Psychosocial correlates of cancer survival: a subsequent report 3 to 8 years after cancer diagnosis.

Professional and public interest in possible relationships between psychosocial factors and disease outcome continues to increase. Published research in this area, however, is marked by contradictory results. Positive relationships between a variety of psychosocial factors and length of survival from cancer are reported, but other studies uncover no such associations. In a previously reported prospective investigation of 359 patients with newly diagnosed malignant diseases, we found no relationship between clinical outcome and any psychosocial factor studied. We have continued to observe these patients, who are now up to 8 years post-diagnosis, and report here additional data on their disease outcomes as they relate to psychosocial factors assessed at diagnosis. Two groups of patients were studied: 204 patients with advanced, prognostically poor malignant disease at diagnosis; and 155 patients with intermediate or high-risk melanoma or breast cancer. Shortly after diagnosis, patients completed a self-report questionnaire that assessed seven psychosocial factors previously reported to predict longevity in the general population. Factors included social ties and marital history, job satisfaction, use of psychotropic drugs, general life satisfaction, subjective view of adult health, hopelessness, and perception of amount of adjustment required to cope with the new diagnosis. Clinical factors--performance status and extent of disease at diagnosis--predicted clinical outcome. No psychosocial factor consistently was associated with length of survival or remission. Results of additional exploratory analyses also are reported.

Anxiety levels in patients randomized to adjuvant therapy versus observation for early breast cancer.

We studied anxiety levels in 68 patients who had been randomized to adjuvant chemotherapy v observation on two Eastern Cooperative Oncology Group (ECOG) protocols. All subjects were women who had undergone total or modified radical mastectomy for breast cancer. Immediately before breast protocol randomization and again 3, 6, and 12 months later, patients completed two self-report measures: the State-Trait Anxiety Inventory and the SCL-90. There were no consistent trends in anxiety levels over time. At each test point, patients under observation displayed higher anxiety scores than did patients receiving adjuvant therapy, but these differences failed to attain statistical significance. Power calculations indicate that these results rule out the possibility of major differences in anxiety levels among patients randomized to observation v adjuvant therapy, but a larger patient sample is required before a definitive statement can be made about smaller differences.

How useful are unconventional cancer treatments?

Unconventional cancer treatments are used frequently. Therefore, oncologists need to know about them. This article gives an overview of current knowledge on the most prevalent complementary or alternative cancer therapies. A distinction is made between alleged cures, preventive and adjunctive measures. Shark cartilage, mistletoe, thymus therapy, essiac, hydrazine sulphate, 714-X, dietary regimens, green tea and Panax ginseng are all covered specifically. None of these treatments offer reasonable hope for a cure. Some strategies are promising in terms of cancer prevention. The true potential of unconventional therapies might lie in adjunctive and palliative care. It is concluded that good evidence in this area is scarce. Vis-à-vis the high prevalence of unconventional cancer treatments, rigorous investigations are mandatory, not least for increasing the safety of future patients.

Does use of alternative medicine predict survival from cancer?

This study examines the association between alternative medicines (AM) and cancer survival. A national multicentre study was carried out in Norway in December 1992 to assess the prevalence of AM use among cancer patients. One of the aims of this study was to assess the association between AM and long-time survival. In January 2001, survival data were obtained with a follow-up of 8 years for 515 cancer patients. A total of 112 (22%) assessable patients used AM. During the follow-up period, 350 patients died. Death rates were higher in AM users (79%) than in those who did not use AM (65%). In a Cox regression model adjusted for demographic, disease and treatment factors, the hazard ratio of death for any use of AM compared with no use was 1.30, (95% Confidence Interval (CI) 0.99, 1.70; P=0.056), suggesting that AM use may predict a shorter survival. Sensitivity analyses strengthened the negative association between AM use and survival. AM use had the most detrimental effect in patients with an ECOG (Eastern Cooperative Oncology Group) performance status (PS) of 0 (hazard ratio for use=2.32, 95% CI, 1.44, 3.74, P=0.001), when compared with an ECOG PS of 1 or higher. The use of AM seems to predict a shorter survival from cancer. The effect appears predominantly in patients with a good PS.

Knowledge of and attitudes toward complementary and alternative therapies; a national multicentre study of oncology professionals in Norway.

This study reports on oncology professionals' knowledge and attitude toward complementary and alternative medicines (CAM), classified according to their primary application as complementary or alternative methods. In June 2002, we conducted a national, multicentre survey of 828 Norwegian oncologists, nurses, clerks and therapeutic radiographers. A response rate of 61% was achieved. Only a few physicians (4%) described their reactions to alternative medicine as positive compared with nurses (33%), therapeutic radiographers (32%) and clerks (55%) (P<0.0001). Females showed a more positive view than males (33% versus 14%, P<0.0001). More participants expressed a positive attitude to complementary versus alternative medicines. Most respondents regarded healing by hand or prayer, homeopathy, and Iscador (mistletoe) as alternative therapies. In contrast, most respondents classified acupuncture, meditation, reflexology, music/art-therapy, aromatherapy and massage as complementary therapies. This survey demonstrates major differences, by gender as well as oncology health profession in views about and the classification of various CAM methods.

Patients' choice of treatment in stage D prostate cancer.

Given the current preference of many patients for an active role in decision-making regarding their care, the feasibility of patients making their own treatment choices was investigated, and the reasons for their selections were studied. Subjects comprised previously untreated Stage D prostate cancer patients for whom hormonal therapy was indicated. Thirteen institutions entered 159 patients into the study. After discussing treatment choices with their physicians, the patients took home a two-page letter explaining two options: surgical castration and therapy with Zoladex (goserelin acetate), a depot luteinizing hormone-releasing hormone (LHRH) analogue injected subcutaneously every twenty-eight days. Patients were encouraged to discuss the treatment choices with their families. After selecting a treatment approach, patients completed a "decision questionnaire" and then treatment was initiated. Of the 147 patients who completed baseline questionnaires, 78 percent selected Zoladex and 22 percent selected orchiectomy. The primary reason for selecting Zoladex included avoidance of surgery (36%), success of treatment (18%), convenience of the drug (10%), and physician's advice (10%). Patients chose surgery primarily because of convenience (32%) and success of treatment (29%). Three months later, patients and their wives completed another questionnaire, which assessed their satisfaction with their treatment choices. Ninety-three percent of patients and 91 percent of patients' wives indicated that they would select the same treatment again.

Counseling the cancer patient who wants to try unorthodox or questionable therapies.

More than half of all patients diagnosed with malignant disease eventually try an unorthodox treatment. In order to counsel their patients appropriately about alternative treatments, oncologists and other health professionals need to familiarize themselves with the most commonly used unorthodox therapies and the reasons why patients turn to these therapies. Patients often seek "alternative" therapies because of several widespread beliefs about American medicine, one being that determination and will can cure cancer, and another being that nutrition also may effect a cure. The concerned physician needs to explain why the unorthodox therapy will not be effective, and try to provide, in an acceptable way, that part of the unorthodox treatment which will not cause harm. Most importantly, physicians need to deal with their patients' interest in unorthodox therapies seriously, and to listen and answer questions, as these needs are unfailingly well met by unorthodox practitioners.

A pilot study of the Functional Living Index-Cancer (FLIC) Scale for the assessment of quality of life for metastatic lung cancer patients. An Eastern Cooperative Oncology Group study.

Quality of life is an important factor in the assessment of cancer therapy, but it is difficult to define and measure. The Functional Living Index-Cancer (FLIC) was designed specifically for cancer patients under treatment. The Eastern Cooperative Oncology Group (ECOG) mounted a pilot study to assess the feasibility and sensitivity of the patient-oriented FLIC scale for assessment of quality of life. The results of this study show that the FLIC scores correlate with the functional status of patients on treatment: high scores on the FLIC prior to therapy were found to correlate with good performance status (p = 0.0001), and decreases in the FLIC score during therapy correlated with a decline in performance status (p = 0.0001), with poor performance status (p = 0.0002), and greater than 5% recent weight loss (p = 0.004). However, there was poor compliance to completion of the instrument, indicating a need for future research into this aspect of assessing quality of life in the cooperative group setting.

Chemotherapeutic toxicity--the relationship between patients' pretreatment expectations and posttreatment results.

Patients receiving the same cancer chemotherapy regimens exhibit a highly variable incidence of toxic side effects. We studied 56 patients about to receive chemotherapy for the first time to determine whether their expectations of individual side effects were associated with the frequency and severity of the toxicity that they subsequently experienced. Patients completed a self-report questionnaire containing a list of 16 potential toxicities, asking them to indicate how certain they were of experiencing or not experiencing each. Prior to their third treatment, patients again completed a self-report scale indicating the incidence and severity of each side effect experienced. The frequency of actual side effects was much greater than patients anticipated. The most commonly reported side effects were tiredness, changes in appetite or taste, nervousness, and nausea. Patients' expectations failed to predict the occurrence or severity of the experience of common side effects. Anxiety levels and meaning attributed to side effects also were not associated with side effects experienced. Although psychological factors may play a role, it is likely that unique physiologic parameters account primarily for the variable and unpredictable relationship between chemotherapeutic agents and the side effects they induce.

Patients' perceptions of the cosmetic impact of melanoma resection.

This study investigated the relationship between primary versus grafted closure for melanoma and the cosmetic impact on the patient of the resulting scar. A total of 176 patients with melanoma completed a multiple-choice questionnaire designed for this study. Two factors were significantly related to negative cosmetic impact: severity of scar indentation (but not scar length) and the extent to which patients were unprepared for the actual size of their scars. Patients whose scars were deeply indented as well as those whose scars were larger than anticipated displayed greatest distress about their appearance. Cosmetic impact was greater for women than for men. These observations suggest that primary closures, rather than closures requiring skin grafts, have important psychological benefits for patients and that physicians can assist postoperative adjustment by giving patients accurate information about the expected appearance of their scars.

The use of photographs of postoperative results prior to melanoma resection.

A total of 99 patients scheduled for resection of stage I melanoma were assigned randomly to be shown individually relevant photographs of anticipated postoperative results. All patients had received verbal information on this subject during discussions with their plastic surgeons. Anticipated and actual cosmetic impact or distress was measured with a self-report questionnaire given prior to and 6 months following surgery. Patients were least distressed postoperatively when their scars were not larger than anticipated. However, photographs failed to achieve the expected benefit of increasing the accuracy of patients' expectations of their postoperative appearance. Consequently, photographs had no effect on levels of preoperative or postoperative distress. Selective attention and preferences for limited information among some patients are suggested explanations for these results.

Complementary therapies: overview and state of the art.

Studies to determine the prevalence of complementary and alternative medicine (CAM) use among cancer patients show international interest in a wide collection of therapies and a broad span of use, ranging from 7% to 64% of patients sampled. The absence of consistent results across studies is due primarily to differing definitions of unconventional cancer therapies from study to study. Treatments promoted as alternatives to mainstream cancer cures (e.g., the recently disproved "cancer cure" of Italy's Dr. Di Bella) should be distinguished from complementary therapies, which are applied as adjuncts to mainstream care in an integrated fashion. The latter include mind-body techniques and herbal remedies, among many other remedies, all aimed at symptom control and enhanced quality of life. This differentiation provides a clearer understanding of CAM activity and enables selective evaluation of CAM's clinical effects. It permits us to avoid accepting or rejecting all of CAM out of hand. Health care professionals as well as patients and their families have become increasingly knowledgeable about complementary therapies that can be helpful to patients with cancer. Many such therapies have been well studied (meditation, tai chi), and others remain highly questionable (homeopathy, electromagnetics). Their benefits and potential problems are reviewed.

Methodologic issues in palliative care psychosocial research.

The conduct of psychosocial research with palliative care patients or staff presents a major investigative challenge. The fragility of patients and their physical or cognitive limitations severely curtail the types of studies that are possible and the research methods that can be applied. A major limitation is that randomization, a critical experimental design feature, is rarely possible or ethical as a means of evaluating palliative care. However, even given the practical limitations of constructing a randomized experimental design, methodologically acceptable studies are possible, and methodologically inappropriate approaches can be avoided. Case reports (anecdotal studies) produce data that cannot be generalized to other patients. Single-test, no control group studies should be avoided for similar reasons. Acceptable research techniques that are feasible in the palliative care setting are renewed: careful research questions and associated hypotheses; determining appropriate sample sizes; developing comparison groups; selecting and evaluating an appropriate interview guide or questionnaire; avoiding interviewing bias, and so on. Moreover, it is necessary for the professional standing of palliative care that the exchange of information between palliative care staff and other health professionals be based upon scientifically sound studies.

Symptom prevalence and control during cancer patients' last days of life.

The lack of control of physical suffering among cancer patients in the last days or hours of life is a common medical problem but it is rarely discussed in an open fashion. We carried out a prospective study of the dying of 120 terminal cancer patients assisted by a home care team. We documented how long it was before death that physical symptoms, unendurable to the patient and controlled only by sedation-inducing sleep, appeared. In 63 patients (52.5%), unendurable symptoms due to tumor progression or irreversible acute organic phenomena appeared, on average two days before death. Of the 63 patients, 47 had only one uncontrollable symptom, 15 had two symptoms and one patient had three symptoms. The most common symptoms included dyspnea (33 patients), pain (31), delirium (11), and vomiting (5). The most frequent symptoms were dyspnea in lung and head and neck disease; pain in breast, gastrointestinal tract, colon-rectum, and male genitourinary tract cancer; and vomiting in female genitourinary tract malignancies. Data reported emphasize the clinical relevance of physical symptoms in the last days of life in terminal cancer patients and how these serve to indicate imminent death. More than 50% of these patients die with physical suffering that is controllable only by means of sedation.