Absence of major depressive disorder in female cancer patients.

This investigation evaluated the prevalence of depression in female patients who had cancer in any of five predesignated sites. Five hundred five women aged 17 to 80 (190 with breast cancer, 143 with gynecologic malignancies, 111 with melanoma, 37 with bowel cancer, and 24 with lymphoma) were randomly screened. Assessment included the Hamilton rating scale for depression, the Zung self-rating depression scale, the Karnofsky performance scale, and a 10-cm visual pain analogue line. The results revealed a mean Hamilton of 10.2 (range, 0 to 41; SD, 7.5), a mean Zung score of 35.3 (range, 11 to 68; SD, 9.6), a Karnofsky median score of 80, and a median pain score of 0. Scores on the Zung scale were highly correlated with those of the Hamilton scale (r = .75). Based on cutoff scores accepted as indicating depression (Hamilton greater than or equal to 20 and Zung greater than or equal to 50), patients were depressed. The depressed subgroup was in significantly more pain, experienced greater physical disability, and was more likely to have had prior episodes of depression as compared to the non-depressed women. The two best predictors of current depression were performance status (Karnofsky) and history of depression. No relationship was found between depression and other demographic variables or disease parameters (diagnosis, time since diagnosis, stage or phase of illness, and current treatment). Our findings indicate that the prevalence of major depression in cancer patients is lower than many previous studies have indicated and falls within the range seen in the general population.

Childhood cancer: Parental discord and divorce.

Parents of 191 children who were treated for cancer over a seven-year period completed and returned a questionnaire concerning marital status. Contrary to the prediction of a high divorce rate among these families, the study found a person-year divorce rate of 1.19%. This is slightly lower than the 2.03% person-year divorce rate among married couples with children in the states of Kansas and Missouri. The Arnold sign indicator analysis of the Minnesota multiphasic personality inventory was used to measure marital stress in 38 intact couples whose children were treated for cancer. The study sample experienced more stress than a comparison group of 23 couples who had hemophilic children. Both of these populations had more stress than a normal standardization group but less than a standardization group of marriage counselees.

Management of stressful periods in childhood cancer.

There are four major periods of stress for a family having a child with cancer. They are diagnosis, remission, death, and long-term survival. Each of these periods has particular management problems requiring careful assessment and intervention. The author provides such management strategies in this article.

The high cost of cancer.

Anxiety about managing the financial costs of cancer is equaled only by fear of the disease itself. In addition to the rising cost of medical care, nonmedical costs contribute a large share of the financial burden. A number of studies, which are reviewed in this article, document the significance of costs incurred in the areas of food, family care, clothing, transportation, lodging and other miscellaneous items, and, in addition, loss of wages. Four factors account for variability in financial cost: level of care, performance status of the patient, family size, and distance from the hospital. Concern is expressed about the high cost of cancer treatment and the question posed as to who should be responsible for payment.

Psychiatric syndromes in pediatric oncology patients.

While all these problems have been seen in pediatric cancer patients, and some may occur more frequently than in the general population, it is worth reemphasizing that the majority of patients and families are psychiatrically intact. They are generally highly resilient and resourceful in coping with this potentially devastating illness. A vigorous program of support groups, recreational therapy, and academics can enhance the patients' and families' ability to function. For those few who develop psychiatric disorders, effective therapeutic intervention is very important in their recovery from both psychiatric and oncologic illness.

Cancer during adolescence.

Specific developmental issues and long-term psychosocial implications are associated with a diagnosis of cancer during the period of adolescence. Effects on the adolescent's developing independence, sexual identity, and social and psychological maturity must be considered. Repercussions of these disruptions emphasize the need for creative treatment approaches which incorporate both immediate and long-term preventive and rehabilitative strategies.

Psychosocial consequences of cure.

Survivors of childhood cancer, having overcome the biggest hurdle to a normal life span, must continue to be vigilant toward health care issues as well as toward certain psychological and social problems for which they are at a greater than normal risk. The long-term survivor's knowledge about his/her illness, its treatment, and the consequent need for health surveillance and maintenance practices must be continually updated. Equally important is the survivor's preparation for coping with any long-term consequences of disruption in family, academic, and social activities engendered by cancer treatment. Existing research has frequently focused on patients diagnosed in early childhood. Recent studies, however, suggest that the developmental disruptions may have special significance for the adolescent, who is already struggling with unique issues of separation, changes in peer relationships, emergent sexuality, and future academic and occupational goals. Previous investigations addressing the medical and psychiatric problems encountered by the long-term survivor of adolescent cancer are presented with a focus on current psychological adjustment and degree of emancipation achieved. A recent pilot study, from three major medical centers, collected extensive interview data on a group of long-term survivors and sibling controls. Preliminary analyses of these data are described, and areas for future research are suggested.

Childhood cancer. Medical costs.

The financial burden of cancer treatment is a major source of stress for families of children with cancer. A previous study demonstrated that out of pocket nonmedical costs incurred because of the illness were consuming 26% of the weekly budget. A one-month sampling of medical charges were collected for 64 families of children undergoing outpatient treatment of cancer. Families of ten patients who had died also participated; total cancer center medical charges throughout the illness were collected. Monthly charges for living patients varied greatly with diagnosis, ranging from $100 to $1800. Total cancer center charges throughout the illness for the decreased patients ranged from $8000 to $53,000 (mean, +34,558). More than 50% of the charges were incurred in the diagnostic and terminal stages of illness. One sign of the hardship endured by the families was the outstanding debts to the cancer center long after the patient's death. Medical costs constituted an average of 5.8% of the families' weekly budgets. Overall, medical costs to the family were found to be much less than the nonmedical costs incurred during treatment.

Refusal of treatment: a new dilemma for oncologists.

Thirteen cases of childhood malignancy are described in which treatment was refused. Four groups are presented: 1) the parents refused treatment for a child with a good prognosis, 2) parents refused treatment for a child with a poor prognosis, 2) the patients refused treatment, and 4) child abuse or neglect occurred in conjunction with refusal of treatment. Parents refused treatment on the basis of religious grounds, seeking unproven methods of treatment, a conviction that treatment was worthless, or a feeling that treatment of the child interfered with the parents' life-style. Children refused treatment because they did not like the therapy side effects, did not like painful procedures, or felt the disease was hopeless. Some families refused treatment at one point, then later asked to resume treatment. Management of these cases depends, to a great extent, on prognosis. Those children having a good prognosis can be called to the attention of the juvenile court on the basis of medical neglect. In children with a poor prognosis, recourse to the juvenile court is not indicated. In all cases, frequent communication with the families is extremely important even when treatment has been refused.

A performance status scale for head and neck cancer patients.

Effective assessment of treatment outcome and the development of successful rehabilitation for head and neck cancer patients demand an evaluation of the relevant parameters of functional status. This paper reports the development and testing of a new Performance Status Scale for Head and Neck Cancer Patients designed to assess the unique areas of dysfunction experienced by this population. The instrument is a simple, practical, clinician-rated assessment tool consisting of three subscales: (1) Understandability of Speech, (2) Normalcy of Diet, and (3) Eating in Public. The scale was administered to a group of 181 head and neck patients and a comparison group of 30 breast cancer patients. Results indicate that the scale is reliable across raters and sensitive to functional differences across a broad spectrum of head and neck cancer.

Psychological correlates of compliance.

A urinary assay (17 kgs/creatinine) was used to measure compliance in 31 acute lymphocytic leukemia patients under 15 years of age receiving oral prednisone. Demographic data and psychological test responses of patients and their parents were correlated with the urinary assays. Results indicated that while the rate of compliance was the same for boys and girls, the psychological correlates were very different. Parental personality traits and attitudes were more involved with boy's compliance than with girl's. Some of the parent variables associated with compliance in boys were hostility, anxiety, and obsessive-compulsive behavior. Parents described compliant boys as vulnerable. These traits usually are considered maladaptive but in this case appear to facilitate boy's compliance. For girls, far fewer parent variables were associated with compliance. Parents seemed to have less worry and concern about their daughters and presumably give them the responsibility for their own medication. It was the girl's own anxiety which predicted compliance.

Postnatal somatic growth in infants with atypical fetal growth patterns.

We differentiate patterns of postnatal physical growth in 61 fullterm newborns with either normal or atypical somatic fetal growth. At birth, 14 normal babies had average ponderal indices, 14 were overweight for length (high ponderal index), 18 were underweight for length (low ponderal index), and 15 had short crown-heel lengths for dates and normal ponderal indices. Appropriate statistical analyses determined attained and velocity growth of the four groups during the first postnatal year. Statistically significant and marked differences in postnatal growth were noted between short babies and babies with low ponderal indices. The slow postnatal growth of the short infants appeared to be a continuum of their fetal growth pattern. On the other hand, infants born with low ponderal indices accelerated their weight gains and reversed the malnourished state in which they were born. These findings suggest that there are two distinct types of fetal growth retardation.

Adaptation of siblings to childhood malignancy.

To explore the impact of childhood cancer, school-aged patients and their healthy siblings from 71 families were given one or more of the following psychologic tests: the Piers-Harris Children's Self-Concept Scale, the Bene-Anthony Family Relations Test, and the Thematic Apperception Test. The siblings showed even more distress than the patients in the areas of perceived social isolation, perception of their parents as overindulgent and overprotective of the sick child, fear of confronting family members with negative feelings, and concern with failure (older siblings only). In other areas, such as anxiety and vulnerability to illness and injury, the patients' and siblings' experience appeared very similar. These results indicate that siblings, like patients, experience severe stress when confronted with a chronic, life-threatening illness such as cancer. In recognizing and attending to their needs, one can practice primary prevention in pediatrics by facilitating their healthy adaptation to a very difficult situation.

School phobia in children with malignant neoplasms.

With the advent of improved therapy, many of the childhood malignant diseases have become chronic. This group of patients and their families demonstrate many problems usually not associated with the primary disease, but which can become incapacitating. School phobia was selected as one such problem for this study. The 11 cases reported here demonstrate the insidious and subtle nature of the onset of the disease. With aggressive management, some long-standing cases of school phobia could be reversed, but not all. In a group subjected to a prophylactic regime at the onset of their malignant neoplasm, there have been no new cases of school phobia. It is important for pediatricians caring for these children to search actively for the signs of school phobia and intervene as soon as possible.

Poor drug compliance in an adolescent with leukemia.

Poor drug compliance in pediatric patients is a frustrating problem for it is common, difficult to document, and difficult to change. This report describes an adolescent who was found to be noncompliant in taking his therapy for acute lymphoblastic leukemia. 17kgs assay showed noncompliance with prednisone therapy three times--the third episode thwarting a reinduction attempt. Psychological testing was performed to assess factors that may have contributed to this noncompliance. This patient was found to have low anxiety, excess hostility, borderline intelligence, and a feeling that his fate was predetermined. Intervention therapy was attempted by additional counseling and education about the basic disease, but this was unsuccessful. Drug compliance was eventually achieved only through hospitalization. Identification of psychological factors and clinical situations associated with poor drug compliance is discussed.

The long-term effects of cranial irradiation on the central nervous system.

Cranial irradiation and chemotherapy may have significant long-term deleterious effects on children with brain tumors. Intellectual deterioration, endocrinopathies, leukoencephalopathy, extraneural metastases, and oncogenesis may all complicate the treatment of central nervous system neoplasia. These long-term effects of therapy have important implications, as some are amenable to treatment and others may be prevented by the careful monitoring of drug and radiation administration. Until recently, the survivals of children with brain tumors were limited, so that concerns over long-term effects of therapy were unnecessary. As children with certain types of brain tumors now have a better prognosis, these long-term and possibly remediable effects have important implications. This article emphasizes radiation effects on intellect, endocrine function, and oncogenesis. Recommendations for baseline and longitudinal evaluations of children with brain tumors are suggested.

The measurement of performance in childhood cancer patients.

The performance status of the child with cancer is an important outcome consideration in pediatric oncology research and practice. However, no single measure for children has been available. This is a report of the development and standardization of such a scale. The play-performance scale for children is a parent-rated instrument which records usual play activity as the index of performance. Performance status ratings were obtained on three groups of children: patients (n = 98), patients' siblings (n = 29), and an independent sample of hospital employees' children (n = 40). Children with all types and stages of childhood malignant neoplasms were represented. Test results established the parent as a competent, reliable rater and demonstrated the validity of the scale. Interrater reliability was examined using correlational statistics and percentage agreement. Agreement between parents was good, and there were no systematic rater biases. In addition, parents' ratings significantly discriminated differences in levels of functioning (mean score, patients 75.4 versus siblings 97.4). Correlational and analysis of variance (ANOVA) procedures demonstrated that the play-performance scale was significantly related to the global performance measures of experienced clinicians and was sensitive to change. Inpatients received a mean score of 42.3, outpatients 90.7, and normals 98.2. These findings indicate that the scale is both feasible and effective. It is concise, can be administered repeatedly even to extremely ill patients, and uses parents as observer reporters. The play-performance scale for children provides quantifiable, reproducible, and meaningful data, which is necessary for effective monitoring and management of the child with cancer.

Childhood cancer: nonmedical costs of the illness.

The financial burden of cancer treatment is a major source of anxiety for the families of pediatric cancer patients. Parents of these patients report that nonmedical, out-of-pocket expenditures are the most troublesome because, unlike medical bills, nonmedical costs must be paid immediately and are rarely reimbursed. Data on nonmedical expenditures (transportation, food, lodging, clothing, family care, and miscellaneous) were collected from 70 patients' families for one-week periods at three-month intervals. Multiple regression analysis was carried out to ascertain the factors influencing costs. Factors contributing to nonmedical costs included level of care, the patient's Performance Status, distance from the treatment center, and family size. Thirty-two families reported loss of pay when one or both parents accompanied the child to the hospital. When this loss was combined with the nonmedical costs, the results indicated a serious strain on the family budget. For half the families surveyed, the total expenses plus loss of pay amounted to more than 25% of the weekly family income.