Positive changes, increased spiritual importance, and complementary and alternative medicine (CAM) use among cancer survivors.

PURPOSE: Spirituality is an important component of the cancer experience. This study aims to assess characteristics of spiritual health following a cancer diagnosis, and evaluate the relationship between spiritual change and the use of complementary and alternative medicine (CAM) among a population-based cohort of cancer survivors. METHOD: A mailed, cross-sectional survey was completed by 614 cancer survivors identified through the Pennsylvania Cancer Registry. All subjects were 3 to 4.5 years postdiagnosis. Relationships between various characteristics of spiritual health and CAM use were examined, along with clinical and sociodemographic factors. RESULTS: Although large proportions of individuals reported that having cancer had positively affected their spiritual well-being (eg, 40.3% experienced highly positive spiritual changes, 68% felt a high sense of purpose, 75.9% reported being very hopeful), some individuals experienced negative spiritual change (36.1%) and continued to experience high levels of uncertainty (27.2%). In multivariate analyses, those survivors who felt spiritual life became more important (adjusted odds ratio [AOR] = 1.92, 95% confidence interval (CI) = 1.21-3.04, P = .006), or experienced positive changes resulting from the cancer experience (AOR = 1.99, 95% CI = 1.26-3.15, P = .003), were more likely to use CAM than those who stated otherwise. CONCLUSIONS: Having cancer affects many different aspects of spiritual well-being, both positively and negatively. Positive changes and increased spiritual importance appear to be associated with the use of CAM. Prospective research is needed to test whether integrating CAM into conventional cancer care systems will facilitate positive, spiritually transformative processes among diverse groups of cancer survivors.

Advance care planning and hospice enrollment: who really makes the decision to enroll?

PURPOSE: The purpose of this study was to assess patient participation in advance care planning (ACP) and the decision to enroll in hospice. METHODS: One hundred sixty-five family members of patients who died in hospice between January 2004 and September 2004 returned an anonymous survey (165/380; 43% response rate). RESULTS: Forty-nine percent of family members reported that the patient was not involved in the hospice enrollment decision. The majority of respondents (78%) reported one or more people helped make the decision to enroll in hospice. For patients reported as being involved in the decision to enroll in hospice (either independently or in a shared capacity) they were more likely to have cancer (odds ratio [OR] = 2.3, p = 0.02), die at home (OR = 3.3, p = 0.006), have a length of stay in hospice greater than 7 days (OR = 2.1, p = 0.03), and less likely to have dementia (OR = 0.43, p = 0.001). White respondents were more likely to report having ACP discussions with the patient about: feeding tubes (OR = 4.7; p = 0.001), cardiopulmonary resuscitation (CPR; OR = 3.9; p = 0.002), or mechanical ventilation (OR = 2.7; p = 0.02) than non-white respondents. White respondents were more likely than non-white respondents to report that the patient had a written advance directive (OR = 4.2, p = 0.001). DISCUSSION: These data indicate that some patients are not actively involved in the decision to enroll in hospice and that others, often physicians and family members, are making these decisions for the patient collaboratively. These data support the need for early education and interventions that assist patients and families in discussing ACP preferences and the need for greater understanding of how involved patients want to be with the decision to enroll in hospice.

Methodology and outcomes of a family medicine research fellowship.

There has not been a strong tradition of training researchers to provide the great amount of new evidence needed for the practice of family medicine. Few models for creating successful family medicine researchers have been presented in the literature. The authors report on the methodology and outcomes of a faculty development research fellowship in the University of Pennsylvania's Department of Family Medicine and Community Health. The fellowship focuses on the two domains-intensive research training and academic career development-and frames them with coursework in a content-appropriate master's degree program and clinical practice in an underserved community. Fifteen fellows have completed the program, which began in 1997. Most fellows' research work has been related to primary care and health disparities. Program completers have been the principal investigators on 39 funded studies and coinvestigators on 24 funded studies. They have, at the time this article was written, described their work in 236 publications, 114 of them peer reviewed. All but one program completer hold academic faculty positions, and 12 practice in underserved areas. In a research-intense institution, the fellowship program successfully trained family physicians to be independent clinical researchers and leaders who have substantially contributed to the national effort to mitigate health disparities through practice and research. The authors suggest that the outcomes strongly support the development of similar training opportunities in family medicine departments in other resource- and research-rich institutions.

Cancer survivors with unmet needs were more likely to use complementary and alternative medicine.

PURPOSE: Despite advancements in cancer care, cancer survivors continue to experience a substantial level of physical and emotional unmet needs (UMN). This study aims to determine the relationship between patients' perceived UMN and their use of complementary and alternative medicine (CAM) to help with cancer problems during and after treatment. METHODS: A mailed, cross-sectional survey was completed by 614 cancer survivors identified through the Pennsylvania Cancer Registry 3.5 to 4 years from initial diagnosis. Relationships among UMN and CAM use along with clinical and socio-demographic factors were examined. RESULTS: Respondents who identified any UMN were 63% more likely to report CAM use than those without UMN (58% vs. 36%), p < 0.001. UMN remained the only independent predictor (adjusted odds ratio = 2.30, 95% confidence interval = 1.57-3.36, p < 0.001) of CAM use in a multivariate logistic regression model that included age, sex, marital status, education, previous chemotherapy and radiotherapy. Adjusted for covariates, UMN in domains of emotional, physical, nutritional, financial, informational, treatment-related, employment-related, and daily living activities were all related to CAM use, whereas UMN in transportation, home care, medical staff, family and spirituality were not related to CAM use. Patients who experienced multiple types of unmet needs were also more likely to use multiple types of CAM (p < 0.001 for model). CONCLUSIONS: Cancer survivors who experienced unmet needs within the existing cancer treatment and support system were more likely to use CAM to help with cancer problems. Research is needed to determine if appropriate CAM use decreases unmet needs among cancer survivors.

Unmet psychosocial needs of Pennsylvanians with cancer: 1986-2005.

BACKGROUND: The purpose of the current study was to identify unmet psychosocial needs of cancer survivors, understand the distribution of needs across subgroups, and compare unmet needs in 2005 with those identified by Houts et al. in 1986. METHODS: Using a sequential mixed methods design, qualitative interviews were conducted with 32 cancer survivors or family members to identify the psychosocial needs of people from the time of cancer diagnosis through survivorship. These data were used to modify a needs assessment that was mailed to a stratified random sample of survivors obtained from the Pennsylvania Cancer Registry. RESULTS: A total of 614 survivors returned usable questionnaires. Nearly two-thirds of respondents reported experiencing at least 1 unmet psychosocial need, particularly emotional, physical, and treatment-related needs. It is likely that unmet needs in insurance, employment, information, and home care increased during the 20-year interval between surveys. Demographics associated with increased unmet need included later stage of disease at the time of diagnosis, younger age, more comorbidities, and lower income. CONCLUSIONS: Unmet psychosocial need remains high despite 20 years of effort to address psychosocial issues. This may be due to a mismatch between needs and services. Unmet need may be related to access issues, a lack of awareness of resources, "new" needs that have arisen in a changing healthcare climate, and patient preferences for types of service. Cancer treatment staff should be especially alert for psychosocial problems in younger individuals with an additional illness burden.

Patient characteristics associated with participation in a practice-based study of depression in late life: the Spectrum study.

OBJECTIVE: An important component of generalizing study results to patients is the extent to which study participants adequately represent individuals targeted for the study. The Spectrum study of depression in older primary care patients was utilized to consider patient characteristics associated with nonparticipation. METHOD: Interviewers utilized a validated questionnaire to screen adults aged 65 years and older for depression who presented to one of the participating primary care practices in the Baltimore, Maryland area. Screening interviews included information about sociodemographic factors, functioning, health, and attitudes about depression and its treatment in order to compare participants with persons who declined. RESULTS: In all, 2,560 adults aged 65 years and older were screened. Comparison of the characteristics of the patients who were eligible for the study (n = 773) with patients who participated fully in the in-home evaluation (n = 355) found that the study sample included proportionately more persons who: 1) were less than 80 years old; 2) completed high school; and 3) reported two or more visits to the practice site within six months of the interview. Among patients who were depressed, no significant differences were found in the characteristics of those who met study eligibility criteria and those who agreed to participate. CONCLUSIONS: Persons over the age of 80 years of age or those with less than a high school education may require tailored strategies for recruitment even when approached by a trained interviewer in a primary care doctor's office.

Physical functioning, depression, and preferences for treatment at the end of life: the Johns Hopkins Precursors Study.

OBJECTIVES: To examine the relationship between worsening physical function and depression and preferences for life-sustaining treatment. DESIGN: Mailed survey of older physicians. SETTING: Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University. PARTICIPANTS: Physicians who completed the life-sustaining treatment questionnaire in 1998 and provided information about health status in 1992 and 1998 (n=645, 83% of respondents to the 1998 questionnaire; mean age 68). MEASUREMENTS: Preferences for life-sustaining treatment, assessed using a checklist questionnaire in response to a standard vignette. RESULTS: Of 645 physicians, 11% experienced clinically significant decline in physical functioning, and 18% experienced worsening depression over the 6-year period. Physicians with clinically significant functional decline were more likely (adjusted odds ratio (AOR)=2.14, 95% confidence interval (CI)=1.18-3.88) to prefer high-burden life-sustaining treatment. Worsening depression substantially modified the association between declining functioning and treatment preferences. Physicians with declining functioning and worsening depression were more likely (AOR=5.33, 95% CI=1.60-17.8) to prefer high-burden treatment than respondents without declining function or worsening depression. CONCLUSION: This study calls attention to the need for clinical reassessment of preferences for potentially life-sustaining treatment when health has declined to prevent underestimating the preferences of older patients.

The role of physicians in assessing older drivers: barriers, opportunities, and strategies.

BACKGROUND: Evaluation of the older driver is a difficult task for primary care physicians. We investigated the physician-perceived barriers to assessing older drivers in primary care practice. METHODS: Twenty family physicians whose patients had completed a clinical questionnaire and neuropsychological tests participated in one of 2 focus groups. Physicians were asked about barriers to assessing older drivers in primary care and the usefulness of neuropsychological tests for assessing driving ability. RESULTS: A number of themes emerged related to barriers in the assessment of the older driver. Major themes included concerns about being liable for the results of driving related screening and about patients reacting unfavorably to a driving assessment including cognitive tests. Physicians uniformly agreed that a protocol to guide driving assessment would be useful. CONCLUSIONS: Physicians encounter a number of barriers to assessing older drivers but recognize the importance of driving within the context of geriatric functional assessment.

Computer-assisted assessment of depression and function in older primary care patients.

We wanted to test the psychometric reliability and validity of self-reported information on psychological and functional status gathered by computer in a sample of primary care outpatients. Persons aged 65 years and older visiting a primary care medical practice in Baltimore (n=240) were approached. Complete baseline data were obtained for 54 patients and 34 patients completed 1-week retest follow-up. Standard instruments were administered by computer and also given as paper and pencil tests. Test-retest reliability estimates were calculated and comparisons across mode of administration were made. Separately, an interviewer administered a questionnaire to gauge patient attitudes and feelings after using the computer. Most participants (72%) reported no previous computer use. Nevertheless, inter-method reliability of the GDS15 at baseline (0.719, n=47), intra-method reliability of the computer in time (0.797, n=31), inter-method reliability of the CESDR20 at baseline (0.740, n=53), and the correlation between the CESDR20 computer version at baseline and follow-up (0.849, n=34) were all excellent. The inter-method reliability of the CESDR20 at follow-up (0.615, n=37) was lower but still acceptable. Although 28% were anxious prior to using the computer testing system, that percent decreased to 19% while using the system. The efficiency and reliability in comparison to the paper instruments were good or better. Even though most participants had not ever used a computer prior to participating in the study, they had generally favorable attitudes toward the use of computers, and also reported having favorable experience with the computer testing system.

Personal characteristics of older primary care patients who provide a buccal swab for apolipoprotein E testing and banking of genetic material: the spectrum study.

OBJECTIVE: To determine the personal characteristics and reasons associated with providing a buccal swab for apolipoprotein E (APOE) genetic testing in a primary care study. METHODS: The study sample consisted of 342 adults aged 65 years and older recruited from primary care settings. RESULTS: In all, 88% of patients agreed to provide a DNA sample for APOE genotyping and 78% of persons providing a sample agreed to banking of the DNA. Persons aged 80 years and older and African-Americans were less likely to participate in APOE genotyping. Concern about confidentiality was the most common reason for not wanting to provide a DNA sample or to have DNA banked. CONCLUSION: We found stronger relationships between sociodemographic variables of age and ethnicity with participation in genetic testing than we did between level of educational attainment, gender, function, cognition, and affect.

Life-sustaining treatments: what do physicians want and do they express their wishes to others?

OBJECTIVES: To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life-sustaining treatment they wish in the event of incapacity to make these decisions for themselves. DESIGN: Mailed survey to a cohort of physicians. SETTING: Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964. PARTICIPANTS: Physicians who completed the advance directive questionnaire (mean age 68). MEASUREMENTS: Questionnaires were sent out to known surviving physicians of the Precursors Study, an on-going study that began in 1946, asking physicians about their preferences for life-sustaining treatments. RESULTS: Of 999 physicians who were sent the survey, 765 (77%) responded. Forty-six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty-four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49-4.69) or family members (OR = 9.58, 95% CI = 5.33-17.23) were aware of their preferences for end-of-life care and were more likely to refuse treatments than those without advance directives. CONCLUSION: This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians.

Self-examination does not reduce breast cancer mortality.

Breast self-examination does not decrease breast cancer mortality, according to the results of this randomized controlled trial of 266,000 women who were given intensive instruction in breast self-examination. These findings correspond with the US Preventive Services Task Force policy not to recommend breast self-examination for the reduction of breast cancer mortality.