Management of distress in cancer patients

Psychosocial distress is highly prevalent and diverse at all stages of cancer care. In the early 21st century, screening, assessment, and management of psychological distress in cancer patients are supported by a growing body of literature. Psychosocial care of cancer patients snow considered an essential component of quality cancer care by the Institute of Medicine. Increasing numbers of professionals from different disciplines are being trained in the United States and internationally to provide consultative services in support of the psychological care of cancer patients. This review article highlights the psychosocial distress experienced by cancer patients, featuring an overview of the assessment and management of psychological distress in the context of cancer as well as the common psychiatric disorders experienced by cancer patients at all stages of disease.

Patient education level as a predictor of survival in lung cancer clinical trials

PURPOSE

To investigate the effect of socioeconomic status, as measured by education, on the survival of 1,577 lung cancer patients treated on 11 studies conducted by the Cancer and Leukemia Group B.

PATIENTS AND METHODS

Sociodemographic data, including education, was reported by the patient at the time of clinical trial accrual. Cox proportional hazards model stratified by treatment arm/study was used to examine the effect of education on survival after adjustment for known prognostic factors.

RESULTS

The patient population included 1,177 patients diagnosed with non-small-cell lung cancer (NSCLC; stage III or IV) and 400 patients diagnosed with small-cell lung cancer (SCLC; extensive or limited). Patients with less than an eighth grade education (13% of patients) were significantly more likely to be male, nonwhite, and older; have a performance status (PS) of 1 or 2; and have chest pain. Significant predictors of poor survival in the final model included male sex, PS of 1 or 2, dyspnea, weight loss, liver or bone metastases, unmarried, presence of adrenal metastases and high alkaline phosphatase levels among patients with NSCLC, and high WBC levels among patients with advanced disease. Education was not predictive of survival.

CONCLUSION

The physical condition of patients with low education who enroll onto clinical trials is worse than patients with higher education. Once enrolled onto a clinical trial, education does not affect the survival of patients with SCLC or stage III or IV NSCLC. The standardization of treatment and follow-up within a clinical trial, regardless of education, is one possible explanation for this lack of effect.

Assessing anxiety in men with prostate cancer: further data on the reliability and validity of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC)

Identifying which men with prostate cancer might benefit from mental health treatment has proven to be a challenging task. The authors developed the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) in order to facilitate the identification of prostate cancer-related anxiety. A revised version of this scale was tested in a more clinically varied population. Ambulatory men with prostate cancer (N=367) completed a baseline assessment packet that included the MAX-PC and other psychosocial questionnaires. The MAX-PC showed high internal consistency and concurrent and discriminant validity. Factor analysis identified three distinct factors for the MAX-PC that corresponded to the intended subscales (General Prostate Cancer Anxiety, PSA (prostate-specific antigen) Anxiety, and Fear of Recurrence). PSA levels were not correlated with anxiety overall; however, anxiety was significantly higher among patients whose PSA levels were changing (i.e., rising, falling, and unstable), versus those with stable PSA levels. Also, in a multivariate analysis, the change in PSA levels was a significant predictor of MAX-PC scores, but not Hospital Anxiety and Depression Scale (HADS) scores. These results indicate that the MAX-PC is a valid and reliable measure of anxiety that assesses aspects of anxiety unique to men with prostate cancer, and it may provide a more sensitive measure of anxiety than the HADS for this population.

Telephone monitoring of distress in patients aged 65 years or older with advanced stage cancer

BACKGROUND

Significant barriers to cancer patients receiving mental health treatment for distress have been reported in the literature. The objective of the current study was to determine whether distress in older patients (aged 65 years and older) would be reduced with educational materials (EM) supplemented by monthly telephone monitoring (TM) (TM + EM) compared with the use of EM alone because of more timely referrals to appropriate health professionals.

METHODS

One hundred ninety-two older patients with breast, prostate, and colorectal cancers who had advanced disease and currently were receiving treatment were randomized to receive either TM + EM or EM alone. One hundred thirty-one patients were evaluated by telephone interview for psychologic and physical distress and for social support at baseline and at 6 months using the Hospital Anxiety and Depression Scale (HADS), the European Organization for Research and Treatment of Cancer (EORTC)-QLQ-C30 quality-of-life questionnaire, and the Medical Outcomes Study (MOS) Social Support Survey. Patients who in the TM + EM group were called monthly for 6 months to monitor their distress using the HADS and EORTC physical symptom items and the MOS Social Support Survey items, with cutoff levels were established to indicate which patients were in greater distress. Those patients who scored above the cutoff levels were referred to their oncology nurse for referral to the appropriate professional. Patients in the EM group received written materials regarding cancer-related psychosocial issues and available resources.

RESULTS

At 6 months, patients in the TM + EM group reported significantly less anxiety (HADS; P < .0001), depression (HADS; P = .0004), and overall distress (HADS; P < .0001) compared with patients in the EM group.

CONCLUSIONS

Monthly monitoring of older patients' distress with TM and EM along with referral for appropriate help was found to be an efficient means of reducing patients' anxiety and depression compared with patients who received only EM.

Developing a cancer-specific geriatric assessment: a feasibility study

BACKGROUND

As the U.S. population ages, there is an emerging need to characterize the "functional age" of older patients with cancer to tailor treatment decisions and stratify outcomes based on factors other than chronologic age. The goals of the current study were to develop a brief, but comprehensive, primarily self-administered cancer-specific geriatric assessment measure and to determine its feasibility as measured by 1) the percentage of patients able to complete the measure on their own, 2) the length of time to complete, and 3) patient satisfaction with the measure.

METHODS

The geriatric and oncology literature was reviewed to choose validated measures of geriatric assessment across the following domains: functional status, comorbidity, cognition, psychological status, social functioning and support, and nutritional status. Criteria applied to geriatric assessment measurements included reliability, validity, brevity, and ability to self-administer. The measure was administered to patients with breast carcinoma, lung carcinoma, colorectal carcinoma, or lymphoma who were fluent in English and receiving chemotherapy at Memorial Sloan-Kettering Cancer Center (New York, NY) or the University of Chicago (Chicago, IL).

RESULTS

The instrument was completed by 43 patients (mean age, 74 yrs; range, 65-87 yrs). The majority had AJCC Stage IV disease (68%). The mean time to completion of the assessment was 27 minutes (range, 8-45 mins). Most patients were able to complete the self-administered portion of the assessment without assistance (78%) and were satisfied with the questionnaire length (90%). There was no association noted between age (P = 0.56) or educational level (P = 0.99) and the ability to complete the assessment without assistance.

CONCLUSIONS

In this cohort, this brief but comprehensive geriatric assessment could be completed by the majority of patients without assistance. Prospective trials of its generalizability, reliability, and validity are justified.

Screening for psychologic distress in ambulatory cancer patients

BACKGROUND

Based on evidence that psychologic distress often goes unrecognized although it is common among cancer patients, clinical practice guidelines recommend routine screening for distress. For this study, the authors sought to determine whether the single-item Distress Thermometer (DT) compared favorably with longer measures currently used to screen for distress.

METHODS

Patients (n = 380) who were recruited from 5 sites completed the DT and identified the presence or absence of 34 problems using a standardized list. Participants also completed the 14-item Hospital Anxiety and Depression Scale (HADS) and an 18-item version of the Brief Symptom Inventory (BSI-18), both of which have established cutoff scores for identifying clinically significant distress.

RESULTS

Receiver operating characteristic (ROC) curve analyses of DT scores yielded area under the curve estimates relative to the HADS cutoff score (0.80) and the BSI-18 cutoff scores (0.78) indicative of good overall accuracy. ROC analyses also showed that a DT cutoff score of 4 had optimal sensitivity and specificity relative to both the HADS and BSI-18 cutoff scores. Additional analyses indicated that, compared with patients who had DT scores < 4, patients who had DT scores > or = 4 were more likely to be women, have a poorer performance status, and report practical, family, emotional, and physical problems (P < or = 0.05).

CONCLUSIONS

Findings confirm that the single-item DT compares favorably with longer measures used to screen for distress. A DT cutoff score of 4 yielded optimal sensitivity and specificity in a general cancer population relative to established cutoff scores on longer measures. The use of this cutoff score identified patients with a range of problems that were likely to reflect psychologic distress.

Single-agent versus combination chemotherapy in advanced non-small-cell lung cancer: the cancer and leukemia group B (study 9730)

PURPOSE

We compared the efficacy of combination chemotherapy versus single-agent therapy in patients with advanced non-small-cell lung cancer.

PATIENTS AND METHODS

A total of 561 eligible patients were randomly assigned to receive paclitaxel alone or in combination with carboplatin.

RESULTS

The response rate was 17% in the paclitaxel arm and 30% in the carboplatin-paclitaxel arm (P < .0001). Median failure-free survival was 2.5 months in the paclitaxel arm and 4.6 months in the carboplatin-paclitaxel arm (P = .0002). Median survival times were 6.7 months (95% CI, 5.8 to 7.8) and 8.8 months (95% CI, 8.0 to 9.9), and 1-year survival rates were 32% (95% CI, 27% to 38%), and 37% (95% CI, 32% to 43%), respectively. The overall survival distributions were not statistically different: hazard ratio = 0.91 (95% CI, 0.77 to 1.17; P = .25). Hematological toxicity and nausea were more frequent in the combination arm, but febrile neutropenia and toxic deaths were equally low in both arms. There was no significant survival difference in elderly patients. Performance status 2 patients treated with combination chemotherapy had a better survival rate than those treated with single-agent therapy (P = .019).

CONCLUSION

Combination chemotherapy improves response rate and failure-free survival compared with single-agent therapy, but there was no statistically significant difference in the primary end point of overall survival. The results in elderly patients were similar to younger patients. Performance status 2 patients had a superior outcome when treated with combination chemotherapy.

Pathways for psychosocial care of cancer survivors

Today, the growing number of survivors from many sites of cancer necessitates that thought be given to ways that ensure follow-up psychosocial care and its integration into ongoing medical surveillance. The establishment of standards of care together with evidence- and consensus-based clinical practice guidelines have provided a highly effective method of enhancing quality care for treatment of cancer. There remain, however, major problems in dissemination and application of these guidelines on the clinical level. The National Comprehensive Cancer Network (NCCN) formed a Panel on Distress Management that developed the first set of consensus-based standards for psychosocial care and clinical practice guidelines specific to cancer illnesses. This article proposes the extension of their concepts to cancer survivors. A model is presented that can assist oncologists and multidisciplinary teams in busy ambulatory settings to more readily identify those survivors who are distressed, whose quality of life is impaired, and who may benefit from further psychological evaluation and treatment. Three groups of cancer survivors are identified for whom pathways for psychosocial care should be defined and developed: 1) survivors with physical sequelae, often resulting in significant neuropsychologic and physical consequences; 2) survivors with psychological sequelae or psychiatric disorders that interfere with functioning and quality of life; and 3) survivors with subsyndromal symptoms who have no identified physical or psychiatric sequelae, but who may nonetheless need help integrating the cancer experience into their lives to increase a sense of purpose, direction, and well being. A rapid screening tool for distress could be used at the time of follow-up visits to oncologists or physicians to identify patients with psychological, social, or spiritual concerns and could serve as a pathway for evaluation and referral for psychosocial counseling. Treating distress in these areas is to be viewed as an integral part of surveillance for survivors, and pathways to ensure integration are important.

IPOS Sutherland Memorial Lecture: An international perspective on the development of psychosocial oncology: overcoming cultural and attitudinal barriers to improve psychosocial care

Around the world, traditionally the diagnosis of cancer and its prognosis was withheld from patients for centuries, due to the stigma and fears attached to it. This custom of 'never telling' precluded talking with patients about their feelings and how they were coping with illness and the threat of death. In the last quarter of the twentieth century, patient's right of access to information, coupled with the diminished stigma attached to cancer, encouraged physicians into a more open dialogue. In the majority of countries today, patients learn their diagnosis and know their treatment options. This change permitted the first formal psychosocial studies of patients in the 1950s, and the beginning of research into coping and development of interventions to improve quality of life. However, a second independent stigma, also present for centuries, has persisted: the stigma associated with mental disorders (even in the context of severe physical illness). This prejudice about mental problems has been a barrier to the integration of the psychosocial domain into total cancer care; the identification of patients who are distressed; and, patient's acceptance of psychological help. Despite these barriers, psychosocial oncology has developed worldwide, with a small, but active cadre of investigators and clinicians engaging in clinical, educational and research aspects of psycho-oncology. The International Psycho-Oncology Society (IPOS), since 1984, has brought them together. The Sutherland Memorial Lecture has honored nine individuals from five countries who have made major contributions to the field: 1982, Avery Weisman; 1984, Bernard Fox; 1987, Morton Bard; 1991, Margit von Kerekjarto; 1993, Ned Cassem; 1996, Steven Greer; 1998, Hiroomi Kawano; 2000, Robert Zittoun; and 2003, Jimmie Holland. The scientific base for psychosocial oncology is now secure with a body of knowledge, textbooks and journals which have led to the development of evidence-based clinical practice guidelines for psychosocial services in several countries. A benchmark now exists against which care can be monitored and accountability established. The next 25 years will see an improvement in the psychosocial care of patients, based on research that gives a scientific basis for interventions, and a reduction in the barriers to psychosocial care in cancer.

Clinical practice guidelines for the management of psychosocial distress at the end of life

After years of neglect, care at the end of life is receiving increasing attention and concern. It is then that the body is consumed by a progressive and mortal illness, and the person must cope not only with the bodily symptoms, but also with the existential crisis of the end of life and approaching death. As the body suffers, the mind is indeed “commanded … to suffer with the body,” as Shakespeare so well described. Thus, suffering near the end of life encompasses both the mind and the body. Providing optimal symptom relief and alleviation of suffering is the highest priority. However, evidence suggests that we continue to fall far short of this ideal (American Society of Clinical Oncology, 1996; Cassem, 1997; Cassel & Foley, 1999; Carver & Foley, 2000). Although pain management guidelines have been the most widely disseminated, we know that many patients continue to suffer not only from pain, but other troubling physical symptoms in their final days (American Nursing Association, 1991; Carr et al., 1994; American Pain Society, 1995; American Academy of Neurology, 1996; American Board of Internal Medicine, 1996; Ahmedzai, 1998). Despite clear advances in the identification and treatment of psychiatric disorders, we continue to underdiagnose and undertreat the debilitating symptoms of depression, anxiety, and delirium in the final stages of life (Carroll et al., 1993; Hirschfeld et al., 1997; Holland, 1997, 1998, 1999; Breitbart et al., 2000; Chochinov & Breitbart, 2000). And, beyond these physical and psychological symptoms, we fall even shorter of our goals of alleviating the spiritual, psychosocial, and existential suffering of the dying patient and family (Cherny & Portenoy, 1994; Cherny et al., 1996; Fitchett & Handzo, 1998; Karasu, 2000). And this is in spite of the ethical imperative “to comfort always” (Pellegrino, 2000).

American Cancer Society Award lecture. Psychological care of patients: psycho-oncology's contribution

The centuries-old stigma attached to cancer precluded patients' being told their diagnoses, and thus, delayed any exploration of how they dealt with their illness. This situation changed in the United States in the 1970s when patients began to be told their cancer diagnosis, permitting the first formal study of the psychological impact of cancer. However, a second and equally long-held stigma attached to mental illness has been another barrier and this has kept patients from being willing to acknowledge their psychological problems and to seek counseling. This "double stigma" has slowed the development of psycho-oncology. However, we began to see rapid changes occurring in the last quarter of the 20th century. Valid assessment instruments were developed which were used in well-designed studies. Data from these studies and clinical observations led to increased recognition that psychosocial services are needed by many patients and provide significant assistance in coping with illness. Psycho-oncology has two dimensions: first, the study of the psychological reaction of patients at all stages of the disease, as well as of the family and oncology staff; second, exploring the psychological, social, and behavioral factors that impact on cancer risk and survival. Psycho-oncology now has a recognized role within the oncologic community through clinical care, research, and training as it relates to prevention of cancer through lifestyle changes, evaluation of quality of life, symptom control, palliative care and survivorship. Presently, there are sufficient research studies from which standards of care have been established. Both evidence and consensus-based clinical practice guidelines have been promulgated. It now possible to monitor the quality of existing psychosocial services by using these benchmarks of quality that have evolved in recent years.

Quality of life impact of three different doses of suramin in patients with metastatic hormone-refractory prostate carcinoma

BACKGROUND

Research has suggested that men with hormone-refractory prostate carcinoma have a lower quality of life (QOL) compared with men who have hormone-sensitive prostate carcinoma and that quality of life (QOL) steadily declines over the last year of life for men with prostate carcinoma. The primary purpose of the current study was to evaluate whether there was evidence of palliative effects associated with suramin at any of the three doses administered in the original clinical trial.

METHODS

Patients with histologically confirmed advanced hormone-refractory adenocarcinoma of the prostate were randomized to receive suramin at a low dose (n = 129; median age, 69 years), an intermediate dose (n = 129; median age, 71 years), or a high dose (n = 127; median age, 70 years) as part of the Intergroup 0159/Cancer and Leukemia Group B 9480 trial. Patients completed a battery of assessment tools, including the Functional Assessment of Cancer Therapy (FACT)-Prostate, the Center for Epidemiological Studies-Depression Scale (CES-D), the Brief Pain Inventory, and an opioid medication log, at baseline, on Day 1 of the sixth week of active therapy, during the second week after treatment termination, and 3 months after administration of the final suramin dose.

RESULTS

Patients who received low-dose suramin reported improvement in QOL (FACT-General: P < 0.01; FACT-Treatment Outcome Index: P < 0.01) and decreased levels of depression (CES-D: P < 0.0006) during treatment compared with patients in the intermediate- and high-dose arms. After treatment, all groups experienced equal decreases in FACT and CES-D scores.

CONCLUSIONS

The pattern of results suggests that the lowest dose of suramin administered had a palliative effect in terms of improvement in QOL and decreased levels of depression and that this effect was lost once suramin was discontinued.

Long-term adjustment of survivors of early-stage breast carcinoma, 20 years after adjuvant chemotherapy

BACKGROUND

The long-term impact of breast carcinoma and its treatment was assessed in 153 breast carcinoma survivors previously treated on a Phase III randomized trial (Cancer and Leukemia Group B [CALGB 7581]) a median of 20 years after entry to CALGB 7581.

METHODS

Survivors were interviewed by telephone using the following standardized measures: Brief Symptom Inventory (BSI), PostTraumatic Stress Disorder Checklist with the trauma defined as survivors' response to having had cancer (PCL-C), Conditioned Nausea, Vomiting and Distress, European Organization for Research and Treatment of Cancer QLQ-C30 (quality of life), Life Experience Survey (stressful events), MOS Social Support Survey, comorbid conditions (Older Americans Resources and Services Questionnaire), and items developed to assess long-term breast carcinoma treatment side effects and their interference with functioning.

RESULTS

Only 5% of survivors had scores that were suggestive of clinical levels of distress (BSI), 15% reported 2 or more posttraumatic stress disorder (PTSD) symptoms (PCL-C) that were moderately to extremely bothersome, 1-6% reported conditioned nausea, emesis, and distress as a consequence of sights, smells, and tastes triggered by reminders of their treatment, 29% reported sexual problems attributed to having had cancer, 39% reported lymphedema, and 33%, reported numbness. Survivors who reported greater lymphedema and numbness that interfered with functioning had significantly worse PTSD (PCL-C; P = 0.008) com- pared with survivors who reported less lymphedema and numbness. Survivors with a lower level of education (P = 0.026), less adequate social support (P = 0.0033), more severe negative life events (P = 0.0098), and greater dissatisfaction with their medical care (P = 0.037) had worse PTSD compared with other survivors.

CONCLUSIONS

Twenty years after the initial treatment, the impact of breast carcinoma on survivors' adjustment was minimal. However, the higher prevalence of PTSD symptoms in response to having had cancer is indicative of continuing psychologic sequelae long after treatment completion. Findings related to lymphedema and numbness and continued symptoms of PTSD suggest that the long-term psychologic and medical sequelae on adjustment may be underrecognized. To establish in more detail whether survivors' overall psychologic state is any different from that of individuals without cancer, a population of community residents without cancer would need to be studied.

The memorial anxiety scale for prostate cancer: validation of a new scale to measure anxiety in men with with prostate cancer

BACKGROUND

The psychological difficulties facing men with prostate cancer are acknowledged widely, yet identifying men who may benefit from mental health treatment has proven to be a challenging task. The authors developed the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) to facilitate the identification and assessment of men with prostate cancer-related anxiety. This scale consists of three subscales that measure general prostate cancer anxiety, anxiety related to prostate specific antigen (PSA) levels in particular, and fear of recurrence.

METHODS

Ambulatory men with prostate cancer (n = 385 patients) were recruited from clinics throughout the United States. Prior to routine PSA tests, participants completed a baseline assessment packet that included the Hospital Anxiety and Depression Scale; the Distress Thermometer; the Functional Assessment of Cancer Therapy Scale, Prostate Module; and measures of role functioning, sleep, and urinary functioning. PSA values from the last three tests also were collected. Follow-up evaluation was completed within 2 weeks after patients learned of their PSA test result using a subset of these scales.

RESULTS

Analysis of the MAX-PC revealed a high degree of internal consistency and test-retest reliability for the total score and for the three subscales, although reliability was somewhat weaker for the PSA Anxiety Scale. Concurrent validity was demonstrated by correlations between the MAX-PC and measures of anxiety. Overall changes in PSA levels were correlated only modestly with changes in MAX-PC scores (correlation coefficient, 0.13; P = 0.02).

CONCLUSIONS

The MAX-PC appears to be a valid and reliable measure of anxiety in men with prostate cancer receiving ambulatory care.