The influence of distressing symptoms to levels of depression in cancer patients

PURPOSE

Our objectives were to identify the depression and the distressing symptoms in younger and elderly advanced cancer patients.

METHODS

: The instruments that have been used were the Beck Depression Inventory (BDI) for younger patients, the Geriatric Depression Scale (GDS) for geriatric patients and the M. D. Anderson Symptom Inventory (MDASI) for the severity and impact of cancer-related symptoms.

RESULTS

A trend for significant correlation was found between the GDS and MDASI symptoms for nausea (p=0.058), while a significant correlation was observed for increased sadness (p=0.011), increased constipation (p=0.021), interference of symptoms in mood (p=0.012) and in relations with people (p=0.007); interference of symptoms in mood was the most important risk factor. For younger patients, many statistically significant associations were found between distressing symptoms and depression; however, interference of symptoms in mood (p=0.045) was the only important risk factor.

CONCLUSION

Health-care professionals should take into consideration the risk factors for depressive symptoms suggesting a holistic care in advanced cancer patients.

Validation of the revised Bakas Caregiving Outcomes Scale in Greek caregivers of patients with advanced cancer receiving palliative radiotherapy

PURPOSE

Caregiver burden considerably affects the lives of families providing care to people with advanced cancer. The aim of this study was to validate the Greek translation of the revised Bakas Caregiving Outcomes Scale (BCOS) with a sample of informal caregivers of people with advanced cancer receiving outpatient palliative radiotherapy.

METHODS

Following a formal "forward-backward" method to translate the original BCOS into Greek, the scale was administered to 100 consecutive family caregivers. Participants also completed the Greek Hospital Anxiety and Depression Scale (G-HADS) and five quality-of-life related linear analogue scale assessment (LASA) scales. Validity and reliability analyses were performed.

RESULTS

The Cronbach's α coefficient for the total BCOS score was 0.83. Test-retest reliability analysis in a subgroup of caregivers (n = 40) revealed good short-term stability over a 2-week interval. Exploratory factor analysis generated a one-factor structure for the Greek translation, which was further confirmed through confirmatory factor analysis. Construct validity was supported through the scale's high correlations with G-HADS anxiety (-0.524; p < 0.001) and depression (-0.533; p < 0.001) scores, and LASA quality of life scores (0.696; p < 0.001). The BCOS discriminated well between groups of caregivers with different levels of quality of life. A total score of 52.5 offered high sensitivity (91 %) and specificity (86 %) in detecting highly burdened caregivers.

CONCLUSIONS

The Greek version of the BCOS is a psychometrically sound instrument that can be usefully implemented into clinical practice to identify family caregivers in need for support, and stimulate relevant research in our country.

Differences in levels of self-efficacy and anxiety between cancer and chronically-ill patients attending a Palliative Care Unit

PURPOSE

To investigate the differences in anxiety and self-efficacy beliefs as well as the sociodemographic and clinical characteristics, between cancer and chronically-ill patients.

METHODS

A total of 175 patients from a pain relief and palliative care unit participated in this study. Patient sociode-mographic and clinical characteristics were recorded. Patients completed the Greek version of the Spielberger State-Trait Anxiety Inventory (STAI) and the Greek version of the General Perceived Self-Efficacy Scale (GSE).

RESULTS

No statistically significant differences were found between the two patient populations regarding self-efficacy. Statistically significant differences were found between chronically-ill and cancer patients in the scales of "emotionality" (p<0.0005), and "self-deprecation" (p<0.0005). Statistically significant negative correlations were found between all STAI scales and self-efficacy for both cancer and chronically-ill patients (r ranged from -0.231 to -0.503).

CONCLUSION

Chronically-ill patients experienced increased anxiety compared to cancer patients. Self-efficacy had a significant negative correlation with anxiety between the two groups of patients.

Geriatric depression in advanced cancer patients: the effect of cognitive and physical functioning

AIM

The aims of the current study were to evaluate geriatric depression and its risk factors in advanced cancer patients.

METHODS

A cross-sectional study was carried out in a palliative care unit in Greece. Patients completed the Geriatric Depression Scale, the M. D. Anderson Symptoms Instrument (MDASI), the Activities of Daily Living and the Mini-Mental State Examination. Patients were included if they were aged >65 years, if they had cancer, were able to communicate and had agreed to sign informed consent. The final sample consisted of 92 elderly advanced cancer patients.

RESULTS

The prevalence of depression was found to be 67.4%. The univariate comparison between the depressed elderly and non-depressed group showed that patients with metastases were found to be 2.2-fold more likely to suffer from geriatric depression compared with those without metastases (P = 0.074). Patients with moderate or severe cognitive impairment were found to be 3.61-fold more likely to suffer from geriatric depression in comparison with those with normal cognitive function (P = 0.019). In the multiple logistic regression analysis, elderly with cognitive impairment were 3.3-fold more likely to have geriatric depression than those without (adjusted odds ratio = 3.3 [95% CI 0.99-10.74], P = 0.052) and MDASI factor 1 was consistently a significant risk factor for depression in the elderly; when MDASI factor 1 increased by 1 unit, the odds of being classified as depressed increased by 7.6%.

CONCLUSIONS

The present study found that cognitive impairment and symptoms such as enjoyment of life, walking, relationship with people, general activity, sadness and pain (MDASI F1) are strong independent predictors of depression in the elderly.

Relationship of general self-efficacy with anxiety, symptom severity and quality of life in cancer patients before and after radiotherapy treatment

PURPOSE

Treatment-related symptoms can increase psychological and physical distress and alter the patient's quality of life. The present study evaluates prospectively treatment-related symptoms, general self-efficacy, anxiety and quality of life (QoL) in patients with different types of cancer undergoing external beam radiotherapy (RT) and the relationship of patients' general self-efficacy with the assessed measures, at the baseline and their absolute change 1 month after the end of the treatment.

METHODS

The sample consisted of 90 cancer patients. General self-efficacy was assessed using the General Perceived Self-efficacy (GSE). QoL was evaluated using the Linear Analogue Scale Assessment (LASA), anxiety with the Anxiety subscale of the Hospital Anxiety and Depression (HAD) scale, whereas symptom severity and interference were assessed using the MD Anderson Symptom Inventory (MDASI). The instruments were administered first at the beginning of the RT and then 1 month after the completion of the RT.

RESULTS

At post-treatment, general self-efficacy was reduced (28.86 ± 6.42), anxiety scores were elevated (9.56 ± 4.42), QoL scores were reduced (6.74 ± 1.81) and symptoms severity were deteriorated (3.24 ± 2.62). Pre-treatment and post-treatment absolute change scores revealed statistically significant negative correlations between general self-efficacy absolute scores and anxiety (p < 0.0005). Moderate negative correlations between general self-efficacy absolute scores and symptoms (MDASI symptom severity: p = 0.003, symptom interference: p = 0.002), whereas a low positive correlation was found between general self-efficacy absolute scores and LASA energy scale (p = 0.048).

CONCLUSIONS

A sense of self-efficacy and its relationship with anxiety, symptom distress and quality of life are important factors for patients receiving radiotherapy. Health care professionals need to be aware of anxiety, symptom severity and patient's quality of life prior to treatment initiation.

Posttraumatic stress disorder and preparatory grief in advanced cancer

PURPOSE

The purpose of the current study was to investigate the prevalence of posttraumatic stress disorder (PTSD) and its association with sociodemographic variables and preparatory grief in patients with advanced cancer.

METHODS

195 advanced cancer patients participated in the study. Out of them, 170 had PTSD and 25 had other anxiety disorders. The diagnoses were made in strict accordance with Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I)-Clinician version. Patients completed also the Preparatory Grief in Advanced Cancer Patients (PGAC) scale.

RESULTS

Patients with PTSD were younger (63.54 ± 12.07 years) than those without PTSD (70.36 ± 13.03 years, p=0.010). Patients with PTSD revealed more preparatory grief (37.69 ± 12.11) than those without PTSD (29.58 ± 14.04, p= 0.003). Multiple logistic regression analysis showed that preparatory grief (p=0.012), and metastatic disease (p=0.009) remained in the model whereas age showed a trend for independent significance (p=0.067).

CONCLUSION

In advanced cancer stages, younger patients, those with metastatic disease or patients with elevated scores on preparatory grief seemed to have a greater likelihood to develop PTSD. Thus, given the prevalence of PTSD in advanced cancer patients, health care professionals should be able to better recognize those who are at risk for or exhibit symptoms of this disorder so that appropriate treatment referrals can be made.

Comparison of the impact of radiotherapy and radiochemotherapy on the quality of life of 1-year survivors with cervical cancer

Improvement of screening programs and new treatment strategies against cervical cancer (CC) have increased survival rates of patients in the last decades. As more women survive this type of cancer, their quality of life (QOL) has become a field of great scientific and social importance. Different types of therapy have varying results on the QOL of patients. In this study, we compared the impact of radiotherapy (RAD) and radiochemotherapy (RAD/CHEM) on CC patients’ QOL. Our sample included 105 women who suffered from CC stages IA–IIIA. They were treated either with RAD or RAD/CHEM, and filled in the questionnaires 1 year after treatment completion. We used 4 questionnaires, EORTC QLQ C-30, EORTC QLQ-C24, Questionnaire of Post-traumatic Psychological Disorder, and Greek Symptom Control Questionnaire by M.D. Anderson, in order to assess their QOL. Except for differences in descriptive characteristics of the patients’ (age, number of children, contraceptives) and early toxicity in some organs, no statistically significant difference was observed in the main (physical, sexual, emotional) aspects of life between the 2 groups of treated patients. Treatment type had no effect on total QOL. In conclusion, the addition of CHEM to RAD in the treatment plan of CC patients had no significant impact on their QOL.

Melanoma: the radiotherapeutic point of view; review of the current literature

Surgery remains the mainstay of melanoma therapy at all sites. Melanoma is widely believed to be a radioresistant tumor, a misconception that has historically led to the limited use of RT for its treatment. We searched pubmed from 1978 until 2010 by means of prospective randomized trials. The aim was to assess the potential impact of radiotherapy (RT) on local control, quality of life and overall survival. Radiotherapy should be considered in lentigo maligna, especially in elderly patients with extensive or unresectable disease in difficult areas on the face, with adequate tumor control with good cosmetic and functional results. In addition, radiation therapy provides effective palliation in patients with metastatic malignant melanoma. Doses up to 30 Gy or BED > 39.0Gy were found to be associated with prolonged palliation. These findings should be viewed with caution because the lack of data regarding performance status as well as other unknown confounding factors limits the applicability of retrospectives studies. We recommend that higher doses of RT be considered when using RT for the palliation of patients with metastatic melanoma and a performance status that could tolerate such therapy. In the future, the combination of radiation therapy with hyperthermia may be a reasonable therapeutic option.

The mediation effect of anxiety between post-traumatic stress symptoms and preparatory grief in advanced cancer patients

CONTEXT

The relationship between anxiety and preparatory grief is complex and poorly understood.

OBJECTIVES

To investigate the relationship between anxiety, post-traumatic stress symptoms, and preparatory grief in a sample of patients with advanced cancer.

METHODS

Ninety-four patients with advanced cancer completed the Greek version of the Impact of Events Scale-Revised (IES-R-Gr), the Anxiety subscale of the Greek Hospital Anxiety and Depression Scale, and the Preparatory Grief in Advanced Cancer Patients (PGAC) scale.

RESULTS

Statistically significant associations were found between IES-R-Gr subscales, anxiety (P<0.0005), and PGAC (P<0.0005).

CONCLUSION

Some of the effect of post-traumatic stress symptoms on preparatory grief is mediated by anxiety.

Potential role of the alcohol and smoking in the squamous cell carcinoma of the head and neck: review of the current literature and new perspectives

Alcohol and tobacco are responsible for a very large proportion of chronic disease and some tumors in particular may be the result of interactions between the two risk factors. The present systematic literature review was conducted to judge combined effects of alcohol drinking and tobacco, as well as and genetic polymorphisms on alcohol-related cancer risk. We can conclude that the interaction of smoking and alcohol significantly increases the risk for aero-digestive cancers. Unfortunately, little is known about mechanisms and details of interaction with regard to disease outcomes, which is why particular questions must be targeted in future research efforts.

Intranasal fentanyl: from pharmacokinetics and bioavailability to current treatment applications

Fentanyl, a short-acting synthetic pure opiate, offers an excellent option for the treatment of cancer and chronic pain. While oral administration is not an option, its high potency and lipophilicity have made intranasal administration feasible. Intranasal fentanyl has a bioavailability of 89%, with a short onset of action ( approximately 7 min) and duration times ( approximately 1 h). It bypasses the oral/gastrointestinal route, delivers the analgesic dose in a volume of 150 microl that can be adequately absorbed and, with a pH of 6.4, avoids local irritation. Intranasal fentanyl has been investigated to assess its potential as a well-tolerated acute postoperative breakthrough pain relief medication. It has been shown to be superior to oral transmucosal fentanyl for the treatment of cancer breakthrough pain. Similar analgesic effects to fentanyl or morphine intravenously and orally, with a similar safety profile, have been reported for postoperative or acute pain treatment of children and adults in the prehospital and hospital settings.

Self-efficacy, depression, and physical distress in males and females with cancer

AIMS

to examine the relationship between self-efficacy with depression and physical distressing symptoms in males and females with cancer.

METHODS

a total of 41 males and 49 females with cancer completed the General Perceived Self-Efficacy Scale (GSE), depression scale, from the Hospital Anxiety and Depression Scale (HAD-D), and the MD Anderson Symptom Inventory (MDASI).

RESULTS

correlations were found between depression and self-efficacy in males (r = -.501, P = .001) and females (r = -.588, P < .0005). The multivariate regression analysis revealed that education and depression could influence self-efficacy in male population. Urogenital versus breast cancer as well as depression seemed to influence females' self-efficacy.

CONCLUSIONS

patients who had higher self-efficacy had lower depressive symptoms. Men with depressive symptoms and women with breast cancer and depression are more likely to have low self-efficacy than patients with other cancer types.

Hypofractionated radiotherapy in non small cell lung cancer: a review of the current literature

Hypofractionated irradiation has an established role in the palliative treatment of patients with advanced medically inoperable non - small cell lung cancer (NSCLC ) and poor performance status. Also hypofractionated radiotherapy merits careful consideration in the curative treatment of patients with Stage I and II disease using contemporary technology. The biological effect of radiation on tumours is increased as the overall treatment time is shortened. Hypofractionated field radiotherapy offers acceptable palliation with minimal toxicity. The rates of palliation for hemoptysis , chest pain , cough and dyspnea reported from studies with very short regimen ( 8,5 Gy x 2 ), are comparable to those of other trials that used more protracted palliative treatment . The observed toxicity is minimal, and no cases of oesophagitis, pneumonitis, or radiation myelopathy developed. The minimal toxicity is a reflection of both the low biologic total dose and the tight RT design. Therefore the radiation side effects appear to be related to the technique of RT delivered rather than the patient's PS. Hence, widely believed dogmas concerning the tolerance of critical structures to conventionally fractionated doses, such as the dose-volume effect, total dose, and time (latency) dependency, has to be re-evaluated for hypofractionated radiation therapy. As well there is data suggesting that the small stages I - II NSCLC are likely to benefit from hypofractionated regimens too. Hypofractionated stereotactic radiotherapy is a new technically complex approach to the treatment of early-stage nonsmall cell lung cancer. It is capable to deliver much higher doses to the cancer than is possible with standard techniques, and as a result, rates of tumour control are high and similar to what can be achieved by surgical resection. Refinements of technique and dose as well as randomized data are required before stereotactic radiotherapy can be endorsed as a standard of care for patients with inoperable peripherally located T1 non small cell lung cancer. A clear advantage of the very short hypofractionated palliative regimen is that it allows patients with a short expected survival time to spend more of their remaining time away from the hospital.

Use of the Greek McGill Pain Questionnaire in cancer patients

Cancer directly causes pain and raises a significant clinical problem. Pain is the most dominant cause of suffering in cancer patients. The accurate assessment of pain is a prerequisite for its effective relief, and therefore, a universal methodology for the assessment of the pain status of a patient is required. There are many different methods and various instruments for the measurement of pain. The McGill Pain Questionnaire is a multidimensional instrument for the assessment of pain intensity and the multiple dimensions of the pain experience. Several translations and version of the McGill Pain Questionnaire exist. The Greek version was developed in Athens and has been tested for its use in cancer patients receiving palliative care. The Greek McGill Pain Questionnaire validation study provided preliminary evidence of the validity and reliability of the questionnaire. Future studies are needed to confirm the validity of the instrument in order to render it fully utilizable for the assessment of pain caused by the diverse conditions experienced by Greek patients.

A comparative study of prophylactic antiemetic treatment in cancer patients receiving radiotherapy

PURPOSE

Gastrointestinal side effects can often complicate radiotherapy (RT) in cancer patients. This work presents results of a retrospective open label study aiming to evaluate the optimum prophylactic treatment for nausea and vomiting in patients receiving fractionated radical or palliative RT.

METHODS

576 cancer patients were allocated in 5 treatment groups: 120 patients received tropisetron, 129 tropisetron plus dexamethasone, 101 metochlopramide, 119 dexamethasone, and 107 received metochlopramide plus dexamethasone. To determine the optimum antiemetic prophylactic treatment, nausea and vomiting were evaluated at baseline, 24 and 72 h after the initiation of RT, and at the end of every week during RT. Adverse effects, Eastern Cooperative Oncology Group (ECOG) performance status (PS), and the intensity of nausea and vomiting were recorded.

RESULTS

Statistically significant differences in incidence and intensity of nausea and vomiting were found among the 5 antiemetic treatment groups from the 1st till the 5th week of the RT. Tropisetron + dexamethasone group had significantly reduced odds for nausea and vomiting, and significantly less severe nausea and vomiting than any other treatment group. Factors significantly associated with increased ECOG PS were palliative RT, dose fraction >3Gy, field size >200 cm(2), and treatment with metochlopramide, metochlopramide+dexamethasone and dexamethasone.

CONCLUSION

Patients receiving prophylactic antiemetic treatment with tropisetron+dexamethasone completed RT with lower intensity of nausea and vomiting and lower ECOG PS scores compared to groups that received other antiemetic treatments.

Ethical and practical challenges in implementing informed consent in HIV/AIDS clinical trials in developing or resource-limited countries

BACKGROUND/RATIONALE

Ethical issues regarding HIV/AIDS human research in the developing world remain under continuous evaluation; a critical area of concern includes informed consent. This paper reviews several of the most important ethical and practical aspects of informed consent in HIV research in developing countries. Enhancement of overall understanding of such key issues might promote higher ethical standards of future research.

OBJECTIVES

The major objective was to address informed consent in human research in non-Western societies, and specifically in HIV clinical trials of affected adults. Secondary end-points included the consent complexities in HIV research involving vulnerable patient populations in resource-limited nations, such as children, adolescents and women.

METHODS

A systematic review of the published literature using MEDLINE and EMBASE from 1998 until December 2008 was performed, using the search terms 'HIV/AIDS', 'informed consent', 'clinical trials', 'developing world'.

RESULTS

Ethical complexities such as participants' diminished autonomy, coercion or monetary inducement, language difficulties, illiteracy or lack of true understanding of the entire study, cultural barriers mainly due to communitarianism and social diversities were identified in the 44 studies reviewed. Informed consent of vulnerable patient populations must be tailored to their sex and developmental age, while counselling is fundamental. Children and adolescents' assent must be ensured. Local language is to be used, while trusted community leaders and local cultural representatives may convey information.

DISCUSSION

Despite the heterogeneity of studies, similarities were identified. Providing adequate and comprehensive information and assessing the true understanding of the research represent fundamental prerequisites. Potential solutions to the critical areas of concern include peer counselling and meetings with local community leaders or local cultural representatives.

CONCLUSIONS

International investigators of HIV human research should bear in mind these ethical issues and their potential solutions, when trying to ensure ethical research conduct, based on a truly informed and culturally relevant consent.