Do cancer patients change their diet in the e-health information era? A review of the literature and a survey as a proposal for the Italian population.

In recent years, there has been an explosion in the amount of available information on cancer in parallel with an ever-increasing number of cancer survivors. Cancer patients and long-term survivors are known to be more sensitive to health-related information and dietary changes could represent a potential consequence of this huge availability of messages. In our review about dietary changes after cancer diagnosis, we found that this topic is particularly investigated among the breast cancer population. The literature examined show that breast cancer patients modify their eating habits after diagnosis in a percentage that varies between approximately 30% and 60%. The most reported changes were an increased consumption of fruit and vegetables, a decrease in the consumption of red meat, fats and sugary foods. Patients who reported changes were more likely to be younger, with higher educational levels and with a longer period of time since their diagnosis of cancer. It also emerged that cancer patients are often more likely to use supplements. This topic has not been investigated in cancer patients in Italy, therefore, we propose an approach to explore it with a structured questionnaire: The "ECHO SURVEY - Eating habits CHanges in Oncologic patients".

Characteristics of terminal cancer patients who committed suicide during a home palliative care program.

Cancer patients may commit suicide at any stage of the disease and many risk factors of suicide have been described in the literature. To identify the possible vulnerability factors of suicide in five terminal cancer patients who committed suicide while they were cared for at home by well-trained palliative care teams, a psychological autopsy study was carried out by reviewing their medical records; their report of symptoms at the time of care; and with the caregivers', doctors', and nurses' recollection of events by means of a structured interview prepared ad hoc. We collected data regarding the physical, emotional, and social suffering of the patients, their personality profile, and their feelings with respect to the illness and disability. The interviews lasted for a mean of two hours and were performed from 2-8 years after the suicide events by the social worker at the Rehabilitation and Palliative Care Division. The interviews took place between June 1996 and January 1998. All the patients showed great concern about the lack of autonomy and independence, refused dependence on others and had fear/worry of losing their autonomy. Four patients presented functional and physical impairments, uncontrolled pain, awareness of being in the terminal stage, and mild to moderate depression. They had a feeling of hopelessness consequent to their clinical conditions, fear of suffering, and feeling of being a burden on others. They had a strong character and managerial professions. They had isolated themselves from others and they had previously talked about suicide. Before committing suicide, three patients had adverse physical/emotional consequences to the oncological treatments-they showed aggressiveness towards their family and one towards the home care physician. Multiple vulnerability factors were present simultaneously in all patients. However, the loss of, and the fear of losing, autonomy and their independence and of being a burden on others were the most relevant. The identification of a cancer patient at risk of committing suicide forms the first step for the prevention of and the setting up of adequate psychosocial rehabilitation of these patients whenever possible.

Attitudes towards intramural continuing medical education: a european perspective.

Continuing medical education (CME) is now one of the key areas of development in medical education. This paper describes the development of an intramural continuing medical education programme de novo in a newly opened cancer institute in Italy, which provided a unique opportunity to study attitudes towards the concepts and goals of continuing medical education as most of the individuals involved in this programme were exposed to continuing medical education for the first time. The continuing medical education programme was overseen by a CME committee for 1 year. Three 1-hour sessions were delivered each week and one credit point was awarded for each session. The sessions included grand rounds, clinical-based teaching and a 3-weekly rotating schedule of pathology, radiology and research. Participants were all the medical doctors attending the European Institute of Oncology. Attendance at greater than 50% of the total sessions available yearly qualified the individual for certification by the CME committee of the Institute. A questionnaire was circulated to all medical doctors at the Institute at the end of the academic year to assess attitudes to CME in general. Forty-six out of 84 questionnaires were returned. The majority of those involved in this CME intramural programme undertook self-directed CME activities and at least 50% had not previously attended either grand rounds or research seminars. Most felt that CME should not be mandatory but that its activities should be monitored. The greatest difficulty with CME was in its timing.

Suicide among patients with cancer cared for at home by palliative-care teams.

Patients with terminal cancer are thought to be at high risk of committing suicide. In a population of 17,964 patients with terminal cancer cared for at home by 12 palliative-care teams, five patients committed suicide. We speculate that continuing care made up by symptomatic treatment and psychosocial support given to these patients may reduce the risk.

Evaluation of the EORTC QLQ-C30 questionnaire: a comparison with SF-36 Health Survey in a cohort of Italian long-survival cancer patients.

BACKGROUND: Despite the large amount of data available about the EORTC QLQ-C30 questionnaire, there have been very few studies focussed on long-survival cancer patients, and no data are available on its performance in the Italian setting. PATIENTS AND METHODS: Within the framework of a project aimed at evaluating the characteristics of available HR-QOL questionnaires in the Italian language, the EORTC QLQ-C30 questionnaire together with the Short Form 36-item Health Survey (SF-36) were mail-administered to a sample of patients previously recruited in two large multicenter randomized clinical trials on early breast and colon cancers. The properties of the questionnaire were evaluated using standard psychometric techniques and correlation analyses with demographic and clinical independent variables. RESULTS: In the sample of patients who sent back the questionnaires under evaluation, the EORTC QLQ-C30 showed satisfactory acceptability (response rate = 64% and very low prevalence of missing at item and scale level), and the psychometric analyses confirmed the multi-dimensional conceptualisation in terms of convergent and discriminant validity. Moreover, EORTC QLQ-C30 scales showed substantial correlation with the homologous SF-36 scales. Few socio-demographic (age, gender, schooling) and clinical (type of cancer disease) variables were associated with HR-QOL. Breast cancer patients reported, on average, worse physical health-related scores, but after adjustment for age and education, most of the differences disappeared. CONCLUSIONS: These findings confirm the validity and robustness of the EORTC QLQ-C30 in this sample of long-survival Italian cancer patients. Further ad hoc validation studies are required to evaluate its significance in these particular patients.

Personalized surgery for rectal tumours: the patient's opinion counts.

In recent times there have been many important changes in the surgical management of rectal cancer. The general thrust of these changes has been towards a less invasive approach with preservation of intestinal continuity and avoidance of the psychological sequelae of a stoma. It is also becoming increasingly apparent that profound sexual and autonomic dysfunction can be associated with abdominoperineal resection. This paper highlights these issues and the conflict between performing an adequate oncological procedure and reducing the incidence of postoperative psychological morbidity. It outlines the great changes there have been in surgical technique and their relevance to psychological problems after surgery for rectal cancer. The need for auditing psychological morbidity when assessing the outcome of surgical series is emphasised, as is the importance of involving the patient in the medical decision making.

Psychosocial adaptation after liver transplantation with particular reference to recipients aware of their cancer.

This study investigated the Psychosocial adjustment in 40 patients who received orthotopic liver transplantation (OLT) for several endstage liver diseases. Twenty patients were grafted because they suffered from liver Cancer as well as cirrhosis. Particular attention was paid to evaluating whether cancer could affect recipients' coping with transplant. Each patient underwent a semi-structured interview to obtain information on their psychosocial life, relationship with the donor, organ acceptance and life expectancy. Interview was performed I year after transplantation. A psychodiagnostic evaluation was also performed using a Minnesota Multiphasic Personality Inventory (MMPI) and a Human Figure Test. Psychosocial adaptation in everyday life following liver transplantation seemed good in most of the patients, whatever the indication for transplantation might be. It can he seen that by replacing the diseased organ a high percentage of oncological patients overcame their fear of cancer.

Guidelines on artificial nutrition versus hydration in terminal cancer patients. European Association for Palliative Care.

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step 1: define the eight key elements necessary to reach a decision; Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e., improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

Isolated anomalous inferior vena cava with azygos drainage.

In a 79-year-old female with shortness of breath, catheterization via the femoral vein encountered difficulty entering the right heart; venography revealed anomalous drainage of the inferior vena cava via a dilated azygos vein permitting subsequent catheterization. Similar difficulties during catheterization merit consideration of this congenital anomaly, which is virtually always discovered in the pediatric population in association with other congenital anomalies. Its unique discovery at advanced age indicates its benignity as an isolated abnormality.

Prevalence of sexual dysfunction in male cancer patients treated with rectal excision and coloanal anastomosis.

Impotency due to parasympathetic nerve injury is one of the most feared consequences of rectal cancer surgery. Sexual relationships make a significant contribution to the quality of life for almost everybody. Rectal excision and coloanal anastomosis (CAA) is a new surgical procedure for low rectal tumor with little data regarding the prevalence of sexual impairment as yet. We have examined the sexual life of 21 male patients who have undergone CAA by means a self-administered questionnaire. Only two patients reported reactive impotency. On the other hand 17 out of 21 patients had no ejaculation after undergoing surgery. According to our data it appears that CAA results in surgery a low degree of sexual impairment (impotency). Both sexual dysfunction and quality of life investigations should be integrated with oncological results when reporting data about colorectal surgery.

Total rectal resection and colo-anal anastomosis for low rectal tumours: comparative results in a group of young and old patients.

Rectal cancer incidence is increasing among the elderly who are more often considered for palliation rather than for surgical cure. Moreover, sphincter-sparing surgery is often avoided when treating the elderly. We report our experience on a consecutive series of 38 subjects, suffering from a lower third rectal tumour with a median distance of 5.6 cm from the anal verge (7 Dukes' A, 6 Dukes' B, 17 Dukes' C, 3 Dukes' D, 3 anastomotic recurrences and 2 large villous adenomas). All subjects were prospectively collected in a 2-year period and treated with total resection and colo-anal hand-sewn anastomosis on a J colic reservoir. 20 patients younger than 65 years and 18 over 65 years were matched for surgical complications, late morbidity, oncological and functional results but no statistical difference was found. Our hope is that a conservative approach in treating the low rectal tumours will progressively be accepted for elderly patients.

Psychological aspects of genital human papillomavirus infection: a preliminary report.

Genital human papillomavirus (HPV) infection can lead to self-inflicted blame and hypochondriac fears as well as to problems with sexuality. The aim of this study was to assess the psychological and psychodynamic aspects of patients with widespread genital HPV infection entering into a clinical trial in which they were randomly assigned to three treatment groups: CO2 laser ablation, intramuscular interferon-alpha, CO2 laser ablation plus intramuscular interferon-alpha. Fifty-one patients were studied. Patients were asked to take a series of questionnaires which included a self-rating questionnaire for gathering information on sexuality, emotional relationship with the partner and social life. A visual analog scale was used to rate intensity of pain during sexual intercourse. Each patient went also through an in-depth interview with a clinical psychologist and filled out two personality tests to measure depression (CDQ = IPAT depression test) and anxiety (ASQ = IPAT anxiety test). Results indicated a high percentage of sexual impairments after therapy (28 cases), presence of fear of cancer (14 cases) and worsenings in the emotional relationship with the partner. No difference was found among groups of treatment.

The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology.

BACKGROUND: In 1986, the European Organization for Research and Treatment of Cancer (EORTC) initiated a research program to develop an integrated, modular approach for evaluating the quality of life of patients participating in international clinical trials. PURPOSE: We report here the results of an international field study of the practicality, reliability, and validity of the EORTC QLQ-C30, the current core questionnaire. The QLQ-C30 incorporates nine multi-item scales: five functional scales (physical, role, cognitive, emotional, and social); three symptom scales (fatigue, pain, and nausea and vomiting); and a global health and quality-of-life scale. Several single-item symptom measures are also included. METHODS: The questionnaire was administered before treatment and once during treatment to 305 patients with nonresectable lung cancer from centers in 13 countries. Clinical variables assessed included disease stage, weight loss, performance status, and treatment toxicity. RESULTS: The average time required to complete the questionnaire was approximately 11 minutes, and most patients required no assistance. The data supported the hypothesized scale structure of the questionnaire with the exception of role functioning (work and household activities), which was also the only multi-item scale that failed to meet the minimal standards for reliability (Cronbach's alpha coefficient > or = .70) either before or during treatment. Validity was shown by three findings. First, while all interscale correlations were statistically significant, the correlation was moderate, indicating that the scales were assessing distinct components of the quality-of-life construct. Second, most of the functional and symptom measures discriminated clearly between patients differing in clinical status as defined by the Eastern Cooperative Oncology Group performance status scale, weight loss, and treatment toxicity. Third, there were statistically significant changes, in the expected direction, in physical and role functioning, global quality of life, fatigue, and nausea and vomiting, for patients whose performance status had improved or worsened during treatment. The reliability and validity of the questionnaire were highly consistent across the three language-cultural groups studied: patients from English-speaking countries, Northern Europe, and Southern Europe. CONCLUSIONS: These results support the EORTC QLQ-C30 as a reliable and valid measure of the quality of life of cancer patients in multicultural clinical research settings. Work is ongoing to examine the performance of the questionnaire among more heterogenous patient samples and in phase II and phase III clinical trials.

Problems after hysterectomy. A comparative content analysis of 60 interviews with cancer and non-cancer hysterectomized women.

Sixty patients who had undergone hysterectomy for neoplastic pathologies (30 cases) and benign pathologies (30 cases) were interviewed with the aim of understanding the relationship they had with the disease, the loss of the uterus and sexuality. Out of the cancer group 21 cases showed fear of recurrence of the disease, 19 cases showed sexual dysfunctions, while only 9 patients referred to having experienced the loss of the uterus as a traumatic event for their femininity. Non-cancer patients revealed reactive sexual difficulties. Out of this sample, 17 cases described their sexual life as unsatisfying.

Psychological aspects of testis cancer therapy: a prospective study.

We examined the impact of testis cancer and its curative therapies on the outlook of life, working activity, partner relationship and sexual function in 31 consecutive patients 18 to 51 years old (mean age 29.3 years, median 28 years) who already had undergone orchiectomy. Of the patients 13 subsequently were treated with chemotherapy alone, 6 with retroperitoneal lymph node dissection alone, and 7 with chemotherapy and an operation, while 5 seminoma patients were treated with radiotherapy. The patients were examined 3, 6 and 18 months after orchiectomy. Each patient was required to fill out a questionnaire to gather information relative to their work activities, emotional relationship with the partner and sexual life. The patients also completed an assessment form on the quality of life (Spitzer QL-Index) and a series of horizontal analogues to evaluate anxiety, mood, nausea, weakness and general health status. The statistical analysis of the linear and quadratic components for the variables under study was done with the general linear model for block design. Psychosocial adaptability of these patients, regardless of the treatment they underwent, in time became progressively less problematic and the development of psychosocial problems during the long-term adjustment was low. Only 2 patients reported worsening of the emotional relationship with the partner after treatment: 1 underwent chemotherapy and an operation, and 1 underwent radiotherapy. With regard to sexual life, no serious dysfunction was noted apart from the loss of ejaculation in 11 of 13 patients who underwent retroperitoneal lymph node dissection. Of our sample patients who had lost ejaculation only 2 suffered from a high state of anxiety. The anxiety scores on the last completed linear analogue were 2.6 and 4.1, whereas at the same time the mood scores were 1.9 and 4.4. Therefore, it is important for the clinician to assess the psychogenic aspect of this side effect when this type of operation is proposed.

Psychologic aspects of patients participating in a phase I study with the synthetic retinoid 4-hydroxyphenyl retinamide.

One hundred and one patients participating in a phase I study with the synthetic retinoid 4-HPR (4-hydroxyphenyl retinamide) were evaluated. The study was set up by Veronesi et al. during 1986 at the National Cancer Institute of Milan. The patients were randomized into 4 groups of therapy: 25 in the placebo group, 25 in the group receiving a daily dose of 100 mg of HPR, 26 in the group receiving 200 mg/day of HPR, and 25 in the group receiving 300 mg/day of HPR. All patients were previously treated at our Institute for breast cancer. None had received adjuvant therapy, chemotherapy or hormone therapy. After 4-5 months from the beginning of treatment, all patients received a series of tests to evaluate anxiety, depression and sexual life. Moreover, during one the follow-up checkups after 4-5 months, the patients filled-out a self-scoring mood questionnaire. The results did not show any particular differences between the groups, although we found that the administered drug and experimental setting do not interfere with the psychologic state of the participating patients.