Self-reported late effects and long-term follow-up care among 1889 long-term Norwegian Childhood, Adolescent, and Young Adult Cancer Survivors (the NOR-CAYACS study).

PURPOSE: The majority of childhood, adolescent, and young adult cancer survivors (CAYACS) are at risk of late effects but may not receive long-term follow-up care for these. Here, we investigated (1) self-reported late effects, (2) long-term follow-up care, and (3) factors associated with receiving follow-up care in a population-based sample of Norwegian long-term CAYACS. METHODS: Survivors were identified by the Cancer Registry of Norway. All > 5-year survivors diagnosed between 1985 and 2009 with childhood cancer (CCS, 0-18 years old, excluding CNS), breast cancer (BC, stages I-III), colorectal cancer (CRC), leukemias (LEUK), non-Hodgkin lymphoma (NHL), or malignant melanoma (MM) at age 19-39 years were mailed a questionnaire (NOR-CAYACS study). Descriptive statistics and logistic regression models were used to analyze occurrence of late effects, long-term follow-up care for these, and associated factors. RESULTS: Of 2104 responding survivors, 1889 were eligible for analyses. Of these, 68% were females, with a mean age of 43 years at survey, on average 17 years since diagnosis, and diagnosed with CCS (31%), BC (26%), CRC (8%), NHL (12%), LEUK (7%), and MM (16%). Overall, 61.5% reported the experience of at least one late effect, the most common being concentration/memory problems (28.1%) and fatigue (25.2%). Sixty-nine percent reported not having received long-term follow-up care focusing on late effects. Lower age at survey (p = 0.001), higher education (p = 0.012), and increasing number of late effects (p = < 0.001) were associated with increased likelihood of follow-up care in the multivariate model. CONCLUSIONS: The majority of survivors reported at least one late effect, but not receiving specific follow-up care for these. This indicates a need for structured models of long-term follow-up to ensure adequate access to care.

Emotional concerns in follow-up consultations between paediatric oncologists and adolescent survivors: a video-based observational study.

OBJECTIVE: The present study aimed to explore (a) to what extent adolescent cancer survivors express emotional concerns during follow-up consultations, (b) the content of these expressions, and (c) the responses to their concerns by the paediatric haemato-oncologists (oncologists). METHODS: Sixty-six follow-up consultations between adolescent patients (aged 12-20 years old; mean = 16) and oncologists (n = 10) were video recorded. Emotional concerns were coded using the Verona coding definitions of emotional sequences (VR-CoDES). The content of the concerns was analysed using thematic analysis. RESULTS: Emotional concerns (n = 115) were identified in 50% of the consultations. Of the concerns, 87% were expressed implicitly as hints to the underlying emotion (cues) rather than explicitly (concerns). The oncologists elicited 66.9% of these expressions. Four main categories of emotional concerns were identified in the thematic analysis: physical (31%), psychological (29%), social (17%), and cancer related (23%). The majority (76.5%) of the oncologists' responses to the cues and/or concerns provided space for further disclosure. The oncologists responded less explicitly to the emotional aspects of physical and cancer-related issues in comparison with the cues or concerns of psychological origin. More cues and concerns were expressed when parents were not present in the consultation. CONCLUSIONS: In this study, almost half of the adolescent patients presented emotional concerns, and a subgroup presented many concerns; these were mainly expressed when initiated by the oncologists. Oncologists should therefore be attentive to hints to underlying emotions to help the adolescent bring forward his or her concerns.

Using the Mini-Mental State Examination to screen for delirium in elderly patients with hip fracture.

BACKGROUND: The main aim of this paper was to examine the usefulness of the Mini-Mental State Examination (MMSE) for screening delirium in elderly patients with hip fracture. METHODS: The sample included 364 elderly patients with hip fracture admitted to two hospitals in Oslo. Delirium was assessed by the Confusion Assessment Method (CAM) as an approximation of the gold standard, DSM-IV. To evaluate the psychometric properties of the MMSE scale, we used the Mokken nonparametric latent trait model for unidimensional scaling. RESULTS: In total, 76 (21%) patients were diagnosed with delirium based on the CAM, and 141 (43%) had preexisting cognitive impairment. As a screening tool, the recommended MMSE cut-point of 24 showed an acceptable sensitivity of 88% with a specificity of 54%. The prediction of delirium, based on logistic regression on the MMSE total score and on the 5 items selected by the stepwise logistic regression procedure, gave clearly less acceptable results. CONCLUSIONS: Our study indicates that the MMSE may be useful in screening for delirium, but the high percentage of false positives shows that it does not have diagnostic potential in patients with hip fracture.

The length of consent documents in oncological trials is doubled in twenty years.

BACKGROUND: The aim of the study was to investigate whether the length of informed consent documents (ICDs) for oncological trials have increased from 1987 to 2007 and analyze the content of the ICDs. DESIGN: In total, 87 ICDs from oncological trials approved by the Regional Committee for Medical and Health Research Ethics (REC) in the central region of Norway from 1987 to 2007 were analyzed. A list of 17 basic (fundamental medical and ethical aspects) and 30 formal (juridical aspects, financing, insurance and storage of data) content components was constructed based upon international and REC guidelines for ICDs. The number of words and presence of components were registered for all ICDs. RESULTS: The mean length of the ICDs increased from 338 (range 276-464) words in 1987-1990 to 1087 words (range 399-2345) in 2005-2007. The number of components increased from nine to 25 during the same period. Basic components increased steadily from seven in 1987-1989 to 14 in 2005-2007 while the components concerning formalities increased substantially from two to 11. CONCLUSIONS: The increased length of the ICDs is explained by an increased complexity of the documents and especially more information about formalities. This development increasingly demands competent readers and might prohibit truly informed consents.

Alterations of gene expression in blood cells associated with chronic fatigue in breast cancer survivors.

Fatigue is one of the most frequent complaints among breast cancer survivors. However, mechanisms underlying persisting fatigue after end of treatment are poorly understood. To explore whether biological processes underlying persistent fatigue can affect gene expression of blood cells, genome-wide expression analyses were performed on whole blood samples from breast cancer survivors classified as chronic fatigued 2-6 years after diagnosis. Non-fatigued survivors served as controls. Several gene sets involved in plasma- and B-cell pathways differed between the chronic fatigued and the non-fatigued, suggesting that a dysregulation in these pathways is associated with chronic fatigue and that a B-cell-mediated inflammatory process might underlie fatigue. The chronic fatigued also had a higher level of leucocytes, lymphocytes and neutrophiles compared with the non-fatigued, thus further indicating that an activation of the immune system plays a role in the biology of chronic fatigue in breast cancer survivors.

Pain assessment tools in palliative care: an urgent need for consensus.

At present, there is no universally accepted cancer pain assessment tool for use in palliative care (PC). The European Palliative Care Research Collaborative (EPCRC), therefore, aims to develop an international consensus-based computerised pain assessment tool. As part of this process, we have performed (1) a literature review on pain assessment tools for use in the PC and (2) an international expert survey to gain information on the relevant dimensions for pain assessment in PC. 230 publications were identified, only six met the inclusion criteria. Three further articles were identified through manual searching, totalling 11 different pain assessment tools. Nine tools were multidimensional. Pain intensity was assessed in seven, using various numerical/verbal rating scales (NRS/VRS); five tools focused on pain management. Three publications did not identify the rationale for the need to develop a new tool, and the selection procedure for items/dimensions was not described in six tools. Patient and/or professional expert groups were involved in the development of five tools and only two tools were extensively validated or cross-culturally tested. Thirty-two experts (71%) completed the expert survey and identified 'intensity', 'temporal pattern', 'relief/exacerbation', 'pain quality' and 'location' as the five most relevant dimensions. Most preferred assessment of 'pain intensity' was by NRS rather than VRS. Time windows extending 24 h were regarded as less relevant. Development of PC pain assessment tools seems to be a continuous process, which does not adhere to systematic guidelines, thus does not contribute to a universally accepted tool. No tool contained all relevant dimensions as defined by the experts. Many tools focused on particular dimensions, suggesting that specific research interests may drive the tool development process. Extensive literature reviews, expert and patient input and clinical studies are a needed approach in the development of a new consensus-based pain assessment tool.

Prescriptions of analgesics during complete disease trajectories in patients who are diagnosed with and die from cancer within the five-year period 2005-2009.

BACKGROUND: Even though validation studies of the WHO analgesic ladder have indicated that the simple approach of the analgesic ladder can provide adequate pain control in most patients, prevalence studies have documented a high prevalence of pain in cancer patients. Little is known about how analgesics are actually prescribed for cancer pain. The aim of the study was to study prescriptions of analgesics during the entire disease trajectory in patients dying from cancer within five years of diagnosis. METHODS: Complete national data from the Norwegian Cancer Registry, the Norwegian Prescription Database, the Cause of Death Registry and Statistics Norway were used to study prescriptions of analgesics in a complete study population of all patients dying from cancer within five years of diagnosis in Norway from 2005 to 2009. RESULTS: Of a total of 10,977 subjects who received prescriptions for analgesics between diagnosis and death, 56% started analgesic treatment at step I of the analgesic ladder, 29% started at step II and 14% started at step III. Of the patients starting at step I, 28% continued to step II, 37% bypassed step II and moved directly to step III whereas the remaining 35% remained at step I. Approximately 60% received one or more dispensed prescription of a step III analgesic during the disease trajectory, whereas nearly 20% remained at step I and 20% at step II respectively. CONCLUSION: The study indicates that clinicians seem to individually tailor analgesic treatment instead of applying the stepwise approach in the WHO analgesic ladder. SIGNIFICANCE: Complete national data covering the complete disease trajectory in cancer patients dying within five years of diagnosis. The majority of patients do not receive treatment in concordance with the stepwise approach suggested by the WHO analgesic ladder.

Sequences of talk about emotional concerns in follow-up consultations with adolescent childhood cancer survivors.

OBJECTIVE: To explore practices regarding communication about emotional concerns in follow-up consultations with adolescent cancer survivors and pediatrician. METHOD: Seven video-taped follow-up consultations with adolescent survivors which contained many examples of emotional cues and concern were analyzed according to principles of conversation analysis. RESULTS: During talk about emotional concerns, a task-focused asymmetric pattern of pediatrician questions and patient responses was most often upheld. In a number of cases a gradual build-up of emotional expression from a weak hint to a more explicit expression of emotional concern was observed, often facilitated by the pediatricians. Most often work-up was relatively brief, sometimes with a brief positive reappraisal, but more comprehensive elaboration was also seen. Topic shifts were often abrupt. CONCLUSION: Pediatricians and patients used some of the same conventions as in everyday conversation during emotional talk in medical encounters. We observed shifts between informal talk and a typical task-focused mode. Conscious attention to such shifts and to the sequential nature of emotional talk could be helpful for doctors in designing their responses to patients' emotional concerns. PRACTICE IMPLICATIONS: Our findings may contribute to insight in how clinicians respond to emotional concerns in follow-up consultations and have implications for communication skills training.

Hodgkin's disease survivors more fatigued than the general population.

PURPOSE: To estimate the level of fatigue and frequency of fatigue cases among Hodgkin's disease survivors (HDS) and compare them with normative data from the general population. PATIENTS AND METHODS: A cross-sectional follow-up study was done of 557 HDS (age range, 19 to 74 years) treated at the Norwegian Radium Hospital from 1971 to 1991. The sample was approached by mail, and their data were compared with normative data from 2,214 controls (age range, 19 to 74 years) representative of the general Norwegian population. Of the 557 HDS, 459 (82%) responded. The mean age (+/- SD) at the time of study was 44+/-12 years, and the mean observation time was 12+/-6 years. The Fatigue Questionnaire (11 items) measures physical and mental fatigue. Two systems of scoring were used, dichotomized (0, 0, 1, and 1) and Likert (0, 1, 2, and 3). Total fatigue (TF) constitutes the sum of all the Likert scores. Caseness was defined as a total dichotomized score of > or =4 and fatigue that lasted 6 months or longer. RESULTS: The HDS had significantly higher levels of TF than the controls (14.3 v 12.2) (P < .001). Fatigue among the HDS equaled that of the controls in poorest health. More HDS (61%) than controls (31%) reported fatigue symptoms lasting 6 months or longer (P < .001). Fatigue cases were more frequent among HDS (men, 24%; women, 27%) than among the controls (men, 9%; women, 12%) (P < .001). Disease stage/substage IB/IIB predicted fatigue caseness (P = .03). No significant associations were found between treatment characteristics and fatigue. CONCLUSION: Hodgkin's disease survivors are considerably more fatigued than the general population and report fatigue of a substantially longer duration.

Quality of life in palliative cancer care: results from a cluster randomized trial.

PURPOSE: To assess the impact of comprehensive palliative care on patients' quality of life. The intervention was based on cooperation between a palliative medicine unit and the community service and was compared with conventional care. PATIENTS AND METHODS: A cluster randomized trial was carried out, with community health care districts defined as the clusters. Patients from these districts who had malignant disease and survival expectancy between 2 to 9 months were entered onto the trial. The main quality-of-life end points were physical and emotional functioning, pain, and psychologic distress assessed monthly by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) questionnaire and Impact of Event scale (IES). In total, 235 intervention patients and 199 controls were included. RESULTS: During the initial 4 months of follow-up, the compliance was good (72%) and comparable among treatment groups. No significant differences on any of the quality-of-life scores were found. At later assessments and for scores that were made within 3 months before death, there was also no consistent tendency in favor of any treatment group on the main outcomes or other EORTC QLQ-C30 scales/items. CONCLUSION: A general program of palliative care may be important to ensure flexibility and to meet the needs of terminally ill patients. However, to achieve improvements on a group level of the various dimensions of quality of life, specific interventions directed toward specific symptoms or problems may have to be defined, evaluated, and included in the program.

Depression in advanced cancer--assessment challenges and associations with disease load.

BACKGROUND: Patients with advanced cancer commonly experience multiple somatic symptoms and declining functioning. Some highly prevalent symptoms also overlap with diagnostic symptom-criteria of depression. Thus, assessing depression in these patients can be challenging. We therefore investigated 1) the effect of different scoring-methods of depressive symptoms on detecting depression, and 2) the relationship between disease load and depression amongst patients with advanced cancer. METHODS: The sample included 969 patients in the European Palliative Care Research Collaborative-Computer Symptom Assessment Study (EPCRC-CSA). Inclusion criteria were: incurable metastatic/locally advanced cancer and ≥ 18 years. Biomarkers and length of survival were registered from patient-records. Depression was assessed using the Patient Health Questionnaire (PHQ-9) and applying three scoring-methods: inclusive (algorithm scoring including the somatic symptom-criteria), exclusive (algorithm scoring excluding the somatic symptom-criteria) and sum-score (sum of all symptoms with a cut-off ≥ 8). RESULTS: Depression prevalence rates varied according to scoring-method: inclusive 13.7%, exclusive 14.9% and sum-score 45.3%. Agreement between the algorithm scoring-methods was excellent (Kappa = 0.81), but low between the inclusive and sum scoring-methods (Kappa = 0.32). Depression was significantly associated with more pain (OR-range: 1.09-1.19, p < 0.001-0.04) and lower performance status (KPS-score, OR-range = 0.68-0.72, p < 0.001) irrespective of scoring-method. LIMITATIONS: Depression was assessed using self-report, not clinical interviews. CONCLUSIONS: The scoring-method, not excluding somatic symptoms, had the greatest effect on assessment outcomes. Increasing pain and poorer than expected physical condition should alert clinicians to possible co-morbid depression. The large discrepancy in prevalence rates between scoring-methods reinforces the need for consensus and validation of depression definitions and assessment in populations with high disease load.

Disclosing the cancer diagnosis: the patients' experiences.

497 Norwegian cancer patients (346 females, 151 males, mean age = 56 years (S.D. = 12)), admitted to a cancer rehabilitation centre, were surveyed on how they were told their diagnosis. Predictors of general satisfaction with the information were assessed. 43% of the subjects were informed by phone, letter or in the corridor/on the round and estimated that the information was presented in less than 5 minutes. Satisfaction with the information was predicted by perceiving the physicians as personally interested (B = 0.528, P < 0.001), comprehending the information (B = 0.245, P < 0.001), being informed in the physicians' offices (B = 0.338, P < 0.001), being informed by physicians at oncological departments (B = 0.278, P = 0.01) and increasing time spent on the disclosure (B = 0.140, P = 0.01). Other aspects of physician-patient communication than the pure presentation of valid information is highly valued by the patients. However, a substantial proportion of physicians present the cancer diagnosis in such a manner that the possibility of engaging in conversation about the diagnosis and the effect upon the patient is very limited. The findings call for remedial attention to the subject and improvement in performance.

Attitudes toward informing the cancer patient--a survey of Norwegian physicians.

To examine Norwegian physicians' attitudes to informing patients of a diagnosis of cancer, a random sample of 1467 were surveyed. The respondents rated their level of agreement to 14 statements, and the responses were analysed by chi-squared statistics. 990 physicians responded (67%). Only 30.5% of the responding physicians had treated more than 10 cancer patients the previous year, which included 7.8% who had treated more than 50. 40.4% had treated none. The great majority (81%) preferred full information of the diagnosis. Physicians with increasing age preferred relatives not being present and gave priority to factual information and informing patients with the same diagnosis identically. Hospital physicians (39.5%) more often preferred other health professionals being present than physicians in private practice (18%) (P < 0.001). Number of cancer patients treated was not associated with attitudes toward the disclosure of information. Norwegian physicians prefer revealing the cancer diagnosis to patients, but have divergent opinions about how to do so. Some of these indicate suboptimal information-giving.

Exercise reduces fatigue in chronic fatigued Hodgkins disease survivors--results from a pilot study.

The aims of this pilot study were to compare aerobic capacity in non-fatigued and fatigued Hodgkin's disease survivors (HDS) and to assess the feasibility of an exercise-programme and its effects upon fatigue, physical functioning and aerobic capacity in chronic fatigued HDS. 53 HDS (85%) of originally 62 survivors treated at the Trondheim University Hospital in the period 1987-1997 completed a questionnaire including the Fatigue Questionnaire (FQ). 18 subjects were identified with chronic fatigue. 15 non-fatigued HDS matched for gender and age were drawn as controls. Both groups were invited to medical examination and exercise tests. All 15 fifteen non-fatigued HDS showed up to the medical examination. 12 of the 18 patients with chronic fatigue completed the tests and nine agreed to enter a home-based exercise intervention. Outcome measures were aerobic capacity, fatigue and physical functioning. No significant difference in aerobic capacity was found between the chronic fatigued HDS and the controls. Fatigue, physical functioning and maximal aerobic capacity were significantly improved after the intervention. Aerobic exercise had a positive effect upon chronic fatigue in HDS. However, the study is a pilot study and needs confirmation in a larger group of subjects. The intervention was well accepted, and the majority of the patients adhered to the programme.

Physical exercise results in the improved subjective well-being of a few or is effective rehabilitation for all cancer patients?

Physical exercise as an intervention in cancer patients has attracted increasing interest. This review examines the published randomised controlled trials on physical exercise, during and after cancer treatment, focusing primarily on recruitment of patients, patient compliance, content of the intervention programmes and outcome measures. We performed systematic searches of PubMed, PsychInfo, Cancerlit and the Cochrane Library using the MESH terms exercise, neoplasms, cancer, rehabilitation and intervention. We identified 12 randomised trials with sample sizes ranging from 21 to 155 patients. Only four studies reported the number of patients assessed for eligibility and the reasons for exclusion; 15% to 30% of patients assessed for eligibility were randomised into the intervention programmes. Drop-out rates in the trials ranged from 0% to 34%. Most studies included female breast cancer patients (nine studies, 62% of total number of patients). Interventions included aerobic exercise training (10 studies) and resistance exercise (two studies). The studies used a wide range of instruments to assess health-related quality of life (HRQOL) and the physical exercise capacity. The studies indicated promising effects on both physiological and psychological outcomes. Randomised clinical studies are few, small in scope, and mainly focus on breast cancer patients. Complete knowledge about the type of physical exercise most beneficial for patients at different stages of the disease progression is still lacking. Future work should identify fewer and more specific endpoints.

Socio-medical situation for long-term survivors of Hodgkin's disease: a survey of 459 patients treated at one institution.

We present the socio-medical situation for 459 adult disease-free long-term survivors of Hodgkin's disease (HD) 3-23 years after first line curative treatment. In 1994, 557 patients were sent a self-report questionnaire relating to their social status and 459 patients (82%) replied. Educational or professional plans were changed due to HD in 142 patients (32%). After 6, 12 and 18 months from start of treatment, 52, 82 and 95% of the patients, respectively, had returned to their job or education. The sum of full-time and part-time employment was in men 78% at diagnosis and 85% at follow-up, and in women 57% at diagnosis and 64% at follow-up. Only 2% of men and 3% of women did not have a job at follow-up in 1994. At diagnosis 2% of the patients were permanently disabled versus 19% at follow-up in 1994. Age > 40 years at diagnosis, increased the total score of psychological distress and fatigue and long-term disablement after first line treatment were predictors for permanent disablement. Transient or permanent sexual problems were reported in 16% and 13%, respectively. MVPP (mustine, vinblastine, procarbazine and prednisone) or LVPP (chlorambucil, vinblastine, procarbazine and prednisone) chemotherapy was responsible for most cases of early menopause in women older than 30 years, and of infertility in both men and women. In summary, most long-term HD survivors had adapted well to their socio-medical situation except a high number of permanently disabled patients. By focusing more on factors predisposing for permanent disablement and early treatment for these, more patients may be helped to return to their job.

Translation and performance of the Norwegian SF-36 Health Survey in patients with rheumatoid arthritis. I. Data quality, scaling assumptions, reliability, and construct validity.

The SF-36 was translated into Norwegian following the procedures developed by the International Quality of Life Assessment (IQOLA) Project. To test for the appropriateness of the Norwegian Version 1.1 of the SF-36 in patients with rheumatoid arthritis (RA), 1552 RA patients were mailed the form. Psychometric methods used in previous U.S. and Swedish studies were replicated. The response rate was 66%. The sample (mean age 62 years, mean disease duration 13 years) was over-represented by females (79%). Totally, 74% of the questionnaires were complete. Missing value rates per item ranged from 0.4% to 9.0% (mean 4.2%). In the Role-Emotional scale, all three items had missing value rates above average and higher than reported in the U.S. and Swedish studies. Tests of scaling assumptions confirmed the hypothesized structure of the questionnaire, but results were suboptimal in the General Health scale. In all scales the Cronbach's alphas exceeded the 0.70 standard for group comparisons. In the Physical Functioning scale, Cronbach's alpha exceeded the 0.90 standard for individual comparisons. There was good evidence for the construct validity of the questionnaire. Generally, the Norwegian SF-36 version 1.1 distributed to RA patients held the psychometric properties found in other countries and in normal populations. The translations of items in the General Health and Role-Emotional scales were reassessed. Minor deficiencies were detected and changed (SF-36 Norwegian Version 1.2).

A prospective study of health-related quality of life, fatigue, anxiety and depression 3-5 years after stem cell transplantation.

Health-related quality of life (HRQOL), fatigue and psychological distress were prospectively assessed in 248 cancer patients treated with allogeneic (SCT, N=61), or autologous (ASCT, N=69) stem cell transplantation or conventional chemotherapy (CT, N=118) of whom 128 completed the assessments after 3 years. The European Organization for Treatment and Research of Cancer Core Quality of Life Questionnaire and the Hospital Anxiety and Depression Scale were administered nine (SCT/ASCT groups) or seven times (CT group) during the first year. The Fatigue Questionnaire was added at the final assessment. The SCT group displayed greater changes from baseline scores than the ASCT group, with more symptoms in the first months post transplant. A gradual improvement was found in both groups during the following 4-6 months, before stabilizing at baseline levels. Only minor changes were observed after the first year. All groups reported more fatigue than the population values after 3 years (P<0.01). The ASCT group also reported less optimal HRQOL (P<0.01-0.0001). No differences were found in anxiety and depression. Despite a faster recovery during the first months after transplant, the ASCT patients reported poorer functioning and more fatigue compared to the SCT group after 3 years. This suggests a need for a closer follow-up of these patients with special emphasis on functional status and fatigue.

The course of anxiety and depression during the first year after allogeneic or autologous stem cell transplantation.

Psychological distress is frequently reported in transplant survivors. We prospectively assessed anxiety and depression before transplant, in the isolation period and during a follow-up period of 1 year. The Hospital Anxiety and Depression Scale (HADS) was administered to 131 cancer patients treated with high-dose chemotherapy followed by allogeneic (SCT) or autologous (ASCT) stem cell transplantation, and a concurrent group of 123 lymphoma patients receiving standard chemotherapy (CT) who served as a reference group. Relatively low levels of anxiety and depression were found. The level of anxiety slightly declined from baseline during follow-up (mean scores SCT: from 5.3 to 3.6, CT: from 6.0 to 4.2) or remained fairly stable (ASCT: from 5.4 to 4.8). The level of depression peaked when the transplant patients were in protective isolation or shortly thereafter (SCT: 6.1, ASCT: 6.4), but stabilized at baseline levels after 4 months. The highest level of depression in the CT group was reported 4 months after start of chemotherapy (3.4). Elevated levels of anxiety and depression at baseline predicted more anxiety and depression at the later assessments (P values < 0.0001). The ASCT group had higher levels of anxiety after 1 year (mean 4.8) than those found in the other two groups (SCT: 3.6, CT: 4.2), although they were not statistically significant. This study revealed lower than expected levels of anxiety and depression after intensive chemotherapy followed by SCT or ASCT. There was a decline in psychological distress during the 1-year follow-up period.

Fatigue and psychiatric morbidity among Hodgkin's disease survivors.

Fatigue is prevalent among cancer patients, including Hodgkin's disease survivors (HDS). Fatigue is poorly understood, and the clinical management is consequently difficult. This cross-sectional study examined how fatigue related to psychiatric morbidity among 457 HDS (aged 19-74 years, 56% males) treated during the period 1971-1991. The subjects were mailed a questionnaire including the Fatigue Questionnaire, the Hospital Anxiety and Depression Scale, and measures of previous psychiatric problems. Fatigue correlated moderately with anxiety and depression (r = 0.44 and 0.41 respectively). Twenty-six percent of the HDS had substantial fatigue for 6 months or longer (=cases). They had higher levels of anxiety (mean 7.3, 95% CI 6.4-8.1) and depression (mean 4.5, 95% CI 3.8-5.2) than the non-cases (anxiety: mean 4.3, 95% CI 3.9-4.7; depression: mean 2.1, 95% CI 1.8-2.5). Past psychiatric problems were not reported more commonly among the fatigue cases than among the non-cases. A multiple logistic regression analysis identified age (OR 1.04, 95% CI 1.02-1.06), anxiety (OR 1.2, 95% CI 1.2-1.3), and no self-reported psychiatric symptoms during treatment (OR 2.3, 95% CI 1.3-4.2) as predictors of fatigue caseness. One-half of the fatigue cases among HDS have psychological distress that might respond to treatment. Chronic fatigue among HDS is not predicted by previous psychiatric problems.