How do the information needs of cancer patients differ at different stages of the cancer journey? A cross-sectional survey.

OBJECTIVES: Providing information to cancer patients can have significant benefits to their psychological wellbeing. The aim of this study was to investigate whether and how information needs may differ for patients at different stages of the cancer journey. DESIGN: Cross-sectional, self-completed survey using convenience sampling. SETTING: Oncology outpatients in Wolverhampton, West Midlands. PARTICIPANTS: Cancer patients aged 18 years and over. MAIN OUTCOME MEASURES: The survey used Likert scales to determine whether patients wished to know more about 35 items of information categorized under seven domains: cancer (diagnosis); prognosis; treatment; rehabilitation; psychological/spiritual; social/family; and body image/sexuality. Each domain was scored, with higher scores indicating a greater wish for information. RESULTS: There were 187 participants (50% response rate). Patients tended to want more information, particularly related to prognosis. Post-treatment patients continued to have information needs comparable to patients undergoing treatment or at the pre-treatment stage, except with reference to treatment-related information (p = <0.01), although as time from diagnosis increased, information needs reduced. Educational attainment, age, treatment status, gender and ethnicity were all significant predictors of scores in various domains. CONCLUSION: This study indicates that the time since diagnosis may interact with various demographic and disease-related factors in contributing to the information needs of cancer patients. The majority of cancer patients wish to know more about a wide range of factors, and such information seeking preferences are present regardless of an individual's stage following diagnosis.

Controlling the toxicity of palliative radiotherapy: the role of 5-HT3 antagonists.

A significant number of cancer patients undergoing palliative radiotherapy experience treatment-related nausea and vomiting. A number of factors are known to influence the incidence and severity of radiation-induced sickness including the site, field size and dose per fraction. The age of the patient and the level of patient anxiety may also play a role. Furthermore, there is some evidence that high alcohol consumption has a protective effect against radiation-induced illness. It is generally accepted that there is a high risk of nausea and vomiting associated with high doses of radiotherapy; however, this effect has never been adequately quantified. Nonetheless, as a consequence of radiation-induced nausea and vomiting, patients may experience a decrease in their quality of life and may choose to delay or even refuse further treatment. Thus, controlling the adverse side effects associated with radiation therapy is critical to optimal patient care.

The role of palliative radiotherapy for bone metastases.

Painful bone metastases are a clear indication for the use of radiotherapy, with reported response rates of up to 85% of patients treated. In an attempt to define the optimal use of palliative radiotherapy when used in this situation, the data for the efficacy, toxicity and choice of dose and fractionation are reviewed. Although there have been some recent trials demonstrating the value of hypofractionated radiation therapy, half-body irradiation and 89-strontium, in general there is a lack of information in this clinical area, particularly on the duration of beneficial effect and on treatment toxicity. The available data suggest that single-fraction radiation is as effective as short-course fractionated treatment, and may be isotoxic when 5HT3 antagonists are used. Future implications for research are discussed.

Palliative radiotherapy in the UK.

A number of different palliative radiotherapy techniques and fractionation schedules have been used in the UK over the past several years. In an attempt to standardize treatment practices, a handful of studies have been conducted in recent years compiling basic demographic data on the use of palliative radiotherapy as well as response data for the various techniques currently in use. In one study conducted at Mount Vernon Hospital, just outside of London, Maher and colleagues collected data on 425 consecutive patients given radiotherapy during a six-week period in 1988. Of those, 211 (49.6%) patients received radical treatment for long-term tumor control, and the remaining 214 (50.4%) patients received palliative treatment for symptom relief in the case of incurable cancer. Of the 214 patients treated with palliative radiotherapy, 90 (42%) patients were treated for bone secondaries, 63 (29%) patients for primary carcinoma of the bronchus, 12 (6%) patients for brain secondaries and 49 (23%) patients for other miscellaneous reasons. There is evidence that in the last few years British practice in palliative radiotherapy has changed substantially, largely as a result of the findings of recent clinical trials. This review will summarize the data relating to the radiotherapeutic management of bone secondaries, advanced lung cancer and cerebral metastases.

Final results of the Royal College of Radiologists' trial comparing two different radiotherapy schedules in the treatment of cerebral metastases.

Between February 1990 and February 1993, 25 centres in the UK recruited 544 patients into a prospective randomized trial comparing two whole-brain radiotherapy regimens (30 Gy in ten fractions over 2 weeks versus 12 Gy in two fractions on consecutive days) for the treatment of patients with symptomatic cerebral metastases. Of these patients 533 were eligible for analysis: 270 assigned to the two-fraction arm and 263 to the ten-fraction arm. The two groups were well balanced with respect to patient characteristics. Median survival was 77 days with two fractions (95% CI 68-89) and 84 days for the longer schedule (95% CI 67-102). Analysis of the survival curves showed a marginal advantage for ten fractions (P = 0.04). Performance status (P = 0.0001), site of primary tumour (P = 0.006), dose of dexamethasone (P = 0.004), age (P = 0.04) and randomization treatment (P = 0.03) were independant factors associated with survival. The classification of patients into good or poor risk groups based on these factors, excluding treatment, showed highly significant differences in survival (P < 0.0001). Predictive models suggested that any benefit attributable to the longer radiotherapy schedule was confined to those in a good prognostic group (these patients formed 22% of the study population). Radiation related side effects, other than alopecia, were seen in 12% of patients receiving two fractions and 8% of those given ten fractions. The short survival of many patients hampered the assessment of response, but overall responses were seen in 39% of those given two fractions and 44% of patients receiving ten fractions. These results suggest that any increase in survival due to longer radiotherapy treatment is confined to good prognosis patients, but, for the majority, there is no advantage and the value of radiotherapy for these patients relates purely to the possibility of control or relief of distressing symptoms.

Lymphoma of the prostate treated with radiotherapy.

Primary prostatic lymphoma is a rare disease. We report a 73-year-old man who initially presented with features of bladder outflow obstruction. Histology revealed non-Hodgkin's lymphoma. He was treated with radical radiotherapy with complete regression of disease. Although the follow-up period is, as yet, relatively short, the apparently good result in this patient supports the view of other recent reports that the outcome in this situation depends on the features of the individual disease rather than it being universally poor as had been previously suggested.

A prospective randomized trial to evaluate different oral dose regimens of medroxyprogesterone acetate in women with advanced breast cancer.

A prospective randomized study was conducted to try to answer two questions: is a loading dose of medroxyprogesterone acetate (1000 mg p.o. q.d.s. for 48 h) superior to conventional dosing; and does an oral maintenance dose of 1000 mg daily offer any advantage over 500 mg daily in women with advanced breast cancer who have failed to respond to, or have relapsed after, tamoxifen? Of 211 patients randomized, 207 were evaluable. There was no improvement in response rates, time to response, response duration or overall survival as a result of the loading dose. When comparing high and low maintenance doses, there was a significant difference in response rates (48% versus 32%; chi 2 = 10.09, df = 2, P = 0.006) and survival (66% versus 41% alive at 12 months; chi 2 = 9.06, df = 1, P = 0.003) in favour of the higher dose regimen, although there was no significant difference in the duration of response. There was no additional toxicity attributable to the loading dose regimen, but side effects were more frequent with the high dose maintenance schedule (141 of 201 adverse effects occurring in these two groups) although the incidence of severe toxicity was similar with both high dose and low dose treatments.

Screening for anxiety and depression in cancer patients: the effects of disease and treatment.

The General Health Questionnaire 28 (GHQ 28), Hospital Anxiety and Depression Scale (HADS), and Rotterdam Symptom Checklist (RSCL) seemed promising in their ability to detect anxiety and depression in cancer patients. To compare their screening performance, 513 patients were recruited from four cancer centres, and visited at home by a trained interviewer. Paired combinations of questionnaires (GHQ 28 + HADS, GHQ 28 + RSCL or RSCL+HADS) were used, and then the Psychiatric Assessment Schedule was administered to enable a psychiatric diagnosis to be made using DSM III diagnostic criteria. A receiver operating characteristics curve was drawn by plotting the true positive rate (sensitivity) against the false positive rate (1-specificity) for each possible score on each questionnaire. In the overall sample, the HADS and RSCL performed well comparably. The HADS did best in those free of disease and when the disease was judged to be stable. Only the RSCL performed well in those with progressive disease. Both the HADS and RSCL were effective in those on treatment. The GHQ was superior to the RSCL in those off treatment. The choice of questionnaire and threshold score should take disease and treatment status into account, but all three questionnaires have a definite role in screening out anxiety and depression.

A review of ondansetron in the management of radiotherapy-induced emesis.

This paper reviews experience with ondansetron in radiotherapy-induced emesis. The efficacy of ondansetron is assessed following a number of different radiotherapy regimens: single-dose radiotherapy, fractionated radiotherapy, total body irradiation (TBI) and hemi-body irradiation. In single-dose radiation-induced emesis, ondansetron (8 mg orally 3 times daily) provided superior anti-emetic control compared with metoclopramide (10 mg orally 3 times daily): 92 and 46% of patients, respectively, experienced complete control of emesis (0 emetic episodes) in the first 24 h following treatment (p < 0.001). Similarly, ondansetron (8 mg orally 3 times daily) was significantly (p < 0.001) more effective than prochlorperazine (10 mg orally 3 times daily) with 59 and 35% of patients, respectively, achieving complete control of emesis on the 'worst day' of a fractionated radiotherapy regimen (up to 20 fractions). Two studies evaluating the efficacy of ondansetron in TBI-induced emesis have demonstrated that ondansetron is effective in paediatric and adult patients receiving chemotherapy and TBI prior to bone marrow transplantation. In these studies, 57-81% of patients experienced 2 or fewer emetic episodes during TBI. For hemi-body irradiation, ondansetron (8 mg) and dexamethasone (8 mg) given orally produced complete control of emesis in 12 out of 14 patients. The effectiveness of this regimen now enables patients receiving hemi-body irradiation to be treated as outpatients in many cases. Anecdotal data also shows that ondansetron is effective when given as intervention treatment in patients with established emesis. In none of the studies were there any serious adverse events following ondansetron treatment. It can therefore be concluded that ondansetron is an effective and well tolerated antiemetic for the prophylaxis and treatment of radiation-induced emesis and nausea. The use of effective anti-emetic treatments may have resource implications such as reducing bed occupancy and enabling the use of fewer, larger fractions of radiotherapy.

A phase II evaluation of human lymphoblastoid interferon (Wellferon) in relapsed high grade malignant glioma. Medical Research Council Brain Tumour Working Party.

During the 1980s a number of studies suggested there might be a role for interferon in the treatment of high grade gliomas. In the light of these reports a formal Phase II evaluation of human lymphoblastoid interferon (Wellferon) was undertaken in patients with high grade gliomas which had relapsed after conventional radiotherapy; 14 patients were treated and no objective clinical responses were seen. This indicates that the overall response rate to interferon therapy in this situation would be less than 20%. It is therefore concluded that interferon administration is unlikely to be of value in the management of relapsed high grade gliomas.

The quality of life of early breast cancer patients treated by two different radiotherapy regimens.

A cohort of 63 patients participating in a prospectively randomized trial evaluating two different radiotherapy regimens and adjuvant tamoxifen in the conservative management of early breast cancer were monitored by a series of psychological measures. The aim was to determine whether there was any difference between the radiotherapy schedules in terms of their impact on the patient's quality of life and whether measures of coping style and trait anxiety could be used to predict the subjective response to treatment. Overall, radiotherapy had little effect on quality of life and the differences between the two regimens were minor with significantly more of those women on the longer treatment schedule experiencing a transient weight change, disruption of private life and loss of positivity compared with those on the shorter schedule. In anticipating psychological adjustment to treatment, coping style proved unhelpful but trait anxiety was found to be a robust indicator of response, suggesting that it may be possible to determine in advance those patients who are likely to exhibit psychological distress during radiotherapy.

A prospective randomized double-blind trial comparing ondansetron versus prochlorperazine for the prevention of nausea and vomiting in patients undergoing fractionated radiotherapy.

In a multicentre, international double-blind trial, patients undergoing courses of five or more daily radiotherapy treatments to the upper abdomen were randomized to receive either oral ondansetron 8 mg t.d.s. or oral prochlorperazine 10 mg t.d.s. throughout their radiation course in order to try to prevent nausea and vomiting. A total of 192 patients were recruited, 135 of whom were included in the efficacy analysis; of these, 70 received ondansetron and 65 prochlorperazine. Forty-three (61%) of the patients prescribed ondansetron and 23 (35%) of those given prochlorperazine had a complete response, with no emetic episodes throughout their treatment course (P = 0.002). There was, however, no significant difference between the two groups with respect to the incidence and severity of nausea. Seventeen (24%) of the patients on ondansetron and 19 (29%) of those given prochlorperazine were treatment failures, experiencing more than five emetic episodes on their worst day during the study. Both drugs were well tolerated, although constipation was seen more commonly with ondansetron.

A report of the consensus workshop panel on the treatment of brain metastases.

The consensus workshop on management of brain metastases focused on several broad issues concerning the patient with brain metastases. These issues included: What are the goals of treatment? Who should not be treated with radiation? What are the optimal treatment regimens? What are the areas of controversy where future investigations may be useful? The brain consensus panel attempted to develop guidelines for radiation oncologists through use of a decision tree format. Existing data to support management decisions, particularly those regarding radiation treatment, were reviewed. Data regarding cost of treatment as well as data regarding explicit quality of life measures were felt to be very important but were largely not available and therefore played little scientific role in the guideline development. Areas where controversy existed and where consensus could not be reached were identified.

Clinical oncology services to district general hospitals: report of a working party of the Royal College of Radiologists.

We conducted a survey of multidisciplinary non-surgical cancer services in district general hospitals without departments of radiotherapy and oncology. All consultants in clinical oncology (radiotherapy and oncology) in the United Kingdom were sent a questionnaire. This report is based on the analysis of information on 235 district general hospitals, which have an average of 450 acute or general beds. Non-surgical medical care for cancer patients at these hospitals is mainly provided by consultants in clinical oncology based at cancer centres. Initial assessment and follow-up, and some investigations and drug treatment, are organized at the district general hospitals, but radiotherapy and a substantial proportion of cytotoxic chemotherapy is administered at the cancer centres. The principal finding of the survey is that the average total weekly commitment of consultants in clinical oncology at district general hospitals is just under two sessions. We estimate that for each session at present provided at these hospitals there are five new cancer patients who would benefit from a specialized oncological opinion. For each new patient consultation there is a need for 5-10 times as many follow-up consultations. It is clear that the time available for cancer patients at district general hospitals, which on average are 22 miles away from the cancer centres, is far from adequate. We believe that it is correct to continue to base cancer services at cancer centres. This helps to ensure the maintenance of high standards and continuity of care. There is no need to alter the system, but there is a need to increase substantially specialist oncological presence at district general hospitals through the appointment of additional visiting consultants.

Results of a randomized, double-blind comparative study of ondansetron and metoclopramide in the prevention of nausea and vomiting following high-dose upper abdominal irradiation.

Ondansetron is a 5-hydroxytryptamine 3-receptor antagonist which has shown activity in the prevention of cytotoxic-induced emesis. Preliminary non-randomized studies also indicated efficacy in preventing sickness following radiotherapy. The present study was therefore undertaken to compare the efficacy and safety of ondansetron (8 mg tds orally) and metoclopramide (10 mg tds orally) in preventing sickness after single-exposure radiotherapy treatments of 8-10 Gy to the upper abdomen. Of 82 evaluable patients 38 received ondansetron and 44 metoclopramide. On the first day after irradiation vomiting or retching was prevented in all but one of the patients on ondansetron whereas metoclopramide achieved complete control of these symptoms in only 46% of subjects (P less than 0.001). Similarly nausea was significantly better controlled by ondansetron in the first 24 hours after treatment (P = 0.001). Complete or major control of vomiting or retching was maintained for 92%-100% of patients on ondansetron during the five days of the study period. In the metoclopramide group the proportion of patients with equivalent control improved from 70% on day 1 to 95 on day 5. Both drugs were well-tolerated.