Hypnosis decreases presurgical distress in excisional breast biopsy patients.

BACKGROUND: Excisional breast biopsy is associated with presurgical psychological distress. Such distress is emotionally taxing, and may have negative implications for postsurgical side effects and satisfaction with anesthesia. We investigated the ability of a brief hypnosis session to reduce presurgical psychological distress in excisional breast biopsy patients. METHODS: Ninety patients presenting for excisional breast biopsy were randomly assigned to receive either a 15-minute presurgery hypnosis session (n = 49, mean age: 46.4 (95% CI: 42.3-50.4)) or a 15-minute presurgery attention control session (n = 41, mean age: 45.0 (95% CI: 40.8-49.2)). The hypnosis session involved suggestions for increased relaxation and decreased distress. The attention control session involved nondirective empathic listening. Presurgery distress was measured using visual analog scales (VAS) and the short version of the Profile of Mood States (SV-POMS). Data were analyzed using analysis of variance and chi2 procedures. RESULTS: Groups did not differ in terms of the following: demographics (age, education, ethnicity, marital status, all P's > 0.28); medical variables (presurgery diagnosis, previous excisional biopsy, previous breast cancer, all P's > 0.11); or preintervention distress (SV-POMS P > 0.74) assessed on the day of surgery. Postintervention, and before surgery, patients in the hypnosis group had significantly lower mean values for presurgery VAS emotional upset (16.5 vs 38.2, P < 0.0001, d = .85), VAS depressed mood (6.6 vs 19.9, P < 0.02, d = .67), and SV-POMS anxiety (10.0 vs 5.0, P < 0.0001, d = 0.85); and significantly higher levels for VAS relaxation (75.7 vs 54.2, P < 0.001, d = -0.76) than attention controls. CONCLUSIONS: The study results indicate that a brief presurgery hypnosis intervention can be an effective means of controlling presurgical distress in women awaiting diagnostic breast cancer surgery.

Cytologic findings of spindle cell ductal carcinoma in situ of the breast: a case report.

BACKGROUND: Ductal carcinoma in situ (DCIS), spindle cell type, is a rare and recently recognized entity in the breast. While the histologic features have been described in detail, no cytologic descriptions exist. We describe the cytologic and corresponding histologic findings in a case of spindle cell DCIS. CASE: A 35-year-old woman underwent fine needle aspiration (FNA) of a 1.5-cm, palpable mass. The aspirate showed predominantly clusters and a smaller population of single cells in a necrotic background. The cells were mostly spindled, The cells were mostly spindled, with a minor population of epithelioid cells. They had a high nuclear/cytoplasmic ratio, with hyperchromatic and pleomorphic nuclei that contained prominent nucleoli, altogether diagnostic of malignancy. Given the biphasic cell composition, a diagnosis of metaplastic carcinoma was favored and excision recommended; it showed spindle cell DCIS. CONCLUSION: The cytologic features of spindle cell DCIS and metaplastic spindle cell carcinoma are similar and almost indistinguishable. Despite its rarity, spindle cell DCIS should be considered in the differential diagnosis of biphasic and spindle cell lesions in the breast.

Disrupted sleep the night before breast surgery is associated with increased postoperative pain.

Despite the best available clinical care, pain after surgery is a virtually universal patient experience that can have pervasive negative consequences. Given the large variability among patients in postoperative pain levels, research on novel modifiable risk factors is needed. One such factor suggested by recent experimental studies indicates that disruption of even a single night's sleep can increase subsequent pain in healthy volunteers. In this preliminary clinical study, we tested the hypothesis that poor sleep the night before surgery would predict heightened postoperative pain. Patients (n=24) scheduled for routine breast-conserving surgical procedures for the diagnosis or treatment of cancer were recruited and wore an actigraphy device providing objective, validated measures of sleep duration and disruption (low sleep efficiency). Pain severity and interference with daily activities for the week after surgery was assessed with the Brief Pain Inventory. As hypothesized, multiple regression analyses revealed that lower sleep efficiency was a significant predictor of greater pain severity and interference, controlling for age, race, and perioperative analgesics as appropriate. Sleep efficiency was not significantly related to measures of depressed mood, emotional upset, or relaxation assessed on the morning of surgery. Patients with sleep efficiency in the lowest tertile had clinically higher levels of pain (>2 points) compared with patients in the highest sleep efficiency tertile. Sleep duration had no significant effects. This preliminary clinical study supports the possibility that sleep disruption on the night before surgery may increase patients' experience of pain after surgery. Research to investigate the mechanisms underlying these effects and to explore the possible clinical benefits of interventions to improve patients' sleep before surgery is now warranted.

Anticipatory psychological distress in women scheduled for diagnostic and curative breast cancer surgery.

BACKGROUND: Psychological distress is a central experience for women facing diagnostic and curative breast cancer surgery. PURPOSE: The present study was designed to predict anticipatory distress in 187 women scheduled to undergo excisional breast biopsy or lumpectomy. METHOD: Participants completed questionnaires assessing emotional distress and predictors of this distress (surgery type, worry about the surgical procedure, and worry about what the surgeon will find). RESULTS: The study found that lumpectomy patients experienced greater anticipatory distress than excisional breast biopsy patients on three of the four distress measures (all ps < 0.05) and that worry about what the surgeon might find partially mediated these effects. CONCLUSION: The results suggest that although women awaiting lumpectomy are more distressed than women awaiting biopsy, both groups report substantial distress, and, consequently, psychosocial interventions are recommended for both groups.

A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients.

BACKGROUND: Breast cancer surgery is associated with side effects, including postsurgical pain, nausea, and fatigue. We carried out a randomized clinical trial to test the hypotheses that a brief presurgery hypnosis intervention would decrease intraoperative anesthesia and analgesic use and side effects associated with breast cancer surgery and that it would be cost effective. METHODS: We randomly assigned 200 patients who were scheduled to undergo excisional breast biopsy or lumpectomy (mean age 48.5 years) to a 15-minute presurgery hypnosis session conducted by a psychologist or nondirective empathic listening (attention control). Patients were not blinded to group assignment. Intraoperative anesthesia use (i.e., of the analgesics lidocaine and fentanyl and the sedatives propofol and midazolam) was assessed. Patient-reported pain and other side effects as measured on a visual analog scale (0-100) were assessed at discharge, as was use of analgesics in the recovery room. Institutional costs and time in the operating room were assessed via chart review. RESULTS: Patients in the hypnosis group required less propofol (means = 64.01 versus 96.64 microg; difference = 32.63; 95% confidence interval [CI] = 3.95 to 61.30) and lidocaine (means = 24.23 versus 31.09 mL; difference = 6.86; 95% CI = 3.05 to 10.68) than patients in the control group. Patients in the hypnosis group also reported less pain intensity (means = 22.43 versus 47.83; difference = 25.40; 95% CI = 17.56 to 33.25), pain unpleasantness (means = 21.19 versus 39.05; difference = 17.86; 95% CI = 9.92 to 25.80), nausea (means = 6.57 versus 25.49; difference = 18.92; 95% CI = 12.98 to 24.87), fatigue (means = 29.47 versus 54.20; difference = 24.73; 95% CI = 16.64 to 32.83), discomfort (means = 23.01 versus 43.20; difference = 20.19; 95% CI = 12.36 to 28.02), and emotional upset (means = 8.67 versus 33.46; difference = 24.79; 95% CI = 18.56 to 31.03). No statistically significant differences were seen in the use of fentanyl, midazolam, or recovery room analgesics. Institutional costs for surgical breast cancer procedures were $8561 per patient at Mount Sinai School of Medicine. Patients in the hypnosis group cost the institution $772.71 less per patient than those in the control group (95% CI = 75.10 to 1469.89), mainly due to reduced surgical time. CONCLUSIONS: Hypnosis was superior to attention control regarding propofol and lidocaine use; pain, nausea, fatigue, discomfort, and emotional upset at discharge; and institutional cost. Overall, the present data support the use of hypnosis with breast cancer surgery patients.

Radiation-associated extraskeletal osteosarcoma of the chest wall.

Radiation-associated sarcoma is a rare but potential complication of radiation therapy. Most reported cases of osteosarcoma of the chest wall following radiation therapy for breast cancer arise from the chest wall skeletal structures. In contrast, few cases of extraskeletal osteosarcomas have been reported. We report a rare example of an extraskeletal osteosarcoma involving the pectoralis major muscle occurring after radiation therapy for breast cancer. Extraskeletal osteosarcomas are rare soft tissue tumors with a high rate of local recurrence and a poor prognosis.

Sources of anticipatory distress among breast surgery patients.

Surgical consultation concerning the possibility of breast cancer is a distressing experience, and having to take the next step of breast surgery even more so for many women. However, the sources of variability in such presurgical distress are not well understood. Sixty-one women (mean age = 51) were recruited immediately following surgical consultation in which a recommendation of breast surgery (excisional biopsy/lumpectomy) was made. Patients completed measures of distress, worry about cancer and surgery, trait anxiety, optimism and pessimism prior to surgery. Surprisingly, results revealed no effect of surgeon-provided information concerning preliminary diagnosis on patient distress. Rather, worry about what the surgeon might find concerning the breast mass during surgery, worry about having to go through the operative procedures, and patient optimism were the only factors that uniquely contributed to patient distress (p's < 0.05). This study provides a foundation for future clinical interventions to reduce presurgery distress.