The factor structure and use of the Demoralization Scale (DS-IT) in Italian cancer patients.

OBJECTIVE: Demoralization is a commonly observed syndrome in cancer patients, deserving to be carefully assessed in cross-cultural contexts. AIMS: To examine the factor structure and concurrent and divergent validity of the Italian version of the Demoralization Scale (DS-IT) in cancer patients. METHODS: The sample included 194 Italian cancer outpatients who were assessed by using the DS-IT and the Diagnostic Criteria of Psychosomatic Research-Demoralization module to examine demoralization. The Patient Health Questionnaire-9 (PHQ-9) to explore depression and the Mini-Mental Adjustment-to-Cancer-Hopelessness/Helplessness scale (Mini-MAC-HH) to explore maladaptive coping were also administered. RESULTS: Four factors were extracted by exploratory factor analysis on the DS-IT (disheartenment, α = .87; sense of failure, α = .77; dysphoria, α = .73; loss of meaning/purpose, α = .72; total = 0.91), accounting for 57.1% of the variance. The DS-IT factors shared between 17% and 36% of the variance. Patients reporting a diagnosis of demoralization on the Diagnostic Criteria of Psychosomatic Research-Demoralization module (23.7%) had higher scores on DS-IT loss of meaning/purpose, sense of failure, dysphoria, and DS-IT total. About half of those who were highly demoralized were not depressed and among those who had moderate or moderately severe demoralization, about 80% were not depressed on the PHQ-9. The DS-IT was significantly associated with PHQ-9 and Mini-MAC-HH. CONCLUSIONS: The study presents further evidence that demoralization is a significant clinical condition and that the DS-IT demonstrates satisfactory levels of validity and reliability to support its use in patients in the ambulatory cancer setting.

Awareness of cancer, satisfaction with care, emotional distress, and adjustment to illness: an Italian multicenter study.

OBJECTIVE: The aim of the study was to examine awareness of cancer and the relationship with distress and satisfaction with care among Italian cancer patients. METHODS: Two hundred sixty-two cancer patients consecutively admitted to the Day Hospital of four cancer centers in Italy completed the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core-30, the EORTC Inpatient Satisfaction-32, the EORTC Information Questionnaire-25, the distress thermometer, the Mini-mental Adjustment to Cancer scale, a visual analogue scale of illness awareness, and questions related to the admission and unmet needs. RESULTS: Eighty-seven percent of patients were aware of their diagnosis, but 49% of those with metastatic cancer thought they have a curable disease. About one-third felt that family members often (16%) or always (13%) were hiding information or bad news in order to protect them. In multivariate analysis, the perception of being protected from bad news by the family was associated with the perceived need to talk more with the family but was not associated with demographic or clinical (Karnofsky Performance Status and stage) variables, lower emotional distress, and greater satisfaction with care and information. Also, awareness of diagnosis and prognosis was not associated with demographic or clinical variables, emotional distress, or satisfaction with care and information CONCLUSIONS: Most cancer patients were fully informed about their diagnosis, although awareness of disease was not coincident with awareness of prognosis and disease progression. Information and knowledge were not destructive of hope and did not increase distress. Family issues are still a significant factor molding openness and sharing of information.

Dignity and Psychosocial-Related Variables in Advanced and Nonadvanced Cancer Patients by Using the Patient Dignity Inventory-Italian Version.

CONTEXT: The Patient Dignity Inventory (PDI) is a valid and reliable instrument to measure dignity, as a state of physical, mental, social, and spiritual well-being in palliative care patients and an essential dimension for a comprehensive patient-centered approach. OBJECTIVES: We examined the factor structure and correlation of the Italian version of the PDI (PDI-IT) with psychosocial variables among advanced and nonadvanced cancer outpatients in two Italian centers. METHODS: In a sample of 194 patients, principal component analysis, reliability analysis (Cronbach's coefficient alpha), and correlation analysis of the PDI-IT were performed. Concurrent validity was evaluated with respect to the Italian versions of Patient Health Questionnaire-9 (PHQ-9), as a measure of depression, the Mini-Mental Adjustment to Cancer-Hopelessness Scale, as a measure of dysfunctional coping, and the Demoralization Scale (DS-IT), as a measure of demoralization. RESULTS: Three factors were extracted by exploratory factor analysis, which accounted for 64.38% of the variance, namely existential distress (Cronbach's α = 0.95), psychological distress (Cronbach's α = 0.88), and physical distress (Cronbach's α = 0.81), with a Cronbach's α coefficient for the PDI-IT total score of 0.96. PDI-IT factors were significantly intercorrelated and shared between 42% and 53% of the variance. Higher scores on all the PDI-IT factors and PDI-IT total were found among patients who were clinically depressed (PHQ-9) and among those who were demoralized on the DS-IT. Significant correlations were also found between all PDI-IT and the DS-IT, PHQ-9, and the Mini-Mental Adjustment to Cancer-Hopelessness Scale. CONCLUSIONS: The study confirmed that the PDI-IT is a valid instrument to be applied in oncology and measuring three factors, namely existential, psychological, and physical distress, as core dimensions of dignity, to be monitored and treated in clinical settings.

Cytokines, fatigue, and cutaneous erythema in early stage breast cancer patients receiving adjuvant radiation therapy.

We investigated the hypothesis that patients developing high-grade erythema of the breast skin during radiation treatment could be more likely to present increased levels of proinflammatory cytokines which may lead, in turn, to associated fatigue. Forty women with early stage breast cancer who received adjuvant radiotherapy were enrolled from 2007 to 2010. Fatigue symptoms, erythema, and cytokine levels (IL-1ß, IL-2, IL6, IL-8, TNF-α, and MCP-1) were registered at baseline, during treatment, and after radiotherapy completion. Seven (17.5%) patients presented fatigue without associated depression/anxiety. Grade ≥2 erythema was observed in 5 of these 7 patients. IL-1ß, IL-2, IL-6, and TNF-α were statistically increased 4 weeks after radiotherapy (P < 0.05). After the Heckman two-step analysis, a statistically significant influence of skin erythema on proinflammatory markers increase (P = 0.00001) was recorded; in the second step, these blood markers showed a significant impact on fatigue (P = 0.026). A seeming increase of fatigue, erythema, and proinflammatory markers was observed between the fourth and the fifth week of treatment followed by a decrease after RT. There were no significant effects of hormone therapy, breast volume, and anemia on fatigue. Our study seems to suggest that fatigue is related to high-grade breast skin erythema during radiotherapy through the increase of cytokines levels.

[Italian version of Demoralization Scale: a validation study]. / La versione italiana della Demoralization Scale: uno studio di validazione.

OBJECTIVE: Demoralization and depressive symptoms are very common in chronic organic diseases. The aim of the present study is to evaluate reliability and psychometric properties of the Italian version of the Demoralization Scale (DS) in patients with advanced cancer. METHODS: The Italian version of DS was administered to a sample consisting of 100 patients affected by different forms of cancer. The following scales were also administered: Patient Health Questionnaire, Beck Depression Inventory (BDI), Mini-Mental Adjustment to Cancer (MAC) and Karnofsky Performance Status Scale. RESULTS: The total mean score of the DS was 23.9±14.5. The study showed a good degree of stability and internal consistency of DS total score (α=0.90) and the 5 factors represented by loss of meaning and purpose (α=0.69), dysphoria (α=0.72), disheartenment (α=0.84), helplessness (α=0.50) and sense of failure (α=0.74). Significant correlations were found between DS total score and BDI (r=0.74) and between DS factors and BDI (r=0.64 for loss of meaning and purpose; r=0.55 for dysphoria; r=0.71 for disheartenment; r=0.51 for helplessness; r=0.46 for sense of failure). Good correlations were also found between DS total score and Hopelessness scale of MAC (r=0,51). According to different cut-off values, between 28 and 32 patients were seriously demoralized and 40 had moderate levels of demoralization. Between 6 and 20 patients were seriously demoralized but not clinically depressed; between 16 and 31 patients with moderate levels of demoralization had no depression. CONCLUSION: Results provide further evidence that the DS is a valid and reliable instrument of high clinical relevance in patients with advanced cancer and confirm the hypothesis of the ontological difference between demoralization and depression.