Providing psychosocial group support for young women with breast cancer: findings from a wellness-based community collaboration.

This article describes our experience offering a collaborative, wellness-based group support program for young women with breast cancer. Goals were (1) to identify needs and priorities of young women with breast cancer; (2) to test the feasibility of a collaboration between an academic medical center, a regional cancer center, and a community-based agency; and (3) to positively influence participants' overall quality of life (QOL), emotional distress, and psychological well-being. The group intervention consisted of presentation of various topics, group discussion, and relaxation exercises. No significant changes on QOL or emotional measures were seen. Participants rated the session on symptom management as most useful and identified two areas for potential improvement (more homogeneity of participants, suggestions for additional topics).

A prospective quality-of-life study in men with clinically localized prostate carcinoma treated with radical prostatectomy, external beam radiotherapy, or interstitial brachytherapy.

PURPOSE: To prospectively assess the health-related quality of life (HRQOL) and changes in HRQOL during the first year after 3 different treatments for clinically localized prostate cancer. METHODS AND MATERIALS: Ninety men with T1-T2 adenocarcinoma of the prostate were treated with curative intent between May 1998 and June 1999 and completed a quality-of-life Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire before treatment (T0) and 1 month (T1), 3 months (T3), and 12 months (T12) after treatment. Forty-four men were treated with permanent source interstitial brachytherapy (IB), 23 received external beam radiotherapy (EBRT), and 23 men were treated with radical prostatectomy (RP). The mean age of the entire study population was 65.9 years (median 67, range 42-79). The mean pretreatment prostate-specific antigen level of the entire study population was 6.81 ng/mL (median 6.25, range 1.33-19.6). The Gleason score was

Prospective trial for the treatment of malignant peritoneal mesothelioma.

Malignant peritoneal mesothelioma (MPM) is a rare and often rapidly fatal disease with median survival of 5 to 12 months for untreated cases and 16 months reported after multimodality treatment. We report a prospective clinical treatment study using cytoreductive surgery combined with intraoperative intraperitoneal heated chemotherapy (IPHC) perfusion using mitomycin C for MPM. Twelve patients (11 male with a mean age 51 years) were treated. Seven patients presented with bulky disease and seven with ascites. All underwent exploratory laparotomy with histologically confirmed diagnosis of MPM. Surgical debulking as feasible was performed. Complete gross tumor removal was possible in only one patient. Cytoreduction was followed by a 2-hour closed low-volume IPHC using mitomycin C. One patient died 50 days postoperatively from complications relating to small bowel perforation. Hematologic toxicity of the procedure was minimal. Ascites was controlled in all patients and permanently in 86 per cent of patients presenting with ascites. To date median survival is 34.2 months with median follow-up of 45.2 months. One patient was re-explored for ventral hernia 2 years post-IPHC, had negative peritoneal biopsies, and remains disease-free at 5 years. Given the dismal prognosis associated with MPM the results of treatment with cytoreductive surgery combined with IPHC perfusion are encouraging. The rarity of MPM makes appropriately powered prospective randomized trials unlikely. Therefore, we now offer this approach off protocol; however, further study of this combined modality therapy is warranted.

Risk assessment of first-degree relatives of women with breast cancer: a feasibility study.

PURPOSE/OBJECTIVES: To measure psychological distress and test the feasibility of a psychological intervention to reduce distress in patients undergoing risk assessment. DESIGN: Descriptive. SETTING: A comprehensive cancer center located in the southeastern United States. SAMPLE: 20 first-degree relatives of women diagnosed with breast cancer (X age = 42; range = 21-70) completed the risk assessment process. Three were lost to follow-up at three months, leaving a total of 17 evaluable patients. METHODS: Data collection was by means of family/medical history forms and questionnaires administered at baseline and one and three months. Participants were randomized to either a control group consisting of standard education about risk for breast cancer or to an intervention group consisting of standard education plus a psychological intervention designed to teach stress-management skills. MAIN RESEARCH VARIABLES: Psychological distress, depressive symptoms, intrusive thoughts about breast cancer, and perceived risk for developing breast cancer. FINDINGS: Delivery of a psychological intervention proved feasible. Although no statistically significant differences existed between the intervention and control groups on distress and depressive symptoms, the intervention group reported fewer intrusive thoughts about breast cancer at follow-up. Risk did not predict anxiety levels. A large majority (73%) of the women overestimated the risk of breast cancer at baseline. CONCLUSIONS: This study demonstrated the feasibility of a multidisciplinary team approach to breast cancer risk assessment and counseling and management of psychological distress in first-degree relatives of women with breast cancer. The data suggest that a psychological intervention may reduce cancer-specific psychological distress in women at increased risk for breast cancer. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses can play an important role in the delivery of interventions to educate and reduce distress in women undergoing breast cancer risk assessment.

Quality of life after intraperitoneal hyperthermic chemotherapy (IPHC) for peritoneal carcinomatosis.

AIMS: This study assessed the functional status and quality of life (QOL) of patients with disseminated peritoneal cancer (DPC) before and after cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy (IPHC). METHODS: Patients with confirmed or suspected diagnosis of gastro-intestinal cancer including stomach, pancreas, hepatobiliary and colorectal cancer with peritoneal implants were enrolled in the study. Sixty-four patients completed the Functional Assessment of Cancer Therapy-Colon (FACT-C) scale and several other instruments at baseline. Forty-eight, 40, 39 and 31 patients were assessed at approximately 2 weeks post-surgery, and 3, 6 and 12 months respectively. RESULTS: There was a significant overall effect on the physical (P=0.0025), emotional (P<0.0001) and functional well-being (P=0.0044) subscales and the FACT-C (P=0.0076). Physical and functional well-being scores decreased at post-surgery follow-up and increased relative to baseline at 3, 6 and 12 months. Nineteen per cent, 46%, 59% and 74% of patients resumed greater than 50% of their normal activities post-operatively at 3, 6 and 12 months respectively. A percentage of patients reported depressive symptoms: baseline (28%), post-operatively (33%), 3 months (23%), 6 months (21%) and 12 months (29%). CONCLUSIONS: Cytoreductive surgery followed by IPHC was well tolerated. Most patients returned to baseline or better levels of functioning within 3 months post-treatment.

Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for disseminated peritoneal cancer of gastrointestinal origin.

No standard effective treatment exists for peritoneal carcinomatosis of gastrointestinal origin. The pharmacokinetic advantage of intraperitoneal chemotherapy and the synergy of heat and certain anticancer agents have prompted researchers to investigate intraperitoneal hyperthermic chemotherapy in treating disseminated peritoneal cancers. We have conducted a large Phase II trial to determine the safety and efficacy of aggressive cytoreductive surgery and intraperitoneal hyperthermic chemotherapy (IPHC) in treating peritoneal carcinomatosis of gastrointestinal origin. Patients with disseminated peritoneal carcinomatosis of gastrointestinal origin with or without malignant ascites were eligible. After aggressive surgical debulking, patients were administered a 2-hour heated (40.5 degrees C) intraperitoneal perfusion with mitomycin C. The major response variable monitored was overall survival. Patients were assessed for toxicity after IPHC administration using the National Cancer Institute Common Toxicity Criteria. Eighty-four patients with peritoneal carcinomatosis of gastrointestinal origin were evaluated for survival and toxicity (colon, n = 38; appendix, n = 22; stomach, n = 19; other gastrointestinal, n = 5). Thirty-nine (46%) patients had malignant ascites at the time of therapy. The operative mortality (30-day) was 6 per cent. Hematologic toxicity was the most common toxicity but was of mild to moderate severity (7 and 4% of patients had grade 3/4 white blood cell or platelet toxicity, respectively). The overall median survival was 14.3 months. The median survival of patients with peritoneal carcinomatosis of appendiceal, colorectal, and gastric origins were 31.1+, 14.6, and 10.1 months, respectively. Significant differences in median survival were seen in patients without and with malignant ascites (27.7 vs 7.6 months; P = 0.0004) and R0/R1 (complete gross tumor resection) versus R2 (gross residual tumor) surgical resection status (28.5+ vs 10.8 months, P = 0.0002). These data suggest that aggressive cytoreductive surgery with IPHC using mitomycin C is safe and effective in treating peritoneal carcinomatosis of gastrointestinal origin. Additional studies and broader applications of this treatment are encouraged.

A prospective analysis of patient-reported quality of life after prostate brachytherapy.

The purpose of this study was to prospectively assess the patient-reported quality of life (QOL) and changes in QOL during the first 3 months after prostate brachytherapy (PB). Seventy-four men treated with PB between September 1997 and December 1998 completed a QOL questionnaire (Functional Assessment of Cancer Therapy-Prostate [FACT-P]) and a measurement of urinary symptoms (International Prostate Symptom Score [IPSS]) before treatment (T0), 1 month (T1), and 3 months (T3) following PB. All participants were treated with (125)I alone. The mean score (and standard deviation) at T0, T1, and T3 FACT-P questionnaire are as follows: 139.2 (15.7), 125.4 (20.2), and 133.0 (18.2). For the global test across time, statistically significant differences were observed for the cumulative scores of FACT-P (P < .0001). Examination of the subscales within the FACT-P instrument demonstrated statistically significant changes over time for the following: physical well-being, functional well-being and the prostate cancer subscale. The mean score (and standard deviation) at T0, T1, and T3 for the IPSS questionnaire are as follows: 9.1 (5.9), 20.0 (7.8), and 16.6 (7.2). For the global test across time, statistically significant differences were observed for the IPSS scores (P < .0001). Clinically meaningful decreases in QOL are evident within weeks after PB. Moderate to severe urinary symptoms persist for at least 3 months following PB.

Involving family members in cancer care: focus group considerations of patients and oncological providers.

Family members are an integral part of a patient's cancer care from the moment the diagnosis is delivered to the conclusion of treatment. Family members bring with them a range of emotional reactions, interpersonal dynamics and expectations for the care the patient receives. This study is part of a multi-institutional project to continue to improve the process of cancer care. In this study, 19 focus groups (11 patient and 8 provider) were conducted concerning issues related to doctor-patient communication in eight cancer centers in the United States. The content of the conversations was analyzed and thematic categories emerged that highlight the various strengths and difficulties associated with family involvement. The focus groups' comments support the need for explicit conversations between professional caregivers, patients and their loved ones, in order to negotiate the expectations and needs of each team member. Implications for clinical practice and strategies for working with family members are offered.

A preliminary analysis of health-related quality of life in the first year after permanent source interstitial brachytherapy (PIB) for clinically localized prostate cancer.

PURPOSE: To prospectively assess the health-related quality of life (HRQOL) and changes in HRQOL during the first year after permanent source interstitial brachytherapy (PIB). METHODS AND MATERIALS: Thirty-one men treated with PIB between September 1997 and March 1998 completed a quality of life (functional assessment of cancer therapy-prostate: FACT-P) and a urinary symptom questionnaire (international prostate symptom score: IPSS) prior to treatment (T0), 1 month (T1), 3 months (T3), 6 months (T6), and 12 months (T12) following PIB. All participants were treated with 125I alone. Repeated measures analyses of variance (ANOVA) were conducted on all quality of life and urinary outcome measures for all 31 patients at all time points. RESULTS: The median age of the study population was 66 (range 51-80). All men had clinical T1c-T2b prostate cancer. The Gleason score was < or =6 in 27/31 (87%). Median pretreatment PSA was 7.8 ng/ml (range 1.1-20.6). The mean score (and standard deviation) at T0, T1, T3, T6, and T12 for the FACT-P questionnaire are as follows: 140.5 (13.5), 132.7 (15.3), 137.2 (17.4), 140.1 (16.0), and 142.4 (15.3). For the global test across time, statistically significant differences were observed for the cumulative scores of FACT-P (p<0.0012). The decrease in HRQOL was most marked 1 month following PIB. Examination of the subscales within the FACT-P instrument demonstrated statistically significant changes over time for the following: physical well-being (PWB), functional well-being (FWB), and prostate cancer (PCS). By 3 months, all HRQOL measures had returned to near baseline. The mean score (and standard deviation) at T0, T1, T3, T6, and T12 for the IPSS questionnaire are as follows: 8.3 (5.5), 18.4 (8.0), 15.7 (7.4), 13.7 (7.4), and 10.2 (5.7). For the global test across time, statistically significant differences were observed for the IPSS scores (p<0.0001). The maximum increase in IPSS occurred 1 month following PIB. CONCLUSION: The results of this preliminary analysis suggest that clinically meaningful decreases in HRQOL, as measured by the FACT-P instrument, are evident within weeks after PIB. By 3 months, however, FACT-P scores return to near baseline levels. A validated instrument designed to measure urinary symptoms (IPSS) demonstrates that moderate to severe urinary symptoms persist for at least 3-6 months following PIB. One year following PIB, the scores on the FACT-P and IPSS questionnaires had returned to baseline.

Turning toward death together: conversation in mortal time.

Death has a different meaning for everyone it touches, and these meanings have serious impact on how each person communicates with others as they deal with it together. This paper is a reflection on clinical experience in dealing with the dying and their caregivers in a comprehensive cancer center. By "mortal time," we mean the psychological state human beings enter when confronted with the prospect of death. Our focus is on a particular and powerful instance of the entry into mortal time--the diagnosis of a terminal illness. The experience of mortal time is profoundly subjective. Authentic conversation has the power not only to enhance how people cope practically with dying, but to illuminate and enrich the very meaning of life for patients and caregivers alike, as they enter the sacred moment of mortal time together.

Early quality of life assessment in men treated with permanent source interstitial brachytherapy for clinically localized prostate cancer.

PURPOSE: We prospectively assessed quality of life changes with time using validated instruments in men with clinically localized prostate cancer treated with permanent source interstitial brachytherapy. MATERIALS AND METHODS: A total of 46 men consecutively treated with permanent source interstitial brachytherapy between September 1997 and June 1998 completed quality of life (Functional Assessment of Cancer Therapy-Prostate [FACT-P]) and urinary symptom (International Prostate Symptom Score [I-PSS]) questionnaires before (T0), and 1 (T1) and 3 (T3) months after treatment. All participants were treated with 125iodine alone. Repeated measures analyses of variance were conducted on all quality of life and urinary outcome measures for 44 patients with data at all 3 time points. RESULTS: Median patient age was 68 years (range 51 to 80). All men had clinical T1c to T2b prostate cancer, Gleason score was 6 or less in 36 (78%) and median pretreatment prostate specific antigen was 7 ng./ml. (range 1.1 to 20.6). Mean score (and standard deviation) at T0, T1 and T3 for each questionnaire was FACT-P 138.9 (14.4), 128.6 (19.4) and 136.7 (17.4), TO versus T1 p = 0.0005 and T0 versus T3 p = 0.6612, and I-PSS 8.3 (5.4), 19.7 (9.0) and 15.7 (7.2), T0 versus T1 p = 0.0001 and T0 versus T3 p = 0.0001. For the global test across time statistically significant differences were observed for the cumulative scores of FACT-P, I-PSS, physical well-being and prostate cancer subscales of the FACT-P and the Trial Outcome Index. By 3 months all quality of life measures had returned to baseline. Urinary symptoms as measured by I-PSS persisted for at least 3 months. CONCLUSIONS: Clinically meaningful decreases in quality of life, as measured by the FACT-P instrument, were evident within weeks after permanent source interstitial brachytherapy. However, by 3 months FACT-P scores returned to near baseline levels. A validated instrument designed to measure urinary symptoms (I-PSS) demonstrated that moderate to severe urinary symptoms persisted for at least 3 months following permanent source interstitial brachytherapy. An instrument specifically designed to measure urinary symptoms can provide additional clinical information when combined with FACT-P.

Reducing distress in cancer patients with an orientation program.

The purpose of this study was to test a brief orientation program for reducing anxiety, depressive symptoms, and overall distress in cancer patients at their initial clinic visit. One hundred and fifty consecutively referred patients seen in an oncology outpatient clinic were randomly assigned to an intervention or usual care control group. The intervention group received a clinic tour, general information about clinic operations, and a question and answer session with an oncology counselor. Outcome measures included the State-Trait Anxiety Inventory (STAI), the Brief Profile of Mood States (POMS), the Center for Epidemiologic Studies-Depression (CES-D) Scale, and an oncology clinic questionnaire which were administered at the initial clinic visit and follow-up. There were no statistically significant clinical or demographic differences between groups at initial assessment. At follow-up, the intervention group had lower state anxiety, lower overall distress, and fewer patients reporting depressive symptoms. Patients in the intervention group demonstrated significantly more knowledge about clinic operations and greater satisfaction with care. These data provide evidence that anxiety, distress and depressive symptoms can be reduced with an orientation program. This finding has particular relevance in the early stages of diagnosis where patients may suffer symptoms of anxiety and depression.

Quality of life and psychological distress of bone marrow transplant recipients: the 'time trajectory' to recovery over the first year.

The purpose of this study was to measure the trajectory of psychosocial recovery over the first year after bone marrow transplantation (BMT). BMT patients were assessed at baseline (n = 86), hospital discharge (n = 74), 100 days (n = 64) and at 1 year (n = 45). Participants completed the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale (FACT-BMT), the Profile of Mood States Total Mood Disturbance Scale (POMS-TMDS), the Medical Outcomes Social Support Survey (MOS-SSS), the Center for Epidemiologic Studies-Depression (CES-D) scale screener, a performance Status Rating Scale (PSR), and an interview questionnaire. The recovery trajectory in this patient population showed three distinct trends. The trajectory for distress was linear and improved over time with approximately 20% of patients continuing to have psychological distress at 1 year. Secondly, the trend for overall quality of life was parabolic, worsening at discharge, then improving at 100 days and at 1 year. However, there were individual areas of deficit at follow-up, eg fatigue, even while overall quality of life mean scores improved. Thirdly, the trend for patient concerns over time was linear and worsening. These recovery trajectories suggest psychosocial interventions before and after BMT that may prepare patients for increasing and worsening concerns even as physical well-being improves.

Health education to increase screening for cervical cancer among Lumbee Indian women in North Carolina.

Although age-adjusted mortality rates from cancer among Native-Americans are generally lower than for the US population as a whole, cervical cancer mortality rates are higher. This report presents results from a National Cancer Institute-funded health education program conducted among the Lumbee tribe in North Carolina that was designed to increase the proportion of women, age 18 and older, who receive Pap smears to screen for cervical cancer. The Solomon Four Group research design was used for this project. Participants were selected at random from the enrollment records of the Lumbee tribe and data collection was carried out during face-to-face interviews. The health education program was provided one-on-one in women's homes by a trained lay health educator and included verbal, print and videotape information. A total of 979 women were enrolled in the study, and 125 were lost to follow-up between the pre-test and post-test. Women who received the education program were found to be more likely to have knowledge of the Pap smear and to report a Pap smear in the past year at the post-test than those in the control group, regardless of whether they received the pre-test interview, P < 0.05. Women most likely to respond to the education program were also likely to have reported that they receive an annual physical examination. Women with better knowledge of the Pap smear tended to have more education, higher income and greater identification with Native-American culture than those with less knowledge. We conclude that the health education program was associated with greater knowledge about cervical cancer prevention and higher proportions of Lumbee women obtaining Pap smears in the past year.

The psychosocial impact of the diagnosis and treatment of laryngeal cancer.

The diagnosis and treatment of laryngeal cancer involves psychosocial stress for most patients because the disease can be life threatening and treatment is potentially disfiguring. Loss of voice, appearance changes, and functional limitations all pose threats to self image and identity. Since voice is essential to psychological identity, laryngectomy may pose significant short- and long-term adjustment problems. Risk for psychological disturbance and problems at the initiation of treatment and adaptation following treatment can be predicted based on certain patient information. The integration of a multidisciplinary team at the outset of treatment planning is crucial in helping patients adjust to the impact of laryngeal cancer.

Quality of life measurement in bone marrow transplantation: development of the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) scale.

We developed a 12-item bone marrow transplant subscale (BMTS) for the general Functional Assessment of Cancer Therapy (FACT) measure. The subscale combined with the FACT, (FACT-BMT) is a 47-item, valid and reliable measure of five dimensions of quality of life in bone marrow transplant patients. The three-step validation process involved the generation and selection of BMT-specific items and the testing of the overall measure. Items were selected from a list produced by seven oncology experts and 15 patients and were designed to assess content not represented in the general FACT items. A total of 182 patients completed the FACT-BMT at baseline, prior to BMT. An analysis measuring sensitivity to change was performed with 74 patients after transplantation and 60 patients over the three time-points of baseline, hospital discharge and 100 days. The FACT-BMT and all subscales were correlated, sensitivity to change was measured, and the internal consistency for each scale was calculated. Coefficients of reliability and validity ranged from 0.86 to 0.89 for the entire FACT-BMT and 0.54 to 0.63 for the BMTS. The BMTS was able to discriminate patients on the basis of performance status rating and also demonstrated sensitivity to change over time. The FACT-BMT has good psychometric properties for use in assessing quality of life in bone marrow transplant patients. The addition of the bone marrow transplant subscale to the general FACT measure makes it an excellent choice for use in BMT clinical trials.

Effectiveness of health education to increase screening for cervical cancer among eastern-band Cherokee Indian women in North Carolina.

BACKGROUND: The North Carolina Native American Cervical Cancer Prevention Project was a 5-year, National Cancer Institute-funded trial of health education designed to increase screening for cervical cancer among Native-American women in North Carolina. PURPOSE: This study was conducted to evaluate the effectiveness of this education program in the Eastern-Band Cherokee target population. METHODS: Cherokee tribal lands were mapped and all households (N = 2223) were listed to ensure maximum coverage of the eligible population (women, aged 18 years and older, who were enrolled tribal members). Eligible women were identified by the use of a brief questionnaire administered to an adult member of the household. Of the 1279 households with eligible women, 1020 (79.8%) agreed to participate. The intervention was an individualized health education program delivered by female Cherokee lay health educators. The participants were randomly assigned to receive or not to receive the intervention (i.e., to program and control groups, respectively) by use of the Solomon Four-Group design. Data were collected in face-to-face interviews conducted in the participant's home. Of the 996 women who were ultimately enrolled, 540 were randomly assigned to receive a pretest (preintervention) interview that involved administration of a 96-item questionnaire designed to collect data on knowledge, intentions, and behaviors related to cervical cancer; of these 540 women, 263 were randomly assigned to receive the education program. The remaining 456 women did not receive the pretest, but 218 were randomly assigned to receive the education program. Six months after receiving the education program, the women in all four groups were administered a post-test that was identical to the pretest. Logistic regression was used to assess the effects of the pretest and the educational program. All P values resulted from two-sided statistical tests. RESULTS: Eight hundred and fifteen (81.8%) of the 996 participants completed the post-test interview. The remaining 181 women who were lost to follow-up were evenly distributed among the four study groups. At the post-test, 282 (73.2%) of the 385 women who received the education program reported having had a Pap smear following the intervention, compared with 275 (64%) of the 430 control subjects. Women who received the education program were more likely to answer all knowledge items correctly on the post-test (odds ratio [OR] = 2.18, 95% confidence interval [CI] = 1.08-4.39) and to report having obtained a Pap smear in the past year (OR = 2.06, 95% CI = 1.14-3.72) than women in the control groups. CONCLUSION: Women who received the education program exhibited a greater knowledge about cervical cancer prevention and were more likely to have reported having had a Pap smear within the past year than women who did not receive the program.

Psychosocial care of the patient with cancer. A model for organizing services.

PURPOSE: Although the need and demand for psychosocial oncology services among patients with cancer is likely to grow, access to psychosocial services varies widely within treatment settings. Surveys and observations by clinicians indicate that these services are inadequate at most sites. There are many obstacles to service organization in this patient population. This article describes a model for delivering integrated psychosocial care that has applicability in cancer centers and other settings. DESCRIPTION OF PROGRAM: Psychosocial oncology services in the Comprehensive Cancer Center of Wake Forest University have been systematically organized into two program components: the Cancer Patient Support Program (CPSP) and the Psychosocial Oncology Program. These programs are unique in offering psychosocial support and counseling services that are integrated into the medical care of patients. The CPSP provides services through clinical staff members, core volunteers, and doctoral- and master's-level counseling students. The type of social support provided includes emotional support, help with tasks, informational support, and companionship support. The Psychosocial Oncology Program provides psychological assessment and counseling for patients and family members suffering from more intense psychological disturbance. A doctoral-level licensed practicing psychologist and a part-time master's-prepared counselor, both with responsibilities in the CPSP as well, make up the staff. CLINICAL IMPLICATIONS: The key element in any psychosocial oncology program is the healing relationships formed when one person cares for another. In the psychosocial oncology service structure described, patients with cancer and their families have the opportunity to be served on two different levels, depending on the intensity of the psychological disturbance. The time has come for psychosocial services to be offered in all treatment settings. The psychosocial oncology programs described here can be replicated in most cancer centers.