Narrative medicine: feasibility of a digital narrative diary application in oncology.

OBJECTIVES: We implemented narrative medicine in clinical practice using the Digital Narrative Medicine (DNM) platform. METHODS: We conducted a preliminary, open, uncontrolled, real-life study in the oncology and radiotherapy departments of Istituto di Ricovero e Cura a Carattere Scientifico National Cancer Institute Regina Elena, Rome, Italy. We recruited adult Italian-speaking patients who then completed the DNM diary from the start of treatment. The primary endpoint was DNM feasibility; secondary endpoints were health care professionals' opinions about communication, therapeutic alliance, and information collection and patients' opinions about therapeutic alliance, awareness, and coping ability. We used open- and closed-ended questions (scores 1 to 5) and a structured interview. RESULTS: Thirty-one patients (67%) used the diary (84% women). Health care professionals' mean scores for feasibility and utility were ≥4.0. Patients' utility scores were related to health care professionals' feedback regarding the narratives. The main advantages for health care professionals were the opportunity to obtain relevant patient data and to strengthen communication and patient relationships (mean scores 4.4-5.0). Both groups strongly encouraged introduction of the diary in clinical practice. CONCLUSION: Use of the DNM in oncology patients assisted clinicians with understanding their patients experience.

[Application of narrative medicine in oncological clinical practice: impact on health care professional.] / Applicazione della medicina narrativa nella pratica clinica oncologica: l'impatto sull'operatore.

INTRODUCTION: Narrative medicine makes explicit the experience of disease and enhances the subjective view in the cure. In addition, the narrative approach involves personal experience and emotional resonances of the health care professional leading him to redefine the values in terms of health and disease. The IMPERO study aims to explore the personal "life experience" of health care professionals involved in studies exploring a new methodological clinical approach: the use of a digital narrative diary in collecting and integrating theme-oriented narration in clinical practice. METHODS: Qualitative study based on the interviews of three health care professionals (two oncologists and one nurse) involved in the AMENO study. The main topic of the interviews was the "perceived" and the intimate experience of each health care professional, particularly on the meaning and the role regarding their personal and professional experience while coping with patients narration. The analysis of data focuses on three aspects: a) the health care professionals' point of view using the diary as a tool for narrative-based medicine; b) the work environment as a framework for the use of the digital diary; c) the mental construction concerning the meaning of the tool and its preliminary use in clinical practice. RESULTS: The diary is appreciate as a tool for the application of narrative-based medicine; the reading/writing format is considered of high quality and suitable for clinical practice processes. The narration drives a change in the patient-health care professional relationship: the patient is valued as an "individual". An atmosphere of empathy and greater intimacy is created. The perceptions developed over the years of clinical practice, which reflect personal and professional concepts (knowledge and individual believes in illness, health, healing, etc.), influence the perception of the narrative instrument and its clinical use. The work context influences the use of the diary, limiting its potential. Narrative medicine is a way of reorganizing the criteria that contribute in defining the quality of patient care by focusing on the patient-health care professional relationship. DISCUSSION: The approach of narrative medicine must be reviewed in the light of the relational systemic theory which allows us to understand several aspects: the training in narrative medicine itself, the acquisition of professional skills by practitioners, and the organizational development of the institutions (the organizational structures but also the values and professional culture of work).

Report of two cases of quintuple primary malignancies and review of the literature.

Multiple primary malignant neoplasms (MPMN) are not uncommon, however, finding more than three primary malignancies in one individual is unusual. Surviving five malignancies is considered exceptional. Two patients surviving five primary malignant neoplasms for 12 and 18 years are reported: a 55-year-old woman with a squamous cell carcinoma of the larynx, two carcinomas of the breast, a carcinoma of the kidney and an adenocarcinoma of the colon, and a 75-year-old woman with a sarcoma of the myometrium, a carcinoma of the thyroid, an adenocarcinoma of the rectum, a leiomyosarcoma of the colon and a bronchial carcinoid. Only twelve other reported cases with five or more primary infiltrating malignancies involving more than three sites, diagnosed while the patient was alive have been found. Relevant features were that colon cancer was quite often present more than once and survival was longer than expected for the stage (median overall survival, 20 years; 95% confidence interval: 12-28 years).

Weekly paclitaxel, 5-fluorouracil and folinic acid with granulocyte colony-stimulating factor support in metastatic breast cancer patients: a phase II study.

We conducted a phase II study to determine the activity and tolerability of weekly paclitaxel, 5-fluorouracil (5-FU) and folinic acid plus granulocyte colony-stimulating factor (G-CSF) support in anthracycline-pre-treated or -resistant metastatic breast cancer patients. The phase II study was designed following the Simon optimal-two stage method. Patients received paclitaxel 80 mg/m, folinic acid 10 mg/m and bolus infusion of 5-FU 300 mg/m every week plus G-CSF on day 3 for 24 consecutive weeks in the absence of disease progression. From May 1998 to May 2000, 51 patients entered the study. Patients received a median relative dose intensity of 97.5% (range 81-100%). No severe toxicities were observed. Seven patients (14%) experienced neutropenia grade 2. Seven patients (14%) experienced grade 2 anemia. Two patients (4%) experienced severe asthenia. Three out of 50 evaluable patients [6%, 95% confidence interval (CI) 2-12.6%] showed a complete response, whereas 23 (46%, 95% CI 32.2-59.8%) had a partial response, with an overall response rate of 52% (95% CI 38.2-65.8%). In addition, eight patients (15.7%) had stable disease. In the 13 patients untreated for metastatic disease, the overall response rate was 92.3% (CI 77.8-100), with one complete response and 11 partial responses (84.6% CI 65-100%). In the whole group, the median time to progression and overall survival were 8 (range 1-18) and 14 months (95% CI 11-17), respectively. Thus, in metastatic breast cancer patients pre-treated with anthracyclines, the weekly administration of paclitaxel, 5-FU and folinic acid with G-CSF support seems to be extremely tolerable and active.

Is there a benefit by the sequence anastrozole-formestane for postmenopausal metastatic breast cancer women?

To explore the different sequence interactions between reversible non-steroidal (anastrozole, ANZ and letrozole, LTZ) and non-reversible steroidal aromatase inhibitors (formestane, FOR and exemestane, EXE), we evaluated the clinical benefit (CB) in postmenopausal breast cancer patients, who had previously received anastrozole and subsequently formestane. In 19 out of 21 patients (90.5%), a clinical benefit response was achieved by anastrozole, with a median duration of 12 months. Out of the 21 women progressing on anastrozole, 12 achieved stable disease (SD)>/=6 months by formestane only. The overall clinical benefit was 66.5%. The median duration of clinical benefit was 11 months with a time to progression of 6.5 months. The median duration of clinical benefit in our series is similar to that reported in two phase II trials with the sequence aminogluthetimide-->formestane and aminogluthetimide-->exemestane as third-line hormonal therapy, suggesting a non-cross-resistance between the two classes of inhibitors.