Neurobiological and psychological evidence of chronic stress in prostate cancer patients.

To measure the prevalence and severity of Generalised Anxiety Disorder (GAD), hypo- and hypercortisolaemia, and their association in a sample of prostate cancer (PCa) patients, 97 Australian PCa patients completed a background questionnaire and the GAD-7, and provided a sample of saliva collected 30-45 min after waking. The mean GAD7 score was 9.67 (SD = 3.09), and prevalence rates for current anxiety were higher than those reported for non-PCa males of a similar age. Mean salivary cortisol concentrations (30.78 nmol/L, SD = 13.97 nmol/L) were also higher than for age-comparative non-PCa men. There was a significant inverse correlation between GAD and cortisol (r = -. 209, p < .05), and four subgroups of GAD-cortisol patients were able to be identified, with evidence of both hyper- and hypocortisolaemia. These findings provide initial neurobiological evidence of the chronic and profound nature of stress experienced by PCa patients, and also suggest a possible measure that might be used to identify most at-risk PCa patients.

Measuring depression in prostate cancer patients: does the scale used make a difference?

This study investigated differences in the scores, relative severity and major depressive disorder (MDD) and subsyndromal depression status from three standardised self-report scales for depression in prostate cancer (PCa) patients. The Hospital Anxiety and Depression Scale Depression subscale (HADS-D), the Self-rating Depression Scale (SDS) and the Patient Health Questionnaire (PHQ-9) for depression were administered to a sample of 138 PCa patients via mail-out self-reports in Queensland, Australia during May 2014. Despite significant correlations between the total scores from the three scales, severity classification differed across the three scales and there was evidence of considerable underestimation of depression by the HADS-D compared to the PHQ-9, and a similar tendency for the SDS. When patients were classified as fulfilling the criteria for Subsyndromal Depression on the PHQ-9, there were statistically significant differences in the proportion of patients who met those criteria using the HADS-D and the SDS, with large underestimation also present for these two scales. Scale construction and depression items included can produce different results across scales, making inter-study comparisons difficult. Implications for research and clinical practice are described.

Total depression and subtypes in prostate cancer survivors 10 years after treatment.

To describe the prevalence, severity and nature of depression in a sample of prostate cancer (PCa) survivors 10 years after diagnosis and treatment, 146 Australian patients from the RADAR trial who received their diagnosis 10 years previously completed the Zung Self-rating Depression Scale and a background questionnaire. Prevalence rates for clinically significant depression and severe depression were higher than those reported for the non-PCa men of the same age in Australia. The most common subtype of depression was Anhedonia, followed by Cognitive depression. Change in eating habits was the most powerful depression symptom predicting Anhedonia. By providing the first detailed documentation of major depression prevalence in PCa survivors, plus describing the nature of that depression, these data suggest that there is an ongoing need to provide treatments for these men and that those treatments should be focussed upon loss of previously available sources of enjoyment.

Acute and Late Bowel Toxicity in Radiotherapy Patients with Inflammatory Bowel Disease: A Systematic Review.

AIMS: Inflammatory bowel disease has traditionally been considered a relative contraindication for radiotherapy due to a perceived increased risk of disease exacerbation and bowel toxicity. The aim of this review was to evaluate the current literature regarding rates of radiotherapy-induced acute and late bowel toxicity in patients with inflammatory bowel disease and to compare these data with those of patients without the disease. MATERIALS AND METHODS: An Ovid Medline search was conducted to identify original articles pertaining to the review question. Using the PRISMA convention a total of 442 articles screened, resulting 8 articles which were suitable for inclusion in the review. RESULTS: In general, the grading of toxicity was scored using either the Radiation Therapy Oncology Group or Common Terminology Criteria for Adverse Events scoring systems. It was found that acute bowel toxicity of ≥ grade 3 occurred in 20% of patients receiving external beam radiotherapy (EBRT) and in 7% of patients receiving brachytherapy. Late bowel toxicity ≥ grade 3 occurred in 15% of EBRT patients and in 5% of patients receiving brachytherapy. Brachytherapy was shown to have similar rates of toxicity and EBRT produced a moderate increase in both acute and late toxicity when compared with individuals without inflammatory bowel disease. CONCLUSION: In view of these results, we suggest that brachytherapy should be considered as a suitable treatment option for treating pelvic malignancy in patients with inflammatory bowel disease, whereas EBRT should be used with caution.

The Hot Flush Beliefs and Behaviour Scale for Men (HFBBS-Men) undergoing treatment for prostate cancer.

OBJECTIVE: Hot flushes and night sweats (HFNS) are commonly experienced by men receiving treatment for prostate cancer. Cognitive behavioural therapy (CBT) has been found to be an effective treatment for HFNS in women, but cognitions and behavioural reactions to HFNS in men are under-researched. This study describes the development of the HFNS beliefs and behaviour scale for men. METHODS: HFNS beliefs and behaviour items were generated from a qualitative study, from pilot interviews with men with prostate cancer and HFNS, and from scales used for women. 118 men with prostate cancer, aged above 18, English-speaking, who had minimum of seven HFNS weekly for at least 1 month, completed the initial measure, and measures of HFNS frequency, problem rating, anxiety and depression (HADS). Principal components analyses with orthogonal rotation determined the most coherent solution. RESULTS: Exploratory factor analysis culminated in a 17-item HFNS beliefs and behaviour scale for men (HFBBS-Men) with three subscales: (1) HFNS social context and sleep, (2) Calm/Acceptance, (3) Humour/Openness. The subscales had reasonable internal consistency (Cronbach alpha 0.56-0.83). Validity was supported, by correlations between subscale 1, HFNS frequency, problem-rating and mood; men with locally advanced cancer more likely to adopt Calm/Acceptance and those with metastatic cancer Humour/Openness. CONCLUSIONS: Preliminary analysis of the HFBBS-Men suggests that it is a psychometrically sound instrument, grounded in men's experiences. As a measure of cognitive and behavioural reactions to HF/NS, the HFBBS-Men should increase understanding of the mediators of outcomes of psychological interventions, such as CBT.

Does resilience 'buffer' against depression in prostate cancer patients? A multi-site replication study.

Although psychological resilience has been shown to 'buffer' against depression following major stressors, no studies have reported on this relationship within the prostate cancer (PCa) population, many of whom are at elevated risk of depression, health problems and suicide. To investigate the effects of resilience upon anxiety and depression in the PCa population, postal surveys of 425 PCa patients were collected from two sites: 189 PCa patients at site 1 and 236 at site 2. Background data plus responses to depression and resilience scales were collected. Results indicated that total resilience score was a significant buffer against depression across both sites. Resilience had different underlying component factor structures across sites, but only one (common) factor significantly (inversely) predicted depression. Within that factor, only some specific items significantly predicted depression scores, suggesting a focused relationship between resilience and depression. It may be concluded that measures of resilience may be used to screen depression at-risk PCa patients. These patients might benefit from resilience training to enhance their ability to cope effectively with the stress of their diagnosis and treatment. A focus upon specific aspects of overall resilience may be of further benefit in both these processes.

The incidence and causes of different subtypes of depression in prostate cancer patients: implications for cancer care.

Although depression occurs in prostate cancer patients at a higher incidence than in age-matched non-cancer peers, little is known about the relative incidence of subtypes of depression among these patients. To examine this issue, 507 prostate cancer patients completed a survey questionnaire of background factors, depression symptoms, and common prostate cancer-related stressors. Five common subtypes of depression were defined from the wider literature, and patients' depressive symptomatology was used to determine their scores on each of the five depression subtypes. Nearly half of the patients had scores which could be classified as clinically significant for at least one of the five depression subtypes, with some patients showing clinically significant scores for multiple depression subtypes. Different depression subtypes were predicted by different prostate-cancer-related stressors. Because each of the five depressive subtypes examined here has different symptomatologies and treatment recommendations, these data suggest that treatment goals for prostate cancer patients might vary according to the type of depression a patient presents.

Pregnancy and radiotherapy: management options for minimising risk, case series and comprehensive literature review.

This article reviews the efficacy and safety of radiotherapy in patients with cancer who are pregnant. Our review provided extended follow-up results in nine cases, presents a technical discussion on measures taken to minimise foetal radiation exposure and provides a comprehensive summary of the literature. Nine patients who received radiotherapy while pregnant are described. The clinical presentation and outcomes of these and 100 additional cases identified on a systematic literature review are presented. Comparisons of scattered radiation doses from three linear accelerators are presented. The average maternal follow-up in our series was 8.9 years with one patient having a recurrence of their astrocytoma. In terms of foetal outcome, there were one death in utero, one elective termination of pregnancy and one on which no data were available. Six children, on whom long-term follow-up (average 10.3 years) was obtainable, were in good health. Overall, there had been 109 cases of radiotherapy in pregnancy that met our search criteria with 13 adverse outcomes and a median follow-up of 37 months. Comparisons of three linear accelerators demonstrated significant differences in the amount of scattered radiation to the abdominal surface. In summary radiotherapy during pregnancy can be associated with a significant number of adverse outcomes. While it may be difficult for a patient not to attribute these effects to radiotherapy, it is also difficult to define the mechanisms by which radiotherapy would have caused them, if that were the case.

Effects of interval between diagnosis and time of survey upon preferred information format for prostate cancer patients.

Previous data indicate that receiving adequate information about their cancer can assist patients to cope with treatment and comply with treatment regimes. The aim of the present study was to determine whether time since diagnosis affected patients' evaluations of the information they had received at the time of their diagnosis. Two hundred and thirty-seven patients who had received a diagnosis and treatment for prostate cancer 4 months earlier completed a questionnaire about their ratings of, and preferences for, various types of information, their anxiety and depression levels and some background data. The most common and preferred form of information that the patients in the current study received was verbal information during an interview with their oncologist. Demographic factors and levels of anxiety and depression did not influence patient information preferences. Time since diagnosis was associated with elevated anxiety and depression, and consequent lower recall of having received information, but also with positive inflation of the value of the material that they did recall having received. Patients may not recall information given to them early after diagnosis and may make unreliable evaluations of its value to them due to psychological state.

Adverse effects of a multicentre system for ethics approval on the progress of a prospective multicentre trial of cancer treatment: how many patients die waiting?

BACKGROUND: As cancer survival is improving approximately by 1-2% per year, delays in the clinical trials that lead to that improvement could cost lives. AIMS: To review the process of ethics committee approval for a multicentre clinical trial of cancer treatment and to estimate the delay it will cause in obtaining the results and the effects of such delays on survival for all cancers in Australia. METHODS: A survey was sent to each of the 15 centres participating in the study to obtain details about submissions they had made to their ethics committees and the replies received from them. RESULTS: The survey response rate was 100%. The average time required to complete an ethics submission was 12 h, and the average length of time for a final reply was 70 days. Wide variation was noted in the replies, 40% were considered constructive. Most centres said the effort in ethics submissions is sufficient to limit participation in other clinical trials that are available. CONCLUSION: The multicentre system of ethics approval has significantly delayed this multicentre trial and may delay advances in cancer care. Extrapolating this delay to determine an influence on improvements in cancer survival suggests that it may be responsible for 60 cancer deaths per year. A method for measuring the effect on the shape of the accrual curve is defined, and the term DIABOLECAL (Delays in Accrual Brought On Largely by Ethics Committee Activity Lag-time) is proposed to describe it. Attempts to overcome this problem have been introduced overseas.

Patient information preferences among breast and prostate cancer patients.

Preferences for information about their disease and treatment were collected from 392 patients who had been treated for either breast or prostate cancer an average of 2 years previously. Type of information that they had received, their ratings of its value to them and their preferred format for further information were examined. The most common and most preferred form of information was through doctor interview, followed by educational booklets. Prostate cancer patients preferred videotapes; breast cancer patients tended to prefer individualized approaches including a tour of the department. Effects of age, educational levels, occupational backgrounds and self-reports for anxiety and depression at the time of the survey and at time of diagnosis were analysed. Prostate cancer patients who were most severely depressed showed a preference for not receiving any information at all, perhaps reflecting a tendency towards withdrawal.

Do written consent forms provide medicolegal protection from litigation in radiotherapy?

Two methods were used in an attempt to determine whether written consent forms serve a useful medicolegal purpose in Australian radiotherapy departments. First a survey was posted to all practising radiation oncologists to ask about their use of written consent forms and whether they had ever been useful in any claims made against them. Second, the largest medical defence organization in Australia was contacted for de-identified details about every claim ever made against a radiation oncologist. The survey yielded a response rate of 50.3%. Only one respondent indicated that any consent form had ever played a role in any claim and was not prepared to discuss it. Many radiation oncologists did not routinely use a consent form and its use could not be considered standard practice. The submitted consent forms generally did not contain warnings to the patient about specific risks of treatment. The details of the previous claims provided by the medical defence organization indicated that more often claims arose from circumstances in which a written consent form could not provide any useful protection such as radiation dose calculation errors. The medicolegal value of written consent forms in radiotherapy seems low, although further research may be necessary before dispensing with them completely.

A prospective trial of short-fractionation radiotherapy for the palliation of liver metastases.

The purpose of this study was to prospectively examine the effectiveness and tolerability of a simple radiotherapy technique for the palliation of symptomatic liver metastases. Twenty-eight patients with symptomatic liver metastases were enrolled from seven centres, and received targeted (partial or whole) liver irradiation consisting of 10 Gy in two fractions over 2 days. Symptoms at baseline were hepatic pain (27 patients), abdominal distension (19), night sweats (12), nausea (18) and vomiting (eight). Twenty-two patients (76%) had failed previous treatment with chemotherapy, hormonal therapy and/or high-dose steroids. Symptoms and potential toxicities were prospectively assessed at the time of treatment, then 2, 6 and 10 weeks later. Individual symptom response rates were 53-66% at 2 weeks. Partial or complete global symptomatic responses were noted in 15 patients (54%) overall. The treatment was well tolerated with two patients (7%) experiencing grade 3 toxicity (one vomiting and one diarrhoea); however, four patients reported temporary worsening of pain shortly after treatment. This simple and well-tolerated treatment achieves useful palliation.

Prosthetic devices within radiotherapy fields: planning implications and results.

Prosthetic devices made of plastic or silicon are occasionally present in patients requiring radiotherapy (RT). The effect of RT on these devices and the potential implications of their presence on RT planning are relatively unknown. Three examples are presented in which various devices were included in RT fields. In two of the examples in vitro testing of the devices with high single doses of radiation was undertaken. Radiotherapy was given to all patients with high doses received by the devices. Minor adjustments were made to the planning techniques to reduce the doses to the devices. Neither significant complications nor any malfunctions of the devices were noted subsequently.

Osteolymphoma (primary bone lymphoma): an Australian review of 70 cases. Australasian Radiation Oncology Lymphoma Group (AROLG).

BACKGROUND: To examine prognostic factors, treatment outcomes and design future studies for Osteolymphoma (OL)--also known as primary bone lymphoma. METHODS: Between 1979 and 1993, 70 patients with OL were treated in nine Australian centres. The effect of patient-, tumour-, and treatment-related factors on local control, distant disease-free survival and overall survival were assessed by multivariate analysis. RESULTS: Most patients (94%) received radiotherapy (RT) (median dose 40 Gy) and 56% received chemotherapy. Multifocal disease was present in 20% of patients. The five year rates of overall survival and local control were 59% and 82%. Although there was a trend towards better results with the addition of chemotherapy, on multivariate analysis, there were no factors identified which appeared to impact upon overall and disease-free survival. Among the distant recurrences, there was a high proportion in bone (33%). Six patients suffered pathological fractures after treatment. CONCLUSION: High rates of local control were achieved by RT, but the overall survival remains relatively poor, worse than nodal lymphoma. The natural history of the disease suggests that OL may be a distinct entity, different to nodal lymphomas, so the results of clinical trials in nodal lymphoma may not be relevant to OL. Prospective studies could define the outcome of combined modality therapy and set a benchmark for testing further proposals, as well as improving our knowledge of the clinical features of OL.

Validation of a malnutrition screening tool for patients receiving radiotherapy.

Nutrition screening identifies individuals who are malnourished or at risk of becoming malnourished and who may benefit from nutrition support. The aim of this study was to validate a new malnutrition screening tool (MST) in cancer patients undergoing radiotherapy. The MST was compared with the subjective global assessment (SGA) of nutritional status. One hundred and six patients attending two cancer care centres in Australia were independently rated as well nourished or malnourished using SGA and at risk or not at risk of malnutrition using the MST. Convergent validity of the MST was established by determining the ability of the MST to predict SGA. According to SGA, 89% of the patients were well nourished and 11% were moderately malnourished. According to the MST, 28% of patients were at risk of malnutrition. The MST had a sensitivity of 100% and a specificity of 81%. The positive predictive value was 0.4 and the negative predictive value was 1.0. The MST is easy to use and is a strong predictor of nutritional status. The malnutrition screening tool is a simple, quick, valid tool that can be used to identify radiation oncology outpatients who are at risk of malnutrition.

The doses received by the breast during mantle radiotherapy.

PURPOSE: To accurately measure the dose received by the breast during mantle radiotherapy. METHODS AND MATERIALS: A phantom containing lung-equivalent material was used to measure the doses received by the breast during mantle radiotherapy given by anterior and posterior opposing fields. These were measured using thermoluminescent dosimeters and compared with point dose calculations obtained by computer planning. RESULTS: Most of the breast lies under the lung shields or inferior to the mantle field, but the upper outer quadrant of the breast remains unshielded. In the unshielded areas of the breast, the average dose measured was nearly 13% higher than the dose prescribed at the central axis. In the shielded parts of the breast, the average measured dose was nearly 10% of the dose prescribed at the central axes, decreasing from 18% superiorly to 4% inferiorly. The posterior field contributed 45% to the dose in the breast, even though doses were prescribed at the midplane. The computer calculations systematically varied from measured doses by up to 35%, becoming less accurate towards the inferior edge of the field. CONCLUSIONS: In a conventional course of mantle radiotherapy (for example, 36 Gy in 20 fractions), most of the breast is shielded but will receive a dose of 3-4 Gy, higher than expected largely due to internally scattered radiation passing through the lungs from the posterior field. Computer dose calculations may poorly reflect actual off-axis doses in large fields with complex shielding, containing inhomogeneous tissue.

The role of the gallium scan in primary extranodal lymphoma.

UNLABELLED: The purpose of this study was to examine the factors influencing gallium scan positivity for patients with primary extranodal lymphoma and to examine the role of the gallium scan in staging the disease and assessing response to initial treatment. METHODS: Ninety-two patients with extranodal lymphoma who had a gallium scan were reviewed. The influences of tumor site, size, grade and the presence of clinically detectable disease after biopsy on the rate of gallium scan positivity were analyzed. The role of the gallium scan in staging and selecting treatment was assessed. Nineteen patients had a gallium scan to assess their response to treatment, and its predictive value was reviewed. RESULTS: The overall gallium scan positivity (sensitivity) rate was 70%. This rate was low in patients whose extranodal lymphoma occurred in skin, intestine and testis, or was low grade (0%-25%). When these patients were excluded, the rate rose to 88%. Gallium scan positivity was not related to the presence of clinically detectable disease after biopsy and there was insufficient data about tumor size to determine a relationship. The gallium scan increased the disease stage in six patients (7%) and changed the initial treatment in six patients (7%). The gallium scan became negative in 15 (79%) of those patients who had a gallium scan to assess their response to treatment. All but two of these patients remain alive with a median follow-up of 3.75 yr. CONCLUSION: The gallium scan was rarely positive for patients with skin, intestinal, testicular and low-grade lymphomas, but was otherwise comparable to lymphoma arising in lymph nodes. The result affected staging or treatment in seven patients (8%). After treatment, an initially-positive gallium scan usually became negative, a conversion associated with a favorable outcome.