Trained facilitators' experiences with structured advance care planning conversations in oncology: an international focus group study within the ACTION trial.

BACKGROUND: In oncology, Health Care Professionals often experience conducting Advance Care Planning (ACP) conversations as difficult and are hesitant to start them. A structured approach could help to overcome this. In the ACTION trial, a Phase III multi-center cluster-randomized clinical trial in six European countries (Belgium, Denmark, Italy, the Netherlands, Slovenia, United Kingdom), patients with advanced lung or colorectal cancer are invited to have one or two structured ACP conversations with a trained facilitator. It is unclear how trained facilitators experience conducting structured ACP conversations. This study aims to understand how facilitators experience delivering the ACTION Respecting Choices (RC) ACP conversation. METHODS: A qualitative study involving focus groups with RC facilitators. Focus group interviews were recorded, transcribed, anonymized, translated into English, and thematically analysed, supported by NVivo 11. The international research team was involved in data analysis from initial coding and discussion towards final themes. RESULTS: Seven focus groups were conducted, involving 28 of in total 39 trained facilitators, with different professional backgrounds from all participating countries. Alongside some cultural differences, six themes were identified. These reflect that most facilitators welcomed the opportunity to participate in the ACTION trial, seeing it as a means of learning new skills in an important area. The RC script was seen as supportive to ask questions, including those perceived as difficult to ask, but was also experienced as a barrier to a spontaneous conversation. Facilitators noticed that most patients were positive about their ACTION RC ACP conversation, which had prompted them to become aware of their wishes and to share these with others. The facilitators observed that it took patients substantial effort to have these conversations. In response, facilitators took responsibility for enabling patients to experience a conversation from which they could benefit. Facilitators emphasized the need for training, support and advanced communication skills to be able to work with the script. CONCLUSIONS: Facilitators experienced benefits and challenges in conducting scripted ACP conversations. They mentioned the importance of being skilled and experienced in carrying out ACP conversations in order to be able to explore the patients' preferences while staying attuned to patients' needs. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number registry 63110516 ( ISRCTN63110516 ) per 10/3/2014.

Live concerts reduce cancer inpatients' anxiety.

In Italy a new experience of music medicine called "The Music Givers" is spreading among Oncology Units; it aims to organise weekly live concerts (length 45-60 min) followed by a buffet. Purpose of the present study is to evaluate the effect of the format of The Music Givers on cancer in-patients' anxiety. State-Trait Anxiety Inventory (STAI-Y) was administered to 111 in-patients before and after the concerts. After the concerts we observed a 3.87 point decrease in state anxiety (p < .001) and statistically significant differences in most of the domains assessed by STAI-Y. These results invite a reflection on the importance of offering to inpatients events such as live music concerts, in order to improve their psychological condition during hospitalisation.

Use of the Needs Evaluation Questionnaire with cancer outpatients.

PURPOSE: The Needs Evaluation Questionnaire (NEQ) is a self-administered instrument with 23 dichotomous items that is used both in oncology clinical practice and in research. It was originally developed for use in setting of hospitalization. The aim of the present study was to assess the factor structure of the NEQ in an outpatient oncology sample and to compare the unmet needs of inpatients and outpatients in the Italian context. METHODS: In 6 Italian oncology departments, 783 patients completed the NEQ. Patients included in the study had different primary tumor sites and were in different phases of the disease and care process. There were 195 inpatients and 588 outpatients total. RESULTS: Confirmatory factor analysis (CFA) showed that, with outpatients, the NEQ retained the distribution of the items in five main areas previously described with inpatients. Cancer outpatients expressed high percentages of unmet needs primarily concerning "material needs" and "needs for psycho-emotional support." Our survey also suggested that, in addition to the 23 original items, four new items could be tested for specific use with outpatients. CONCLUSIONS: Our findings highlight the importance of establishing routine assessment of unmet needs also in clinical oncology settings different from wards-such as day hospitals, ambulatory rehabilitation, or follow-up ambulatory care-where, at least in the Italian context, the rate of unmet needs is currently considerably high. The NEQ could be an effective tool for this assessment.

Is it possible to encourage hope in non-advanced cancer patients? We must try.

BACKGROUND: Data are lacking on the relationship between hope and other variables in non-advanced cancer patients. The study explored the relationship between hope, symptoms, needs, and spirituality/religiosity in patients treated in a supportive care unit (SCU). PATIENTS AND METHODS: From September 2013 to March 2014, the consecutive patients who accepted to complete: (i) Needs Evaluation Questionnaire (NEQ), (ii) the Edmonton Symptom Assessment System (ESAS), (iii) Hope Herth Index (HHI), and (iv) the System of Belief Inventory (SBI) were enrolled. Moreover, clinical/demographic data were collected and the findings were analyzed. RESULTS: A total of 276 patients who completed the HHI questionnaire (participation rate 276/300 = 92%) were included; 131 reported HHI total score >37 (median value). The majority of patients had a Karnofsky performance status >80; 71% were on cancer therapies, and only 29 patients had metastases or relapse. Patients with higher HHI scores were less educated (P = 0.012), reported lower ESAS total score (15.4 versus 22.6, P < 0.001), and had less often been referred to a psychologist previously to the study (P = 0.002); patients with a higher HHI score also reported higher spirituality (P < 0.001). Some NEQ items resulted significantly associated with HHI score after adjustment for other variables: the need to have sincere clinicians (ß = -2.7), better dialogue (ß = -2.1), and more reassurance from the clinicians (ß = -2.5); better attention (ß = -4.4) and respect for intimacy (ß = -3.3) from nurses; to speak with people who have the same illness experience (ß = -2.5), to be more reassured by relatives (ß = -3.3) and to feel less abandoned (ß = -4.3). Higher SBI scores were independently associated with higher HHI scores (ß = 1.7 for 10 points increase). CONCLUSIONS: In cancer patients, hope can be encouraged by clinicians through dialogue, sincerity, and reassurance, as well as assessing and considering the patients' needs (above all the psycho-emotional), symptoms, psychological frailty, and their spiritual/religious resources.

International study of the place of death of people with cancer: a population-level comparison of 14 countries across 4 continents using death certificate data.

BACKGROUND: Where people die can influence a number of indicators of the quality of dying. We aimed to describe the place of death of people with cancer and its associations with clinical, socio-demographic and healthcare supply characteristics in 14 countries. METHODS: Cross-sectional study using death certificate data for all deaths from cancer (ICD-10 codes C00-C97) in 2008 in Belgium, Canada, Czech Republic, England, France, Hungary, Italy, Mexico, the Netherlands, New Zealand, South Korea, Spain (2010), USA (2007) and Wales (N=1,355,910). Multivariable logistic regression analyses evaluated factors associated with home death within countries and differences across countries. RESULTS: Between 12% (South Korea) and 57% (Mexico) of cancer deaths occurred at home; between 26% (Netherlands, New Zealand) and 87% (South Korea) occurred in hospital. The large between-country differences in home or hospital deaths were partly explained by differences in availability of hospital- and long-term care beds and general practitioners. Haematologic rather than solid cancer (odds ratios (ORs) 1.29-3.17) and being married rather than divorced (ORs 1.17-2.54) were most consistently associated with home death across countries. CONCLUSIONS: A large country variation in the place of death can partly be explained by countries' healthcare resources. Country-specific choices regarding the organisation of end-of-life cancer care likely explain an additional part. These findings indicate the further challenge to evaluate how different specific policies can influence place of death patterns.

Complementary needs behind complementary therapies in cancer patients.

OBJECTIVE: Although many studies indicate that the use of complementary and alternative medicine by cancer patients is common and widespread, few studies have focused on unmet needs of patients using complementary therapies (CTs). The aim of the present study was to evaluate, through a quantitative approach, possible associations between the use of CTs and the presence of specific unmet needs in cancer patients. METHODS: In six Italian oncology departments, 783 patients were interviewed about CTs use and completed the Needs Evaluation Questionnaire. Patients included in the study had different primary tumor sites and were in different phases of the disease and care process. RESULTS: At the time of the survey, 38.3% of patients were using one or more types of CTs. According to Needs Evaluation Questionnaire, the use of CTs was associated (p < .05) with the need to be more involved in therapeutic choices (40% vs. 31.7%), the need to have a better dialogue with clinicians (44.4% vs. 37.2%), and the need to have more economic-insurance information in relation to their illness (46.1% vs. 36.4%). Statistical significance was confirmed with multivariable analysis for the last two items, whereas three more needs were associated with the use of CTs after adjustment: to receive more explanation on treatments (46.8% vs. 41.0%), to receive more comprehensible information (38% vs. 31.9%), and to receive more attention from nurses (16% vs. 12.1%). CONCLUSIONS: Our study shows interesting differences regarding perceived needs between cancer patients who use and who do not use CTs. Unmet needs that are more expressed in CTs users should be known and, when possible, could be taken into account to improve both psychosocial interventions in the context of conventional care process and the quality of the relationship between patient and medical and nursing staff.

Careful monitoring of the use of sedative drugs at the end of life: the role of Epidemiology. The ITAELD study.

BACKGROUND: Sedative drugs are often used at the end of life for different clinical indications, and sometimes sedation is not interrupted until the patient dies. The aim of this study was to estimate the prevalence of patients who died while deeply sedated in Italy in 2007. METHODS: Cross-sectional survey which asked physicians about the last death that occurred among their assisted patients during the last year, and about their attitudes towards end-of-life decisions. All general practitioners (N=5,710) and a random sample of hospital physicians (N=8,950) from 14 Italian provinces were invited to participate. RESULTS: The response rate was 20%. Among 1855 reported deaths, 1466 (79.2%) were classified by physicians as expected or non-sudden; 18.2% of these expected or non-sudden deaths occurred while the patient was deeply sedated. GPs were the least likely to report deep sedation, whereas anesthetists were the most likely. In 8% of cases, sedation occurred along with an abrupt increase in the dosage of opioids during the last day of life, reaching a dosage considered higher than necessary by the doctor. No association with positive attitudes of the physician towards physician assisted death was found, whereas reporting sedation was associated with a positive attitude towards respecting the choice of relatives to forgo life-sustaining treatment in the case of an incompetent patient. CONCLUSION: Our study confirms the high prevalence of patients in Italy who die while being deeply sedated and shows that different practices may converge under the same label. Careful descriptive language is needed.

End-of-life preferences in advanced cancer patients willing to discuss issues surrounding their terminal condition.

The aim of the present study is to describe end-of-life preferences of advanced cancer patients willing to talk about death issues. Eighty-eight advanced cancer patients were interviewed through End of Life Preferences Interview (ELPI), a 23-item interview covering a wide range of end-of-life care issues. Most interviewed subjects were home care patients and their median survival after ELPI administration was 69 days. In total, 100% of responders expressed the will to receive some kind of information on the disease process and/or the treatments proposed. Approximately 77% declared to be willing to talk about what it is important at the end of life in case of worsening of their conditions and 31% prefer to be left alone in difficult moments. Approximately 67% choose home as the preferred place of death and 63% think it is preferable to die in a state of unconsciousness induced by drugs. About half of responders declare to believe in any kind of life after death and 40% consider very important to find any meaning at the end of life. ELPI can be a useful instrument to adapt the model of care to the specific needs and values of each patient.

Italian validation of the Purpose In Life (PIL) test and the Seeking Of Noetic Goals (SONG) test in a population of cancer patients.

OBJECTIVE: The first instruments developed to evaluate specific logotherapeutic dimensions were the Purpose In Life (PIL) and the Seeking Of Noetic Goals (SONG) tests, designed to reflect Frankl's concepts of, respectively, meaning in life attainment and will to meaning. This study aims to perform the Italian cultural adaptation and the psychometric validation of the PIL and SONG questionnaires. METHODS: We administered the PIL and SONG, culturally adapted into the Italian language, to 266 cancer patients. The psychometric validation appraised construct validity, internal consistency, test-retest reliability, known-group validity, and convergent validity of the two questionnaires with respect to one another. RESULTS: The factorial analysis indicates that the original single-factor solution can be maintained for both instruments (proportion of variance explained by the first factor 77% and 71% for the PIL and SONG, respectively). The results show excellent internal consistency (Cronbach's alpha of 0.91 for the PIL and 0.90 for the SONG) and test-retest reliability (intraclass correlation coefficient of 0.92 for the PIL and 0.81 for the SONG). As expected, males, believers, patients nearer to the diagnosis, and patients not undergoing psychological therapy have higher PIL and lower SONG scores, while expectations for age were not confirmed. The average level for the PIL was 107.3, while for the SONG, it was 66.1, and a negative correlation (-0.47) between PIL and SONG scores indicates good convergent validity of the two instruments. CONCLUSION: Italian versions of the PIL and SONG are adequate and reliable self-report instruments for evaluating purpose in life and the motivation to find purpose for cancer patient populations.

Does an organised screening programme reduce the inequalities in breast cancer survival?

BACKGROUND: The aim of the present study was to examine whether the implementation of an organised mammographic screening programme in Florence has been successful in reducing socioeconomic inequalities in breast cancer survival. PATIENTS AND METHODS: All invasive breast cancer cases diagnosed in women resident in the city of Florence in a prescreening period and in the first 10 years of the screening programme were selected. Their socioeconomic status (SES) was determined by using the national census 2001 data. All breast cancers were followed up to 10 years after the diagnosis. RESULTS: In the prescreening period, the survival of deprived women was 12 percentage points lower than the reference class, both in the younger age class (<50 years old) and in the age class target of the screening programme (50-69 years old). This difference progressively decreases until disappearing completely during the first 10 years of the screening programme for the age class invited to screening, whereas it remains stable in the younger age class. Participation in breast cancer screening and diagnostic accuracy were similar by SES. CONCLUSION: The organised breast cancer screening implemented in the Florentine area achieved the goal of reducing inequalities in breast cancer survival.

Assessment of psychological distress in cancer patients: a pivotal role for clinical interview.

OBJECTIVE: The evaluation of psychological distress in cancer patients recently entered oncologic clinical practice. The objective of this study was to evaluate the role of clinical interview within psycho-oncologic assessment. METHODS: Questionnaires assessing distress (PDI), psychopathology (MHQ, HADS) and needs (NEQ) and a subsequent clinical interview were proposed to 320 consecutive inpatients from the Oncology Department of Careggi Hospital in Florence. RESULTS: The clinical interview made it possible to evaluate a significant percentage of patients (30%) who did not fill in questionnaires and to detect the presence of distress in 39 (13.7%) patients who would not have received a diagnosis in a protocol for the assessment of distress based only on questionnaires. It also provided the possibility to ask for help or to receive clinical support to a high percentage of patients (44.1%) who had not requested to speak to a psychologist through the questionnaires (NEQ). Moreover, 25% of patients who received prolonged clinical support had a low score in tests detecting distress, indicating that the opportunity for therapeutic support can emerge during a clinical interview, also in the absence of relevant symptoms detected by questionnaires. CONCLUSIONS: The use of more than one questionnaire in the assessment of distress and psychopathology is associated with reduced compliance and redundant information. On the other hand, clinical interview has a pivotal role in clinical evaluation and access to psychological support. We conclude that optimal efficacy of programs assessing distress in cancer patients is reached when a single questionnaire evaluating distress is associated with a clinical interview.

Deaths of children occurring at home in six European countries.

OBJECTIVES: Until now there have been no population-based European data available regarding place of death of children. This study aimed to compare proportions of home death for all children and for children dying from complex chronic conditions (CCC) in six European countries and to investigate related socio-demographic and clinical factors. METHODS: Data were collected from the death certificates of all deceased children aged 1-17 years in Belgium, the Netherlands, Norway, England, Wales (2003) and Italy (2002). Gender, cause and place of death (home vs. outside home) and socio-demographic factors (socio-economic status, degree of urbanization and number of hospital beds in the area) were included in the analyses. Data were analysed using frequencies and multivariate logistic regression. RESULTS: In total 3328 deaths were included in the analyses; 1037 (31.2%) related to CCC. The proportion of home deaths varied between 19.6% in Italy and 28.6% in the Netherlands and was higher for children dying from CCC in all the countries studied, varying between 21.7% in Italy and 50% in the Netherlands. Among children dying from CCC, home death was more likely for cancer patients and those aged over 10 years. After controlling for potentially related clinical and socio-demographic factors, differences in the proportion of home deaths between countries remained significant, with higher proportions in Belgium and the Netherlands as compared with Italy. CONCLUSIONS: Although home deaths comprise a substantial proportion of all deaths of children with CCCs, variation among disease categories and across countries suggest that considerable potential still exists for further improvements in facilitating end-of-life care in the home for those children and families who desire to be in this location.

Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients' life. Results of an Italian mortality follow-back survey.

BACKGROUND: This study estimates prevalence, management, and relief of pain during the last 3 months of life of a representative sample of dying cancer patients in Italy. PATIENTS AND METHODS: This is a mortality follow-back survey (the Italian Survey of the Dying of Cancer). Caregivers were interviewed, after the patient's death, about pain experienced by the patients in all settings of care. RESULTS: According to caregivers' reports, 82.3% [95% confidence interval (CI) 79.9% to 84.4%] patients experienced pain, and 61.0% (95% CI 57.9% to 64.0%) very distressing pain. The younger population experienced a higher prevalence of pain in respect to older patients (P < 0.01). Patients with tumors of the central nervous system experienced the lowest prevalence (51.9%). According to caregivers' reports, only 59.5% (95% CI 3.7% to 65.0%) received analgesic treatment with opioids for moderate to severe pain. Not surprisingly, pain was 'only partially relieved' or 'not relieved at all' in 54% of the patients with very distressing pain. CONCLUSIONS: Although potentially slightly biased, the results from this survey regarding undermedication and poor treatment results for cancer related pain are unequivocal. The research agenda should focus on testing the effectiveness of interventions to improve the quality of pain assessment and management.

Population-based study of dying in hospital in six European countries.

This study examined the proportion of deaths taking place in hospitals in six European countries in relation to demographic, epidemiologic and healthcare factors. Retrospective analyses were performed on a database integrating death certificate data of all deaths in 2002 in Sweden and 2003 in Belgium, England, Scotland, the Netherlands and Wales (N = 891,780). Data were linked with regional healthcare statistics. Of all deaths, from 33.9% (the Netherlands) to 62.8% (Wales) occurred in hospital. Large country differences in hospital deaths were partly explained by the availability of care home and hospital beds. Differences between countries were strikingly large in older patients and cancer patients. Older patients had a higher probability of dying in hospital in Sweden, Scotland, England and Wales than in Flanders and, in particular, in the Netherlands. Cancer patients often died in hospitals in Sweden but less frequently so in the Netherlands and England. Country differences in the proportion of patients dying in hospital are only partly the result of differences in health care provision, and are in particular larger for certain patient categories, suggesting country-specific end-of-life practices in these categories. These findings can contribute to rational public health policies aimed at reducing hospital deaths.

Effectiveness of service screening: a case-control study to assess breast cancer mortality reduction.

The aim of this study was the evaluation of the impact of service screening programmes on breast cancer mortality in five regions of Italy. We conducted a matched case-control study with four controls for each case. Cases were defined as breast cancer deaths occurred not later than 31 December 2002. Controls were sampled from the local municipality list and matched by date of birth. Screening histories were assessed by the local, computerised, screening database and subjects were classified as either invited or not-yet-invited and as either screened or unscreened. There were a total of 1750 breast cancer deaths within the 50 to 74-year-old breast cancer cases and a total of 7000 controls. The logistic conditional estimate of the cumulative odds ratios comparing invited with not-yet-invited women was 0.75 (95% CI: 0.62-0.92). Restricting the analyses to invited women, the odds ratio of screened to never-respondent women corrected for self-selection bias was 0.55 (95% CI: 0.36-0.85). The introduction of breast cancer screening programmes in Italy is associated with a reduction in breast cancer mortality attributable to the additional impact of service screening over and above the background access to mammography.

Continuous deep sedation in home palliative care units: case studies in the Florence area in 2000 and in 2003-2004.

AIM: The aim of this paper was to describe the frequency and the characteristics of continuous deep sedation in terminally ill patients. METHODS: All patients who died in home palliative care units in the Florence area between March 1-December 31, 2000 and July 1, 2003-June 30, 2004 were prospectively analysed with regard to social, demographic, and clinical characteristics. RESULTS: The data presented refer to 1075 patients (331 in 2000 and 744 in 2003-2004). Continuous deep sedation was applied in 14.2% and in 12% of patients, respectively. At baseline, patients who were sedated during the final stages of their life were more likely to be younger in age, to have poorer quality of life and better performance status. Such characteristics did not differ between the two periods. Hydration was not performed in 65% of all patients who finally received sedation in the period 2003-2004 versus 33% in those who did in 2000. In 2003-2004, the decision to use sedation was discussed with patients in 39% of those who were sedated. In 2003-2004, we noticed an increase in the use of benzodiazepines for continuous deep sedation from 43% to 87%. The increase in opioid average dosage from the onset of sedation until the last 24 h of their life was about seven-fold in 2000 and almost twice that amount in 2003-2004 in those patients who were not undergoing treatment with opioids when sedation started. CONCLUSION: The monitoring of end-of-life decision making and of medical practices involved in continuous deep sedation contributes to an enhancement in the quality of caring for terminally ill patients.

Different kinetics of immunologic recovery using nelfinavir or lopinavir/ritonavir-based regimens in children with perinatal HIV-1 infection.

The choice to include the optimal protease inhibitor (PI) in highly active antiretroviral therapy (HAART) regimens in children with perinatal HIV-1 infection is still under debate. Virologic and immunologic outcomes of three different regimens in an observational paediatric cohort were compared. Data from 12 saquinavir-, 18 nelfinavir-, and 10 lopinavir/ritonavir-treated children were analyzed after 4 and 24 weeks of therapy. Immunologic and virologic outcomes were compared using multivariate analysis adjusting the results for age, baseline CD4+ T-lymphocyte count and baseline viral load. Saquinavir-treated children displayed significant reduction in viral load at week 24 (but not at week 4) and no increase in CD4+ T-lymphocyte count, indicating a poor advantage in using this drug. Lopinavir/ritonavir-treated children presented lower viral loads than nelfinavir-treated children at week 4 (P=0.020) and week 24 (P<0.0001). Virologic failure occurred in 6/18 (33.3%) nelfinavir-treated children but in no child receiving lopinavir/ritonavir (P=0.013). An undetectable viral load was achieved in 9/10 (90.0%) lopinavir/ritonavir- vs. 3/18 (16.6%) nelfinavir-treated children (P<0.0001). No significant difference in CD4+ T-lymphocyte count was observed between lopinavir/ritonavir- and nelfinavir-treated children at weeks 4 and 24. However, a different kinetic of the immunologic recovery was observed. Lopinavir/ritonavir-treated children displayed higher CD4+ T-lymphocyte counts than saquinavir-treated children since the first month of therapy (week 4: P=0.042; week 24: P= 0.029) while nelfinavir-treated children took 24 weeks to reach such an outcome (P=0.034). Since lopinavir/ritonavir-based regimen controls viral replication more efficiently and restores CD4+ T-lymphocyte count more quickly than saquinavir- or nelfinavir-based HAART, it may be considered when a salvage therapy or a rapid increase in CD4+ T-lymphocytes is necessary.

Breast cancer mortality trends in two areas of the province of Florence, Italy, where screening programmes started in the 1970s and 1990s.

We compared breast cancer mortality rates in the period 1985-2000 in two areas of the province of Florence, Italy, where breast cancer screening programmes started in the 1970s (early screening (ES) area) and in 1990s (late screening (LS) area). The overall age-standardised mortality decreased in the whole period by 40.9% in the ES area (P<0.001), and by 11.3% in the LS area (P=0.030). Significant decreases in the ES area were detected in groups aged 45-54 years (61.1%; P= 0.018) and 65-74 years (44.7%; P= 0.049), whereas in the LS area no significant decrease was detected in any age group. The relatively low compliance in the first years of the programme in both areas, and the long enrollment period in the LS area could have reduced the effect on mortality. Our findings suggest that the drop in mortality in the ES area (41%) could be explained by both service screening and better care. The slight decrease in mortality in the LS area (11%) could be mainly due to better care. A reduction of about 30% is attributable to screening in the ES area over the period 1985-2000.

Suicide mortality is decreasing among cancer patients in Central Italy.

The objective of this study was to discover whether suicide mortality among patients diagnosed with cancer during the period 1985-1999 had decreased with calendar time in comparison to the rate in the general population. 90?197 cancer patients resident in Tuscany, Central Italy and incident during the period 1985-1999 were followed up for life status to 31 December 2000. The mortality codes for suicide were considered (E950-E959). Time trends for suicide rates were assessed by using Kernel smoothing estimators, standardised mortality ratios and Poisson analysis of the observed/expected ratios. The standardised mortality ratios were 324, 224, and 185 for cancer patients diagnosed during the periods 1985-1989, 1990-1994, and 1995-1999, respectively. Tests for linear trends were borderline significant (P=0.053). Suicide mortality among cancer patients in central Italy had decreased with calendar time relative to the suicide trend in the general population. Improved treatment options and better communication of diagnosis are possible explanations of this finding.