Oral combination chemotherapy in conjunction with filgrastim (G-CSF) in the treatment of AIDS-related non-Hodgkin's lymphoma: evaluation of the role of G-CSF; quality-of-life analysis and long-term follow-up.

In 1993 we reported the efficacy and toxicity profile of an oral combination regimen administered to 18 patients with AIDS-related lymphoma (NHL-1 study). We observed a 61% response rate; 39% one-year survival rate; nearly two-thirds of patients developed > or = grade 3 leukopenia; and 28% of cycles were associated with febrile neutropenia. These results prompted us to shorten the duration of therapy and to add G-CSF to ameliorate the myelosuppression. Twenty patients with biopsy-proven AIDS-related lymphoma were treated with three 6-week cycles of oral chemotherapy consisting of lomustine (CCNU) 100 mg/m2 on day 1, cycles no. 1 and 3; etoposide 200 mg/m2 days 1-3; cyclophosphamide and procarbazine both 100 mg/m2 days 22-31; and G-CSF 5 microg/kg subcutaneously days 5-21 and days 33-42 (NHL-2 study). The following analyses were undertaken: (1) evaluation of toxicity and efficacy parameters for patients in the current (NHL-2) study; (2) analysis of the clinical role of G-CSF by (historical) comparison with the NHL-1 study of the same regimen without G-CSF; (3) quality-of-life assessments using the Functional Living Index-Cancer (FLIC) and Brief Symptom Inventory (BSI) instruments for all 38 patients (NHL-1+2); and (4) long-term follow-up for all 38 patients. In the current study the overall objective response using ECOG criteria was 70% (95% CI, 50-90%) with 6 CRs (30%) and 8 PRs (40%). The median survival duration was 7.3 months (range: 0.5-51+ months). One patient developed CNS relapse. There were no significant differences with respect to demographics or prognostic factors between the patient populations of the NHL-1 study and the current study (P > 0.2 for each factor). Myelosuppression was the major toxicity in both studies. In the current study versus the NHL-1 study, although the lower incidences of grade 3/4 myelosuppression (51% vs. 64%) and febrile neutropenia (17% vs. 28%) on a per cycle basis were not statistically significant, fewer patients (40% vs. 60%) were affected. However, the severity of myelotoxicity was lessened with the addition of G-CSF, measured in terms of the discontinuation of therapy, myelotoxic deaths, and freedom from grade 3/4 myelotoxicity ( P < 0.02). The number of hospitalizations for febrile neutropenia (7 in the NHL-2 study vs. 13 in the NHL-1 study) was also significantly different (P < 0.05). Quality-of-life analysis confirmed no significant functional or psychological deterioration during therapy except for patients experiencing febrile neutropenia, whose functional capacity deteriorated (P < 0.04). The 1-year, 18-month, and 2-year survival rates for the combined studies (38 patients) were 32%, 21%, and 13%, respectively. At time of death 49% of patients were free from progression of their lymphoma. Administration of the oral regimen has resulted in 13% of patients surviving two years, and half of patients surviving free from progression of their lymphoma. This regimen is efficacious and considerate of patient quality-of-life issues. The addition of G-CSF to the regimen decreases the frequency of hospitalization for febrile neutropenia.

Posttraumatic stress disorder in breast cancer patients following autologous bone marrow transplantation or conventional cancer treatments.

We assessed 17 women who had undergone autologous bone marrow transplants (BMT) for their breast cancer and 20 other women who had been treated for breast cancer (but not with BMT) by structured clinical interviews examining each stage of the breast cancer experience (e.g. initial diagnosis, initial treatment, recurrence of cancer (if applicable) and BMT (if applicable)) and at follow-up points; 3, 6 and 12 months (if applicable) posttreatment. The two groups did not differ on incidence of posttraumatic stress disorder (PTSD), major depressive disorder (MDD) or generalized anxiety disorder at any stage. We found a high rate of PTSD over the cancer experience, 35% for the combined sample, with cancer diagnosis being the most likely point for developing PTSD, 27% for the combined sample. None of the 17 women who had undergone BMT developed PTSD as a result of the treatment.

The psychosocial effects of rheumatoid arthritis on the patient and the well partner.

Rheumatoid arthritis (RA) is a chronic disorder that can have a severe impact on patient's lives. This present study investigated four questions regarding the psychosocial effects on patients and their well partners. First we found that depression for both patients and partners were slightly elevated and 35.7% of patients and 23.3% of well partners had scores above the cut-off for possible clinical depression on the Center for Epidemiological Studies Depression Scale. Second, there was no significant difference between the patients' level of distress and that of the partners. Third, there were moderate positive correlations between patients' and partners' scores on measure of psychological functioning. Fourth, there were no differences in either the patients' or partners' well-being based on the gender of the patient. Finally, an exploratory analysis was conducted to examine the factors which influence the patients' and partners' depression and their view of the relationship.

The crisis of cancer: psychological impact on family caregivers.

Cancer causes changes in the family's identity, roles, and daily functioning. Studies document that spouses are as distressed as cancer patients and that spousal and patient distress are correlated. Three major areas of caregiver concern are: fear of cancer and its spread, helping patients deal with the emotional ramifications of the disease, and managing the disruptions caused by cancer. From 20% to 30% of partners suffer from psychological impairment and mood disturbance as a result of the spouse's cancer. Factors that may predict high levels of spousal distress include: disease stage; emotional adjustment of the patient; gender, age, and other characteristics of the spouse; marital adjustment; and family functioning. Studies show that interventions do not reduce spousal distress. Future studies should explore the role of mediating factors, such as coping style, marital adjustment, and family functioning, on the relationship between illness demands or prognosis and distress. Interventions could then be targeted to high-risk individuals.

A problem solving intervention for caregivers of cancer patients.

Effects of a psychosocial intervention program on spouses of cancer patients, and on the cancer patients themselves, will be described. A six session intervention program, which included support, problem-solving and coping skills, was designed to help spouses to cope with the stress of caring for their partner. Forty male and forty female spouses of cancer patients of a regional oncology center were randomly assigned to intervention or usual treatment conditions. Spouses and patients were interviewed prior to intervention, and within two weeks after intervention on a battery of assessment instruments including: (1) demographic variables; (2) psychological variables; (3) health status; (4) social supports; (5) assessment of pressing problems; (6) coping skills; (7) burden levels; and (8) marital satisfaction. Participants were found to be more psychologically distressed than the general population but were not as distressed as psychiatric outpatients. Differences were also found in marital satisfaction and coping activities, when compared to the general population. No significant differences between the conditions were found on any of the measures. Caregivers' level of caregiving activities proved to be low. It is suggested that this may account for why the intervention only appeared effective for a distressed subsample of the caregivers in the study. The implications of these findings is discussed. Recommendations are also made for future research on cancer caregivers.

Psychosocial oncology research. Where we have been, where we are going, and why we will not get there.

Quality of life, symptom management, and social support are the traditional foci for the practice of psychosocial oncology and clinical research into the behavioral and psychologic aspects of cancer. The current paradigm for research in this area primarily assesses patient responses to cancer related stressors and the means of ameliorating the negative aspects of those responses. However, clinically meaningful interventions have been the exception, rather than the rule. The authors think that the central event initiating a stressful response is the interaction between the patient and physician conveying the diagnosis, prognosis, or treatment plan. The authors think addressing the initial event in a cascade of responses is an important prerequisite for progress in this area.

Novel oral combination chemotherapy in the treatment of intermediate-grade and high-grade AIDS-related non-Hodgkin's lymphoma.

PURPOSE: To determine the toxicity, response, and survival rate of orally administered combination chemotherapy in patients with AIDS-related intermediate- and high-grade non-Hodgkin's lymphoma. Secondary objectives included prospective quality-of-life assessment and quantitation of cell-associated p24 antigen (p24 Ag) by flow cytometry. PATIENTS AND METHODS: Eighteen patients with biopsy-proven lymphoma were treated with oral chemotherapy consisting of lomustine (CCNU) 100 mg/m2 on day 1, etoposide 200 mg/m2 on days 1 through 3; cyclophosphamide 100 mg/m2 on days 22 through 31, and procarbazine 100 mg/m2 on days 22 through 31 at 6-week intervals. A variety of clinical assessments were performed: prospective quality-of-life assessment using the Functional Living Index-Cancer (FLIC) and Brief Symptom Inventory (BSI) instruments; indirect immunofluorescence with flow cytometry to measure cell-associated p24 antigen; and price of the oral regimen compared with two other intravenous combination chemotherapy regimens. RESULTS: The overall objective response rate using Eastern Cooperative Oncology Group (ECOG) criteria was 61% (95% confidence interval, 39% to 84%), with seven complete remissions (39%) and four partial remissions (22%). The median survival duration was 7 months, with a range of 11 days to 36 months. The treatment-related mortality rate was 11%. One patient developed CNS progression. Myelosuppression was the most frequent and severe toxicity encountered. Predictor variables of performance status (PS), prior history of thrush, and CD4 lymphocyte count were found to be of prognostic value. In a separate analysis, scores on the three subscales of the BSI were also found to be predictive of complete response. The price of this regimen is several thousand dollars less than that of other intravenous combination chemotherapy regimens. CONCLUSION: This regimen is active in patients with AIDS-related non-Hodgkin's lymphoma. Because it is important to design systemic cytotoxic chemotherapy regimens that are cost-effective, considerate of quality-of-life issues, and efficacious in this patient population, this approach should be compared with standard intravenous combination chemotherapy regimens in randomized controlled clinical trials.

The impact of family presence on the physician-cancer patient interaction.

Physician behaviors were studied in 473 interactions between oncologists and adult cancer outpatients. Ninety-nine of these interactions occurred when family members were present during the visit. Patients with family members present were likely to be sicker as demonstrated by a poorer performance status. Contrary to earlier reports, age of the patient did not predict whether the patient was likely to be accompanied by a family member. The physician behaviors were factor analyzed to produce six factors and a multivariate analysis of variance was conducted using the presence of family and performance status as independent variables. The time the physician spent in the patient's room, patient satisfaction and quality of life were also examined in separate analyses. The time the physician spent with the patient was greater when family were present. The results showed that, in general, physicians provide more information when patients are accompanied by family members, or if no family are present, when the patient has a worse performance status. Patient satisfaction and quality of life were rated lower for patients with a worse performance status and were not impacted by physician behaviors. Physicians' behavior was affected by both the presence of a family member, and the patient's performance status.

Physician behaviors, patient perceptions, and patient characteristics as predictors of satisfaction of hospitalized adult cancer patients.

To examine potential predictors of cancer patient satisfaction with physician behavior, 366 cases were studied. Physician behavior was measured on morning rounds using the Physician Behavior Check List (PBCL). Patient satisfaction and perceptions were assessed after the visit. Patient characteristics were obtained from the chart and the physician. Results showed wide variation in physician behavior; no "standard" set of behaviors was seen in all interactions. Patient satisfaction was high (mean = 87.8 mm on a 100-mm scale). Path analysis showed four variables predicted 62% of the variance in patient satisfaction. The strongest predictor was the patient perception item, "perception of needs addressed that day." Other predictors were perception of emotional support provided by the physician, age (older), and one physician behavior, "discusses treatment." Patient perceptions of needs met or emotional support provided were predicted by perceptions of the occurrence of physician behaviors involving information such as the diagnosis and tests and treatment. Overall, patient perceptions of physician behaviors were stronger predictors of patient satisfaction than the actual occurrence or absence of those behaviors.

Information and decision-making preferences of hospitalized adult cancer patients.

Physician behaviors and patient responses were studied in 439 interactions between hospitalized adult cancer patients and oncologists to investigate patient preferences for a participatory role in the interaction. Patients were asked their preference for information to be given (minimal; only if it is good news; or all information, good or bad) and their preference for participation in decision-making (prefer doctor makes therapeutic decisions or prefer to participate in decisions). The majority (92%) preferred all information be given, but only 69% preferred to participate in therapeutic decisions. Of those wanting all the information, 24.9% preferred the physician to make the therapeutic decisions. This group was comprised primarily of older, sicker males. Those who did not want to participate were also slightly more satisfied (P less than 0.05). These data suggest that, although most patients prefer all information to be given to them, almost one-fourth of them preferred a more authoritarian, rather than participatory, relationship with their oncologist.

The impact of a designated cancer unit on house staff behaviors toward patients.

To examine the impact of a subspecialty care unit on house staff behavior toward patients, fourteen internal medicine teams were observed in 1213 interactions with patients on morning rounds using a previously devised instrument, the Physician Behavior Check List. The eight teams assigned to the hematology/oncology unit (HO teams) saw significantly more cancer patients than did the six teams assigned to general medicine floors (GM teams). Patients seen by HO teams were sicker (P less than 0.001). Hematology/oncology teams engaged in fewer support behaviors, particularly with the sickest cancer patients, than did the GM teams. Teams did not differ on time spent with patient or patient involvement but HO teams were rated significantly lower on addressing the patient's needs. The authors propose the concentration of sick cancer patients on a designated cancer unit diminishes house staff ability to engage in supportive behaviors and to address the needs of patients during morning rounds.

The impact of oncologists' behaviors on patient satisfaction with morning rounds.

Morning rounds are the major focus of physician-patient interaction for hospitalized cancer patients. To determine the impact of specific physician behaviors on patient satisfaction with these rounds, the authors examined 401 such individual interactions using a previously developed Physician Behavior Check List (PBCL) and several visual analogue scales that assessed patient satisfaction. Patient satisfaction for the entire group was high (X = 8.56 on a 10 cm scale) and failed to correlate significantly with specific physician behaviors. By splitting at the median, high and low satisfaction groups were obtained. For the high satisfaction group older age, a poorer prognosis, and a positive quality of the day's news were associated with higher satisfaction. Use of the patient's first name and attempts to establish privacy during an exam were positively correlated with satisfaction, whereas discussing the role of the family and examining nontruncal areas had a negative impact. For the lower satisfaction group, a series of routine social skills behaviors (e.g., sitting while talking to patients, not interrupting) and two medically related behaviors correlated best with patient satisfaction. There was little significant impact on satisfaction of behaviors related to the provision of either medical information or emotional support.

Psychosocial aspects of cancer in adults: implications for teaching medical students.

This article addresses psychosocial aspects of cancer and the cancer patient that the authors feel are important to teach medical students. A section on understanding the cancer patient deals with patient psychosocial responses to a diagnosis of cancer. Loss of control, anger and guilt, fear of abandonment, fear of pain, psychiatric disorders, and psychosocial factors all need to be explored by the health care team. Interventions, such as education, support groups, environmental manipulation, or psychological counseling including imagery or relaxation have proved to be effective. Relaxation therapy can also help to counteract the side effects of chemotherapy such as anticipatory nausea and vomiting. An increasing openness about discussing dying and the development of hospices have resulted in improvements of the care of the dying patient and family. Family members should be involved in the care of the cancer patient and can support the patient by promoting autonomy and control and by encouraging communication and expression of feelings. The doctor-patient relationship is central, and is changing from a paternalistic model to one encouraging greater patient participation. In studying the behavior of physicians at Albany Medical College, the authors found that oncologists spend more time with patients with the poorest prognoses. Patient satisfaction with the relationship was found to be high. Students can be instructed in these psychosocial aspects of oncology by means of videotapes, role-playing, or patient presentations, and more importantly by using the physicians as a role model. Comprehensive care of the cancer patient necessitates the integration of psychosocial aspects of care into the overall assessment and management plan. This article reviews the psychosocial aspects of care of the adult cancer patient taught to second year medical students as part of a 42 hour course entitled "The Cellular Basis of Cancer Medicine" at Albany Medical College. The didactic material covered in this article is based on local clinical work and research endeavors with adult cancer patients and is included in the course syllabus given to the students. The students are divided into four small groups, each of which has one of four teaching experiences, each lasting for 2 hours. The psychosocial aspects of cancer is one of the small groups. This group, consisting of 32 students each, is taught by a medical oncologist and a behavioral scientist. Videotapes of interviews done with patients and/or live interviews with patients are used to highlight the material covered in the syllabus.(ABSTRACT TRUNCATED AT 400 WORDS)

Interactions between oncologists and patients during rounds.

Physician behavior during inpatient rounds was observed and quantified for 394 interactions between patients with cancer and physicians. Most patients had solid tumors (90%) and a limited prognosis despite treatment (61%). The physicians spent 1.45 +/- 0.58 h on morning rounds seeing an average of 9.3 +/- 3.39 patients. For each patient an average of 3.61 +/- 2.83 min was spent in the room. The rest of the time was involved in reviewing the results of diagnostic tests, discussing treatment plans, and updating patient's charts. Time spent in the room was significantly related to the patient's sex and diagnosis. Physicians spent more time with patients having the poorest prognosis (p = 0.009). Specific behaviors were analyzed using a Physician Behavior Check List that allows accurate recording of behavior during a brief patients-physician encounter. Factor analysis of responses to the check list resulted in four factors that explained 58.7% of the variance. The physician behavior factor scores failed to correlate with factor scores from the responses of the same physicians to the Cancer Attitude Survey. In addition, the physicians were unable to accurately estimate the time they actually spent with patients or the frequency of specific behaviors that occurred during these interactions.

Attitudes toward cancer. II: A comparative analysis of cancer patients, medical students, medical residents, physicians and cancer educators.

The current investigation was designed to determine how cancer patients, medical students, medical residents, nononcologically oriented physicians, and cancer educators differ with respect to attitudes towards cancer. A total of 372 individuals completed the Cancer Attitude Survey. Cancer educators displayed more confidence in the patient's ability to cope with diagnostic and prognostic information than students, other physicians, and patients themselves. Patients and cancer educators favored aggressive therapy to greater extent than other physicians, students, and alumni. Among nononcologic physicians and students there were significant effects of respondent's sex and prior personal experience with cancer on the attitudes expressed. Cancer educators differed significantly by specialty with surgical oncologists most likely to favor aggressive therapy. When compared to physician groups studied in the 1960s, our overall physician group (residents, cancer educators, and other physicians) was more likely to exhibit: (1) confidence in the patient's coping ability; (2) skepticism about the efficacy of early diagnosis and the value of aggressive treatment; and (3) stronger beliefs in the patient's ability to prepare for and accept death. Comparisons of our medical student group with students studied by Haley and his colleagues revealed a similar picture. Implications of these findings for the education of medical students are discussed.

Attitudes toward cancer: I. The impact of a comprehensive oncology course on second-year medical students.

This study focuses on the change in medical students' attitudes toward cancer and related issues when the factual knowledge concerning the contemporary treatment of the cancer patient is increased. The Cancer Attitude Survey, as instrument consisting of 33 original items developed by Haley et al.9 and 27 additional items developed by the present authors, was administered to a sophomore class of medical students before and after on oncology course. Depsite the absence of formal attempts to teach specific attitudes, significant changes in attitudes were observed in responses to 18 of the 60 items (30%). After completing the course, students were more likely to favor an active role both for the patient and for the physician en each stage of the treatment process. Although students were more likely to favor aggressive treatment, they also indicated that appropriate limit should be set. Implications for teaching and for further research on attitudes and behavior are noted.

The impact on patient satisfaction of the introduction of family medicine residents into a model practice facility.

This study examines the effects on patient satisfaction of the introduction of family medicine residents into the staff of an ongoing private practice that joined a Department of Family Medicine. Questionnaires were administered to clinic patients during a four-week period four months prior to when residents began seeing patients at the clinic and again five months after residents joined the clinic staff. Satisfaction at both times was high; however, significant declines from Time 1 to Time 2 were noted on most items. Analysis showed that this decline was not related to dissatisfaction within the residents. A questionnaire was also mailed to a sample of patients who had not visited the clinic more than once during the first year of the resident program there. Three fourths of these individuals still viewed themselves as patients of the clinic. Implications of these findings for family medicine residency training programs are discussed.

The young widow: depressive symptomatology throughout the grief process.

The purpose of this investigation was to examine patterns of abatement of depressive symptomatology in 30 young widows at three time periods: immediately following the death of the husband, a year later, and at present. Data on all three time periods were gathered during one interview. The study thus provides retrospective information on patterns of depressive symptomatology. It was expected that such information would enhance understanding of the stages of the grief process described by Glick et al. and by Maddison.