Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial

Cognitive-existential group therapy for patients with primary breast cancer--techniques and themes

We describe a model of cognitive-existential group therapy designed to be integrated over 6 months with regimens of adjuvant chemotherapy given as conventional medical treatment to breast cancer patients with stage 1 and 2 disease. Our broad therapy goals are for members to develop a supportive network, work through grief over losses, improve problem solving and develop cognitive strategies to maximise coping, enhance a sense of mastery over life and re-evaluate priorities for the future. Specific group themes include death anxiety, fear of recurrence, living with uncertainty, understanding treatment with chemotherapy, radiotherapy and hormone regimens, the collaborative doctor-patient relationship, body and self image, sexuality, relationships with partner, friends and family, surgical reconstruction, life style effects and future goals. Active coping skills are developed through teaching formal problem solving and cognitive restructuring of automatic negative thoughts. Technical aspects of the therapy are discussed.

The emergence of the 'waiting game': a critical examination of the psychosocial issues in diagnosing breast cancer

Undergoing diagnostic investigations for symptoms of breast disease constitutes an intensely stressful experience for any woman. The widespread use of contemporary fine-needle techniques throughout specialist breast clinics, whilst removing the necessity of hospitalization and general anaesthesia for many women, has introduced the notion of the 'waiting game'. The ability to ascertain definitive results within a matter of hours has led to diversification in the structure of diagnostic breast services; however, the significance of the 'waiting game' in terms of distress experienced by women has not been investigated. This paper systematically reviews the research that has explored psychosocial morbidity in this phase of the disease trajectory, and provides summative recommendations for further research.

Physicians' opinions about decision aids for patients considering systemic adjuvant therapy for axillary-node negative breast cancer

PURPOSE

To examine variations in physicians' opinions about the appropriateness and content of decision aids for women with breast cancer and criteria for their evaluation.

METHODS

Cross-sectional survey of all 144 Ontario oncologists by Dillman's mailed survey design. The response rate was 87%.

RESULTS

The predominant current practice pattern was to spontaneously inform patients about the treatment recommendations, degree of certainty regarding the recommendations, treatment regime, benefits and side effects. Most respondents (94%) endorsed patient decision aids, particularly when there was high uncertainty about providing adjuvant treatment. Over three-quarters endorsed measuring the following outcomes of decision aids: patients' clarity of trade-offs involved (e.g. survival vs. side effects); comprehension of treatment alternatives, risks and benefits; accuracy of expectations; decision satisfaction; anxiety; commitment to the decision; length of time to complete the decision aid; and decision uncertainty. The least support was for the use of the decision itself as an outcome measure.

CONCLUSIONS

There is considerable consensus regarding the indications for, content and criteria for evaluating decision aids which should be considered when developing aids relevant to the needs of clinicians and patients.

Sexual dysfunction in treated breast cancer patients

BACKGROUND

This study examined the impact of breast cancer therapy on women's sexuality.

PATIENTS AND METHODS

A questionnaire concerning various sexual problems experienced before and after treatment was anonymously completed by 50 women in the outpatient clinic of our hospital's Division of Radiation Oncology. To be eligible, subjects had to be disease-free and sexually active. They also had to have undergone surgery at least one year previously and have completed CT and or RT. Fifty-eight percent of the women involved had undergone mastectomy and 42% had undergone quadrantectomy followed by RT.

RESULTS

Ninety percent of the subjects continued sexual activity after treatment, but there was an increase in the incidence of sexual problems which resulted in a slight reduction in the quality of their sex lives. Sixty-four percent of the women experienced an absence of sexual desire and 48% low sexual desire, while 38% had dyspareunia, 44% frigidity and 42% lubrication problems. Vaginismus, brief intercourse and female orgasmic disorder were reported by 30% of the subjects. Thirty-six percent suffered from sexual dysfunction before treatment, which worsened in about 27%, while in 49% of women sexual problems arose mainly after chemotherapy (26%) or surgery (12%). About one-half experienced changes in the relationship with their partner.

CONCLUSION

Breast cancer patients experienced sexual dysfunction: ours found it easier to discuss the problems with their partner during their illness (62%) than with doctors and psychologists (15%).

The development of a training model to improve health professionals' skills, self-efficacy and outcome expectancies when communicating with cancer patients

Health professionals such as doctors and nurses are in a key position to help reduce the high prevalence of affective disorders and psychological problems experienced by cancer patients. This role, however, is inhibited by ineffective communication practices which include the use of distancing strategies and avoidance by the health professional. A number of contributory factors such as skill deficits and anxiety about negative consequences for the patient and the health professional have been identified in previous research and brief problem-focused training workshops developed to address these factors with only limited success. Researchers in applied psychology have recommended that the development of training programmes and their evaluation are based upon approaches which take into account cognitive and affective factors as well as change in skills. The aim of this paper is to develop a conceptual model of communication behaviour in the cancer setting. The model aims to take account of the role that knowledge and skill deficits, self-efficacy and outcome expectancy beliefs and perceived support plays in the ability and willingness of health professionals to assess their patients' concerns. It has been applied to guide the development of a revised approach to brief, problem-focused workshops for health professionals. It also allows a systematic and multi-dimensional evaluation of training outcomes. Preliminary results indicate this is a promising area of communications research.

International experiences with the Hospital Anxiety and Depression Scale--a review of validation data and clinical results

More than 200 published studies from most medical settings worldwide have reported experiences with the Hospital Anxiety and Depression Scale (HADS) which was specifically developed by Zigmond and Snaith for use with physically ill patients. Although introduced in 1983, there is still no comprehensive documentation of its psychometric properties. The present review summarizes available data on reliability and validity and gives an overview of clinical studies conducted with this instrument and their most important findings. The HADS gives clinically meaningful results as a psychological screening tool, in clinical group comparisons and in correlational studies with several aspects of disease and quality of life. It is sensitive to changes both during the course of diseases and in response to psychotherapeutic and psychopharmacological intervention. Finally, HADS scores predict psychosocial and possibly also physical outcome.

Pain and other symptoms during the first year after radical and conservative surgery for breast cancer

This study assessed pain, neurological symptoms, oedema of the ipsilateral arm, anxiety and depression occurring in women treated surgically for breast cancer, the impact of these symptoms on daily life and how they evolved during the 1 year follow-up. Ninety-three consecutive patients with non-metastasised breast cancer who were treated during 1993-94 were examined before surgery and after 1, 6 and 12 months. They were asked about pain, neurological symptoms and oedema in the breast scar region and/or ipsilateral arm. Sensory testing was performed, and gripping force and the circumference of the arm were measured. Anxiety and depression were evaluated. One year after surgery, 80% of the women had treatment-related symptoms in the breast scar region and virtually all patients had symptoms in the ipsilateral arm. The incidence of chronic post-treatment pain was higher after conservative surgery than after radical surgery (breast area: 33% vs 17%, NS; ipsilateral arm: 23% vs 13%, NS). Numbness occurred in 75% and oedema of the ipsilateral arm in over 30% of the patients after both radical and conservative surgery. Phantom sensations in the breast were reported by 25% of the patients. No difference in psychic morbidity was detected after the two types of surgery. Both the anxiety and depression scores were highest before surgery, decreasing with time, and were significantly correlated with preoperative stressful events.

Behavioural oncology: psychosocial aspects of understanding and treating malignant disease

Behavioural, or psychosocial, oncology refers to the application of the findings and methods of psychology (or more generally the social sciences) to understanding and treating malignant disease. The diagnosis and treatment of cancer are stressful experiences and clinicians can do much to promote adjustment by establishing good rapport, providing appropriate information and by involving patients in management decisions if they wish. Randomized clinical trials of various psychological interventions have shown that a great deal can be done to minimize distress, improve control of various side-effects and enhance quality of life. Although several randomized studies have found that patients who have received a psychological intervention live longer, more studies are urgently needed to confirm this. If survival can be prolonged in this way, it is likely that the underlying psychobiology will vary from one tumour type to another. Attention needs to be directed at how behavioural oncology services should best be delivered within the context of different health services.

Information needs of cancer patients in west Scotland: cross sectional survey of patients' views

OBJECTIVE

To assess the needs of patients with cancer for information about their condition.

DESIGN

Cross sectional survey of patients' views by means of semistructured interview with questionnaire.

SETTING

A regional cancer centre and two university hospitals in west Scotland.

SUBJECTS

250 (93%) of 269 cancer patients invited to participate in study who were selected by age, sex, socioeconomic status, and tumour site to be representative of cancer patients in west Scotland.

MAIN OUTCOME MEASURES

Patients' need to know whether they had cancer, the medical name of their illness, progress through treatment, how treatment works, side effects, chances of cure, and treatment options.

RESULTS

79% (95% confidence interval 73% to 84%) of patients wanted as much information as possible, and 96% (93% to 98%) had a need or an absolute need to know if they had cancer. Most patients also wanted to know the chance of cure (91% (87% to 94%)) and about side effects of treatment (94% (90% to 97%)). When the replies were cross tabulated with patients' age, sex, deprivation score, and type of treatment there was a linear trend for patients from more affluent areas to want more information and those from deprived areas to want less. There was a strong preference for diagnosis of cancer to be given by a hospital doctor (60% (53% to 66%).

CONCLUSION

Almost all patients wanted to know their diagnosis, and most wanted to know about prognosis, treatment options, and side effects.

Group cognitive behavioural therapy interventions with cancer patients: a review of the literature

At present there is considerable evidence that suggests cancer patients, once diagnosed, experience significant and long-term psychosocial problems. Several studies have evaluated group interventions, but only a few have used group cognitive behavioural therapy (GCBT) with cancer patients. The following paper represents a review of the literature of GCBT, illustrating the key findings from these studies.

Measuring quality of life in oncology: is it worthwhile? II. Experiences from the treatment of cancer

This is the second part of the paper on quality of life in cancer patients which appeared in this journal (Montazeri et al., 1996a). In this part experiences from the treatment of cancer are given and relevant literature is reviewed. Several topics have been covered, including new directions and methods in assessing quality of life. It is argued that in a chronic condition, adding life to years instead of years to life is an important task. Adding years to life may prolong survival, but whether this is to the benefit of patients is debatable. Considering patients' views, their values and preferences may improve the quality of care and at the same time, reduce the psychological distress and physical discomfort in patients with cancer. It is concluded that quality of life measures have considerable potential in this challenging issue.

Group cognitive behavioural therapy: an intervention for cancer patients

There is considerable evidence to suggest that cancer patients, including those with advanced disease, experience significant and long-term psychosocial problems. Work using group cognitive behavioural therapy with cancer patients has recently demonstrated a way in which it may be possible to treat emotionally distressed individuals effectively. This article reviews the literature on group cognitive behavioural psychotherapy and discusses for practitioners of all disciplines the important techniques, the value of time-limited interventions, the type of patients who may benefit, and where and how to facilitate successful interventions. Health workers with an interest in the emotional care of patients are thus provided with some understanding of the value that group cognitive behavioural psychotherapy may hold for them.

Adjustment to breast cancer: the psychobiological effects of psychosocial interventions

This review focuses on the effects of psychosocial interventions on psychological and biological functioning of breast cancer patients. Once in their lifetime, one out of eleven women receive a diagnosis of breast cancer. A diagnosis of breast cancer is a severe stressful life event with profound consequences on all aspects of human life. Whether a woman will regain emotional balance and accept the idea of living with a potentially life threatening disease depends on her psychological resiliency. Provision of psychosocial interventions can improve these women's coping abilities and reduce emotional distress and feelings of isolation, and improve psychosexual functioning. Additionally, there exists some evidence that psychotherapy may prolong survival. Prolongation of survival may be related, in part, to an increase in certain aspects of immune function (e.g., natural killer cell activity). This is plausible because the function of the immune system seems to be related to mammary tumor growth. Therefore, future research should examine the degree to which the effects on mammary tumor growth relate to immune system changes.

Doctor-patient interactions in oncology

Studies which apply content analysis techniques to the cancer consultation are few. This descriptive study examines the structure and content of the bad news cancer consultations of 117 outpatients newly referred to the Medical Oncology Department of a large London teaching hospital. From previous communication research three main hypotheses are formed: (i) the cancer consultation is clinician-dominated rather than patient-centred; (ii) the level of psychosocial discussion between clinicians and patients is low and (iii) patient characteristics such as sex, age and prognostic category influence clinician behaviours. Each patient had two consultations with one of 5 oncologists. Both these were audiotaped with the patients' consent. The tapes were content coded using the Roter Interaction Analysis System. Results showed that clinicians tended to use closed rather than open questions. Patients asked few questions and were seldom given space to initiate discussion. Thus, the level of patient-centredness was low. Despite the fact that consultations concerned life threatening disease and often contained information regarding toxic treatment which is known to provoke psychological dysfunction, the number of questions relating to patients' psychological health were few. The amount of discussion concerning medical topics from both parties was 2.5 times greater than the amount of psychosocial discussion. Although there was a suggestion in the data that 3 clinicians showed variations in behaviour according to patient age and prognostic group, the number of patients for each doctor was small. Patients were well informed about their diagnosis, prognosis and treatment options, but their emotional well-being was rarely probed.

Ethical and practical problems of early anti-cancer drug trials: a review of the literature

Early clinical trials for new anti-cancer drug treatments typically use patients with cancer as research subjects. This paper identifies some of the ethical and practical concerns that arise from the recruitment of a vulnerable group of patients and their exposure to a drug of unknown risk or benefit. This review discusses the ethical principles related to recruitment and informed consent in cancer trials, and indicates that there is a lack of consensus concerning the requirements, process and practice of informed consent. It is suggested that, as yet, little is known about patients' decision making framework in this situation, and the need for further work that concentrates on the patient's point of view is highlighted. The paper concludes by discussing some of the difficulties associated with obtaining patients' opinions, and suggests that the use of a qualitative approach may overcome some of these problems.

Psychosocial aspects of participation in early anticancer drug trials. Report of a pilot study

Despite improvements in the treatment of many cancers, the need for effective new therapies is as great as ever. However, evaluating new drug treatments for cancer in clinical practice raises complex problems. Early trials of new drugs offer little in the way of therapeutic benefit, since their main aim is to identify toxic effects of the drug and subsequent doses for testing. The ethical and practical problems that these trials raise have received some attention in the literature. The main focus of previous studies has been the process of informed consent for trial participation, which has tended to reflect the perspective of the clinicians involved. Little attention has been given to patients' views in this context, and still less work has explored the total experience of clinical trial participation. In order to address these gaps in the literature, a research study was developed to explore the psychosocial aspects of participation in early anticancer drug trials from the perspective of the patient. This article reports the findings of a pilot study. The pilot study obtained the views of seven patients as they progressed through an anticancer drug trial. The informed consent process, the reasons behind decision-making concerning trial participation, and the impact of participation on the lives of the patients were explored, along with changing needs for information, care, and support as the trial progressed. Findings identify psychosocial aspects of clinical trial participation related to information, decision-making, and support from the perspective of those actually taking part.

Clinical supervision: a plea for 'pit head time' in cancer nursing

The concept of clinical supervision has received considerable attention in the nursing literature of late, enjoying favour not only with many practitioners and managers, but academics and policy makers alike. The following paper considers the utility of clinical supervision within the cancer nursing setting, concentrating particularly on the development of self-awareness and the facilitation of responsive, reflective, therapeutic relationships. The paper is predicated on the belief that clinical supervision not only provides a valuable means of peer review and support, for nurses both in the pre- and post-registration spheres, but that structured process of systematic supervision sustains the necessary environment for the protection and enhancement of quality nursing interventions (Butterworth, 1992). The potential of clinical supervision, as regards the wider development of nursing as a practice discipline, is illustrated by the incorporation of an extensive literature review which explores the theoretical and practical imperatives pertaining to the notion of clinical supervision, not only in relation to the individual, but to cancer nursing and nursing per se.

Information needs and sources of information for women with breast cancer: a follow-up study

This paper reports a study which examined the specific information needs and sources of information for 105 women with breast cancer at two time points, the time of diagnosis and a mean of 21 months from diagnosis. At diagnosis the priority information needs concerned survival issues. Further from diagnosis survival issues were still a concern, but information about the risk to family members of getting breast cancer showed a significant increase in importance. Information about sexual attractiveness was ranked last at both the newly diagnosed and follow-up stages. Information sources at the time of diagnosis centred around the specialist breast care service, while further from diagnosis few professional or voluntary sector sources were utilized, with women receiving most of their information from media sources such as women's magazines. The relevance of these findings for nurses and other health care professionals is discussed.

Psychosocial support, treatment of metastatic disease and palliative care

This article deals with four linked but distinct aspects of care for women with breast cancer, with an emphasis on the pivotal role of the general practitioner: 1. Modern medicine is fast recognising the need for psychosocial support of patients; in fact, for an integrated approach to caring for the whole person at all stages of illness. 2. Oncological treatment of metastatic disease needs to be individualised and based on realistic expectations of outcome balanced against side effects. 3. An open dialogue about the role and appropriateness of so-called "alternative" or "complementary" therapies is needed. 4. Despite significant improvements in palliative care quality and access in Australia in the last decade, many practitioners still require support and advice in this demanding area of care (particularly about difficult symptom control).

Radiotherapy for cancer. Quality of life

This synthesis of the literature on the quality of life in relation to radiotherapy is based on 78 scientific articles, including 12 randomized studies, 25 prospective studies, and 20 retrospective studies. These studies involve 9884 patients. Radiotherapy is often organ-preserving, which inherently promotes a better quality of life. Many quality of life aspects related to radiotherapy have been studied, but seldom by prospective randomized studies that compare radiotherapy to other treatment (eg, surgery or chemotherapy). Radiotherapy involves numerous physical and psychological symptoms, mainly during the course of treatment. Examples include skin irritation and fatigue. Radiotherapy directed at the brain has delayed effects, in children treatment carries a substantial risk for lowering the IQ. The risk for encephalopathy in adults is probably underestimated. Patients with cancer in the head and neck may experience adverse side effects in the irradiated area long after the conclusion of radiotherapy. There are no confirmed differences in quality of life between breast cancer patients receiving adjuvant radiotherapy and those receiving chemotherapy. Impotency problems and urinary incontinence appear following radical surgery and radiotherapy for prostate cancer. The risk for delayed complications is low after radiotherapy for testicular cancer. Patients receiving radiotherapy for gynecologic cancers are often troubled by local side effects long after the conclusion of treatment.

Can mood disorder in women with breast cancer be identified preoperatively?

The Hospital Anxiety and Depression (HAD) scale, a self-report questionnaire, was tested as a method of identifying mood disorder among patients with operable breast cancer during the year after diagnosis. In a cohort of 91 patients anxiety and depression were assessed preoperatively, and at 3 and 12 months post-operatively, using a standardised psychiatric interview and diagnostic rating criteria. The patients also completed the HAD scale at each assessment. Fifty out of 91 (55%) patients were full or borderline cases of depression and/or anxiety at one or more assessment points. Using a receiver operator characteristic curve analysis, the optimum threshold for the preoperative HAD scale total score to identify psychiatric disorder either preoperatively or at 3 and 12 months post-operatively was 11. With this threshold 70% of both full and borderline cases occurring at any of the assessment points were correctly identified. The false-positive rate was 12%. This approach was particularly sensitive to full cases, correctly identifying 90% of them. The potential for the preoperative HAD scale total score to identify mood disorder in the year after diagnosis was influenced by age. Among women aged less than 50 years, a preoperative HAD scale total score > or = 11 provided a highly sensitive indicator of mood disorder (full and borderline cases) at any time in the year after diagnosis (sensitivity = 90%). The false-positive rate was 40%. Among women older than 50 who experienced a mood disorder, only 57% were correctly identified by a HAD scale total score of > or = 11 (sensitivity = 57%). However, the false-positive rate among older women was low (3%). This simple preoperative screening approach can be used to identify patients who have or are at high risk of developing severe mood disorder in the year after diagnosis. The HAD scale is also sensitive to the detection of borderline mood disorder in patients under the age of 50. It is a specific screening tool among patients over 50, but is not sensitive to the detection of borderline mood disorder in this age group.

Menopause: a problem for breast cancer patients

Many women who are treated for breast cancer will subsequently undergo the menopause, either as a result of cancer treatment or as a natural process. For this group of women hormone replacement therapy is currently not recommended and so women lose a major option to help control menopausal symptoms. The extent of this problem has not been widely researched and alternative methods of coping with menopause in this group have not been explored. This paper reviews the menopause in relation to these women and suggests avenues for future research.

Depressive symptomatology of post-menopausal breast cancer patients: a comparison of women recently treated by mastectomy or by breast-conserving therapy

The aim of this study was to detect differences in depressive symptomatology in post-menopausal breast cancer patients who had recently undergone either mastectomy or breast conserving therapy. We measured depressive symptoms shortly after diagnosis and surgery as well as 6 months later. There were no significant differences in mean scores and relative risk estimates between the two treatment groups at either time of measurement. From this study we conclude that women treated by breast-conserving therapy have comparable levels of depressive symptoms to women treated by mastectomy during the first 8 months after diagnosis. Breast-conserving therapy can have cosmetic and physical advantages, but requires as much psychological adjustment as mastectomy does.

The information needs of women newly diagnosed with breast cancer

Nurses can play a key role in patient education, including providing patients with useful and appropriate information. Rather than focusing on the process of education or information giving by nurses, this study places emphasis on the content of that information by taking the patients' perspective and asking the patients themselves what particular types of information are perceived as important at a specific point in time. The aim of the study was to explore what particular types of information were important to women newly diagnosed with breast cancer; to enable nurses and other health care professionals to utilize their time as effectively as possible and provide a high-quality service to individuals in their care. Women with breast cancer (a mean of 2.5 weeks from diagnosis) were interviewed and asked to compare items of information. The items of information were presented in pairs and the women stated a preference for one item in that pair. Thirty-six pairs were presented in total. The analysis involved the use of a Thurstone scaling model, which allowed rank orderings, or profiles of information needs, to be developed, reflecting the perceived importance of each item. Information about the likelihood of cure, the spread of the disease and treatment options were perceived as the most important items of information at the time of diagnosis. Other information needs, in order of descending priority, included information about the risk to family, side-effects of treatments, impact on family, self-care, effect on social life and sexual attractiveness. Profiles of information needs were produced to take account of differences in age, level of education and social class.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of patient education on decisions about breast cancer treatments: a preliminary report

The authors examined the effects of materials for educating patients about treatment options for breast cancer on knowledge about the disease, preferences for alternative treatments, and how changes in knowledge and preferences were related. Eighty-two undergraduate students acted as advisors to a hypothetical patient. They completed a knowledge test and rated their preferences for three options--breast-sparing surgery with radiation, mastectomy followed by reconstructive surgery, and mastectomy followed by use of a breast prosthesis--before and after viewing a videotape or a booklet version of the educational materials. Both formats increased knowledge scores. Treatment preferences were not affected by reading the booklet, but viewing the videotape resulted in a preference shift toward breast-sparing surgery. This media difference may be due to features of the video that were not reproduced in the booklet, such as interviews with other patients. Knowledge gains were uncorrelated with preference changes.

Presenting clinical trial information: a comparison of methods

The study objective was to assess the relative effects of 2 approaches to teaching about a clinical trial, in terms of patients' satisfaction, information understanding, and whether or not they would enter such a trial. One hundred patients receiving radiation therapy for a variety of cancer diagnoses were randomized to receive information about a hypothetical trial, either by audio tape or interactive computer program. A day later, information understanding was assessed. One week later, method satisfaction and whether respondents would enter such a trial were assessed. There were no differences in understanding or satisfaction. Members of the computer program group tended to report a more positive attitude towards trial entry (chi 2 = 4.0; 1 df; P = 0.05). Overall, refusers tended to be women with higher understanding scores. The results suggest that teaching with interactive components might not adversely affect trial accrual. Further work involving an actual trial entry decision is merited; the sex of the respondent should be controlled in designing this future work.

Effective physician-patient communication and health outcomes: a review

OBJECTIVE

To ascertain whether the quality of physician-patient communication makes a significant difference to patient health outcomes.

DATA SOURCES

The MEDLINE database was searched for articles published from 1983 to 1993 using "physician-patient relations" as the primary medical subject heading. Several bibliographies and conference proceedings were also reviewed.

STUDY SELECTION

Randomized controlled trials (RCTs) and analytic studies of physician-patient communication in which patient health was an outcome variable.

DATA EXTRACTION

The following information was recorded about each study: sample size, patient characteristics, clinical setting, elements of communication assessed, patient outcomes measured, and direction and significance of any association found between aspects of communication and patient outcomes.

DATA SYNTHESIS

Of the 21 studies that met the final criteria for review, 16 reported positive results, 4 reported negative (i.e., nonsignificant) results, and 1 was inconclusive. The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control.

CONCLUSIONS

Most of the studies reviewed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes. The components of effective communication identified by these studies can be used as the basis both for curriculum development in medical education and for patient education programs. Future research should focus on evaluating such educational programs.

Therapy of small breast cancer--four-year results of a prospective non-randomized study. German Breast Cancer Study Group (GBSG)

BACKGROUND

In the early 1980s breast preservation was a rarely applied therapeutic modality in the primary treatment of breast cancer in the Federal Republic of Germany. Reports coming from retrospective studies as well as preliminary results from randomized trials made it desirable to introduce breast preservation in the form of a controlled clinical trial.

STUDY DESIGN

In stage pT1 N0 M0 breast cancer, mastectomy as the standard treatment was to be compared with radiotherapy of the remaining breast tissue. The study design originally planned as a randomized trial had to be changed into a prospective observation study due to the low randomization rate. Univeriate analysis of prognostic variables was the first step to a valid treatment comparison. Those factors determined as being significant were included together with the treatment effects in a multivariate analysis. A high therapeutic standard was guaranteed by quality control.

RESULTS

1036 out of 1119 recruited patients are evaluable. After a median follow-up of 48 months the following preliminary results can be reported. With the exception of death without recurrence from breast cancer, the 143 events are evenly distributed among the two treatment groups. Locoregional recurrence of the whole patient population was 5%. Out of all prognostic factors examined only tumor size and grading are significant in regard to recurrent disease. Recurrence-free survival decreased in cases with 'uncertain' tumor margins, whereas the width of the margin had no influence on recurrent disease. There was no significant difference in quality of life between the two treatment groups.

CONCLUSIONS

The four-year results of this study are in accordance with those of other breast preservation trials: There is no significant difference between the two treatment groups in the occurrence of locoregional failure. Incomplete tumorectomy has a negative influence on recurrence. Quality of life seems more dependent on the acceptance of the therapy by the patient than on the therapeutic modality itself. Breast preservation can also be performed appropriately in smaller institutions if the therapeutic standard is guaranteed by quality control.

Doctor-patient communication: a review of the literature

Communication can be seen as the main ingredient in medical care. In reviewing doctor-patient communication, the following topics are addressed: (1) different purposes of medical communication; (2) analysis of doctor-patient communication; (3) specific communicative behaviors; (4) the influence of communicative behaviors on patient outcomes; and (5) concluding remarks. Three different purposes of communication are identified, namely: (a) creating a good inter-personal relationship; (b) exchanging information; and (c) making treatment-related decisions. Communication during medical encounters can be analyzed by using different interaction analysis systems (IAS). These systems differ with regard to their clinical relevance, observational strategy, reliability/validity and channels of communicative behavior. Several communicative behaviors that occur in consultations are discussed: instrumental (cure oriented) vs affective (care oriented) behavior, verbal vs non-verbal behavior, privacy behavior, high vs low controlling behavior, and medical vs everyday language vocabularies. Consequences of specific physician behaviors on certain patient outcomes, namely: satisfaction, compliance/adherence to treatment, recall and understanding of information, and health status/psychiatric morbidity are described. Finally, a framework relating background, process and outcome variables is presented.

The efficacy of audiotapes in promoting psychological well-being in cancer patients: a randomised, controlled trial

Open or uncontrolled studies have suggested that providing cancer patients with audiotapes of their clinical interviews can improve information recall and reduce psychological distress. We tested these hypotheses in a 'clinician-blind', prospective, randomised controlled trial. A total of 117 patients newly referred to a medical oncology clinic who were to be given 'bad news' had their consultations audiotaped. Blind to the clinician, patients were randomly allocated to receive a copy of the tape to play at home or not (control group). At 6 months follow-up, tape group patients reported positive attitudes to the audiotape and were shown to recall significantly more information about their illness than did controls. Overall improvement in psychological distress at 1 and 6 months follow-up, as measured with the 30-item General Health Questionnaire and the Hospital Anxiety and Depression Scale was no different in the two groups. However, a second-order interaction suggested that poor-prognosis patients were disadvantaged specifically by access to the audiotape, with less improvement in psychological distress at 6 months follow-up than non-tape controls. Patient access to audiotapes of clinical interviews promotes factual retention but does not reliably reduce psychological distress and may be actively unhelpful in some subgroups of patients.

Breast cancer: causes of patients' distress identified by qualitative analysis

BACKGROUND

Previous investigations of the psychological consequences of having breast cancer have usually involved quantitative analysis within medical models.

AIM

This qualitative study set out to identify key events which had caused distress to women with breast cancer and to compare the frequency of these events with doctors' beliefs about their relative frequency.

METHOD

The causes of distress in 26 women with breast cancer were identified by qualitative analysis of unstructured interviews. Subsequently, all hospital doctors and general practitioners in the Exeter health district were sent a list in random order of the eight events which had most commonly caused distress and were asked to rank them in order of frequency for patients with breast cancer.

RESULTS

The responses suggest a mismatch between the doctors' expectations and the experience of the patients.

CONCLUSION

Patients may suffer distress in areas of management doctors do not suspect are important; qualitative analysis can identify these areas.