrombocytopenia remain problems when marrow purged with 4-hydroperoxy-cyclophosphamide (4-HC) is employed for autotransplants. Toxic effects of 4-HC on early progenitor and stem cells might play an important causative role. Surprisingly, few investigations have examined the effects of 4-HC on progenitor cells other than colony-forming units-granulocyte/macrophage (CFU-GM) and burst-forming units-erythroid (BFU-E), and only one study could be found where 4-HC exposure was carried out on cells purified beyond the buffy coat stage. Since the cellular milieu, and in particular the red blood cell count, can ameliorate 4-HC toxicity, the suppressive effect of this agent on marrow stem cells might be underestimated. We therefore investigated the relative 4-HC sensitivity of different human bone marrow progenitor cells in vitro using partially purified adherent cell- and T lymphocyte-depleted bone marrow mononuclear cells (A-T-MNC). Cells were exposed to increasing doses (10 to 200 micrograms/mL) of 4-HC using a standard purging protocol established for bone marrow buffy coat cells. Effects on mixed (CFU-Mix), erythroid (CFU-E and BFU-E), granulocyte-macrophage (CFU-GM), and stromal cell (CFU-F) progenitors were determined. In addition, we examined the 4-HC sensitivity of megakaryocyte progenitors (CFU-Meg) since, to our knowledge, this has not been reported before. As expected, increasing doses of 4-HC led to progressive inhibition of hematopoietic colony formation. CFU-F, CFU-Mix, and CFU-Meg appeared most resistant to 4-HC exposure, while CFU-E, BFU-E, and CFU-GM appeared most sensitive. At doses over 100 micrograms/mL, the usual concentration recommended for purging of buffy coat cells, hematopoietic colony formation was completely inhibited. These data suggest that if more highly purified marrow cells are employed for purging, lower 4-HC doses may need to be used. They also suggest that the thrombocytopenia that frequently accompanies 4-HC purging is not likely due to loss of CFU-Meg.

The ability to evaluate prognostic variables on frozen section in hysterectomies performed for endometrial carcinoma.

The purpose of this study was to evaluate the ability of the pathologist to assess intraoperatively the hysterectomy specimen in patients with endometrial carcinoma. The past few years have seen the definition of prognostic variables that predict the ultimate outcome of patients with endometrial carcinoma. As a result, the International Federation of Gynecology and Obstetrics (FIGO) revised the staging system to take into account such prognostic factors as grade, depth of myometrial penetration by tumor, cervical involvement, adnexal metastasis, peritoneal cytology, and involvement of pelvic and para-aortic lymph nodes. The need for node evaluation has led to considerable controversy as to whether all hysterectomies for Stage I disease should be performed by gynecologic oncologists. To help predict which patients will need node sampling, several published studies have shown that determination of depth of myometrial penetration can be accomplished by gross evaluation of the uterine specimen, and even more accurately on frozen section. These studies recorded excellent results, but were limited to evaluation by pathologists with specific expertise in gynecologic pathology. The current study evaluated the ability to assess tumor grade, depth of invasion, and presence of cervical invasion by intra-operative evaluation of sixty hysterectomy specimens from patients with clinical Stage I disease. The gross and frozen section reports used for this study were produced by anatomic pathologists ranging in experience level from lecturer to professor, with varying levels of experience in gynecologic pathology. Our results indicate that the level of experience of the pathologist does not affect the ability to accurately assess the specimen for the parameters described. This, in turn, allows the surgeon to correctly determine the need for lymph node sampling in 94% of cases.

Survival and quality of life among patients receiving unproven as compared with conventional cancer therapy.

BACKGROUND: Cancer treatments without proved efficacy have achieved new levels of popularity, particularly among well-educated patients. The value of these therapies is vigorously debated. METHODS: We compared the length of survival and quality of life in patients who received treatment at a prominent unorthodox cancer clinic in addition to conventional treatment and in matched control patients from an academic cancer center who received only conventional treatment. All the patients had documented extensive malignant disease associated with a predicted median survival time of less than one year. The study sample consisted of 78 pairs of patients matched according to sex, race, age, diagnosis, and time from the diagnosis of metastatic or recurrent disease, who were enrolled over a period of 3 1/2 years. Periodic follow-up (approximately every two months) continued until death. RESULTS: There was no difference between the two patient groups in length of survival. Median survival for both groups was 15 months (P = 0.22; relative risk, 1.23; 95 percent confidence interval, 0.88 to 1.72). Quality-of-life scores were consistently better among conventionally treated patients from enrollment on. CONCLUSIONS: For this sample of patients with extensive disease and for this particular unorthodox treatment regimen, conventional and unorthodox treatments produced similar results.

Methodologic issues in palliative care psychosocial research.

The conduct of psychosocial research with palliative care patients or staff presents a major investigative challenge. The fragility of patients and their physical or cognitive limitations severely curtail the types of studies that are possible and the research methods that can be applied. A major limitation is that randomization, a critical experimental design feature, is rarely possible or ethical as a means of evaluating palliative care. However, even given the practical limitations of constructing a randomized experimental design, methodologically acceptable studies are possible, and methodologically inappropriate approaches can be avoided. Case reports (anecdotal studies) produce data that cannot be generalized to other patients. Single-test, no control group studies should be avoided for similar reasons. Acceptable research techniques that are feasible in the palliative care setting are renewed: careful research questions and associated hypotheses; determining appropriate sample sizes; developing comparison groups; selecting and evaluating an appropriate interview guide or questionnaire; avoiding interviewing bias, and so on. Moreover, it is necessary for the professional standing of palliative care that the exchange of information between palliative care staff and other health professionals be based upon scientifically sound studies.

Psychosocial correlates of cancer survival: a subsequent report 3 to 8 years after cancer diagnosis.

Professional and public interest in possible relationships between psychosocial factors and disease outcome continues to increase. Published research in this area, however, is marked by contradictory results. Positive relationships between a variety of psychosocial factors and length of survival from cancer are reported, but other studies uncover no such associations. In a previously reported prospective investigation of 359 patients with newly diagnosed malignant diseases, we found no relationship between clinical outcome and any psychosocial factor studied. We have continued to observe these patients, who are now up to 8 years post-diagnosis, and report here additional data on their disease outcomes as they relate to psychosocial factors assessed at diagnosis. Two groups of patients were studied: 204 patients with advanced, prognostically poor malignant disease at diagnosis; and 155 patients with intermediate or high-risk melanoma or breast cancer. Shortly after diagnosis, patients completed a self-report questionnaire that assessed seven psychosocial factors previously reported to predict longevity in the general population. Factors included social ties and marital history, job satisfaction, use of psychotropic drugs, general life satisfaction, subjective view of adult health, hopelessness, and perception of amount of adjustment required to cope with the new diagnosis. Clinical factors--performance status and extent of disease at diagnosis--predicted clinical outcome. No psychosocial factor consistently was associated with length of survival or remission. Results of additional exploratory analyses also are reported.

"Catalyst" symptoms in malignant melanoma.

Despite efforts to identify and cure early melanoma, mortality from this potentially curable disease continues to increase. In a retrospective analysis of the charts of 568 patients treated for superficial spreading melanomas during a ten-year period, the authors studied the relations between type of symptom, symptom duration, and thickness of the lesion. "Catalyst" symptoms, the particular events that preceded diagnosis, were identified. Patients described 75 different catalyst symptoms or symptom combinations. Bleeding precipitated prompt medical attention but was associated with the deepest lesions (mean thickness 1.77 mm); ulceration, itching and tenderness were associated with delays of several months and lesions of intermediate thickness (1.13 to 1.28 mm); and changes in size, color, or elevation eventuated in diagnosis an average of a year after patients' observations of these changes, with mean lesion thickness of .80 mm to 1.33 mm. Patients react slowly to signs and symptoms of early melanoma.

How well do physicians recognize melanoma and other problem lesions?

The alarming increase in the incidence of cutaneous malignant melanoma in the United States emphasizes the importance of its early detection and treatment. Early detection requires accurate clinical recognition of both malignant and precancerous skin lesions (dysplastic nevi). This study presents data on dermatologists' and nondermatologists' ability to diagnose skin lesions. A total of 105 nondermatologist physicians, from first-year residents to practicing physicians, and forty-eight dermatologists were asked to identify color slides or photographs of eleven cutaneous lesions, including malignant melanomas, dysplastic nevi, and innocuous lesions such as seborrheic keratoses and common moles. Diagnosis of cutaneous lesions was generally inaccurate among nondermatologists. Only 38% correctly identified four or more of the six melanomas as melanoma of any type, and 58% were unable to diagnose dysplastic nevi. Only 17% categorized their relevant training as excellent or good. Improved training in the diagnosis of skin lesions for practicing physicians and house staff is required if mortality from malignant melanoma is to be decreased in the United States.

Factors associated with psychological distress in cancer patients.

We studied the mental health of 1,278 patients with cancer and 645 family members of patients with cancer to delineate clinical and demographic characteristics associated with poor psychological status. For both patients and their matched relatives, there was a direct relationship between poorer mental health scores and younger age. Highly significant age differences emerged as well for subscale scores of anxiety, depression, and general positive affect in patients, and for depression, emotional ties, and loss of control in relatives. Treatment status, performance status, and sex also contributed significantly to mental health scores. Patients at greatest risk for psychological problems are young, female, receiving palliative or active treatment as opposed to follow-up care, and symptomatic or not fully ambulatory. Clinicians should be alert to the potential for psychological problems among patients in these categories.

Chemotherapeutic toxicity--the relationship between patients' pretreatment expectations and posttreatment results.

Patients receiving the same cancer chemotherapy regimens exhibit a highly variable incidence of toxic side effects. We studied 56 patients about to receive chemotherapy for the first time to determine whether their expectations of individual side effects were associated with the frequency and severity of the toxicity that they subsequently experienced. Patients completed a self-report questionnaire containing a list of 16 potential toxicities, asking them to indicate how certain they were of experiencing or not experiencing each. Prior to their third treatment, patients again completed a self-report scale indicating the incidence and severity of each side effect experienced. The frequency of actual side effects was much greater than patients anticipated. The most commonly reported side effects were tiredness, changes in appetite or taste, nervousness, and nausea. Patients' expectations failed to predict the occurrence or severity of the experience of common side effects. Anxiety levels and meaning attributed to side effects also were not associated with side effects experienced. Although psychological factors may play a role, it is likely that unique physiologic parameters account primarily for the variable and unpredictable relationship between chemotherapeutic agents and the side effects they induce.

Discriminant scorecard for diagnosis of invasive pulmonary aspergillosis in patients with acute leukemia.

Invasive pulmonary aspergillosis, a serious opportunistic infection in adult patients with acute leukemia, is difficult to diagnose antemortem. To identify patients with invasive pulmonary aspergillosis without reliance on invasive diagnostic procedures, a discriminant scorecard for invasive pulmonary aspergillosis based on clinical parameters was evaluated in a three-phase study. In phase I, the records of 62 patients, including 15 with invasive pulmonary aspergillosis, were reviewed. Eleven clinical parameters distinguished patients with invasive pulmonary aspergillosis from control subjects. These parameters were combined into a discriminant scorecard. In phase II, the discriminant scorecard was validated by a blinded, retrospective review of 94 consecutive admissions. The discriminant scorecard score was highly associated with the clinical outcome (p less than 0.0005). The sensitivity of the discriminant scorecard was calculated as a range from 62.9 to 92.8 percent and the specificity as a range from 87.5 to 98.3 percent. In phase III, the clinical utility of the discriminant scorecard was determined by its prospective application to 49 consecutive patient admissions. The discriminant scorecard identified patients with invasive pulmonary aspergillosis at an average of 4.1 days prior to clinical recognition of the disease and initiation of amphotericin B therapy. The discriminant scorecard outperformed a complex function based on multiple linear regressions, was easy to use, and did not require difficult calculations. Thus, for this patient population, the discriminant scorecard was an accurate, useful noninvasive screening test for invasive pulmonary aspergillosis. The scorecard allows more rapid clinical identification of patients with this infection and could lead to improved patient survival through earlier diagnostic and therapeutic intervention.

Psychosocial correlates of survival in advanced malignant disease?

Prospective studies of the general population have isolated specific social and psychological factors as independent predictors of longevity. This study assesses the ability of these factors, plus two others said to influence survival in patients with cancer, to predict survival and the time to relapse after a diagnosis of cancer. Patients with unresectable cancers (n = 204) were followed to determine the length of survival. Patients with Stage I or II melanoma or Stage II breast cancer (n = 155) were followed to determine the time to relapse. Analysis of data on these 359 patients indicates that social and psychological factors individually or in combination do not influence the length of survival or the time to relapse (P less than 0.10). The specific diagnosis (F = 2.0, P = 0.06), performance status (F = 0.66, P = 0.62), extent of disease (F = 1.12, P = 0.89), and therapy (F = 1.08, P = 0.35) were also unrelated to the psychosocial factors studied. Although these factors may contribute to the initiation of morbidity, the biology of the disease appears to predominate and to override the potential influence of life-style and psychosocial variables once the disease process is established.

A psychological analysis of cancer patients and their next-of-kin.

A supportive family environment is thought to enhance the capacity of cancer patients to adapt to their illness and treatment. But families, like patients, vary in their ability to cope with the impact of a cancer diagnosis in a family member and in their ability to fulfill the patient's needs. Increased understanding of the interrelationships between the family's and patient's responses to illness is of fundamental importance to the care of the patient with cancer. A heterogeneous sample of 201 cancer patients and their relatives were studied to determine compatibility of psychological status and to isolate clinical and demographic variables associated with psychological distress. Self-report tests of anxiety, mood disturbance, and mental health were applied. Despite large individual variation, the psychological status of patients and their matched relatives was closely correlated. The patient's treatment status affected both patients and their next-of-kin. Psychological well-being worsened according to whether patients were receiving follow-up care, active treatment, or palliative therapy. These data suggest a mutuality of psychological response between patients and their families. Supportive intervention for the patient or relative who manifests distress, therefore, should benefit both. Because patients and relatives involved with palliative treatment are most in need of psychological assistance, particular attention should be paid to this group, as is attempted in hospice care.

Lack of association between intraocular melanoma and cutaneous dysplastic nevi.

The occurrence of uveal and cutaneous malignant melanoma and the dysplastic nevus syndrome in the same individual suggests an etiologic relationship among these diseases. Thus, the dysplastic nevus syndrome could be viewed as marking an increased risk of both cutaneous and ocular melanoma. We postulated that if such a relationship exists, patients with both forms of melanoma should have a high prevalence of dysplastic nevi. We examined 44 patients (31 women and 13 men ranging in age from 20 to 80 years) with uveal melanoma for evidence of cutaneous melanoma and dysplastic nevi. We also examined photographs of 46 patients (24 men and 22 women ranging in age from 19 to 67 years) with nonfamilial cutaneous melanoma to determine the prevalence of dysplastic nevi. We found a 4.5% prevalence of dysplastic nevi in patients with uveal melanoma, significantly lower than the 41% prevalence in patients with cutaneous melanoma (two of 44 patients vs 19 of 46 patients). This study indicates that uveal and cutaneous melanoma are not etiologically linked through dysplastic nevi and suggests that patients with uveal melanoma are no more likely to have cutaneous dysplastic nevi than the general population.

The use of photographs of postoperative results prior to melanoma resection.

A total of 99 patients scheduled for resection of stage I melanoma were assigned randomly to be shown individually relevant photographs of anticipated postoperative results. All patients had received verbal information on this subject during discussions with their plastic surgeons. Anticipated and actual cosmetic impact or distress was measured with a self-report questionnaire given prior to and 6 months following surgery. Patients were least distressed postoperatively when their scars were not larger than anticipated. However, photographs failed to achieve the expected benefit of increasing the accuracy of patients' expectations of their postoperative appearance. Consequently, photographs had no effect on levels of preoperative or postoperative distress. Selective attention and preferences for limited information among some patients are suggested explanations for these results.

Psychosocial status in chronic illness. A comparative analysis of six diagnostic groups.

Assumptions that psychological attributes are specific to particular diagnoses characterize many investigations of chronically ill patients. We studied 758 patients, each of whom had one of six different chronic illnesses, to determine and compare their scores on the Mental Health Index. Five groups of physically ill patients (with arthritis, diabetes, cancer, renal disease, or dermatologic disorders) did not differ significantly from one another or from the general public, but all had significantly higher scores for psychological status when compared with the sixth group, patients under treatment for depression. There was a significant direct relation between higher mental-health scores and advancing age across all patient populations. Patients with recently diagnosed illness in all groups had poorer mental-health scores than did patients whose illness had been diagnosed more than four months previously. A direct relation between declining physical status and mental-health scores was observed. These results suggest that psychological adaptation among patients with chronic illnesses is remarkably effective and fundamentally independent of specific diagnosis.

Contemporary unorthodox treatments in cancer medicine. A study of patients, treatments, and practitioners.

Public education, legislative action, and medical advances have failed to deter patients from seeking unorthodox treatments for cancer and other diseases. To study this phenomenon, we interviewed 304 cancer center inpatients and 356 patients under the care of unorthodox practitioners. A concomitant survey of unorthodox practitioners documented their backgrounds and practices. Eight percent of all patients studied never received any conventional therapy, and 54% of patients on conventional therapy also used unorthodox treatments. Forty percent of patients abandoned conventional care entirely after adopting alternative methods. Patients interviewed did not conform to the stereotype of poorly educated, end-stage patients who had exhausted conventional treatment. Practitioners also deviated from the traditional portrait: Of 138 unorthodox practitioners studied, 60% were physicians(M.D.s). Patients are attracted to therapeutic alternatives that reflect social emphasis on personal responsibility, pollution and nutrition, and that move away from perceived deficiencies in conventional medical care.