A longitudinal qualitative study of the experience of working following treatment for gynaecological cancer.

OBJECTIVE: There are an increasing number of gynaecological cancer survivors for whom returning to work is a realistic outcome. There is little research to date specifically examining the return to work experience of survivors of gynaecological cancers. The aim of this study was to explore gynaecological cancer survivors' experience of work over a 1-year period post-treatment. METHODS: A total of 55 gynaecological cancer survivors completed a semi-structured interview following completion of their treatment and of these 36 also completed a follow-up interview 12 months later. In total, 91 interviews were recorded and transcribed verbatim. Framework analysis of the transcripts was undertaken. RESULTS: Three super-ordinate themes were identified and these were labelled 'Meaning of work', 'Disclosure of cancer diagnosis' and 'Readjustment'. Overall, there were few changes in working patterns between the two interview points with the majority of women returning to the same role. Although a desire to make work-related changes was expressed at baseline, few women had initiated such changes 1-year post-treatment. CONCLUSIONS: Employees may experience difficulties due to residual symptoms, such as continuing fatigue, or as a result of unrealistic expectations about returning to full employment soon after treatment has completed. The results highlight the need for an intervention to support gynaecological cancer survivors to cope with long-term residual symptoms and manage expectations about returning to work.

Cancer survivors' and employers' perceptions of working following cancer treatment.

BACKGROUND: Earlier diagnosis and improvements in treatment survival rates have led to an increase in the number of cancer survivors for whom returning to work is a realistic outcome. However, cancer survivors face a number of challenges when returning to the workplace. Little is known about how patients' illness and treatment beliefs affect return to work or of employers' beliefs about the impact of cancer on work. AIMS: To determine patient and employers' beliefs about the impact of cancer on returning to work and to identify differences in the beliefs held by patients and employers. METHODS: Patients absent from work due to breast, urological, gynaecological or head and neck cancers completed a questionnaire within 4 weeks of completing treatment. Unlinked employer respondents from medium to large organizations completed the same questionnaire. The questionnaire focused on the perceived impact of cancer and its treatment on work and an adapted version of the Brief Illness Perceptions Questionnaire. RESULTS: One hundred and ninety four patients (response rate of 82%) and 252 employers (response rate 31%) completed the questionnaire. Organizational respondents consistently reported more negative beliefs about the impact of cancer and treatment on work and in general held more negative illness perceptions about cancer in relation to work. CONCLUSIONS: A discrepancy between beliefs of organizational respondents and cancer survivors could impact on an employees' management of their work and on employers' responsiveness to the needs of survivors. Therefore, it is important that return to work plans include the elicitation of employee beliefs.

Assessing patients' beliefs about cardiac rehabilitation as a basis for predicting attendance after acute myocardial infarction.

BACKGROUND: Some sociodemographic and psychological variables such as patients' belief about illness are associated with attendance at cardiac rehabilitation. Exploration of patients' beliefs about treatment regarding cardiac rehabilitation has been limited to qualitative studies; their role in relation to attendance at cardiac rehabilitation after acute myocardial infarction (AMI) remains speculative. OBJECTIVES: To develop a valid and reliable measure of patients' beliefs regarding cardiac rehabilitation and to ascertain the relationship between such beliefs and attendance. DESIGN: A prospective questionnaire-based study. SETTING: Coronary care unit of a London teaching hospital. PATIENTS: 130 patients with AMI; 104 (83%) men; mean age 58.4 (standard deviation (SD) 10.7) years. INTERVENTIONS: Patients completed a 26-item questionnaire consisting of statements pertaining to beliefs about cardiac rehabilitation. MAIN OUTCOME MEASURES: Cardiac rehabilitation attendance; beliefs of patients about cardiac rehabilitation. RESULTS: Four subscales pertaining to patients' beliefs about cardiac rehabilitation were produced, accounting for 65.3% of the attendance variance: perceived necessity of cardiac rehabilitation (alpha = 0.71), concerns about exercise (alpha = 0.79), practical barriers (alpha = 0.70) and perceived personal suitability (alpha = 0.74). Patients who attended were more likely to believe that cardiac rehabilitation was necessary and to understand its role compared with non-attenders (17.7 (SD 2.7) v 16.9 (SD 3.0), p = 0.029). Patients who thought cardiac rehabilitation was suitable for a younger, more active person were less likely to attend (5.6 (SD 1.9) v 4.6 (SD 1.7), p = 0.007). Patients who expressed concerns about exercise or who reported practical barriers to attendance were less likely to attend, although these did not reach statistical significance. CONCLUSION: Beliefs about cardiac rehabilitation can be quantified and differ between attenders and non-attenders of cardiac rehabilitation.

A qualitative study investigating patients' beliefs about cardiac rehabilitation.

BACKGROUND: The opportunity to attend a cardiac rehabilitation course is usually offered to patients who have suffered a myocardial infarction. However, despite referral, many patients fail to attend. OBJECTIVE: To elicit patients' beliefs about the role of the cardiac rehabilitation course following myocardial infarction. DESIGN: Qualitative study using in-depth semi-structured interviews. SETTING: London Teaching Hospital. SUBJECTS: Thirteen patients were interviewed after discharge from hospital following myocardial infarction, but prior to attendance at cardiac rehabilitation. MAIN OUTCOME MEASURES: Patients' beliefs about cardiac rehabilitation that may act as barriers to attendance. RESULTS: Themes identified included: the content of cardiac rehabilitation, perceptions of exercise, benefits of cardiac rehabilitation, explicit barriers to attendance and cardiac knowledge. Whilst some patients viewed cardiac rehabilitation as an important and necessary part of recovery others expressed doubt that it was appropriate for them. Some patients were uncertain of the course content and misunderstood the role of exercise and its perceived effects. Misconceptions with regard to cardiac knowledge were also apparent. The combination of erroneous beliefs about cardiac rehabilitation and cardiac misconceptions seemed to result in doubts regarding attendance. CONCLUSIONS: Prior to course attendance some patients hold erroneous beliefs about the course content, especially the exercise component. Co-existent cardiac misconceptions are also apparent. Further research is needed to clarify the extent to which these beliefs may contribute to the decision not to attend cardiac rehabilitation.

Factors associated with cardiac rehabilitation attendance: a systematic review of the literature.

BACKGROUND: Many eligible patients fail to attend cardiac rehabilitation courses. OBJECTIVE: To undertake a systematic literature review of studies that have investigated factors associated with cardiac rehabilitation attendance. METHODS: Literature published between 1978 and 2001 was searched using the MEDLINE, PSYCINFO and CINAHL computerized databases. Studies were sought that examined course attendance in eligible patient samples. Studies had to include at least one baseline predictor variable. RESULTS: Fifteen studies were identified and predictor variables were usually categorized as sociodemographic, medical and psychological. Nonattenders are more likely to be older, to have lower income/greater deprivation, to deny the severity of their illness; they are less likely to believe they can influence its outcome or to perceive that their physician recommends cardiac rehabilitation. Job status, gender and health concerns play an indirect role in attendance behaviour. Comparison of results between studies could be influenced by different case-mix, measurement instruments and country of origin. CONCLUSION: A number of factors predict cardiac rehabilitation attendance and some of these are potentially modifiable.

Does angina vary with the menstrual cycle in women with premenopausal coronary artery disease?

OBJECTIVE: To determine whether angina in women with established coronary heart disease varies with changes in hormone concentrations during the menstrual cycle. DESIGN: Subjects were prospectively studied once a week for four weeks. SETTING: Cardiology outpatient department of tertiary referral centre. SUBJECTS: Nine premenopausal women, mean (SEM) age 38.89 (2.18) years, with established coronary heart disease, symptomatic angina, and a positive exercise test. MAIN OUTCOME MEASURE: Myocardial ischaemia as determined by time to 1 mm ST depression during symptom limited exercise testing. Position in the menstrual cycle was established from hormone concentrations. RESULTS: The early follicular phase, when oestradiol and progesterone concentrations were both low, was associated with the worst exercise performance in terms of time to onset of myocardial ischaemia, at 290 (79) seconds; the best performance (418 (71) seconds) was when oestrogen concentrations were highest in the mid-cycle (p < 0.05). Similar trends were observed in other measured variables. Progesterone concentrations did not influence exercise performance. CONCLUSIONS: During the menstrual cycle myocardial ischaemia was more easily induced when oestrogen concentrations were low. This may be important for timing the assessment and evaluating treatment in women with coronary heart disease.

Acute effects of hormone replacement with tibolone on myocardial ischaemia in women with angina.

This study was designed to evaluate whether hormone replacement therapy with tibolone demonstrated similar effects to those observed with oestrogen on myocardial ischaemia and angina. Ten postmenopausal women with documented coronary artery disease were evaluated by treadmill exercise electrocardiograms before and 24 hours after the oral administration of tibolone 2.5 mg. Onset of myocardial ischemia, as defined by ST segment depression, increased by a median 102 seconds (p = 0.022). Time to onset of angina increased by 31 seconds (p = 0.038), while total exercise time was not significantly affected (p = 0.24). Haemodynamic variables in the form of heart rate, systolic blood pressure and their product were unaffected by tibolone administration. We conclude that tibolone appears to show similar anti-ischaemic properties to oestrogen.

Whose illness is it anyway? Why patient perceptions matter.

Recent studies indicate it is frequently patients' implicit understanding and attitude towards their illness that affect health behaviours such as compliance with medication, follow-up and rehabilitation attendance--important mediators of physical and psychological outcome. An overview of the theory that forms the basis for such findings attempts to explain how illness perceptions mediate health outcome. By examining research which has demonstrated important relationships between illness beliefs and physiological/functional outcome in specific illnesses, this review attempts to bring together psychological theory and clinical outcome measurements; this should demonstrate the value and importance to health-care professionals of considering the patient perception framework.

A profile of long-stay psychogeriatric patients.

An assessment of 106 long-stay psychogeriatric in-patients in an East London borough was made using the CAPE and supplementary items in order to obtain a comprehensive picture of their needs; 51 long-stay residents in the care of local authority social services provided a comparison. Patients in hospital were found to be more disturbed, more disabled and more dependent than residents in local authority care.

Psychosocial morbidity in patients awaiting breast biopsy.

Psychosocial morbidity was compared in 91 patients awaiting breast biopsy and 30 women awaiting elective cholecystectomy. Somatic symptoms and social dysfunction were prominent in cholecystectomy patients. Patients subsequently found to have benign breast disease had the highest levels of psychological morbidity. Patients found to have breast cancer appeared no more anxious or depressed than those awaiting cholecystectomy. However, within the breast cancer group, patients aged 45 or less were significantly more anxious than those over 45, and a past history of psychological upset, prior to discovery of breast disease, was positively and independently associated with anxiety. Results are consistent with recent research suggesting an association between benign breast disease and a predisposition to psychological morbidity.

Psychosocial consequences of mastectomy: levels of morbidity and associated factors.

Psychosocial morbidity was examined in 90 consecutive patients with Stage I or II breast cancer aged under 70 treated by mastectomy. In the two years after surgery, the prevalences of depression and anxiety of clinical degree were generally under 10%--less than half of those reported in early controlled studies in the United Kingdom. However, cancer patients aged under 50 showed significantly higher prevalences compared with cancer patients aged 50 or above and compared with matched control subjects with benign breast disease. Social and work problems were common at all ages. Sexual problems were more severe than mood disturbance. Patients at risk of mood disturbance could be predicted by a combination of age, measures of emotional lability and whether or not they were receiving chemotherapy. The results of this study are consistent with those of other recent reports from the United Kingdom and United States, which show that following mastectomy, mood disturbance of clinical degree may be considerably less common than has previously been supposed.

Validity of the General Health Questionnaire and its subscales in patients receiving chemotherapy for early breast cancer.

The performance of the General Health Questionnaire as a case detector was assessed in 75 patients receiving chemotherapy for early breast cancer. The questionnaire and its subscales were found to be valid when compared with observer ratings. The misclassification rate of the 60-item version of the questionnaire was lowest when the standard threshold score for clinical morbidity was doubled to 24. It was lowest for the 28-item version when the threshold score was doubled to 10. Suggested threshold scores for clinical morbidity for the subscales are: anxiety and insomnia subscale 6/7; severe depression subscale 2/3; somatic symptoms subscale 6/7; and social dysfunction subscale 7/8. However, lower thresholds would be appropriate if the questionnaire were used as screening instrument prior to interview by a trained observer.

Psychosocial effects of radiotherapy after mastectomy.

Psychosocial morbidity was measured in 47 patients who received postoperative radiotherapy and in 38 who received no further treatment after mastectomy. Roughly one third of all patients experienced depression or anxiety. One month after operation, before radiotherapy, there were no significant differences between the two groups in any of the measures of psychosocial morbidity. Knowledge of impending treatment did not seem to influence morbidity. At three months patients who had completed radiotherapy had significantly more somatic symptoms and social dysfunction than those not so treated. At six months the radiotherapy group continued to show more somatic symptoms, but a year after operation there were no significant differences between the groups. Although several patients who received radiotherapy were upset by their treatment, the study failed to confirm that depression and anxiety were commoner among those given radiotherapy than among patients given no further treatment.

The impact of a liaison psychiatry service on patterns of referral in a general hospital.

A retrospective study of psychiatric referrals from a general hospital inpatient population was carried out for three separate years, 1973, 1976 and 1979. Reorganisation of the liaison service to the responsibility of one consultant team was associated with changes in referral rate and disposal. In particular, there was a significant increase in the referral rate of patients from medical and surgical wards who were not involved in acts of deliberate self-harm.

Uplifted marine terraces along the alpine fault, new zealand.

Three types of evidence indicate that marine terraces are widespread in the Southern Alps of New Zealand. (i) Remnants of shore platforms occur as distinct levels of notched ridge crests and flat summits; degraded sea cliffs are common. (ii) Scattered quartz beach pebbles occur on 16 of 18 levels of exhumed shore platforms in the Fox- Franz Josef type area to altitudes as high as 1700 meters. (iii) Altitudinal spacings of New Zealand terrace flights allow correlation with 18 dated global marine terraces at New Guinea, which were formed during glacio-eustatic highstands of sea level within the last 336 x 10(3) years. Inferred uplift rates at Fox-Franz Josef increased from 3.2 to 7.8 meters per 10(3) years since about 135 x 10(3) to 140 x 10(3) years ago, presumably because of increased convergence between the Pacific and Australian plates.

Psychological impact of adjuvant chemotherapy in the first two years after mastectomy.

Psychological symptoms were assessed over two years in a randomised trial of three forms of treatment given to women after mastectomy for stage II breast cancer. The treatments were: three weeks' radiotherapy; one year's adjuvant chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil; and radiotherapy followed by chemotherapy. Analysis of the results on an intention to treat basis showed no substantial differences in depression or anxiety among groups at one, three, or six months after the operation. At 13 months, however, patients who had been allocated chemotherapy had significantly more symptoms, especially depression, than control patients treated with radiotherapy alone. Conditioned reflex nausea and vomiting increased considerably during the second six months of chemotherapy and persisted for up to a year afterwards. The psychological morbidity of adjuvant chemotherapy could be substantially reduced if courses of treatment were restricted to about six months.

The social, emotional and financial implications of adjuvant chemotherapy in breast cancer.

The incidence and severity of toxicity, the extent of emotional disturbance and cost of adjuvant chemotherapy were assessed in patients with early breast cancer randomized to receive either radiotherapy, chemotherapy (CMF) or radiotherapy followed by chemotherapy. Nausea and vomiting occurred in 85 per cent of patients receiving chemotherapy and contributed significantly to distress. Over one-third of patients required a wig or developed mucosal ulceration. Nevertheless, most patients were able to return to work during treatment. Leucopoenia was more commonly encountered in those patients who received radiotherapy prior to chemotherapy. Twelve months after mastectomy, psychiatric morbidity was present in 13 of 34 patients receiving chemotherapy with or without radiotherapy, compared with only 1 of 18 receiving radiotherapy alone. Anxiety was common in both groups. This trend was still present 6 months after the completion of chemotherapy. The cost of chemotherapy is discussed.