The experience of leukaemia and bone marrow transplant: searching for meaning and agency

This qualitative study examines the experience of haematological cancer as described by ten people who have been through leukaemia or lymphoma and a bone marrow transplant. The focus is on the interaction of these participants with this challenging experience and the meaning it had for them. The descriptions of their thoughts, feelings and actions as they negotiated the period from diagnosis to treatment and survival reveal that these people brought both the present values in their life, as well as a life-long pattern of dealing with adversity, into their confrontation of a life-threatening illness. Issues of personal meaning and agency (the capacity to act and control valued aspects of one's life) were found to be paramount. These results are then discussed with a view to their implications for patient care.

Clinical hypnosis in the alleviation of procedure-related pain in pediatric oncology patients

This prospective controlled trial investigated the efficacy of a manual-based clinical hypnosis intervention in alleviating pain in 80 pediatric cancer patients (6-16 years of age) undergoing regular lumbar punctures. Patients were randomly assigned to 1 of 4 groups: direct hypnosis with standard medical treatment, indirect hypnosis with standard medical treatment, attention control with standard medical treatment, and standard medical treatment alone. Patients in the hypnosis groups reported less pain and anxiety and were rated as demonstrating less behavioral distress than those in the control groups. Direct and indirect suggestions were equally effective, and the level of hypnotizability was significantly associated with treatment benefit in the hypnosis groups. Therapeutic benefit degraded when patients were switched to self-hypnosis. The study indicates that hypnosis is effective in preparing pediatric oncology patients for lumbar puncture, but the presence of the therapist may be critical.

Comparison of interviewed and non-interviewed non-Hodgkin's lymphoma (NHL) patients in the San Francisco Bay Area

PURPOSE

To determine whether interviewed non-Hodgkin's lymphoma (NHL) patients differed from non-interviewed NHL patients and to revise the population-based risk estimate for NHL associated with HIV infection in homosexual men in the San Francisco Bay Area. Differences between study participants and non-participants are a concern in epidemiologic studies. Recruitment techniques can be modified when nonparticipation is a result of subject refusal. However, the solutions for nonparticipation due to death are less clear, especially when rapid case ascertainment (RCA) is used to identify newly diagnosed patients.

METHODS

A large population-based case-control study was conducted in the San Francisco Bay Area between 1988 and 1995 to investigate risk factors for NHL. Nearly 1600 patients were interviewed and included in this study. A total of 1047 NHL patients were not interviewed because they had died prior to contact (602 patients) or we had received their RCA information after the study had ended (445 patients). We compared available demographic, clinical, and histologic profiles of the interviewed and non-interviewed NHL patients.

RESULTS

Compared with the interviewed group, the non-interviewed group was younger, had more single HIV-infected homosexual men and a higher incidence of high-grade and "not-otherwise-specified" lymphoma. When categorized by sex and sexual preference, median age at diagnosis of NHL was the same for the interviewed and non-interviewed homosexual men. Combining interviewed and non-interviewed patients, the estimated risk for NHL associated with HIV infection in homosexual men [odds ratio (OR) = 50] is substantially higher than we had estimated in our earlier publications (OR = 20).

CONCLUSIONS

High-grade lymphomas associated with poor survival in homosexual men are likely to be under-represented in case-control studies of NHL.

Psychological outcomes in long-term survivors of childhood leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma: a report from the Childhood Cancer Survivor Study

OBJECTIVE

To evaluate and compare psychological outcomes in long-term survivors of pediatric leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma and sibling controls.

METHODS

Adult survivors of childhood leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma (N = 5736) and sibling controls (N = 2565) were administered a long-term follow-up questionnaire allowing assessment of symptoms associated with depression and somatic distress.

RESULTS

The majority of respondents in this study did not demonstrate symptomatology indicative of depression or somatic distress. Survivors, however, were significantly more likely than sibling controls to report symptoms of depression and somatic distress. Women were significantly more likely to indicate symptoms of depression and somatic distress than were men; however, this difference did not vary by survivor/sibling status. Similarly, socioeconomic (SES) variables predicted symptomatic levels of depression and somatic distress for both survivors and siblings, and these effects did not vary by survivor/sibling status. Among leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma survivors, in addition to gender and SES, the only treatment variable that predicted scores indicating depressive symptomatology was exposure to intensive chemotherapy. Exposure to intensive chemotherapy also predicted scores indicative of somatic distress symptoms. No other medical variables, including diagnostic category, age at diagnosis, time since diagnosis, and duration of treatment, predicted symptomatic scores for depression and somatic distress.

CONCLUSIONS

This large, sibling-controlled, multisite study of young adult survivors of childhood leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma found that survivors had significant increased risk for reporting symptoms of depression and somatic distress and that intensive chemotherapy added to this risk. However, being a cancer survivor did not compound the effects of gender and SES variables on the 2 outcomes measured. The ability of SES, gender, and treatment-related variables to predict psychological symptoms in this cohort of childhood survivors and sibling controls calls for future research into varied biological and psychosocial pathways by which cancer influences future psychosocial functioning.

Struggling with paradoxes: the process of spiritual development in women with cancer

PURPOSE/OBJECTIVES

To examine the process of spiritual development in women diagnosed with cancer within five years of initial treatment.

DESIGN

Exploratory, qualitative.

SETTING

Outpatients in the mid-central and southwestern United States.

SAMPLE

10 Caucasian women, ages 45-70, who completed initial treatment, were not undergoing treatment for recurrence, and were within five years of diagnosis for breast or ovarian cancer or non-Hodgkin's lymphoma.

METHODS

Data collected during two semistructured interviews, coded and analyzed using grounded theory techniques. Frame of reference--symbolic interactionism.

MAIN RESEARCH VARIABLES

Developmental processes of spirituality; responses to diagnosis, treatment, and survival of cancer.

FINDINGS

Diagnosis of cancer threatened the meaning of the women's lives, resulting in a sense of disintegration. This problem was resolved through the basic social psychological process of Struggling With Paradoxes, a three-phase process of Deciphering the Meaning of Cancer for Me, Recognizing Human Limitations, and Learning to Live with Uncertainty. In phase I, the paradoxes focused on the possibility of death, distress, vulnerability, and maintaining connection. In phase II, the paradoxes involved confronting death, asking difficult questions, and letting go of ultimate control of their lives. In phase III, the paradoxes centered on uncertainty, redefining meaning, and identifying spiritual growth. Reintegration occurred over time, although when threatened by the possibility of recurrence, disintegration resurfaced for a time.

CONCLUSIONS

Findings emphasize not only the importance of spirituality, but also that spiritual experience is individualized and developmental in nature. Spiritual growth occurs over time following the diagnosis of cancer and is not necessarily related to age.

IMPLICATIONS FOR NURSING PRACTICE

Spiritual concerns may be painful for patients to address; spiritual caregiving requires an acknowledgment of need by the woman with cancer and a caring, sensitive caregiver. Nurses should be aware of the phases of spiritual development so that interventions can be designed to address individual needs that may vary over time.

Health status and health-related quality of life in survivors of cancer in childhood in Latin America: a MISPHO feasibility study

Cancer is an increasing cause of disease-related death in childhood within developing countries, where the great majority of the world's children reside. The improving prospects for survival in such children, and the corresponding challenge of undertaking economic evaluations of related health interventions, provide a stimulus to study the health-status and health-related quality of life in survivors of cancer in childhood in Latin America. Spanish language versions of questionnaires for proxy assessors, based on the Health Utilities Index (HUI), were used to elicit responses from parents and physicians. The HUI is a family of multi-attribute, generic, preference-linked measures of health status and health-related quality of life that are reliable, responsive and valid, and have been used previously in pediatric oncology. Valid responses were received from 178 parents and 144 physicians in 6 centres in 4 countries (Cuba, Honduras, Colombia and Uruguay). For children with acute lymphoblastic leukemia the major morbidity burdens were in the attributes of emotion, cognition and pain. The overall burden of morbidity was greater in children with non-Hodgkin's lymphoma. In survivors of Hodgkin's disease and Wilms' tumor the attributes most affected were emotion and pain. In general, there was considerable agreement between the assessments provided independently by parents and physicians. This study demonstrates the feasibility of conducting such measurements in developing countries, and reveals similarities in health status and health-related quality of life to comparable populations in more privileged societies.

Quality of life-adjusted survival analysis of high-dose therapy with autologous bone marrow transplantation versus sequential chemotherapy for patients with aggressive lymphoma in first complete remission. Groupe d'Etude les Lymphomes de l'Adulte (GELA)

Evaluating high-dose therapy (HDT) with autologous stem cell transplantation (ASCT) in term of both duration and quality of life (QOL) presents major interests for patients with non-Hodgkin lymphoma. The quality-adjusted time without symptom and toxicity (Q-TWiST) methodology was applied to the LNH87-2 trial comparing HDT with ASCT versus sequential chemotherapy in 541 patients in first complete remission (CR). Overall survival (OS) and disease-free survival (DFS) curves were used to estimate duration of 4 health states: acute short-term toxicity (Tox1), secondary toxicity (Tox2), time without symptom and toxicity (TWiST), and relapse (Rel). Areas under survival curves (AUC) were retrospectively weighted according to QOL coefficients. HDT increased, but not significantly, TWiST (+2. 4 months in AUC, P =.17) and decreased Rel (-3 months, P <.01). Survival estimates did not differ between the 2 treatments (AUC 47.7 months for OS, 39.7 months for DFS). High-risk patients treated by HDT versus chemotherapy had a significant benefit in DFS (AUC 28.8 versus 24.9 months, P <.01) but not in OS (AUC 37.3 versus 36 months, P =.27). Sensitivity analysis, performed by varying QOL coefficients, demonstrated significant quality-adjusted survival gain in high-risk patients treated by HDT. In low-risk patients, a diagram provided an aid to clinical decision-making. This analysis supports the use of HDT in these patients with adverse prognostic factors in the first CR, even after adjusting for QOL using the Q-TWiST method. (Blood. 2000;95:3687-3692)

Physical exercise and quality of life in cancer patients following high dose chemotherapy and autologous bone marrow transplantation

Preliminary evidence indicates that physical exercise may be an effective strategy for the rehabilitation of cancer patients following high dose chemotherapy (HDC) and bone marrow transplantation (BMT), but the focus of this research has been on physical fitness and medical outcomes. In the present study, we employed a prospective design to examine the relationship between physical exercise and various quality of life (QOL) indices in 25 BMT patients. Participants completed weekly self-administered questionnaires upon being admitted to hospital, and monitored the frequency and duration of their exercise during hospitalization. Statistical analyses indicated that exercise during hospitalization was significantly correlated with almost all QOL indices, including physical well-being, psychological well-being, depression, anxiety and days hospitalized. Moreover, only some of the correlations were attenuated after controlling for relevant demographic and medical variables. It was concluded that physical exercise may be related to QOL in BMT patients, but that experimental research is needed before any definitive conclusions can be drawn.

Feelings of oncology patients about being nursed in protective isolation as a consequence of cancer chemotherapy treatment

This qualitative research explores the feelings of oncology patients nursed in protective isolation following high-dose chemotherapy. Five patients described their feelings about the isolation experience during audio-taped interviews lasting between a half and one hour. Tapes were transcribed and analysed, with emergent themes considered in relation to the other interviews and to the literature. The research findings indicate that cancer patients have specific concerns with regard to their experience in the isolation environment, which fall into four distinct categories of: 'being shut in'; 'coping with the experience'; 'being alone'; and 'maintaining contact with the outside world'. In addition, patients have concerns with regard to the experience of having cancer, that impinge upon the isolation experience. These are: 'having cancer'; 'suffering chemotherapy'; 'knowing what to expect'; and 'developing relationships with the health professionals'. The core variable is 'something that I have to go through'. The nature of the relationship between the categories led to the development of an integrative model for exploring the feelings of cancer patients nursed in isolation. Most of the informants coped well with the isolation experience and described feeling supported by the nursing staff. Their overriding concern in fact, reflected a desire to receive information about their disease and reassurance regarding their treatment. Being in isolation appears to inhibit communication about these issues.

Primary central nervous system lymphoma: from clinical presentation to diagnosis

Immunocompetent patients with primary central nervous system lymphoma (PCNSL) present with a median age of 55 years, immunosuppressed patients with a median age of 40 years. They show a broad range of signs and symptoms. Symptoms of increased intracranial pressure and personality change are most frequent, followed in frequency by ataxia and hemiparesis. The median time from onset of symptoms to diagnosis is 3-5 months in immunocompetent patients and 2 months in immunodeficient patients. The time to diagnosis can be considerably longer in patients with slowly developing personality change or fluctuating symptoms due to spontaneous or steroid-induced remission of so-called sentinel lesions. Native CT scans show iso- or hyperdense lesions with homogenous contrast enhancement. T1-weighted MRI scans show hypointense and T2-weighted scans hyperintense lesions. The definitive diagnosis of PCNSL requires biopsy. In some cases, however, the definitive diagnosis may exclusively be made by the demonstration of malignant B-lymphocytes in the cerebrospinal fluid.

Intravenous methotrexate as initial treatment for primary central nervous system lymphoma: response to therapy and quality of life of patients

In anticipation of a consortium study of methotrexate (MTX) therapy provided to patients with primary central nervous system lymphoma (PCNSL) we have provided intravenous MTX without irradiation therapy to 31 nonimmunosuppressed individuals. Twenty (65%) achieved complete response and 11 (35%) partial response to therapy. For the 31 patients the median survival was 30.43 months with an actuarial median follow-up time of 30.69 months. The 2+ year survival was 63% for all patients and 90% for complete responders. Of 375 drug cycles, grade 3 leukopenia was identified in 3 cycles, mucositis in 6 cycles and delayed drug clearance in 47 cycles. Recurrences included brain (9/20) and/or spinal fluid (2/20). The median Karnofsky scale improved from 40 (10-80) prior to therapy to 90 after treatment. Eleven patients, in complete response for a median of 22+ months after diagnosis were evaluated using 4 instruments that assess Quality of Life Functional Assessment of Cancer Therapy - Brain (FACT-BR) modified, Symptom Questionnaire, Social Adjustment Scale-Self-Report and Problem Solving Inventory. Their psychosocial adjustment, well-being and stress coping abilities were comparable to the normative groups. Further there was no evidence of any MTX-induced, Magnetic Resonance Imaging (MRI)-detected encephalopathy in these individuals and there was preservation of clinical cognition and memory. We conclude that therapy with MTX, without radiation can be used in PCNSL patients without limitations of age or pretreatment Karnofsky scores. Further rates of response and median survival approach those of therapies using multiple drugs and radiation, but with a less likely risk of dementia.

The consequences of treatment and disease in patients with primary CNS non-Hodgkin's lymphoma: cognitive function and performance status. North Central Cancer Treatment Group

Per protocol, patients with primary CNS non-Hodgkin's lymphoma in an intergroup phase II trial conducted by the North Central Cancer Treatment Group and the Eastern Cooperative Oncology Group had their cognitive functions measured using the Folstein and Folstein Mini-Mental Status Examination (MMSE) and their physical functions measured using the Eastern Cooperative Oncology Group Performance Score (PS) at study entry, at each treatment evaluation, and at quarterly intervals thereafter until disease progression or death. Of the 53 eligible participants who began therapy, 46 (87%) had baseline MMSE scores recorded, 36 (68%) had at least one follow-up MMSE, and 32 (60%) had both, while 52 (98%) had baseline PS, 49 (92%) had at least one follow-up PS, and 48 (91%) had both. Patterns of MMSE and PS values over time were studied in each individual, in the group as a whole, in the 20 patients who completed the study regimen, in the 23 who survived more than a year, and in patients who were classified as nonprogressors at each key evaluation. For each patient, all recorded values were plotted versus time, with dates of disease progression and death included, to look for signs of decline in cognitive or physical function preceding adverse events. Long-term declines in scores of both cognitive and physical function were observed in many treated patients with primary CNS non-Hodgkin's lymphoma. Nearly all patients who were alive more than 52 weeks after study entry had a demonstrable decline in cognitive and physical functionality. Such declines may occur before disease progression is documented; they may also occur in some patients who have long-term follow-up without evidence of disease progression. Declining MMSE and PS was a poor predictor of disease progression. There was no association of PS and toxicity. The data from this study demonstrated the considerable difficulties we encountered conducting an ancillary study such as this within a multicenter clinical trial. Firstly, the test instruments written into the protocol were unable to tell if the declines seen were due to disease, treatment, co-morbidity, or other factors. Secondly, the missing data created difficulties in interpreting outcome.

Lymphomatosis cerebri presenting as a rapidly progressive dementia: clinical, neuroimaging and pathologic findings

Primary central nervous system lymphoma (PCNSL) usually presents with clinical and neuroimaging findings consistent with single or multiple intracranial mass lesions. On cranial magnetic resonance imaging (MRI), such lesions are nearly always contrast enhancing, reflecting disruption of the blood-brain barrier at the site of tumor nodules. We describe 2 cases from the UCLA Medical Center who developed a rapidly progressive dementia due to extensive gray and white matter cerebral lesions involving much of the brain. In the patient who came to autopsy, widely infiltrating, focally necrotic B-cell plasmacytoid lymphoma was noted throughout the cerebral neuraxis. MRI findings in case 2 were consistent with diffuse lymphomatous brain infiltration without mass lesions, which was biopsy proven. We conclude that PCNSL may occur in a diffusely infiltrating form which may occur without MRI evidence of mass lesions or blood-brain barrier compromise. We refer to this entity as 'lymphomatosis cerebri' and add it to the differential diagnosis of a rapidly progressive dementia.

Experiences of parents of childhood cancer survivors: a qualitative analysis

As the prognosis of childhood cancer improves, so does concern for the quality of survival. Because childhood cancer affects the entire family, insight is needed into the late consequences for parents and how they cope with it. For this purpose, a qualitative research method was used because this method enables a description of what it is like to live through childhood cancer in all its aspects. Parents whose child survived cancer were interviewed in depth about the late consequences of the disease. To maximize contrast in parental experience and in coping with the disease, variational sampling was used. Results indicated that parents experienced changes of a definitive and long-lasting nature as a result of cancer in their child. In spite of the child's survival, feelings of loss and perseveration of problems prevailed. To cope with late sequelae, characteristic strategies were identified including the position parents adopt a life or death perspective on the final outcome of the disease, the extent to which they express emotions, and the use of family planning and parenting behavior. Coping strategies used had not only an effect on the individual parent but also on the other family members. Parents who used coping strategies in a non-extreme way appeared to be functioning well. Implications for patient care and research are discussed.

Quality of life in patients with low-grade non-Hodgkin's lymphoma

Low-grade non-Hodgkin's lymphoma (NHL) is an indolent form of the disease with a generally slow course of progression. Although still usually incurable, low-grade disease has shown responsiveness to some of the newer chemotherapeutic and nonchemotherapeutic treatment options. However, since cure remains elusive, and since many patients with lowgrade NHL may have few or even no symptoms initially, the decision about whether or not to initiate treatment logically must include quality-of-life (QOL) issues. This paper summarizes clinical and diagnostic characteristics of low-grade NHL that have some bearing on QOL considerations. Adverse effects of the more common treatment approaches are discussed according to their QOL implications, illustrating the relevance of QOL to the clinical management of low-grade disease. Finally, data from an ongoing study using the Functional Assessment of Cancer Therapy (FACT) measurement system are presented. These data offer a basis for comparing the QOL of patients with NHL to that of individuals with other solid tumors, and also illustrate the effects of chemotherapy on QOL.

Prospective study of cancer patients and their spouses: the weakness of marital strength

In a prospective study, 133 married cancer patients and their spouses were interviewed within a month of diagnosis and administered three self-reports: The Brief Symptom Inventory (BSI) to assess psychological distress, the Impact of Events Scale (IES) to assess coping, and the Family Adaptability and Cohesion Scales (FACES III) to assess family relations. Patients and spouses were moderately distressed. The patient's psychological distress was explained by the level of intrusion, by the spouse's psychological distress and cohesion which had a protective effect (R2.41). The spouse's distress was explained by intrusion, gender and, to some extent, by the patient's distress (R2.41); but cohesion had no influence. Only half of the group (as couples) reached the last follow-up nearly 2 years later. A disassociation seems to have occurred; family relations, as well as partner's distress, did not have an influence on either the patient's or spouse's distress. The information gathered at the beginning of the study explained about 25% of the distress 2 years later of male patients and their wives, and that of female patients but not of their husbands.

[Diagnosis and treatment of non-Hodgkin lymphoma in elderly patients]

Non-Hodgkin's lymphoma (NHL) is relatively frequent among elderly patients: more than half of the diagnoses in the Netherlands concern patients aged 65 years or above. The treatment depends on histological type, clinical stage and prognostic group. Increasingly, a treatment decision is made after determination of the prognostic group on the basis of the expected response and survival. In elderly patients intensive treatment frequently has more toxic effects. The expected gain in survival has to be weighed against more toxicity and loss of quality of life during and after the therapy. This is notably important for patients with low grade NHL, which requires only intermittent treatment. It is possible to cure some elderly patients with NHL of intermediate or high grade malignancy provided they are adequately treated with combination chemotherapy. Patients with low grade NHL or poor clinical condition may benefit temporarily from palliative treatment, in the planning of which quality of life has to be taken into account.

Replenishing the spirit by meditative prayer and guided imagery

OBJECTIVES

To review relevant literature describing prayer and guided imagery, and to demonstrate via the use of a vignette, the use of both prayer and guided imagery as one approach to offer spiritual care to oncology patients.

DATA SOURCES

Review and research articles from multiple disciplines, and personal clinical experience.

CONCLUSION

Meditative prayer and guided imagery are two approaches that can be used to provide spiritual care to cancer patients and families. While research has focused on elements of spirituality, research related to clinical interventions is limited.

IMPLICATIONS FOR NURSING PRACTICE

Guided imagery, metaphors, meditative prayer, and prayers of silence are effective approaches the nurse can implement when caring for the patient with cancer.

Blood cell transplantation: its impact on one family

OBJECTIVES

To share a story about being the wife of a cancer survivor who had a blood cell transplantation (BCT).

DATA SOURCES

Personal experience, and published articles related to the impact of cancer on the family.

CONCLUSIONS

Cancer affects not only the patient but the entire family unit. Yet, family members are a forgotten population. With advances in cancer treatment, survivorship has increased resulting in caregiving demands that can last for years. The lack of research related to the impact of BCT on family members must be addressed.

IMPLICATIONS FOR NURSING PRACTICE

There are many ways that nurses can provide holistic care to family members who have a loved one going through a BCT. Physical, psychological, social, and spiritual aspects of care can make a tremendous impact on the lives of patients and family members.

Survivors of acute leukaemia and highly malignant lymphoma--retrospective views of daily life problems during treatment and when in remission

Fifty-four former patients, in remission after acute leukaemia or highly malignant lymphoma, responded to a questionnaire covering their physical problems, their view of the help they received, who was most helpful to them during the treatment phase, and the impact of the disease and treatment on their current life. Energy loss and nutritional problems were most troublesome during the treatment phase, signifying many other physical problems. Patients with acute leukaemia had more problems, and thought the care was worse than did patients with highly malignant lymphoma. Serious physical problems correlated with low satisfaction with practical help received, indicating that the nurses failed to meet the needs of those suffering the most. Reduced psychological and sexual energy persisted in remission, showed no correlation with the extent of physical problems during the treatment phase, but correlated with co-existing problems and sensitivity to infections, with a great need for intimate help and counselling and with a low sense of coherence. Family relationships were said to have improved, while work and finances were negatively affected. The results indicate that nursing care should actively focus on physical problems, especially on energy loss and nutritional problems. The overwhelming fatigue hinders patients in taking physical care of themselves, and may be overlooked by the nurse since their motor capability seems intact. The long-term effect of the illness means a reduced psychological and sexual energy and a high degree of existential problems and sensitivity to infections, which indicates the importance of follow-up care, and perhaps especially of counselling for the long-term reactions and disturbance of equilibrium.