Lesson in psycho-oncology

As a new subspecialty of oncology, psycho-oncology's emergent role reflects the growing interest and concern over the past 25 years, on the part of both oncologists and the general public, in the psychological, behavioral, and social factors related to cancer prevention and treatment. Today, total care of cancer patients must include concern for psychosocial well-being and management of distress must be fully integrated with the other aspects of the patient's treatment plan. Prevention efforts are rooted in the willingness and ability of individuals to change lifestyle and risk behaviors, and this has to be elucidated by research in psycho-oncology. Further, psycho-oncology advances theory and practice related to the effects of cancer on psychological function and provides expertise in the prevention of cancer. Thus, psycho-oncology has a unique role to play in cancer treatment and prevention.

Management of grief and loss: medicine's obligation and challenge

One of medicine's least taught and acknowledged areas is the physicians' obligation to the surviving families of patients who have died under our care. The uncomfortable feelings engendered by the death of a patient often lead to ending contact with the family of the deceased. However, this response fails to recognize the importance of the role that the treating physician continues to have for the surviving family. A phone call, letter, or attendance at the funeral has enormous meaning and value for the family. This role also provides the doctor with an opportunity to deal with the "minigrief" reaction that follows the death of a special patient, and it reduces the adverse effects of unacknowledged, cumulative losses that lead to burnout. Although the deaths of patients and our efforts to help their grieving relatives may be the "dark" side of medicine, this side can be among the most rewarding when it helps bereaved loved ones and ourselves to survive loss.

Impact of azacytidine on the quality of life of patients with myelodysplastic syndrome treated in a randomized phase III trial: a Cancer and Leukemia Group B study

PURPOSE

The impact of azacytidine (Aza C) on the quality of life of 191 patients with myelodysplastic syndrome was assessed in a phase III Cancer and Leukemia Group B trial (9221).

PATIENTS AND METHODS

One hundred ninety-one patients (mean age, 67.5 years; 69% male) were randomized to receive either Aza C (75 mg/m(2) subcutaneous for 7 days every 4 weeks) or supportive care, with supportive care patients crossing over to Aza C upon disease progression. Quality of life was assessed by centrally conducted telephone interviews at baseline and days 50, 106, and 182. Overall quality of life, psychological state, and social functioning were assessed by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and the Mental Health Inventory (MHI).

RESULTS

Patients on the Aza C arm experienced significantly greater improvement in fatigue (EORTC, P =.001), dyspnea (EORTC, P =.0014), physical functioning (EORTC, P =.0002), positive affect (MHI, P =.0077), and psychological distress (MHI, P =.015) over the course of the study period than those in the supportive care arm. Particularly striking were improvements in fatigue and psychological state (MHI) in patients treated with Aza C compared with those receiving supportive care for patients who remained on study through at least day 106, corresponding to four cycles of Aza C. Significant differences between the two groups in quality of life were maintained even after controlling for the number of RBC transfusions.

CONCLUSION

Improved quality of life for patients treated with Aza C coupled with significantly greater treatment response and delayed time to transformation to acute myeloid leukemia or death compared with patients on supportive care (P <.001) establishes Aza C as an important treatment option for myelodysplastic syndrome.

Randomized controlled trial of azacitidine in patients with the myelodysplastic syndrome: a study of the cancer and leukemia group B

PURPOSE

Patients with high-risk myelodysplastic syndrome (MDS) have high mortality from bone marrow failure or transformation to acute leukemia. Supportive care is standard therapy. We previously reported that azacitidine (Aza C) was active in patients with high-risk MDS.

PATIENTS AND METHODS

A randomized controlled trial was undertaken in 191 patients with MDS to compare Aza C (75 mg/m(2)/d subcutaneously for 7 days every 28 days) with supportive care. MDS was defined by French-American-British criteria. New rigorous response criteria were applied. Both arms received transfusions and antibiotics as required. Patients in the supportive care arm whose disease worsened were permitted to cross over to Aza C.

RESULTS

Responses occurred in 60% of patients on the Aza C arm (7% complete response, 16% partial response, 37% improved) compared with 5% (improved) receiving supportive care (P <.001). Median time to leukemic transformation or death was 21 months for Aza C versus 13 months for supportive care (P =.007). Transformation to acute myelogenous leukemia occurred as the first event in 15% of patients on the Aza C arm and in 38% receiving supportive care (P =.001). Eliminating the confounding effect of early cross-over to Aza C, a landmark analysis after 6 months showed median survival of an additional 18 months for Aza C and 11 months for supportive care (P =.03). Quality-of-life assessment found significant major advantages in physical function, symptoms, and psychological state for patients initially randomized to Aza C.

CONCLUSION

Aza C treatment results in significantly higher response rates, improved quality of life, reduced risk of leukemic transformation, and improved survival compared with supportive care. Aza C provides a new treatment option that is superior to supportive care for patients with the MDS subtypes and specific entry criteria treated in this study.

History of psycho-oncology: overcoming attitudinal and conceptual barriers

The formal beginnings of psycho-oncology date to the mid-1970s, when the stigma making the word "cancer" unspeakable was diminished to the point that the diagnosis could be revealed and the feelings of patients about their illness could be explored for the first time. However, a second stigma has contributed to the late development of interest in the psychological dimensions of cancer: negative attitudes attached to mental illness and psychological problems, even in the context of medical illness. It is important to understand these historical underpinnings because they continue to color contemporary attitudes and beliefs about cancer and its psychiatric comorbidity and psychosocial problems. Over the last quarter of the past century, psycho-oncology became a subspecialty of oncology with its own body of knowledge contributing to cancer care. In the new millennium, a significant base of literature, training programs, and a broad research agenda have evolved with applications at all points on the cancer continuum: behavioral research in changing lifestyle and habits to reduce cancer risk; study of behaviors and attitudes to ensure early detection; study of psychological issues related to genetic risk and testing; symptom control (anxiety, depression, delirium, pain, and fatigue) during active treatment; management of psychological sequelae in cancer survivors; and management of the psychological aspects of palliative and end-of-life care. Links between psychological and physiological domains of relevance to cancer risk and survival are being actively explored through psychoneuroimmunology. Research in these areas will occupy the research agenda for the first quarter of the new century. At the start of the third millennium, psycho-oncology has come of age as one of the youngest subspecialties of oncology, as one of the most clearly defined subspecialties of consultation-liaison psychiatry, and as an example of the value of a broad multidisciplinary application of the behavioral and social sciences.

Improving the human side of cancer care: psycho-oncology's contribution

Psycho-oncology is only about twenty-five years old, emerging since the diagnosis of cancer began to be revealed and honest discussions could occur about this illness. The stigma has diminished and much progress has been made in that short period. This small new field brings concepts to care that incorporate both prevention and delivery of services to reduce distress and enhance well-being. Its first dimension studies the psychological reaction of patients at all stages of the disease, as well as those of the family and healthcare staff, and the second dimension explores the psychological, social, and behavioral factors that may impact on cancer incidence and survival. Psycho-oncology has a place at the table within the oncology community, both in clinical care and in research, especially related to prevention, quality of life, symptom control, and palliative care. Psycho-oncology is part of the continuum of cancer care that includes primary and secondary prevention at one end, and survivors and palliative care at the other. Our present body of information rests on a large database of research. Implementation of what we know now could greatly improve the psychological well-being and quality of life of patients with cancer.

The system of belief inventory (SBI-15): a validation study in Israel

This study focused on the validation of measures assessing religiosity by means of three self-report instruments: the System of Belief Inventory (SBI-15R), the Religious Orientation Inventory (ROI), and the Index of Core Spiritual Experiences (INSPIRIT). These instruments were developed and validated previously in the United States. The study measured the extent to which the self-reports maintain their validity when administered in a different country with its own distinct language, culture and religion (e.g. Israel). It was found that all three self-reports have very good external validity and high convergent reliability, with the SBI demonstrating extremely high internal reliability.

Persistent symptoms among survivors of Hodgkin's disease: an explanatory model based on classical conditioning

Persistent symptoms of nausea, distress, and vomiting triggered by reminders of cancer treatment were examined among 273 Hodgkin's disease survivors, 1 to 20 years posttreatment. Prevalence rates were high for distress and nausea but low for vomiting. Retrospective report of anticipatory symptoms during treatment was the strongest predictor of persistent symptoms, suggesting that treatment-induced symptoms are less likely to persist if conditioning does not occur initially. Time since treatment was also a significant predictor, with patients more recently treated more likely to experience persistent symptoms. Thus, an explanatory model based on classical conditioning theory successfully predicted presence of persistent symptoms. Symptoms also were associated with ongoing psychological distress, suggesting that quality of life is diminished among survivors with persistent symptoms. Recommendations for prevention and treatment of symptoms are discussed.

Stress and burnout in oncology

This article identifies the professional stressors experienced by nurses, house staff, and medical oncologists and examines the effect of stress and personality attributes on burnout scores. A survey was conducted of 261 house staff, nurses, and medical oncologists in a cancer research hospital, and oncologists in outside clinical practices. It measured burnout, psychological distress, and physical symptoms. Each participant completed a questionnaire that quantified life stressors, personality attributes, burnout, psychological distress, physical symptoms, coping strategies, and social support. The results showed that house staff experienced the greatest burnout. They also reported greater emotional exhaustion, a feeling of emotional distance from patients, and a poorer sense of personal accomplishment. Negative work events contributed significantly to level of burnout; however, having a "hardy" personality helped to alleviate burnout. Nurses reported more physical symptoms than house staff and oncologists. However, they were less emotionally distant from patients. Women reported a lower sense of accomplishment and greater distress. The four most frequent methods of relaxing were talking to friends, using humor, drinking coffee or eating, and watching television. One unexpected finding was that the greater the perception of oneself as religious, the lower the level of burnout. Thus, while the rewards of working in oncology are usually sufficient to keep nurses and doctors in the field, they also experience burnout symptoms that vary by gender and personal attributes. House staff are most stressed and report the greatest and most severe symptoms of stress. Interventions are needed that address the specific problems of each group.

Psychosocial aspects of cancer genetics: women at high risk for breast and ovarian cancer

In the past five years the advent of cancer genetic testing has created concern about the negative psychosocial sequelae of genetic counseling and testing. Research indicates that the women most likely to seek genetic testing are anxious about carrying a gene mutation and developing breast cancer. Women who are at high risk have poor knowledge and the expectation of being a gene-mutation carrier. High levels of distress have been shown to interfere with decision-making about genetic testing. Further, individuals who decline genetic testing may be at increased risk for depressive symptoms even more than those who are found to be gene-mutation carriers. There is great concern that inappropriate candidates will seek genetic testing. Improved education and access to genetic counseling are essential to help women make appropriate decisions about genetic testing. Strategies for the prevention of breast and ovarian cancer are explored, and methods to reduce the adverse psychosocial effects of decision-making about genetic testing and preventive treatment strategies are suggested.

Involving family members in cancer care: focus group considerations of patients and oncological providers

Family members are an integral part of a patient's cancer care from the moment the diagnosis is delivered to the conclusion of treatment. Family members bring with them a range of emotional reactions, interpersonal dynamics and expectations for the care the patient receives. This study is part of a multi-institutional project to continue to improve the process of cancer care. In this study, 19 focus groups (11 patient and 8 provider) were conducted concerning issues related to doctor-patient communication in eight cancer centers in the United States. The content of the conversations was analyzed and thematic categories emerged that highlight the various strengths and difficulties associated with family involvement. The focus groups' comments support the need for explicit conversations between professional caregivers, patients and their loved ones, in order to negotiate the expectations and needs of each team member. Implications for clinical practice and strategies for working with family members are offered.

A pilot study of interpersonal psychotherapy by telephone with cancer patients and their partners

A single-arm pilot study explored the feasibility of adapting in Interpersonal Psychotherapy (IPT) by telephone to reduce psychological distress and to enhance coping during cancer treatment. Therapy focuses on role transitions, interpersonal conflicts, and grief precipitated by cancer. Breast cancer patients receiving high-dose chemotherapy received weekly sessions with a psychologist throughout chemotherapy and for 1 month afterwards. Patients could invite one 'partner' to receive individual telephone IPT. Psychosocial functioning was assessed using standardized measures at study entry, after chemotherapy, and following telephone IPT. Accrual and participation supplied evidence of feasibility: 14 patients and 10 partners were recruited, 82.5% of those eligible. Patients had a mean of 16 sessions; partners had a mean of 11. Participants rated their satisfaction with the program between 'good' and 'excellent'. A test of the efficacy of telephone IPT requires a larger, randomized trial. In order to standardize the intervention, a treatment manual was developed. This study indicated the importance of outreach to family members as well as to cancer patients, intensive patient education about oncology treatment and the medical care setting, and psychosocial services that continue after cancer treatment has been completed.

Psycho-oncology: where have we been? Where are we going?

This article reviews the development of the subspeciality of psycho-oncology and its contributions to patient care, encouraging more attention to and research into the care of the total patient: the physical, psychological, social and spiritual aspects of care. The result is enhanced quality of life as the patient is studied in the domains of living that are important, extending across the continuum of care from diagnosis to palliative care. In addition, cancer prevention and early detection depends largely on changing attitudes and behaviours that put people at greater risk. This is an important area of research for psycho-oncologists. In the past two decades, research has contributed to our understanding of the psychological responses that accompany a cancer diagnosis. Oncologists better recognise psychological distress and psychiatric disorders such as anxiety, depression and delirium (in hospitalised patients) as frequent comorbid disorders. The development of valid assessment tools for the patients' self-report has been important. Increasingly, outcome measures in controlled trials of new therapies include quality of life, and no longer look at survival alone. The future will continue to bring new challenges to psycho-oncology as patients face new challenges in treatment. A major aim of the next century will be to bring this integrated approach to all patients in an affordable manner.

The role of religious and spiritual beliefs in coping with malignant melanoma

This study investigated the role of spiritual and religious beliefs in ambulatory patients coping with malignant melanoma. One-hundred and seventeen patients with melanoma being seen in an outpatient clinic completed a battery of measurements including the newly validated Systems of Belief Inventory (SBI-54). No correlation was found between SBI-54 scores and levels of distress. However, there was a correlation between greater reliance on spiritual and religious beliefs and use of an active-cognitive coping style (r = 0.46, p < 0.0001). Data suggest that use of religious and spiritual beliefs is associated with an active rather than passive form of coping. We suggest that such beliefs provide a helpful active-cognitive framework for many individuals from which to face the existential crises of life-threatening illness.

A brief spiritual beliefs inventory for use in quality of life research in life-threatening illness

This paper reports on the initial efforts to validate a brief self-report inventory, the Systems of Belief Inventory(SBI-15R), for use in quality of life (QOL) and psychosocial research studying adjustment to illness. The SBI-15R was designed to measure religious and spiritual beliefs and practices, and the social support derived from a community sharing those beliefs. The authors proposed this scale to address the need for greater exploration of spiritual and religious beliefs in QOL, stress and coping research. Phase I: Item generation. The research team identified four domains comprised of 35 items that make up spiritual and religious beliefs and practices. The instrument was piloted in a structured interview format on 12 hospitalized patients with varying sites of cancer. Phase II: Formation of SBI-54. After these initial efforts, the research team increased the number of items to 54 and adopted a self-report format. To assess patients reactions to the questionnaire, the new version was piloted on 50 outpatients with malignant melanoma. Phase III: Initial validation. To begin establishing validation, 301 healthy individuals with no history of cancer or serious illness in the prior year were asked to complete the SBI-54 and several other instruments. A principal components analysis with varimax rotation of the SBI-54 identified two factors, in contrast to the four which were hypothesized, one measuring spiritual beliefs and practices, the other measuring social support related to the respondent's religious community. Phase IV: Item reduction of the SBI-54. A shortened version of the SBI-54 with 15 items, five from the items identifying factor I and ten from those identifying factor II, was developed to lessen patient burden. The new SBI-15 correlated highly with the SBI-54, and demonstrated convergent, divergent, and discriminant validity. Revision of SBI-15. The investigators rephrased one statement in order to broaden the applicability of the SBI-15 to patients other than those with a diagnosis of cancer, and to healthy individuals. DISCUSSION. The SBI-15R met tests of internal consistency, test-retest reliability, and convergent, divergent, and discriminant validity in both physically healthy and physically ill individuals. The SBI-15R may have value in measuring religious and spiritual beliefs as a potentially mediating variable in coping with life-threatening illness, and in the measurement of QOL.

Testing for drugs of abuse in saliva and sweat

The detection of marijuana, cocaine, opiates, amphetamines, benzodiazepines, barbiturates, PCP, alcohol and nicotine in saliva and sweat is reviewed, with emphasis on forensic applications. The short window of detection and lower levels of drugs present compared to levels found in urine limits the applications of sweat and saliva screening for drug use determination. However, these matrices may be applicable for use in driving while intoxicated and surveying populations for illicit drug use. Although not an illicit drug, the detection of ethanol is reviewed because of its importance in driving under the influence. Only with alcohol may saliva be used to estimate blood levels and the degree of impairment because of the problems with oral contamination and drug concentrations varying depending upon how the saliva is obtained. The detection of nicotine and cotinine (from smoking tobacco) is also covered because of its use in life insurance screening and surveying for passive exposure.

A controlled trial of fluoxetine and desipramine in depressed women with advanced cancer

BACKGROUND

This study was conducted to determine the efficacy and tolerability of fluoxetine and desipramine in treating depressive symptoms in women with cancer.

METHOD

In this prospective, 6-week, double-blind, placebo-controlled trial, we compared fluoxetine with desipramine in treating depressive symptoms in 40 women diagnosed with cancer. Scales used to measure efficacy and tolerability were the Hamilton Depression Rating Scale (HAM-D), the Hamilton Anxiety Rating Scale (HAM-A), the Clinical and Patient's Global Impression (CGI and PGI) scales, the Functional Living Index for Cancer (FLIC), the Memorial Pain Assessment Card (MPAC), and the SF-36 Health Survey.

RESULTS

Fluoxetine and desipramine treatments improved depression and anxiety symptoms. There was a trend towards significance in improvement of FLIC scores (as evidenced by greater numerical improvements with fluoxetine treatment). Fluoxetine treatment alone was associated with statistically significant improvements in MPAC Mood scale scores. Both treatments showed statistically significant improvements in the quality of life SF-36 scores in Role Emotional, Social Functioning, Mental Health, and Vitality.

CONCLUSIONS

Both fluoxetine and desipramine were effective and well-tolerated in improving depressive symptoms and quality of life in women with advanced cancer. Fluoxetine may offer greater benefit to these patients, as evidenced by greater improvements in fluoxetine-treated patients on several quality of life measures. Our results, while meaningful, should be confirmed in a larger patients sample. However, experience from studies of antidepressant use in patients with advanced cancer has shown that intercurrent disease and treatment variables make it difficult to conduct large studies.

Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study

BACKGROUND

As more oncology care is moved to the outpatient setting, the need for a rapid means for oncologists to identify patients with significant distress has increased. Concurrent with this move has been the pressure to reduce time spent with each patient, adding to the likelihood that a distressed patient will not be recognized and will remain untreated in the current health care environment.

METHODS

A pilot program was conducted in a prostate carcinoma oncology clinic to test the feasibility of a two-stage approach that identifies patients in significant distress and refers them for treatment. Two pencil and paper self-report measures were used to detect psychologic distress in patients over the previous week: 1) The Hospital Anxiety and Depression Scale (HADS) and 2) "The Distress Thermometer." Patients who scored above an agreed upon cutoff score on either measure (HADS = 15+; Thermometer = 5+) were referred to the psychiatric liaison in the clinic for evaluation.

RESULTS

Compliance in filling out the measures was excellent; only 8 of 121 patients (6.6%) refused. Thirty-one percent of evaluable patients were referred based on elevated scores. Seventeen of 29 patients actually were evaluated. Eight of 17 patients met Diagnostic and Statistical Manual (of Mental Disorders)-IV criteria for a psychiatric disorder.

CONCLUSIONS

This approach for rapid screening for distress was acceptable in prostate carcinoma patients, although these older men were reluctant to agree to evaluation and treatment. This simple screening method needs further testing and the identification of barriers on the part of the patient and oncologist that impede the identification of the most distressed patients.

Psychologic and neuropsychologic functioning of patients with limited small-cell lung cancer treated with chemotherapy and radiation therapy with or without warfarin: a study by the Cancer and Leukemia Group B

PURPOSE

The current study assessed the psychologic and neuropsychologic functioning of patients with small-cell lung cancer who were randomized in a large clinical trial to receive intensive doxorubicin, cyclophosphamide, etoposide (ACE)/cisplatin, cyclophosphamide, etoposide (PCE) chemotherapy and radiation therapy (RT) to the primary tumor and prophylactic whole-brain irradiation with (regimen I) or without (regimen II) warfarin.

PATIENTS AND METHODS

Patients' emotional states and cognitive functioning were assessed using the Profile of Mood States (POMS) and Trail Making B Test (Trails B), respectively. Two hundred ninety-five patients completed the POMS and Trails B at pretreatment, 224 patients after the completion of the ACE course of chemotherapy (week 9), and 177 patients after the completion of the PCE chemotherapy and RT (week 17).

RESULTS

No differences on the POMS or Trails B measures were found between the two treatment arms as predicted, given that the only difference between the two treatment arms was the presence or absence of warfarin. Analysis of the POMS revealed that, overall, mean scores remained stable over the course of treatment; however, women showed a trend toward higher mean scores, which indicated a higher level of distress, compared with men at the pretreatment assessment. Examination of cognitive functioning, measured by the Trails B, revealed improved performance from baseline to post-ACE chemotherapy, which is consistent with a practice effect, but a significant worsening of Trails B scores post-RT compared with the pre-RT assessments, which is consistent with impaired cognitive functioning because of treatment (P < .0001).

CONCLUSION

Emotional state, measured by the POMS, did not differ between the groups or change significantly over time in this study of small-cell lung cancer patients treated with a combination of chemotherapy and RT plus or minus warfarin. However, the pattern of relatively stable POMS scores and poorer Trails B performance post-RT suggested that this combination of chemotherapy and RT had a negative impact on cognitive functioning.