Self-reported distress and problems after treatment for gynecological cancer - Correlation between a short screening tool and longer measures of anxiety/depression and health-related quality of life.

INTRODUCTION: The National Comprehensive Cancer Network (NCCN) distress thermometer and problem list (DTPL) is a brief self-report screening measure for use in follow-up cancer care. The aims of this study were to explore the correlations between scores on the DTPL and scores on longer measures of anxiety/depression and health-related quality of life among women treated for gynecological cancer, and to define a cutoff score on the DT representing high levels of psychological distress in this patient group. MATERIAL AND METHODS: During outpatient visits, 144 women filled in the DTPL, the Hospital Anxiety and Depression Scale (HADS) and the RAND-36-Item Short Form Health Survey (RAND-36) between October 2019 and March 2020. We assessed the agreement between the DT-scores and the HADS scores, explored variables associated with high levels of distress on the DT, and studied the associations between DTPL-scores and scores of health-related quality of life (HRQoL) from RAND-36. RESULTS: In receiver operating characteristic curve analysis between the distress score from the DT and a HADS total score ≥15 (defining high levels of anxiety/depression symptoms), the area under the curve was 0.81 (95% CI: 0.74-0.89). Using a cutoff of ≥5 on the DT (scale 0-10), we found a balanced level of sensitivity (81%) and specificity (71%) towards a HADS total score of ≥15. The scores of distress and problems reported on the DTPL correlated significantly with the majority of HRQoL function scales from RAND-36. CONCLUSIONS: The NCCN DTPL can be used as a screening measure for self-reported distress and problems after treatment for gynecological cancer. A score of ≥5 on DT may indicate high level of anxiety/depression as measured by HADS. The tool may help identify patients in need of referral to supportive care and rehabilitation facilities.

Associations of the 2018 World Cancer Research Fund/American Institute of Cancer Research (WCRF/AICR) cancer prevention recommendations with stages of colorectal carcinogenesis.

BACKGROUND: While adherence to cancer prevention recommendations is linked to lower risk of colorectal cancer (CRC), few have studied associations across the entire spectrum of colorectal carcinogenesis. Here, we studied the relationship of the standardized 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Score for cancer prevention recommendations with detection of colorectal lesions in a screening setting. As a secondary objective, we examined to what extent the recommendations were being followed in an external cohort of CRC patients. METHODS: Adherence to the seven-point 2018 WCRF/AICR Score was measured in screening participants receiving a positive fecal immunochemical test and in CRC patients participating in an intervention study. Dietary intake, body fatness and physical activity were assessed using self-administered questionnaires. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for screen-detected lesions. RESULTS: Of 1486 screening participants, 548 were free from adenomas, 524 had non-advanced adenomas, 349 had advanced lesions and 65 had CRC. Adherence to the 2018 WCRF/AICR Score was inversely associated with advanced lesions; OR 0.82 (95% CI 0.71, 0.94) per score point, but not with CRC. Of the seven individual components included in the score, alcohol, and BMI seemed to be the most influential. Of the 430 CRC patients included in the external cohort, the greatest potential for lifestyle improvement was seen for the recommendations concerning alcohol and red and processed meat, where 10% and 2% fully adhered, respectively. CONCLUSIONS: Adherence to the 2018 WCRF/AICR Score was associated with lower probability of screen-detected advanced precancerous lesions, but not CRC. Although some components of the score seemed to be more influential than others (i.e., alcohol and BMI), taking a holistic approach to cancer prevention is likely the best way to prevent the occurrence of precancerous colorectal lesions.

Practicing Integrated Care Pathways in Norwegian Hospitals: Coordination through Industrialized Standardization, Value Chains, and Quality Management or an Organizational Equivalent to Improvised Jazz Standards.

The goal of coordinating pathways for cancer patients through their diagnostic and treatment journey is often approached by borrowing strategies from traditional industries, including standardization, process redesign, and variation reduction. However, the usefulness of these strategies is sometimes limited in the face of the complexity and uncertainty that characterize these processes over time and the situation at both patient and institutional levels. We found this to be the case when we did an in-depth qualitative study of coordination processes in patient pathways for three diagnoses in four Norwegian hospitals. What allows these hospitals to accomplish coordination is supplementing standardization with improvisation. This improvisation is embedded in four types of emerging semi-formal structures: collegial communities, networks, boundary spanners, and physical proximity. The hierarchical higher administrative levels appear to have a limited ability to manage and support coordination of these emerging structures when needed. We claim that this can be explained by viewing line management as representative of an economic-administrative institutional logic while these emerging structures represent a medical-professional logic that privileges proximity to the variation and complexity in the situations. The challenge is then to find a way for emergent and formal structures to coexist.

Tomato-based randomized controlled trial in prostate cancer patients: Effect on PSA.

BACKGROUND & AIMS: The effect of lycopene-containing foods in prostate cancer development remains undetermined. We tested whether a lycopene-rich tomato intervention could reduce the levels of prostate specific antigen (PSA) in prostate cancer patients. METHODS: Prior to their curative treatment, 79 patients with prostate cancer were randomized to a nutritional intervention with either 1) tomato products containing 30 mg lycopene per day; 2) tomato products plus selenium, omega-3 fatty acids, soy isoflavones, grape/pomegranate juice, and green/black tea (tomato-plus); or 3) control diet for 3 weeks. RESULTS: The main analysis, which included patients in all risk categories, did not reveal differences in changes of PSA-values between the intervention and control groups. Post-hoc, exploratory analyses within intermediate risk (n = 41) patients based on tumor classification and Gleason score post-surgery, revealed that median PSA decreased significantly in the tomato group as compared to controls (-2.9% and +6.5% respectively, p = 0.016). In separate post-hoc analyses, we observed that median PSA-values decreased by 1% in patients with the highest increases in plasma lycopene, selenium and C20:5 n-3 fatty acid, compared to an 8.5% increase in the patients with the lowest increase in lycopene, selenium and C20:5 n-3 fatty acid (p = 0.003). Also, PSA decreased in patients with the highest increase in lycopene alone (p = 0.009). CONCLUSIONS: Three week nutritional interventions with tomato-products alone or in combination with selenium and n-3 fatty acids lower PSA in patients with non-metastatic prostate cancer. Our observation suggests that the effect may depend on both aggressiveness of the disease and the blood levels of lycopene, selenium and omega-3 fatty acids.

Total antioxidant intake and prostate cancer in the Cancer of the Prostate in Sweden (CAPS) study. A case control study.

BACKGROUND: The total intake of dietary antioxidants may reduce prostate cancer risk but available data are sparse and the possible role of supplements unclear. We investigated the potential association between total and dietary antioxidant intake and prostate cancer in a Swedish population. METHODS: We used FFQ data from 1499 cases and 1112 controls in the population based case-control study Cancer of the Prostate in Sweden (CAPS). The ferric reducing antioxidant potential (FRAP) assay was used to assess the total antioxidant capacity (TAC) of diet and supplements. We calculated odds ratios (ORs) for the risk of prostate cancer across quintiles of antioxidant intake from all foods, from fruit and vegetables only, and from dietary supplements using unconditional logistic regression. RESULTS: Coffee comprised 62 % of the dietary antioxidant intake, tea 4 %, berries 4 %, chocolate 2 %, and boiled potatoes 2 %. In total 19 % and 13 % of the population took multivitamins and supplemental Vitamin C respectively, on a regular basis. Antioxidant intake from all foods and from fruits and vegetables separately measured by the FRAP assay was not associated with prostate cancer risk. For antioxidant intake from supplements we found a positive association with total, advanced, localized, high grade and low grade prostate cancer in those above median supplemental TAC intake of users compared to non-users (Adjusted ORs for total prostate cancer: 1.37, 95 % CI 1.08-1.73, advanced: 1.51, 95 % CI 1.11-2.06, localized: 1.36. 95 % CI 1.06-1.76, high grade 1.60, 95 % CI 1.06-2.40, low grade 1.36, 95 % CI 1.03-1.81). A high intake of coffee (≥6 cups/day) was associated with a possible risk reduction of fatal and significantly with reduced risk for high grade prostate cancer, adjusted OR: 0.45 (95 % CI: 0.22-0.90), whereas a high intake of chocolate was positively associated with risk of total, advanced, localized and low grade disease (adjusted OR for total: 1.43, 95 % CI 1.12-1.82, advanced: 1.40, 95 % CI 1.01-1.96, localized: 1.43, 95 % CI 1.08-1.88, low-grade: 1.41, 95 % CI 1.03-1.93). CONCLUSIONS: Total antioxidant intake from diet was not associated with prostate cancer risk. Supplement use may be associated with greater risk of disease.

Total antioxidant intake in relation to prostate cancer incidence in the Health Professionals Follow-Up Study.

Epidemiologic evidence on the association of antioxidant intake and prostate cancer incidence is inconsistent. Total antioxidant intake and prostate cancer incidence have not previously been examined. Using the ferric-reducing antioxidant potential (FRAP) assay, the total antioxidant content (TAC) of diet and supplements was assessed in relation to prostate cancer incidence. A prospective cohort of 47,896 men aged 40-75 years was followed from 1986 to 2008 for prostate cancer incidence (N = 5,656), and they completed food frequency questionnaires (FFQs) every 4 years. A FRAP value was assigned to each item in the FFQ, and for each individual, TAC scores for diet, supplements and both (total) were calculated. Major contributors of TAC intake at baseline were coffee (28%), fruit and vegetables (23%) and dietary supplements (23%). In multivariate analyses for dietary TAC a weak inverse association was observed [highest versus lowest quintiles: 0.91 (0.83-1.00, p-trend = 0.03) for total prostate cancer and 0.81 (0.64-1.01, p-trend = 0.04) for advanced prostate cancer]; this association was mainly due to coffee. No association of total TAC on prostate cancer incidence was observed. A positive association with lethal and advanced prostate cancers was observed in the highest quintile of supplemental TAC intake: 1.28 (0.98-1.65, p-trend < 0.01) and 1.15 (0.92-1.43, p-trend = 0.04). The weak association between dietary antioxidant intake and reduced prostate cancer incidence may be related to specific antioxidants in coffee, to nonantioxidant coffee compounds or other effects of drinking coffee. The indication of increased risk for lethal and advanced prostate cancers with high TAC intake from supplements warrants further investigation.

Cancer risk with folic acid supplements: a systematic review and meta-analysis.

Objective To explore if there is an increased cancer risk associated with folic acid supplements given orally. Design Systematic review and meta-analysis of controlled studies of folic acid supplementation in humans reporting cancer incidence and/or cancer mortality. Studies on folic acid fortification of foods were not included. Data sources Cochrane Library, Medline, Embase and Centre of Reviews and Dissemination, clinical trial registries and hand-searching of key journals. Results From 4104 potential references, 19 studies contributed data to our meta-analyses, including 12 randomised controlled trials (RCTs). Meta-analysis of the 10 RCTs reporting overall cancer incidence (N=38 233) gave an RR of developing cancer in patients randomised to folic acid supplements of 1.07 (95% CI 1.00 to 1.14) compared to controls. Overall cancer incidence was not reported in the seven observational studies. Meta-analyses of six RCTs reporting prostate cancer incidence showed an RR of prostate cancer of 1.24 (95% CI 1.03 to 1.49) for the men receiving folic acid compared to controls. No significant difference in cancer incidence was shown between groups receiving folic acid and placebo/control group, for any other cancer type. Total cancer mortality was reported in six RCTs, and a meta-analysis of these did not show any significant difference in cancer mortality in folic acid supplemented groups compared to controls (RR 1.09, 95% CI 0.90 to 1.30). None of the observational studies addressed mortality. Conclusions A meta-analysis of 10 RCTs showed a borderline significant increase in frequency of overall cancer in the folic acid group compared to controls. Overall cancer incidence was not reported in the seven observational studies. Prostate cancer was the only cancer type found to be increased after folic acid supplementation (meta-analyses of six RCTs). Prospective studies of cancer development in populations where food is fortified with folic acid could indicate whether fortification similar to supplementation moderately increases prostate cancer risk.

Clinicians' use of guidelines as illustrated by curative treatment of prostate cancer at a comprehensive cancer center.

BACKGROUND: We studied compliance to guidelines of curative treatments in prostate cancer (PCa), which were of special interest due to recent introduction of new treatment technologies and the fact that there existed a real choice between surgery and radiotherapy. MATERIAL AND METHODS: We did retrospective analyses of guidelines adherence for all PCa patients receiving curative treatment at the Norwegian Radium Hospital from 2004 to 2007 after the introduction of robot-assisted prostatectomy and after-loading brachytherapy. The patients were classified into three groups in relation to guidelines: the accordance, accordance after discussion, and the deviance groups. In time Period I (2004-2005) the 2003 EAU guidelines were used and in Period II (2006-2007) in-house guidelines with minor modifications of EAU were applied. RESULTS: During the observation period 859 patients had curative treatment for PCa, and 83% of the patients were treated according to guidelines. In the deviance group (N=146), 119 men (82%) got prostatectomy instead of radiotherapy. The reasons for deviation in the second period were age >65 years (N=70) and surgery in cases with T3 tumors (N=10), Gleason score >8 (N=13) and combinations (N=26). Deviances from guidelines in the radiotherapy group (N=27) mainly concerned patient selecting this treatment due to expectations of preserving sexuality and/or fertility. CONCLUSIONS: In spite of acceptable overall compliance to guidelines for curative PCa treatment, the proportion of non-adherence should not been overseen, in particular when new treatment technologies are introduced. Guidelines for PCa need to be monitored regularly, and the compliance to guidelines has to be assessed on a regular basis. Guidelines should avoid too strict criteria, particularly in relation to age.

Postradiotherapy plasma lutein, alpha-carotene, and beta-carotene are positively associated with survival in patients with head and neck squamous cell carcinoma.

The aim of our study was to compare plasma carotenoids (i.e., biomarkers of fruits and vegetables intake) and tocopherols in 29 head and neck squamous cell carcinoma (HNSCC) patients with 51 healthy controls and to explore the possibility whether these plasma antioxidants could be related to outcome among patients. The patients' blood samples were taken at the end of radiotherapy. We observed that plasma lutein, zeaxanthin, alpha-carotene, beta-carotene, lycopene, and total carotenoids were significantly lower in HNSCC patients than controls. Among the patients, 18 died and 11 were still alive during median follow-up of 55 mo for survivors. We found a significant positive association between postradiotherapy plasma carotenoids (lutein, alpha-carotene, and beta-carotene) and progression-free survival in these patients. This study indicates that increasing postradiotherapy plasma carotenoid concentration may reduce risk of premature death or recurrence of tumor in HNSCC patients. Increasing plasma carotenoid concentration should be done by increasing intake of carotenoid-rich fruits and vegetables, as other studies have shown either no or negative effects due to use of carotenoid supplements.

[Effects of public initiatives aimed at reducing neural tube defects with folic acid supplementation]. / Effekt av offentlige tiltak for å forebygge nevralrørsdefekter med folat.

BACKGROUND: In order to prevent neural tube defects, a daily supplement of 400 microg (microgram) folic acid has been recommended in Norway since 1998, during the last month before conception and the first two or three months of pregnancy. Compliance with and effects of this recommendation has recently been evaluated in Norway in a report to the Directorate of Health and Social Welfare. MATERIAL AND METHODS: Reports published on periconceptional folic acid intake in Norway and some other countries from 1998 to autumn 2003 have been evaluated. RESULTS: In spite of several information activities, few Norwegian women start folic acid supplementation before verified pregnancy. The supplementation is started too late for the prevention of neural tube defects. A reduction is not observed in Norway. Internationally, information has not proven effective either, whereas compulsory fortification of foods with folic acid has been associated with reduced incidence. Information about periconceptional folic acid intake should be intensified. Compulsory fortification of foods with folic acid will affect the whole population, not only the target group of fertile women. If ongoing large intervention studies show improved clinical prognosis for patients with cardiovascular disease, this will be an additional argument for fortification of foods.

[Does folic acid have effects on other health problems than neural tube defects?]. / Effekt av folat på andre helseproblemer enn nevralrørsdefekter?

BACKGROUND: While it is widely accepted that periconceptional supplement of 400 microg (microgram) folic acid reduces the risk of neural tube defects in pregnancy, it remains to be established whether folic acid has other beneficial effects on larger population groups. Evidence concerning effect of increased intake on cardiovascular disease, cancer and other diseases has recently been evaluated in a report to the Directorate of Health and Social Welfare in Norway. MATERIAL AND METHODS: Research reports published mainly from 1998 to 2003 on folic acid intake and disease have been evaluated. RESULTS: Sufficient evidence that increased folic acid intake may prevent cancer or cardiovascular diseases is not yet available, hence at present there is no indication for recommending augmented intake for other groups than fertile women. However, several intervention studies with folic acid supplementation are in progress to establish its effect on cardiovascular mortality and morbidity. INTERPRETATION: If the ongoing intervention studies show a beneficial clinical effect on cardiovascular disease, it would be a further argument for fortification of foods, in addition to reducing the risk of neural tube defects in pregnancy.